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Tri-State Medical Association Meets February, 19-20-21
U.N. C
Volume 9i1
Number 1
JANUARY, .1929
Single Copies SOe
$2.50 Per ABB«m
CONTENTS
Original Articles
Management of the Complications of Diabetes, W. J. Mallory 1
The Therapy of Amebiasis (Report of Cases), A. B. Hodges 5
Mucous Membrane Cysts of the Maxillary Sinus, J. P. Matheson 0
Instructive Fracture and Other Orthopedic Cases, J. S. Gaul . 1?
Agranulocytic Angina, O. O. Ashworth and E. A. Hines, jr. 22
Some Neglected Factors in Hospital Management, Malcolm Thompson 26
Clinic and Group Practice, Harold Glascock _ _ 27
Case Reports
Ruptured Duodenal Ulcer With Symptoms Simulating Ruptured Tubal Pregnancy,
R. B. McKnight . 21
Chronic Intestinal Amebiasis, L. G. Gage 30
President's Pace
Tri-State Medical Association 31
Medical Society N. C.
Editorial
Dr. Charles L. Minor, P. H. Ringer
Dr. Charles L. Minor, Haywood Parker
In Memoriam — Dr. Charles L. Minor, Vestry Trinity Church _
In Memory of Dr. Minor, Buncombe County Medical Society
Dr. Robert Vance Bravvley, J. E. Stokes
Dr. James William McNeill, O. L. MacFadyen
Dr. Franklin Jefferson Garre, H. J. Ledbetter
Achille Murat Willis
Dr. Joshua Tayloe
Our Own Cravings as Reliable Guides
Interest in Garnishment Law and News Items
To Authors
One Kind of Advertising
_ 44
(Continued on inside of front cover)
ENTERED CHARLOTTE, N. C, POSTOFFICE SECOND CLASS MAIL
Published Mo||hly by Jas. Kl. Northington, Charlottt, N. C.
Tkf Coming Tri-State Mectine . a.
Prccnostic j J. K. Hall
The Right Book at L;
Human Lactation, F.
\>nigo, V. K. Hart ^g
Prccnostic ■ J. K. Hall ^«
The Right Book at Last ._ \ ~ *"
Human Lactation, F. H. Richardson ^,
\frtigo, V. K. Hart ~ "
Sifkle-Cell Anemia, N. M. Smith '_ '^ *„
Common Foot Ailment? in Children, 0. L. Miller ^ '__ " et
Cohabitation Pyelitis, R. P. Finncv _^ — mi^ZIZIIZZZIZZ~~~ ??
Routine X-Rays in Public Health Work, J. D. MacRae -HZZZZZZZ S4
Infectious Ganarcnous Dermatitis, George Benet _ '_ ' 5-
E., E., N T Mouth and Sinus Conditions in 271 Health Examinations V.' RrTavior" 56
LooKing Backward and Forward, H. J. Langston „
Influenza, E. G. Williams _, ~~ ^'
Dr. Thomas Dale, of Charleston, R. E. Seibels 59
-^'^'i^";"^ Sampso": Robeson; Richmond (Va.^ ; Danville (Va.) Hospitals: Marion
n ■ R \"T • n"'"T A l\: ^^ ^ ^ ^'''"'' ^'- J- -^^ Marshall: Dr. A. T. Millis;
Dr. R. A. Deane: Dr. J. A. Shaw; Dr. J. S. Hitchcock; Dr. W. W Keen- Dr Clara
-n"'r' w ^- ^ ^L^^^S^^' I3r. L. A. Walker; Dr. J. L. Clinton ;Dr V t Lassie
Dr G. W. Cook: Dr. G. W. Black; Dr. W. F. Martin; Dr. H. F Lon- Dr B H
n^'w' ° w'', ^- ^^''\'''- ^' J- "■ ^''^'^^ Dr W. A. Woodruff; DrC.' ^Barker:
Dr Harry Walker: Dr. J. R. Anderson; The Drs. Parrot; Dr. J. W. Tankersley.
Bjti 'RrviEws
?^r!!r,T'M'''H-'''^'.^-^^''."\"''^ -'''■*'"'■ Compend of Diseases of Skin. Schamhtri;
TW.=^t . ;, ;"'^ ^"'IT^'I General Surgery, GraMm, (2) Eve, Ear, Nose a>d
Tkroat, Small, Andrews, Skambaugk.
MARINOL
In the highest degree tolerable and agreeable— so agreeable that a
physician tells us he has "actually seen children fight for it."
MARINOL is susceptible to digestion and assimilation to a degree
almost inconceivable of cod liver oil. The oil globules are so diffusible, so
minutely divided (by homogenization) that there are millions of them, ia
colloidal suspension, in a quarter of a teaspoonful.
MARINOL — a vitamin, mineral, dynamic food.
FAIRCHILD BROS & FOSTER
NEW YORK
SOUTHERN MEDICINE and SURGERY
VOL. XCI CHARLOTTE, N. C, JANUARY. 1929 NO. 1
Management of the Complications of Diabetes — Acidosis and
Infections*
W. J, Mai.lory, :\I.D., Washington, D. C.
The gravest complications of diabetes are
coma and infection. Either one of these pre-
sents a great menace to the life of the pa-
tient; wRen the two occur together, as is so
frec|uently the case, the situation is desper-
ate.
For the sake of simplicity it is best to con-
sider coma and infection separately at first,
and later the two combined, for the reason
that the treatment of coma is the same
whether it occurs alone or in association with
infection.
The diagnosis of coma is easy; but the
acidosis — which precedes coma by hours or
days — should he recognized and coma pre-
vented.
The onset is extremely insidious. The first
symptoms are not coma or even drowsiness,
but restle.'^sness with gastro-intestinal disturb-
ance— as constipation, pain in the epigas-
trium, nausea and vomiting. The first vom-
itus consists of food; later, bile-stained fluids,
and often it is even Wood-tinged. With a
subnormal temperature, falling blood pres-
i^ure, increasing pulse rate and a leucocyte
Count of 20,000 to 30,000, one must be on
guard against making a diagnosis of some
acute condition in the abdomen demanding
surgical treatment.
The later symptoms are more characteris-
tic and should be easily distinguished from
other causes of somnolence and unconscious-
ness. The patient's color is usually strikingly
go:,'d. The skin may be either dry or moist.
There is neither cyanosis or stertor. The pu-
pils are equal and react to light. The eye-
,/~ balls are soft and the lids droop. The breath-
■1- 'p-r is characteristic (Kussmaul type of air
^hunger) with deep and regular inspiration
- and expiration.
'Presented by invitation to the Seaboard Medical
Association, Washington, \. C, iJeiember o, I'^JS
Complete unconsciousness is a late condi-
tion. The patient moves about in bed, may
answer questions, and can swallow fluids. A
fruity odor may be noticed on the breath
(acetone) and. of course, the urine contains
sugar and diacetic acid. Albumin and casts
when found should not deflect our attention
from the real cause of the coma.
Hyperglycemia is present, but the degree
of increase in the blood sugar is not as accu-
rate an index of the severity of the condition
as is the carbon dioxide combining power of
the blood. I have seen acidosis and coma
with blood sugar values from 180 to 1284
(twice to thirteen times normal).
In difi'erential diagnosis it must not be for-
gotten that an adult diabetic may have cere-
bral hemorrhage, uremia, tumor, cerebral ab-
scess, cranial fracture, and especially hypo-
glycemia (insulin shock).
A comparison of the well known symptoms
of cerebral lesions with those above given for
diabetic acidosis will usually lead to the right
conclusion, provided their possibility is borne
in mind.
To those who have not had the opportunity
of contrasting the two, insulin shock and
coma may present a temporary difficulty. In
both instances coma is present in the sense
of unconsciousness, but the following points
will serve to indicate insulin shock: It comes
on quickly and is usually well established
within an hour after the first symptoms.
lsuall_\- there are preliminary subjective
symptoms of weakness, sweating, visual dis-
turbances and marked psychic disturbances.
When the patient becomes unconscious he lies
quietly, the eyes are open and staring, the
color is noticeably good. The lips, ears and
cheeks are flushed pink; the breathing may
be ciilur (|uiet and regular or shallow and
incL'iilar, init there is no Kussmaul type of
breathing.
SOUTHERN MEDICINE AND SURGERY
January, 1929
If in doubt do not give insulin on the sup-
position that acidosis is present; but, if lab-
oratory aid is not immediately available, give
some form of sugar in liquid form — for ex-
ample, orange juice or syrui^ — because this
sugar will do good in acidosis and, of course,
it is a specific in insulin shock. If the pa-
tient can not or will not swallow, adrenalin
hypodermically will usually restore him suf-
ficiently to permit the administration of or-
ange juice or other sugar solution by mouth.
Because of the fleeting action of adrenalin the
sugar should be given immediately it can be
taken. The quickest way, by far, to restore
such a patient is by the administration of
glucose intravenously. This is effective with-
in two minutes.
A patient who is to be treated for diabetic
acidosis most certainly should be in bed in
a hospital, with special night and day nurses,
preferably those who have had some training
and experience in nursing such patients.
To prevent chilling I should prefer a warm
room and warm blankets to any other means
of applying heat to the body; because such
patients not only blister much more easily
than any others, but, if a burn occurs it may
lead to very serious consequences.
The following procedures should be insti-
tuted, in the order given:
1. Blood should be taken in sufficient
amount (10 c.c.) for a blood sugar and car-
bon dioxide combining power determination.
2. Insulin should be given (20 or 30 units)
immediately, and repeated as described later
on.
3. A specimen of urine should be examine-',
for sugar and diacetic acid as well as given
the usual routine analysis.
4. Fluid should be given by hypodermocly-
sis, 500 to 800 c.c. under the breast, repeated
three or four times in the first 24 hours, then
decreased as the patient improves and is able
to retain large amounts of fluid by mouth.
Other methods of administering fluid, such
as the murphy drip or retention enema, should
not be relied upon because the fluid may be
retained for a few hours and then expelled.
An unknown amount may have been absorb-
ed, but one is often left in doubt on this
most important point. Also, enemata some-
times cause nausea and vomiting, which it is
especially desirable to avoid with these pa-
tUBts.
The importance of large amounts of fluid
cannot be overestimated. Dehydration is
always a serious feature in the pathology of
acidosis and abundant fluid combats this and
provides for the dilution and elimination of
the toxic ketone bodies. I have seen patients
die after coma when consciousness had been
regained and the blood sugar and carbon
dioxide combining power of the blood were
approximately normal, and at necropsy only
great dehydration could be found.
5. The bowels must be moved. For this
purpose enemata are inadequate. A good re-
turn may bpf reported, but on inspection it
is seen to consist of a cloudy fluid with little
or no fecal material. Since finding at ne-
cropsy the large and even the small bowel
containing formed feces, I have used croton
oil (4 minims in a dram of glycerine) by
mouth. This supposedly drastic remedy
moves the bowels once or twice in two or
three hours without ill effect. I have not
seen it cause nausea or vomiting. A smaller
dose is insufficient. If one dose does not
prove effectual it may be repeated.
6. Carbohydrate should be given in the
amount of at least 100 grams each 24 hours.
This can be easily 'and simply accomplished
by giving one glass of orange juice during
each four-hour period, beginning by feeding
teaspoon fuls at a time. When the patient
can take more fluid weak tea may be added.
I find this especially acceptable, and appar-
ently it checks vomiting. Sugar may be given
in the tea, counting a teaspoonful as 5 grams
of carbohydrate. Protein and fats may be
ignored during the first 24 hours and even
until the patient is out of coma.
7. Sod'um bicarbonate may be given in
limited amounts, not more than 30 grams or
8 teaspoopfuls in 24 hours. I saw one pa-
tient, who had been in coma three days and
had received very large doses of sodium bicar-
bonate, die within three hours after admission
to the hospital. The carbon dioxide combin-
ing power of the blood was 120, fully double
the normal figure. If carbohydrate is given
and insulin in sufficient amount to burn it,
with abundant fluids for elimination, sodium
bicarbonate is not indicated.
Heart stimulants are often used because
the pulse is fast and even irregular, but I
have observed no beneficial effects from any
form of digitalis. ?trychnine i& not indicated
January, 1929
ORIGINAL COMMUNICATIONS
and I doubt that any kind of stimulant is
required if the important measures are
adopted. If abundant amount of fluid is
siven and retained and carbohydrate with
insulin used, the heart will do well without
stimulation.
8. The transition from fractional feedings
to three meals a day — at first liquid, later
semi-solid, and finally solid — should be made
as soon as the patient is conscious, and the
time of insulin dosage changed to two or
three times a day. Abundant fluid intake
should be encouraged until the patient is en-
tirely normal.
The results of the management should be
checked by frequent urine and blood exam-
inations, in order to avoid hypoglycemia on
the one hand and a return to acidosis on the
other, and diet and insulin dosage need to be
adjusted accordingly.
All infections, whether general or local,
jireatly predispose to acidosis and coma. In
the acute specific infectious diseases, or non-
specific infections of the respiratory tract — •
as tonsillitis, bronchitis or pneumonia — any
rational treatment is applicable without con-
flict, provided emesis and purgation are
avoided: these result in dehydration and rel-
ative starvation, either of which is dangerous
in diabetes.
Rest in bed is imperative and adequate
sleep essential. The diet should be equal to
the basic caloric requirement of the patient —
around carbohydrates 75, proteins 50, fats
90 — and may be given either in liquid, sort
or solid form as desired.
Fluid should be given freely; the total
amount of urine examined quantitatively for
sugar every day, and, whether or not the pa-
tient has received insulin previously, a suffi-
c'ent dosage of this should be given to main-
tain the blood sugar within normal limits.
The bowels should be moved daily with an
enema or mild laxative.
Conditions requiring surgical treatment are
i)cst considered as emergency procedures and
"jierations of election. In cases demanding
immediate surgical treatment the lluid should
be administered at the earliest moment and
an initial dose of insulin given. .\s an anes-
thetic, ethylene gas is to be preferred to ether,
ai'd, on rplurn of ilic |)alicnl from Ihe oper-
ating room, the aki\e described measures for
acidosis should be adopted promptly.
In operations of election, such as thyroid-
ectomy or cataract operation, where several
days may be available for preparation, the
patient can and should be brought to a con-
dition of carbohydrate equilibrium — where the
diet is sufficient for the basis requirement,
the blood sugar is kept within normal level,
and the urine free of sugar — by the neces-
sary dosage of insulin.
Fasting and dehydration should be abso-
lutely prohibited. Either of these is exceed-
ingly dangerous and may bring to disastrous
termination a case that might have been most
creditably successful.
On the morning of the operation the pa-
tient should receive a liquid breakfast con-
taining the total amount of dextrose usually
given at that meal, with the usual dose of
insulin. Two hours later the operation may
be Iiegun.
As a general anesthetic, ethylene is to be
preferred, while spina' or local anesthesia may
be used in suitable cases; but local anesthe-
sia should not be used in any operation on
the extremities because of the great tendency
to sloughage in the diabetic, which is mark-
edly iiicreased by any tension of the tissues.
On return from the operating room the pa-
tient should receive orange juice or sweetened
tea as soon as anything can be taken by
mouth. This may be given easily within two
hours, and the previously used dosage of in-
sulin continued. If shock comes on, normal
saline solution by hypodermoclysis must be
given. A blood sugar test and carbon dioxide
combining power determination should be
made just before operation and another soon
afterward.
In the presence of carbuncles or infected
gangrenous extremities, the same preparation
as that used in operations of election is de-
sirable; but this is not always possible in the
same degree, for the reason that infection
•^epms to inhibit or partially interfere with
the action of the insulin. In the race be-
tween the unfavorable progress of the infec-
tion and the control of acidosis the infection
may win if one waits too long. However, if
the patient is fed and insulin given, acidosis
can usually be avoided.
In such instances it is safer to proceed with
siiri,'cry as in cnurgcncy operations and,
ciilier by excision oi .unputaticn, to remove
the focus of infection. This usually converts
SOUTHERN MEDICINE AND SURGERY
January, 1929
a septic into an aseptic case, or, at least
greatly reduces the toxic absorption, and re-
sults in a great reduction of the tendency to
acidosis. The patient's tolerance is increased
and smaller doses of insulin become effective.
SUMM.ARY
1. Acidosis and coma are dangerously in-
sidious in onset.
2. Infection, fasting, purgation and dehy-
dration greatly predispose to acidosis.
3. In any and all surgical procedures —
whether a cataract operation, laparotomy, or
amputation — diabetes must be managed accu-
rately both before and immediately after the
operation. This requires real co-operation
between the surgeon and the physician.
4. Blood sugar determinations before an
operation are more important than a wasser-
mann test. Urine tests alone are inadequate.
5. The present very high mortality rate in
surgical operations on the diabetic is due to
(a) delay in treating infection, (b) opera-
tions on previously undiagnosed diabetes, and
(c) the bad effect of fasting, purgation and
dehydration.
6. Early consultation and prompt collabor-
ation between the surgeon and the physician
will do much to safeguard the patient from
needless disaster.
January, 1929
SOUTHERN MEDICINE AND SURGERY
The Therapy of Amebiasis, With Report of Cases''
A. B. Hodges, M.D., Norfolk, \'a.
St. Christopher's Clinic
It is not the purpose of this paper to deal
with the entire subject of amebiasis, but it
does seem wise to review briefly certain lea-
tuies of the disease, especially those which
have a definite bearing on therapy.
Until the past decade the disease was
thought to occur principally in tropical and
subtropical countries, and it was regarded as
an index of the sanitary intelligence of a com-
munity; but an increasing number of publi-
cations are reporting many cases in the tem-
porate zones, and in individuals who have not
been in tropical regions and who have been
dwelling under modern sanitary conditions.
One reason why the condition has not been
recognized more often is the difficulty of
finding the amoebae and of distinguishing the
entamocbae histolytica from the other amoe-
bae which sometimes inhabit the intestinal
canal. Then, too, we have recently learned
that the disease e.xists in a fairly large num-
ber of persons without at any time producing
acute manifestations. In these cases it is
extremely difficult to demonstrate the amoe-
bae, motile or encysted.
GROUPS THE MILD, THE ACUTE AND THE
CHRONIC
In the niHd form the onset is gradual.
There may be lassitude, abdominal discom-
fort and slight diarrhea, or no symptoms may
be present. However, there are usually two
or three stools a day. .\ few amoebae may be
found or only cysts be present in the stools.
Acute amebic dysentery is familiar to
everyone and needs no comment.
The chronic form may be acute or sub-
acute in the beginning, and gradually pass
into the chronic stage. It is characterized
by alternating periods of diarrhea and con-
stipation. During the diarrhea there is ab-
dominal pain and the passage of mucus and
blood. The patient may lose weight: but
the emaciation is not extreme, and the gen-
eral health not greatly impaired. This form
is often very resistant to treatment.
The principal drugs now used in the treat-
ment of amebiasis are emetine, yatren, sto-
•Prcsented to the Seaboard Medical .Association,
Washington, N. C, December 6, 1928.
\arsol and treparsol (arsenicals), and aura-
mine, a coal tar derivative.
Emetine is J.he oldest of this group, having
been introduced in 1912. Its very prompt
act on on the acute manifestations of the dis-
ease is familiar to everyone, but a permanent
cure is rarely obtained by the doses com-
monly used. Employing very large doses the
p.'rcentage of permanent cures reported varies
from 28 to 70. The hydrochloride is the
form in which the alkaloid is generally used,
ar.d is given subcutaneously or intramuscu-
larh'. As the intramuscular injections pro-
duce less local irritation than the subcutane-
ous, the former is the preferable route of ad-
ministration. Some physicians have combin-
ed emetine injections with emetine periodide
and emetol per rectum: we have had no ex-
perience with these drugs. Emetine is a pro-
toplasmic poison and the efficient therapeutic
dose approaches closely the toxic dose. The
symptoms of intoxication are general weak-
ness and neuritis. Death occurs usually from
heart failure. Some physicians have used as
much as 12 grains by injection and 6 grains
by mouth over a period of 12 days, and oth-
ers, 10 grains by injection and 60 grains of
emetine bismuth iodide by mouth over a pe-
riod of 10 days. We, however, are more con-
servative and give 4 grains intramuscularly
o\er a period of 6 days, and repeat at weekly
intervals. The danger of emetine poisoning
certainly forms a serious obstacle to its pro-
longed use.
Yatren is a product of the German chemi-
cal industry, and was first used by Muehlens
in the treatment of amebiasis in 1925. It
contains iodine, oxychinoline, sodium sulpho-
iiate and sodium bicarbonate, and is a \'cIlow-
ish, tasteless powder, light and easily dis-
M.lved in warm water up to S per cent. It
does not disintegrate with heat until a tem-
perature of 22:^ degrees C. is reached, or until
boiled for 15 minutes, when it becomes toxic.
Its toxicity for mammals is very slight, its
lethal dose for mice and rats is 0.6 gram per
kilogram body weight. Its mode of action
in amei)iasis is difficult to understand, for in
spite of its bactericidal properties, its amebi-
cidal potency in vitro is low. It probably
SOUTHERN MEDICINE AND SURGERY
Januafy, 1920
acts — as is true of a number of other drugs^
through cell stimulation.
The drug is given by mouth and by ene-
mata. By mouth it frequently causes slight
diarrhea, with three to five yellowish stools
a day. Its daily use by enemata is irritating
and most workers use the drug alternately
p)er OS and per rectum. Our method of em-
ploying the drug is as follows: The patient
is put to bed for the first seven days, and at
least a half day on the 10th, 14th and 21st
days of treatment. On the 1st, 3rd, 5th and
7th days, O.S gram capsules six times a day
are given. On the 2nd, 4th, 6th, 10th, 14th
and 21st days, yatren as follows: First a
cleansing enema is given at a temperature as
near 40 degrees C. as the patient will stand.
This is followed by 3 grams of yatren in 200
c.c. of distilled water by rectum. The yatren
is dissolved at 80 degrees C. and the solution
given at approximately 30 degrees C. This
should be retained until completely absorbed.
Because of the recognized advantage of a
bland diet in the treatment of amebiasis, we
give our patients a diet consisting largely of
milk, soft cereals, purees of vegetables, and
clear soups for the first week. Later scraped
beef is allowed, and after the second week a
regular diet.
\'ery spectacular effects have been reported
in the old chronic cases which have previously
resisted all forms of treatment. In the Pe-
kin Union INIedical College Hospital, out of
88 patients followed for a period from three
to six months, with 3 to 6 stool examinations,
79 remained free from symptoms and cysts.
Because yatren is a little irritating when
given per rectum, and because its oral ad-
ministration causes slight diarrhea, it has
seemed to some workers wise to employ eme-
tine during the stage of active diarrhea and
yatren after the diarrhea has been controlled.
This has been the method we have adopted,
and certainly it seems justified in view of the
marked and rapid control of the acute mani-
festations which emetine exerts.
There is one very great advantage of yat-
ren over the other drugs commonly employ-
ed. When given by mouth and per rectum
in the doses previously mentioned it is non-
toxic. There is, however, one disadvantage.
It is a proprietary drug.
Yatren is sold in this country under the
name anayodin by Ernst Bischoff Company,
Inc., of New York, and is marketed in 25
gram bottles.
We have had no experience with the other
drugs which have been mentioned, so I shall
deal with them very briefly.
Stovarsol is a pentavalent arsenical com-
pound. It was first used in amebiasis by
iNIarchoux in 1923 with very good results.
The percentage of cures, however, does not
seem to be any greater than that of yatren,
and the drug has the disadvantage of being
more toxic.
Treparsol is also a pentavalent arsenical
compound and contains a little more arsenic
than stovarsol. It seems to be about as effi-
cacious as stovarsol, but like it is toxic at
times.
Auramine is an aniline dye. It has been
used in its pure state and also in combina-
tion with emetine as auremetine. Sufficient
data are not at hand from which conclusions
can be drawn.
I shall now present briefly the records of
three cases in which yatren has been used.
Case No. 1. — White man, aged 27. Dur-
ing the summer of 1922, while on vacation
in Currituck county, N. C, he was seized
with abdominal pain and diarrhea. A few
hours later tenesmus began, and twenty-four
hours later mucus, pus and blood appeared
in the stools. For two years there were fre-
quent attacks of diarrhea with intervening
free periods. In August, 1924, two years
after the onset, he came to the St. Christo-
pher's clinic. Entamoeba histolytica was found
in the stools, and emetine hydrochloride given
intramuscularly over a period of four weeks.
The diarrhea ceased after the third day and
he began to gain in weight. Symptoms were
absent for eight months when the diarrhea
returned.
He was treated irregularly with emetine
by another physician until November, 1927,
a period of two and one-half years. During
this time there were frequent attacks of
diarrhea which were always controlled by
emetine but returned shortly after the drug
was stopped. When he consulted us the sec-
ond time he was having six to eight watery
stools a day and amoebae were easily found.
Four grains of emetine were given intramus-
cularly over a period of six days, followed
by a course of yatren. Diarrhea ceased on
the third day of emetine administration, and
January, 1929
SOtJtttEftM MEDtettCfi AfCt) StJRGEfeY
»
has not returned, a period of one year. The
patient has gained fifteen pounds and is feel-
ing very well. No active amoebae or cysts
have been found in the stools.
This case illustrates several important
points, namely, the prompt action of emetine
on the acute symptoms, the failure of eme-
tine to cure the disease in many cases, and
the danger of concluding that the disease has
been cured even after a latent period of eight
months' duration.
Case No. 2. — White man, first seen by us
July 25, 1927. His illness began acutely,
thirteen months before, with abdominal pain
and the passage of fifteen to twenty stools a
day. These were watery and mucus and blood
were present. The diarrhea continued, but
with less severity, for several weeks, then dis-
appeared, only to return in about two weeks.
Then for a period of thirteen months he had
many attacks of diarrhea and lost about 25
pounds. Motile entamoehae histolytica were
readily found in the stools and emetine in-
tramuscularly was started. The diarrhea
ceased after four injections and he received
three courses of emetine at weekly intervals.
The patient remained free from symptoms
for one month after the treatment was dis-
continued, at which time the diarrhea re-
turned, and active amoebae were again pres-
ent in the stools. One-half grain of emetine
daily for three days was given, the diarrhea
ceased, and he was sent into the hospital for
a course of yatren. He left the hospital in
November, 1927, and since then has been
quite well and has regained the weight lost.
Case No. 3. — White man, aged 45, came
into our clinic on February 12, 1927, with
this history. For about two weeks he had
been suffering from slight diarrhea. At times
the stools were watery and as frequent as
four a day, at other times they were semi-
formed and only twice a day. The onset was
gradual, and at no time had there been ab-
dominal pain or mucus, pus, or blood in the
stools. The patient felt quite well and had
lost no weight, and only consulted a physician
because he realized that the frequent defeca-
tion was abnormal for him.
The physical examination was essentially
negative. The stools were carefully exam-
ined but amoebae were not found. He was
given some of the customary drugs for diar-
rhea but he continued to have from two to
three soft stools a day.
In July, 1927, following strenuous exercise,
he had a chill followed by fever. The tem-
perature reached 101 degrees F. The bowel
movements Increased from two to eight a day,
were watery, associated with tenesmus, and
mucus with blood was passed. This lasted
for two or three days and subsided. A phy-
sician was not consulted during this acute ex-
acerbation. One month later he was again
seen by us and a careful search for amoebae
made, but none were found.
Because of the history, which was charac-
teristic of amebic dysentery, he was given a
course of emetine hydrochloride. By the third
day the diarrhea had ceased. Three similar
courses were given at weekly intervals, then
the drug was given only once a week. One
month after the last course of emetine, and
while the patient was getting one grain of
emetine each week, the diarrhea returned. He
was given again one course of emetine and
the diarrhea ceased after two injections. The
last injection was on October 31, 192 7, and
the patient was well until January, 1928.
On January 5, 1928, the patient developed
acute appendicitis and the following day an
appendectomy was done. Six days after the
operation diarrhea returned and he had from
s.x to eight movements a day with abdominal
discomfort and tenesmus.
One course of emetine was given and the
diarrhea ceased after the fifth injection. A
course of yatren was started on January 20th.
He remained free from diarrhea for about
one month when the old symptoms returned
and emetine was again given with immediate
relief which lasted only three weeks. Because
amoebae could not be found in the stools the
patient was referred to Dr. Louis Hamman,
of Baltimore, who placed him in the Johns
Hopk;ns Hospital for study. Dr. Bauer, of
the School of Hygiene and Public Health,
foui.d the cysts of entamoeba histolytica and
confirmed the diagnosis. On discharge from
the hospital Dr. Hamman suggested that
yatren be tried again. Because it was not
convenient at that time for the patient to
enter the hospital, one course of emetine was
g.ven. The diarrhea ceased as befort, and
much to our surprise has not returned. The
patient has been free from all symptoms, eats
everything that he likes, and has taken no
drugs for nearly eight months.
SOUTHERN MEDICINE AND SURGERY
January, 1920
This patient was ni>t cured by one course
of yatren, and may not be cured at the pres-
ent time, for only eight months have elapsed
since the cessation of symptoms. Neither the
cysts nor the motile forms of amoebae can be
found in the stools. If the disease should
again manifest itself, we expect to give him
another course of vatren.
In concluding, then, I would like to direct
your attention to the usefulness of yatren in
the treatment of amebiasis, especially when
combined with emetine. From the literature
it appears that the results have been as satis-
factory, if not more, than the results ob-
tained with the other drugs, and it has the
advantage of being non-to.\ic.
January, IQ^"
S6tJTiiER>J MEbtCiNE ANi) StJkGERV
Mucous Membrane Cysts of the Maxillary Sinus
Prescittrd m a llicui l(
J. P. Matheson, JM.D., Charlotte, X. C.
- (idmission lo the American Lttryiif^oUii^ii-a', Otnloi^icn! nnd RJiiiiologiciif
Sociel V
The authors of some text books mention
briefly the subject of mucous membrane cysts
of the maxillary sinus, but it is certain that
many rhinologists are too ready to dismiss
patients as having no sinus disease, who com-
plain of vague headaches and neuralgia-like
pains and in whom the nasal examination
shows no pathology and transillumination is
clear.
It is not the ])urpose of this paper to deal
with purulent antrum infections nor the usual
polypoid changes of the mucosa, but rather
to present the problem of diagnosis and
method of dealing with the relatively infre-
quent condition of cysts in the maxillary
sinus.
INCIDENCE
The infrequency of this type of disease has
been shown in that only eight cases have been
discovered in the examination and x-ray of the
sinuses of approximately 1100 patients. The
usual method of nasal examination before and
after shrinking with cocaine and adrenalin,
and even after nasopharyngoscopic examina-
tion, failed to give any evidence of the pres-
ence of these cysts. Xo ethmoid involvement
was perceptible. Transillumination of all the
sinuses in everj' instance was clear. No den-
tal pathology was demonstrable.
SYMPTOMS
None of these patients gave a clear-cut and
defmite history that would suggest nasal
pathology to an examiner, and particularly
after a routine office examination had been
entirely negative, the first impression was
that of neurasthenia, or that the patient falls
into that large class of people with unex-
plained neuralgias and headaches.
One complaint which was common to all
was, as the patients expressed it, that of
headache, On closer questioning and inves-
tigation it was found that it was not exactly
a headache, but rather a dull pain and feel-
ing of pressure in the upper half of one side
of the face. This pain was rather vaguely
located "around the eye" and "in tlie cheek."
One patient complained of attacks of sneez-
ing when in drafts or when exposed to sud-
den temperature change. Nothing was found
in her examination suggesting an allergic
condition or sinus disease.
All of these patients had had previous
medical examination with negative findings.
The eyes had been refracted by a competent
ophthalmologist. Three of them had had
teeth removed as a possible cause of these
headaches and two of them had had tonsil-
lectomies.
EXAMINATION
As stated before, routine office examina-
tion was entirely negative as pointing to any
sinus pathology. Xo secretion could be found
in the nose, and the mucous membrane was
normal in every respect. Transillumination
in every instance was remarkably clear.
While in most instances too much reliance
on any one laboratory method or examination
is to be condemned, with this type of path-
ology, dependence must be placed in the
x-ray. A clear-cut rounded shadow of the
cyst was seen in all of these cases. Even
after a tentative diagnosis had been estab-
lished by x-ray, puncture of the antrum and
irrigation gave no further information, except
in one instance where about two drams of
clear straw-colored fluid flowed out of the
trocar on withdrawal of the stylet. Relying
upon the x-ray, these patients were operated
on, the Caldwell-Luc operation being done,
and the cysts were found corresponding ex-
actly to the location shown in the x-ray.
Contrary to the usual experience with polyps
and mucous membrane lesions, only one of
these cysts was attached near the ostium and
only one showed a definitely constricted base
or pedicle, the others having a wide flat base
or attachment and perhaps could more accu-
rately be called blebs than cysts. The loca-
tion of the attachment varied considerably,
three of them presenting on the external or
outer wall of the septum.
PATHOI.OCV
The walls of these cysts were extremely
thin and the fluid within varied in color and
10
SOUTMEftN MEfilCtUe AKt) StmCEftV
Januar 1029
somewhat in consistency, but always was
glairy in character. The contents of three
of these cysts to all macroscopic appearances
was creamy yellow pus. However, smears
taken directly at the time of operation show-
ed no bacteria present. Cultures were neg-
ative with one exception, which proved to be
a gram-negative, typical Bacillus influenzae,
The microscopical examination of tissue from
two cysts showed merely a thin layer of sub-
mucosal tissue covered by cuboidal epithe-
lium. The submucosal tissue showed many
cholesterin clefts. These cysts were unilat-
eral in every instance and in only two antra
were more than one cyst found. According
to Hajek (Nasal Accessory Sinuses, V'olume
1, Page 178), these cysts may be formed
from a cicatricial narrowing of the gland out-
let and are probably due to an old inflamma-
tory lesion. At operation the remaining mu-
cous membrane, other than that directly cov-
ering the cyst or cysts, gave no macroscopic
evidence of pathological, change.
The pain, following the distribution of the
fifth nerve, can be most likely accounted for
by pressure of the cyst within the antrum
cavity. The location of most of the cysts
on the outer antral wall near the infraorbital
foramen makes this view easily acceptable.
The sneezing complained of by one of the
patients was of course a reflex manifestation.
DIFFERENTIAL DIAGNOSIS
Occasionally solitary cysts are encountered
in x-ray examination of patients with foreign
protein sensitization. However, these can be
usually classified by means of skin tests and
characteristic appearance of nasal mucosa;
and certainly they show a different micro-
scopical pathology in that there is an abund-
ance of eosinophiles in all the allergic cases.
In one instance the x-ray showed what
seemed to be a large cyst attached to the
sufjerior wall of the antrum and a smaller
cyst on the floor. At operation the small
cyst was found on the floor, but the larger
shadow had been caused by a rounded mass
of orbital fat coming through a bony dehis-
cence in the roof of the antrum. Further
questioning revealed that there had been an
injury several years before to this cheek pro-
duced by a fall.
Relief Following Cocainization of Meckel's
Ganglion. — It is of interest to note that in
two of these patients temporary relief (last-
ing from two to five days) was obtained by
cocainization of the spheno-palatine ganglion.
Thus it would seem advisable to have routine
sinus x-rays in all cases of spheno-palatine
ganglion irritation, even though to all clinical
appearances the sinuses are negative.
RESULTS AFTER OPERATION
The usual Caldwell-Luc operation was done
in every instance with removal of the cyst,
and, with but one exception, these patients
were relieved by operation. This patient
was a woman to whom operation and removal
of a large maxillary sinus cyst gave no relief
from the headaches and neuralgia-like pains
over the face. She had had a previous pan-
hysterectomy, and most likely the aches and
pains from which she still suffers are due to
endocrine gland deficiency, and were not due
to the antrum pathology present. {See pho-
tograph patient J. E. S.)
SUGGESTIONS AS TO FURTHER STUDY
As a further clinical aid it has been kept
in mind that the use of iodized oil (as rec-
ommended by Proetz, of St. Louis), might
be used in doubtful cases, although the usual
x-ray technique used by the hospital roent-
genologist has so far demonstrated these cysts
very clearly without other aid.
Further microscopical study is being car-
ried out. This may at sometime show why
some of these cysts cause the various symp-
toms complained of, and may give further
interesting evidence as to their etiology.
CONCLUSIONS
1. Translucent mucous membrane cysts of
the antra must be considered as a possible
diagnosis, even though nasal examination is
negative, in cases of unexplained headache
and neuralgia-like pains.
2. With this pathology present, x-ray is
the only accurate means of diagnosis.
3. Relief can be obtained in most instances
by the usual Caldwell-Luc operation and re-
moval of the cyst.
Case Reports
1. C. E. R. Man, aged 50.
History: Complained for the last six
months of increasing drowsiness, occasional
severe generalized headaches, and constant
pain under the right eye. There has been
inability to concentrate. There was an en-
tirely negative history of nasal trouble.
Examination: Mucous membrane in the
Jam -cy, 19:20
SOUTHERN MEmCINE ANt) SURGERY
nose normal in appearance. Septum not de-
viated. Xasopharyngo'scopic examination neg-
ative. Transillumination of all sinuses very
clear. The x-ray showed a large cyst almost
completely filling the right antrum. (See
photograph oj x-ray Xo. 1). After the x-ray
had shown the presence of a cyst, puncture
of the antrum was followed by the drainage
of two drams of clear straw colored fluid.
Caldwell-Luc operation was done and a large
thin walled cyst, approximately one inch in
diameter, was removed intact. (See photo-
graph oj cyst Xo. 1). This was attached
near the ostium. The rest of the antrum
mucosa was normal in appearance. The pa-
tient made a rapid and uneventful recovery
and has been completely relieved of the
symptoms for 16 months following opera-
tion.
2. Al. A. B. Woman, aged 46.
History: Dull aching sensation in the
right side of the face and head for one year.
Some pain in the right eye. Xo history of
colds.
History of slight post-nasal discharge.
Examination: All teeth removed. Trans-
illumination of sinuses very clear. Previous
clean tonsillectomy. Slight deviation of the
septum. Xasopharyngoscopic examination
negative. X-ray report — Cyst in right an-
trum. (See photograph oj x-ray no. 2). Ir-
rigation of the right antrum negative.
Operation: Cyst found in the right an-
trum. Cultures from cyst content negative.
Xo recurrence of symptoms up to the present
time, six months after operation.
3. J. McG. Woman, aged 42.
History: Constant dull headaches and
aching sensation around the eyes and more
marked on the left for several years, worse
during the last six months. Xo nasal block-
ing or discharge. History of frequent slight
colds. Sneezing when in drafts or when ex-
posed to sudden temperature changes.
Case 3
Case S
Southern medicine and surgery
January, 1929
Examination: Septum irregular. Trans-
illumination of all sinuses clear. ]Mucous
membrane of the nose normal in appearance.
Nasopharyngoscopic examination negative.
X-ray report — Large cyst in the left antrum.
{See photograph oj x-ray no. 3). Irrigation
of the antra negative.
Operation: Large cyst three-quarters of an
inch in diameter found attached on the or-
bital wall of the left antrum. No recurrence
of symptoms up to the present time, 16
months after operation.
4. /. IF. :Man, aged 35.
History: Constant dull pain for the last
six months, radiating from the right cheek to
the top of the head. No history of colds. No
history of nasal discharge.
Examination: Teeth in good condition.
Chronically infected tonsils. Examination of
nasopharynx negative. Deviation of the sep-
tum to the left. Transillumination of all
sinuses very clear. Nasopharyngoscopic ex-
amination negative. X-ray report — Cyst in
right antrum. [See photograph oj x-ray no.
4).
5. J. E. S. Woman, aged 49.
History: History of severe dull generalized
headaches for about twenty years. These
headaches are more marked on the left side,
begin in the teeth, and radiate through the
cheek to the left eye and top of the head.
She had a panhysterectomy fifteen years ago.
No history of colds. No discharge from nose
or obstruction to breathing. Patient emo-
tional and very nervous.
Examination: Septum not deviated. JVIu-
cous membrane in the nose normal. All sinuses
transilluminate very clear. Nasopharyngo-
scopic examination negative. X-ray report
— Cyst in left antrum. {Sec photograph oj
x-ray no. 5). Irrigation of antrum negative.
Operation: Cyst found in the left antrum.
Cultures showed a gram-negative bacillus,
typical in morphology of Bacillus influenzae.
No relief after operation.
Januar>', 1929
SOUTHERN MEDICINE AND SURGERY
Some Instructive Fracture and Other Orthopedic Cases
J. S. Gaul, M.D., Charlotte, N. C.
In presenting this paper it is the intention
of the author to show the x-ray negatives of
these cases, to give a brief synopsis, and to
comment on each case or group of cases.
I. FRACTURES OF THE SKULL
The chief considerations in any fracture
of the skull are: presence or absence of intra-
cranial hemorrhage, the amount and particu-
lar damage to brain tissue, and the presence
or absence of intracranial pressure.
Massive hemorrhage, which is practically
always at the base, does not concern us, for
the diagnosis is plain, and the supervention
of death is sure and swift.
Hemorrhage about the vault has localizing
symptoms, and the slowly progressing char-
acter of the symptoms points to the nature
and location of the hemorrhage. There is
justification for operating in these cases, for
there is some hope of rendering a real service
to the patient.
In the greatest percentage of fatal cases of
skull fracture death results from intracranial
pressure. The increase in intracranial pres-
sure may be due to slow hemorrhage, but
more often to edema of the brain with con-
sequent swelling of the organ within an un-
yielding bo.\. Fortunately there are two
clinical observations available which clearly
indicate increased pressure, namely, the pulse
rate and the blood-pressure. We all appre-
ciate that stimulation of the vagus center and
of the blood pressure regulating mechanism
causes a slowing of the pulse and a rise in
blood-pressure.
It becomes the duty then to closely observe
at frequent intervals the pulse and blood-
pressure for the first two hours. It is better
to chart these observations on a regular pulse
chart. The two curves are clearly apart in
normal conditions, and, as there is a stimu-
lation of the mechanical control in the early
stages following cranial injuries, the curves
are even further apart than normal. As the
intracranial pressure increases, the paralysis
of these centers begins to take place and the
curves approach. It is a clinical observation
that when the curves have crossed in any
case, the prognosis is hopeless.
One of the most important contributions
to the treatment of these cases is the intra-
venous use of saturated magnesium sulphate
solution. Following Dowman, I have used
10 c.c. of a 10 per cent solution intravenously
every six hours or oftener, w-hile the patient
is unconscious, and an ounce of magnesium
sulphate by mouth once daily or oftener when
conscious. It is interesting to note that in
the administration by mouth the patient can
be given lemonade and broths without vio-
lent purging, whereas water will most cer-
tainU' produce numerous stools.
M
n
,CAsc« 1 ., ']Wr- %
^^^Httfe CAS e *^J^^f^
l^r'
14
SOUTHERN MEDICINE AND SURGERY
January, 192?
Case 1. — Admitted to the Charlotte Sana-
torium, December 27, 1927, in an uncon-
scious condition, with multiple linear frac-
tures of the vault and base, the result of an
automobile accident. She was bleeding from
both ears, from the external canthus of the
right eye and from the nose. No evidence
of paralysis. X-ray report says, "The lines
are so incerlaced and numerous that it is dif-
ficult to describe." Patient had a pulse rate
of 52 and systolic pressure of 110. Thirty
minutes later pulse rate was 90 and pressure
105. Two c.c. of 50 per cent magnesium sul-
phate given intravenously. Twenty minutes
later pulse was 76 and pressure 116. By use of
magnesium sulphate every four hours for
three doses, and then every six hours for two
days the pulse and pressure were maintained
at about these latter levels. Patient was
then given half-ounce saturated magnesium
sulphate each morning by mouth for the next
four days and then at irregular intervals.
She made full recovery without neurological
sequelae.
Case 2. — Admitted to Charlotte Sanato-
rium .\ugust 16, 1926, in extremely grave
condition with a compound fracture of right
frontal bone, fracture of the right zygoma,
right superior maxilla and the mandible. He
also had simple fracture in the lower third
of both bones of the right leg, and compound
fracture of the left fibula. Patient was un-
conscious, pulse 110, systolic pressure 116,
temperature 102. He was given 10 c.c. of
periods and two days later was mentally clear
all day for the first time and has remained
so since. The fractures of the jaw and legs
were reduced.
These two cases are reported because of
their severity. They would unquestionably
have gone to a fatal termination if
any surgery had been resorted to. While it
is true that decompression would have re-
lieved the intracranial pressure, the added
trauma from surgical intervention would have
unquestionaby produced death; and, to have
treated them expectantly, awaiting an inter-
val operation, would have permitted so much
increased intracranial pressure as to produce
paralysis of the vital centers. This techi-
nique permits us to take advantage of na-
ture's mechanism for the control of intra-
cranial hemorrhage, particularly from the
smaller vessels in the torn brain tissue, by
causing a swelling of the brain. The result-
ing compression against the vault adequately
controls the bleeding. The amount of swell-
ing is fairly well controlled by the salt action
for the first two days, when sufficient throm-
bosis has occurred in the involved vessels so
that as a result the hemorrhage is stopped
and the \'ital centers kept functioning.
INJURIES TO CERVICAL SPINE
Case i. — .Admitted to Good Samaritan
Hospital with complete motor and sensory
paralysis below the shoulder girdle as the
result of injury sustained when caught in an
elevator. X-rav revealed crushing fracture
10 per cent magnesium sulphate intravenously and partial dislocatimi (if the third and fourth
every six hours, maintaining the rate between cervical vertebrae. Under traction and ma-
80 and 100, and the systolic pressure in the nipulation through the mouth the lesion was
region of 115. On the fifth day patient was reduced with full return of function. .A
conscious for the first time for only short Calot jacket incorjiorating the head was ap-
January, 1929
SOUTHERN MEDICINE AND SURGERY
IS
plied, and remained on for six weeks. A
leather thomas collar was then applied and
worn for eight weeks. He has fully recov-
ered and returned to full duty.
Case 4. — Admitted to Charlotte Sanatorium
.Xuijust 9, 1926. as the result of manipulation
b\- a chiropractor done for the relief of pain
in the neck. Following the manipulation he
became completely paralyzed from the level
of the shoulders down. The history revealed
that he had been in an automobile accident,
was thrown on his neck and shoulders and
had sustained a crushing fracture of the body
of the tifth cervical vertebra. The chiroprac-
tic manipulation slipped the fifth forward on
the sixth and the laminae impinged the cord.
Under ether anesthesia, it was reduced by
traction and manipulation through the mouth
and a cast applied. The following day he
had recovered in the left upper extremity,
the bowels and the bladder. In two weeks
he had recovered all but the abduction of
the right arm. A special splint was made
incorporating airplane splint for arms and
jury-mast for head and neck. He had fully
recovered and returned to his work as a
brick mason.
Case 5. — Admitted to Good Samaritan
Hospital, June 20. 1928, completely paraU'zed
from shoulders down, the result of an auto
16
SOUTHERN MEDICINE AND SURGERY
January, 1929
accident. He sustained a fracture dislocation
of the third, fourth and fifth cervical verte-
brae with complete severance of the cord.
He died twenty-four hours later from paraly-
sis of the diaphragm. A laminectomy done
revealed a complete severance of the cord
with extensive hemorrhage, which probably
involved the second segment of the cord and
brought about paralysis of the phrenic nerves.
DORSAL SPINE
Case 6. — Girl, aged 15, onset of rachitis
began five years ago and progressed rapidly.
The vital capacity of the lungs' was reduced
t(.) 5.5 per cent. She had a marked exoph-
thalmus. Traction jackets with special turn
buckles have been applied. Patient is still
under treatment. The vital capacity of the
lungs as measured by respirometer shows 90
per cent at present time. The exophthalmus
has practically disappeared and the child has
increased three inches in height. When max-
imum benefit is reached she will be held in
special jacket until the age is reached where
the bony cage becomes fixed.
Case 1. — Family history of tuberculosis,
personal history of tuberculosis. Four years
ago patient injured dorsal spine in an auto
accident. Has noticed pain in back since.
One year ago pain became severe and spas-
January, 1929
SOUTHERN MEDICINE AND SURGERV
if
modic in character, radiating around left side
of chest. X-ray reveals active tuberculosis
of body of fourth and fifty dorsal vertebrae
with crushing taking place on left side.
Patient treated in recumbency and traction,
then plaster packets, and is now wearing a
special spine brace.
Case 8. — Patient has complained of pain
in lumbar region for a number of years, but
more particularly since the birth of a child
two years ago. She has had severe antrum
infection. This case has been interesting from
many standpoints. She has six lumbar ver-
tebrae, has a sacralization (A) left trans-
verse process of sixth lumbar. This has sug-
gested some sacro-iliac involvement and has
been treated as such in other clinics. The
x-ray shows an infectious arthritis in the
articular facets between the fifth and sixth
lumbar right side to which is added a trau-
matic element due to the sixth lumbar being
fixed with the sacralization, thus throwing the
flexion and extension at the fifth and sixth
articulation. Patient has been fitted with
special low back type brace and is entirely
free from pain.
Case 9. — This case shows metastatic carci-
noma of the spine from primary lesion in the
breast. She was kept comfortable the last
two years of her life by use of a spine brace
and x-ray therapy.
Case 10. — Congenital lesion of spina bifida
occulta which had been complicated by a
spondylolisthesis with slipping forward of the
first lumbar on the second, and the fifth on
the sacrum. This the result of direct trau-
ma. Patient had lost use of the lower ex-
tremities, bowels and bladder. .Xdmitted to
the Presbyterian Hospital June 8, 1028.
Traction applied to head and pelvis, spon-
dylollthsesis reduced and traction jacket ap-
plied. Following this the legs became spai;-
tic and there was spastic contracture of the
lx)wel and bladder. He had clonus, spastic
knee and achilles jerks, and ]3ositive ojipen-
heim reaction. Two weeks later spasticity
became lessened and reflexes assumed more
nearly normal reactions. Sensation has fully
returned, spasticity has disappeared; coordina-
tion is fair, but muscle sense poor. He is
wearing a special design of spine brace.
Case 11. — Patient gave history of jiain in
back for several years and weakness of the
legs on. straining at stool or after lifting.
He had lost the use of his lower extremities,
bowels and bladder for three months. Ad-
mitted to the Presbyterian Hospital February
2, 192 7, and a large fibroma measuring 2J/S
inches x 1 inch removed from the right half
of eighth, ninth and tenth dorsal. The cord
did not pulsate below this level until after
removal of the tumor. The tumor had eroded
completely through the spine. Patient recov-
ered use of bowels in two weeks and some
use of the bladder. The legs were very spas-
tic, particularly the adductor and hamstring
groups. Three months later Stoeffel neurec-
tomies on the sciatic branches to the ham-
strings and^.of the superficial and deep ob-
turators relieved the spasticity and patient
now walks unassisted, with very good gait
and has full function of the bowels and blad-
der.
" Ciisc 12. — \\'hite woman, aged 64. De-
cember 9, 1925, patient attempted to hold a
wheelbarrow firmly on the ground while a
man loaded a ttee on to it. It suddenly over-
turned. She felt something give way on the
right side of the lumbar spine and appeared
for treatment completely flexed to right side.
X-ray revealed fracture of articular facet
right side fourth lumbar vertebra. Traction
used and cast applied at St. Peter's Hospital.
Patient has made full recovery with a flexible
spine and free from pain.
Case 13. — Introduced to show a crushing
fracture of the seventh dorsal vertebra. This
fracture was unrecognized at time of injury
at Tulsa, Oklahoma, in September, 1926. It
illustrates necessity of x-ray examination in
all injuries to the spine.
Case 14. — Introduced to show an unusual
perpendicular fracture through a wing of the
ilium.
Cases IS and 16. — .Admitted to the Char-
lotte Sanatorium November IS, 1927, with
fracture of pelvis and scapula. Made good
recovery. Note from Herr \l. Wolf of Liez-
am-Rhein, March 12, 1928, states that the
patient has good function of shoulder and
without complaint in pelvis.
Case 17. — Calcifying olecranon bursa the
result of trauma December 20, 1927. Patient
had pain along the course of the ulnar nerve
and muscular weaknses in fourth and fifth
fingers, .\dmitted to the Charlotte Sanato-
rium March 7, 1928, and bursa removed.
SOUTHERN MEDICINE AND SURGERY
January, 1929
April 17, 1928, patient had resumed his work
as a carpenter.
Case 18. — Case shown because of the un-
usual stripping of the periosteum in a dis-
location of the elbow. She also had a frac-
ture through the head of the radius. Ad-
mitted to St. Peters Hospital, September 25,
1928, for treatment. Dismissed to home in
Birmingham, .-Ma., October 10, 1928, and re-
ferred to Dr. E. L. Scott who, in note Octo-
ber 18, 1928, says "My personal feelings are
that you have obtained an extremely good
re&ult in an adult dislocation of the elbow
and with the exception of a little difficulty
in supination and pronation the joint and its
motions are good."
.Cases 19 and 20. — Illustrate periosteal
tears in a disldcateti elbow joint.
HIP JOINT
Numerous conditions occur about the hip
joint which are often difficult to recognize.
The diagnosis is not easy and the treatment
»ft^ difficult to decide upon.
Case 21. — ;Uiu£trates a severe ncn-suppur-
ative osteomyelitis in region of the great
trochanter and neck. Patient had a tempera-
ture ranging from 103 to 104.5 for a period
of two weeks. The hip was tender and
guarded. Cast was applied and remained on
one month. Patient has fully recovered with
full function of the hip.
Case 22. — .Admitted to Presbyterian Hos-
pital, arthrotomy done, drainage down to
joint capsule and traction ap])lied. While
there has been some destruction and distor-
tion of the head, patient has recovered with
fair function in the hip.
Case 23. — Illustrates Legg-Perthe's disease
with flattening of the head and thickening of
the neck of the femur. There was no tem-
perature, but a persistent limp. Patient has
10— MEDICAL—
fully recovered with limited ahduclion but
with good flexion and extension.
Case 24. — Patient noted a limp in left hip
one year ago. In April, 1928, she made a
misstep and experienced pain and the limp
increased. She noticed the leg gelling shorter.
jX.-ray revealed a coxa vara with tJie head slip-
^nmmn-, 1029
SOWttERN MEmctMft km SttftGERY
II
ping on the neck. Admilled {n the Charlotte
Sanatorium July 7, 192.S, and the leg manip-
ulated, carrying it into extreme abduction to
force the neck to rotate on the head. Cast
applied. Patient is free from pain and there
is no difference in the length of the e.xtremi-
ties: She walks without a lim[). Cast still
protecting.
Case 25. — Admitted to the .Miny H(is]>ital
August 20, 1928, referred by Dr. .Mcknight,
with acute tuberculosis of the left hip joint.
.A wilson fusion of the joint was done turn-
ing graft down from the wing of the ilium.
X-ray October 30, 1928, states "There is
callus at both ends of graft and ankylosis is
taking place."
JO
SOUTHERN MEDICINE AND SURGERY
JatlUa^', 1920
Case 26. — Illustrates interesting Brodie's
abscess in region of epiphyseal lime of femur.
Patient complained of pain and swelling of
knee joint. Treated conservatively with ex-
cellent result. The swelling of joint with an
abscess so near it in the cortex of femur in-
vited the supposition that it had probably
ruptured into the capsule of the joint.
Case 27. — Shows a fracture of the anterior
tibial spine as a result of avulsion of the joint
due to accident. Treated conservatively with
good function of the joint, no pain, and with
but slight abnormal lateral mobility, but not
has 85 degrees flexion and a stabile joint,
free from pain, walks without limp and with-
out assistance of any kind.
Case 29. — Patient for past year has com-
plained of pain in right foot in region of sec-
ond metatarsal and has been unable to walk
because of pain. X-ray shows a simple cyst
in the shaft of second metatarsal. July 11,
1928, admitted to Presbyterian Hospital and
cyst and distal half of metatarsal removed.
:\Ietatarsal bar supplied for the shoe. Re-
covery good.
Case 30.— November 21, 192 7, admitted to
CASE. *29
CASE # 30
sufficient to be disabling.
Case 28.— December 26, 1927, patient sus-
tained a severe compound fracture of femur
entering the knee joint. The resulting scars
completely bound down the quadriceps ten-
don so that flexion of the joint was not per-
mitted. September 5, 1928, admitted to
Charlotte Sanatorium and a bennett opera-
tion done on the quadriceps tendon. Patient
Charlotte Sanatorium with numerous fractures
sustained when a huge steel plate fell on him.
The case is shown because of the rare crush-
ing fracture of the astragalus without injury
to the other bones of the foot. Patient made
good recovery.
Case 31. — Patient complained bitterly of
pain on plantar surface of heel, and on dor-
sum of the left foot. X-ray revealed an ex-
January, 1020
SOOTMEftN MEWCtNE AMt» StftGERV
.^1
osto?:s of internal cuneiform and first meta-
tarsal and a spur on os calsis. Admitted to
Charlotte Sanatorium July 14, 1928. The
exostosis of metatarso-tarsal joint was re-
moved and this joint fused. The spur was
removed through lateral incision turning down
the sole. Patient has returned to her teach-
ing duties free from pain.
RuPTURKD Duodenal Ulcer With Symp-
toms Simulating Ruptured Tubal
Pregnancy
R. B. Mcknight, M.D., charlotte
The patient was a young white woman
nineteen years of age. The evening of Octo-
ber 31st she had joined the masqueraders
down town celebrating Hallowe'en. She took
a drink of liquor and was thoroughly enjoy-
ing herself when she was seized with sudden
excruciating pains in the lower abdomen ac-
companied by a moderate amount of nausea,
but no vomiting. These pains soon became
more localized in the right lower quadrant,
although she felt some distress in the entire
abdomen. I saw her about half an hour
after the onset of her trouble. She could not
lie still so severe was her pain, but rolled and
tossed with the thighs flexed. She said that
she had had some dyspeptic symptoms but
was somewhat relieved following an operation
about eighteen months ago when her appen-
dix and left tube and ovary had been remov-
ed. -About two weeks previously she had had
a little nausea and had vomited once or twice.
She did not recall the exact date of her last
menstrual period.
Examination revealed a young girl of about
nineteen years of age in obvious pain. The
right lower abdomen was board-like in hard-
ness and exquisitely tender. There was some
generalizetl abdominal tenderness, but nothing
like as severe as in the right lower quadrant.
She would cr_\- out with pain when the pal-
pating hand barely touched the right lower
region of the abdomen. Pelvic examination
revealed a two-finger vagina; marked tender-
ness in the right fornix and definite fluctua-
tion in this region and in the cul-de-sac.
Blood count was normal with the exception
of 20,000 white cells. The urine showed a
faint trace of albumin. Blood-pressure was
110 74, pulse 120 and temperature 99.0. I
made a diagnosis of ruptured tubal pregnancy
and advised immediate exploration.
Operation was performed under spinal
anesthesia. Incision from a point about one
inch to the right of the umbilicus extending
downward four inches. On opening the peri-
toneum there was a slight odor. The abdo-
men was filled with a thin yellowish white
material. The pelvis was thoroughly explor-
ed and a large cystic ovary which completely
collapsed when punctured, was removed. The
left ovary and tube had been removed at a
previous operation. The appendix stump
was normal. She was given a few whiffs of
ether and the incision extended upward. A
perforated duodenal ulcer about an inch from
the pylorus was found. This was excised
with a cautery and a duodenoplasty done.
The abdomen was cleansed as thoroughly as
possible, one penrose drain placed and the
usual closure made.
Convalesence was entirely normal. She
left the hospital the twentieth day after opera-
tion with the woimd healed. She has been on
a routine modified ulcer diet and has had no
gastro-intestinal disturijances since operation.
SOUTHERN MEDtClNE ANt) SURGERY
January, 1929
Agranulocytic Angina — Further Case Report
O. O. AsHWOETH, M.D., Richmond, Va.
and
E. A. HiNES, JR., INI.D., Richmond, Va.
From the Medical Department of St. Elizabeth's Hospital
Schultz in 1922 reported a group of cases
with severe gangrenous stomatitis and unusual
blood picture occurring in the middle age
with negative past history. Because of the
absence of the granulocytic blood cells, he
attached the name "agranulocytic angina."
On examination of the blood in the cases
which he reported, the red blood cells, hemo-
globin and blood platelets were normal. The
white blood cells were greatly reduced in
number and on differential count the poly-
morphonuclear leucocytes were decreased or
absent. Following this initial report, similar
cases were reported by other German writers.
In 1924, Lovett was accredited with report-
ing the first case in the United States. Since
Lovett's report, Skiles, Pelnar, Moore, Wie-
der. Lanter, Kastlin and others have reported
similar cases.
The fir.?t case which came under our obser-
vation was in 1926. Since that time we have
had two additional cases. A protocol of the
records in each case are as follows:
CASE 1. — A married woman, aged 32, was
admitted to St. Elizabeth's Hospital, Septem-
ber 18, 1926,
Past History: The patient had had a thor-
ough physical examination six weeks prior to
the present illness. Her chief complaints at
that time were nervousness, lack of endur-
ance, irritability and menorrhagia. The posi-
tive physical findings were pyorrhea alveo-
laris, evidence of right apical pulmonary fib-
rosis, retroversion of uterus with second de-
gree prolapse, chronic cystic cervicitis and
loss of weight. Laboratory examination show-
ed the following: Blood: hemoglobin, 60 per
cent; r. b. c. 4,000,000; w. b. c. 3,500; coag-
ulation time normal; wassermann negative.
Urine: 24 hour specimen normal. Stomach
contents showed a normal acidity, A gen-
eral program was outlined to improve the
patient's living conditions with especial at-
tention to rest and diet. Blaud's mass, gr.
X, t. i. d., p. c, and sodium cacodylate, gr,
V, q. 0. d., were prescribed for the anemia.
Luminal, gr. 3 j t. i. d., was given for nerv-
ousness. By this treatment, she improved
symptomatically and had gained six pounds
prior to onset of the present illness.
Present Illness: Two days prior to ad-
mission to the hospital, the patient had com-
plained of general lassitude, chilly sensations,
and generalized joint pains. The positive
findings from a complete physical examina-
tion at that time were as follows: Moderate
injection of posterior pharynx with tonsils
normal, slight fibrosis at right pulmonary
apex, pyorrhea alveolaris, and an appearance
of secondary anemia. The temperature was
101 degrees F., pulse 100, respirations 20, A
tentative diagnosis of influenza was made on
the basis of the acute symptoms, and the
usual treatment for the disease was instituted.
This consisted of rest in bed, forcing fluids,
small doses of salicylates and throat gargles.
The patient was seen on the following day
when her pulse, temperature and respiration
were essentially the same and there were no
additional symptoms.
Her pharynx showed more congestion with
considerable edema of the soft palate and
surrounding tissues. A dark grayish ulcer
was noticed on the left tonsil. The super-
ficial necrotic area could be wiped away, and
this was not followed by bleeding. At six
o'clock the following morning the patient was
seen for the third time. She appeared ex-
tremely toxic with a pinched expression about
the face. The skin and mucous membranes
were slightly cyanotic. The only additional
subjective symptom was intense pain in the
throat which was not relieved by oral admin-
istration of two grains of codeine sulphate.
The throat picture was essentially the same,
except that the edema seemed more marked
and an additional ulcer was on the opposite
tonsil.
On admission to the hospital six hours la-
ter, there was the same toxic appearance. The
features were drawn, the pupils dilated, and
the eyes seemed to protrude with an expres-
January, 1929
SOUTHERN MEDICINE AND SURGERY
had
23
sion of apprehensidn. The skin and mucous
surfaces were definitely cyanotic. There was
no icterus. Objectively, dyspnea was the
most marked sign present. A suggestive in-
spiratory crow was noted, but she could talk.
The throat showed still more generalized
hyperemia and edema, and the ulcers had
crown larger. The throat was so immobile
that she could not gargle. The temperature
was 103 degrees F., pulse 118 and slightly
irregular, and respirations were 36.
Laboratory examination showed: Blood;
hemoglobin 60 per cent; r. b. c. 4,000,000;
w. b. c. 160; differential count: large lympho-
cytes 40 per cent, small lymphocytes 25 per
cent; polymorphonuclears 22 per cent; tran-
sitionals 2 per cent, eosinophiles 2 per cent,
basophiles 3 per cent and myelocytes 5 per
cent. The report of the blood examination
was checked by two interns and the labora-
tory technician. .\ smear from the pharynx
and tonsils showed many spirochetes and
fusiform bacilli, rare long chain streptococci,
many staphylococci and many cocci occurring
in pairs. A culture was made for diphtheria,
which proved negative. Other cultures were
examined by the Virginia State Board of
Health and reported negative. The blood
wassermann was negative. Blood culture was
negative.
Throughout the day, the patient received
1,000 c.c. of normal saline by hypodermocly-
sis and was treated symjitomatically with
opiates, strophanthin, adrenalin chloride and
caffein sodio-benzoate. Forty thousand units
of diphtheria antitox-n were administered in
two doses. No anaphylaxis followed either
injection. Dyspnea became progressively
more marked, but at all times it was possible
for the patient to reply to questions distinct-
ly.
About 6:45 in the evening, muscle twitch-
ing began in the upper extremities and a little
later in the lower extremities. Respiration
became very difficult, shallower and slower,
and cyanosis more marked. Twenty minutes
later breathing ceased.
CASK 2. — A married woman, aged 45, ad-
mitted U> .St. Elizabeths Hospital on .\pril
12, 1928.
Past History: Patient gave a history of
having been treated at Saranac for pulmonary
tuberculosis ten years previously with subse-
quent quiescence of all symptoms. She had
thyroid gland removed fifteen years
ago. Since these instances, up to the present
illness, the patient had been in very good
health.
Present Illness: Ten days prior to ad-
mission to the hospital, the patient became
suddenly ill, complaining of malaise and sore
throat. This was followed by a rather severe
ch'll and elevation of temperature to 101 de-
grees. On the following day, she felt some-
what better and was able to get up. but later
in the d.iy, she had another severe chill and
returned to bed. On the fourth day, her
family physician was called and he found
marked edema and inflammation of the
pharynx and tonsils, but no ulceration.
Smear from the throat showed a few short
chain streptococci and the usual bacterial
flora. Because of lack of improvement, she
was brought to the hospital ten days after
the onset of illness.
On examination after admission, she was
found in a semi-comatose condition, toxic and
apparently very ill, complaining of a pain in
the throai. The soft palate and uvula were
markedly edematous and there was a dark
grayish membrane on the posterior pharynx.
She was slightly obese. There was some
evidence of pulmonary fibrosis. The heart
was normal. Blood pressure 130/80. Ab-
dominal exam'nation negative. Temperature
103 degrees, pulse 130, respirations 26.
Laboratory examination at onset of illness
showed hemoglobin 85 per cent; r. b. c. 4,-
000,000; w. b. c. 6.000; differential count:
polymorphonuclears 41 percent; lymphocytes
56 per cent; myelocytes 3 per cent. Daily
blood counts showed a gradual decline with
decreasing polymorphonuclears. Total white
count 3,200 on admission to hospital. Smear
from throat showed many gram-positive and
gram-negative diplococci and many gram-
positive staphylococci. Urine: many hyaline
and granular casts, trace of albumin and a
trace of acetone. Wassermann negative. On
the second day, the w. b. c. dropjjed to 1,600,
|). 30, 1. 67, m. 3. On the third day, the
w. b. c. S20. .Accurate differential count
could not he made, but polymorphonuclears
were practically absent. R. b. c. 4.000.000,
hemoglobin 83 per cent. \ transfusion by
the syringe method increased the hemoglobin
to 95 per cent, r. b. c. 4,000,000. On the
fourth day only five white blood cells could
24
SOUTHERN MEDICINE AND SURGERY
Januafy, 1929
be found on six smears. The hemoglobin was
70 per cent, r. b. c. 3,800,000. .Another trans-
fusion raised the hemoglobin to 80 per cent
and the w. b. c. to 760. On the fifth day,
the w. b. c. was 680, and on the sixth day
160. Shortly before death, the \v. b. c. had
dropped to 40 and no white blood cells could
be found on ten smears. Repeated blood cul-
tures were negative, e.xcept in the culture
taken on the day of death, in which instance,
a hemolytic diplococcus resembling pneumo-
coccus was isolated.
Treatment: In addition to repeated trans-
fusions, the patient was given streptococOis
immunogen following an initial dose of anti-
streptococcus serum, polyvalent, in an effort
to stimulate the leucopoietic tissue. One
litre of 5 per cent glucose was given intra-
venously on the days that transfusions were
not given. The patient's temperature varied
from 101 degrees to 106.4 degrees. ^Morphine
was given as necessary to quiet. In spite of
all treatment, there was no sustained improve-
ment, and the patient gradually went into a
complete coma and died si.xteen days after
onset.
CASE 3: A married woman, agfed 52, ad-
mitted to St. Elizabeth's Hospital on July 21,
1928.
Past History: Negative.
Present Illness: Two daj'S before admis-
sion to the hospital, the patient was complain-
ing of headache, malaise, sore throat, soreness
around the anus.
On admission, the symptoms were the same
e.xcept that the sore throat was more severe
and the temperature was 104 degrees, pulse
120, respirations 22. Physical examination on
admission was negative except for jaundice,
marked edema of the soft palate and a dark
grayish membranous deposit in the posterior
pharynx. There was slight tenderness over
the right antrum. The liver and spleen were
not palpable. There were numerous grayish
ulcerations around the anus which had some-
what the appearance of blisters. There were
numerous cutaneous petechial hemorrhages
over the 'body.
Laboratory examinations on admission:
Urine showed an occasional pus cell and rare
hyaline cast. I'henolsulphonephthalein out-
put 87 per cent in two hours. Blood: hemo-
globin 69 per cent; r. b. c. 3,540,000; w. b.
c. 4,200; differential: polymorphonuclears
73, lymphocytes 24, transitionals 2. Blood
wassermann negative. Smear from throat
showed an occasional short chain streptococ-
cus and many large bacilli. Culture was neg-
ative for diphtheria and blood culture nega-
tive. On the following day, the patient
seemed somewhat better and more comfort-
able. No blood count was made. On the
third day the pharynx was more markedly
injected and edematous and the abdomen
slightly distended. The patient, in addition
to pain in the throat, complained of general
pain, especially in the extremities. Blood
count: hemoglobin 67 per cent; r. b. c. 3,740,-
000; w. b. c. 400. Correct differential count
could not be made, but only lymphocytes
were seen on the smears.
Treatment consisted of an astringent nasal
spray, local application of 4 per cent mercu-
rochrome to pharynx and to blisters around
anus, a blood transfusion, 10 per cent glucose
in Ringer's solution intravenously, digitalis,
and morphine as indicated. The patient grad-
ually lapsed into a comatose condition and
died on the eighth day of illness.
COMMENT
Since 1924 numerous cases of agranulocytic
angina have been reported in the United
States and, prior to this time, a dozen cases
have been described in Germany. No causa-
tive factor has been isolated. Lovett suspects
tne bacillus pyocyaneus. Alorre and W'leder
lound only \ mcent's organisms from throat
smears. Skiles thinks the condition may be
due to either one of two factors: a specific
iniecuon resulting in local necrosis with the
lormation ol a specific toxin for the bone
marrow, or a primary affection of the bone
marrow resulting in an inhibition of the
granulocytic formation, due to lowering of
tne resistance of the patient. From a review
ol two cases coming under his own observa-
tion and forty-three cases from the literature,
George J. Kastlin concludes that the inflam-
matory sites in agranulocytic angina have a
wide distribution and, in general, would ap-
pear to be due to a secondary infection. Some
have suggested a more inclusive nomenclature
such as sepsis with granulocytic decrease.
The main features seem to be ulcerative an-
gina and a great reduction in leucocytes, af-
fecting chiefly the granulocytic series. The
onset and course are acute, and the outcome
Januan-, tOJd
SfttJtttEkN MEbtCtNE AND StTRGERV
2-!
is usually fatal, the characteristic lesions
are dirty, ragged, grayish, rapidly spreading
ulcers, which may occur on the tonsils,
pharynx, gums, tongue, larynx and genitalia.
At autopsy, typical necrotic lesions have
been found throughout the gastro-intestinal
tract and in the spleen and lymphatic system.
The most characteristic lesion is in the bone
marrow, which shows an entire absence, or
a greatly diminished number of, granulocytes
and their precursors, while the lymphoid and
red cell elements are slightly if at all reduced.
The disease occurs at all ages in both sexes
but most commonly in females. The symp-
toms are usually of sudden onset with throat,
neck and joint pain, high fever, chills and
malaise, which progress to a severe toxemia
and prostration. The onset usually comes in
a period of good health, but may follow va-
rious chronic conditions. The ulcerative sites
show a lack of the usual cellular response of
inflammation.
Treatment: Local treatment of the throat
seems to be a matter of choice with the at-
tending physician. Intravenous arsphenamine,
tartar emetic, and diphtheria antitoxin have
been used, also transfusions and the injection
of non-specific protein— as by the author —
in an effort to stimulate leucopoiesis. X-ray
treatments over the long bones with carefully
controlled small doses seems to offer the most
hope. The disease does not always terminate
fatally. On recovery the blood picture re-
turns to normal. Several patients apparently
have recovered and succumbed to a second
attack. Further observations will have to
be made before this disease can be given a
clinical classification. It will iu" interesting
to take from the exudate some nf the usual
pharyngeal lesions and, by injection, attempt
to produce this disease in lower animals. The
writers regret that such experiments have not
been carried out in those cases which have
come under their observation.
BIBLIOGRAPHY
Gundrum: .^rch. Int. Med., 41:,U.5, March, 1Q2S.
Whitchcid; Virginia Medical Monthly. 54:701,
March, 102S.
Fricdemann: Deutsche Med. Wchnschr., 5.i:2103,
Dec. 2.i, 1027.
Sachs: .Nebraska Med. Jour., L1:S1, March, 102S.
Finnigan: J. Missouri M. .\., 24:258, June, 1927.
Hart: Laryngoscope, .iO:7QS, Nov., 11)27.
Schultz: Deutriche Med. Wchnsch., 53:121.^ Julv
15, 1027.
Zikowskv: Wicn Klin. VVchnschr., 40:.w6, Nov.,
1027.
Kastin: \m. J. Med. Sc, I7.<:70Q, June, 1027.
Prendergast: Canad. M. .■\. Jour.. 17:44o, .\pril.
1027.
Hart: Laryngoscope, i~:SS~, Ma\ , 1Q27.
Boltzer: V'irchow's Arch. F. Path. .Vnat., 2()2:(iSl,
1020.
Cannon: South. M. J., 20:141, Feb., 1027.
Freer: \h. J. \. M. .\.. S7:.?oo, Julv ,U, 1020.
Hill: Cal. and West. Med., 25:oOo, .\ov.. lo.'o.
Roche and Mozer: Presse Med., ,U:1171. Sept.
15. 1020.
Gamna: Ab. J. A. M. .A., 87:21.n, Dec. l.S, lo2o.
Schenck and Pepper: .Am. J. Med. Sc, 171:.520,
March, 1026.
Hunter: Laryngoscope, .<6:34S, May, 102o.
Bfab: Ab. J. A. M. A., 86:237, Jan. 10. 1020.
Skitcs: J. A. M. A., 84:.!o4, Jan. .il, 1025.
Moore and Wiedcr: J. .\. M. .\., 85:512, .\ug. 15,
1025.
Schultz and Jacobwitz: .Ab. J. \. M. .\., 85:1025,
Dec. 12. 1025.
Zadek: Ab. J. A. M. A., 85:77, Julv 4, 1Q25.
David: Med. Klinik, 21:1220, .Aug. 14, 1025.
Piette: J. A. M. A., 84:1415, Mav 0, 1025.
Pelnar: Ab. J. A. M. A., 84:74, Jan. 3, 1025.
Lovett: J. A. M. A., 83:1498, Nov. 8, 1024.
Petri: Ab. J. A. M. A., 83:798, Sept. 6, 1024.
Lauter: Ab. J. A. M. A., 83:1466, Nov. 1, 1924.
i6
SOWttEftM MEOtCINB ANt) StJRGERY
Januafy, 1929
Some Neglected Factors In Hospital Management
Malcolm Thompson, M.D., Greenville, N. C.
From the Surgical Service of the Pitt Community Hospital
The principles governing management of
operating rooms and of hospitals are gener-
ally understood. There is a wide variation
of the methods of putting them into practice,
some of them less useful than others. It is
with this idea in mind that we present a few
of the methods found to be satisfactory by
us and at the same time call attention to
some practices which we believe are either
dangerous or of doubtful value.
The importance of droplet contamination
has been emphasized by a number of writers,
but surgeons have been slow to put their
teachings into daily practice. Masks worn
at the operating table by the surgeon and
his assistants should cover the nose as well
as the mouth. If the nose is not covered,
protection to the fullest extent is not being
given the patient. The masks that we have
found most suitable consist of ordinary gauze
36 inches long, 3 inches wide,, and of 10
thicknesses. They cover both the nose and
the mouth and are fastened in place by tying
or pinning over the top of the head. They
are not expensive, they can be easily steril-
ized, a new one can be readily obtained for
each operation, and they do not cause fogging
of spectacles when properly applied.
During operations the anesthetist should
wear a mask or there should be an ether
screen that prevents him from breathing upon
the patient. This can not be urged too
strongly. We believe that many cases of
unexplained post-operative infection are due
to droplet contamination from the anesthetist
or others.
An error that is frequently seen is that of
surgeons powdering their hands near the in-
struments or dressings. Powder that has
touched their hands and epithelial debris
from their hands almost certainly are sources
of contamination.
The patched glove is ant)ther element of
danger. Many patches are loosely applied
and in the course of long operations will leak
or come off. Only a new glove or one that
has been expertly patched is safe. The stick-
ing of gloves during operation is dangerous
for surgeon and patient, and can be easily
prevented by the proper care. Following use
gloves should be tested by the operators by
being filled with water. In this way the
work of the nurse can be checked and the
surgeon can determine whether he has or has
not been guilty of faulty technique by punc-
turing his gloves. Strange to relate in this
supposedly aseptic age we have recently seen
surgeons deliberately touch sterile rubber
gloves with their bare hands in the process
of adjusting the gloves. By having the cuffs
turned back, one can put on rubber gloves
without contaminating the outside of the
glove.
The importance of good records cannot be
over emphasized. Frequently we see a good
record spoiled by poor notes describing
the operation. A satisfactory and time sav-
ing plan is as follows: While the operator
is sewing up the wound the assistant dictates
the operative finding to the head nurse who
writes them upon the back of the anesthetic
sheet. This becomes at once a permanent
and valuable record. Frequently when writ-
ing to the family physician an exact copy of
these notes are sent to him which saves time
in the writing of letters and explains the pro-
cedure to him satisfactorily.
To examine microscopically every specimen
removed has always seemed to us to be a
waste of time and money. Every specimen
should be minutely examined grossly, how-
ever, and then when indicated microscopic
examination can be done. The surgeon as
well as the pathologist should make this gross
examination. Unless the surgeon does this
he will not be giving his best service to the
patient. Dr. L. L. McArthur has reported
a case that illustrates the importance of this.
After easily removing the gall-bladder from
a young woman and after closing the wound
he examined the specimen. To his great sur-
prise he found a portion of the common duct
attached to the specimen, it having had an
anomalous course in this patient. He stated
the facts clearly to the relatives, reopened
the original incision and performed a primary
January, 1929
SOUTHERN MEDICINE AND SURGERY
27
repair of the duct. In our clinic the surgeon
examines the specimens and dictates the re-
sults of his examination before leaving the
operating room. This can be done between
cases, when more than one case is to be oper-
ated upon in the same morning.
SEVEN— MEDICAL—
The value of records is frequently cheapen-
ed by their having been written by one of
small experience. When, as above outlined,
the records can be made by the attending
surgeon himself or his assistant, they will be
of much greater value.
Every good business concern makes a bal-
ance of assets and liabilities at regular inter-
vals. A mere glance at the statement shows
the standing and rate of progress. For hos-
pitals and surgeons the monthly analysis
sheet serves a similar purpose, and is equally
as important. Many of the smaller hospitals
do not keep these sheets, however, and many
larger hospitals are either without them or
have surgeons upon their staffs who know
nothing about their importance.
During a recent visit to three of the most
famous hospitals in the country six surgeons
were asked to state their incidence of post-
operative pneumonia. Not one of them could
give any definite statement; neither could
they say whether or riot such records were
readily available. Had they kept and studied
a monthly analysis sheet, such a display of
lack of interest would not have occurred.
No surgeon or group of surgeons can consist-
ently improve their results unless they first
know what those results are.
In our institution, on the first day of each
month the superintendent makes out an
analysis of the previous month's work. The
number of admissions to each department is
tabulated, the number and character of the
operations, the complications if any, and the
result. Upon the same sheet, the hospital
numbers and names of any patients who have
died or had complications are placed, and
with them the cause of death or complication,
if such is discoverable. This report is sub-
mitted to the staff for criticism at its regular
monthly meeting. Much interest has been
displayed in it and it has been a source not
only of information but of great stimulation.
Hospitals are no longer in the experimental
stage. Increasingly large numbers of the
public are entering them with confidence and
hope. Surgeons and hospitals must render a
strict accountancy of the trust that is theirs.
Unless this accountancy comes from within it
will be forced upon us from without in the
form of state or federal supervision.
Clinic And Group Practice
Harold Glascock, M.D., Raleigh, N. C.
Man- Elizabeth Clinic
1 he word "clinic" has been commercialized
more or less since it was made popular by
the achievement of William and Charles
Mayo. • The succefe of the Mayo clinic was
made household comment 20 years ago, and
since that rime rtiany medical partnershiiK
arid groups have sprung up over the entire
I'nited Stj'tes where two or more physicians
cCiUid organize themselves, and practically all
ojierate under the name, clinic.
It was recognized at once by alert physi-
cians tha't grouping had financial, as well as
patrmr arlvantages; it would combine a num-
ber of physicians Who would "woVk in their
respective fields of siiecialized practice and
h'lld all (iihcr lypOs of work rcirui't'tl llnougl;
their influence, to refer to the other members
of the group. Each would heartily endorse
the other and thus they would tie into the
organization the general influence of each
member both with the laity and the profes-
sion,
.\n organizatiiin with this aim is easily ef-
fected and does not place upon the members
any obligation or res|:)onsil)ility that one does
not assume in ordinary practice.
In group practice the patient is received
and referred to the physician that handles the
practice peculiar to his ailment: a history is
taken, an examination is made and treatment
is begun. .\ provisional diagnosis may or
may not he made. No detailerl study of the
case is made and no painstaluiig record is
made of the uise fer future stuidy. Group
SOUTHERN MEDICINE AND StJ^GBRY
January, 1929
practice thrives upon its convenience of re-
cruiting and handling of patients, and com-
bination of personalities. Few physicians are
willing to give up practice and substitute for
it hard study on clinical cases.
.A clinic carries the idea of a well taken
history, a thorough and detailed examination,
an exhaustive study, an analysis, and a diag-
nosis that will explain the symptoms and
pathology, paralleling an investigation into
the causes and characteristics of the disease
and its actions under different environment,
and the reaction and maneuvering of the body
to overcome the disease. A clinic thrives
upon thorough investigation and revelation.
A clinician thrives upon knowledge obtain-
ed from patients: he catalogues it and moulds
it into an experience which fosters judgment.
He follows the case into its utmost ramitica-
tions and strives to get all the details and
traces all leads to a definite conclusion. He
tabulates the findings and analyzes them and
draws his conclusions, and bases his diagnosis
on sound clinical reasoning and thus the pa-
tient gets a finished and conclusive diagnosis.
It is impossible to form, act or be a clinic
without studying, acting and being, not in
name, but in faith, effort and consummation.
One cannot get the clinical idea by staying
at home and praying for clinical guidance;
he must absorb it by studying clinics, asso-
ciating with clinics and clinicians; he must
live the clinical idea.
The clinical idea should be studied with
much zeal, for it holds great success for those
who would grasp its meaning and follow its
teaching, but it will never unfold itself to the
physician who would attain, but not strive.
.A physician interested in forming a clinic
should study what constitutes a clinic; how
clinics succeed; how to get efficiency in a
clinic; what systems are necessary for a
clinic; what is there in the clinic idea that is
unlike other methods of practice; what kind
of a record is most suitable and beneficial for
clinical purposes; what is the best method of
keeping records; how to get the best infor-
mation for clinical purposes; what are the
main essentials in record work; how best to
obtain the most knowledge from the patient:
what are the benefits of a clinic to keen medi-
cal judgment; how to detail examinations to
get the essentials without lost motion; how
I u make exaininalioijs.comj)k'le^hi.)»L lo..avuid.
making statements that cannot be substanti-
ated; how to get the full advantage and bene-
fit of each department; how to create enthu-
siasm in your associates and a longing thirst
for medical knowledge: how to obtain a quick
method for obtaining information by other
departments; how to get each department to
function so that no department can feel that
any stone has been left unturned by anyone
to make a diagnosis; how to complete a record
that will be acceptable to other members of
the staff who might wish to consult the rec-
ord; how to form departments so they will
grasp and digest all methods relative to their
departments; how to develop the clinical
spirit in members of the organization; how
to make each man concerned in the clinic
measure up to the expectations of the other
men: how to create a zeal for knowledge;
how to train men to tabulate their findings:
what nature and kind of help is needed for a
clinic; what method of fees and collections
are necessary for a clinic; how to bunch
charges; how to ?oltectihow to save in each
department; ho" to educate physicians in
clinical work and i dvu ate them to the clinical
idea instead of ^Mour- ;v,iclice, and how to
make them see'the v;iiip nf ji; how to educate
the public to the clinical idep of examination,
diagnosis and treatment.
The failure to solve the above will prevent
many so-called clinics from ever getting be-
yond the field of group practice.
Group practice favors convenient handling
of patients; economy in equipment; conveni-
ence in dispensing patients; convenient con-
sultation and a satisfactory grouping of fees;
but the thoroughness of study, research, and
the desire to master, do not prevail in this
type of organization as it does in a clinic.
When a physician has thoroughly studied
fifty cases of a single disease and bases his
conclusions on his own cases, sifting facts
from ideas and theories, his opinion is begin-
ning to be worth something and he can speak
with some authority. When one speaks from
a book he speaks from the experience of the
writer, but when he speaks from facts, col-
lected from a large number of his own clinical
cases, he speaks from his own experience and
personal knowledge. Intelligent diagnosis is
born of study and close observation.
There can be no better' aid to keen diag-
nostic (levelnip.me.iU .lhaji.fa.nEiuHy .prepared
January, 102Q
SOUTHERN MEDICINE AND SURGERY
records for future study. Like clothes, the
records do not make the doctor but the rec-
ord indicates the doctor: the record is the
doctor's "return check" for what he puts forth
on the case: it is the best indicator that a
doctor can have of efficient work, and unless
he has records tti back u]) his statements his
medical opinion is low in the scale of real
worth, and lacks authority.
It is hoped that more groups will develop
into clinics, for it is in the clinic, th;it medi-
cine reaches its highest ideals and develop-
ment, and through which the people gain the
greatest good. A thorough clinical examina-
tion and study is the best foundation for
health and longevity that a patient can ob-
tain, and the clinic is the greatest avenue for
the development of keen medical knowledge
and judgment.
SOUTHERN MEDICINE AND SURGERY
January, 1920
Chronic Intestinal Amebiasis
Ltcirs G. Gage, M.D., Charlotte
The Nalle Clinic
Craig, of the Army Medical Corps, has on
several occasions called attention to the fact
that so-called carriers of the entamoeba hys-
iolylka are frequently or, as he contends, in
most cases, affected to some extent by the
parasite. He makes the statement that the
presence of cysts of this parasite in the stool
is evidence that the tissues of the host are
being invaded by the parasite. This is true,
he says, because the entamoeba hystolytica is
incapable of existence except as a parasite in
the tissue of the host.
His latest article appeared in the Journal
of the American Medical Association for April
28, 1928. In this article he takes up. the
symptoms produced by the carrier state and
recommends as treatment the arsenical sto-
varsol, in doses of 125 grams three times a
day for periods of one week at a time until
the cysts disappear from the stool. He calls
attention to the danger of overdosage with
the drug and consequent arsenical poisoning.
Case 1. — On December 8, 1927, a married
woman 28 years old applied to me for exam-
ination because she had been unable to put
on weight that had been lost, and because
she did not feel that she had the proper
amount of energy. There was no regional
discomfort and no history of dysentery. She
was inclined to be constipated. The positive
findings on physical examination were, under-
nutrition (her best weight several years pre-
viously was 107, present weight 93), rather
marked pyorrhea alveolaris, and cysts of
entamoeba hystolytica in the stool.
This patient was given stovarsol 250 mgm.
t.i.d. p.c. to be taken for one week. At the
end of the week, when all but two of the
prescribed tablets had been consumed, the
patient complained of cramps in the lower
abdomen quickly followed by generalized
edema and erythremia of the skin.
Sodium thiosulphate was immediately
started and the patient made an uneventful
recovery from the acute arsenic poisoning.
The cysts disappeared from the stool at the
end of the treatment. One subsequent ex-
amination failed l<i show anv. Besides the
arsenic treatment this patient was referred to
a dentist who has treated her for pyorrhea.
She was also given mineral oil for constipa-
tion. At present she says she feels perfectly
well and is gaining weight. She seems greatly
pleased with her changed condition.
Case 2.— On JNIay 14, 1928, a S4-year-old
banker consulted me in an apologetic man-
ner. He explained that it might seem foolish
for a person to seek a doctor's advice when
he had no complaint except that he felt ex-
tremely tired all the time. He stated that
the condition started in the summer about
four years ago. The following winter he felt
better. The next summer the tired feeling
returned and has since persisted even in the
winter. It had, however, approached the point
of prostration in the summer so that he had
been in the habit of going to bed as soon as
his day's work was over. In the morning, he
felt as tired as he did when he retired.
This patient said that he had been a suf-
ferer from "neuritis" at intervals for seven-
teen years. Nineteen years previous to ex-
amination he had an attack of dysentery
which w;'s diagnosed amebic dysentery.
This patient was a large man considerably
overweight. Physical examination otherwise
showed no pathology except red, ragged, em-
bedded tonsils, and abundant cysts of enta-
moeba hystolytica in the stools.
Because of arsenic poisoning in my first
patient and Craig's caution about the same
condition, this patient was told to take one-
half a 250 mgm. tablet three times a day
after meals for one week, .-^t the end of this
week the patient stated that he was feeling
a great deal better. Examinations of stools
revealed no cysts. The patient was then
given emetine hydrochloride. 1 grain once a
day for 12 doses. Following this he took
stovarsol for another week. His stools re-
mained free from cysts. The last examina-
tion was made October 23, 1928.
The patient came in at this time because
he had had an attack of neuritis in the left
shoulder about three weeks previously, and
had not felt very well since. He stated that
throughout the past summed he felt as well
as he ever did in h's life. His old feeling of
fatigue h;id <Miliiely (lis.i]i|ieared.
January, 1929
SOUTHERN MEDICINE AND SURGERY
PRESIDENT'S PAGE
Tri-State Medical Association oj the Carolinas and Virginia
Jas. K. Hall
Certainly not since 1920, when I was made
secretary of this organization, has the pro-
gram been so near to completion so long be-
fore the meeting as it is at this time. I write
just before the year expires, and even at this
moment the list of essayists is almost of suf-
ficient length.
For more than one reason the meeting in
Greensboro will be the best the Association
has experienced in many years. Greensboro
must be about the geographic center of the
-Association's territory. And Greensboro is
easily accessible. Railroads converge there,
and hard surface roads come into Greensboro
almost as multitudinously as spokes come
into the hub of a wheel. From every section
of South Carolina and of Virginia the drive
to Greensboro even in February should be
delightful. If any member has doubt about
the proper road to travel, or about the con-
dition of the road, let him call upon the state's
highway commission at Columbia, Raleigh,
nr Richmond for information. The informa-
tion will be promptly and gladly given, with
a map. And the O. Henry Hotel is a good
hotel. .\nd so also is the King Cotton Hotel
only a block or so from the 0. Henry.
But the meeting is going to be a success
Iiecause it is going to furnish a program that
will help us all to practice medicine more
helpfully. For the first time in the history
of the Association we are going to have some
clinics, and these clinics will be conducted
by some of the leading teacher-clinicians of
this country. Here they are: Dr. Thomas
-McCrae. Philadelphia, will hold a clinic in
medicine, and he will also present a medical
paper. Dr. McCrae occupies the chair of
medicine in the Jefferson Medical College,
and he is regarded as one of the best diag-
nosticians and teachers in this country.
Dr. .\. Benson Cannon, New York, will
hold a clinic in skin diseases and present a
p;;per on dermatdlogy. Almost everybody
h:is some sort of skin trouble, and few doctors
have any definite knowledge of skin diseases.
Dr, Cannon, long the assistant of Dr. John
A. Fordyce, is associate professor of derma-
tology in the medical school of Columbia
University, and one of the clinic chiefs in
the Vanderbilt Clinic.
Dr. Edwards A. Park has lately come from
Vale University to Johns Hopkins University
as professor of pediatrics. Dr. Park will give
a paper on pediatrics and he will also hold a
clinic in diseases of children.
Dr. Warren T. Vaughan, Richmond, will
conduct an allergy clinic.
Dr. Winfred Overholser, Boston, is an of-
ficial of Massachusetts in the department of
mental disease. Unlike most other states,
Massachusetts thinks it unwise simply to do
something to a human being who has done
something to the state. Massachusetts has
most of her criminals examined medically,
and the state is trying to find out what and
why crime is. And Dr. Overholser will tell
us how Massachusetts is tackling the prob-
lem. .And there will be a clinic in diseases of
the mind and of the nervous sj'stem. No
other clinics have such interest. Do you know
Gladys? I'erhaps not.
Dr. John A. Kolmer, of the laboratory de-
partment of the medical school of the Uni-
\'ersity of Pennsylvania will talk to us about
the usefulness of the clinical laboratory in
medical diagnosis. Dr. Kolmer has already
assured me that he will make use of no high-
hat methods and that he will try to answer
earnest inquiries.
Dr. Walter E. Lee, Philadelphia, will pre-
sent a paper on surgery of the chest, illus-
trated by a movie film.
Dr. J. L. Miller, Thomas, West Virginia,
practices medicine by day and lives by night
in the Elysian fields. There he associates in
his library with Hippocrates, Aristotle, Galen,
Harvey, Pare, Hunter, Rush, and other mem-
bers of that large host of brave men who
blazed the trail along which medicine has
crawled forward throughout the centuries. Dr.
Miller has the most interesting private col-
lection of medical memorabilia in this coun-
32 SODTHERN MEDICINE AND SURGERY January, 1929
try. He will talk to us about historic medi- cises and that it runs along without distract-
cine. ing diversions of any kind. A golf tourna-
The doctors of Greensboro and that pop- ^^^^^ j^ ^^^ ^ fg^^^j.^ ^j ^^g curriculum. If
ulous region round about it assure us that we
the length of the program justifies the exten-
sion the
the meeting opens without preliminary exer- of two.
shall be amplv supplied with an abundance
of clinical material. Please remember that sion the meeting will cover three days mstead
CORRESPONDENCE
4211 Sansom St., West Philadelphia,
November 22, 1928.
Dear Dr. Northington:
I have just been reading my recently re-
ceived copy of Southern Medicine and Sur-
gery, which I always enjoy getting. You
wrote an editorial entitled, "Doctors' Bills
Should Have Special Consideration." In it
you refer to the passage of a new "Garnish-
ment Law." In an early issue I would be
delighted to have you define in some detail
such a proposed law and perhaps if possible
present some evidence as to how it works in
those states which have passed such a law. I
believe that a further discussion of this sub-
ject in your journal would be of interest to
many of its subscribers. (My ignorance
upon it is complete!)
Your last issue was a very good one from
all points of view. I am always interested in
the News Items. I believe that a more ex-
tended news item section would be also of
interest — with notes from as many counties
as possible. They need not be long — but
there is a lot of human interest in such a
column.
Sincerely yours,
DOUGL.\S P. MURPHY.
January. 1929
SOUTHERN MEDICINE AND SURGERY
PRESIDENT'S PAGE*
Medical Society of the State of North Carolina
Thurman D. KHchin
Received too late for publication in December, published as appropriate to any season. — Editor.
"The world has grown old with its burden
of care, but at Christmas it always is young."
At this season the carefree child and the over-
worked physician alike are infected with the
spirit of this glad season. The germ was
planted two thousand years ago when Mary
and Joseph made their memorable journey
from Nazareth to Bethlehem where the angel
sang of a better day and the star guided the
three doctors from the East. It is not to be
wondered at that the three men who saw the
star were men who had spent their lives for
the good of others. For the coming of the
Christ Child changed the age-old principle of
".\n eye for an eye and a tooth for a tooth"
to ''Ye that are strong ought to bear the in-
firmities of the weak" and "Pure religion and
undefiled . . is to visit the fatherless and
widows in their afflication" — which being in-
terpreted means human suffering in all its
forms. These principles are just as truly
parts of the teaching and practice of Christ
as "Go 3'e into all the world and preach."
Surely the full gospel of Christ means to save
both soul and body of man. His teachings
are full and unmistakable that He came that
they might have life — both spiritual and
physical life. As we look back over these two
thousand intervening years, can we help won-
dering why His people have to such a large
extent neglected His teachings and ignored
His commands concerning the physical man!
The world is indebted today to the faithful
men and women who have preached "Ye
must be born again"; the great spiritual com-
mand must be reiterated until, as John said,
".\t the name of Jesus every knee shall bow. '
Hut along with this spiritual reviving there
must go physical healing. The future must
see going up in the same town the church and
the hospital. The chimes in the church tower
and the siren of the ambulance would blend
in harmonious praise of Him who came that
they might have abundant life! Make a trip
over our state with this idea in mind, and it
will be seen that towns of every size arc well
supplied with modern church buildings, but
far too few towns — and these of larger size — ■
have hospitals. Many of these are private
hospitals, built and maintained by individual
physicians. These hospitals were not built
for gain, because very few hospitals are self
supporting; the physician is so conscious of
the need, he is forced to build and operate his
hospital in order to serve the community
more effectively. We cannot overestimate the
services of these privately owned hospitals;
it is not too much to say that no one factor
has done more for North Carolina medicine
than these have done.
But back to the idea of the twofold minis-
try of the Gospel of Christ! Let me ask you
to think again of the thousands of church
buildings of which we are justly proud and
in contrast of the pitifully small number of
hospitals. Allow me to use as an illustration
the religious denomination to which I belong.
It has twenty-four hundred churches and one
hospital in North Carolina. The church
buildings cost more than twenty million dol-
lars and the hospital considerably less than
half a million dollars! The enormous differ-
ence in the amounts invested shows the con-
ception of the relative importance of the two
phases of Christ's teachings in the minds of
the people. With figures such as these before
us, is it not time for the doctors to call the
attention of their particular religious bodies
to the fact that the denominations are neg-
lecting the clear teaching of Christ? Should
not they be made to see that they are failing
to take advantage of the wonderful op[5ortu-
nity of reaching the spiritual man through
the physical body?
It has been a gratifying and not unusual
sight to see the church and the school house
on the same hill, where the soul and the mind
could be cared for. Should there not be an-
other building along with these, a building
dedicated to the care of the body? If this
could be done, the future of our civilization
Mould indeed be secure, resting upon this
tripod— the church, the Fcbool. the hospital,
SOUTHERN MEDICINE AND SURGERY
January, 1929
Southern Medicine and Sur^er^g
Official Organ of
rXri-State Medical Association of the Carolinas and Virginia
1 Medical Society of the State of North Carolina
James jNI. Northington, M.D., Editor
James K. Hall, M.D
Frank Howard Richardson, M.D
W. M. RoBEY, D.D.S
Department Editors
-Richmond, Va...
-Black Mountain, N. C-
-Charlotte. N. C.
J. P. Matheson, M.D.
H. L. Sloan, M.D
C. N. Peeler, M.D
F. E. Motley, M.D
The Barret Laboratories
O. L. Miller, M.D
-Human Behavior
Pediatrics
Dentistry
Charlotte, N. C.
Diseases of the
Eye, Ear, Nose and Throat
Hamr-ton W. McKay, M.D
John D. MacRae, M.D..
Joseph A. Elliott, M.D
Paul H. Rtnger, M.D
Geo. H. Bunph, M.D
Federick R. Taylor. M.D. _
Henry J. Lancston, M.D
Chas. R. Robins, M.D
Olin B. Chamberlain, M.D-
Lot'is L. Williams, M.D
Various Avthors
Charlotte, N. C
Gastonia, N. C
Charlotte, N. C
__Asheville, N. C
.Charlotte, N. C
_A5hcville, N. C
.-Columbia, S. C
-Orthopedic Surgery
Urology
Radiology
_High Point. N. C.
.Danville, Va
-Richmond, Va. ._.
-Charleston, S. C...
..Richmond, Va
Dermal ology
-Internal Medicine
Surgery
-Periodic Examinations
Obstetrics
Gynecology
.Neurology
Public Health
Historic Medicine
Dr. Charles L. Minor
The editor exercises his privilege to choose
as his subject for January, 1929, a tribute to
his friend and colleague of many years' stand-
ing, whose death on December 26, 1928,
brought to an end a life devoted to the prac-
tice of medicine, to the advancement of medi-
cal ideals, and to the upbuilding of a higher
standard of general educational breadth for
members of the profession.
Born in 1865, Dr. Minor, after preliminary
education at the Episcopal High School at
Alexandria, Va., studied medicine at the Uni-
versity of Virginia, graduating there in 1886.
His graduation was followed by an intern-
ship of two years at St. Luke's Hospital in
New York, which, in turn, was succeeded by
two years of study in Europe. London, Dub-
lin and principally Vienna were the cities in
which he worked. L'pon his return to the
L'nited States he took up the practice of medi-
cine in Washington, D. C. Two years later,
because of his health, he came to Asheville,
and, having gained the mastery over the dis-
ease that had laid its hold upon him, began
practice again, devoting his attention partic-
ularly to pulmonary diseases. In this field
he soon became an outstanding figure, nation-
ally and internationally.
With the passing of years his practice grew,
his fame grew and his reputation spread. In
due time well-deserved honors were his lot,
among; which may be mentioned, the presi-
dency of the American Climatological and
Clinical Association in 1913, the presidency
of the National Tuberculosis Association in
1918, the presidency of the Southern Medi-
cal Association in 1925, and the conference
of the degree of LL.D. by the L^niversity of
North Carolina in 1926.
In September, 1925, Dr. IMinor suffered an
attack of coronary occlusion. INIaking a good
recovery, he continued his practice to an ex-
tent cornmensurate with conservation of his
energies until, in November, 1928, repeated
cardiac warnings forced him to seek rest.
Unfortunately no benefit was derived, and on
the 20th of December he returned to his
home. .After suffering several heart attacks
during the succeeding days, he died very
suddenly on the morning of the day after
Christmas. These are the bald facts of a
J»»ugry, 1929
SOtTTWERN MEDICINE AND StmCERY
n
busy, versatile and varied life.
Those who eiijoj'ed the privilege of know-
ing him well found a man keenly alive to
the progress of medical science, devoted to
his practice and to his patients, eager to do
all in his power to help those appealing to
him for aid. He was one of the very first to
stress the importance of the psychic handling
of tuberculous individuals, and many and
many a time his inspiring talks in the pri-
vacy of the consultation room sent the patient
out with "consolation for the past, comfort
for the present, and hope for the future."
A speaker of marked conciseness and lu-
cidity, and a man who, although devoting
his attention primarily to diseases of the
lungs, did not lose sight of the importance
of the science of medicine as a whole, he was
a constant attendant at medical meetings and
a leader in discussions. With strong per-
sonal convictions and opinions, he did not
hesitate to express them nor to defend them
when challenged ; and, though he might speak
bluntly in the heat of argument, he never
bore ill-will, and the battle of one hour led
to the friendship of the next.
Because of the fact that Dr. Minor prac-
ticed in a city where there was no medical
school, the South and the nation lost one of
the best teachers imaginable. Fired by an
enthusiasm which was contagious, he pos-
sessed that rare gift of logical exposition com-
bined with an intense desire to make his pre-
sentation of the subject in hand appeal to the
intellect and common sense of his auditors.
While no classes in our medical school ever
had the consecutive benefits of his profound
knowledge and of his great gift in imparting
it, hundreds of men throughout the country
today are thankful for what they learned sit-
ting at his side in his office while he exam-
ined a patient and gave freely and gladly of
his knowledge and experience in the detection
and interpretation of the pathology of pul-
monary conditions.
What Dr. Minor valued most in his pro-
fessional life was the confidence and esteem
of his fellow practitioners. This to him was
priceless, and it was ever his endeavor in his
dealings with patients referred to him and
with physicians referring them, to show that
that confidence had not been misplaced.
In private life he was devoted to his fam-
ily, to his church and to the betterment of
the city in which he lived. A zealous »md
tireless reader — not only of medicine, but of
history, biography, philosophy, art; with an
amazingly retentive memory, he again and
again surprised his friends by his encyclope-
dic knowledge of subjects far afield from his
chosen vocation. He was one of the found-
ers, twenty-five years ago, of the Pen and
Plate Club of Asheville, a limited organiza-
tion meeting monthly for dinner which was
followed by a paper and full and free dis-
cussion. This club, in which his interests
never waned, functions actively at the end
of a quarter of a century.
Of his more personal traits it is difficult
for the writer to speak because of his very
deep and sincere affection for one that is no
more. He was one of the most lovable men
that ever lived, responding to evidences of
affection and of esteem and returning them
to the fullest measure. He was a good friend
and a jxior enemy. He was a man of strong
Kkes and dislikes; but, while the former car-
ried with them all the evidences of devotion
and loyalty, the latter failed to contain malice
and resentment. There never was a man more
v.illing to admit his mistake when convinced,
just as there never was a man more tenacious
of his opinion as long as he was satisfied that
it was correct.
His interests were many and varied, and
into each one he put all the fire of his nature
and ail the zeal of his intense temperament.
He was a leader and not a follower, a pioneer
and not a trailer, one who looked forward
and not back and strove to urge his fellows
along the upward road. And now he is gone.
The South and the nation have lost a great
doctor, a true friend and a good man. He
leaves behind him a memory that will ever
be green and a void that will not be filled.
— Paul II. Ringer.
I
Dr. Charles L. Minor
Dr. Minor was more than a distinguished
arid beloved physician,— he was an outstand-
ing and useful citizen. He was always keenly
ai.d actively alive to the best interests of his
community, his state, and his nation. His
active and brilliant mind, cultured and broad-
ened by education and travel, and spurred by
his un.selfish zeal for civic betterments in
every line, was constantly devising and sug-
gesting reforms and improvements, many
26
SdtJtHERN MfeblCtNE A^ StRGfeRY
January, 1920
very practical and necessary, some deemed
idealistic by those of lesser vision. His ear-
nest and zealous advocacy of these unselfish
suggestions made him a stimulating, construc-
tive and outstanding citizen. He was a leader
in thought rather than a leader of men. His
ideals were too high, his mind too active, and
his spirit too impatient for successful mass
leadership.
He was not only a dreamer and a thinker;
he was also a worker, and he gave freely and
liberally of his time and his means to various
organizations for the social, intellectual, and
general civic betterment of his community,
and he took an active and interested part in
their actual work. He was a founder of the
Pen and Plate Club, and one of the organiz-
ers of the Civitan Club, in both of which he
was an outstanding leader. He was an active
member of various other organizations for
social, intellectual and civic improvement,
and in all of them he was a helpful and stim-
ulating influence.
Dr. Minor was a man of deep spirituality
which gave to his sparkling, vivacious nature
a peculiar charm, and made him a most de-
lightful friend and companion. He dearly
loved social intercourse with congenial spirits,
and his home was the center of gracious hos-
pitality, constantly dispensing the purest and
best in social and intellectual enjoyment.
Dr. Minor was a most valuable citizen,
whose strong personality, and unselfish activi-
ties will leave a lasting and stimulating influ-
ence on this community.
We shall miss him sadly; we will cherish
his memory.
— Haywood Parker.
In Memoeiam
Dr. Charles L. Minor —
Distinguished and beloved physician.
Public spirited, unselfish citizen,
Kind and hospitable neighbor.
Loyal and loving friend,
Faithful and devoted churchman,
A cultured, christian gentleman,
died at his home in Biltmore Forest in the
early morning of December 26, 1928.
During his entire residence in Asheville,
Dr. Minor was a faithful and helpful mem-
ber of Trinity church, and so long as his
health permitted, he was a regular attendant
upon its services. He believed in and ad-
hered to the old-fashioned custom of the en-
tire family attending church and worshiping
together; and the older members of Trinity
still remember the beautiful and inspiring
sight of the entire Minor family regularly in
their pew on Sunday mornings, the little ones
joining reverently with their parents in the
services of the church.
Dr. ]\Iinor was devoted and loyal to his
church and gave freely and liberally of his
thought, his time and his means for the up-
building of Christ's Kingdom on earth. He
was especially interested in missions, both
domestic and foreign, and by precept and
e.xample he was their constant advocate; as
lay-reader, he gave long and faithful service
to Haw Creek Mission, and as vestryman he
first proposed and ever insisted that the Eas-
ter offering should be devoted solely to mis-
sions.
For more than twenty-five years he was a
faithful and valued member of this vestry
and was always alert to the interests of the
parish. He was keenly desirous of the very
best obtainable for Trinity that it might bet-
ter minister to the spiritual needs of its mem-
bers and of this community. His active and
brilliant mind and devoted enthusiasm often
led and at times out-stripped his fellow ves-
trymen with constructive suggestions; and
while he was frank, outspoken and earnest in
his advocacy of any cause he espoused, he
always graciously acquiesced in the verdict
of the majority of his fellow vestrymen. His
earnest enthusiasm and devotion were stim-
ulating and inspiring and will be sadly miss-
ed.
This vestry desires and now orders that its
records shall preserve this appreciation and
memorial of our fellow vestryman, who has
gone before us to rest in peace with our Heav-
enly Father, to whom we give grateful thanks
for the useful, helpful life and good e.xample
of our fellow vestryman and our friend —
Charles L. Minor.
THE VESTRY OF TRINITY EPISCOPAL
CHURCH.
.\sheville, N. C, January, 1929.
In ;\Iemory of Dr. JMinor
Death comes with great poignancy and
fraught with deepest feeling, when it ends the
life of the true physician, bringing to his fel-
low doctors a sense of irreparable loss.
Januan-, 1929
SOUTHERN MEDICINE AND SURGERY
37
In the death of Dr. Charles L. Minor, the
Buncombe County Medical Society, his com-
munity, state, and country mourn the passing
of one whose high place in an honored pro-
fession, whose sterling ideals of virtue and
civic leadership, whose character and work
have left an indelible mark on all fortunate
enough to come within his sphere.
A man whose creed was supreme loyalty to
his profession, whose practice was infinite care
of every individual patient, whose talents and
abilities were manifold, wide, and wise, whose
interests embraced active participation in the
affairs of his beloved church and city leaves a
void not soon to be filled.
Dr. Minor was honored and appreciated as
well as loved, not only by the hundreds of
devoted patients to whom in his long, useful
life he ministered; but so highly thought of
v/as he by his professional brothers that he
was the recipient of the highest honors that
could be accorded him by his medical col-
leagues.
As one of the founders of the National So-
ciety for the Study and Prevention of Tuber-
culosis,— later and now known as the Na-
tional Tuberculosis Association, — he always
was active in its affairs, and served it as
president in 1917-1918. A deep student of
the problem of climate in its relation to dis-
ease, he was ever active in the American Cli-
matological and Clinical Association, of which
he was president in 1912. The Southern Med-
ical Association honored him and itself by
making him president in 1924.
Dr. JMinor's practice knew not the limits
of his community and state, but his patients
came from many states and countries. His
zealous interest for his patient, his detailed
knowledge and sympathy with each sufferer's
ills of the body and the soul, his incessant
thirst for more knowledge were all spent by
a body many times wracked by physical ills.
Despite numerous serious sicknesses that
might have sadly handicapped a lesser soul,
his triumph was that of a soul and spirit that
knew not failure nor defeat.
And so, in the passing of this great man
and physician, it is altogether fitting that
those of us who knew him best and honored
him most should pause to pay this tribute of
respect to his memory. In special meeting
assembled, the Buncombe County Medical
Society orders that this minute of respect to
his memory be placed forever on the pages of
its records, and extends to his bereaved fam-
ily the sympathy of his fellow members.
For the BUNCOMBE COUNTY MEDICAL
SOCIETY.
M. C. Millcndcr,
Joseph B. Greene,
CItas. Hartwcll Cocke.
Asheville, X. C, December 26, 1928.
Dr. Robert Vance Br.awley
Dr. Robert Vance Brawley died at his home
in Salisbury, on January 5th, 1929, following
an attack of pneumonia. By his death the
Medical Society of the State of North Caro-
lina, and the Rowan County Medical Society
have lost one of their most consistent, inter-
ested and popular attendants; and our local
profession one of its most noted Specialists,
and a genial and lovable associate.
Dr. Brawley possessed an outstanding per-
sonality. His creed, marked by its consist-
ency and sincerity, was reverent belief in the
fellowship of God and man. He felt an ar-
dent, ever-present comradeship for those of
high and low estate, the rich and the poor,
the prince and the plebeian. In him a spirit
of sympathy and understanding was easily
aroused; then the kindliness, generosity and
gentleness of a great heart went out to the
humblest of his clientele.
Dr. Brawley was ever tolerant towards op-
position, reasonable in adverse criticism; to-
wards competition broadminded, fair and
just always! In his views and opinions char-
itable; he was critical or inconsistent never!
One of Dr. Brawley 's friends said of him re-
cently, "His daily life was one of modesty
and simple living," and this was literally true.
To those of us who knew him longest and
b:sl, he possessed two or three every-day vir-
tues which won for him many friends and ad-
mirers. He was the embodiment of geniality.
He radiated good cheer and kindliness. His
h:',ndclasp will be long felt, and his hearty
lau'/h will go on vibrating through the days
to come. Who that basked in that sunshine
will ever forget its beneficent beams?
Dr. Brawley's cordial greeting and kindly
banter carried him into the hearts of his pa-
tients and his friends. They were an out-
ward and visible sign of a daily philosophy
that a man without a feeling of fellowship in
his heart is one his fellows will surely avoid.
38
SOUTHERN MEDICINE AND SURGERV
January, 1920
Another likable characteristic of the one we
mourn and would honor was his marvelous
capacity for keeping friendships. Here again
his workaday creed seemed to us a living en-
dorsement of Morris" dictum: "Fellowship is
heaven and the lack of it hell, and the deeds
you do upon earth — it is for fellowship's sake
that you do them." Vance never sat in the
scorner's seat, or hurled the cynic's ban;
rather was his heart's desire —
"Let me live in a house by the side of the
road,
And be a friend to man."
Dr. Brawley was a devout member of St.
Luke's church and a faithful vestryman. He
was the father in a home of love, happiness
and gaiety. As a host he was unexcelled in
pitality, natural to the genuine goodwill he
held toward his fellowman.
~The somewhat sudden death of our dear
friend leaves one lesson at least and one that
affects us all — not to concern ourselves about
having courage to die, but to seek, rather
courage to live rightly and bravely. So will
the tender memory of our friend Vance Braw-
ley ever remain in our hearts and thoughts!
He now resting in peace to us may say —
"And let us also learn to maintain good
works for necessary uses, that they be not
unfruitful."
— /. Ernest Stokes.
Dr. James William McNeill
Dr. James William McNeill was born at
"Ardlussa," beautiful home of his family for
many generations, in Cumberland county,
near Fayetteville, N. C, June 28. 1849, and
died at Fayetteville, January 7, 1929. To
this former president of the North Carolina
Medical Society, Dean of the profession in
Cumberland county and one of the few phy-
sicians in this state who have practiced medi-
cine for more than half a century, death came
suddenly at his home on Gillespie street.
Dr. McNeill was easily one of the fore-
most members of his profession in the state.
As a citizen he was one of the leading spirits
of Fayetteville. His interest was almost uni-
versal. He was not only a pioneer in the
modern practice of medicine, but he was es-
sentially a humanitarian. He loved men in
all their relations, and it was his highest
pleasure to relieve suffering. During all his
more than fifty years' residence here he took
an active and leading part in all community
efforts. He was a keen lover of all forms of
clean sports.
He was descended from a hardy race of
Scotch settlers, the first of whom in this
country was Neill McNeill, the far famed
Sotch pioneer who made the first settlement
on the banks of Cross Creek. His father was
the late Hector McNeill, sheriff of Cumber-
land county for many years, and his mother
was ^largaret McNeill.
He began the study of medicine in 1871
under Dr. D. McL. Graham at Duplin Cross
Roads (now Wallace). In those days it was
not required to have a license to practice,
neither was a diploma from any institution
required. In September, 1872, he matricu-
lated at Bellevue Hospital Medical College.
In 1873 he again returned to study under
Dr. Graham, and in 1874 he re-entered Belle-
vue, where he graduated in 1876. In May,
1876, the North Carolina Medical Society
met in Fayetteville, at which time Dr. Mc-
Neill was licensed to practice medicine and
joined the State Society, of which he has
been a member ever since. He was elected
president of the North Carolina INIedical So-
ciety in 1892.
On May 3, 1927, the Cumberland County
Medical Society held a meeting in honor of
Dr. McNeill, who at that time had rounded
out 51 years of practice in this city. Dr. J.
F. Highsmith, on behalf of the Cumberland
County Medical Society, presented Dr. Mc-
Neill with a beautiful loving cup suitably en-
graved.
During the world war Dr. McNeill was
chairman of the draft board for his county.
He served two terms in the State Legislature
as a representative of Cumberland county. In
that position as in all other relations, he was
a strong advocate of temperance reform. He
also served as a member of the board of
county commissioners, and at various times
did service on the city board of aldermen.
In all these positions of trust he made an
enviable record and always gave his utmost
efforts to the work in hand.
Dr. McNeill was in his 80th year. Only
one month ago, on December 5th, he and his
beloved wife celebrated the 51st anniversary
januarj', 1929
SOUTHERN MEMCINE AND SURGEkY
3«
of their marriage. Their golden wedding in
1927 was marked by a reception given in
their honor by the congregation of the First
Presbyterian church in the church parlors.
It was his church work that lay, perhaps,
nearest the heart of this great hearted man.
The missions of the First Presbyterian
church had claimed a generous share of his
love and care during all the years in which
he was a member and oflicer of the congre-
gation. He was made a deacon of the church
in January, 1875, and later became a ruling
elder, which position he held since. He was
one of the two survivors of the original evan-
gelistic committee of the North Carolina
Synod. He was one of the organizers of the
Men's Evangelistic Federation of this city,
and was indefatigable in his labors for that
body.
The highest dignitaries of the church, the
state, and the profession did honor to his
funeral rites: but the most revealing and ap-
pealing feature was shown when an humble
band of convicts from the two prison camps
of the county stepped forward to fill the
grave of the man they loved for the kindly
interest he had invariably shown in them and
their brothers in misfortune. They attended
the service in the church and asked to be
allowed this further privilege. For more than
twelve years Dr. McXeill had not failed on
a single Sunday to visit the prison camps to
talk and pray with the men there and to give
them his counsel in their problems, and he
never left until he had given each prisoner a
coin with which to buy tobacco.
In the death of this good man, his com-
munity has sustained a heavy loss. A con-
scientious devoted christian, a public spirited
citizen, a loving husband and father, a genial
and faithful friend has gone to his reward.
—0. L. McFadyen.
Dr. Franklin Jefferson Garrf.tt
Frank Garrett was born on the 27th of
JIarch, 1864, the son of Thomas and Martha
Garrett. His paternal grandfather served in
the Continental army during the Revolution,
and was present at the surrender of the Brit-
ish at Yorktown.
Born at the close of the great civil con-
flict, when our social and economic systems
were in ruins, our accumulated wealth wast-
ed, our country devastated and our homes in
ashes, he had to face the horrors of recon-
struction— those trying times our people were
struggling to build a new system upon and
out of the wreck of the old. Amid these hard
conditions his youth and early manhood were
spent, and by them was his character mould-
ed.
He has often told me of his struggle for an
education, how he would get up by light and
pl(jvv several hours before school time, and
when he came home from school plow several
hours until it was dark. He walked three
or four miles to school. Contrast this with
the school busses and palatial schoolhouses
of today and you can get some idea of the
quality of the man who made good under
these adverse circumstances.
Such a one was Dr. Garrett. He possessed
in a large degree those qualities — tenacity of
purpose, the ability to work long and pa-
tiently—which command success. Thus his
career began — going to the short and ineffi-
cient free schools, working before and after
school, studying at home, and when he had
qualified himself, teaching school and earning
money to obtain more schooling.
It was an odyssey of pluck, unremitting
toil, unflagging energy, and a stern determina-
tion to get an education.
These ciualities characterized him through-
out life. In 1886 he entered the medical
school of the University of Maryland as a
student of medicine, the study and practice
of v.hich was the passion of his life. After
attending lectures for one year, he obtained
a license to practice medicine from the State
Board of Examiners and in 1887 began the
practice of his profession at the Old Fair
Grounds, ten miles north of Rockingham.
After practicing one or two years he returned
to Baltimore and graduated from the Univer-
sity of Maryland in 1889.
Returning home he resumed the practice
of medicine. Then followed many arduous
years, years of struggle, of hardships endured,
of triumph and defeat. With horse and
buggy, over roads which would be considered
almost impassable now, through deej) sand
and mud and slush, in heat and cold and
snow and sleet, in sunshine and in storm, he
responded to every call. In many a lonely
farmhouse, in many a solitary cabin he fought
his grim fight with disease and death, and
ministered with mi^ht and main and with
46
SOtJTHERN MEDICINE AND SURGERY
January, 1929
rare courage and unflagging zeal to almost
every conceivable form of human ill.
In 1900 he moved six miles to the village
of Roberdell, N. C, two and a half miles
from Rockingham, and a few years later to
Rockingham itself. During these years he
ministered to an ever widening circle of pa-
tients. He was untiring and faithful and en-
joyed a large and lucrative practice.
About fifteen years ago, his health partially
failing, he went to Baltimore and specialized
in diseases of the eye, ear and throat. Dur-
ing the years that remained to him he prac-
tically limited his work to a general office
practice, giving special attention to the spe-
cial sense organs.
On December 8th he was operated upon at
the Johns Hopkins Hospital. He was recov-
ering nicely from his operation when he de-
veloped pneumonia from which he died on
the night of December 22nd.
Thus lived and died Dr. Franklin Jefferson
Garrett, physician and gentleman. Born amid
the ruins of a social order, without the ad-
vantages of wealth, he, by his own unaided
efforts attained an honored and honorable
position, and by his unfailing kindness, up-
rightness of character and devotion to duty,
won the love and friendship of a whole coun-
tryside.
On Christmas Eve his sorrowing profes-
sional associates and a host of those who
knew and loved him, laid away all that was
mortal of Dr. Garrett in Eastside cemetery
and covered the mound that marks his resting
place with a profusion of flowers.
"After life's fitful fever, he sleeps well."
"May he rest in peace."
]. M. Lcdbetter.
ACHILLE MURAT WiLLIS
On January 3rd Southern Surgery sustained
a heavy loss. On that day the disease from
which he had suffered for a year or more —
with exacerbations and remissions, with alter-
nating periods of exaltation and depression —
brought Murat Willis to his death.
Although born in Alabama and spending
the first few years of his life there, he always
regarded himself as a Virginian, since his
family had been prominent in that colony
and state from the early days, and his imme-
diate branch returned to the mother state
when he was yet a boy.
Descended from Napoleon's great General
of Cavalry and Marshal, Joachim Murat, and
the Emperor's sister Caroline, Murat Willis
inherited much of the brilliancy and pertin-
acity, with no little of the impetuosity, of his
forebears. All these qualities he needed, for
when he was but a youth it became neces-
sary that he piece out his education by his
own efforts, and at eighteen he was selling
life insurance in Richmond. But already the
solid foundation had been laid in the schools
of Mobile, at Woodberry Forest Academy
and Fredericksburg College, and this founda-
tion was all that was required by one of his
keen mind and resolute purpose.
Four years later he began his study of
medicine, and in 1904 he was graduated with
honors from the Medical College of Virginia,
receiving the best appointment within the
gift of the college, an internship in Memorial
Hospital. Dr. George Ben Johnston was so
pleased with his manner of discharging his
hospital duties that he offered him an assist-
antship, which was accepted after some
months of work at Harvard. Soon Dr. Wil-
lis was taken into partnership and, in 1909,
the two built the Johnston-Willis Hospital,
in 1916, immediately after Dr. Johnston's
death. Dr. Willis became president of this
institution, and he has been its moving spirit
ever since. With the growth of the work of
Dr. Willis and his associates, it soon became
necessary that more commodious quarters be
supplied. This resulted in the present hand-
some structures opposite the beautiful grounds
of the Battle Abbey.
From his graduation to the year of his
death Dr. Willis had taught classes in his
Alma Mater, since 1922 as Professor of Sur-
gery. His teaching was always characterized
by earnestness and sincerity; he was always
looking and working for something better for
his patients and his students.
He was a member of the American Medical
Association, Southern Surgical Association,
the Surgical Research Society, the American
College of Surgeons, Richmond Academy of
Medicine and Surgery, the Southern Medical
Association and the Tri-State Medical Asso-
ciation of the Carolinas and Virginia. He
contributed a valuable paper to the last meet-
ing of the Tri-State.
Perhaps his greatest single contribution to
the advancement of surgery, was his great
January, 1920
SOUTHERN MEDlCiNje AKD SURGERY
41
service in laboriously compiling the records
and insistently calling attention to the fact
that the death-rate from appendicitis over the
past several years had been steadily mount-
ing. On this subject he addressed learned
societies, and the greatest medical journals
were glad to publish his words of warning
and his proposals for remedy. In last year
the Boston Medical and Surgical Journal, —
the second oldest published in English and
as distinguished as it is aged — published such
a paper from the pen of Dr. Willis.
He was one of the founders and organizers
of Park View Hospital, Rocky Mount, X. C.
In 1927 and 8, at the request of the authori-
ties of Northampton County, Virginia, he
organized, staffed, and set going the Com-
munity Hospital, at Nassawadox.
Two of the high-souled acts of his, on
which one loves to linger, are his organiza-
tion of the George Ben Johnston Memorial
Hospital at Abingdon, and his dedication of
Darlington Hall, the new home for nurses at
the Johnston-Willis Hospital, to the memory
of Miss Laura Darlington, the hospital's Su-
perintendent of Nurses from its foundation
until her death in 1917. These acts illustrate
his never-failing appreciation of his friends
and his loyalty to their memories.
Last July a telegram came from Dr. Willis
containing an invitation to join him for some
days. There had been no communication for
several months. I assumed that he was at
Pinehurst, or maybe Asheville. What was
my surprise when the top line showed that it
came from The Cavalier Hotel, Virginia
Beach! Soon thereafter letters came, then
cards from European cities.
On October 23rd, soon after his return
from Europe, Darlington Hall was dedicated.
Never had 1 seen him better, more filled with
joy of being. Whether going about his rou-
tine hospital duties, arranging the dedication
exercises and carrying out his part in them,
or boyishly playing with his lovely children, —
life was at high tide. It is good to remember
him so.
— Jas. M. Northingtnn.
20th a telegram came from Dr. Dave saying
that Dr. Josh was dead from a stroke. Christ-
mas brought little joy to Washington town
and Beaufort county; Dr. Josh, the friend
and succor equally of the hif^h and mighty
and of them who h;i\'e no helper, had just
died.
The son of an honored doctor, David T.
Tayloe, and the younger brother of another,
of the same name, and possessed of a heart
which beat in sympathy with distress, noth-
ing was more natural than that Josh Tayloe
would take to medicine; and from his grad-
uation in 1892 from Bellevue Hospital Medi-
cal School to the day of his death he was
doctor to his people.
He was born in Washington and he loved
his relatives, his friends and his work too
well to be willing to leave them often or for
long. That they reciprocated this feeling is
evidenced by their making him alderman,
county coroner, superintendent of health and
mayor — and even more by the demonstra-
tions of the multitude to whom he was doctor,
indc-cd.
Directly after his graduation he associated
himself in practice with Dr. Dave Tayloe,
and the relationship between these brothers
has been a thing beautiful to see and think
on. As Dr. Dave's boys came to be doctors,
and they joined on one by one, new units
ol strength had been added to this medical
staff, with no loosening of the bonds which
bound all its members in harmony, loyalty
and affection.
As a doctor his greatest delight was in
ministering to the worthy poor; as a brother
he was devoted, thoughtful and self sacrific-
ing; as a friend he lacked nothing. Whence
comes such another?
— Jas. M. Xorlhington.
Dr. Joshua Tayloe
December 4th I sat beside Dr. Josh at din-
ner, and our conversation was mostly about
the sudden taking off of Mr. C. C. Codding-
ton, well known to both of us. December
Our Own Cravings as Reli.able Guides
We are getting away from the dominance
of the "original sin" concept. Walking bare-
foot on hot irons, lying on a bed of
thorns, wearing sharp pebbles in the shoes
and a camel's hair shirt next the skin, fast-
ing, refusing to molest our body vermin, re-
fraining from bathing; — all which practices
had their origin in the idea that it was sinful
to be comfortable, and its corollary that tor-
turing oneself was an act of piety and grace
— all these have about gone out; and it is
42
SOUTHRRN MEiDtCiNft A!rt> StTRfttHY
January, 1539
to be noted that there has been an almost
regular mitigation in severity.
Some now living can remember when it
was the orthodox medical practice to deny
cold water to a patient burning with fever;
and certainly this was a holdover from the
priest-doctor era; a product of the reasoning
that man being inherently wicked, all his
natural cravings are bad, for himself as well
as for others. As contrasted with this de-
moniac teaching, the red Indians of America
not only gave cold water to those with fever,
but bathed them frequently with it. This
practice was observed by members of one of
the earliest European expeditions to touch
on the shores of what is now North Carolina,
and the recorder expresses great wonder that
"many so treated recover."
Now it seems that it is about to be con-
ceded by doctors in general, and we hope
accepted by the laity, that our appetites for
food are about 90 per cent trustworthy as to
quality, quantity and spacing. A good many
of us have long contended that our economy
had arranged automatic alarms to serve no-
tice on us when we needed water, rest, sleep,
fats, proteins, carbohydrates, mineral salts,
or vitamins. Our own opinion is that if each
person in North Carolina were restricted each
day for a year to a menu prescribed by the
ablest doctors in the world in every partic-
ular— as to kind, method of preparation, time
taken for eating and time between meals;
and, through that same year, the people of
Virginia to follow the immemorial custom of
being governed largely by appetite and avail-
able supply, the end of the year would find
many more healthy Virginians than North
Carolinians.
A recent experiment' with newly- weaned
infants convinces Davis that such children
choose with remarkably good results from a
wide range of commonly used food materials,
served unseasoned and, when cooked at all,
only in the simplest manner.
The experiment amazed the observer by the
selections made in such— as to kind, quantity
and variety— as to maintain themselves at
their very best. The evidence is in favor of
a wide range, and for allowing glands and
red meats to children who desire these foods.
Recollections of our own childhood are
clear on the point of being allowed to eat raw
potatoes, turnips and cabbage stalks freely,
go in swimming during dog-days, and other-
wise defy the superstitions as to health which
caused some of our playmates to be denied
much happiness; and it was noted on a recent
visit that two of them had lost all their teeth.
Some few persons, perhaps five per cent,
need to have diets prescribed. For the ninety-
five, dieting, other than that which experience
has taught each one, is mostly humbug.
1. Davis, Clara M.: Self Selection of Diet by
^ewly Weaned Jnianis. Am. J, Dis. Child., 36:651
Interest in Garnishment Law and
Nevv^s Items
Under "Correspondence" wll be found an
interesting letter from Dr. Douglas Murphy,
formerly of Rutherfordton, now of Philadel-
phia. ..J, I
Attempting to supply the information Re-
quested: In this state taxes may be col-
lected by garnishment proceedings. This
journal has had legal notice served to appear
and show whether or not it had in hand any
funds due a certain employee. Our informa-
tion is that the Virginia law provides for
garnishment for the collection of any debt,
the process being proving a claim (getting
judgment) and having proper papers served
on an employer, which will require that
amounts thus attached be paid to the gar-
nisher till the debt is satisfied, single men
having no exemption and married men an
exemption of $50.00 per month.
Of course, an employer could pay on ac-
count whatever he owes the garnishee and
discharge him, and that provides one of the
strongest incentives to the payment of debts.
We assume the efficacy of such a law is ob-
vious.
It will be noted that our correspondent is
also interested in personal items. This jour-
nal has earnestly and patiently sought such
items, from every part of our territory for
every month of the year. It is our hope that
Dr. Murphy's request will awaken an inter-
est on the part of doctors in every county in
North Carolina, and particularly the secreta-
ries of County IMedical Societies, which will
cause them to send in these items each month.
We gladly publish such items from other
states, which are served by their own medical
journals; we particularly v/ant items from
North Carolina, because, unless they appear
Januan-, 1929
SOUTHERN MEDICINE AND SURGERY
in Southern Medicine and Surgery they will
likelv be lost altogether to doctors.
To Authors
Have somcthiri!; to say; say it; quit. — Anon.
In the most recent issue of the New Or-
leans Medical and Surgical Journal there is
just the kind of editorial which could be ex-
pected of the publication of the medical pro-
fession of a section which has known schol-
arship for many generations. It deals with
"Usacre of Words": words — those combina-
tions of letters which sometimes represent
only an arbitrary arrangement of ink marks,
but which can be made to show forth ideas.
Here is what the editor has to say on this:
"The use of slang, solecisms and jargon in
medical meetings and writings has spread to
stich an extent that what to medical men
often seems plain every-day English, would
appear to other educated individuals as mean-
ingless and barbarous. The summation of
th's violating of accepted usage is found even
in the titles of books — a form of expression
which most certainly should be impeccable.
The 'acute abdomen' — what does that term
mean? As well speak of the 'acute toe'' or a
'chronic breast.' Surgeons are prone to say
they are going 'to operate a patient' or 'to
operate an appendix.' It is true that patients
may be worked, so to speak, but undoubtedly
when ill they would prefer to be worked upon,
rather than to be operated. Good usage re-
quires that one speak of operating a machine,
but of operating upon persons. Internists
often speak of the 'old cardiac' or 'nephritic'
Again a questionable expression is employed.
Patients are said to be tubercular; perhaps
they are similar to the anatomic tubercle or
nodule to which the word tubercular refers,
but the internist undoubtedly means that they
are tuberculo^w — affected with tuberculosis.
''Such incorrect use of words may be ex-
cused on the same plea that slang is condoned.
In ordinary confabulations slang frequently
adds to the word picture painted by the
talker, but in thoughtfully prepared scientific
writings it is inexcusable and so is the use of
jargon."
Readers, you are asked to digest that: for
they be words of truth and soberness I There
be many who scoff at efforts at clarity of ex-
pression, who are content to let go in the
gensral direction of an idea confidently ex-
pecting to convey their meaning. How many
of you have ever killed any birds by firing
in the general direction of the covey on the
rise? Our experience is that you must pick
out one bird, aim carefully at it, and fire only
when you have drawn a head; otherwise your
bag will be empty, unless you claim the birds
brought down by hunters who have learned
that haphazard methods produce unsatisfac-
tory results.
It seems that the back-slapping, buddying,
leveling, standardizing tendency of the age
finds one expression in a loose usage of words.
Your banker still believes in accuracy; he
deals in dollars: can we, who have to do with
lives, be less careful? Even if it be necessary
that there be a "get together" meeting, "stand
thou still a while," and let those on a lower
level come up.
In April, 1928, the Texas State Journal «/
Medicine carried an editorial appealing to
would-be contributors to its pages to conform
to certain minimum standards. These funda-
mental requirements, which have been adopt-
ed by the House of Delegates of that jtate's
^ledical Association are cited:
"Papers presented by members of the .Asso-
ciation must have first been read in full be-
fore a component county society, or, where a
component county society is not available for
this purpose, the district society of which the
author is a member. The secretary of such
society shall certify to the section secretary
that such paper has been so read. It shall
be the duty of the officers of sections to ascer-
tain from members who are on their respective
programs v,-hether this requirement has been
met, and they shall refuse to permit the read-
ing of such papers before their respective sec-
tions unless this by-law has been complied
with. Papers offered to the scientific sections
shall be considered the pledged properly of
the State .'\ssociation, and shall in fact be-
come the property of the said Slate .Associa-
tion when presented, and prospective authors
shall be so informed by section officers in
advance of the acceptance of their contribu-
tions. Papers shall be delivered to the secre-
tary of the section as soon as they have been
read before the section; and in the instance
the author is not able to present his paper, he
shall see that it comes into the posression of
the section secretary in time fur presentation
if it is the desire of the section chairman t«
S6eTHERN MEDICINE AND SURGERY
January, 1929
have it so presented. All such papers shall
be prepaied in typewritten form, shall be
originals, written on one side oj the paper
only, doiiblcd-spaccd and with ample margins,
and not bound." [Italics ours. — S. M. & S.]
Some of the foregoing is applicable only to
societies having subdivisions. IMuch of it is
of so common-sense a character as affects any-
thing offered for publication, as to need no
comment. Even at the risk of being redund-
ant, however, we wish to emphasize the ne-
cessity for typewritten, "original" copies,
double spacing, and ample margins. Hand-
writings will not be accepted by the lino-
typer; carbons are indistinct and will smear;
and, without space for editing neither the
author nor the publisher can be done justice.
h few additional suggestions for the pro-
motion of mutual happiness:
Alhumrw is white of egg. the occurrence of
which in urine must be indeed rare.
Ajhci and r/fect are quite distinct words.
"Case" and "patient" are not interchange-
able terms. Patients die; cases do not.
There is a definite rule by which certain
words end in -ine, and others in -in. ,
'Morphia and strychnw are tolerated; but
they evoke little enthusiasm.
It is doubtful if the word "personally" has
ever added anything of solid value to a dis-
course.
Proofs are sent to be read — and read care-
fully.
One Kind of .Advertising
The mails of December 26th brought us a
post card reading:
"The Light That Saved the King. Of
course j'ou have read how the Prince of Wales
on his arrival at King's bedside insisted upon
modern methods of treatment, and a vibrator
and ultra violet light were used and the light
produced immediate results and will doubtless
be given credit for saving King's life.
"Now we have the ultra violet lamps, all
sizes and styles. We have one at only $47.50
you can experiment with if you can't afford
to pay more. There may be some Kings in
your section needing such treatment before
winter ends.
"Shall we send you literature. If so return
card and wc will understand."
Having seen a statement in a column con-
ducted by "the world's highest paid editorial
writer" to the general effect of that made in
the first paragraph, that paragraph gave little
surprise; though it would seem that appliance
dealers, who make their livings out of doc-
tors, should know them better than to think
that the best doctors in Britain would know
less about therapy than the Prince of Wales,
or that they would accept him as senior medi-
cal consultant. Further, those who know
anything of the Prince would not, for a mo-
ment, entertain the idea that he would pre-
sume to attempt to dictate what should be
done.
There's more to it, though.
The British Medical Journal is a weekly.
Each of its issues since that of December 1st
has carried a good deal about the King's ill-
ness. Bulletins have been issued regularly
since November 21st. In none of these have
we been able to find any reference to the
use of light therapy, or to any change made
which would suggest that the Prince had
usurped the functions of the King's doctors.
\\'e do find, hex/ever, in the issue for De-
cember 22nd: 'Oa Wednesday, December
12th, a few hours after pus had been located
in the pleural cavity ***** the empyema
was evacuated by rib resection under a gen-
eral anesthetic that evening, and the reports
on Thursday indicated that His Majesty had
come safely through the operation, and that
drainage was proceeding."
So it is plain that the major therapy used
on this royal patient is not that coming from
a comparatively new and complicated ma-
chine, but from a surgical operation which
was centuries old when Christ was born.
"The Light That Saved the King'' was the
light let in through a hole in his side.
The ultraviolet rays have proved their use-
fulness; their reputation can only be injured
by this kind of advertising. "A good wine
needs no bush."
The Coming Tei-State JNIeeting
For the meeting of the Tri-State Medical
.Association of the Carolinas and Virginia set
for February 19th, 20th and 21st, a program
has been arranged to which your earnest at-
tention is invited. .All the features of this
program will be available to every member,
as we, meeting in one body, have it constantly
January, 1929
SOUTHERN MEDICINE AND SURGERY
4S
impressed on us that, general diseases having
local manifestations, and local diseases being
often dependent on general conditions, a sick
man must be dealt with as a whole.
Following is an outline of the program
substantially as it will be delivered. No at-
tempt is made here to indicate the order in
which the features will be arranged:
Dr. J. L. Miller, Thomas, W. V'a. (invited guest),
will give a paper on Historic Medicine; Dr. Winfred
Overholser, Boston, Mass. (invited guest), will talk
about mental abnormality and criminality ; Dr.
Thomas McCrac, Philadelphia, Pa. (invited guest),
will hold a clinic in internal medicine and will pre-
sent a paper dealing with some phase of medicine;
Dr. John A. Kolmer, Philadelphia, Pa. (invited
guest), will talk about the helpfulness of laboratory
work in the diagnosis of disease; Dr. Warren T.
Vaughan, Richmond, Va., allergy clinic; Dr. Walter
Estell Lcc, Philadelphia, Pa. (invited guest), "The
Relation of .Atelectasis to Post-operative Pneumonia,"
lantern slides; Dr. Edwards A. Park, Johns Hopkins
University (invited guest) will hold a clinic in the
diseases of children and present a paper dealing
with that domain of medicine; Dr. A. Benson Can-
non, Xcw York (invited guest) will hold a clinic in
diseases of the skin and present a paper dealing with
L diseases of that organ ; President's Address, Dr. Jas.
I K. Hall, Richmond; Dr. H. W. Lewis, Dumbarton,
Va., '"Gongvlonema, with Case Report in a Woman";
Dr. W. k. Graham, Richmond, Va.
.M'PLICATIONS FOR PLACE ON TRI-STATE
PROGRAM
{Listed in order oj date of receipt. Where no title.
is given it is to be supplied before final programs are
printed.)
Dr. H. W. McKay, Charlotte, N. C; Dr. R. M.
Pollitzer, Greenville, S. C, "Serum Sickness"; Dr.
R. T. Ferguson, Charlotte, N. C, "Sterihty"; Dr.
Chas. O'H. Laughinghouse, Raleigh, N, C., "Preven-
tion of Rabies by Legal Enactment"; Dr. R. Finley
Gayle, Richmond, \a.; Dr. Carl B. Epps, Sumter,
S. C, "Iodine and Surgery in the Treatment of
Goiter"; Dr. .\. G. Breni^er, Charlotte, N. C, "Early
Pcricnrdotomy in Purulent Pericarditis"; Dr. A. A.
Barron, Charlotte, N. C; Dr. Robt. E. Seibels, Co-
lumbia, S. C, "The History of the Introduction of
the Vaginal Speculum"; Dr. J. S. Gaul, Charlotte,
X. C, "Broken Backs"; Dr. L. G. Bcall, Black
Mountain, N". C; Dr. DeWitt Kluttz. Greenville,
S. C, "Abdominal Symptoms from Extra Abdomi-
nal Lesions"; Dr. C. O. DcLaney, Winstnn-Salom,
N. C, "A Better Perspective of Urology"; Dr. R. B.
Davis, Greensboro, .\". C, "Gas Gangrene as It
Affects th; Surgical Patient"; Dr. W. L. Peple,
Richmond, Va.. ".Arterio-Venous Aneurysm," with
Case Report; Dr. J. Allison Hodges, Richmond, Va.,
"Some Misconceptions of Psychoanalysis"; Dr. W.
deB. MacNider, Chapel Hill, N. C, "Kidney Repair
and Resistance," lantern slides; Dr. \V. C. Tate,
Banner Elk, N. C; Dr. H. J. Langston, Danville,
Va., "Repair of Old and New Lacerations of the
Birth Canal"; Dr. G. H. Bunch, Columbia, S. C;
Dr. H. C. Neblett, Charlotte, N. C; Dr. J. D.
Ilishsmith, Fayctteville, N. C, "Surgery of the
Prostate Gland and Bladder"; Dr. J. M. Hutcheson,
Richmond, Va.; Dr. J. E. Rawls, Suffolk, Va., "The
So-called Murphy vs. Ochsner Treatment of .Appen-
dicitis"; Dr. M. O. Burke, Richmond, Va., "Chronic
Appendicitis as a Cause of Indigestion"; Dr. .Alfred
L. Gray, Richmond, Va., "Some Obscure Deforming
Bone (Tonditions"; Dr. Garnctt Nelson, Richmond,
Va., "Nephrosis," Report of Case, lantern slides;
Drs. Dewey Davis and Douglas VanderHoof, Rich-
mond, Va., "Coronary Occlusion with report of two
cases which came to autopsy"; Dr. F. S. Johns,
Richmond, Va.; Dr. Ivan Procter, Raleigh, N. C;
Dr. .\. B. Greenwood, .Ashevillc, N. C; Dr. Parran
Jarboe, Greensboro, N. C; Dr. W. C. Ashworth,
Green.sboro, N. C; Dr. Linwood D. Keyser, Roa-
noke, Va., "The Continuous Irrigation of Wound
Cavities, Some Clinical Observations on the Effect
of Normal Saline-Boric Acid Solution in Promoting
V\'ound Granulation"; Dr. C. C. Coleman, Rich-
mond, Va., "Differential Diagnosis of Brain Tumor
from Cerebral Vascular Disease," lantern slides; Dr.
E. G. Gill, Roanoke, Va., "Foreign Bodies in the
.Air and Food Passages."
(Additional titles received: Dr. McKay, "Stric-
ture of Female Urethra"; Dr. Gayle, Psychiatric
Coisideralion of Abortion; Dr. Barron, "Further
Considrr^ilion of Brain and Cord Conditions" ; Dr.
Bunch, F.nce phalocele" ; Dr. Procter, "Fibroids" ;
Dr. Jarhue, "Pre- and Post-operative Treatment" ;
Dr. .'ishworth, "Institutional Treatment of Addic-
tions.")
Scrutinize it carefully, fellow-members and
other subscribers. Then show it to some of
your doctor friends, make hotel reservations
for the meeting, and bring these friends up
to Greensboro with you. Bring patients up
for diagnosis, notifying Dr. R. B. Davis,
Chairman of the Committee of Arrangements,
Greensboro, in advance. Along with each
patient bring history and record of your study
of the case so far.
We are going to have a great meeting, de-
voted wholly to study. No preliminaries. No
entertainment. Nothing but serious attempts
to learn what to do about sickness. Come.
SOUTHERN MEDICINE AND SURGERY
January, 1929
DEPARTMENTS
HUMAN BEHAVIOR
Jamf.s K. Hat.l, M.D., Editor
Richmond, \'a.
Prognostic
A few years ago the appointment by the
Governor of a gentleman to fill a vacancy on
the board of directors of the State Hospital
at Raleigh caused another gentleman to re-
mark that the time was at hand in which to
get Dr. Albert Anderson out of the superin-
tendency of that institution. J'lst at the be-
ginning of the recent trial of Dr. Anderson
the remark was made that little hope was
entertained of being able to convict Dr. An-
derson of any crime, but that it might be
possible lo seem to tarnish him to such a
degree that the new Governor of the state
would feel it incumbent upon himself to ask
for Dr. .Anderson's retirement. Most people
who have good sense and honest hearts prob-
ably realize that the trial of Dr. Anderson
was only an incident in the general local plan
to get him out of the superintendency. The
trial constituted only the boldest, the most
outspoken, and the most dramatic move yet
made in that direction. I find myself won-
dering if the people of the state know that
fact. That it is a fact I have no doubt at
all.
Just aftf-r the fusion party came into power
in North Carolina about thirty j'ears ago an
effort was made to remove Dr. P. L. Murphy
from the superintendency of the State Hos-
pital at Morganton, a position which he had
held with great credit to himself and with
enormous u'^efulness to the state since the
doors of that hospital were opened first in
1883. The effort failed. My recollection is
that a pronouncement of the Supreme Court
kept Dr. Murphy in office. The movement
to oust him was purely political and it de-
served to fail. The State Hospital at Mor-
ganton. now presided over by Dr. John jMc-
Campbell, was investigated only a year or so
ago. The removal a few years ago from the
superintendency of the Caswell Training
School at Kinston, of Dr. C. B. McNairy
reflected no credit at all upon the state. .\nd
not long ago grave charges wer* preferred
against the State Board of Health— at least
against some of those in its employ. Dr. P.
L. ]Murphy used to say that he would not
have the superintendency of the State Hos-
pital at Raleigh if it were offered him on a
gold platter, because the two-by-four politi-
cians of the state were always trying to make
use of that hospital for their own purposes.
There are undoubtedly those who are un-
able to escape the painful belief that the
Commissioner of Public Welfare of North
Carolina was one of the chief driving influ-
ences against Dr. Albert Anderson in his re-
cent trial. Throughout the trial, at any rate,
the Commissioner occupied a seat at the t?i-
ble of the prosecutors. Next to the Com-
missioner throughout the trial sat Dr. Crane,
a member of the faculty of the University
of North Carolira. He has some connection
with the Depa;tov-t of Public Welfare of
the state. I realize, of course, that the Com-
missioner of Public Welfare may occasionally
be called upon to b^n.r testimony against a
citizen of the state. But I think of the Com-
missioner of Public Welfare as a judicial
rather than a prosecutory officer. A prosecu-
tor develops a suspicious and a detective state
of mind. Such a transformation must nec-
essarily take place in the attitude of one
wliose d'lty it is to prosecute. Such an offi-
cer must necessarily be on the lookout for
reasons for prosecuting. But the Department
of I^ublic Welfare, if it is to function to the
limit of its usefulness, must work in conjunc-
tion with many other agencies of the state.
Were I the superintendent of a state hospital
(thank God I am not!) I could not work
with any degree of concordance with a Com-
missioner of Public Welfare whom I thou li'
to be on .the lookout for reasons for prosecut-
ing me. If the office of the Attorney Gen-
eral, and the office of the District Solicitor
.^hould need the assistance of the prosecu*'- ■
skill of the Commissioner of Public Wei'
they .should have such assistance, in (i li i
Ihat their work be well done, but I am of Mie
opinion that a Commissioner of Public Wel-
fare can not concomitantly act in the dual
January, 1929
SOUTHERN MEDICINE AND SURGERY
capacity of prosecutor and general welfare
a.iient. Some functions are not miscible, just
as some chemical substances are not.
T continue to find myself wondering why
the charges against Dr. Anderson were not
laid before his board of directors. They are
intelligent, honest, patriotic men. Their duty
is to manage the institution which the gov-
ernor of the state placed in their care. Does
any one know of any rational or legal reason
why the charges should not have been heard
by the board? The Commissioner of Public
Welfare probably could have taken them
there. The Attorney General could have
directed all complainers to the board. Even
the Solicitor might have doubted for a mo-
ment the wisdom and the propriety of his
usurping the function of the board of direc-
tors. Does any one know why the board of
directors was denied the opportunity to hear
the charges? What was the reason? I have
not the slightest doubt that the superintend-
ent of almost every state hospital in the coun-
try on every day of the year that he makes
rounds through his wards is subjected to just
about such criticisms as Dr. Anderson was
subjected to in Wake Superior Court. More
or less regularly such superintendents are
charged by some of their patients with being
ignoramuses, adulterers, thieves, embezzlers,
and murderers. Such charges do not sound
out of place in some of the wards in an in-
sane asylum, but such charges should not be
extra-muralized and dignified by prosecutory
iteration and reiteration in a criminal court
e.Ncept for the most valid and substantial rea-
sons.
The problems arising out of disorders of
conduct weigh with increasing heaviness upon
all governments — municipal, state and fed-
eral. Because of the ignorance of all of us
of the fundamental nature of these problems,
and !)erause of the scarcity of trained work-
ers in these domains, limited progress is be-
ing made in welfare work. And even that
little bit of progress will give way to retro-
gression if the various agencies are going to
work discordantly, and not harmoniously. In
the meantime, I believe psychiatric work in
North Carolina is being pushed back ruth-
lessly and relentlessly.
Many citizens of the State of North Caro-
lina must be wondering how and why Dr.
Crane, a member of the faculty of the Uni-
versity of North Carolina, finds the time in
which to SL'at himself at the table of the dis-
trict's prosecuting attorney for a solid week
during the trial of a state offcial in a criminal
court. What business has the University, or
one of its professors, in engaging in the prose-
cuting of state officials, or of anybody else?
Governor Gardner is the son of a physician,
and it is impossible to believe that he would
wittingly lend himself to the wiles of those
who would have Dr. Anderson removed from
office, however specious the pretext might be.
But there is little doubt that such appeals
have already been made to Governor Gard-
ner, and less doubt that similar appeals will
continue to be made to him. But some day
the medical profession of the state will surely
arise and speak its mind.
The Right Book .at Last
Every once in a while I find some book
for which I have subconsciously long been
\earning. White's Lectures in Psychiatry
has given me a feeling of such complete sat-
isfaction as no other volume, big or little,
that has come into my hands for a long, long
time.
It is not easy to talk or to write about
mental" states, normal or abnormal, and keep
one's mental feet always on the ground. But
White never leaves the earth and takes to
the clouds; even if he does occasionally take
a short flight up into the psychoanalytical
realms he never leaves his friends below him
in the low grounds of doubt and perplexity
and mystification — he always transports them
along with him and interprets the landscape
for them. I know of no teacher so provoca-
tive of individualistic thinking. He thinks
his own thoughts and he inspires his students
and fellow-workers into the belief or the de-
lusion that they are capable of doing as great
things. And that is a splendid, encouraging
feeling to arouse in any mere mortal. I have
a number — scores perhaps — of books dealing
with disorders of the mind. Were I told
tonight that I should have to give all of them
up save only one I should grasp in both
hands. White's Lectures in Psychiatry, and
cling to it with all my strength. Why? It
is small, 167 pages all together, it is light,
it is engaging in its charm and simplicity, it
is lucid, and from the first word of it to the
last it is informative. The two final chapters
4t
SOUTHERN MEDICINE AND SURGERY
January, 192*
in the little volume enable me to have a con-
ception of dementia praecox which tends to
clarify one of the great medical obscurities.
This presentation of psychiatric thought is
made in the form of twelve lectures, in which
the symptomatology in its various kinds is
illustrated by fifty patients. The curious be-
havior of so-called insane folks is enormously
interesting to most people. But their con-
duct, per se, has no interest at all for Dr.
White. He is concerned with the meaning
of their behavior just as an internist is con-
cerned with a patient's elevation of temper-
ature, and an orthopedist is concerned with
an individual's posture. Dr. White wonders
what behavior means^ and even in the most
insane patient he is able to understand the
particular conduct as an effort at individual
adjustment. What Dr. White does for me
is to cause me to keep in front of my eyes at
all times a little placard on which is stamped
in bold type this interrogation: What does
this thine; mean? The lectures are intended,
of course, for those beginning the study of
psychiatry, and a copy of them should be
amongst the books of every medical student.
The forcefulness and the simplicity of the
point of view will prove stimulating and in-
spiring to welfare workers, criminologists,
ministers, practitioners of medicine, and all
people in general who are interested in the
meaning of human behavior.
He has been interrogating himself about the
meaning of mental disorders for many years,
and in these lectures are presented the an-
swers to many of his own questions.
The little book is the most interesting
printed matter that I have had hold of for a
long time, and I shall not give it up until a
second edition robs me of it.
I have no idea what the estimate of its
value by the publishers may be; but, un-
doubtly, this estimate is too little. But it
comes from the press of the Nervous and
Mental Disease Publishing Company, 3617
Tenth Street, N. W., Washington City, and
its author is. of course, Dr. William A. White,
superintendent of Saint Elizabeth's Hospital,
Washington.
THE STORK STUTTERS
!j- "I hear your wife gave birth to triplets. Going to
jjj ^U paw the cigars?"
*W ■ "No, I'm gonna pass the hal."— 0*to. Whirlwiitd.
PEDIATRICS
Frank Howard Richardson, M.D., Editor
Black Mountain, N. C.
Human Lactation
Attention has more than once been called,
in this column, to the humiliating fact that
doctors are obliged to turn for the most part
to the work of veterinarians, dairy experi-
menters, etc., for their knowledge of lactation,
rather than to the original work of observers
of their own profession. In other words,
much of what we know about the secretion
of human milk is merely by analogy with
known facts established regarding the most
noted milk producer among the mammals —
the cow. The pediatric editor has called at-
tention to some of the comparatively rare in-
stances of original work along the line of
observing human lactation; and takes great
pleasure in noting here a recent piece of work
of this sort, that has been abstracted in the
hi'.crnational Medical Digest.
The original study was made by Lowebfeld
and Widdows, in the obstetric department of
the Royal Free Hospital; and was reported
in full in the spring number of the Journal
oj Obstetrics and Gynaecology of the British
Empire, 1928. They call attention to the
scant knowledge of the phenomena of early
human lactation; and note that its develop-
ment in different women varies considerably
both in date of appearance and in composi-
tion.
The first tj'pe shows a tendency to breast
activity during the later months of preg-
nancy; the milk comes in early; it is not
viscid; it is homogeneous; the protein and
ash content are low. The second type shows
inactivity during pregnancy, not producing
an appreciable amount until after the first
twenty-four hours after delivery. It is viscid,
not homogeneous, and is high in protein and
ash content. The duration of colostrum se-
cretion depends upon both the type of mater-
nal development and the vigor of sucking on
the part of the baby.
One observation fits in rather well with the
experience of many observers, although it
disagrees with the accepted dicta. They state
that small quantities of early milk have a
food value approximating to larger quantities
of mature milk. While it has seemed as if
this must be the case, it is very satisfying to
have the impression corroborated by accurate
January, 1939
SOUTHERN MEDICINE AND SURGERY
49
observation.
The percentage of sugar and protein varies
slightly at the beginning and ending of a
feeding; but the differences are without clin-
ical significance. In this it would seem as if
human and bovine lactation were similar; for
it is a well-known fact that "fore-milk'' is
high in sugars, whereas '"strippings" are al-
most pure cream.
Unlike these constituents, the percentages
of calcium and ash are not affected by the
time at which the sample is taken. The per-
centage of fat is dependent inversely upon the
amount of fluid present in the breast at the
time of extraction; and directly upon the
amount of pressure exerted upon the areola, —
a fact of interest to those who rely much
upon manual expression.
It is sincerely to be hoped that others hav-
ing the opportunity to make careful observa-
tions along similar lines, will do so; and
thus remove the stigma that has rested upon
the pediatricians, of being so obsessed with
the elaboration of new substitutes for human
milk, that they have had neither time nor
interest for the study of the normal secretion
of natural food by the mother for the baby.
EYE, EAR, NOSE AND THROAT
For llih issue, V. K. Hart, M.D., Charlotte
Charlotte, N. C.
Vertigo
Dizziness is a very common symptom. Its
cause usually lies in one of two groups: A.
Organic. B. Functional.
The organic may be grouped as: 1. Ocular.
2. Vestibular (middle ear disease with exten-
sion to the inner ear). 3. Intracranial lesions.
The functional may be subdivided into: 1.
Cardiovascular disease. 2. Toxemia from any
drug, organ or focus affecting the labyrinth.
.V Less commonly, certain nervous diseases
such as neurasthenia, hysteria, epilepsy, and
migraine.
Eye strain is probably the most cninmon
cause. The correction of an obvious error of
refraction often gives complete and perma-
nent relief, .^n eye muscle unbalance is often
a factor with or without a refractive error.
Such requires special consideration, and often
special treatment.
Otitis media, acute or chronic, may involve
th? irnfr car 4* any time 'rith a conr^quent
labyrinthitis. That complicating an acute
middle ear is not as common as an extension
from a chronically discharging ear. Either
may give an acute labyrinthitis with intense
vertigo. Such is usually accompanied by
nystagmus to the opposite side. The variety
of labyrinthitis is too big and technical a.
field for discussion here. That complicating
an acute middle ear ordinarily demands a
simple mastoid operation and nothing else.
That with chronic otitis demands more
consideration. The whole clinical picture
and all the laboratory finds must be con-
sidered. Perhaps in an early involvement
a mastoidectomy alone will give relief. If a
serous type has progressed to a frankly sup-
purative type with or without fistula, it may
be necessary to also open the labyrinth. This
is of course a dangerous surgical procedure
and not to be undertaken lightly. A cere-
bellar abscess often complicates a chronic ear
and may give intense vertigo.
This raises the question of brain tumor.
One of the cerebellum, eighth nerve, tempo-
ral lobe and cerebello-pontile angle very com-
monly gives vertigo because of interference
with the labyrinthine pathways. Similarly
any lesion so placed as to interfere with these
pathways may produce dizziness.
So much for organic or direct interference
with labyrinthine pathways. Next are con-
sidered the functional or indirect causes.
Of course, either a high or low blood pres-
sure may give vertigo. The underlying causes
are the problem of the internist. Any cardiac
condition with a changing or abnormal blood
pressure may affect the labyrinth and give
dizziness.
A toxic labyrinthitis is not uncommon. It
may come from any deranged organ or focus
of infection. The treatment is tantamount to
finding the source of the toxemia. Now and
then a diseased pair of tonsils are the of-
fending organs. Likewise, abscessed teeth.
A gastro-intestinal toxemia is frequently a
factor. Nicotine is particularly apt to pro-
duce vertigo. »
Meniere's syndrome — sudden intense ver-
tigo followed by marked deafness and often
tinnitus, in one ear — is probably the result
I if a precipitate hemorrhage into the labyrinth
from toxic or hypertensive origin.
Does direct metastatic infection of the
labynjith occur from distant foci in such
cases? Probably very rarely. If such oc-
SOUTHERN MEDICINE AND SURGERY
January, 1Q29
ciirred one would expect to see evidence of
infection, viz., blood and temperature changes
and general prostration. INIost often, how-
ever, these are absent except when direct ex-
tension from a chronically discharging ear has
occurred.
Lastly neurasthenia, hysteria, epilepsy and
migraine are occasionally accompanied by
vertigo. Treatment must be directed to the
nervous disease present.
LABORATORIES
For this issue, Nannie M. Smith, M.A.
Charlotte
Sickle-cell Anemia
Herrick in 1910 first described the condi-
tion which is termed sickle-cell anemia. He
observed sickle-shaped red cells and red cells
of other unusual shapes in the blood of an
East Indian Negro, who had a severe anemia,
jaundice, and a history of ulcer of the leg.
In the thirteen years that followed only four
other cases of sickle-cell anemia were re-
ported.
In 1913 Sydenstricker, Mulherrin and
Houseal reported two other cases' with obser-
vations in nine of the patients' relatives. In
the same year Huck reported three cases with
observations on seventeen of their relatives.
Sydenstricker in 1924 had completed a se-
ries of eighty cases. The work of these in-
vestigations forms the basis of the present
knowledge of this peculiar condition of the
blood.
Sickle-cell anemia is a familial and heredi-
tary condition which has been found only in
the negro race and in mulattoes. It is thought
to be transmitted according to the mendelian
law. sickling being a dominant characteristic
of the red cells. It occurs in both sexes.
Sickle-cell anemia has been found to be
recognizable in two - phases. In the active
cases, the patient is poorly developed. The
sclerae show a greenish discoloration. The
mucous membranes are pale. The superficial
lymph nodes, the liver, and the heart, are
enlarged. There is an acceleration of the
heart rate and a lowered blood pressure. The
legs quite frequently show ulcers or the scars
of ulcers. There is, in the active cases, pro-
nounced anemia and arthritic and muscular
pain, without evidence of inflammation.
Most ca<;cs show recurrent attacks of epig.is-
tric and ieil hypochondriac pain. There are
commonly fever of a low grade, and night
sweats. The history is one of remissions and
relapses.
In the latent cases there is no striking phy-
sical variation from normal, and symptoms
are not m.arked. There is discoloration of
the sclerae but only a slight enlargement of
tlie lymph glands and the liver. These cases
present no symptoms of anemia; but they
often give a history of rheumatic attacks, of
attacks of epigastric and left hypochondriac
pain, and of periods of weakness and dyspnea.
The urine in both active and latent cases
shows a low specific gravity and a small
amount of albumin. Urobilin is present in
small amounts in the latent cases and in large
amounts in the active cases.
In the active phase the red blood cells may
be reduced to two million or less. The hemo-
globin is reduced in proportion with the red
cells. The leucocytes are increased in num-
brr. varying, according to Sydenstricker, be-
tween 11,000 and 64,000. Reticulated red
cells are increased in number. Many sickle
cells are present in stained smears and in
preparations of the fresh blood. Many nor-
moblasts and occasional nucleated sickle cells
are seen. Large amounts of bilirubin are of-
ten present.
The blood in the latent phase ordinarily
shows no anemia or increase in leucocytes.
The fresh blood at first shows marked changes
in shape; but, when it is sealed under a cover-
slip and examined after from a few hours to
thirty-six hours, the typical abnormal forms
are seen. In sealed preparations the sickle
cells put out long flagella-like processes.
Experiments have shown that sickle-cell
formation takes place in a saline or citrate
su-^pcnsion as well as in the presence of se-
rum. Susceptible cells when washed assume
their abnormal forms in the presence of nor-
mal serum. Normal cells do not become
sickle cells in the presence of serum from a
person who has the quality of forming sickle
cells. Sickle-ccll formation has been found
to be inhibited by cold, and accelerated by
heat. Rile pigment and bile salts also accel-
erate their formation.
Josephs noticed that, after the blood af a
patient having sickle-cell anemia had been
washed six times with saline, the cells lost
their typical abnormal shape and did not
resume it even after forty-eight hotirs. How-
ever, when these cells were mixed with tht
janujin', i929
SOUTHERN MEDICINE AND SURGERY
ii
six portions of saline used to wash them, they
again became sickle-shaped except in the
saline of the last two washings. He found
also that the v«ashed blood of persons having
sickle-cell anemia resumed its abnormal shape
when mixed with saline used to wash normal
blood. Normal blood is not affected by the
presence of saline used to wash blood with
the sickle-cell trait.
Hahn and Gillespie observed that a saline
suspension of cells with the sickle-cell trait,
when allowed to sediment by gravity, showed
sickling of the cells in the bottom of the tube,
but did not show sickle cells after agitation
of the contents of the tube. They conducted
experiments to determine whether or not va-
riations in oxygen tension is responsible for
the phenomenon of sickling in cells which are
predisposed by heredity to the formation of
sickle-shaped cells. They assumed that the
red cells in the saline suspension continued a
metabolism which used up the oxygen in the
medium. Therefore, in their experiments,
they took into consideration the presence of
carbon dioxide, variation in the hydrogen ion
concentration, and deprivation of oxygen.
They found that, when carbon dioxide, hy-
drogen and nitrous oxide were passed over a
suspension of susceptible cells in a gas cham-
ber, sickle cells were found in a few minutes.
Nitrogen did not cause sickle-cell formation,
and ethylene was inconstant in its effects.
Admission of o.xygen to the cells after ex-
posure to the gases which caused sickle-cell
formation caused them to resume their nor-
mal shape. The cells retained their normal
shape in the presence of carbon monoxide.
It was found that carbon monoxide as well
as oxygen caused cells which had become
sickle-shaped after exposure to carbon diox-
ide, hydrogen and nitrous oxide, to re-
sume their normal shape. This fact led Hahn
and Gillespie to conclude that since none of
the gases which induce sickle-cell formation,
form as stable a compound with hemoglobin
as do carbon monoxide and oxygen, when
hemoglobin is in the combined state (with
carbon monoxide or o.xygen) the discoid or
normal form is stable; and that when the
hemoglobin is in the uncombined state the
distorted form is stable.
Since carbon dioxide altered the hydro-
gen ion concentration of the cell suspension
medium, it was thought that there might be
some relation between the formation of sickle
cells and the hydrogen ion concentration of
the medium. Cell suspensions were acidified
and tested with the gases which did not form
sickle cells in suspensions and sickle cells
foimed in a few minutes.
Acidification was not necessary to the pro-
duction of sickle cells with the gases, hydro-
gen and nitrous oxide, nor with ethylene, on
occasional trials. It was thought probable
that these inconsistencies arose from varia-
tions in sensitiveness to asphyxia of cells from
different persons, and from accidental shifts
in the hydrogen ion concentration.
ORTHOPEDIC SURGERY
O. L. Miller, M.D., Editor
Charlotte, N. C.
Common Foot .'\ilments in Children
Most children are born with good feet and
they are well taken care of until about adol-
escence. The worst enemy to the welfare of
the human foot is style in footwear — not
shoes but footwear. Some footwear could not
literally be called shoes. Style in footwear is
not given much attention until about adoles-
cence, hence the explanation of the general
well being of the foot up to that period.
FLAT-FOOT
Pediatricians and doctors in general prac-
tice see a good many children from about
age two to eight, whose mothers are worried
because the children apparently have flat-
foot. This condition occurs in children who
have been improperly fed in infancy. It is
seen most often in the child who was a bottle
baby, and this type of foot affection is akin
to rickets. As certain children, with a meta-
bolic imbalance called rickets, acquire knock-
knees and bowlegs, so do they for the same
reason get relaxation of the multiform struc-
tures about the feet and acquire the deform-
ity of flat-foot. Some children with this type
of flat-foot seem to have discomfort and oth-
ers do not. They are usually j^resented to
the doctor because the mother is alarmed
about the ugly appearance of the feet.
The treatment is both medical and ortho-
pedic. The child should be managed from a
dietary and hygienic standpoint just as he
would be if he had any of the other symp-
toms of rickets. After a period of time he
will be generally stronger and in just that
proportion will the structures about his feet
Si
SOUTHERN MEDICINE AND SURGERY
January, 192^
be less relaxed and these members be more
normal in appearance. The time for this
change or improvement to take place will be
from a number of months to several years.
The orthopedic management of flat-foot in
the child is to give moderate support to the
relaxed structures along the lateral arches,
while the anti-rachitic diet and exercise are
depended on to bring about permanent cor-
rection, or satisfactory improvement in the
strength and appearance of the feet. In the
very small child, a lift (inside, outside, or
both) along the inner aspect of the shoe can
be recommended. This will throw the weight
more normally through the foot and prevent
the heavier thrust through the little arches.
If tliis is done, the foot will be better off
right at once and will look a great deal bet-
ter in the shoe. In the older child (four years
or older) special exercises can be prescribed
to strengthen the muscles and ligaments on
the inner aspect of the feet, and this will
very much supplement the help expected from
shoes raised on their inner border as suggest-
ed above.
Exercises which strengthen the feet are
those which bring into use the anterior and
posterior tibial muscles and the muscles and
ligaments which ilex the toes. The child
should be taught to adduct the whole foot in
a series of exercises lasting for fifteen or
twenty minutes, and to do this at least twice
a day. He should also be taught to forcibly
flex the toes, adduct and dorsi-flex the fore
part of the foot. A very simple way to get
this exercise done is to give the child twenty-
five small marbles and let him pick them up
from the floor with his toes and drop them
into his shoe, while the shoe rests to the inner
side of the foot at work. Doing such exer-
cises religiously over a period of several
months and wearing shoes with inside lifts
will do a great deal toward making a very
competent, well appearing foot out of a po-
tentially poor one.
If a child grows into early adolescence with
structurally weak, flat-foot and refuses to
respond to more conservative measures, oper-
ations can be done which will contribute to-
ward improvement. However, such opera-
tions are not indicated until the foot has had
considerable bone growth.
HEEL PAIN
Occasionally, a child at about age ten or
twelve will have pain in the heel, and limp
about for several weeks. Ruling out old-
time "stone bruise" or splinters, this will
usually be an infectious epiphysitis. In such
cases one should look out for infectious foci
somewhere in the body, as this is distinctly
an infectious affair, though a history of slight
injury is usually given. If the foot is rested
a few days and the infectious focus removed,
the child will soon be well. This same infec-
tion intensified may become osteomyelitis of
the OS calcis which of course is a disease of
some gravity and is not being discussed here.
The heel pain occurs most frequently in boys,
and is probably due to the fact that at the
age period boys are putting so much more
stress on their feet, and the resistance in their
epiphyses is lowered because of rapid growth.
SCAPHOIDITIS
At about age fourteen and even later, one
will occasionalh' see a pathological condition
referred to the lateral arch of the foot which
is due to a low grade infectious process in
the scaphoid bone. This process is very simi-
lar to the heel pain just described, and such
infections occur in the foot in three selective
places — 03 calcis, scaphoid bone and head of
one of the metatarsals.
In a case of scaphoiditis, one should sus-
pect prior infection somewhere and try to find
it. The tender area should be strapped with
adhesive to take some of the weight stress
off, and, if the pain is very annoying, put
the patient to bed and apply hot applications
for a few days. As a rule, this ailment gets
permanently well in a few weeks, unless it is
excited by unusual trauma.
It is well to bear in mind, and teach, that
a child has good muscles, or potentially good
muscles, to maintain the arches and general
strength of the feet and that, if they are
properly developed, he will have good feet.
If the muscles are not used in the right way
and are allowed to become lazy or atrophied,
the feet will have p>oor, weak posture com-
parable to the poor posture of stooped shoul-
ders and round backs. They may get along
without serious symptoms in early life, but
will sooner or later find themselves unable
to perform important tasks requiring extra
use of the feet.
Fortunately, children can get very sensible
shoes; and they do exercise the feet in their
normal activities. We do not see so many
January, 19^9
SOUTHERN MEDICINE AND SURGERY
n
besetting foot ailments in child life, and I
expect to deal with the adult foot ailments
in another article. Some of these ailments
are — arch troubles, heel spurs, arthritis, bun-
ions, hallux valgus, hammer toes, corns, etc.
UROLOGY
For this issue, Roy P. Finney, B.S., M.D.
Spartanburg, S. C.
COH.^BITATION PYELITIS
Though pyelitis in its most limited sense
simply means infection and inflammation of
the mucous membrane lining the pelvis of
the kidney it is by no means a stereotyped
disease. There are many and varied clinical
types. Of these one of the most interesting
and certainly not the least important is that
of cohabitation or post-nuptial pyelitis.
The first comprehensive description of it
was given by Rovsing in 1897 who reported
three cases. Wildbolz, Sippel, Braash, and
others have supplied instructive papers on
the subject but most of these have appeared
in foreign journals or in periodicals devoted
to one of the specialties so that it is not
unusual to find a doctor who is unacquainted
with the important features of the disease.
Post-nuptial pyelitis, as the name implies,
comes on soon after marriage. The most
important factor in the pathogenesis is the
trauma and congestion incident to the first
sexual acts. A small vaginal orifice and hy-
pertonic perineal muscles, or a thick unyield-
ing hymen, predispose to the disease. A hus-
band who, in the ardor and pride of muscu-
lar manhood, asserts his newly acquired rights
with reckless abandon, is capable of produc-
ing serious trauma, not only to the vagina,
but to the urethra and even the bladder.
Some dispute has arisen as to the route of
invasion; whether by direct extension along
the lumen of the urethra, by way of the lym-
phatics, or through the blood stream. Logic
and the most impressive evidence indicates
that it is an example of simple ascending in-
fection along the urethral lumen; urethritis,
cystitis, and pyelitis occurring in sequence.
The causative organism is always the colon
bacillus.
There are no dependable statistics as to
the frequency of the condition. Severe or
protracted cases requiring the immediate ser-
vices of the urologist are comparatively rare.
However, it is certain that many cases of
minor severity remain latent, or are unrecog-
nized, only to flare up when pregnancy, stone,
or some other factor, interferes with kidney
drainage.
The disease develops usually during the
second or third week following matrimony.
The onset of chills, fever and pain in the
back is always preceded by symptoms of cys-
titis. Frequent and painful urination, with
urgency and strangury, may be quite marked
a week or more before fever and prostration
indicate kidney involvement. Of striking in-
terest is the fact that, as fever and toxemia
increase, the bladder symptoms diminish. In
my experience it is most unusual to hear a
patient with severe acute pyelitis complain of
dysuria.
Diagnosis should never be difficult. A his-
tory of painful and frequent urination in a
recently married woman generally means
pyelo-cystitis.
If it is not pyelo-cystitis, it is gonorrhea;
but here one should be extremely careful, for
there is a medico-legal aspect that should be
borne in mind. The latter diagnosis should
never be made verbally unless it can be sub-
stantiated by smears and cultures. The
quantity and character of vaginal and ureth-
ral discharge is of no differential signiiicance
whatever. Pus may literally pour from the
urethra in a colon bacillus infection, and
may be so scant as to be scarcely noticeable
in active gonorrhea. It is possible of course
for the two to occur together; but, even so,
proper laboratory tests supplemented by cys-
toscopy will clear up the diagnosis without
difficulty.
The treatment of post-nuptial pyelo-cys-
titis is at first distinctly medical. If the pa-
tient is seen before fever and toxemia appear
she should be put to bed, given a mild cathar-
tic and forbidden sexual excitement. Her
fluid intake is limited and caprokol, ten cap-
sules per day, administered. One ounce of a
freshly prepared ten per cent solution of ar-
gyrol is gently instilled into the empty blad-
der once daily, and suitable antiseptics ap-
plied to the vagina if vaginitis is present.
Such treatment will frequently abort or pre-
vent a severe kidney infection. Caprokol is
a weak bactericide to the colon bacillus, but
it does seem to alleviate bladder pain' and
itrangury.
54
SOUTHERN MEDICINE AND SURGERY
Januati,', 1929
If high temperature and toxemia are pres-
ent the medical regime is considerably dif-
ferent from that described above. Fluids are
administered in large quantities by mouth,
or by proctoclysis and hypodermoclysis if the
stomach is rebellious. Caprokol is useless
because one dare not limit the fluid intake in
the face of hyperpyrexia and toxemia. ^Sleth-
enamine may be used in large doses if the
bladder is not irritable; but, if it is, one of
the alkaline diuretics is given instead. If
distinct improvement is not brought about
by this plan of treatment in a few days ure-
teral catheters must be inserted for the pur-
pose of lavaging and draining the renal pelves.
The physician who is tardy in offering his
patient the benefits of cystoscopic treatment
is derelict in his duty.
It is urgent that treatment be continued
without interruption until the urine is free of
pus and bacteria. Pregnancy should not be
allowed to occur until this has been accom-
plished.
RADIOLOGY
John D. M.^cRae, M.D., Editor
Asheville, N. C.
Routine Use of X-rays in Public Health
Work
Routine examination of children in schools
and clinics discovers many who are under-
nourished. Occasionally they are in groups
and the problem is to ascertain the state of
health of individuals to classify them. Often
these groups are analyzed and causes recog-
nized; then remedies may be applied under-
standingly.
It must be remembered that the study of
groups is primarily a study of individuals
and nothing less than thorough and careful
examination of each child will produce satis-
factory results.
Undernourishment may be from eating the,
wrong kind of food or from not enough food
and it may be secondary to diseased teeth,
tonsils or sinuses.
The School Board, through its health offi-
cers and nurses, tonsil and dental clinics and
school lunches, accomplishes much toward im-
proving the health of children.
The x-rays are not especially useful in the
tonsil clinic. Though there has been quite a
vogue for x-ray treatment of hypertrophied
tonsils, it is generally held that surgical ex-
cision is the correct method of treatment. In
the dental clinic x-ray examination is of so
great use that it should be available for those
children who need dental x-rays.
Undernourishment is so generally associat-
ed with rickets and tuberculosis that in its
presence these diseases must be sought for
and recognized or eliminated. Even when
foci of infection in teeth or tonsils do exist
their removal by special treatment is not
enough. Such processes are prone to cause
lymph adenopathy, and childhood tuberculo-
sis is notably a disease of Ij'mphoid tissues.
Only the most discriminating examination will
serve to differentiate and fix the diagnosis in
childhood tuberculosis.
Physical examination, history of symptoms
and history of contact with tuberculosis may
serve to make a diagnosis but more often
than not the von Pirquet test must be done
and x-ray study of the chest also, before a
diagnosis can be arrived at. For this reason
it is urged that every child, whose health is
below par, should have a thorough examina-
tion which shall include all the above men-
tioned elements; that is, physical examina-
tion, history taking with special reference to
contacts and clinical behavior, von Pirquet
test and x-ray study.
At this point it would be a fault not to call
attention to the fact that considerable skill
is required for interpretation of chest films,
especially those of children, and this work
should not be undertaken by the untrained
but delegated to an experienced radiologist.
Equipment for this work requires x-ray
machinery which permits instant exposure
and stereoscopic films and the development
of a technic which is standardized so that it
may be duplicated at will.
It is not necessary to quote statistics. The
medical profession and the public also know
of the great prevalence of tuberculosis and
of the need for early diagnosis.
It is desirable to impress those who are
interested with the fact that no examination
for suspected tuberculosis is complete with-
out a competent x-ray study and public
health investigations will be greatly increased
in value by the routine use of x-rays.
After considering the common infections
and childhood tuberculosis in their relation
to undernourishment, another most important
nutritional disease presents itself: rachitis or
rickets.
January, 1029
SOUTttERN MEDICINE AND StJRGERY
ti
Rickets occurs in a larger per cent of young
children than is commonly realized. Drs.
Groover, Christie and Merritt examined 926
children who were practically an average of
the school children in Washington, D. C.
They found evidence of rickets in some form
in 66 per cent of them. Other investigators
have made similar observations. The disease
occurs with varying frequency in most parts
of the world. Some races are more subject
to rickets than others. Also it is more often
found in city children than in those who
grow up in rural districts. In spite of the
fact that this is a disease of the early months
and years of life its incidence is very consid-
erable in children in school. Most cases of
rickets will be found in the pediatric clinics.
The cause of rickets is not known but it is
associated with undernutrition, lack of fresh
air and sunlight and with poor housing condi-
tions. Treatment is very effective.
The disease manifests itself in the bones.
There is calcium deficiency and lack of bone
development. Secondarily there are certain
characteristic deformities. The skull tends to
become square in form and the fontanelles
are delayed in closing. The most usual le-
sions are in the long bones where epiphysis
joins the shaft. At the epiphyseal lines cal-
cium fails to deposit and the end of the dia-
physis broadens to present the appearance of
an inverted saucer. There is some conden-
sation of bone cells at this place which is
recognized after healing and growth takes
place as a transverse stria of dense bone.
There may be multiple striae which indicate
that there have been exacerbations during the
progress of the disease. Enlargements of the
limbs are noted at the wrists and ankles and
also at the ends of the ribs where they join
the costal carlila.r;cs. Tenderness develops
and results in disuse. Bone atrophy follows
disuse and is also accentuated by reason of
calcium deficiency. Following atrophy, frac-
tures are common.
X-ray studies demonstrate the characteris-
tic rachitic changes even more definitely than
symptomatology. This should be borne in
mind in examination of undernourished chil-
dren.
As there are other diseases which produce
similar changes, the interpretation calls for
differential diagnosis which must be based on
IN CONCLUSION
The examination of children in schools and
in pediatric clinics, which are conducted by
public health agencies deal largely with the
undernourished. Two most important dis-
eases associated with this state are tuberculo-
sis and rickets.
Of all the methods of examination of chil-
dren suspected of having these diseases none
are more useful than x-rays.
Good lechnic and good radiograms are es-
sential but they have little value in the hands
of the untrained.
Public health agencies should be more care-
ful in delegating this work to skilled radiolo-
gists.
SURGERY
For this issue. Georc.f. Benet, M D., Columhia
Infectious Gangrenous Dermatitis
The current issue of the United States Vet-
erans' Bureau Medical Bulletin publishes an
article on Progressive Gangrenous Ulceration
of the Abdominal Wall, by Dr. F. N. Gor-
don. This condition is one that has received
scant attention in the literature, and is one
of great interest to surgeons generally. Com-
plications following surgical procedures are
many and varied, but usually amenable to
treatment. Gangrenous ulceration is not
amenable to treatment, unless promptly diag-
nosed, and radically treated. It will not yield
to the usual treatment of ulcerated conditions.
Xo mention is made of the disease in Cran-
don's After Treatment, and a search of the
literature reveals only five case reports, prior
to Gordon's case. Cullen reported a case in
1924, shortly followed by Christopher and
Brewer. iMayeda's case report appeared in
1926, and Shipley's in 1928. With the ex-
ception of Christopher's case, the condition
invariably followed an appendiceal abscess.
Gordon describes the lesion as "carbuncular-
like, spreading, serpigenous, gangrenous, and
intractible, resisting all measures adopted to
promote healing of ulcerations. Spreading
with great rapidity at first, this slows uj) as
the ulcerated surface widens, and there is a
tendency for the part first involved to heal.
The ulceration extends from the skin down
to the deep fascia."
S6
SOUTHERN MEDICTNE AN» StmOERY
January, 1920
streptococcus, — Christopher, a Gram-positive
coccus, and a Gram-negative bacillus, — Ma-
yeda, a diphtheroid bacillus, — Shipley, a
Gram-positive coccus. Brewer reports a
haemolj'tic staphylococcus aureus, and a
diphtheroid bacillus. It has been suggested
that some j'east, or fungus originating within
the intestinal lumen is responsible. However,
in Christopher's case, gangrene developed
about the drainage wound of an empyema.
Shipley believes that two organisms are pres-
ent, each acting to increase the virulence of
the other, and that this symbiotic combina-
tion produces the destructive sloughing le-
sion.
The ulceration resists all efforts at treat-
ment,— "neither heat, cold, light, nor other
forms of radiation, had the slightest deter-
rent effect upon the spread of the ulceration."
(Gordon). In each case report referred to,
all methods of treatment were tried, and with-
out success, until the actual cautery was em-
ployed. The cautery is used beyond the
limits of the lesion, and "boldly," as one
writer describes the procedure. Healing iri-
variably followed, although it was necessary
to repeat the cauterization on several occa-
sions.
We have had one such case in our experi-
ence. A healthy young man, aged 22, was
op)erated on for appendiceal abscess, with a
resultant fecal fistula. This fistula persisted
for one week, and closed spontaneously. On
the 10th day after operation, it was noted
that the skin about the wound became dark
and gangrenous. This ulcerating area en-
larged rapidly, with great destruction of skin.
The condition finallj' involved the entire ab-
dominal wall, and extended down onto the
right thigh, and around the right flank. The
pain was excruciating, requiring morphine.
The infection was serpigenous, marginated,
and appeared to burrow beneath the skin
proper, causing complete separation of the
skin from the underlying structures. The
base of the destroyed area was covered with
a necrotic, purulent material. The entire sur-
face was tender, rendering local applications
and dressings difficult. The condition per-
sisted for a period of four weeks, and during
this time many and various measures were
attempted, including light, heat, wet dress-
ings, dry dressings, and even x-ray. Cultures
taken from the surface of the lesion showed
various strains of staphylococci, streptococci
and unrecognized bacilli — the usual findings
from superficial abscesses. No yeast organ-
isms were found. Of the various forms of
treatment tried, none was found to have the
slightest effect. The patient was emaciated,
markedly anemic, and his condition critical.
At this stage of the disease, his temperature
ranged from 99 to 102; pulse 100 to 140,
weak and irregular. Leucocytes, 40,000; red
cells, 3,500,00, hemoglobin 74 per cent, polys,
87 per cent, lymphocytes, 13 per cent. The
general picture was one of extreme sepsis, and
the prognosis was considered grave. Dr.
Richard Allison saw the patient at this time,
and made the correct diagnosis, i. e., infec-
tious gangrenous dermatitis. Two direct
blood transfusions were given, and under
ether anesthesia the entire margin of the ul-
ceration was desiccated, using the bipolar
endothermy method. Improvement was im- .
mediate. A second cauterization was done
after several days and the lesion rapidly
healed. After nine months the man is appar-
ently well. There is no cicatrix, and no trou-
blesome scars. No skin grafts were necessary.
There is no hernia about the original opera-
tive wound.
This is a brief, preliminary report of this
case. It is brought before the readers of this
journal to impress the fact that prompt diag-
nosis, and radical use of the cautery, will
quickly heal an otherwise intractable condi-
tion which may easily terminate fatally.
PERIODIC EXAMINATIONS
Frederick R. Taylor, B.S., M.D., Editor
High Point, N. C.
Eye, Ear, Nose, Sinus, Mouth and Throat
Conditions Found in Two Hundred
AND Seventy-one Consecutive
Health Examinations
Far more defects are found in this class
than in any other, as might be expected, yet
the figures show a number of things of inter-
est.
Eye Conditions Cases
Cataract, traumatic _ 1
Eyestrain (the commonest defect found).. 87
Glass eye 1
Glaucoma, chronic 1
Hordeolum 1
Pterygium, unilateral 2
Pterygium, bilateral 3
januafv-, 1929
SOUtttERK MEbtCtNE ANb StftGEkY
it
Undeveloped optic nerve, unilateral
1
Total - 97
Ear, Xose, Sinus and Throat
Cor3-za, acute - -. — - 3
Deafness, partial 13
Eczema of external ear — 1
Eustachian tube, obstructed -, 1
Laryngitis, acute 1
^lyringitis, acute 1
Nasal septum, marked deflection __ 8
Nasopharyngitis, chronic .— 1
Otitis media, bilateral .- 1
Rhinitis, chronic 1
Sinusitis, chronic antral „ 4
Sinusitis, chronic frontal 2
Sinusitis, chronic mastoid - 1
Chronic pansinusitis - 1
Tonsils, chronic infected _ 32
Tonsils, hypertrophied 1
Total - - --. 72
Teeth and Tongue
Dental infection of all kinds 83
Glossitis 1
Total 84
It should be noted that these defects were
found by ordinary methods of physical ex-
amination such as any general practitioner
should use. Had special technic been used
in either eye, ear, nose and throat exam-
inations or dental examination, no doubt a
larger number of defects would be found.
The ophthalmoscope was used occasionally,
but revealed nothing remarkable except the
undeveloped optic nerve, and that was recog-
nized simply as an abnormality, the chief
symptom of which was blindness of the eye
involved, the diagnosis having been previously
made by an ophthalmologist. The otoscope
was also used, but every general practitioner
should look at ear drums, especially if he
does not have a nearby otologist upon whom
he can call. X-ray of teeth, careful refrac-
tion, etc., would no doubt have shown much
more of importance. The single case of hy-
pertrophied tonsils is explained by the fact
that our work was practically entirely with
adults; had children been included, many
more cases would doubtless have been found.
The importance of skilled ophthalmic, den-
tal, and ear, nose and throat work to any
community is almost impossible to overesti-
mate. Such work cannot be done in the most
adequate way without the co-operation of the
general physician, who, through health exam-
inations, is in a position to refer many per-
sons for this Vi'ork and thereby save much
serious toxemia and strain.
OBSTETRICS
Hkxky J. Langston, B..\., M.D,, Editor
Danville, Va.
Backward and Forward
In a short time reports will be in giving
the number of births in the United States for
192S. The indications are that we will still
maintain our position as a nation with a very
high stillbirth rate and a very high infant
mortality shortly after birth. Maternal mor-
tality will be about the same as it was in
1927— between 15,000 and 20,000 mothers
dead. Morbid conditions in approximately a
million women that have been delivered in
1928 will be as great as in former years.
Midwives will probably have delivered in the
neighborhood of thirty babies out of every
hundred; doctors seventy. The human waste,
human suffering and human sorrow will be
as great as in former years.
As we take this backward look we believe
we are justified in urging that each physician
make a most careful review of his year's
work; find out the exact number of stillbirths
he has had and why he lost each baby; find
out the causes of deaths of premature babies,
and see if it was possible to have had a rem-
edy for this loss; study the morbid conditions
of the women he has delivered and see why
they are now pathological instead of physio-
logical. We have every reason to believe
that over one-half of the women delivered in
1928 have pathological conditions, which will
prevail until they are corrected by the gyne-
cologist. We believe that most of these path-
ological conditions could have been corrected
properly at the time of the birth of the baby,
were the profession at large willing to desert
the old teaching of letting the lacerations re-
main as they are until puerperium has passed
and then have the lacerations repaired. The
expense of these morbid conditions in these
women reaches up into the millions of dollars
annually, besides the suffering and the ab-
sence of these mothers from needy homes, the
cost of which cannot be accurately estimated.
When all the reports are in we will find
Si
SOUTHERN MEDICINE AND SURGERY
January, 1920
that toxemia of pregnancj^ and eclampsia will
be as great in 1928 as in former years. Some
of us bslieve that these toxemias and eclamp-
sias are preventable conditions, and that the
medical profession has not filled its full mis-
sion until it has eliminated these toxemias
and eclampsias; which cost man}' women
their lives, which are responsible for many
stillbirths, and which produce pathological
conditions which mothers carry, or are carried
by, to their graves.
When we look backward at our failures,
we believe we will find these failures are due
to the fact that we are not using the knowl-
edge that we now have: we are not measur-
ing our women; we are not weighing them,
and we are not keeping an accurate check of
the blood pressure or accurate records of
urinalyses, and correlating all of these so as
to make a correct interpretation of the con-
dition of each patient. Many babies have
been brought into the world injured or killed
because these principles were not followed in
the prenatal care of the patient, the physician
just allowing the case to rock along until the
hour of labor and, then, when he encountered
difficulty, he went into it with the hope of
coming out all right without having at his
finger tips the important information he could
have had if he had observed the principles
mentioned above.
We do not look backward on last year's
■work with the idea of discouraging anyone,
but with the honest objective of awakening
ourselves to the important mission of giving
to the motliers who are to give birth to the
1929 babies the very best in us in helping
them to come to the hour of labor in perfect
condition so as to enable them, with our as-
sistance, to give birth to an uninjured child
and at the same time be sure that any in-
juries to the birth canal are properly cared
for at the time of birth; that we v;ill be more
and more concerned about having healthy and
normal women to occupy all the homes of
the nation, and in that way they will be able
to be good wives, good mothers and good
citizens.
We should look forward with an open mind
to the following important things in prenatal
care and delivery:
1. To give onr best service in prenatal
care, which consists in regular weighing of
the patient, every tvro weeks, and at this time
blood pressure taken and urinalysis made
with the hope of correlating all of these and
keeping the patient very close to her normal
Vvcight, certainly not allowing her to gain
over twenty pounds.
2. That we will accurately measure the
pelvis and do our utmost to accurately esti-
mate the size of baby so as to be certain that
the birth canal is not too small for the pas-
sage of baby. If the birth canal is too small
for the passage of baby, then we will not
allow our patient to go through the so-called
test of labor, but after she has gone into labor
far a little while we will use the cesarean
method of delivery and thereby save both
mother and baby.
3. That by proper care we will eliminate
most toxemias of pregnancy and eclampsia;
and, if the toxemia and eclampsia conditions
persist and we find we cannot carry our pa-
tient to the hour of labor we will properly ,
deliver a premature baby which may or may
not live.
4. That we will do our utmost to eliminate
stillbirths by studying each case most care-
fully; thus we will find that with each suc-
ceeding case we will improve on our prenatal
care and method of delivery and in taking
care of patient during the puerperium.
5. That by proper study of these patients
we will keep them on the right sort of diet,
the right sort of exercise and thereby keep
their bodies physiologically in good condition.
6. That we will try to follow every new
truth in the field of obstetrics whose objective
is to see that every mother will come to the
hour of labor unafraid and will be sure to
come through that period all right with the
assistance of the best knowledge that can be
had in the practice of obstetrics.
7. That we as medical men who are inter-
ested in human reproduction, human happi-
ness, human health and human peace will help
the laity to see to it that the field of obstet-
rics is occupied by competent medical men
who will deliver all the babies and that the
midwives will help us to take care of the
mothers during puerperium, also they wdll
stimulate the desire of women to be properly
cared for through the prenatal period. These
competent men will at the time of delivery
take care of injuries to the birth canal, both
the cervix and the vagina, repairing them
properly then. It will be discovered that in
January, 1039
SOUTHERN MEDICINE AND SURGERY
proportion to the number of repairs made to
the injured birth canals the number of path-
ological conditions will be eliminated.
As we look forward to the work of 1929
we hope that the little ones to be born will
be brought into the world uninjured; that
the mothers who are to give birth to these
little ones come through the experience alive
vvith bodies uninjured, with minds not filled
with the horrors of labor; but that, on the
other hand, they will have the joy of knowing
that the medical profession is honestly trying
to help them throu-zh this terrible ordeal in
the most scientific way, turn them back to
their homes physically fit to be wives and
mothers and good citizens. The way is wide
open and progress can be made in this im-
portant field which will eliminate many of our
failures of, the past. Our forward look then
is to open our minds and let the field of ob-
stetrics snow scientifically from every angle.
PUBLIC HEALTH
For litis issue, Envio:-: G. Wuxiams, M.D.
Ccmmissioner of Health of Virginia
Influenza
At the present time everybody is, or should
be, interested in the influenza situation in
Virginia and throughout the country. The
present epidemic of influenza appeared first
in California in October. It was unexpected
as the health prophets were not anticipating
an epidemic of influenza again for another
fifteen or twenty years. As far as records
show, it had appeared in epidemic form about
every thirty-three to forty years. We had
an epidemic in 1918, 1888-89, and in 1851-
52.
The newspaper reports of the outbreak in
California were not taken very seriously at
first nor were close records kept of it as it
sproad eastward. It first appeared in epi-
demic form in Southwest Virginia just after
Thanksgiving day. It was not looked upon
as very serious until it had been in Virginia
about ten days. Then it began spreading
rapidly and attacked certain communities
rather heavily. On December 10 the State
Health Department sent out return postcards
to every doctor in the state to find out the
situation. In this way we found that the
most heavily infected section was still the
Southwest and south of the Valley. In the
last week it has been reported rather exten-
sively but not so heavily in Tidewater Vir-
ginia, although there were apparently some
genuine outbreaks of the disease on the East-
ern Shore. This was probably brouc:ht down
from Baltimore where in the last ten days it
hns been very prevalent.
Recent reports from California and Mon-
tana show from the course of the disease that
it is the same disease as of 1918, less virulent
but attended with marked prostration and
marked tendency to relapse if the patient gets
up too soon. When the disease strikes a
community it is very communicable and af-
fects from IS to 40 per cent of the population.
It reaches the height of epidemic in about
two weeks and continues thereafter for three
weeks or longer. The cases become more
severe as the outbreak progresses. Our ex-
perience so far is similar to that reported
fiom the far West. The type is milder, it is
very communicable and there is a marked
tendency to relapse. It is severest in chil-
dren and elderly people. These are more apt
to have pneumonia. At first, it seemed that
more young adults, high school and college
boys and girls were seriously affected, but
later experience shows that it is more severe
in elderly people and in children.
It is a disease that cannot be controlled by
the health officers. There is no specific pre-
vention; there is no specific cure. The pre-
vention of the disease depends on individual
or personal hygiene.
The influenza germs are found in the se-
cretions of the nose and mouth. If, by any
means, a well person gets these germs into
his mouth, he is very apt to get the disease.
It does not always follow that a man will
get the disease even if he does get the germs
in his mouth, because some may not be sus-
ceptible to the germs and others may at the
time have such bodily resistance that they
will not succumb to the poison. However, it
is a very dangerous thing to take chances
with the germs.
Quarantine; will not. prevent. Of course,
quarantine reduces the voluine of an epidemic,
but a person cannot be put into quarantine
until he is actually sick, and in the matter
of influenza a person is able to spread the
disease for a day or two before he gives any
signs of illness.
You may properly ask, "How are we to
prevent the spread of influenza?" As I said
before, you cannot get influenza unlees you
iO
SOUTHERN MEDICINE AND SURGERY
January, 1929
get into your mouth the influenza germs; and
you can only get that germ into your mouth
from the nose or mouth of some one who had
the germ. Now let us see how this transfer
is made.
There is nothing complicated about it.
There are only two ways of transference. One
is by breathing in the infected droplets and
the other is by getting the germ off some
object which has touched the mouth of a
sick person or has come into contact with
some secretions from the sick person's nose
or mouth. If you cough or sneeze into the
air, you send out innumerable small globules
of spray and they may contain thousands of
germs. These globules are very light and
ihey stay suspended in the air for a long
time before they sink to the ground. Any
person breathing that polluted air will get
the germs that are in it. Consequently we
give, as our first health rule, this simple warn-
ing: "When you cough or sneeze, cover your
nose and mouth with a handkerchief or bend
your head toward the ground."
If everybody, old and young, could be
made to take this single precaution, a long
step would have been taken toward the stop-
page of epidemics of influenza.
The other rule is equally simple. We say,
"Do not put into your mouth fingers, pencils
or anything else that does not belong there,
and do not use a common drinking cup." In
other words, do not let the secretions of some-
one else get into your mouth. If someone
bites an apple and then lets you have a bite,
you must get some of their mouth secretions
into your mouth; if you use a cup which he
has used, the same thing happens; if you
shake hands with a person who has coughed
into that hand, you will get some of his mouth
secretions on your hand, and then if you put
a finger into your mouth the germs will go
with the finger.
If, in addition to obedience to the first
rule, there should also be obedience to the
second, health officers would have an eas}'
time combatting outbreaks.
Some authorities are recommending what
they call the alkalinization treatment. It
consists of giving bicarbonate of soda in tea-
spoonful doses night and morning or every
four hours during the day as soon as the first
symptoms appear. In addition to the alka-
Jinc treatrr^nt, the diet 3li,ou!d be supph-
mented by citrus fruits and leafy vegetables.
I do not vouch for the value of the alkaline
treatment, but many good authorities are
recommending it, and it is harmless. Many
believe it to be of great value.
The health department does not demand
for the control of the disease the closing of
schools, churches, movies, etc., but recom-
mends avoidance of crowds and approves the
closing of some boarding schools and colleges
M'hen the facilities are not adequate for car-
ing for the sick in large numbers as will likely
occur if the epidemic strikes the school. In
such cases we do approve letting the pupils
go home anticipating the Christmas holidays.
With proper care on the part of the people in
the observance of simple precautions, we trust
the outbreak may have been lessened and not
have interfered seriously with the joys of
Christmas.
CILLECTION SUGGESTION
(Thr Journal of the Kansas Medical Society)
"Why don't you pay me what you owe,"
Sairl Doc BrownuII to Jim Munro,
'You've sold your wheat and corn and rye
".^nd I've Kas and rlntbes and food to buy."
"Je'-t take yore bill alunt; to hell."
Said Jim Munro to Dae Bruwnell,
■•M\- kids i? well and so's m\- wife.
"I never fcU better in all my life,"
Said Jim 15 he puffed on an old cob pipe
.■\nd munched an apple not quite ripe.
Then old Doc smiled, his c>es aglow,
.And said, very kindly and also slow:
"Let's not quarrel in all this heat
"Just come inside, I'll stand a treat "
Then to the soda squirt he said:
"Two bottles off the ice. labels all red,
"For a coat of arms the devil rampant,
"Jim'll drink up all that I can't."
"Thanks Doc," said Jim, "I was thirty and hot
"But that thar t;z shore techcd the spot."
.About nine that night Doc's telephone rang.
.As he went to the phone he almost sang,
.And the plans he'd made were coming on fine.
Of cour.-e Doc went — wanted to go!
Hut he couldn't drive straight for laughing so.
Doc felt his pulse and looked him over
Then said in a voice both sad and sober:
"Poor old Jim, you were once my friend,
"I hate to sec you approaching the end.
"Four hours ago you were hearty and well
"But now — the Lord alone can tell.
"I know where you'll be when you are dead,
"So I'll just send my bill right on ahead."
"Please save me Doc. vou shore know how.
"I'll pay yore bill. I'll pay it now.
"Git my pants. Ma, and pay his bill
"Give him a dollar for ev'ry pill."
Doc gave him 'omc drops that helped him a heap
.And told him to lie still and he'd go to sleep.
He put on his hat and started for town.
But stopped at the door and said with a frown:
"Bear this in mind — when I ask you to pay
"Think very carefully what you should say.
."That fif y"u drmk, and (hose gre»n apples, too,
'■■^''et' i'st right for ms, but sorta bad for you."
January, 1929
SOUTHERN MEDICINE AND SURGERY
61
HISTORIC MEDICINE
For this i:,nie R. E. Seibels, M.D., Columbia
Editor's Note. — .-1/ the suggestion of Dr. E. J.
Wood (iio-cii deceased), Dr. R. E. Seibels, of Colum-
bia, Dr. R. W. McKay, of Charlotte, and others, we
are. undertaking the cnduct of a Department of
Historic Medicine. Contributions are invited. U'c
are g'ad to initiate it ii.ith so excellent a bit of re-
search.
Dr. Thomas Dale of Charleston
fA Preliminary Note)
Charleston occupied a very prominent place
in the nation in the eighteenth century and
had an attraction for men of culture and
learning out of proportion to the size of its
population. About 1725 the medical profes-
sion was enriched by the arrival there of Dr.
Thomas Dale, who had received his degree
at the University of Leyden. He was the
nephew of Samuel Dale of Braintree, Eng-
land, whose Pharmacologia (published in
1693) was the first systematic work publish-
ed on pharmacology.
Dale's standing in the medical world was
very high, as was shown by his friends among
the outstanding medical figures of the old
world. Their opinion of his scholarship was
high, as evidenced by their permitting him
to translate their writings into English. The
following volumes are known:
"Emmenalogia/ Written, in Latin,/ By
the late learned Dr. John Freind./ Trans-
lated into English/ by Thomas Dale, M.D./
Nihil est mnh(, tti.ti quod turpr out vitinsum
rst. Cicero/ London/ Printed for T. Cox at
the Lamb under the Royal-Exchange, Corn-
hill. MDCCXXLX."
".A/ Treatise/ of Continual Fevers/ in
Four Parts/ to which are added/ Medical
Observations:/ in Three Books," etc./ by
Jodocus Lommius./ Translated from the
Latin/ by Thomas Dale, M.D./ London:/
etc. MDCCXXXIL"
"A/ Parallel/ of the Different/ Methods/
of Extracting the/ Stone/ out of the/ Blad-
der." Translated from the French of Henry
Francis LeDran, etc., revised and corrected/
by Thomas Dale, M. D.. London:/ etc.
1731."
"Nine/ Commentaries/ upon/ Fevers, and
'i"wo Ep'stles Concerning the/ Smallpox/
.Addressed to Dr. Meade/ written in Latin/
by the late Learned Dr. John Freind/. Trans-
lated into English/ by Thomas Dale, M.D./
London:/ etc./ MDCCXXX."
Bound with this:
"An/ Epistle/ to Dr. Richard Meade/
concerning/ some particular kinds of/ Small-
pox."
The translation of the Emmenalogia is ded-
icated to James Douglas, the distinguished
anatomist who gave one of the first compre-
hensive descriptions of the anatomy of the
peritoneum, and whose name is commemor-
ated by being attached to the peritoneal
pouch in the pelvis, which he described so
clearly and accurately.
Dale was a physician of the old school. In
1738 there was a severe epidemic of smallpox
in Charleston with 117 deaths from may 30th
to September 5th. A Scotch physician Kil-
patrick inoculated 800 persons in Charleston
and had only eight deaths. Dale was vio-
lently opposed to the practice of inoculation
and inaugurated and carried on a correspond-
ence with Kilpatrick in the South Carolina
Gazette which is characterized more by bit-
terness of invective than by sound or logical
debate.
In addition to his medical activities he
seems to have been a success socially. On
March 28th, 1733, he was married to Miss
Mary Brewton, daughter of Col. Miles Brew-
ton. A son, Thomas Dale, was born to the
couple; but he died October 17th, 1736, and
a daughter, ^L^ry, was buried in the same
coffin with her mother in 1737. On the 23rd
of November, 1738, he married Anne Smith,
who died without issue in January, 1743. A
third wedding was celebrated June 30th,
1743, when he married Hannah Simons, who
survived him with three children — Thomas
Simons, Jane and Frances. Young Thomas
Dale moved to Scotland and took his degree
in medicine at Edinburgh in 1775. He prac-
ticed many years in London where he achiev-
t2
SOUTHERN MEDICINE AND SURGERY
January, 1929
fcl considerable distinction.
Our Dr. Dale seems to have been greatly
interested in the dramatic arts. In 1734 a
'iheater was built on Queen street near St.
Philip's church. The opening play was "The
Recruiting Officer." by Farquhar, and after
the performance an epilogue was spoken as
lollnv.s :
"lii truth, dear ladiesl 'this a curious mat-
ter.
To prove. TIRESIAS-like, a double na-
ture,
To bid farewell to petticoats and stitching,
and wearing breeches, by their force be-
witching;
From belle to belle with jaunt}- air to
rove,
Play idle tricks, and make unmeaning
love ;
With scandal and quadtille address the
dames.
And strut the fair ones into wanton
flames:
But faith! I pity Rose, poor willing tit,
Of all her joys, and promis'd transport
, bit;
Her eager amorous soldier prov'd at last,
As Cynthia cold, or Farinelli chast;
For how could I, alas! the nymph delight?
Or how perform the duties of the night?
A mere poetical hermaphrodite!
Thus far the bard: — but sure the stupid
rogue
Ne'er wrote before, or ne'er wrote epi-
logue;
For young performers no excuse to frame!
To your indulgence lay no artful claim!
I'll beg myself then: — Pray forgive our
fright;
Think, ladies, on the fears of a first-
night ;
Kindly accept our faint, tho' willing toils;
■\Vithdraw not from us your accustom'd
smiles;
Nor mark how ill I personate the rake;
But spare JACK WILFUL for MONT-
MIA'S sake."
The Gentleman's Magazine of London
printed these verses and stated that they were
written by Thomas Dale, M.D., of Charles-
ton.
Finally, v,e find him occupying a judicial
role as Associate Justice of the Supreme Court
and, in 1739, after the death of Justice
Wright, he was granted a special commission
as acting Chief Justice.
Dr. Dale died September 16, 1750, at the
age of fifty years.
REFERENCES
The Gentleman's Magazine, London. \ol. \T, pa?e
2SS, 17,it).
".■\ Diversion for Colonial Gentlemen," Robert
.•\dger Law, The Texas Review, Vol. I, 1915-16.
"The Historic Evolution oi Variolation," .Arnold
C. Klchs, Jclti:s Hopkins Hospital Bulletin, March,
1013, Vol. XXIV. No. 265.
Dictionary of National Biography.
Medical College of Virgini.'V News
Dr. Joseph L. JNIiller, donor of a rare col-
lection of medical books to the Richmond
Academy of Medicine, will speak on "Physi-
cians of the Old South, Their Character and
Education" on founder's day at the Medical
College of Virginia, February 15, 1929. On
the same occasion Dr. Charles R. Robins,
professor of gynecciogy at the IMedical Col-
lege of Virginia, will rtad a paper on the be-
ginnings in nursing education in the modern
sense at the Medical College of Virginia.
Cabaniss Hall, the new dormitory for wo-
men, chiefly of the school of nursing at the
Medical College of Virginia, will be formally
opened on founder's day, February 15, 1929.
This building accommodates 134 persons, one-
half in single and one-half in double rooms
with hot and cold water in each room. Cer-
tain recreational and teaching facilities as
well as a large dining room, kitchen and ice
making plant are provided for in this build-
ing.
Xeeo More Doctors to Tre.at ^Mental
Diseases
A great shortage of physicians who are
familiar with psychiatry exists in the United
States, according to recent testimony of Dr.
William .-\. White, superintendent of St. Eliz-
abeth's Federal Hospital for the Insane, be-
fore the house committee on appropriations.
The number of physicians in the country,
Dr. White said, approximated 149,000, of
which only 2,000 were thoroughly familiar
with the treatment of mental diseases.
January, 1929
SOUTHERN MEDICINE AND SURGERY
EMMENOIOGIA:
Dy ihc I -.sc L. irr. .! Dr. J ; H N F r. k i v u.
I'm 1 hhm., , DAi,f., M. 0.
'^i^t^^m^^-f^
L 0 X D O :V.
Primal (or T. C 0 X :•: the i.i>»/' i-
'^ / -V / J-
#piL^
ALL LaAln tai GaOea
Coocdy. cali'd the /Urn
mcaam Nighi, by Ci • CU
^«^ In OrivyJ^at, ud ihcf
y<>^ Hxnfin ikiiSii abii
Bni the Gnaifa Mwdi^
Gonlcjncn. tUsBMxt^f Mtll
t^w
rt fwrml iMTIMFlnrt'
Mary Black Clinic & Private Hospital
Spartanburg
South Carolina
H. R. Black, M.D., F.A.C.S., Consultant
S. O. Black, M.D., F.A.C.S., Goiter and General Surgery
H. S. Black, A:B., M.D., Diseases of Women and Abdominal Surgery
H. E. Mason. M.D., General Medicine
Russell F. Wilson, M.D.. Genii o-Vrinary Diseases and X-ray
Paul Black, Hydro- and F.kctro-Tlirrapculist
Especially equipped for:
Hi. Hyarotherapeutic. Dietetic. Metabolic,
Labor.Ttory. X-ray and Radium
Rates per week (payable v/eekly in advance): Wards — $17.50; Two and Three Beds in Room —
$24.50; Private Bcom- $21.00 to $28.00; Private Room with Lavatory and Toilet— $35.00 to $40.00;
Private Room with Bath— $45.00 to $50.00.
Address mmmiinicalion'. to: MISS HELEN LANCASTER. Business Manager
FOR SALE— CHEAP: Ho.'^pital Equipment and Electric Elevator
:MKR1\VETHI-:R hospital .\\D TR.\I.\1.\G school (Ashevllle) has closed.
We will sell at bargain jirices: One set of electric sterilizers, complete, .\nierican
■Tiake, in perfect condition — one autoclave — instruments — utensils — hot and cold
water system which was used for .SO-bed hospital, but will do for smaller or larger.
.Msu one elcclric clcvatur, in nnod condition, cheap. *
Address Meriwether Hospital, 37 Watauga St., Asheville, N. C.
. „ . . . *
SOUTHERN MF.niCINE AND SURGERY
January, 1929
NEWS
The jMarlboro County ^Medical Society
held its annual New Year's meeting and ban-
quet January 10th, at the jNIasonic Temple,
Bennettsville, S. C.
Program: "Achlorhydria, " Dr. Walter R.
Mead, Florence, S. C; "Arsenicals and the
Optic Nerve," Dr. J. Wilkinson Jervey,
Greenville, S. C. — Discussion opened by Dr.
Simons R. Lucas, Florence, S. C; "Restora-
tion of Function by Silk Inserts in Injured
or Destroyed Tendons," Dr. William Tate
Graham, Richmond, Va. — Discussion opened
by Dr. O. L. Miller, Charlotte. X. C; "Ob-
servations on the Treatment of Puerperal
Sepsis," Dr. Oren INIoore, Charlotte, N. C. —
Discussion opened by Dr. Lester A. Wilson,
Charleston, S. C; "Carcinoma of the Cervix
Uteri," Dr. Kenneth JNI. Lynch, Charleston,
S. C. — Discussion opened by Dr. A. Johnson
Buist, Charlestion, S. C; "A Large Gluteal
Aneurism Simulating a Sarcoma of the But-
tock," Dr. Hubert A. Royster, Raleigh, N. C.
^Discussion opened by Dr. AddiSon G. Bre-
nizer, Charlotte, N. C.
Between the afternoon and evening sessions
dinner was served in the banquet hall. Dr.
D. D. Strauss, Sec, Bennettsville.
The Sampson County Medical Society
met at Clinton, N. C, December 3, 1928.
Program: Business meeting and annual
election of officers; dinner at the Rufus King
Hotel; papers and discussions: "Some Re-
marks on the Ethical and Economic Sides of
Practice," Dr. J. S. Brewer, Roseboro; "Early
Diagnosis of Cardio-nephritic Disease," Dr.
Ernest S. Bulluck, Wilmington; "Anesthesia
in Obstetrics," Dr. V. R. Small, Clinton;
"Tubal Pregnancy," Dr. David Rose, Golds-
boro; "Perforating LHcer of the Duodenum,"
Dr. R. L. Pittman, Fayetteville. Dr. Paul
Grumpier, Sec.
The Robeson County Medical Society
held its regular monthly meeting at the Lor-
raine Hotel, Llecember 6th.
The following officers were elected for the
new year: Dr. H. T. Pope, of Lumberton,
president; Dr. H. M. Baker, of Lumberton,
vice-president; Dr. E. L. Bowman, of Lum-
berton, secretary-treasurer. Dr. A. B. Holmes,
of Fairmont, was chosen delegate to the State
Medical Society, with Dr. J. F. Nash, of St.
Pauls, as alternate. Drs. R. S. Beam, of
Lumberton, J. McN. Smith, of Rowland, and
A. B. Holmes were named censors for a period
of three vears.
Richmond .Academy of Medicine
Dr. Wyndham B. Blanton was installed as
president of the Richmond .Academy of Medi-
cine at the regular meeting on January 8.
."^n interesting paper on hysterosalpingogra-
phy, illustrated by lantern slides, was pre-
sented by Dr. M. P. Rucker and Dr. L. J.
Whitehead.
Dr. Lee S. Huizunga, of New Haven, Conn.,
gave an exceedingly interesting talk on lep-
rosy. Dr. Huizunga has devoted many years
to the study of the disease in various parts
of the world, and the malady remains almost
as much of a mystery as it was in ancient
davs.
Two Hospitals at Danville (Va.) Merged
.Announcement has been made of the con-
solidation of Memorial Hospital and Ed-
munds Hospital after several weeks of nego-
tiating. Under the merger terms Dr. T. W^.
Edmunds, owner of one hospital, received
S23,000 on the agreement that he will not
sell the building for hospital purposes within
ten years.
Arrangements have been made to transfer
the 42 pupil nurses at Edmunds Hospital to
Richmond and Charlottesville.
Marion Hospital Opened January 14th
The formal opening and dedication of the
Marion General Hospital was held January
1 4th, when it was opened to the public. The
hospital was sponsored by the Kiwanis Club
and was made possible by the donation of
$35,000 from the citizens of Marion and Mc-
Dowell county and by $25,000 from the
Duke endowment fund.
Dr. ^^'. S. Rankin, of the Duke endow-
ment, and Dr. C. O'H. Laughinghouse, head
of the State Health Department, attended.
For the University of Virginia, the year
1928 has been one of greater expansion thcui
Januaiy, 1929
SOUTHERN MEDICINE AND SURGERY
6S
any previous twelve-month period within the
105 sessions of continuous academic history.
Nearly $6,000,000 has been added to the
productive endowment of the University, and
other gifts received during the year have
reached a total of almost $300,000. Con-
struction has been started, or has been in
progress, on new buildings that are to cost
well above $2,000,000.
President Edwin A. Alderman announced
last June that an alumnus, whose name has
been withheld, had created a trust fund of
between §5,000,000 and $6,000,000 for the
benefit of the University, half of which
would be used for scholarships and fellow-
ships.
This fund has been found to total almost
§6,000,000, which gives the University a total
endowment of §10,000,000. The universities
of only two states, Texas and California, now
have larger productive endowments than the
University of \'irginia.
Dr. Paul Earl Sasser, Conway, S. C, and
Miss Sarah Ellen Freeman, Bennettsville,
S. C, were married December 20th at the
Little Church Around the Corner, Xew York.
Dr. Sasser was graduated from the Univer-
sity of South Carolina and the Medical Col-
lege of the State of South Carolina. After
serving his internship at Roper Hospital in
Charleston, he began his practice of medicine
in association with his brother. Dr. Arch Sas-
ser, in Conway. He is at present taking spe-
cial work in New York, where the young
couple will remain until March 1, after which
time they will make their home in Conway.
Dr. J. A. Marshall, 73, county super-
visor, former county treasurer and former
mayor of Greenwood, S. C, died at a Green-
wood hospital December 20th.
Dr. Marshall was completing his first term
as supervisor, having been elected in 1924.
He was (he county's first treasurer, having
served for ten years from 1897 and was may-
or of the city for one term, several years ago.
He was a graduate of the University of Geor-
gia Medical College and practiced his pro-
fession at Greenwood a number of years,
and later at Brooksville, Fla., before entering
politics.
sian and school teacher of Guilford county,
died at his home at .Guilford C. H. Decem-
ber 16th, after an illness of several months.
Dr. Millis spent most of his life in the
southern part of the county and in northern
Randolph, where he served the community
usefully. Since his retirement in 1890, the
physician had lived at Guilford C. H.
Dr. Robert Armistead Deane, negro phy-
sician, was laid to rest December 15th in St.
Paul's Memorial chapel cemetery, Lawrence-
ville, Va. He died December 13th at the Pe-
tersburg Hospital.
Dr. Deane was a native of Richmond, 'Va.
He was a graduate of Union University and
the Howard University Medical School.
.^bout twelve years ago he located at Law-
renceville and at the time of his death he
had built up a county-wide practice and was
regarded a skill practitioner.
Dr. J. A. Shaw, Fayetteville, while riding
on the running board of a county officers'
cab in an effort to overtake a driver who
had struck his automobile, had his leg frac-
tured.
The accident occurred when a truck swerv-
ed slightly to one side and crushed the doc-
tor's leg against the car. The driver he was
seeking to apprehend made his escape.
Dr. Shaw was taken to the Highsmith Hos-
pital, where he is a member (if the medical
staff.
Dr. .Adrian T. Millis, 80, prominent phy-
Dr. John Sawyer Hitchcock, 59, one
time personal physician to Calvin Coolidge
at Northampton, Mass., died December 14th,
at his residence, "Fall Field," Albemarle
county, Va., after an e.xtended illness. He
was a graduate of Amherst College and the
I'niversity of Virginia. During the Spanish-
American war he served in the medical corps.
For many years he was the head of the health
department of the State of Massachusetts.
Dr. William Williams Keen, Philadel-
phia, December ISth received the gold medal
of the Pennsylvania Society at the organiza-
titon's thirtieth anniversary dinner.
Dr. Keen is 91 years old. He served' as a
surgeon in the Union Army during the War
Between the States, and soon afterward was
largely in.^trumental in introducing antiseptic
66
SOtrrttEftN MEbtCtKE AND StTRGERY
January, 1930
surgery into this country.
Dr. Clara E. Jones, Goldsboro, one of the
most beloved women of North Carolina, is
suffering from the effects of the fall that she
sustained seven weeks ago in Ardmore, a resi-
dential section of Philadelphia.
Dr. Jones was crossing a street when sud-
denly a car driven by a woman whirled around
a corner, striking Dr. Jones, knocking her
down and breaking a leg below the knee.
She was taken to the home of her daughter.
Dr. Margaret Castex Jones Sturgis, in Ard-
nf medicine at the old Columbia University,
as dean of the staff of Garfield Memorial
Hospital, and as attendant and consulting
physician at a number of other hospitals.
It was through his efforts that the medical
department of National University was
founded in 1883, and he received an honorary
LL.D. degree from that college in 1890.
Dr. Cook served with the Seventh Virginia
Cavalry in the Civil War, was a surgeon in
the Spanish-American War, and served on
the draft board in the World War. His son,
Dr. Richard L. Cook, Sunmount, N. Y., sur-
Dr. George E. Kornegay has established
himself at Davis, Carteret county, N. C, for
the practice of his profession. Davis has
been known for some time as "the town with-
out a doctor."
Dr. Levi A. Walker, 55, University Col-
lege of Medicine, Richmond, '98, prominent
for many years in the professional life of
Burlington and Alamance county, died De-
cember 28th, at his home on West Davis
street, following a brief critical illness. He
had been in declining health the past three
years.
At the time of his passing, Dr. Walker
was city health officer, and had been for
many years, and was associated with Dr. P.
C. Brittle in medical practice.
Dr. J. Lewis Clinton and Miss Katie
Rose Crews, both of ^Martinsville, Va., were
married December 24th.
Dr. Vernon Clark Lassiter and Miss
Mary Dorothea Pfohl, both of Winston-
Salem, were married December 22nd.
Dr. Lassiter is a graduate of Emory Uni-
versity in Atlanta. After graduating, he
served as interne at Grady Hospital, Atlanta,
for two years, and for the past three years
has been resident physician at Memorial Hos-
pital, Winston-Salem.
Dr. George Wythe Cook, 82, L^niversity
of Maryland, '69, native of Front Royal, Va.,
died in Washington, D. C, December 26th.
He had been prominent in Washington medi-
cal and social circles for many years.
Dr. Cook had served as clinical professor
Dr. George W. Black announces the re-
moval of his office from Pineville, N. C, to
ISIS South Boulevard, Charlotte, N. C.
Dr. Wm. Francis Martin, Charlotte, has
been made a member of the Executive Com-
mittee of the American Medical Association
of Vienna. Dr. ^Martin studied at Vienna for
several months of last year.
Dr. Henry V. Long, Statesville, has been
appointed a member of the State Board of
Charities and Welfare by Governor IMcLean.
He succeeds Rev. C. H. Durham, of Lumber-
ton, resigned.
Dr. Benjamin HeRxMan Bailey, Sandston,
Va., and Z\Iiss Frances Adcock were mar-
ried December 28th at Orlando. Among the
guests were Dr. and Mrs. J. B. Bailey and
Dr. and Mrs. J. R. Bailey, of Keysville, Va.
Fifty or more of Dr. W. J. Newbill's
(Univ. of ^Maryland, "68) relatives and con-
nections greeted him with words of love and
congratulations on New Year's Day at the
Beach Hotel, Irvington, Va., in honor of his
82nd birthday, R. H. Fleet acting as toast-
master. There were many responses in elo-
quent toasts from Dr. Loverick P. Law, the
Rev. S. .\. Donahue, Dr. W. H. Street and
Arthur James. Doctors present from a dis-
tance were: Dr. Henry Street, Richmond,
and Dr. F. W. Stiff, Harmony.
Dr. J. D. Blair and Miss Nan Brasing-
ton, both of Bennettsville, S. C, were mar-
ried Januar\- 4th.
Dr. \\. A. \\'ooDRUFF, Woodruff, S. C, was
Januah-, 19f0
SOOTttERN MEDICtNE AN15 StTRGERY
It
recently made a trustee of the Medical Col-
lege of the State of South Carolina.
Dr. Charles E. Barker, of Grand Rap-
ids, Mich., physician to President Taft, spoke
at Gaffney, S. C, Sunday, January 13th, un-
der the auspices of the Gaffney Rotary Club.
Dr. Harry Walker, Courtland, \'a., and
Miss Pamela .Ann Gary, Richmond, were
married December 8th in the Little Church
.Around the Corner, Xevv York Citv.
Dr. James Robert Anderson, 67, Tulane,
'82, died at his home at Morganton, N. C,
December 1 2th.
Drs. Albert D. and Mercer Parrott lost
their father, and Drs. James M. and W. T.
Parrott, a brother, when Mr. George F. Par-
rott, of Lenoir county, died on December
10th.
Dr. J. W. Tankersley, Greensboro, and
Miss Nellie Gray Ozment, Guilford Col-
lege, were married in Raleigh, November 3rd.
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"Poor Mary, that was her third husband who
committed suicide."
"Yes, it must have completelv unmanned her." —
C. C. A'. }•. Mercurv.
Irate Father: "What is that stuff on mv mvj car?
Where have you been?"
Calm Son: "Thais only Iraffu jam."- ,1/(i7i/j;ijh
Gargoyle.
Ciillector: "Do you believe in a hereafter?"
Woman at Door: "Certainly I do!"
Collector: "Well, this bill from Dr. Blank is over
two years old; go get the money— that's what I'm
here after!" — Colorado Medicine.
"(live, for any one year, the number of bales of
illon e\portetl from the United States."
"1401; none."— /';>/)'j Magazine.
«8
-^
SOUTHERN MEDICINE AND SURGERY
January, 1929
REVIEW OF RECENT BOOKS
THE TREATMENT OF DIABETES MELLITUS,
by Ellioll P. JosUn. AID. (Harvard), MA. (Yale),
Clinical Professor of Medicine, Harvard Medical
School; consulting Physician, Boston City Hospital;
Physician to New England Deaconess Hospital.
Fourth Edition, enlarged, revised and rewritten.
Illustrated. Lea & Febiger, Philadelphia. ?Q.OO.
"Diabetics and especially diabetic children
are here to stay," says Dr. Joslin. It is only
in the last few years that more than a very
few of these unfortunates could stay here
long, and those stays were far from happy
ones. It is only because of the discoveries
of Banting, and their application by Joslin
and others, that diabetics may stay and stay
in comfort.
The book represent the results of painstak-
ing study of many thousands of the author's
own patients, with the addition of anything
from other sources which "on second or third
perusal seemed worth while."
Section heads are: The Diabetes of To-
day; Insulin; Theory, Incidence, Etiology
and Curability; Physiology and Patholog\';
Urine, Blood and Respiration in Diabetes;
Diet in Health and Diabetes; Onset, Preven-
tion, Classification, Prognosis, Symptoms;
Treatment; Treatment of Acid Intoxication
and Diabetic Coma; Arteriosclerosis and
Heart Disease; Treatment of Complications;
Surgery and Diabetes; Diabetes in Child-
hood; Diabetes in Pregnancy; Glands of In-
ternal Secretion; Diabetes in the Old; Renal
Glycosuria; Management of the Diabetic in
Office and Hospital; Foods and Their Com-
position; Harris and Benedict Prediction Ta-
bles.
Here may be found, clearly set forth, what
is known today on this very common disease.
Every family doctor and every specialist is
vitally concerned with diabetes. Every doc-
tor practicing medicine should have — and
study — this book.
of the .American Dermatological .\ssociation. Eighth
Edition, revised and enlarged. 126 illustrations. P.
Blakifton's Son & Co., Philadelphia. :>2.00.
The text has been thoroughly revised where
revision was needed. The illustrations have
been improved. A review of treatment of
syphilis of the nervous system has been add-
ed. Despite numerous typographical errors,
it would be difficult to think of a text on skin
diseases which a' family doctor could use with
as great profit to himself and his patients.
A COMPEND OF DISEASES OF THE SKIN,
by Jay Frank Schamberg. A.B., M.D., Professor of
Dermatology and Syphilology Graduate School of
Medicine, University of Pennsylvania; Ex-President
THE PRACTICAL MEDICINE SERIES, com-
prising eight volumes on the year's progress in Medi-
cine and Surgery.
Gf.ner.\i. Surgerv, by Evarts A. Graham, A.B.,
M.D.. Professor of Surgery, Washington University
School of Medicine; Surgeon-in-Chief of the Barnes
Hospital and of the Children's Hospital, St. Louis.
Series 102S. The Year Book Publishers, Chicago.
.S^.OO.
The author considers the work which dem-
onstrates the control of paralytic ileus by
splanchnic anesthesia to be an important de-
velopment of the year. The lack of uniform-
ity in the results of treatment of erysipelas
by serum does not deprive the subject of in-
terest. Bell's colloidal lead treatment of can-
cer is discussed; as are the new injection
methods for varicose veins. The test for pan-
creatic disease worked out by Elman and JMc-
Caughan of Washington University is describ-
ed and praised.
The Eve, E.\r, Nose and Thro.\t, Edited IkV
Charles P. Small, M.D., Albert H. Andrews, M.D.,
and Grprge E. Shambaugh, M.D. Series 1928. The
Year Book Publishers, Chicago. S2. 50.
This volume follows more the general plan
of a condensed textbook, with special empha-
sis on recent advances, than that of abstract
and comment; although the latter plan is
made use of to a considerable degree.
The constant keeping in mind of the inter-
dej^endence of the head specialists and family
doctors makes the method of procedure of
especial value.
SOUTHERN MEDICINE and SURGERY
VOL. XCI CHARLOTTE, N. C, FEBRUARY. 1929 NO. 2
Combined Drug Therapy in some Problems of Cardio-Vascular-
Renal Disease*
T. G. Murray, M.D., Greenville, S. C.
It is the purpose of this paper to crystallize
our thoughts regarding the relative value of
certain drugs in the treatment of two import-
ant problems of cardio-vascular-renal disease,
namely, edema and high blood pressure. We
meet with these complications frequently,
especially in one particular type of cardio-
rcr:al disease. 1 have in mind the edematous,
dyspneic, hypertensive type with a decompen-
sating heart and a small grey, granular kid-
ney of the so-called chronic interstitial ne-
phritis and arteriosclerosis. In other words
the typical old cardio-renal patient of the
cliarity ward.
During the past summer I treated on the
cliarity ward of the Greenville City Hospital
::bout 14 of these cases, and during this time
made an effort with this limited series to
dcterni ne in some degree the relative value
of a number of drugs, separately and in com-
bination, in the management of edema and
high blood pressure. The drugs with which
we worked particularly were digitalis, citrin
(containing the glucoside, cucurbocitrin),
novasurol (merbaphen), and ammonium chlo-
ride. ?.Iy use of these drugs over a period of
three months brought about in my own mind
some rather defmite, though not dogmatic,
conclusions concerning their use.
Tirst. we observed a group of these pa-
tients v,'ith edema and hypertension which
were given alone the usual text-book dose of
the tincluie of digitalis, that is, 15-20 minims
(not drops) three times a day. The diet v/ps
restricted as usual and they were put at rest
in bed. The blood pressure reading, urine
output and fluid intake were measured and
cherkrd • :!ch day. This group was com-
r-ared with a group receiving no digitalis or
I •i.cr medxation. The group receiving digi-
*P»esente(i to the Greenville Countv Medical So-
ciety, Kovembet o, 1928.
talis was so slowly digitalized that there was
absolutely no difference apparent in the
progress of the two groups for many days.
We then selected another group to the mem-
bers of which we administered a dram of the
tincture of digitalis every four hours until the
to.xic symptoms began to appear. In this
group v/e noted rapid improvement as com-
pared with the two previous groups. There
was a larger output of urine, the edema
cleared up much more rapidly, and the vas-
cular tension steadily, and in some cases rap-
idly, declined. In the case of a negro woman
v.ilh a blood pressure reading of 225 160 who
was edematous and laboring for breath, with
a blood creatinine reading of seven and non-
protein nitrogen of 80, whose urine showed a
heavy 4-plus albumin with granular and hyla-
line casts, — and withal it seemed impossible
that she could live more than a few hours —
v.e administered one-half oimce of the
freshly prepared tincture of digitalis and di-
rected that a dram be given every 4 hours
following. The next day she was fairly com-
fortable, the edema was greatly lessened and
she was breathing with comparative ease.
Improvement continued and she is still living.
This, of course, is not a safe procedure in
every case. This small series of cases con-
vinced me that digitalis is more valuable in
the treatment of edema and hypertension of
c.udio-renal disease than 1 had previously be-
lieved. I am also convinced that large doses
are abL'.olutely essential to oht.iin the iiest and
(luii-kest results.
Next citrin (cucurbocitrin) was tried. The
: cti(!n of this drug is thought to be a selective
o)ie, by its mild and gradual depression of
the vaso-constrictor center, or of the sympa-
thetic ganglia themselves. It is also possible
for the drug to stimulate the depressor fibres
in the blofid vessels owing to the presence
of the drug in the blnod stream. Morsover,
70
SOUTHERN MEDICINE AND SURGERY
February, IM*
citrin miy have a selective action on the
sympathetic vascular iunction, or upon the
vascular wall itself. There is no depression
of the cardiac musculature. In repeated ex-
periments this has never been observed.
The fa-lure of citrin to dilate the blood ves-
sels may be due to a vaso-constrictor cause
too powerful for this drug to overcome.
Bordley and Baker- from their recent
studies are led to believe that arterial hyper-
tension is a compensatory phenomenon de-
pendent on arteriosclerosis in the brain stem;
that the rise in the arterial pressure is due
to cerebral anemia induced by the sclerotic
changes in the finer vessels of the medulla.
Moreover, they state that their findings are
in accord with respect to the association of
arterioscleorsis in the retinal vessels and the
vessels in the base of the brain. In Wilkin-
son's series^ of 68 cases in which this drug
was used, tv.'elve cases showed no response
to the drug. It was observed in these 12
cases that the retinal vessels were markedly
sclerosed.
Likewise, our use of citrin in these ad-
vanced and complicated cardio-renals was not
as satisf-ctory as in earlier cases of hyperten-
sion without failing compensation and with-
out retinal chants. Our findings here coin-
cide with the findings of Wilkinson and
Barksdale^ that citrin has its best therapeutic
value in early, uncomplicated cases of arterial
hypertension. We were pleased to discover,
however, to cur own satisfaction at least, that
citrin, in covibinatlcn ■with digitalis and one
of the diuretics — e'ther novasttrol or ammo-
nium chloride — hns a real place in the treat-
ment of these edematous and hypertensive
victims of cardio-renal disease. Of this com-
bination, I shall have more to say later.
Let us now paj^s io the use of novasurol as
a diuretic. We uicd this drug on seven very
edematous patients, first alone, then in com-
bination with other drugs. We administered
novasurol intravenously to avoid sloughing of
tissue. Beginning with a dose of O.S c.c, we
increased the dose every three days up to 2
c.c. The water intake was measured, also
the urire output for 24 hours. It was ob-
served that 4 of the 7 responded in a very
remarkabl: way. At times the urinary output
in 24 hours increasing from 600 to 1400 c.c,
following the .idminislration of novasurol. In
two casee there was a sli^t increase in urin«
output, while one was absolutely uninfluenced
by the drug. Toxic effects were encountered
in only one of the 7 cases. This man devel-
ijped a mild d'arrhea and a rather distressing
stomatitis, which cleared up quickly. Five
of the seven cases had renal involvements
when novasurol was administered, but after
close obser\'ation, we felt positive that no
further reiial damage was done by the admin-
istration of this drug. We believe that the
chances of kidney damage are much smaller
than is commonly believed; however, we are
mindful of the fact that our series was a
very small one and we should always be on
our guard for toxic side actions of this mer-
curial preparation.
Ammonium chloride was used as a diuretic
alone and in combination. It v/as adminis-
tered in enteric capsules to avoid gastric irri-
tation. It was used alone in 5 cases and
produced a satisfactory, but not a spectacular,
diuresis in all of them. It appeared that
;;mmonium chloride was a less spectacular,
but a more consistent and dependable diure-
tic than novasurol. That is, it never pro-
duced so enormously increased an output as
did novasurol, but it increased the output to
a considerable degree in a larger percentage
of cases. It was interesting to note that, in
some casv°s novasurol hid a remarkable diu-
retic effect and in the same cases ammonium
chloride was ineffective, and likewise, when
ammonium chloride did its best work on some
edematous patients novasurol seemed entirely
ineffective. The fact remains that both drugs
pre good diuretics, but neither is effective in
every case.
Having spent some time observing the ac-
tion of these drugs separately v.e now studied
another series of cases in an effort to deter-
mine the best combination of these drugs to
use. Of course, we cannot apniy the same
rules or the same treatment to all of these
edematous hypertensive, cardio-renal patients;
but we were able to come to some concrete
conclusions applicable to a majority of cases.
CONCLUSIONS
First, we observed that digitalis in large
doses in combination with citrin (cucurbo-
citrin) was more effective than either drug
alone, digitalis improving the force of the
heart action, and citrin lowering the vascular
tension.
SeccHid, it was evident that novasurol ^id
February. !*?♦
SOUTHERN MEDICINE AND SURGERY
Biiwrionium chloride produced more effective
diuresis in combination than did either drug
separately.
Finally, the combination of di-ugs giving
the most convincing and most consistent re-
sults in these decompensated cardio-renal-
vascular cases were found to be: digitalis
;t-ctiiig on the heart, citrin relieving vascular
tension, and novasurol and ammonium chlo-
ride, one or |>referably both, increasing the
urinary output. Thus by the use of these
four drugs in combination, we get direct ac-
tion together on heart, artery and kidney.
Further studies are in progress and will be
reported in future papers.
BIBLIOGRAPHY
1. Wilkinson, Ciuorgc R.: "Further Studies on
the Blood Pressure Lowerintr Effect of Cucurbocitrin
in Man." South Carolina Medical Association Joiir-
nn!, 1Q27. \'ol. xxiii. No. S.
2. Kordley, Jas., and Baker. B. M.. jr.: "A Con-
sideration of .Arteriosclerosis of the Cereliral Vessels
and the Pathoaenesis of Hypertension." Johns Hop-
kins Hospital Bulletin, 1026, Vol. xxxi.\, p. 220.
i. Bark'dalc, Irvini; S.: "Studies on the Blood
Pressure LowcrinK Principle in the Seed of the Wa-
termelon (Cucurbita Citrullus), Am. Jour, of the
.\fcdical Sciences, Jan., 1026, No. 1, Vol clxxi, p.
111.
Report on the Conference on Influenza*
C. O'H. I.AUGHiNGHorsE, M.U., Raleigh, X. C.
Hrkl at the Office of the Surjjeon (knieral U. S. P. H. S., Washington, January 10th, 1Q20
The .Surgeon General being ill, the con-
ference was opened by Assistant Secretary
of the Treasury Shumann. .Assistant Sur-
aeon General W. F. Draper presided. .\
written message from the Surgeon General
was presented on the status of the present
epidemic and purpose of the conference and
a definite program submitted, although no
government funds are available for this pur-
\V-<<e. .\ rcjll-call was made of the State
Health Officers and, while all states were not
represented, all sections were.
Pruf. Edwin O. Jnrdon reviewed the pres-
ent kiiMwledge of the pathology, bacteriology
and epidemiology of influenza. He was able
to give us nothing new. The outstanding
feature of his address was the emphasis put
ufwn the fact that in epidemics of influenza
all suspicious colds were of necessity classi-
fied as influenza : therefore many thousands
'■■f cases so reported were really coryza, rhin-
itis, phtryngitis and bronchitis. Its rapid
spread from the Pacific coast during a period
of ihrci' months proved to his mind, however,
th.nt we were dealing with a definitely epi-
demic influenza. The disea.se is no respecter
of pf-rsons, age. sex or race, and the people
most su.'^crptible who suffer th,- highest death
riilc lire those between 18 and 29. He felt
thai thildan, becau.se of tlieir isolated lives
;-.;ty, Jacoiry 14, VAi
U:i-J\
were probably more or less protected, and
that elderly people were not less susceptible,
but furnished fewer victims because of coming
into contact with fewer persons. The nutri-
tional condition had little or nothing to do
with their resistance. He stated positively
that he did not know the cause of influenza
JMit felt that in this epidemic it was causing
deaths only by making fallow fields for
streptococcic, staphylococcic, pneumococcic,
and other respiratory bacterial infections.
Dr. Frost, of the I'. S. P. H. S., and Mr.
Edgar Snidenstr'cker. statistician, emphasized
the fact that the epidemic of ten years ago
laid the beginning of a scientific foundation
for the study of influenza and the knowledge
iibtained from that epidemic would be used
advantageously in the handling of the pres-
ent one. In 1918 the pandemic of inlluenza
evidenced everywhere a leucopenia in a large
proportion of the cases; the anticipated im-
munity because of previous attacks has not
materialized; moreover, a study of inlluenza
in 1918 and of the disease during the past
iliree months showed marked difference in se-
\crit\- ;i;(I in percentage of population at-
tacked. He thought tfie age incidence
in young adults to be highest; thai children
from five to nine showed .some decline: that
I rum ten to eleven the incidence of infection
gradiislly increased, the \<t:nk bein^ rricbed
!!6« ttve.".'.; ■iciU'j tc ihu'.y. [Isjc.nsr : labora-
tory I'lrustrat'ed th'e fitttttrtocentesis but this
SOUTHERN MEDICINE AND SURGERY
February, 1929
bacterium needs further study before its sig-
nificance can be stated, as is true of the Pfeif-
fer bacillus. The hemolytic streptococci
are found so constantly in normal res-
piratory tracts that we were as yet not in
position to even bring charges against it much
less to convict it. Doctor Frost, after much
d'Fcussion, committed himself to the droplet
as a mode of infection. He warns against
transmission by means of eating utensils.
Such methods as public health authorities
suggest for control are singularly futile. Doc-
tor Frost concluded by making a broad state-
ment that if influenza is to be conquered it
will by systematic labors of research v^orkers
— that experimental research, clinical research
and epidem-ological research are the blessed
trinity from which research workers are to
obtain the information necessary for the
throttling of this disease.
Assistant Surgeon General A. M. Stimson
gave an outline of studies on influenza con-
templated by the Public Health Service. I
will not go into this further than to say that
the U. S. P. H. S. was insistent upon urging
the assistance of state health officers and
physicians in procuring sufficient funds. He
also begged that the Rockefeller Commission
compensate those undertaking original stud-
ies in this disease. Various physicians from
all over the country — Anders, Bloodgood,
\Velch, Christian, Haven Emerson, Rosenau,
Rosenow and other men of national import-
ance discussed the manifestations of the pres-
ent outbreak and compared it with other out-
breaks of influenzT and other infections of
the respiratory tract. These discussions re-
volved around, first, preventive measures;
second, therapeutic measures v.hich may re-
duce mortality. Noth'Rg was advised in the
way of prevention that we are not already
practicing. The consensus of opinion seemed
to be that school children were perhaps safer
at school under school regime than they were
at home. There was a most interesting dis-
cussion of the immunization power of Rose-
row's serum which is put out by Park Davis
Company both to immunize and treat. There
\:z^ 3 t'emendous difference of opinion. For
CAnrnple, Rosenow of Rochester showed sta-
tistics which seemed to prove it had wonder-
ful immurii.'ing influence, while Rosenau of
Harvard, stated that he had used it with no
effect. There was general agreement that, as
a therapeutic measure, serums were of no
avail.
Advice the public health service or authori-
ties were in position to give was taken up,
but nothing new was presented. Lastly, sug
gestions were offered as to the most pronounc-
ed lines of research and what agencies should
undertake this research, whereupon Assistant
Surgeon General Draper appointed three com-
mittees, one on epidemiology, one on preven-
tion, and one on research, to report as soon
as their conclusions were reached. The out-
standing men in the country were put upon
these committees.
Col. Siler, of the U. S. Army, presented
graphs and gave his opinions on the control-
ability of influenza as practiced in the Army.
The Army of th? U. S. is divided topographi-
cally into nine districts: The Southren dis-
trict, the Northern district, East, West and
Central districts, and certain sub-divisions of
these districts. Col. Siler obtains weekly re-
ports from all of these districts. He took the
position that in the Army certain things had
been done in this particular ep"dsmic to de-
crease the number of cases and to pronounc-
edly decrease the death rate, but his report
could h;lp us little since in civil life we have
not the control of our patients that belongs
to Army service. He believes that confine-
ment to bed of all suspicious respiratory dis-
eases immediately upon their appearance, is
the one peg upon which is hung the safety
of the people of this country during the pres-
ent epidemic. After much discussion he ad-
mitted that in the beginning it was impossible
to differentiate influenza from other respira-
tory infections. He puts sick soldiers to bed
early, advises cheerful rooms with tempera-
ture of 60, windows open, and sodium bicar-
bonate. He was pronounced in the opinion
that ordinary respiratory infections are un-
commonly preceded by influenza; that influ-
enza paves the way for pneumonia, pleurisy
and the like by lowering resistance. He said
nothing about abdominal influenza, that there
\v;;5 little influenza, if any, in the North At-
lantic Army jxists, and not a great deal in
tiie Southern posts, but his reports vv^ere daily
increasing; that on the West coast the epi-
('vniic ii.'d been severe and in the Middle
\\'fsl it had beer, territic but had reached its
peak and was subsiding; that in. Chicagoj for
example, the peak w'as reached;, from J"ort.
i'ebruiry, 1929
SOOTHERN MEDICINE AND SURGERY
1i
Sam Houston his reports were very few but
he was anticipating more reports from that
section. The epidemic was quite pronounced
in Panama and very Hght in Hawaii. The
most interesting facts that I got from Col.
Siler's tallc were that in the Army where men
can be controlled the epidemic of influenza
of 1928 and 9 was not lasting longer than
two or three weeks, and that he was trying
to instruct Army officers as to what is a com-
mon cold ar.d what is influenza but he was
meeting with no success.
It was almost the unanimous opinion that
there were no secondary waves. It was
thought best not to send out specific instruc-
tions as to diagnosis because there were not
enough instructions to present in a concise
manner. It was generally agreed that the
mortality rate in this epidemic would be low,
that schools, as a rule, should be kept open.
It was also unanimous that the death rates
through the country had practically doubled
from all causes during the past week.
Interesting points brought out were that
the mortality rate was higher in the rural
districts than in cities, and that the Chicago
epidemic began early in November, reached
its peak December 15th, and that pneumonia
cases increased materially two weeks after
December ISth. It seemed to be the consen-
sus of opinion that there was a much smaller
percentags of pneumonia in this particular
epidemic than that of 1918. Chicago under-
took to control her epidemic by distributing
literature concerning colds by press, radio and
publ c addresses. Theatre owners were urged
to ventilate their theatres.
Then came the report made by Dr. Simon
Fle.xner from the committee on research.
Doctor Flexner asked for group activities in
the study of influenza clinically and epidem-
iologically. The bacteriology and pathology
side of it should be left to research. He dis-
cussed bacteria pneumoncentes as it has oc-
curred since 1918. He does not believe it
to be the cause of influenza.
Dr. L. C. Hogan stated that he had treated
a great many cases with intravenous injec-
tions of sodium salicylate in a sodium bicar-
bonate solution. It relieves pain, accelerates
convalescence and reduces complications.
Fruit juices were discussed with some enthu-
siasm by men from Florida and California.
Rosenow of Rochester stated that careful
study revealed that 41 out of every thousand
who had been vaccinated had the disease;
that 700 out of every thousand who had not
been vaccinated had it; that .64 per thou-
sand vaccinated died, while 4 out of every
thousand unvaccinated died; that of 8,306
persons vaccinated against influenza 31 con-
tracted it, while of 800 unvaccinated .-.07 con-
tracted it. But, in the face of this, another
man of outstanding prominence stated that
vaccination was practically valueless. Dr.
Arthur McCormick, State Health Officer of
Kentucky, stated that the State Board of
Health of Kentucky was preparing and dis-
seminating immunizing influenza serum and
that he had every reason to believe it had
done much to protect his state against influ-
enza. The conference did not go on record
approving vaccination.
It was generally agreed that all institutions,
orphan asylums and the like should be quar-
antined.
It was brought out in the conference from
all sections of the United States that those
were panic-stricken, while those having func-
localities which had no health departments
tioning health departments were going about
their work, accepting the epidemic in a phi-
losophical manner, and using such precau-
tions as the public press and health bulletins
sent out. This is particularly impressive be-
cause it was unanimously agreed that every
county in every state should have a function-
ing health department in order to take care
of such calamities as influenza just as every
municipality has its fire department.
Advices were given to hospitals and to
schools to avoid contact between influenza
patients to protect against cross infection. It
was also advised that hospital herdings in in-
fluenza should be avoided, that hospital cases
should be limited to severe cases only.
Dr. Welch made an illuminating talk, giv-
ing it as his opinion that influenza was caused
by some toxic virus as yet unknown; that
the disease itself did not amount to so much,
but that the toxic virus causing it had the
peculiar power of lessening resistance of the
body to such an extent that it became a fal-
low field for implantation of extraneous in-
fections. He had no fear of a second wave.
Dr. Bloodgood stated that all surgery at
Johns Hopkins other than acute emergency
surgery had been discontinued for the duration
H
soirrHEiN MEDicmi jkHb aaxussk^
PAav»,tr, Isif
of the epidemic. This decision, I think, was
based upon the opinion of Dr. Welch as to
the lessened resistance to other infections.
He was strong in recommending paper hand-
kerchiefs so that they could be burned. He
urged education against spitting, the practic-
ing of personal hygiene, the dissemination of
information that respiratory diseases were in-
fectious, and the avoidance of crowds. He
felt, however, that schools and colleges should
not be closed, but insisted that the assem-
bling of all classes and all groups in one hall
should not be permitted under any circum-
stances. He advised the exclusion of visitors
from institutions and hospitals. Frequent
hand-washing, particularly before meals, re-
fraining from exposure and fatigue, and hold-
ing in abeyance anything like fear, were em-
phasized; also 8 to 10 hours sleep with
plenty of cover, a well-balanced diet, clothing
to suit the environment. Plenty of water,
and cathartics only to meet the usual indica-
ion. Alcohol as an influenza remedy did not
excite the interest that prohibition did in the
last campaign.
Hallus Valgus
Report of End Results
R. L. Anderson, B.S., M.D., Richmond, Va.
In a period of five years in the orthopedic
service at the ^Massachusetts General Hos-
pital, a total of 145 feet were operated upon.
An end result study on 49 out of the 85
patients and on 89 out of the 145 feet of)er-
ated upon was made. This paper is based
on an end result study of these cases. It was
thought projjer to include in that part of the
paper not directly concerned with the end
results other facts related to these patients
on some of whom end results could not be
obtained.
Sixty of these patients were women and 25
men. Undoubtedly the narrow-toed fashion-
able shoes worn by women is a causative fac-
tor. The youngest patient was 15 and the
oldest 81; 12 were between IS and 20; of
those 20 to 60 the number was fifteen to sev-
enteen for each decade. Of the 12 cases
under 20 years, 10 were girls and two boys,
which may be attributed either to girls' shoes,
or to the greater attention paid to their feet,
causing them to consult physicians earlier.
In the other decades the proportion was
fairly parallel to the total number of cases.
(Occupations seemed to have no important
bearing. The housewife was the most fre-
quently affected. Two telephone operators
and one policeni.in were among the number.
Of the men, salesmen, factory workers and
laborers were tl.c' most common occupations.
The average duration of symptoms was 10
years; the shortest one year, the longest (one
F>atient) "from childhood." It was not infre-
quent to find patients who had suffered 20
years or more.
What finally brings these patients to the
hospital? The history was definite in 129
of the 145. Pain alone in and around the
first metatarso-phalangeal joint was the most
common presenting symptom. This was
present in 47 cases. The next most common
complaint was pain and deformity — 28 cases.
Nineteen cases complained of pain and the
bunions. The deformity alone bothered 19.
Bunions were responsible for 1 1 cases appear-
ing; 14 came in for treatment of discharging
bunions.
Out of the 145 patients operated upon, only
17 gave a history of previous treatment. Of
these, six were treated with arch supports
bought from a shoe store, two with special
shoes, two with bunion plasters and in one
case the patient opened an infected bursa.
Only five had been treated by a chiropodist,
it is thought that these figures do not truly
represent the number actually receiving treat-
ment, but it does give a fair picture of the
measures attempted to give relief.
It is well known that hallus valgus is asso-
ciated frequently with various degrees of foot
strain or at least with potentially weak feet.
Eighty-two were found to have feet which
showed evidence of wvaknws, 12 bad prona-
Fabnwry, 1«J«
SOUTHERN MBOICINE AND SOROBRY
tion alone, 31 showed a pronation and a flat-
tening of the anterior arch, with varying de-
grees of callus formation. Thirty-four show-
ed a flattening of the anterior arch alone as-
sociated with hallus valgus. In five the tight-
ness of the tendo Achillis was the only abnor-
mal finding. Hammer toes were associated
in six of the cases; two showed rigid flat feet;
in five there was an ankylosis of the first
metatarso-phalangeal joint; in 12 the bunions
had become infected.
How seveie was the hallus valgus operated
upon? We have used the same classification
that Cleveland uses: slight, deformity 20 de-
grees or less; moderate, 20 to 35 degrees;
severe, 35 degrees or more. Unfortunately
the records did not always state just the
degree of deformity present. We found defi-
nite data on 92 cases of the series. Sixty-
five were severe, 26 moderate, and only one
showed slight deformity. That is what one
would expect with an average duration of
symptoms of ten years. We shall consider
later the degree of improvement shown in
these cases.
Arthritis is found frequently associated
with hallus valgus. Frequently, the subjec-
tive symptoms are probably due to this asso-
ciated ailliritis. Often it is difficult to decide
how much of the patient's trouble is due to
the one a.^.d how much to the other. Roent-
gen ray e.xamination was made in 93 cases:
17 showed evidence of arthritis with spur for-
mation; 30 symptoms such as swelling, red-
ness and heat which were attributed to arth-
ritis. Of these, ten cases had positive roent-
gen ray findings, thirteen had negative find-
ings and ten had not been rayed. So it may
seem that arthritis is a factor in the condi-
tions, which should be kept in mind. Pre-
operative and post-operative roentgen raying
should be made a routine, as this gives more
definite evidence than clinical examination
alone.
We shall describe briefly several of the
operative procedures most commonly used.
A plastic operation devised by Dr. Nathaniel AUi-
ton was periormed in a large number of cases. A
sraight incision is made on the dorsal surface over the
first matatarso-phalangeal joint. The capsule is in-
cised exposing the metatarsal head with its exostosis.
The head is disarticulated. The exostosis is removed
with an Oitcotome and sufficient of the head removed
to allow this joint to be overcorrccted in adduction.
The rough edges of the metatarsal head are smooth-
id With a rasp and the scar surface carbolized fol-
lowed by alcohol. The capsule is resutured with the
toe overcorrected and in marked plantar flexion.
Subcutaneous tissue and sliin are sutured in layers,
rather heavy dressing applied with pad separating
the great toe from the second toe and holding the
toe well over in overcorrection. Perkins has report-
ed a series of 50 cases following this line of proce-
dure, with sati.-factory results in all but two, and a
disappearance of severe valgus deformity in every
case.
The Keller operation was frequently p-'r; rmed in
(lur series. A straight incision is made dori.iily, be-
•jinning proximal to the interphalangcal joint of the
great toe e.xtending to about one inch on the first
metatarsus. Then the first phalanx of the great toe
and the di-tal end of the lir.-t metatarsal are ex-
posed. The joint capsule is iiKised with an osteo-
tome, the exostosis is removed from tlie first meta-
tarsal and carbolic used as in the .Allison operation.
In addition, one-third of the proximal phalanx of
the great toe is removed either with an osteotome
or with a Gigli saw. The rout;h end is smoothed
and carbolized. A purse string suture of the capsule
is then made between the cut surface of the phalanx
and the metatarsal. The remainder of the capsule
and the periosteum are sutured with silk. Subcu-
taneous and skin sutures are made in layers with
silk. A soft dressing holding the toe overcorrected
is now applied as in the Allison operation.
Silver has devised an operation which is logical
and fulfills all theoretical requirements for success-
ful correction of the deformity. A curved incision
is made with the convexity downward over the
joint. The fibrous capsule is exposed and the bursa
is removed. A V incision is made through the cap-
sule forming three flaps — one distal, one dorsal and
one plantar. The distal flap, as broad at its base as
the diameter of the phalanx, is carefully freed and
reflected to serve for the construction of the internal
lateral ligament of the capsule later. The dorsal
and plantar flaps are dissected back until the meta-
t.ir-al head is sufficiently e:vpo:ed. A thin layer of
cortex together with the exostosis is removed, the
articular surface being left intact as far as possible.
The capsulotomy is now performed, with the toe
held in strong dorsoflexion, a tenotome is inserted
betweL'n the capsule and head making first a longi-
tudinal inci-ion dorsally. Then with the toe in
strong plantar flexion, a longitudinal incision is made
here al-o exposing the plantar ed^e of the outside of
the capsule. Then adducting the toe strongly these
two incisions are united by a vertical incision so that
one has on the outer side of the joint a capsular
flap with proximal base. Correction of the meta-
t::ro-phalangcal joint is now possible. The toe is
overcorrected to 45 decrees and in this position the
d'Stal flap made on the medial side of the joint is
pulled strongly bacl.ward and sutured to the periso-
tcum of the metatarsal holding the toe in position
of overcorrection. The proximal, plantar and dorsal
flaps are then closed over the distal flap and finally
the wound is closed in layers. In 49 cases he reports
n. partial relapse of one toe in two cases both bilat-
eral. This operation was performed in five cases in
our series.
In this series of cases the Keller operation
was performed in 85 cases, the Allison opera-
tion in 38 cases, and the plastic operation
with removal of bursa in six. In two cases,
in addition to this latter procedure, the ex-
tensor hallucis longus tendon was divided.
u
SOUTHERN MEDICINE AND SURGERY
ITebruary, 1929
In five the Silver opeiation was performed.
Two formal arthroplasties were done. Once
the second toe was amputated in a patient
81 years old. These operations were by ten
different surgeons of the visiting staff and
twenty of the house staff. The visiting sur-
geons operated in 85 cases and the house staff
in 60.
Ordinarily these operations may be done
quickly. A unilateral operation took an aver-
age of 32 minutes, and a bilateral 55. It is
interesting to both the patient and the hos-
pital to know approximately the length of
time necessary for the patient to remain in
the hospital. The average stay after the Al-
lision operation was ten days, after the Kel-
ler twelve, and after the Silver fifteen.
In 123 cases the wounds healed by primary
intention without drainage; in 15 there was a
sero-sanguinous drainage; in sLx, a frank in-
fection with purulent discharge. One gave a
positive culture of the streptoccocus hemolyt-
icus. The patients whose wounds were clean
remained in the hospital an average of nine
days, those with serous drainage twelve, those
in which the infection occurred 23. The
treatment of the wound is only a part of the
post-operative treatment. As is well known,
hallus valgus has frequently a concomitant
condition of faulty weightbearing.
Sixty -seven out of the 89 cases in which
end results were obtained gave symptoms and
showed signs of needing foot supports. Of
these, 51 received foot plates, 18 were given
shoe plates and exercises, 28 were given neith-
er shoe plates nor exercises.
The patients who had shoe plates wore
them on the average of nine months — shortest
period two months, longest two years. The
usual course in patients who have weak feet
is about as follows: Impressions for plates
are taken pre-operatively, operation is
done, in seven to ten days the sutures are
removed and a small dressing applied, the
Ijatient is encouraged to move the great toe
frequently — actively and passively — especial-
ly in plantar llexion. In addition, he is given
exercises to strengthen the long and anterior
arches of the foot. In fourteen days, the
patient is enc iraged to walk about a little
with ordinary .-a k-s on with the leather cut
over the greai toe. .After 21 days, he is
given his shoe j-lates and is sent to buy new
shoes along orihopedic line.?. In his new
broad shoes and foot plates he walks about
and, after seven to 14 days more, he is about
ready to resume his ordinary life. .After a
convalescence of approximately four weeks,
the patient is encouraged to resume his regu-
lar life.
We now come to the real rasion d'etre of
this paper, namely, the end results. These
were studied from both the view of the pa-
tient and the surgeon. The cases were ana-
lyzed with reference to resultant, 1st, pain;
2nd, deformity; 3rd, motions in the first
metatarso-phalangeal joint. Pain is always
naturally a difficult symptom to analyze. If
there was pain in and around the great toe
joint, an effort was made to find out if it was
slight, moderate or severe. This of course
could not be done mathematically.
Motions in the metatarsophalangeal joint
were considered excellent when active exten-
sion was 30 degrees or more, and active flexion
20 or more; good when extension was from
20 to 30 degrees and flexion ten to twenty;
fair with extension ten to 20 degrees and
flexion five to ten; poor when extension was
less than ten degrees and flexion absent or
less than five degrees.
We made an effort to find out the effect on
pain, deformity and motion in the great to«
joint of certain variables. .Analyses were
made with regard to: types of operations per-
formed; pre-operative condition of the feet;
post-operative care of the feet; arthritis;
healing of the wounds; and degree of im-
provement in deformity.
First, let us discuss briefly the results ob-
tained with the various operative procedures.
Following the plastic operation devised by
Allison 10 per cent of the patients had
slight pain, 15 per cent had moderate
pain, none had severe pain. So, a total of
25 per cent of the cases had some pain in the
first metatarso-phalangeal joint after opera-
tion. -After the Keller operation, none of the
patients had slight or moderate pain, but one
patient (2 per cent) had severe pain. In the
five patients having the Silver operation, one
patient (20 per cent) had moderate pain af-
terwards. Out of a total of 90 cases, nine
or 10 per cent of the patients had more or
less pain.
It is important to trj- to fairly estimate
the degree of correction of deformity.
IJefinite data as to the exact deformity pr«6-
F.fcrMr>-. 1929
SOUTHERN MEDICQfS AtOt SU11CISR¥
a
put before and after operation could not be
obtained in every case. Seventeen cases (65
per cent) undergoing the Allison operation
showed severe deformity in the beginning and
nine (35 per cent) had a moderate deformity,
in the end results, 19 per cent had no de-
formity, 61 per cent had slight deformity and
19 per cent had moderate deformity.
With cases undergoing the Keller opera-
tion, eighteen or 60 per cent had a severe
deformity and twelve or 40 per cent a moder-
ate deformity. In the end results 6 per cent
had no deformity, 66 per cent had a slight
deformity, 22 per cent a moderate deformity
and none a severe deformity. With the Sil-
ver operation, in the three cases with definite
data all had severe deformity in the begin-
ning and in the end results, two or 66 per
cent had no deformity and one had slight
deformity.
Out of a total of 59 cases, nine (16 per
cent) v^ere entirely freed of deformity, 62
per cent had slight, 20 per cent a moderate,
and none a severe deformity. The resultant
slight or moderate deformity was present in
about the same proportion with these types
of operations — 40 per cent with the plastic,
47 per cent with the Keller and 40 per cent
with the Silver operation.
Motion in the first metatarso-phalangeal
joint ran about the same, no matter what
type of operation. Excellent motion occurred
in 15-20 per cent, good 40-50 per cent, fair
30-40 per cent, and poor in about 4 per cent
except in cases v/ith the Silver operation,
which had no cases with poor motion result-
ing.
Let us nov/ consider the effect of pre-oper-
ative pathology on the end results in this
series. Of the 38 cases, with pronated feet
and flattened anterior arches, 55 had some
pain following the operation, of which num-
ber 80 per cent had slight pain and 14 per
cent had moderate and 4 per cent severe
pain. As regards deformity with this type
foot, 39 per cent had persistent deformity —
24 per cent slight, 15 per cent moderate. In
feet with the anterior arches alone affected,
25 per cent had persistent pain — 13 per cent
slight, 12 per cent moderate. The percent-
age of deformity ran parallel with those hav-
ing both flattened arches and pronated feet.
In feet with the arches apparently normal,
•■ly 15 per cent had pwiin after operation.
Deformity was present in 40 per cent, about
the same as with feet having poor anterior
and longitudinal arches. Motion was about
the same regardless of the condition of the
feet.
The ix)st-operative treatment of these cases
following operation it is of importance
to appraise. Thirty-three patients were
cent had slight to moderate pain after oper-
ation, 42 per cent had slight to moderate de-
formity, 15 per cent had excellent motion, 66
per cent good motion, 19 per cent fair mo-
tion.
In cases given shoe plates and exercises,
33 per cent had pain after operation, 44 per
cent had slight to moderate deformity, 83
per cent had good motion and 5 per cent fair
motion. Patients given exercises alone show-
ed only 10 per cent with pain, 60 per cent
had deformity, 20 per cent excellent, 70 per
cent good and 10 per cent fair motion.
In cases given neither shoe plates nor ex-
ercises, only 14 per cent had pain afterwards,
33 per cent had deformity with two or 6 per
cent having severe deformity. Motions were
about the same as in other classes of cases.
It must be borne in mind that cases in which
neither exercises nor plates were given were
probably the most favorable types of cases.
This should not be interpreted to mean that
the post-operative treatment is not necessary
in certain type of cases.
End results were obtained in 16 cases,
showing evidence of arthritis before opera-
tion. Four or 25 per cent of these had pain
post-operatively. Two or 12 per cent had
severe pain. Five or 31 per cent had more
or less deformity after operation. In 25 per
cent motion was excellent, in 25 per cent
good, and in 33 per cent fair and in 12 per
cent poor.
Out of 145 feet operated upon, 12 wounds
showed infection of some kind. Of these,
16 per cent had slight to moderate pain. Ten
or 83 per cent had deformity from slight to
severe, none had excellent motion, 33 per cent
good, 37 per cent fair, and 16 per cent poor
motion. The type of operation gave slight
differences, only in end results.
CONCLUSIONS
Pain. — Pain is relieved in about 90 per
ctBt •! cases with tht opieratioTi for hallu*
SOtJTHERN MEDICINE AND StmOERV
'ffliK<mt, W*
valgus. The Keller operation in our series
relieved this symptom more effectively. The
more normal the foot before the operation,
the less apt the patient is to have pain after
the operation.
Post-operative treatment has little influ-
ence on the persistence of pain.
Arthritis pre-operatively pred.sposes to
greater pain afterwards than in cases of non-
anhritic feet.
The healing of wounds has little apparent
effect on the persistence of pain after opera-
tion.
Dejormity. — Severe deformity is always
relieved by operation. In about 20 per cent
of cases moderate deformity will recur.
Deformity may be well corrected with any
type of of>eration, which is well executed.
Pre-operative condition of the arches of the
feet has no effect on resultant deformity.
Post-operative treatment does not relieve de-
formity if the operation has not removed it.
It does probably prevent recurrence of the
hallus valgus with its train of symptoms.
Some patients need plates, and those needing
exercises should have them independently of
the hallus valgus. This occurs in a large per-
centage of cases. Arthritis pre-existent has
no effect on resultant deformity. Cases in
which infection sets in have much {r«at«r
percentage of deformity than those in whi«k
the wounds remain clean.
Motion. — Motion remains adequate in tko
vast majority of cases no matter what type
operat.on is performed. The condition of tho
aiches of the feet has no effect on the mo-
L on of the metatarso-phalangeal joint. Post-
operat.ve treatment has little effect on motion
e.'-xept that exercises with plates result in bet-
ter motion than when plates alone are used.
Closes Wxth arthritis do not get as good mo-
tion as cases without arthritis. Infection
predisposes to some limitation of mobility.
BIBLIOGRAPHY
1. Cleveland, M.: Hallus Valgus, Final Results m
two hundred operations. Arch. Sitrg., Vol. 14, No. *,
page 1126.
2. Payr, E.: Ab. J. A. M. A., Vol. 65, page 1681,
Ncv. 2, 192S.
3. Perl;;ns, G.: Lancet, Vol. 1, page 540-544,
M:irch 12, 1927.
4. Sliver: Jottr. Bone and Joint Surg., Vol. S,
1923, page 225-232.
5. St.';nd'er: Textbook of Operative Orlhoptdics.
(D. .A.ppAtcn & Co., 1925.)
■Note: The materia! for this paper was •btal>*4
from Dr. Nathaniel .\l!is n's Orthopedic Service at
the Massachu^eLts General Hospital. It was throujli
W.% courlriy in allowing me to work up the material
that I am ab'.e to write this paper. Also, I am a^-
precinlive ot his co-operation in the preparation af
the paper.
if^umty, 1929
sotrrHERN kxDfaMU nth iMgkiiv
Gastric Achlorhydria — Its Significance and Treatment
R. O. Lyday, M.D., M.S., Greensboro, N. C.
The fact that gastric juice contained hydro-
chloric acid was first demonstrated by
Schmidt. By free hydrochloric acid is meant
the acid existing in solution. This is easily
dissociated with the production of a corre-
sponding number of hydrogen ions. The com-
bined acid is that combined in some way with
protein material.
According to Howell, the parietal cells
which furnish the hydrochloric acid are
massed in the glands of the middle and pre-
pyloric regions, scantily in the fundus, and
absent in the pyloric end. More recently,
however, it has been shown that these parie-
tal cells are present even in the cardia. This
observation has an important bearing con-
cerning the advisability of radical surgical
procedures in the treatment of gastric and
duodenal lesions.
The compound hydrochloric acid is formed
from sodium chloride of the blood, the sodium
being replaced in some unknown way by
hydrogen and the substance is secreted upon
the free surface of the stomach as hydrochlo-
ric acid. Cannon says: "Hydrochloric acid
in the stomach seems to favor or produce a
relaxation of the pyloric sphincter, while in
the duodenum, on the contrary, it causes a
contraction of the sphincter. Hydrochloric
»cid in the stomach aids pepsin in the diges-
tion of proteins and is considered valuable
«s a bactericidal agent, preventing fermenta-
tion, etc."'
The absence of free hydrochloric acid from
the gastric contents may be a clinical entity,
which may be of a congenital or acquired
■ature; or it may be secondary to other path-
ological conditions in the human organism.
Under the group first mentioned the condi-
tions are commonly called achlorhydria and
•chylia gastrica. In differentiating between
these two conditions, which are so similar
from a clinical as well as from a laboratory
point of view, some clinicians consider those
cases of absence of hydrochloric acid in which
the total acidity amounts to more than 20
ilegrees as being achlorhydria, and those with
« total acidity below this point as belonging
f the class of achylia gastrica. Physiolo-
fhti, en the other hand, consider the een-
dition achlorhydria when only the free acid
is absent and achylia gastrica when both acid
and ferments are absent. C. S. McVicar be-
lieves that clinicians should restrict it to those
cases which show an absence of both free
hydrochloric acid and pepsin.
The presence or absence of free hydrochlo-
ric acid cannot always be determined by a
single fractional test, for on many occasions
subsequent examination has shown a moder-
ate amount of the acid present, or even the
normal amount in some instances, where not
even a trace could be detected on the first
examination which extended over a period of
two hours. Therefore, more than one frac-
tional test is necessary to prove its absence
from the gastric contents. When the first
test fails to show a trace of free acid it usual-
ly indicates that it is absent or nearly so.
This abnormal gastric secretion is found in
a. cerUin percentage of persons in whom no
history of gastric trouble is obtainable and is
only discovered in a routine gastric analysis.
In many of these its presence cannot be ac-
counted for. It is of no significance from
the point of view of therapy.
Diarrhea is fairly frequent and does not
seem to be related to any certain etiological
factor lying behind the condition we are con-
sidering, but definitely related to the absence
of the acid. As is well known, this form of
diarrhea is usually characterized by several
watery movements coming on immediately
after the ingestion of food. Lack of tonus
of the pyloric sphincter is considered an im-
portant factor in the causation of this symp-
tom. Cannon's views on the control of the
pylorus have recently been called into ques-
tion. McClure, Reynolds and Swartz, on a
basis of radiographic experiments, conclude
tkat acid is not the principal factor controll-
ing the opening and closure of the pyloric
sphincter in man. Bland, Campbell and
Hern, witk simulUneous intubations of the
stomach and duodenum, showed that acid in
tie duodenum does not necessarily close the
pylorus, for the most rapid emptying took
place at the time when the duodenal contents
were unusually acid.
kiurwc that padntB who have
Id
SOUTHERN MEDICINE AND SURGERY
I'ebruary, l9id
this type of diarrhea associated with the con-
dition here described are often relieved by
t!ie free use of dilute hydrochloric acid by
mouth. Ryle says that this may relieve by
increasing the output of pancreatic secretion
enhancing digestion in the small bowel, or
by increasing pyloric tonus without any di-
rect digestive or bactericidal action.
During the latter part of the last century
two cases were reported in which the secre-
tion of hydrochloric acid was said to have
resulted from the oral administration of the
acid. Recently H. V. Dobson, of the IMayo
clmic, by using the same patient for a series
of 19 experiments, made a very thorough in-
vestigation of this condition. Three frac-
tional studies which were made during a pe-
riod of five weeks demonstrated the absence
of free hydrochloric acid from the stomach
contents. A low peptic content was also ob-
tained. To make doubly sure that a true
achlorhj'dria was present the patient was
given h.stamine. Still he continued to show
an abseixe of free acid.
The patient was placed on dilute hydro-
chloric acid in gastron, which is a glycerine
extract of the gastric mucosa of the pig con-
taining much pepsin. At a later date free
acidity was discovered during the early part
of the second hour of digestion. At this time
another histamine test was given and it pro-
duced a free ac.dlty of 23. Improvement in
the patient's condition was shown by an in-
crease in appetite, weight, etc.
Pepsin was present in the gastric contents
in relatively good concentration in all in-
stances when adequate free acidity was ob-
tained whether or not gastron was adminis-
tered. Therefore, it seems that acid is the
more important of the two in the treatment.
His conclusions concerning the action of hy-
drochloric acid in the stomach are as follows:
"The first action of acid in the stomach
seems to be to saturate proteins, then stim-
ulate the production of pepsin, and finally to
provide an acid medium for the action of
pepsin. It also has an antiseptic effect, and
after evacuation into the duodenum, stimu-
lates pancreatic secretion. It is possible that
free acid may have a stimulating effect on
the acid-secreting mechanism resulting in the
production of more acid. For this reason it
is not necessarily true that, in cases of ach-
lorhydria, small doses of acid will suffice as
well as larger doses, since it has been shown
that large doses are necessary to produce free
acidity."
At this point w^e might refer briefly to the
treatment of the clinical condition known as
achlorhydria.
Metkcd of Administration. Hydrochloric
acd should be given in as large amounts as
possible, depending on the individual toler-
ance. As much as two and one-half drams
or more may be given during the digestive
period. Thirty minims in two ounces of
fluid as a vehicle may be given at the middle
of the meal and the same quantity repeated
at 15-minute interval for an hour or more
(Dobson).
I have seen good results follow the admin-
istration of from twenty to thirty minims of
hydrochloric acid to the dram of gastron.
This is added to milk or water and sipped
v.'ith the meals.
In a review of a large series of cases, in
which fractional gastric analyses were made
and checked at a later date, the commonest
condaions found associated with this absence
of free hydrochloric acid in the gastric con-
tents, in the order of their frequency, were:
1. Pernicious anemia in 15 per cent.
2. Chronic cholecystitis in 14.7 per cent.
3. Carcinoma of the stomach in 12.3 per
cent.
4. Achylia gastrica in 11.7 per cent.
5. Achlorhydria as a clinical entity in 11.2
per cent.
In many instances, as previously mention-
ed, the cause for the absence of free hydro-
chloric acid cannot be dstermined, nor is it
of any special significance in many of those
cases wh3re there are no gastro-intestinal
symptoms; yet its absence, particularly if
th:; patient be a middle-aged individual who is
anemic or who gives a history of recent
weight loss, makes it imperative that the phy-
sician rule out those two serious diseases
v/hich are so frequently preceded and asso-
ciated with this condition; namely, pernicious
anemia and carcinoma of the stomach.
February, 1929 SOUTHERN MEDICINE AND SURGERY
Undulant Fever*
p. W. Flagge, M.D., High Point, N. C.
From the Medical Service of the High Point Hospital
Undulant fever has many synonyms, the
more common of which are Malta fever,
Bruce"s septicemia, slow fever (Texas),
Mediterranean phthisis, etc. We find it de-
scribed as a "specific fever, due to the mic-
rococcus melitensis, Bruce (1893) character-
ized by its long undulatory course, early
arthritic symptoms, sweats, increasing debil-
ity and anemia."
For U-, it vould present little more than
passing interest but for the fact that it is
present in our country and spreading v.'ith
undetermined rapidity. It v/as probably rec-
ognized as an entity as early as 400 B. C.
However, it was not until the end of the
eighteenth century that attention was drawn
to the fact that many cases were in and
around Malta, at which time it acquired the
name of Malta fever. Marston, in 1859, suf-
fered with it ar.d was the first to clearly de-
fine and differentiate it from typhus and ty-
phoid fevers. In 1S97, Wright and Douglass
ur;dertcok to jirove by experiment that the
disease could be d'agnosed by agglutination
tests. In 19C4, the British Admiralty and
War Office, in collaboration with the Civil
Goven.ment of the island of Malta, under-
took an exhaustive study of the disease as it
exists on the island and to this report we are
indebted for much of our present knowledge.
Available information relative to its dis-
tribution in the United States by reported
cases is as follov.s: California 2; Connecti-
cut 1; Illinois 4; Maryland 2; Michigan 7;
New York 9; Ohio 1; Pennsylvania 1; South
Dakota 1; Utah 3; Virginia 3; Washington
1; Ontario, Canada, 1. This does not include
the Southwestern states where it is known to
have been prevalent for 35 years. Nor does
this mean the extent of the spread of the in-
fection, for iii the state of Iowa alone inves-
tigation by the U. S. P. H. S. in collaboration
with the State Board of Health has estab-
lished its existence in 83 cases unreported.
Thus we see there is already a fair sprin-
kling of recofnizcd cases over a vide area
with a demo .-.irable concentration in at least
one stole. And, since there is every reason
Tre-cnttd to the GuUi'ord Cpunty. ilcoicaL So
to believe that the average physician is not
on the lookout for its appearance in his own
practice, it is certain that these figures fall
far short of representing the actual existence
of this infection.
Tlie causative agents, the micrococcus
melitensis and the bacillus abortus, are found
in the spleen, liver, kidneys, lymphatic sys-
tem, salivary glands, blood, bile, urine and
miilk. The goat is the natural host; horses,
sheep, cows and ho'rs may be and are infect-
ed. The usual mode of entrance is by the
alimentary tract, but it is possible to be in-
fected through the respiratory tract, the cu-
taneous system, and the generative organs.
It v.ould seem that the greater number of
infections are from the use of milk from goats
and cows and it is clinically proven that the
infection from the goat is by far the more
severe. Laboratory infection by the micro-
coccus melitensis is said to be common.
Of pathology and morbid anatomy it is in-
teresting to note that the disease belongs to
the septicemia group. The infection enters
the blood from the intestines. Here it pro-
duces hemolysins, agglutinins and a .specific
immune body. The question of a permanent
immunity is, however, under dispute, some
authors holding there is "unlimited recur-
re.ice.''
Undulant fever may be said to be protean
in its symptomatology. To look for pathog-
Tiomonic signs and symptoms is certain to
court disaster in diagnosis. Whether the in-
fect'on be of the melitensis or abortus variety
the symptomatology is the same with the ex-
ception that the melitensis infection is usual-
ly the more severe and prolonged. There is
a period of incubation of ten to fifteen days
in man, but, since practxally all who con-
tract the infection may have prolonged ex-
posure, the period of incubation has little sig-
nificance. Kearns states that "what is need-
ed is a widespread clinical consciousness of
the disease, and a h'gh index of clinical sus-
l^'cion that will lead physicians to routinely
lisk for the abortus agglutination test in all
c;ai'.cs of undiagnosed fever."
Commonest of . all. symptoms is the con-
vaouauass of the patieat tiiat he has fevwv
12
POlTTHltW ytWDKaMB AND SURGERY
February, 1*2*
Along with this there will be "lymptoms of
general'zed infection — irregular chills, back-
ache, headache, and more or less copious
night sweats. Less common may be gastro-
intestinal symptoms: vomiting, epigastric
pain, or diarrhea. Of nervous symptoms we
may look for headache, insomnia, dizziness,
drowsiness, etc.
N^aturally, in the case of continued fever
we turn to th? blood for information and
here afaln, omitting one test, we have little
positive information. Leucocytosis is not the
rule and leucopenia is not uncommon. A low
neutro' h'e and a high lymphocyte count,
with a leucopenia is suggestive. A secondary
anemia may be expected if the disease has
existed for a time. A blood culture may be
positive if taken at the height of the fever.
A positive agglutination with either the
abortus bacillus or the micrococcus meliten-
s;.. will be conclusive.
The course of the disease is uncertain and
msKy cases are treated for some of our more
c; nimon infections as pulmonary tuberculosis,
malaria, typhoid and some of the more com-
mon arthritic infections. The diagnosis will
re-t uoon the elimination of other infections
ad the fii.ding of a positive agglutination
t: -t with the above mentioned organisms.
Piophylacf c measures available are the
cl minat on of milk from the diet, or boiling
it if it is thought to be infected. Since milk
i-~ one of our most useful and widely used
rtcles of det, it would seem that the time
is ripe for our national and state health au-
thor,t'.s to take active measures to place in
operation some plan to prevent this most u.«e-
fu! and wholesome food from suffering gen-
eral contamination, rather than depending
upon th; elimination of milk from the diet,
or instituting the expensive procedure of
pa-teurization or steriliz.-ttion.
To date we have no therapeutic measures
that couid be classed as curative, or uniform-
ly affecting the course of the disease. Mer-
cuiochiome in 1 per cent solution in varying
doses has seemed occasionally to have an
abortive effect. The arsphenamines have
hzen tried with some benefit at times and
quinine has also been helpful. When these
measures fail we have little to fall back on
other than symptomatic treatment with jjood
nursing and dietetic measures tbtt «<« mim-
lated to buUd up vesistmtdt.
CONCLUSIONS
Undulant fever exists in the United States
today as an endemic disease.
The rapidity of its spread is so far unde-
termined. Its spread will convert one of our
most wholesome and valuable foods into a
hazard to the health of millions of adults and
children.
This infection should be carried in mind
constantly by the profession, and agglutina-
tion tests demanded of the laboratories of
our Slate Boards of Health.
.\11 cases should be reported early so as to
give our state and national health authorities
a proper persrjective for preventive measures.
CASE REPORT
.Married man, aged 3:3, sales pnimoter. ad-
promoter, admitted July 23, 1928.
Family History. — Not significant.
Previous Personal History. — The usual
diseases of childhood. Tonsillitis frequently. ■
Tonsillectomy in 1920. Muscular rheumatism
frequently. Malaria in childhood. Appendi-
citis, 1916, with operation. Sick headache
occasionally all h's life. For the past three
months more fre.-|iient and persistent. Thinks
that eating to cu - :: '1 nf acid food will
induce he sdacho. S r>i '; , for the past five
or six years, with r:iti]ei severe "cold in the
head" at times during this period. Na.sal
polyp removed in 1927, and again in Febru-
ary, 1928. Smokes from six to ten cigars
[>er day. Eats to excess frequently when well.
Rarely uses alcoholic liquors, but will take
a fecial drink.
Present Illness. — During the month of
.Time spent three weeks in New Jersey and
ii;i? week in New York State. At some in-
definite period during the latter part of June
he began to feel below par and was unable
to a.ssign a reasonable cause. He continued
to work and some-time in July, before the
fourth, went to Grand Rapids, Michigan. On
tlie fourth, he had a sick headache. Took
a rather free purge at this time; a few days
later left for Toronto. En route he suffered
an attack of what he thought to be indiges-
tion due to indiscretion in diet while in
Grand Rapids. In Toronto, was seen by a
physician who diagnosed la grippe and put
him on alkaline treatment. He was very sick
and hud a severe headLache for two days. He
rjSBumtd " oik, but was av/are that he b^d
fWe'r an'd wus itr^ii^ strength. 'Aitei U 'tiw
Fftbnuii?', 192»
SOUTHERN MEDICINE AND SURGERY
•lays, he began to have secere, drenching
Hight-sweats; was extremely nervous and do-
ing his work under great handicap. At times
there would be a distinct chill at night.
There was much general aching, some swell-
ing of the lymph nodes in the neck, but no
joint pams. Outside the spell of acute indi-
gestion, he had no further intestinal symp-
toms other than loss of appetite. He found
tkat he had lost ten pounds in weight during
thf first week of his illness. Becoming un-
able to carry on his work, he returned to his
hotae in Greensboro and with his family went
t© the mountains for a few days, but con-
tiMued to grow worse and was brought home
before the end of the week. He sought the
advice of his physician, who placed him on
l«rge doses of quinine at frequent intervals.
Net improving in his home, he entered a lo-
c«l kotpital and was under observation for
•« unknov-n period. Continuing unimproved,
he entered our institution shortly afterv.ard.
Phi-s-c.il Examination. — A markedly over-
we ght man of age given. Looks anemic and
has rather "knocked out" appearance. Temp.
99.5, pulse 76.
Head— scmsv.hat bald, otherwise normal.
Mouth — one defective posterior molar on
left s:de. Some dentistry in good condition.
Throat — no tonsils, normal.
Neck — short, thick, negative.
Chest— thick walls, respiratory excurs'on
normal and even. The right apex gave a
markedly prolonged expiratory murmur over
tfce supraclavicular region. In this area, oc-
casional inconstant rales.
Abdomen— fat walls, appendiceal scar in
good condition, negative.
Extremities- skin a trifle flabby, normal.
Reflexes — noimal.
Rectum — normal.
Diagnosis (Tentative).— Sinusitis, obesity.
dental decay and infected posterior molar.
Laboratory Findings. — Urine — straw color-
ed, acid. sp. gr. 1012, no albumin, no sugar,
in'croscop'cal normal.
r.lood— July 23, 1928— Hb. 77 per cent;
r.b.c. 3. 850 COO; w.b.c. 5760— p. 79 per cent
!. :0 per cent, e. 1 per cent; August 6, 1928
- -v/.b.c. 5050 — p. 66 per cent, 1,30 per cent,
'\ 2 per cent, t. 2 per cent.
Til lee examinations for malarial plasmodia
^'.cre nen;ative.
W d:il was negative for typhoid, paraty-
phoid (A) and (B) on two occasions. Was-
;e;m.ann negative. Blood culture negative
tv.ice.
X-xray.— July 23, 1928, sinuses show dis-
tinct Laziness of the left antrum.
August 24, 1928, chest, negative x-ray.
On August 2, there having been some sus-
p'c on as to the possibility of the case being
;: dubnt fever, a culture of the bacillus abor-
;-'.2 v,as procured and an agglutination test
i:rde v.'hich was found positive in dilution
of 1/130. Th's test was repeated on August
n a; d found positive in dilution of 1/200.
Th's same serum was forwarded to the U. S.
P. H. Lab. Hygiene, which found it positive
i' d'lution of 1/320.
F.' m d te of entry up the 21st day he suf-
fered irre-rular chilly sensations and ch lis at
• ■■'ht followed by drenching sweats. On the
1 t diy the temperature fell to normal and
ema'r.ed so while he stayed in the institu-
linn. The range of temperature was 98,6 to
102 (once only), the usual diily maximum
beng 101. On the 24th day he seemed quite
veil, except for general weakness, and was
dismissed. Reports after dismissal indicated
that he had no further fever. He resumed
his work about the third week after and has
continued in good health.
^^OUTHSMJ MKBI6IMI AND SUKUERY
Frbruarv, 1«2*
The Diagnosis of Active Incipient Pulmonary Tuberculosis
O. E. Finch, M.D., Raleigh, N. C.
Mary Elizabeth Clinic
By this is meant the earliest form of pul-
monary tuberculosis which can be recognized
by the usual methods at our command. The
importance of early recognizing this condi-
tion is admirably emphasized by Dr. P. P.
McCain, superintendent of the North Caro-
lina State Sanatorium, who wrote: "A recent
survey of the after-results of treatment of
the 3,C00 patients discharged from the North
Carolina Sanatorium during my service over
the past ten years shows the following:
Of the incipient cases 89 per cent are liv-
ing ar.d 80 per cent are working. Of the
moderately advanced cases 59 per cent are
1 v'ng and 13 per cent are working. How
picquent are these figures of the need of an
c.irly diagnosis."
In presenting this subject it is intended
cnl}' to review for mutual benefit some of the
i.iore commonly accepted methods used in
!;:e diagnosis of this disease. Our interest
in this condition can not be too frequently
; I'rred, for only by an early diagnosis can
•. 0 ever hope for eradication. The disease,
f.hen recognized early, is as easily arrested
as almost any of the major conditions for
T hich we arc consulted. We have made
seme progress, but our fight has just begun.
J do not know just how many cases are yet
I'.ot recognized, but I d i know we are finding
more than we did; not that we have so many
more new cases, but we are learning more
Ebout them and are trying to find them.
These patients usually first apply to us for
reiiei. It is upon these first visits to our of-
fices that we should make a complete survey
of the cases. There is no excuse for any of
us to permit a patient to repeatedly apply to
us for rel'cf and we neglect to make a thor-
ough e>:3mination in an honest effort to make
a diagnos's. In the event you have failed to
make a careful examination, do not pat the
patient on tJie back in a reassuring manner
v.ith the statement that he has lungs equal to
?. blacksmith's bellows, and that his lungs are
the best vthich you have ever examined.
The average person today is aware that his
lujig tissue is not all located undernMitJi hi»
breast plate, but that it extends east, west,
north and south, and he expects an reputable
physician to know the anatomic location of
this lung tissue. Do not fool yourself. The
time is rapidly approaching through medical
education of the public, when it will be im-
possible for us to fool or deceive the public.
We must get away from the old slipshod,
obsolete, "no diagnosis" or "run down condi-
tion," "iiervcus indigestion," "spring fever,"
"biliousness," "ovary" or "female trouble,"
"neuralgia of the heart," "growing pains," or
"bad blood." These are camouflages of ig-
norance. They have been overworked and
are as much out of place in our profession
today as a tick-infested scrub bull among a
herd of thoroughbred Holstein cows.
As to the complete examination, I hear the
age-old cry that "the patient will not pay me
for a thorough c>-arri!!iation and the time con-
sumed in mak''..-T :; d'a'wosis." This will
driiend upon yni ; :." Tamining physician.
1 can ."^pjak oniy iriihi c :perience and from
what I iiave learned by inquiry among my
professional friend:-. I am of the opinion,
after ten years of experience", that when a
physic'an explains to the patient that a thor-
ough examination is needed to make a diag-
nosis and for this thorough examination an
extra fee will be charged, the patient invaria-
bly and willingly consents. In the end these
are cur very best pntients, for they pride
themselves in the fact that "Dr. So and So
knows all about rne because he gave me an
a!! over examination." These patients pay
pr.d boost better than any class of patients 1
have. The public have learned that they
CPU not hope to consume even a garage man's
time and not pay him for it.
In this paper I shall not attempt a differ-
ential d'agnosis but to outline the more
prominent reasons for arriving at a diagnosis.
Briefly, aiid in order of their accepted im-
portance, the diagnosis may be considered
under five cardinal points. (1) history; (2)
symptoms; (3) physical signs: (4) x-ray
signs; (.S) specific reactions.
I. History: (a) The presence of tubercu-
Februan-, 102Q
SOUTHERN MEDICINE AND SURGERY
8S
losis in the family. This is not serious as a
matter of heredity but means everything so
far as environment is concerned, (b) Unusual
exposure to the disease, as parents, nurse, or
any intimate association with the disease,
part'cularly during the patient's childhood or
per-adolescent period, (c) debilitating cir-
cumstances, chronic illness, focal infections,
worry, dissipation, unhygienic surroundings,
(d) Occupation is of minor importance.
II. Symptoms: (a) Loss of weight. This
ma_\' be traced back for a period of ten years
in an adult. In addition a failure to gain
throughout a period of six months is consid-
ered a loss of weight. The loss of weight is
always more suggestive if it occurs in spring
and summer. .\ tuberculous patient with-
stands warm weather very poorly, (b) Pain
in chest. This is one of the most conspicu-
ous symptoms. It may be sharp and knife-
like in character, or one small sore spot in-
definitely outlined by the patient. These
areas of pain are usually produced by pleu-
risy, (c) Temperature. The morning tem-
perature normal or subnormal: the afternoon
temperature elevated, maybe very slightly.
Tiie temperature should be recorded every
three hours for a period of ten days, and the
amount of exercise always recorded. A per-
s'stent subnormal temperature, provided the
afternoon temperature more nearly ap-
proaches normal, is suspicious, (d) Indiges-
tion and gas, uneasiness after meals, and loss
of weight are frequent and common symp-
toms; also loss of strength and inability to
perform usual duties without tiring, (e)
Cough may be present but is more commonly
absent. A morning cough in patients other
than cigarette smokers is suggestive. The
cough, if present, is usually hacking in char-
acter. Expectoration may be present, but it
is rare in the early stage, (f) Pulmonary
hemorrhage may occur as the first symptom
or it may never appear. FLarly in the disease
It is always a good progno.stic indication, as
Ih? h morrhage frequently produces a clear-
ir.g of a focus and a good organized blood
clot is formed. Further, it hastens the pa-
I ent to secure professional a'd: it gives him
:i fri'lv, ;ii fl he will he more cautious in his
li.\^;.f;c. (',') Repealed attacks of '■grippe"
11- b::d colds friini which p.ilicnl ii-cumts
j1jh1>, u.ually thee i:^ a lucUng Luugh Itlt
that persists stubbornly, (h) Sputum. The
amount varies with different individuals. If
present there is more in the early morning.
Repeated stains should be made for tubercle
bacilli. Some laboratories digest the sputum
and then centrifugalize as in examination for
casts in urine. If sputum is positive, the
diagnosis is easily made. I prefer, however,
more than one positive report, with the rela-
tive number of bacilli found in one field. A
negative report does not prove the absence
of tuberculosis.
III. Physical signs: Before attempting a
physical examination, it is obviously import-
ant that a good direct light, preferably day-
light, be present; the patient should be nude
to the waist. For the female a V drape
may be empkned. Irrespective of what the
physical findings may be, unless we can ob-
tain a h'story and symptoms as above out-
lined, or at least a major portion of them,
we may usually ignore signs.
(i) Inspection: Watch carefully for the
lagging chest wall as a whole, then detail the
supra- and infraclavicular fossae. Notice for
rlrooping shoulders, the length of line from
shoulder to the neck; watch for differences
of ihe interspace. Considerable information
ma/ be obtained by careful inspection, (b)
Palpation: \'ariations in vocal fremitus are
to be noted. Some claim to detect a differ-
ence in the resistance offered. I cannot, (c)
Percussion, light and heavy may be employed
with distinct advantage. The impaired reso-
nance that you may find over the apex of the
affected side indicates anatomic changes in
the area examined.
(d) .Auscultation over the entire lung, hav-
ing patient breathe through his mouth as nat-
urally as possible, gives invaluable informa-
tion. Then have the patient make deep res-
p'ration, ob'.erving anything of note. Follow
tiiis by deep inspiration and, at the end of
expiration, have patient give a little cough.
The localized apical rales that may be pro-
duced are characteristic of what is to be ex-
pected in incipient tuberculosis, particularly
yiiould these rales persist. Granular breath-
irrg, if present, is now recognized as one of
Ihc e:irrest physical signs manifested in in-
ci|iicnl pulmonar\- tuberculosis; however, it
is not present in every case. This type of
I) eathng i.-^ a rough sputtering ly|ir. it is
produced bv air forcing its way into ihe |-Kir-
tially collapsed vesidc-s, which e.\pan4 inde-
pendently instead of synchronously. Feeble
SOUTHERN MEDICINE AND SURGERY
February, 1929
breathing is next of importance to granular
breathing. If present in the apex it is more
significant of incipient tuberculosis. Prolong-
ed expiration is third in importance and is
more easily recognized. The respiratory
murmur here has usually a harsh, high-pitch-
ed bronchial quality. The normal differences
between the right and left apices are to be
kept in mind; there is to a greater or lesser
extent prolonged expiration over the right
apex posteriorly. This, however, rarely ex-
tends below the seventh cervical vertebra.
.\lso in children there is a tendency toward
an exaggeration of the normal. Vocal reso-
nance is but rarely altered in incipient tuber-
culosis. We expect to find this in advanced
cases.
I\'. X-ray: Here we come to the debata-
ble point in the diagnosis. Some roentgen-
ologists make the bold assertion that they can
positively make a diagnosis of incipient pul-
monary tuberculosis: others say they can
demonstrate tubercles which are indicative of
this condition, while others speak very con-
servatively and say they can demonstrate the
anatomic changes in lung structure. We have
able clinicians who do not agrpe with the
first assertion but find the latter conservative
interpretation invaluable in the diagnosis of
the lesion. The stereoscopic plate is the
shadow of preference and is invaluable in
making the diagnosis. \'ery frequently the
cmploymsnt of x-ray is more valuable as an
aid in excluding other confusing conditions
of the lung than as used for the diagnosis of
incipient tuberculosis. The fluoroscope is
very valuable in estimating the freedom of
respiratory movements, particularly at the
apices and bases of lungs. Further, the free
use of x-ray is useful to make permanent rec-
ords, and later a comparison may be made
as to effects of treatment. The x-ray should
be employed in every suspected case.
V. Specific reactions: The technic of these
reactions will be omitted, as it can be readily
found in any good textbook of medicine. .\
positive reaction to one of the tuberculosis
ikin tests is generally accepted at the present
tme as evidence of a tuberculous infection
somewhere in the body. A positive test,
liowever, does not rnean that the patient has
clinical tuberculosis. It should be kept in
mind that there is a vast difference between
a tuberculosis that is clinically recognizable
and a hypersensitiveness to tuberculin. Hy-
persensitiveness to tuberculin is present in a
large proportion of healthy people, and it is
a mistake to believe they need active treat-
ment for tuberculosis just because they react
positively. On the other hand, a negative re-
action does not entirely free us from respon-
sibility. The intradermic test is more sensi-
tive; but for general practitioners the cutane-
ous or von Pirquet test is the preferable tu-
berculin test to employ, on account of its
simplicity and its generally accepted reliabil-
ity. When this test is positive in a child be-
fore the end of the second year it is gener-
ally accepted as evidence of clinically active
tuberculosis. Beyond the second year it loses
much of its value as a diagnostic sign. The
C(jnjunctival test is mentioned only to be con-
demned, as it is liable to produce serious com-
plications in the eye.
In conclusion, permit me to review briefly
the live essentials in the diagnosis of active
incipient pulmonary tuberculos's.
History: Take time and secure the major
factors as relate to this condition
Symptoms: "Seek and ye shall find," ap-
plies here equally as it did in years long past.
Secure detailed symptoms of all past and pres-
ent trouble.
Physical signs: Can be obtained by any
normal physician who still possesses four of
his five special senses plus some energy and
a determination to get the facts.
X-ray signs: X-ray facilities are within
reach of nearly every man in the state. The
North Carolina Sanatorium will make x-rays
at cost if you will only arrange for an en-
gagement. Use the x-ray freely; you will
find it a valuable aid.
Specific reactions: Very helpful before end
of second year, of doubtful value after that
age. Use them; they may be good alibis for
the future.
Finally: .\fter you have done your best
and you are not sure of your diagnosis, play
the game squarely and tell your patient. On
the other hand, if you are reasonably sure of
your diagnosis so inform your patient,
Ffbruary, 1029
SOUTHERN MEDICINE AND SURGERY
Remarks on the Importance of Roentgenography of the Chest*
E. W. ScHOENHEiT, ^NI.D., Asheville, X. C.
While roentgen ray plates are of very great
value, I am of the opinion that their use has
been considerably abused and that they have
been the cause of much carelessness in physi-
cal examinations. It is important, however,
that no patient who has symptoms refer-
able to the thorax should be pronounced
well until x-ray examinations have been made
and probably they should have repeated ex-
aminations at intervals of a few weeks or
months, but they must be made by one who
has been trained in both technique and diag-
nosis. How many of you who are treating
pulmonary diseases do not frequently see pa-
t'ents who bring films which are absolutely
worthless? The practitioners who do this
kind of work do not realize that technique
which may be suitable for certain fractures
and gross lesions will not be satisfactory for
showing the lighter infiltrations. Unless the
picture is of good quality and taken with
considerable speed much of the detail will be
blotted out and a gt)od plate will show much
more involvement. The patients who bring
these pictures are often disapptjinted when we
say that new pictures must be made, as per-
haps the first ones had been taken only a few
days before, but we should be unable to com-
pare them with our future films and make any
deductions regarding improvement.
I have also been impressed by the fact that
wh'le nvjst patients have had x-ray work
done, very few have had a sputum examina-
tion made, and unfortunately most of them
are positive. When the patient is to be sent
away for treatment a positive sputum would
be better for diagnosis than a poor x-ray pic-
ture. I do not mean that they should wait
for a positive sputum — and the negative cases
should be x-rayed: — but in these above all,
the quality of the film must be good to be of
any value.
The ycjunger generation of physicians has
been severely criticised that they have not the
skill of their predecessors and that they are
Ui.able U> make diagnosis without many and
vnrious laboratory examinations. It can be
.*Prc^ntCf! trj the Kur.t'jmbf. (.'uuijl. Mi.iicil
b»crety, .\iheVille, November ?, 192S.
shown, however, that this criticism is unjust
in most cases. The diagnoses made in the
receiving wards of our city hospitals by the
internes, with very little laboratory aid, are
largely correct. Nevertheless there is a ten-
dency with some men to be guided entirely
by the roentgenogram in chest conditions and
to ignore the importance of the clinical exam-
ination. There is also a tendency among
others to study the x-ray films before making
a physical examination. I believe this influ-
ences the examiner to hear abnormal sounds
where changes are noted in the plate. On
the other hand, if one makes a diagnosis from
the history, symptoms and signs, and checks
up with the x-ray and other laboratory tests
he will be stimulated to more careful work
and will be repaid by the satisfaction that he
is correct in most instances. This reminds
me of the statement by Ur. W. W. Keen:
"With all our varied instruments of precision,
useful as they a^'e, nothincr can replace the
watchful eye, the alert ear, the tactful finger
and the logical mind which correlates the
facts obtained through all these avenues of
information and so reaches an exact diagno-
sis."
I have stressed the importance of quality
in technic|ue. The pictures must also be uni-
form and in the case of lung work, should
always be stereoscopic. Lateral films are of
considerable value at times, especially in
mediastinal diseases.
Pottenger^ in a recent article says that pic-
tures taken in the dorso-ventral position often
do not show the pathological changes that
one would see if they were taken in the re-
versed or ventro-dorsal position, anrl vice-
versa. He believes that many of the discrep-
ancies between physical signs and x-rays may
be harm')nized by takini; platen in h;iih posi-
t'ons.
The x-ra\' is not infallible in the diagnosis
of early tuberculous lesions and it is a mis-
take t(i rely (in it I'litircly. There are cases
with slight iiililtratidn \vlii( li in:i\- nut change
the density of the |j.iiriii li_\ nia nf tlic hing
til the extent that anything may be diagnosed
SOUTHERN MEDICINE AND SURGERY
February. 1929
from the plate; at the same time there may
be characteristic auscultator ysigns. On the
other hand, there are many patients in whom
the physical signs may show no departure
from normal standards in which considerable
mottling may be seen. It is also true that
roentgen examination may reveal deep-seated
les'ons in their incipiency which are not
heard on physical examination, and should we
have waited until pathological sounds were
udible the case would probably have reached
an advanced stage.
When tuberculosis has passed the early
stage the x-ray is less often needed for diag-
nosis, but is valuable for confirming it. It is,
too, of the greatest value in determining the
exact extent of the lesions, and for this pur-
pose is far superior to the clinical examina-
tion. We may examine a patient and after
outlining the diseased area find by the ray
that the lesions were much more extensive.
We may also note on examining for the first
time a patient who is acutely ill, with great
prostration, fever, severe cough and abundant
expectoration, that physical signs reveal
coarse, moist rales throughout one or bath
lungs, and feel that extensive softening is tak-
ing place. The x-ray, however, fnay show no
evidence of widespread involvement. This
may be caused by an old focus which due to
fatigue has been the starting point of a diffuse
bronchial attack, with abundant secretion.
After a period of bed rest most of the signs
clear up and our physical examination coin-
cides more closely with the roentgen appear-
ance.
In addition to det.?rmining the topography
of the lesions the x-ray is of great value in
the diagnosis of cavities, since about 45 per
cent of cavities revealed by ray have no
classical cavernous signs. The cavernous signs
are produced by the vibrations of the cavity
walls during respiration. If the bronchus in
communication with the cavity is obstructed
by fibrous or mucopurulent material there
will be no transmission of vibrations. If the
cavity is deep-seated we may hear only clear,
vesicular breath sounds in the overlying lung,
ar.d as mentioned formerly, the sounds may
be obscured in thick-chested people. Bendove-
of Colorado classifies such cavities as abso-
lutely mute and relatively silent. There are
no abnormal signs over the absolutely mute
and only \esicular breathing is heard. The
relatively silent are those over which no
l\pcal cavity signs are elicited, but which
manifest their presence by abnormal physical
signs such as coarse, moist rales and broncho-
ves'cular breathing. The relatively silent
mike up the great majority, and Bendove ex-
plains the mechanism of their physical s'gns
as being due to the inability of the cavity
walls to produce vibrations because of their
soft ragged condition.
It is of course true that cavities may be
d agnosed by x-ray examination when they
are not present. There has been a great deal
written about annular shadows which were
thought by some to be the result of pleural
adhesions. Others thought that they were
localized pneumothoraces, but it has been
proven by Dunham-' that these annual shad-
ows are cavities. There are times, however,
when trunk shadows may form rings which
look like cavities; but they can usually be
traced out in the stereoscope, .\niple train-
ing in the post-mortem room prevents many
m'stakes in x-ray interpretation.
A recent article in the Southern Medkal
Jcurnal gave a quotation from Sir James
Kingston Fowler, which is well worth repeat-
ing: "Queer things may happen when a clin-
ician scraps his stethoscope and calls in a
radiologist who has not been a pathologist."
Another point regarding annular shadows is
that with the induction of a pneumothorax,
the size and shape will change and the ring
will disappear with complete compression.
This could not happen if due to pleural ad-
hes'ons.
It has been said that if diagnosis is diffi-
cult, prognosis is even more so. It is im-
possible to tell from any x-ray plate what
w'U be the outcome in a specific case, other
than that we may expect a favorable result
in those of slight involvement and mild sym{>
toms; but, when we take new plates at inter-
vals of three months and note the absorption
of caseation and increasing fibrosis or closing
of cavities, we have a very valuable index of
improvement and can be more sure of a good
result. .At times there are patients who show
sight aggravation of symptoms, but the x-
ray shows the formation of new cavities, per-
hips at the base, which were not found by
physical examination, and the outlook is
much more serious. Serial x-ray plates pro-
vide a very interesting study in that we may
February, 1929
SOtJTHERN MEDICINE ANt) StRGERV
Figure I
Pulmonary tuberculosis in a younji man, moder-
ately advanced, active. There is dense infiltration
of the upper half of the right lung with a small
cavity at the level of the bth interspace, posterior,
and infiltration of the left upper lobe. Physical
signs are those of a destructive lesion in the right
upper lobe, medium moist rales, no typical cavity
signs. Sputum positive.
Figure 11
The same patient nine months later. Note the
almost complete absorption of the lesions and closure
of the cavity. All symptoms and signs have dis-
appeared except for a very few dry crackles, heard
posteriorly at the level of the si.xth dorsal vertebra.
Figure 111
Moderately advanced active pulmonary tuberculo-
sis in a young woman, with multiocular cavity in
the left upper lole and small cavity in the right lung
behind the second rib. Physical examination revealed
signs of a lesion extending from apex to third inter-
space on the left, with fine moist rales. Fine rales
heard beneath the right clavicle after cough. Sputum
positive.
Figure I\'
The same patient one year later. There has been
complete healing and absorption of lesions with only
a fibrous nodule in the left upper lobe. All symp-
toms and physical signs have disappeared.
90
SOtTHERN MEDICINE AND SURGERY
Eebruafy, 1920
Figure V
Moderately advancer), active pulmonary tuberculo-
sis in a youns; man with caseous infiltration — "snow
storm" mottlina in the left lung, and infiltration of
the right upper lobe. Physical signs of destructive
lesion in the left upper chest with medium moist
rales. Sputum positive.
Figure VI
The same patient fifteen months later. \ote the
complete absorption of caseation with fibrosis in the
upper lobe. .\11 symptoms have disappeared, a few
scattered dry rales are heard over the left upper lobb
and middle axillary region.
Figure VII
Advanced pulmonary tuberculosis, active, in a
young man. The picture was taken in 1020, at
which time he was under the care of my uncle. Dr.
Karl von Ruck. This shows extensive involvement
of the upper part of both lungs, but the condition of
the right lung is obscured by a partial pneumothorax
which had been induced in 1010. The patient im-
proved rapidly after this and the lung was allowed
to re-expand.
Figure VIII
This is the same patient, this picture having been
taken in .August, 102S, alter his lung had been ne-
cxpanded for nearly eight years. The picture shows
fibrosis of the right apex, pleural adhesions and
numerous calcified points in both lungs. .Ml symp-
toms and physical signs have disappeared. He is
very active and has been for the past six or seven
years.
I
February, 1»JQ
SOUTHERN kntmClNE AND SURGERY
91
watch the regression or extension of lesions
from time to time and observe them to be-
come cicatrized and disappear, or to caseate
and extend further. They are also a great
help to us in estimating the proper treatment
and at what time it should be modified or
changed.
To my mind, the most brilliant results in
phthisio-therapy have been brought about
through artificial pneumothorax. The most
gratifying thing in our work is to see a pa-
tient who appeared to be doomed, begin to
improve after the induction of pneumothorax
and go on to recovery and restoration to an
active life of economic importance.
Many times after physical examination of
the chest, we would deem it unwise to induce
a pneumothorax, because involvement of the
better lung made us fear it would break down
under the additional strain. We have noted,
however, that physical signs, such as rales,
may be transmitted to the opposite side and
cause confusion. It is also quite likely that
constant absorption of toxin from a badly
diseased lung may cause focal reactions in
the better lung giving the impression that
there is considerable activity there. When
x-ray pictures reveal only slight trouble, we
proceed with the pneumothorax with excellent
results. We note that after compression of
the extensively diseased lung the signs in the
good lung clear up because we have stopped
the auto-inoculation of toxin. The patient
has been in a continuous tuberculin reaction
from his own tuberculin. X-ray examinations
aid somewhat in deciding whether a pneumo-
thorax can be induced or whether adhesions
will prevent it; however, the only sure way-
is to try it as x-ray or physical examinations
cannot determine this with certainty. Of
course x-ray pictures are even more import-
ant in considering the more serious operatiims
such as thoracoplasty.
I have spoken mainly of tuberculosis, for
it makes up the larger part of our work.
About five per cent of patients referred to us
as having tuberculosis are not suffering from
that disease. There are many border line
cases in which it is a question whether there
is clinical tuberculosis or not, but I am not
referring to these. We have many patients
with very definite pathological processes who
have been diagnosed tuberculous but who are
really suffering from some other disease of
the chest. The frequency of bronchiectasis
has been brought out by the use of radiogra-
phy after injection of iodized oil. Foreign
bodies are no longer a curiosity. Malignancy
of the lung once thought to be very rare is
seen more often. Micotic infections, anthra-
cosis and pulmonary abscess are frequently
seen. The x-ray is probably our greatest aid
in picking up these different disease entities,
which are not become more frequent in oc-
currence but the refinements of diagnosis
now permit of their being more readily rec-
ognized. Some of our most puzzling cases
are those which have a history and sympto-
matology resembling tuberculosis, with exten-
sive physical signs, such as we see in advanc-
ed phthisis with abundant expectoration
which is negative for tubercle bacilli on re-
peated examinations. \\'hile we occasionally
see a case of this kind that is tuberculous, it
is wise to be on the lookout for other diseases.
The cuts illustrate some of the points I
have mentioned.
REFERENCES
1. F. M. Pottenser: Certain Factors Militating
.■\Rainst .Accurate Correlation of Physical and Roent-
gen Rav E.xaminations of the Chest. Am. J. Med.
Sc, Vol. CLXXV, No. 5, May, 1P2S, page 676.
2. R. A. Bendove: Silent Pulmonary Cavities.
J. .4. M. A., Vol. 87, No. 21, page 17,W.
,^. Dunham, K., and Hayes, J. N.: Comparison
of Stereo-roentpenograms of the Chest with .\utop.sy
Findings.
Trans. Nat. Tub. Assn., lym, page ^2^.
SOUTHERN MEDICINE ANt) StlRGEftV
February, 15^5
Primary Tuberculosis of the Penis
William Frontz, M.D., and Robert \V. McKay, M.D., Baltimore
From the Brady Urological Institute, The Johns Hopkins Hospital
Of the chronic ulcerative lesions occurring
on the penis, primary tuberculosis is probably
the rarest. The disease commonly masquer-
ades under such diagnoses as primary or ter-
tiary syphilis, granuloma inguinale, or chan-
croid, until the failure of the various specific
intravenous and local therapies employed in
these conditions has been demonstrated. The
true nature of the disease usually remains
unsuspected until a biopsy is performed and
the characteristic picture of tuberculosis dis-
covered microscopically.
Primary penile tuberculosis apparently fol-
lows direct inoculation from contact with a
tuberculous cervix during coitus, or probably
more frequently as a result of the practice of
one of the most common perversions during
which the penis is bathed in tuberculous in-
fected sputum. This latter possibility is
strengthened by the numerous reports of cases
which have followed the old technique, now
happily abandoned, of performing ritual cir-
cumcision.
By far the greatest number of cases of
primary tuberculosis of the penis reported in
the literature are those in which the lesion
has occurred in Jewish children following
ritual circumcision. The very interesting
steps of the ritual circumcision are probably
not familiar to those outside of the Jewish
faith. The steps constituting this ritual are
as follows:
1. The Milah: The child sits on a parent's
knee, the JNIohel draws the prepuce forward
and places it in a slit shield, and circumcises
the penis with a single stroke of the knife.
2. The Periah: The mucosal layer cover-
ing the glans penis is next stripped back with
the thumbs and index fingers exposing the
glans.
3. The Mezizah: The ^lohel takes wine
in his mouth and applying his lips to the
penis, exerts suction, spitting the blood and
wine into a jar; the hemorrhage is afterward
controlled.
This was commonly practiced by Jews un-
til some years ago, when at Krakow a great
number of children were infected with syph-
ilis. It was traced to a Mohel who had con-
tracted the disease, and after this the use of
a glass cylinder was introduced, so that the
Mohel should not longer touch his lips to the
wound.
Wilson and Warthin give a very compre-
hensive review of the subject and report
twenty-two cases of tuberculosis of the penis
acquired at time of ritual circumcision. They
also make a very interesting report of two
brothers who were operated upon at the same
time by a surgeon who had just previously
operated upon a tuberculous patient. Both
boys developed tuberculosis of the penis in
the operative area. The lesions in these two
cases responded promptly to local therapy and
light, and the boys had no further evidence of
tuberculosis.
They report, in addition, a case of localized
tuberculosis in a foreskin which was removed
by circumcision. In this latter case there was
no sexual exposure and no known possible
mode of infection. They were under the im-
pression that the lesion in this case was
probably hematogenous in origin and not de-
rived from the mucous membrane by direct
contact. However, no other tuberculous
process could be demonstrated in the patient.
In 342 cases of urogenital tuberculosis ad-
mitted to the Brady Urological Institute,
there are only two cases of primary tubercu-
losis of the penis.
Mode of injection. — Infection is usually
acquired by coitus with a female having tu-
berculous genitals or by direct contact with
tuberculous sputum, as shown above. The
infection may be hematogenous in origin. In
such cases, the primary focus is usually de-
monstrable.
Appearance. — The primary lesion consists
of a small indurated reddened papule which
makes its appearance usually upon the glans
penis, the prepuce or the frenum. In this
particular, it is similar to the common vene-
real lesions which have a certain predilection
to regions most susceptible to injury. In its
first stages, this lesion is very similar in ap-
pearance 10 the non-ulcerative types of chancre
and the attending physician is usually struck
February, 1920
SOUTHERN MEDICINE AND StJRGERY
W
by the fact that it does not disappear under
anti-syphilitic therapy. In the later stages
it closely resembles chancroid. The ulcera-
tion is slowly progressive. Its edges are un-
dermined and its base is covered with a dirty
gray slough. In one of the cases herewith
presented the skin and subcutaneous tissues
were undermined to the extent of at least 1
centimeter. The presence of secondary infec-
tion may markedly change its appearance.
Diai^nosis. — The differential diagnosis of
tuberculosis of the penis frequently involves
considerable difficulty, because of confusion
with other lesions such as chancre, chancroid
and granuloma. In the early stages of the
disease it can very readily be confused with
the papular form of chancre. .•\ dark-field
examination, however, as well as a wasser-
mann reaction should be helpful in making
this differentiation. Therapeutic tests will
also be of aid as tuberculosis will not respond
to intravenous medication with the arsenicals.
In the ulcerative stage of the lesion there is
a great similarity in its appearance with
chancroid. White and Martin, realizing this,
have suggested the autoinoculation test as a
means of differentiating the two lesions. In
practically all chancroids it is possible, if the
secreton from the lesion be applied to an
abraded area, to produce very promptly a le-
sion similar to the original one. In our ex-
perience the only satisfactory and certain
method of diagnosing this lesion is to obtain,
preferably from the edge of the ulcer a speci-
men for microscopic examination. This shows,
of course, in tuberculosis a very characteristic
and unmistakable picture. Some writers have
recommended a search for tubercle bacilli in
the scrapings from the ulcer and others have
reported positive Inidings after guinea pig
inoculation. In our experience, however, these
methods have proved untrustworthy.
The two following cases of primary tuber-
culous ulceration of the penis have come un-
der our personal observation:
CASE 1. — \\'hite married man, aged
ff)rty-eight, blacksmith, appeared first in the
genito-urinary clinic with the complaint of
burning on urination. There was no familial
hstory of tuberculosis. Except for slight
urinary frequency and burning, he had no
symptoms referable to the urinary tract.
There was a history of gonorrhea eighteen
years previously which cleared up promptly
under treatment.
Examination. — There was revealed a hard
indurated lesion involving the meatal margin
which was red, sensitive and superficially ul-
cerated. It was thought to be a chancre al-
though repeated dark-field examinations were
negative for treponema pallidum. The blood
wassermann showed no fixation. The scrotal
contents were normal, and rectal examination
found the prostate and seminal vesicles nor-
mal. The urine voided in the first glass con-
tained pus and gonococci, while the second and
third glasses were clear and negative for pus
and acid-fast bacilli. Further investigation of
the urethra revealed some old infiltrations in
the pendulous portion which yielded to dilata-
tion. Courses of intensive anti-syphilitic treat-
ment and ntravenous tartar emetic left the
parameatal lesion unimproved; in fact, during
the four months covering these treatments,
during which time his wassermann and spinal
fluid were consistently negative, it has pro-
gressed slightly. Biopsy was finally done which
definitely established a diagnosis of tuberculo-
sis (Fi^. I). The ulcer was treated by the Kro-
Fic. I
C'a'^c 1 I.r.w power of section taken from ulcer
for biopsy, showing skin epithelium and tubercle
in lower rinht corner. The ulcer in this case healed
promptly but produced a penile fi tula. There was
no spread of the ulceration.
mayer lamp over a period of four months, dur-
ing which time a small urinary fistula develop-
H
SOUTHERN MEDICINE AND StRGERY
February, 1929
ed to the right of the frenum. The patient was
then lost sight of for a period of eight months,
when he returned complaining of urinary dif-
ficulty. Examination of the meatal area and
the fossa navicularis showed extensive fibro-
sis. The ulceration had healed. This filiform
stricture was treated by an internal urethro-
tomy, followed by dilatations. The patient
has been seen recently, six years after the
appearance of the initial lesion, and his health
has been excellent. There have been no mani-
festations of tuberculosis elsewhere in the
body. Examination of the penis at the pres-
ent time reveals the following: The site of
the former lesion has entirely healed. On
the right side of the glans penis corresponding
to the site of the former lesion, there is a
tiny urinary fistula to the right of the frenum.
There is no other genital pathology. His
urine is clear.
CASE II. — Married white man, aged
thirty-three, plumber, admitted to the Brady
Urological Institute October 13, 1926; dis-
charged November 10, 1927. Patient entered
the hospital because of an ulceration of the
penis. Four months before admission there
was a history of venereal exposure followed
two weeks later by the appearance of a red-
dened, indurated and sensitive papule of the
shaft of the penis, 1 cm. behind the coronary
sulcus. One week later a left inguinal bubo
developed which was incised with evacuation
of considerable pus. The inguinal and penile
lesions slowly progressed, resisting all local
treatment and at the end of four months
from the time of the appearance of the initial
lesion he was admitted to the institute.
Examination. — There was found a well
developed and well nourished young man.
The right inguinal glands were enlarged, firm,
discrete and non-fluctuant. Examination of
heart and lungs was negative. The chest
plate was negative for tuberculosis. No clini-
cal tuberculosis was made out. The blood
wassermann and dark-field examinations were
negative for spirochetes. Genitalia: — Penis:
The dorsal and lateral portions of the prepuce
were gone. On the dorsum of the penis one-
half centimeter back of the corona was an
ulcer, from 2 to 4 mm. in depth and 1 cm.
in diameter. The edges were undermined,
irregular and serrated. The floor of the ulcer
was covered by pale, granular adherent
slough. The lesion was extremely painful and
tender. Its borders were not indurated or
edematous. In the left inguinal region there
was a much larger, but similar ulcer. The
base of this ulcer extended along Poupart's
ligament and was directed upward and to-
ward the midline. It was 1.5 cm. deep, so
deep in fact that the aponeurosis of the ex-
ternal oblique muscle was visible. This area
also was very tender and painful. Scrotal
examination revealed normal testicles, epidi-
dymes, cords and vasa. Rectal examination
showed a normal prostate and seminal vesi-
cles; there was nothing to suggest a seminal
tract tuberculosis. Urine was negative for
Fi-. II
.4. This section taken from skin marj;in of a B. .\ hiwh power magnification of the central
large ulcer in left inguinal region. The lower power tubercle shown in .4. Note the giant cell epithelioid
shows tubercle formation. proliferation and round cells about edge of tubercle.
February, 1929
SOUTHERN MEDICINE AND SURGERY
9S
Fig. Ill
Case 2. The tubcrcn'nu- u'ceration wh'ch began
on the pen's h?.= cxt?nd:'d to both inguinal regions,
fuprspubical!y and into both femoral triangles. Note
the underminins of the ulcer? and the tendency to-
ward hea'.ing. as di p'ayed in the left inguinal region.
The dark area seen on the left side of the penis
represents a penile urin.iry fisiula produced by the
initial tuberculous ksiun whi h has healed in this
locality. The two strips of skin en either side of
the round central ulcer are completely undermined.
(Model by P'ortunato).
pus and tubercle bacilli. The lesions resisted
all attempts at local therapy although there
was some tendency toward healing when the
Kromayer lamp was used. Pinch grafting
was done to parts of the ulcerated area but
very few of the grafts lived. Several debride-
ments were done of the undermined skin
edges. Sections taken from this tissue showed
very typical tuberculosis, with giant cells,
epithelioid proliferations and round cells (Fig.
II). After remaining under our observation
for a period of months he returned home
where he entered a tuberculosis sanitarium.
At time of discharge, the ulcerative lesion
had covered almost all of the left lower quad-
rant (Fig. III). The lesion continued to
progress and the patient died of terminal
broncho-pneumonia two months after leaving
the hospital.
Apparently the resistance to tub^rculotis
infection in the first case was very great, for
even though the first patient had a very short
course of treatment he succeeded in promptly
healing his lesion. The course of the ulcera-
tion in the second patient was slowly but
steadily progressive. The infection was prob-
ably acquired by both patients during coitus.
CONCLUSIONS
1. Primary tuberculosis of the penis is con-
tracted by contact with tuberculous sputum
or during intercourse with a woman have tu-
berculosis of the cervix.
2. The lesion in its early stages resembles
the papular form of chancre, later taking on
the appearance in most instances of chan-
croid.
3. The diagnosis is usually made late, after
local and specific intravenous forms of ther-
apy have proved unsuccessful. The only sat-
isfactory and certain diagnostic method con-
sists in the microscopic examnation of tissue
taken from the margin of the lesion.
4. The most satisfactory form of treatment
is heliotherapy and the regime usually fol-
lowed in generalized tuberculosis.
5. Two cases of primary penile tuberculo-
sis are herewith presented.
BIBLIOGR.APHV
1. Wilson and VVarthin: .{nnals of .Surgerv, 1912,
Vol. 55, p. 305-31,;.
2. N. Senn: Tuberculosis of the Genito-imnary
Organs, p. 10.
3. Verneuil: Hypothesc sur I'Origine de Certaines
Tubcrculeuses Genitals dans les deu.x Sepes, Gaz.
Hebt., 1883, Xos. 14 and 15.
4. Poncet: La Medicine Modernr, Paris, July 20,
1890.
5. Keyes: Genito-nrimiry Diseases, p. 663.
6. Watson and Cunningham: Genito-urinary Dis-
eases, \'ol. 1, p. 30.
SOUTHERN MEDICINE AND SURGERY
Pcbruah', lOfO
Enterostomy — Its Surgical Importance
T. C. BosT, ]NJ.D.. F.A.C.S., Charlotte, N. C.
Chairman's address, Sedicn on Sur.'cr> Xrrth Citri lira Medical Society, Pinehurst. 1Q2S
Enterostomy is a simple life-saving proce-
dure which has greatly reduced the mortality
in cases of intestinal obstruction and general
peritonitis from whatever cause. Peritonitis
and obstruction are in many instances insep-
arable. As pointed out by JMcKinnon, a rup-
tured appendix produces peritonitis, periton-
itis produces obstruction and obstruction in
turn produces the fatality.
Distention is the symptom that demands
immediate attention in obstruction whether
the cause is mechanical or inflammatory.
Kocher and others have shown that gaseous
distention of the bowel alone can produce
gangrene and perforation. Muscle tissue
of the intestinal coats stretched beyond a
certain point loses its contractile power and
peristaltic waves cease. Furthermore it has
been shown by Goetch and others that when
the gas pressure in the intestine equals an
animal's blood pressure a complete circula-
tory stasis results in the bowel wall.
The stomach and colon may be emptied
mechanically, but there is only one efficient
way of emptying the small intestine and that
is by peristaltic waves. When the peristaltic
waves aro lost, the abdomen becomes silent
and as the late Dr. John Wesley Long so well
sa.d "when the bells have ceased to ring,"
we have no way of relieving the distended,
paralyzed intestine. The cue is to take ad
vantage of the peristaltic waves by resorting
to enterostomy sufficiently early to empty the
intestine and prevent its paralysis.
Enterostomy is designed to drain the bowel
of its to.xic material, to relieve gaseous dis-
tention and for the introduction of solutions
into the bowel.
It is my purpose to urge the more frequent
use of the primary enterostomy to prevent
further obstructive symptoms incident to ob
struction and peritonitis, and also earlier en-
terostomies in the event enterostomy was not
done as a part of the primary operation, since
its use is attended with but little danger and
produces wonderful results.
An enterostomy is indicated in severe cases
of ruptured appendix with peritonitis, in in-
testinal obstruction, in post-operative ileus,
in traumatic peritonitis due to ruptured vis-
cus or perforated bowel, in pneumococcic and
streptococcic peritonitis, and in certain cases
of anastomosis or resection of the bowel. To
paraphrase the old adage about drainage;
v.hen in doubt do an enterostomy. The only
contraindication is tuberculous peritonitis.
For several years I have been doing enter-
ostomies not only in all cases of marked dis-
tention, but also in those of moderate disten-
tion with obstructive symptoms, whether of
inflammatory or mechanical origin. Natur-
ally this has mostly been in dealing with rup-
tured appendices with peritonitis. Xo fatali-
ties have occurred in appendi cases, notwith-
standing some of these appeared almost hope-
less.
One of the great arguments in favor of
enterostomy in ruptured appendix with p)eri-
ton.'tis is the well known fact that nearly all
patients with fecal fistula recover. This is
unquestionably due to the fact that nature in
such cases forms a safety valve which de-
compresses or drains the intestine of its gase-
cu.: d'stention and toxic material. Enteros-
tcmy docs this in anticipation of nature's
reeds. Incidentally the same or better results
Cie cccomplished in a surgical way, cleaner
and much more safely and healing is effected
much sooner.
Oiie of the outstanding causes of mortality
in obstruction and peritonitis is operating
U-der ether anesthesia. \\'hether it is a sim-
j le enterostomy or an operation to relieve the
ob:truction, together with an enterostomy,
Cihcr narcosis practically inhibits peristalsis
.or 24 or 36 hours. Thus insult is added to
injury, the narcosis making the partial pa-
ralysis of the bowel complete — and then we
Vvor.der why the intestine will not drain
-h rough the enterostomy tube. A local anes-
thetic is imperatively needed in doing an en-
terostomy and should be employed at pri-
mary operation whenever possible.
The comparatively recent experimental
work of Orr and Haden might tend to cast
some doubt on the value of enterostomy.
They did a series of high jejunostomies on
dogs. Their work was done in the first 10
February, 1929
SOUTHERN MEDICINE AND SURGERY
or 12 inches of the jejunum and in part con-
sisted of obstructing the jejunum and then
doing a jejunostomy above the obstruction.
They concluded that jejunostomy following
obstruction had no beneficial effect on the
duration of life. Also they concluded that
animals with simple jejunostomy d'ed more
quickly than those with obstruction of the
jejunum.
It is reasonable to assume that a high
jejunostomy would be somewhat analogous
to the well known duodenal fistula which
causes such a rapid depletion and dehydra-
tion. Furthermore \\'alters has shown that a
pancreatx duct fistula alone is incompatible
with life. It is probable that other secretions
in the duodenum are necessary to support
life. .Also in high obstruction there is always
a profound metabolic disturbance causing a
constant rise in the non-protein nitrogen and
urea nitrogen, a fall in chlorides, and a rise
in the carbon dioxide combining power of the
blood plasma; also a gastric tetanj' and star-
vation.
In view of these e.xperiments and estab-
lished knowledge of the upper intestinal tract,
our one point to bear in mind in doing an
enterostomy is to avoid the upper jejunum,
and do our enterostomies a reasonable dis-
tance down the intestine.
Generally speaking, I think the non-advo-
cates of enterostomy are those who have done
late cases when patients were in a hopeless
condition. Procrastination is fatal. Do j'our
enterostomy at primary operation, or at any
rate before peristalsis has ceased. Don't wait
for fecal vomiting, which as Handley has well
said should not be looked on as a symptom
of obstruction but as a sign of impending
death. Even in this condition I agree with
Bonney, who holds that no patient should
ever be allowed to die with fecal vomiting
since such a simple procedure as enterostomy
taps its source and establishes free drainage.
In my ruptured appendix ca=cs I do an en-
terostomy in the cecum at the time of oper-
ation which is analogous to a fecal fistula
which type of cases nearly always get well. I
think it is unwise to get out of the contami-
nated field hunting for a distended loop of
ileum to do an enterostomy on. If the patient
is not doing satisfactorily after 24 to 48 hours
I do not hesitate to do another enterostomy
in the ileum or lower jejunum, in a clean
f.cid Ui der local anesthesia.
If enterostomy serves no other purpose
than to prevent post-operative ileus and gase-
ous distention, it is a valuable adjunct. A
Hat abdomen is a safe abdomen, and a dis-
'.eiidid abdomen is unsafe.
TECHNIQUE
A su'table loop is selected and its contents
,re;-t:y expressed. The assistant either holds
both ends firmly with the fingers or applies
Igh'tly a rubber clamp or clamps. Then a
rursc-string suture is placed opposite the
mesenteric border. Traction is applied to this
suture as is done in inverting an appendix
Jtump. The intestine is then incised and a
No. 10 or 12 rubber catheter with fenestra-
t'ons is inserted for a distance of from 2 to 3
irches. The purse-string suture is tied and
the tub? futured with the same stitch. The
catheter is then depressed along the intestine
and several Lembert sutures are inserted
vhich unite the serosa over the tube from 1
to 2 inches. If the omentum presents readily,
the free end of the catheter is passed through
sn opening in it. The catheter may be with-
drawn through the original incision or
through a stab wound.
The catheter may be allowed to drain out
on the flank. This procedure will decrease
th° d'stention of the abdomen and facilitate
the closure. If the drainage is not free, sim-
ple irr^gat'on will probably start it. The
glass tube of a bulb syringe or a small funnel
is fitted into the free end of the catheter for
convenience in pouring in the water, saline,
or glucose.
Occasionally, if the first enterostomy does
rot drain at once, it is advisable to do a sec-
end one higher up in the intestinal canal.
Either one of these may be connected with a
long tube filled with water which is lowered
to that it will syphon off the toxic fecal con-
t?nt.
I f"equentiy do a primary cecostomy
'!irou!'h the stump of the appendix after the
a;pe:"dix has been removed in the usual way,
o;:enin'j the base end, passing the catheter
t'lrou-ih into the cecum, placing two purse-
rtr'ng sutures about the base of the ajjpendix
in the canut coli and inverting the stump as
i.i cholecystostomy.
It should be emphasi/.td that we have a
dihydrated starved and toxic patient. There-
SOUTHERN MEDICINE AND SURGERY
February, 102f
fore, he should have lluid and food by mouth,
by bowel, subcutaneously, and intravenously,
with gastric lavage at frequent intervals, or
until the fluid obtained is clear.
The catheter will usuallv loosen so as to be
day. There may be some fecal discharge for
a day or two, but when enterostomy is care-'
fully done by the method described, healing
usually takes place spontaneously, and a see-
readily withdrawn on the sixth to the eighth ondary closure will not be necessari
Dr. Minor's Position in the Medical World, National and
International"
C. H. Cocke, M. D., Asheville, N. C.
I could not assay, even though I made the
attempt, nor estimate the position and influ-
ence of Doctor Minor in medical affairs be-
yond the limits of his own immediate sphere
of activity; yet, tonight, it is a source of
great pleasure and a privilege for me to bear
;c:timony to the wide influence, the com-
manding personality, and the dominating
leadership which characterized his activities
in all the medical associations with which he
v.as connected. As has been sa'd by many
others, Doctor ^Minor's character was one of
intensity of purpose and breadth, of interest
and outlook. He never aligned himself with
any medical association but that he put into
it so much of himself that he was at once
recognized as among its leaders. Broad vis-
ioned, catholic in his interests, spontaneous,
a:.d sometimes emotional in his varied re-
rponses and reactions, gifted with a wide
knowledge of medicine and with lucid diction
and a fertile imagination, he was quick to
enter debate on any medical subject, for he
never allowed his interest in medicine to be
I'mited to the bounds of the specialty to
V. hch he gave the best of his heart, mind
and soul. His discussions in assemblies of
national and international medical associations
were always well informed, well expressed,
not infrequently the result of real observa-
tion and study, and always stimulating even
when his views collided with your own. Hav-
ing heard and seen Doctor iMinor on many
occasions in these organizations, it is a pleas-
ure to record the measure of respect always
accorded him when he rose to talk.
Doctor Minor was truly loyal, in the best
♦Address ip the Memorial Exercises for D)-. Cjiarles
L Minor at tke meeting of the Buncombe Coujjty
Medical Society',' Aihevillc, N. C, Janaary 21, 1929.
sense, to the organizations with wh'ch he
united. He believed in the force of medical
organizations and immediately joined the
county and state societies in 1895 on com-
mencing practice in Asheville. Directing
most of his thoughts to the study of tuber-
culosis, which had been forced upon him by
reason of his owm illness from this disease,
he immediately became interested in the
subject of climatology. Within four years he
was elected a member of the .American Cli-
matological .Association, then as now, a na-
tional association of I'mited membership'
formed and fostered for the purpose of study-'
ing the relationship of cl mate to disease and
the benefits accruing from various climates.
He at once identified himself with the discus-
sions of this association, was honored by be-
ing elected to the presidency at the Hartford
meeting in 1912 and presided at the annual
meeting in Washington in 1913. For some
time he had realized that cl'matology in our
present state of knowledge offered but few
opportunities for further development, and if
this association, to which he had given his
best and deepest interest, was to preserve its
dominating posit'on in the medical world, it
must broaden its purview. .\nd so, as presi-
dent he advised a change in name to the
.American Climatological and Clinical .Asso-
ciation with the hope that this society would
become, or at least continue to be, the lead-
ing clinical medical association, as distinct
from some of the more experimental and re-
search soc'eties then becoming popular. So
impressed were his colleagues with this that
the association immediately changed its name
and for the past sixteen years had gone on
in incrcasinr; interest along clinical line?.
Those of u:-. m .\5he\ille, who are members
February, 1929
SOUTHERN MEDICINE AND SURGERY
of this society, owe in a large measure our
interest in this work and membership in this
society to the influence and sup[X)rt of Doc-
tor Minor.
From this association was organized, in
1904, the National Association for the Study
and Prevention of Tuberculosis. Doctor Mi-
nor was one of the founders. The name was
later changed to the Xattional Tuberculosis
.Association. He was for a number of years
act've as director and a member of the ex-
ecutive committee. In 1Q17 he served as its
president with d'stinction. So successful has
been the work of this organization that when
one considers the fact that at its foundation
the death rate from tuberculosis was approxi-
mately 186 per 100.000 population and that
the 1928 figures show only a death rate of
70 per 100,000 population, we cannot escape
seeing the enormous benefit that has accrued
to us by reason of its work. While it is not
contended that this tremendous drop is due
entirely to the work of the National Tuber-
culosis .Association, its state, county and local
subsidiaries, its work must be largely respon-
sible for this fine state of affairs and this or-
ganization has been taken as a model for the
foundation of the American Heart .Association
which is attacking the present increasing
death rate from heart disease.
Doctor Minor's interest in the international
aspects of tuberculosis was shown by his activ-
ities in the International Union Against Tu-
berculosis, and he was singularly honored by
being made one of the two delegates from the
United States to the session of this organiza-
tion in London in 1921. He attended the
Brussels meeting in 1919 and at one of these
meetings presented his paper, first in flawless
English and then in very acceptable French,
thus showing h's remarkable versatility and
linguistic accomplishments. He was the only
delegate t(j speak bilingually.
Doctor Minor's interest in the Southern
Med'cal .Association was manifested by fre-
quent attendance, many papers and discus-
sions, and at the Washingtcjn meeting, in the
fall of 1923 he was elected to the presidency,
serving during the year 1924 and pres'ding
at the New Orleans meeting that fall. Since
then he was an honored memi)er of the Board
of Trustees, composed only of recent ex-presi-
dents. In 1923 Doctor Minor was elected,
by reason of his outstanding iironiinencc, tu
full membership in the .Association of Ameri-
can Physicians, one of the outstanding lim-
ited membership organizations of internists in
the country. In 1926 Doctor Minor became
a Fellow of the American College of Physi-
cians and was made Governor for the State
of North Carolina. I had the privilege and
pleasure of hearing his last scientific paper
which he presented before the College at the
New Orleans meeting last March. He did
present another paper, however, before the
Climatological .Association at its Washington
meeting last May, discussing the question of
symbols and other methods for the recording
of physical signs elicited by examination.
In 1908 Doctor Minor wajp chosen by Doc-
tor Arnold C. Klebs (son of the great Pro-
fessor Klebs, who in 1881 cSme so near ante-
dating Koch by the discovery and isolation
of the tubercle bacillus, only to be denied by
reason of staining insufficiences), to write the
chapters on the Symptomatology and Diag-
nosis of Tuberculosis, in Klebs' compilation
on the general subject of tuberculosis by
American authors. The importance of Dr.
Minor's contribution was very definitely rec-
ognized by Dr. Klebs, who allotted him near-
ly one-third of the total number of pages in
this book. .Although many advances have
been made since its publication, this book is
still perhaps, and particularly Doctor Minor's
portion of it, the best thing in English on
the subject.
In 1913 the University of Virginia chapter
of the honorary society Phi Beta Kappa
elected h'm to membership, and in
1922 he was elected to honorary membership
in the Alpha Omega Alpha medical frater-
nity. The main outstanding honor to be
given him by his adopted state was the be-
stowal by the University of North Carolina,
in the year 1926, of the honorary degree of
Doctor of Laws, Honoris Causa.
Doctor Minor in all of his medical activi-
ties was truly the born teacher; a keen ob-
server with a passion for recording his find-
ings, who delighted in giving others the ioene-
fit of his long years of experience and knowl-
edge. His discussions were always marked
by outspokenness and intensity of feeling, and
a definiteness'of opinion that served to make
the spoken words a remarkable stimulus to
all who heard him. He was gifted with pow-
ers of graphic ciescriplion, a complete feat-
SOUTHERN MEDICINE AND SURGERY
February, 1Q29
lessness of attack upon sham and untruth,
and a fine wiUingness to enter the lists of
debate whenever the subject matter interest-
ed him.
I cannot conclude, lades and gentlemen,
this poor estimate of Dr. Minor's fine fame
and great worth without some allusion to my
own deep admiration and respect for this
great man and physician, perhaps the most
widely distinguished physician that North
Carorna has ever produced. It was my good
fortune, through intimate association, to
come within the sphere of h"s influence at
the beginning of my medical career in .\she-
ville, and 1 wish here to pay the tribute of
homage to a friendship and an inspiration
which lasted through all the years until his
career ended in death. At the old school
where he and I at separate times had the
good fortune to attend, there was a Latin tag
of a motto upon the old building which dated
from 1839, that must have had an influence
upon his life — "Fortiter, Fideliter, Feliciter " —
bravely, faithfully, happily! .And so he
Kved — bravely, despite physical illness that
would have crushed a lesser man; faithfully,
with a purpose born of high ideals and a
sense of service to others; happily, that he
nrrht d'spense the benediction of help and
pleasure to others, and truly it may be said
of h'm, as was so beautifully said by Wil-
liam FrncFt Henlev of another —
'It matter; iiut hew straight the gate,
Hew char,'ed with punishments the scroll,
I ;:m the Master of my Fate,
I am the Captain of my Soul."
Dr. Charles L. Minor*
H. H. Briggs, M.D., .\sheville, X. C.
I accepted this honor and duty reluctantly
because on such occasions words have so little
meaning and seem utterly inadequate.
Charles Launcelot Minor was born in Brook-
lyn, N. v., May 10, 1865, the son of John
Monroe Minor. iHe was sent to school at
the age of 11, graduated in medicine at the
U.iiversity of Virginia in 1888, and served
a.i internship of two years in St. Luke's Hos-
pital, Xew ■^"ork. iHe was married to Miss
iNIary Venable, daughter of Chas. S. \'enable,
of Charlottesville, \'a., on December 10,
1890, after which he and his bride started
immediately abroad where he began his post-
graduate studies, first in Munich, and later
in Vienna, Berlin, Paris, Dublin and London.
Returning to .\merica he began practice in
Washington, D. C, in December, 1892. In
1893 he contracted tuberculosis, coming to
Asheville for the cure in 1894, and began
practice here in 1895. He joined the Bun-
combe County iMedical Society soon after his
arrival, and continued a member until his
death on December 26th of last year, 1928 —
about one-third of a century.
*.\ddrcss in the Memorial Kxerci.ses for Dr. Charles
L. Minor at the meeting of the Buncombe County
Medical Society, .\shcvillc, N C, January :?!, lo?').
Dr. iNIinor joins d the Xorth Carolina State
Society in 1898 when Dr. H. B. Weaver, of
our society, was p /es de.it, and won second
place am )ng the car.d dates in the State ex-
am'nat.on. Of the members of the Bun-
combe County ^ledical Society living in 1895
when Dr. iNIinor joined, eight survive, viz.:
Drs. -Ambler, Brownson, Purefoy, Reynolds,
Dan Sevier, Jos. Sevier, Tennent and Weav-
er. Unt.i the last few years, when his health
was failing. Dr. iNIinor was a very active
member of this society, taking part in prac-
tically every discussion, not only in topics
alo.ig the 1 ne of his specialty, but with equal
ease on almost every subject, for his educa-
t'nn was very extensive. His experience in
St. Luke's as interne and especially his two
years abroad under the tutorship of renowned
instructors in various universities, gave him
a broad knowledge of medicine in all its
branches, enabling him to speak fluently on
medical subjects, and with his natural ability
as a speaker, his tall stature, his deep com-
manding voice, he impressed his audiences
both far and near with his attainments, his
versatility, and his ability as a practitioner.
Dr. i\Iinor's position in our society and
cinr ln( :i! profession is well known to all of
Ffbruar>-, 1929
SOUTHERN MEDICINE AND SURGERY
us, and he was the best natiimally and inter-
nationally known practitioner in the South.
He has contributed more, not only scientifi-
cally but in a material way to the local pro-
fession, and to the city, than any other one
practitioner. It is well known that for many
years it v. as through Dr. Minor that many
patients sought Asheville for the cure, and
that not only the City of .-Xsheville but the
medical profession in general were benefited
by their sojourn in our city.
I am sorry that through our carelessness
the records of this society's transactions, to-
gether with its constitution and by-laws, and
its seal, have been lost, covering the society's
earliest existence, from its organization, prob-
ably in 1881, up to about seven years ago,
and comprising about forty years of our his-
tory. As a consequence we have no official
data covering Dr. ^Minor's activity in this
society during the first twenty-five years of
h's membership, and the most active part of
his life's work. This great loss of the so-
ciety's history and property is greatly to be
regretted, and I hope that every member may
so feel this loss and his part in the responsi-
bilit\- that he may make a determined effort
to help tTnd this valued historical data. To
the older members living, especially those
contemporaneous with Dr. Minor, the loss of
this history of his activity and of our associa-
tion with him in our society is most keenly
felt. .And I am sure that the other members
who are younger also share this feeling, and
that each member may have enough pride in
his own membership and so feel the honor
which it confers on him that he may leave
no stone unturned in this search until these
records are found. The stigma of our care-
lessness in this matter should spur us to this
task, and I hope in future a safe or safe de-
posit box may be had and used to prevent
another such disgraceful happening. I hope
\ou may please pardon this diversion.
Dr. Minor served us as president for the
jear 1916. I am unable to find either the
titles or the number of papers which he has
contributed to our scientific meetings, but 1
remember not many years ago he told me
that a doctor should take off enough time
each year to write at least one medical paper,
ar.d that since he himself had been a mem-
ber he hafl written about twenty-five papers,
mr)st of which probably had been presented
to this society. The older ones present will
remember that most of his contributions
were, especially in the earlier years, on some
phase of tuberculosis, as were most of the
papers of other members, for that matter.
In the year 1909 Dr. Arnold C. Klebs pub-
lished his treatiest by .\mercan authors on
tuberculosis, dividing the subject into eti-
ology, pathology, frequency, semeiology, diag-
nosis, prognosis, prevention and treatment.
Dr. Minor was honored by invitation to fur-
nish the chapters on diagnosis which com-
prised 237 of the 818 pages in the book, or
about 30 per cent. This Dr. Minor treated
under headings of subjective symptoms, ob-
jective signs, physical examination and diag-
nosis. Dr. Klebs' estimation of Dr. Minor's
ability to treat the subject is shown by his
allotting to Dr. Minor the most difficult and
the most essential aspects of this subject.
That 63 pages were given over to diagnosis
showed Dr. Minor's interest in this purely-
scientific phase. Ten pages were occupied by
original cuts and photographs illustrating his
own methods of percussion and recording his
physical findings.
While Dr. Elinor was not a research man,
and contributed little either here or elsewhere
to original work, he nevertheless was an origi-
nal thinker, being bound by no conventional-
ity, and produced the most valuable papers
as a whole that I have heard here. His sub-
jects were well selected, well studied, and
their splendid composition and rhetoric made
them most entertaining. His discussions were
also equalh' commendable and entertaining.
Ofttimes he was entertaining without inten-
tion. His remarks were spontaneous, seem-
ingl\- unguarded and unstudied, yet apt, to
the mark, and piercing, necessarily revealing
the unusual type of mind which he [xissessed.
I imagine a psycho-analyst would have classi-
fied Dr. Minor as of the hy|ierthyroid type,
not that he had any endocrine disfunction
(although doubtless he had, as many of us
have) but that his acute sensibility, his alert-
ness of mind, his keen perception, his sensi-
tiveness and rapid physical and mental reac-
tions are possessed by a certain type of indi-
vidual only. We others, less fortunate prob-
ably, who are more phlegmatic, who think
and eat and exist more slowly, we, the ma-
jority, are prone to consider this type as ec-
centric. Wier Mitchell was such, as was
SOUTHERN MEDICINE AND SURGERY
Februan', 1920
Edgar Allan Poe and perhaps Xapxileon even
with his bradycardia. Mussolini is certainly
thus affected; — or shall we say endowed or
blessed — for this type is often found among
geniuses, and who knows but that this type
is the forerunner of what our mental and
nervous evolution is tending toward.
It was to some such type that our beloved
practitioner belonged. This temperament was
for Dr. Minor most fortunate in that he was
thus able to enjoy life to the fullest. His
pleasures were the greatest, his home, his
family, his friends, and his life were the most
enjoyable of all. The temperament fitted the
man. He was an idealist, always endeavor-
ing "to hilch his chariot to a star." His at-
tainments inspired him to further effort and
accomplishment. He shared with his friends
his pleasures and was loyal to them to the
last ditch. While such temperament is capa-
ble of carrying its possessor from the sub-
limest heights to the lowest depths, Dr. Mi-
nor was usually able to ostensibly remain en
haut, and seldom failed to extricate himself
from the gloom that would surround most
individuals whose fate was so unfortunate as
was Dr. Minor's. Dr. Hammond, of Balti-
more, said that he was always on the heights.
During his third-of-a-century's struggle
against tuberculosis, and the last few years'
against even more relentless diseases, he never
lost his nerve, seldom became impatient, and
exhibited an indomitable courage, which, with
his optimism, were the principal factors con-
tributing to his attaining his 64 years of use-
ful life. Of his obstacles he made stepping
stones. His physical handicaps seemed to be
allies. Henry Christian, of Boston, said of
Dr. Minor: "Not in spite of his handicaps,
but because of his handicaps does he live.''
His attainment of being one of the greatest
specialists in tuberculosis in this country, and
his world-wide reputation were due to his
intense study of the disease whose tentacles
had already fastened themselves upon him.
His long suffering had brought him the pa-
tience to withstand the pain incident to his
many operations necessitated by his last in-
firmities. Few of us realize what Dr. Minor
diction of one of St. Paul's Epistles, or Long-
minor operations on the nose many years
ago, one on his antrum, and another on his
tonsils more recently, he has endured a lapa-
rotomy for the resection of a malignant tunjgr
of the bowel, an appendectomy and a pros-
tatectomy in more recent years. And each
time he bravely came back to join the ranks —
the warrior he was.
But there is, from the worldly standpoint,
an unfortunate side to this picture. This
type of man never steps aside to court favors.
He is too busy with life's work or duties to
be politic. He sought no political honors.
He would "rather be right than be president."
He takes for granted that the world under-
stands his motives and will judge him from
them, and he never resorts to the explanations
and excuses behind which cowards hide. Such
men you must know to appreciate. Their
virtues are revealed not on the surface. The
sweetness of their characters grows on you
like the strains of a Beethoven, or the smooth
endured from surgery alone. Aside from two
fellow s poetry. The better you know them,
the fonder you become. Because the multi-
tude was not fortunate enough to know him
as he was, — unaffected, unsuspecting, unso-
phisticated, undesigning and trusting the
world — for this reason Dr. Minor's friends
were noted not so much by their numbers as
by their constancy and steadfastness, qualities
of which Dr. Minor's life was emblematic,
and I am sure no man loved his friends more.
With all his ruggedness of person, his os-
tensible obtrusive.ness. he was humanitarian,
gentle by birth, childlike in his simplicity,
impulsive, and possessed of a big heart. If
perchance he ever read the following lines I
am sure he might have adopted them as a
prayer:
"If I can stop one heart from breaking,
I shall not live in vain ;
II I can ease one life the aching,
Or cnnl one pain.
Or help one faintinc robin
I'nto his nest again,
I shall not live in vain."
Dr. Minor's loss to me personally has been
greater than anything I had expected outside
of that of a near relative. Distance and time
lend to me greater appreciation of his friend-
ship and fellowship. I feel that each one of
us has lobt one of the most valued comrade?
who have fought side by side with us in this
great humanitarian warfare against disease.
.And the admonition which his sincerity of
purpose and his untimely demise bring to me
Fcljruarv, 1Q29
SOUTHERN MEDICINE AND SURGERY
103
and to yiiu reminds me of the immortal lines
of ^McCrae:
"In Flanders fields the poppies blow-
Between the crosses, row on row.
That mark our place; and in the sky
The larks, still bravely sincins. fly
Scarce heard amid the guns below.
\Vc are the Dead. Short days ago
We lived, felt dawn, saw sunset glow.
Loved and were loved, and now we lie
In Flanders fields.
Take up our quarrel with the foe ;
To you from failing hands we throw
The torch ; be yours to hold it high.
If ye break faith with us who die
We shall not sleep, though poppies grow
In Flanders fields."
Lay Control of Medicine*
Thurman D. Kitchin, M.D., Wake Forest, X. C.
The development of the medical profession
through the ages has been gradual, like the
growth of the individual. First, the infant
stage of Babylonian medicine, when the sick
were placed by the roadside in order that
passers-by who had been similarly afflicted
might advise and console: following this, the
childhood stage — that of priest-physician;
then the adolescent period of rational medi-
cine: after this the young manhood of mod-
ern medicine: until now, by reason of its tri-
umph over infections and transmissible dis-
ease, with a definite campaign for individual
preventive medicine under way, the profes-
sion stands on the threshold of maturity.
As we look back on this amazing develop-
ment, with the profession now grown to man's
estate, we may be inclined to underestimate
the difficulty with which this progress has
b;en made.
Through the gloom of the dark ages, when
the Torch of Science was almost extinguished,
it was medicine that for long years nursed
the flickering flame, Medicine has had to
rnmb.il ignnranic, siipcrstilion, inyslicism,
and always -as woll as now- (he bogey of
quackery, the ancient prejudice against hu-
man dissection and animal experimentation.
Even to this day we have with us the anti-
vivisectionist.
Furthermore, the medical profession has
had to fight, almost single-handedly, cults
and fads, which would endanger public wel-
fare by legislation and sentime:it which would
restrict that research which is necessary to
lessen or completely eradicate certain di.seases.
It has had to fight the legalizing of absurd
methods of treatment, to fight the admission
♦Address before Guilford Countv Medical Society,
Greensboro, N. C, January 3, 1929.
of various types of practitioners from enter-
ing the back door of the medical profession —
practitioners of every imaginable kind, who
do not possess the necessary fundamental
knowledge of the human organism, to say
nothing of its myriads of difficult and deli-
cate ramifications, practitioners whose e.x-
ploitation of the public can only result in dis-
aster to public welfare and to individual
health. The medical profession has had to
conduct the tight to defend the public against
fraud and actual danger. It is disheartening
to realize that this line of defense is inter-
preted as a "medical trust," and brought
about an attack by those who misunderstood
our motives (whether purposely or not, we
cannot determine) and spread abroad a pop-
ular but unfounded belief that doctors were
making this fight for their own selfish pur-
poses. The very fact that we have accepted
the responsibility and fought for the public
arouses its suspicion, and since the line of
defense is most emphatically not for the doc-
tor himself, but for the public, it is clear (hat
(he publii iiiiisl he f<ju(alprl lo a jxiint where
llif leadins^ |iro|iIp of the rnmmuiiify will take
up the weapons itid defend thenisel.es. lead-
ing their coir.niur.Ities into their ccr.-.r.:c:-. bat-
tle. That is whera the enichzsis belongs ; and
public-spirited citizen:
te brought to
realize the real and immediate dinger. These
would be joined, of course, by the medical
association and individual physicians: indeed,
the profe.'^sion could be of inestimable value
in furnishing the scientific facts bearing on
the case in question. But the medical pro-
fession should enter the fight at members of
the community, !:ct 2. z :ep2rjtc organiza-
tion f.xpcLiud to plan and ^arry or. the entire
campaign. By enlightening and awakening
the people the problem will be brought out
SOUTHERN MEDICINE AND SURGERY
Februarv, 1020
intti the open and will then appear in its
true light — that is, it will be known to be a
defense of the public against dangerous ex-
ploitation, and not a selfish fight by the doc-
tor for the doctor.
And for the ultimate conquest of disease,
it is necessary for people at large to have an
intelligent appreciation of and a correct atti-
tude toward sciences. There must be confi-
dence in the methods and motives of science.
It must be understood that it jumps at no
conclusions, for "science moves, but slowly,
slowly, creeping on from point to point."
Truly its progress is unhasting, unresting.
Those there are who feel that the world's en-
lightenment is being achieved at a snail's
pace.
1
"Yet 1 doubt not through the ages one increasing
purpo.^ie runs.
And the thoughts of men are widened with the
process of the sun«."
The highway upon which the vehicle of
our progress must travel must be recondition-
ed before we can make our journey ill safety.
There are mud holes of ignorance into wh'ch
our wheels are prone to sink. Ever and anon
we find the way blocked by falge detour signs,
which superstition has placed there in the
hope of leading the unwary travelers
from the path of truth into devious ways:
moreover, the swamps of fear send up mists
and fogs like impenetrable curtains. Before
we c^n hope to start out with any hone of
reachin-^ our destination in safety, much less
to move with anv d°9:ree of speed, we must
resurface our roads with the verities of honest
fact— a firm s'lrface calculated to stand anv
amount of traffic. We must mark our roads
so there, will be no shadow of a doubt as to
whither thevl°ad— education, and education
alojie. will do the marking.
Ta th? uninitiated it might seem that the
med'"cal prnfe^s-'on, having overcome so many
dangers a'-'d d'ff-'culfies in the past would be
able now to devote its full time to the en-
largenient and improvement of its own great
Pro.§ianv but .to paraphrase the old couplet:
When.cne trial passe'h, another .doth him ie-.sc"
.^nd now. when the road should be open
before us, we find a new obstacle in our path-
yray, whicJi has come in from the woods un-
observed,— that is, the gradual intrusion of
non-medical o"ganizations on the dnniain of
med'cine.- This encroachment has been so
gradual that few realize that all that med'cal
men have d'scovered, developed, and accom-
pl'shed, is in danger of being capitalized and
exploited by men who have no connection
with the profession. The various organiza-
tions, foundations, memorials, I'fe extension
bureaus, free clinics, health stations, insti-
tutes, and many others of like nature are
primarily organized by non-medical agencies,
and the physicians doing the work are hardly
more than clerks. Doctors are not permitted
to advertise, yet these organizations do ad-
vertise with the sky as the limit. In many
instances the buildings are furnished by
philanthropy and physicians give their time
and talents, but the non-med'cal managers
and overseers are well paid both in money
and in glory. The charitable instinct of the
doctor is exploited by the self-appointed
prophets of the millenium. Lay control of
medicine will mean more lay (certainly more
outlay) and less medicine and the ultimate
fruit will be medical politicalization — a long
word but an apt one, for it is defined as "the
state of being subjected to political control.'"
It was inevitable that various "uplifting"
organizations should tend to pauperize the
population with its ideals, but more serious
is the burning urge of these "unlifters" and
many of the well meaning th(»ugh misguided
lay organizations to attempt to dominate and
regulate everybod\''s business. Thus we are
confronted today with the spectacle of excel-
lent people, actuated by the best motives,
who have either not informed themselves, or
else have not availed themselves of their op-
portunities to be informed, deciding momen-
tous questions regarding science in general
and medicine in particular. Such offhand de-
cisions made by honest but misguided people
are apt to be disastrous to the very cause
which they are anxious to foster, and humili-
ating to those persons who have spent their
lives trying to arrive at intelligent conclu-
s'ons. So that now we find that the practice
of medicine is heckled from every quarter.
The drift toward paternalism and socialism in
med'cine is mani-fest. No man denies the
right ar.d duty of the state and of lay organi-
zatiors to take care of the paupers but shall
we let our anxiety and sympathy for the
relatively small number of pauper patients
Feliruai^', 1IJ9
SOtTTHERN SfflDlCINE AK» StrR»ERV
l«j
determine thf policy of dealin"; with the vas>
majority who by no means belong in that
class? Man}- pauper patients are more in
need of nourishing food, adequate clothing,
decent shelter and cheerful environment than
of medical attention. Why not do all that
is necessary for these few, instead of flinging
open the doors and providing wholesale medi-
cal aid to pauper and non-paui^er alike! That
our public schools, our highw-ays, our mails,
and other public utilities are financed
through the public treasury might seem to
justify caring for the health of the individual
in a similar manner. But a line must be
drawn somewhere and my plea is that this
Ine be established by common sense and not
by sentimentality. IMoreover, I believe that
personal ambition, the hope of professional
success and prominence, of financial security
and the privilege of personal improvement,
form the main spring of progress. Destroy
the individual iniative of physicians and fu-
ture medicine will be standardized at a low
level. Medicine is the most individualistic
(if all professions and our country the most
individualistic in the world and I hope that
that remnant of individualism which allows
a man to select his own physician and which
allows that physician to handle that patient
in a personal way will be the rock upon
which the waves of sentimentalism and char-
latanry may rend their fury without destroy-
ing the health and happiness of a single
American citizen.
Do not think that I am opposed to change
or that I am satisfied with present conditions.
1 am not hidebound, and I realize that it is
imperative that we go forward. The key to
the situation is the realization that the prin-
ciples of medicine are founded on bedrock
and are everlasting but the times and the
populace to which these principles must be
applied are in a fluid state and therefore ever-
changing. Consequently, medicine must con-
stantly be adapting itself to a progressive
and complex civilization. But this adaptation
should be the natural response to the stimuli
of the environment at a given time and not
brought about by extraneous influences.
Medicine is not an exact science and from its
very nature can never be an exact science.
Accordingly, it can not be blueprinted by ef-
ficiency experts and the doctor ordered to fol-
low instructions. The personal equation must
always be taken into account. The very fact
that the patient selects his doctor enables the
doctor to render aid of a type which an or-
dered doctor (a rubber-stamp physician, a
robot) could never furnish.
Sympathy with suffering mankind and the
inherent urge to help the unfortunate is the
vitamin that infuses red blood into our pro-
fession and actuates its noblest efforts. May
this lofty purpose, this godlike emotion, never
be devitalized and dehumanized by the hum
of machinery set in motion by well meaning
but misinformed lay organizations or the bu-
reaucracy of our own government.
Will of Dr. Wm. Dunlop, Veteran of the
-American Campaigns 1813-1815
(From the Irish Jo'irual of Medical Science)
In the Name of God, Amen. 1, William
Dunlop, of Fairbraid, Western Canada, Es-
quire, being of sound health of body, and my
mind just as usual, which my friends who
flatter me say is no great shakes at the best
of times, do make this my last Will and Testa-
ment as follows:
I leave the projierty of Fairbraid, and aV
other landed property 1 may die possessed cr
to my sisters, Ellen Boyle Story and Elu
abeth Boyle Dunlop, the former because sn^-
is married to a minister whom (God heij
him!) she henpecks: the latter because she »»
an old maid and not market-rife.
I leave my sister Jenny my Bible ....
and when she knows as much of the spirit
of it as she does of the letter, she will be an-
other guise, Christian that she is.
I leave Parson Chevasse (Maggie's hus-
band) the snuffbox I got from the Sarnia
IVIilitia, as a small token of my gratitude for
the service he has done the family in taking
a sister that no man of taste would have ta-
ken.
I give my silver cup with a sovereign in it
to my sister Janet Graham Dunlop, because,
she is an old maid and pious, and thereiore
will necessarily take to horning. [Talkmg
scandal. — Ed.]
106
SOUTHERN MEDICINE ANfi StJRGEkY
February, lOiO
PRESIDENT'S PAGE
!._..
Tri-State Medical Association oj the Carolinas and Virginia
Jas. K. Hall
The program is complete. You have al-
ready received a copy of it in tentative ar-
rangement. The final program will differ lit-
tle from the preliminary arrangement. Even
the excellent clinics that have been arranged
are not going to cause me to doubt for a
moment the value of the theses presented by
the essayists. I have not learned to under-
value didactic instruction. The world's
greatest teachers had no pedagogical arma-
mentarium except good sense and the gift of
teaching. They made use not even of the
blackboard or the printed page. And labora-
tories they never heard of. Socrates and
Jesus and Mahomet impressed those around
them simply by their spoken words and by
their characters. And they remain the
world's greatest teachers.
What fundamental difference can there be
betwixt clinical teaching and any other kind
of teaching? Can not a clinic be held over
a problem? Jesus was constantly holding
clinics. And Socrates had a great ambulatory
clinic. Have better mental clinics ever been
conducted than those he held in Athens? The
value of any clinic lies in the interpretation
of the problem, and such interpretation is
always verbal.
I doubt if a more impressive group of
clinical instructors have ever assembled in
North Carolina than the master teachers who
will interpret the abnormal conditions to us
in Greensboro. They are all exceedingly ac-
tive, busy men, actually engaged in daily
teaching. But they are leaving their classes
in college in order to give us the benefit of
their experience. We are fortunate, indeed.
Dr. Thomas McCrae spends his days in
instructing the students of the Jefferson Medi-
cal College in the art of diagnosis and treat-
ment of disease. Dr. Edwards A. Park
teaches in the Johns Hopkins University the
same art as applied to infancy and childhood.
Dr. Cannon is engaged in the difficult matter
of dealing with those diseases that affect the
skin — the largest and most obvious organ of
the body. Dr. Warren T. Vaughan, out of
his large experience in Richmond, will ex-
plain the allergic reactions of the body. Dr.
Michael P. Lonergan, Clinical Director of the
great Manhattan State Hospital on W'ard's
Island, will conduct the clinic in nervous and
mental diseases — and more beds are occupied
by mental patients alone in the United Stat^
than by those sick with all other ailments.
At the public session in the auditorium of
the North Carolina College for Women on
Tuesday evening a splendid assemblage of
students, members of the faculty, and citizens
of the city will enjoy the program prepared
especially for them. Are criminals — many of
them — mentally abnormal? Hear what Dr.
Overholser, of Boston, thinks about that.
This entire evening program will be broad-
cast.
The session on Wednesday evening will
cover in masterly fashion a large field. I am
certain that no more informative theses have
ever been presented in the state. ]Most of
those who hold clinics will present papers also
at this session. And Dr. John A. Kolmer, of
the University of Pennsylvania, will tell us
how useful the clinical laboratory may be in
the diagnosis and in the treatment of disease.
Dr. Walter E. Lee, also of Philadelphia, will
elaborate his belief that atelectasis of the
lung rather than pneumonia sometimes fol-
lows operation.
And we must bear in mind that the most
alert doctors in the Carolinas and Virginia
always appear on the Tri-State program.
You will be better doctors by hearing their
presentations.
Remember the dates: the session will em-
brace Tuesday, \\'ednesday and Thursday-
February 19-20-21. See the meeting through.
Febniafv, 1929
SOOTHERN MEDlGtNE AND StTRCEftY
10»
Southern Medicine and Sur§erp
Tri-State Medical Association of the Carolinas and Virginia
1 Medical Society of the State of North Carolina
James M. Xorthington, M.D., Editor
James K. Hali . M.D
Frank Howard Richardson, M.l)..
W. M RoBEv, D.D.S. -
J. P. Matheson, M.D
H. L. Sloan, M.D
C. N. Peeler, M.D
F. E. Motley, M.D
The Barret Laboratories
O. L. Miller, M.D
Hamilton \V. McKay, M.D
John D. MacRae, M.D
Joseph A. Elliott, M.D
Paul H Ringer, M.D.
Geo. H. Bunch, M.D.
Federick R. Taylor. M.D.
Henry J. Langston, M.D
Chas. R. Robins, M.D.
Olin B. Chamberlain, M.D
Louis L. Williams, M.D
Various Authors
I
Department Editors
Richmond, Va
Black Mountain, N. C
Charlotte. N. C.
Human Behavior
^.Pediatrics
— Dentistrv
Charlotte, N. C-
Diseases of the
Eye, Ear, Nose and Throat
.Charlotte, N. C Laboratories
_Gastonia, N. C Orthopedic Surgery
.Charlotte, N. C - Urology
_.\sheville, N. C Radiology
.Charlotte, N. C Dermatology
_.\sheville, N. C -. Internal Medicine
-Columbia, S. C . Surgery
-High Point, N. C Periodic Examinations
-Danville, Va . Obstetrics
_ Richmond, Va . - Gynecology
-Charleston, S. C Neurology
-Richmond, Va.-_ Public Health
, Historic Medicine
B.Asic Science Laws as to Medical
Licensure
Acts are in force in five states of the Union
requiring examination by boards independent
of practicing doctors of all "schools" — regu-
lar and irregular — in certain sciences which
are "basic" to a qualification for treat-
ing the sick. These acts vary considerably,
but the general purport of each is to erect a
non-partisan board of scientists for the con-
duct of an e.xamination in these basic sciences
of every one who seeks a license to call him-
self "doctor" and set himself up as a healer,
certainly every one who is to use drugs or
physical means in treatment.
For some two years we have been greatly
interested in this rational attempt at making
it impossible for those not qualified to obtain
medical licensure, by a means which would
seem to deprive the cults of all arguments
they have hitherto offered as to their being
entitled to their own boards, since the reg-
ular profession had one of its own.
In Kansas an attempt is being made to
work out a satisfactory bill, and The Jounuil
oj the Kansas Medical Society has collected
a large quantity of information, which it has
embodied into the main editorial in its issue
for January. This we will use freely, in the
hope that doctors of this state and section
will study the objects, principles, methods
of application, results to date, and opinions
here set forth.
qualifications and appointment
"The board in Connecticut is composed of
three members, none of whom can have a
degree in any of the healing arts or be con-
nected with any hospital.
The board in Minnesota is composed of
five members, two full time paid professors
not actively engaged in practice of healing,
app(jinted from the University of Minnesota,
one M.D., one D.O. and one D.C.
In Nebraska, the Department of Public
Health appoints a board of five members.
The board in Washington consists of five
members appointed by the governor from the
faculties of the University of Washington and
Washington State College.
In Wisconsin the board is composed of
three lay educators, apix)inted by the gover-
nor, none of whom shall be on the faculty of
ahy department teaching methods of treating
the sick.
l«l
sotrrttfifeN MEDiwNE ANO stmcenY
Pebruaty, 192^
SUBJECTS
There is considerable variation in the sub-
jects included under the term basic sciences
in these states. In the Conecticut law, an-
atomy, physiology, hygiene, pathology, and
diagnosis are specified. In the Minnesota
law, anatomy, physiology, pathology, bacte-
riology, hygiene, and after 1931 chemistry,
are specified. In Nebraska all the subjects
included by our bill are specified except diag-
nosis. In the Washington law neither bac-
teriology nor diagnosis is specified. The Wis-
consin law specifies only anatomy, diagnosis,
patholog\' and physiology.
EXCEPTIONS
The laws in these states differ also in the
matter of exceptions. In Conecticut there are
no exceptions. The law in Minnesota does
not apply to nurses, midwives, dentists, op-
tometrists, .... barbers, cosmeticians, chris-
tian scientists, nor to treatment exclusively by
mental or spiritual means.
The law in Nebraska does not apply to
optometrists, dentists, nurses, midwives, nor
to persons practicing healing arts at time of
act, nor to practice of religious tenents where
no drugs are prescribed.
The Washington law makes exception only
to practice of religion or treatment by prayer.
The Wisconsin law makes an exception of
the practice of christian science or treatment
by mental or spiritual means.
FEES
The fee for the basic science examination
in Connecticut is $5.00, in Nebraska, Wash-
ington and Wisconsin it is $10.00 and in
Minnesota it is $15.00.
RECIPROCITY
The provision for reciprocity in Connecti-
cut specifies that the board may issue a cer-
tificate to (1) any person licensed to practice
any branch in another state or District of
Columbia, (2) one having certificate from
National Board of Examiners. Any person
in active practice in another state for five
years need not obtain a certificate. The laws
in Minnesota and Nebraska provide that the
board will issue a certificate of registration
in the basic sciences without examination to
one who passed an examination in basic
sciences or by a board of another state if the
standards are determined by this board to
be as high as this state's, and provided such
other state shall accord like privileges to
Minnesota (Nebraska). Washington has no
reciprocity provision. The Wisconsin law
provides that the board may issue a certifi-
cate to one who presents proof of having
passed an examination in the basic sciences
by a legal board of another state whose
standards are as high as those of Wisconsin.
The proposed law in Kansas makes the
following provision:
'The state board of examiners in the basic
sciences may in its discretion waive the ex-
amination required by section 7, when proof
satisfactory to the board is submitted, show-
ing that the applicant has passed the exam-
ination in the basic sciences before a board
of examiners in the basis sciences or a board
authorized to issue licenses to practice the
healing art, in another state, when the re-
quirements of that state are, in the opinion
of the board, not less than those provided by
this act. The provisions of this section shall
apply only to examinations conducted by the
boards or officers of states that grant like ex-
emptions from examinations in the basic
sciences to persons granted certificates by the
board of this state.'
HOW IT WORKS
There has been very little published con-
cerning the enforcement and the efficiency of
the basic science laws in the five states in
which it has been adopted. There has been
more or less criticism- offered but this seems
to have been entirely by men from states
that do not have a basic science law and in
which they feel that it is not needed. The
subject seems to have been pretty thoroughly
discussed at the Annual Congress on INIedical
Education, Aledical Licensure and Hospitals
in Chicago, February 8, 1928. In the report
of this discussion we find some comments by
men more or less identified with the passage
of the basic science law and its subsequent
administration in four of the states most con-
cerned.
In the course of his remarks, Dr. Rodeck-
er, president of the Wisconsin Board of Med-
ical Examiners, said: 'In Wisconsin, the
chiropractors have their own board. We
have an osteopath who is a member of the
state board of medical examiners. We are
not bothered with other cults and healers.
'As the basic science board ignores all dij-
jerences oj opinion tmong practitioners as
February, 1929
SOUTHERN MEDICJNB AND SURGERY
119
/() the methods of (liogiiosis and treatment,
a eertipeate from this board determines the
jundamental basis of all who would practice
the healing art. Such candidates as these
that are determined fit and no others are per-
mitted to appear before professional examin-
ing boards. The other various examining
boards still retain their original powers of
determining the fitness of a candidate to prac-
time the particular method professed.
'In W'sconsin, since June, 1925, but one
new member of the cult has entered the state.
[Italics ours.S. M. & S.]
This WMS reported by Dr. Evans in his pa-
per at the meeting last year.
'.As our board was one of the pioneers
in the field of basic science, we, or no fair
minded person, could expect perfection in its
infant exemplification. We can see the ne-
cessity for further improvement of the law,
which we expect to amend after the legisla-
tive committee meets next June. One or
more subjects will be added, and probably
another 'examiner -will be added to the
board.'
From a tabulated report submitted by Dr.
Rodecker it appears that during 1927 there
were 106 applicants examined by the basic
science board; of these 99 were medically
trained and 7 non-medically trained. Of those
examined seven failed, all non-medically
trained.
In this discussion Dr. Lehnhoff of Lincoln,
Nebraska, said:
'We have a basic science law in Nebraska.
I recognize that it is weak enough. We are
going to have a better law in Nebraska. Dr.
Rypins says we have to recognize a few facts.
One fact for the state (jf Nebraska is that it
has a multiplicity of boards. Our chiroprac-
tors have their own board and the osteopaths
have theirs. One of the objects of the basic
science law in Nebraska was to raise the
standard of the healing art in general. Of
course, that means to cut out some of the os-
teopaths and chiropractors and to make the
chiropractor, if he must exist, a better prac-
titioner and I believe we have done that.
'I am satisfied that an applicant who had
not passed the basic science board would have
a difficult time in practicing anything of the
healing arts in Nebraska.'
Dr.^Boyer, Duluth, Minnesota, said:
'1 was a member of the legislative comrait-
tee that was instrumental in passing the basic
science law in Minnesota, and I am a member
of the basic science board of Minnesota. The
sole purpose in passing the basic science law
was to raise the standard of those who wished
to treat the sick in Minnesota. "\'ou could
not, and never did, do this with ^he boards
of medical examiners as their influence was
confined to the regulars only. They raised
the standards of the medical schools by way
of the leverage they afforded the Council on
Medical Education and Hospitals. The basic
science boards afford assurance to the public
that those who profess to treat disease shall
have a fundamental knowledge of normal and
pathologic structure and function. In Min-
nesota no applicant for examination may
come before the basic science board who has
not a high school education or its equivalent.
Our experience thus far is that we have had
very few applicants from the cults for basic
science examinations. Our theory is that he
who has a modern high school education will
not only be able to grasp the significance of
the basic medical sciences but will know
enough to choose the regular medical course
or none at all.
'In Minnesota our present law seems best
adapted to our needs. It is, as is nearly all
legislation, a compromise law. It recognizes
the legalized schools of healing other than
regular medicine and also recognizes the de-
mand of the public. \\'e cannot omit consid-
eration of the public from any of our legis-
lative proposals. The people have ideas of
their own regarding medical legislation and
as to whom they want to doctor them. The
various legalized cults always seek gradually
to raise their standards of education, seem-
ingly coming to realize, as they work in the
field, their great handicap of insufficient
knowledge. This inevitably leads them along
the trail followed by the late homeopath, until
they too are lost and swallowed up in the
realm of scientific truth. Our future efforts in
Minnesota will be directed toward preventing
any legislation legalizing any new or addi-
tional cults wishing to establish themselves
within our borders. We believe we are in an
advantageous position in this respect because
of our basic science law and of the composite
nature of our board.'
Dr. Hyde, Greenwich, Connecticut, said:
'In Connecticut we ha\e a much better basic
110
SOUTHERN MEDICINE AND STOGERV
February, 1929
science law ihan has been discussed here to-
day. It has been going for a year now with
great success, and it is a protection to the
pubHc. The secretary of the commissioner of
health told me last week that in the year
and half since it has been in operation he has
had no question in issuing licenses to appli-
cants. The quality has distinctly improved.
In the same period, our own board failures
have decreased by 75 per cent. This law, for
us, I am sure is a marked advance.'
It seemed to be the consensus of opinion
among those who discussed the subject at this
meeting that in those states having multiple
examining boards a basic science act was de-
sirable, but that states having a composite
board had no need for a basis science act
and were better off without. Perhaps that is
so, but it must always be remembered that
the existence of a composite board does not
prevent a legislature creating additional
boards. We had that experience in Kansas,
other states have more recently had the same
experience.
KANSAS' EXPERIENCE AND PLANS
When our medical practice act was passed
and a composite board appointed, it was rec-
ognized by the legislature as a concession to,
and for the benefit of, the medical profession.
By that act the state conceded to the medical
schools represented on the board, the right to
determine who should practice medicine in the
state. When later the osteopathic board was
created, that act was recognized as a conces-
sion to, and for the benefit of, the osteopaths
and it conceded to them the right to deter-
mine who should practice osteopathy in this
state. The passage of the law creating the
chiropractic board was recognized by the
legislature as a concession to, and for the
benefit of, chiropractors and to them was
conceded the right to determine who should
practice chiropractic in the state.
The doctors of medicine having secured
certain concessions for their own benefit, they
had no reasons to object, at least from a leg-
islator's point of view, to similar concessions
and benefits being given to other schools,
sects or cults of practice of the healing art;
such as have already been granted or will be
granted.
In actuality the welfare of the people of
the state was not a consideration in the en-
actment of either of these laws. The boards
which administer these laws are called 'state
boards,' but they are such in name only, for,
though appointed by the governor, they are
chosen from the various groups most con-
cerned in and most benefited by the laws they
administer.
In enacting a law such as the one now
proposed the state does not repudiate the
concessions already granted, but in recogni-
tion of the best interests of its citizens is put-
ting a check on privileges granted these va-
rious boards by establishing a minimum
standard of qualifications for all those to
whom these boards may grant licenses; and
it is creating a board to represent the state —
neither one nor all of the groups of practition-
ers of fhe healing art. For that reason it is
eminently important that this board should be
composed of men who are not identified with
any such groups.
The bill to be introduced in the next Leg-
islature of the State of Kansas an amended
bill is to be offered which 'provides that the
board shall consist of three educators from
the state educational institutions who are
specially qualified in the subjects specified in
the act and who are to be appointed by the
governor.' ''
WHY NOT HERE?
This lengthy dealing is well justified by the
impt)rtance of the subject. We arc very
grateful »o the Editor of the Kansas Journal
for passing the information along, and trust
all into whose hands this journal falls will
study the whole subject carefully, talk over
it with others, bring it before county and dis-
trict society meetings, and begin to lay plans
for having our own legislators pass some such
bill and thus make it impossible for further
additions to be made to the lists in our states
of "doctors" who are "graduates'' of schools
which teach nothing rational e.xcept the gul-
libility of patients and an effective means of
"selling yourself and our system."
.Any legislator can see the justice of such a
law. The plan leaves the cults not a leg to
stand on for it disregards the controversial
matters of treatment, and concerns itself only
with demonstrable facts of chemistry, anat-
omy, bacteriology, physiology, pathology and
such — subjects which all men know are the
foundation of knowledge of disease.
The number of students trained in these
sciences who go off after strange gods of heal-
Fehruaty, 1920
SOUTHERN MEDICINE AND SURGERY
111
ing will be so few as to be negligible, and
they can be dealt with in other ways.
Let's throw in with these states who are
leading in this life-saving movement.
Post-Graduate Instruction Close to
TO Home
In The Head Specialties at Roanoke
As a fixed policy this journal believes in,
encourages and supports local enterprise.
The general tendency, where free choice can
be exercised, is the other way. Most likely
there is not a people without a terse and salty
adage expressing the idea which the clever
Basque words, "Foreign cows have long
horns."
Then, since the opinions of folks generally
on pathology and therapy are very intimately
mixed with their theological conceptions, it is
easy to see how eagerly they will welcome
accounts of miraculous cures at some distant
shrine; — whether altar, pool or clinic; wheth-
er erected to God or to Mammon — and equal-
ly easy to understand why newspapers carry
such accounts.
More than a year ago this journal said edi-
torially:
"It is pertinent to call attention to another
of the peculiarities of the doctor's situation.
He has no redress for his grievance except in
an appeal to the sense of fair-dealing of the
rest of society. A lawyer, a plumber, a mer-
chant, a barber, a telephone man, an automo-
bile distributor, a preacher or an insurance
agent, who is a patient of his can readily pick
up and go to Baltimore, Philadelphia, or Bos-
ton. There's nothing to hinder him. But
when the doctor is forced into court, he is at
the same t.me and by the same process forced
to employ a local lawyer; the doctor must
patronize the local telephone company; he
must spend money with the local plumber,
merchant, barber, and automobile agency; he
must purchase a local product in religion and
life insurance, if he would escape hell — cer-
tainly here, and possibly hereafter."
Commenting on this editorial. Dr. Edward
Jenner Wood wrote, "Our service clubs and
other boosting organizations might learn that
medical service sought for elsewhere can be
equally as well or better done at home."
We are always glad to lift our voice in
favor of home products, even to give home
products the benefit of any reasonable doubt.
The work of the Pediatric Seminar, held
each summ.er at Saluda, and the post-graduate
courses for practitioners given by the Medi-
cal College of the State of South Carolina
are conspicuous illustrations of the feasibility
of getting instruction close to home.
In each of the past two years Dr. E. G.
Gill, his associates and some invited teachers
have given excellent short courses in what we
may call briefly, the head specialties. The
announcement, some notice of which is given
in the news columns, outlines a course which
contains most desirable elements. By clin-
ics, demonstrations, questions and answers,
round table discussions and clinico-pathologi-
cal conferences, those taking and those giving
the course will be made more useful to their
patients and more satisfactory to themselves.
There are many difficulties in the way
of giving such a course without the arrang-
ments of amphitheaters, large laboratories
and other provisions for taking care of stu-
dents. That these difficulties are not insu-
perable, here is an evidence.
The journal congratulates the staff of the
Gill Memorial Hospital on its enterprise and
wishes it every success.
As we have said before:
Not "ourselves alone," but ourselves first —
and preferably.
We desire to remind our readers again and again
that our advertisers should know that The Journal
is read from cover to cover by most of the physicians
of Indiana, so why not answer the advertisements,
even in the way of askins for samples of literature,
or with a note to the effect that you are using the
products advertised in The Jovrnal. It will make
your advertisers feel better, it will help The Journal
and in turn wiM help the readers, for when all is
said and done The Journal in its present form could
not be published were it not for the added income
which comes from advertising. — Indiana State Medi-
cal Journal.
PL.'^CING RESPONSIBILITY
If the P)ole bill becomes part of the law of North
Carolina, let no man say that it has made a monkey
out of the slate. It will in such an event, merely
have served as an official notation of what the
people of me state were made hy a more august
.igent before the bill was passed.
Facts would not lie altered in any case but we
should keep cause and effect clearly defined.
I' is well to remember that a state cannot make
a fool of itself, it can only call attention to its
natural endowments.— 6>(Hctr Murphy in Salisbury
112
SOUTHERN MEDICINE AND SCRGERY
Febniary, W*
DEPARTMENTS
HUMAN BEHAVIOR
James K. Hall, M.D., Editor
Richmond, Va.
Prosecution or Persecution?
Dr. Albert Anderson, Superintendent of the
State Hospital at Raleigh, was recently con-
victed in a special term of the Superior Court
of Wake County on two charges — in each
instance of having worked men patients in
the State Hospital on his own private farm.
Men patients in the sanatorium with which
I am connected do some work almost every
day for the sanatorium. The patients are not
compensated for their work in any way. But
I believe they are benefited by the work and
that I am helping them to get well by pro-
viding the work for them. I do not feel that
in providing work for them on my own pri-
vate property that I am a criminal. I should
not think so if I were sent to prison for a
term of fifty years, even if the sentence were
approved by all the higher courts in the land.
Under certain circumstances a human baing
must have enough opinionatedness and cour-
age to enable him to stand by his own eval-
uations— even of himself. I doubt, too. if
there is a superintendent of a State Hospital
in the United States for whom some patient
does not render some gratuitous service. 1
doubt not at all that many superintendents
of State Hospitals pay some patients to do
work for them. I know the superintendent
of a State Hospital who has been paying a
State Hospital patient a weekly wage for
many years for work done in the superin-
tendent's home. 1 know a State Hospital
patient who has worked for many years in
the home of the hospital's superintendent
without pay because the patient has the de-
lusion that he must not be compensated for
his work.
The State Hospital of average size is a
small town within itself. It is almost im-
possible to prevent life in such an institution
from becoming deadl)' monotonous for those
patients who have considerable intelligence.
The inactive mind deteriorates. The mind
improves with use. The mentality probably
does not wtar out. I doubt if the mind ex-
periences fatigue, although the physical
mechanism through which the mind makes it-
self manifest may become tired.
The greatest problem connected with the
treatment of the so-called insane is to prevent
unhappy introspection. Most of us can not
comfortably make explorations within our-
selves. Many mental patients are self-depre-
ciative and inclined much to make misinter-
pretations— even of their own characters —
generally with resulting personal discomfort.
Any plan or scheme that the superintendent
of a State Hospital can formulate that will
have a tendency to lessen the tedium vitae
vi his patients should be commended, unless ■
the plan be absolutely indecent or dishonor-
able. Providing the circumstances under
which mental patients can do decent work in
the ijut-oi-doors in association with the doc-
tor who is sympathetically interested in their
welfare can not constitute a crime per se —
but only by pronouncement. .\nd the state
official who would ride around in the capital
of the state in broad daylight committing
crimes against the peace and dignity of the
state, day after day, year after year, must
needs be either saturated with stupidity — or
else possessed of the delusion that he dwells
clean beyond the reach of the law.
] find myself unable to believe that Gov-
ernor iMcLean could have approved of the
method adopted by the solicitor and by oth-
ers perhaps to investigate the charges lodged
against Dr. Anderson. The Board of Direc-
tors are charged with the management of the
State Hospital. That is their responsibility.
That is the duty imposed upon them by law.
The executive committee of the board meets
monthly in the State Hospital. Some of the
members of the Board live in and near Ral-
eigh; others live here and there in eastern
North Carolina. Their ears are open to com-
plaints from patients, employees, and from
the citizenship of the state. Why were none
of the charges taken first to the Board? Was
the [purpose of the inquiry to get at the truth
of the charges, or to stigmatize Dr. Anderson,
and burden him with the defense of his char-
acter and his administration? Faults in ad-
ministration are generally investigated first,
February, \Q2Q
SOUTHERN MEDICINE AND SURGERY
at least, by the executive branch of the state,
are they not? I am wholly unprepared to
believe that Governor McLean approved of
the prosecution of Dr. Anderson, or that he
approves of it at this time. The trial was
worse than useless. It was more than unnec-
essary. Ur. Anderson was charged with the
pravest crimes which can be lodged against
a physician and a citizen — criminal neglect
of helnless, sick people entrusted to his care
— and theft. .And he was convicted — of driv-
ing; three or four men patients who presum-
ably wanted to go with him out to his farm,
and working there with them a little while
in a hay field and in a woods. Did the office
of th? .Attorney General have any hope or
any expectation of convicting him? Is the
Eolicitor prideful of his victory? Is the of-
fice of the Attorney General to assist in fur-
ther prosecution of Dr. Anderson? And is
Dr. Crane to leave his classes at the State
University and lend the inspiration of his
presence again to the solicitor in the prose-
cut'on of a fellow state official? Why should
rot the faculty of the School of Law in the
l'niver='ty lend themselves to the solicitor
in h's e.^forts to convict Dr. .Anderson of ad-
d't'onal crimes?
If I be not mistaken the General Assembly
that came into session with the inauguration
of Governor ^IcLean gave to the Governor
the authority to remove from office without
any statement of his reasons any member of
any directorate in the state. If the charges
aga'pst Dr. .Anderson had been carried to the
Board of Directors the directors could easily
have been removed if they had not done in
the circumstances what the Governor conceiv-
ed to be their duty. Why were the members
of the Board of Directors denied their cus-
tomary privilege in hearing the accusation.s
that were being bandied around in Wake
county against their superintendent? Can
not some one answer? Can not the solicitor
answer? What was the reason for the special
term of court? Who thought first of that
necessity? Who pressed the Governor into
calling a special term?
Dr. .Albert .Anderson after years of splen-
did service to the state has been burdened
v.ith a defense debt of fifteen or sixteen thou-
Kand dollars. The County of Wake and the
State of N'orth Carolina have been subjected
to consideraiile expense. Dr. Crane has ijeen
kept away from his professorial activities at
the State University for a week. The State
Commissioner of Public Welfare was with-
drawn from her customary activities for a
number of days. The Assistant .Attorney
General of North Carolina was kept on tip-
toe in the court house of Wake county for
more than a week. More than one hundred
witnesses from here and there were exam'ned
under solemn oath one after the other. What
was the conclusion of the whole matter? It
was undeniably established that Dr. Albert
Anderson drove in an automobile with three
or four men patients out to his farm in the
ed"e of Raleicrh and worked with them in a
hay field. There is no doubt ab)ut it. Dr.
.Anderson under solemn oath said so h'm-
self!
PFDTATRir?
Por this issue. G. W. Kutsciii.r, M.D.,
Unmodified Dried IMilk
The various types and systems of infant
feeding formulae come and go, but one of
the newer constituents of these formulae
se°ms dest'ned to remain. The dried milk
products of several of the prominent manu-
facturers have been tried and tested over a
suffic'ent ner'od of t'me to warrant their safe
iisqrre. Thes" products have furthermore sim-
ni'fiprl the infant feed'Pe problems of more
nhv'c'V'ans than anv of the rnvr'ad of other
prp^nrts so i^r placed on the market.
Dr'Vd m'lk is not a perfect subst'tute for
bi-east m'lk. no matter how closely it simu-
lates the n3tural infant food. One prepared
infant food compares almost exactlv. in type
a"d quantity of the elements, with breast
mMk: but still it lack* somethMii — buffer
substance(?) — which is found only in breast
milk.
Sed«ewick. of .Minneapolis, has stated that
over 90 per cent of mothers, if they so choose,
can nurse their babies. IMost of the remain-
ing 10 per cent are represented by cases in
which the mother dies, has open tuberculosis
or other contagious di-sease, malignancy or
abscessed breast. Such factors as fatigue,
nervousness, brief illnesses, diarrhea and
menstruation are sound reasnn^ for supplying
the infant with artificial or complementary
feedings for a few davs only. 1( is realized,
ihen. that a real need for some safe artificial
SOUTHERN MEDICINE AND SURGERY
February, 1029
food does exist.
In place of breast milk cow's milk serves
best. But, unless certified, or that which is
privately collected under personal supervision,
dried milk takes precedence over fresh cow's
milk. Pasteurized milk will not do! No
matter how thoroughly sterilized pasteurized
milk may be, the debris which accumulates
from careless collection is still present. One
need but centrifuge a quart of ordinary pas-
teurized milk and examine the resulting sedi-
ment, to be convinced of this fact. When
was the bottle of pasteurized milk produced?
It carries no date telling of its birth. It
cannot sour, because of the pasteurization. It
can rot. Certified milk is low in bacteria
count only so long as it is carefully handled.
The same holds true with dried milk, which
is delivered free of all pathogenic bacteria
by reason of the mode of preparation. Dried
nrlk should be handled carefully; all utensils
used to remove the powder from its container
should be clean, and the lid should be re-
placed securely after the can has been open-
ed. This form of food is quite stable and,
under ordinary circumstances, will keep in-
definitely.
Further evidence in favor of. dried milk is
its value when refrigeration is unsatisfactory,
its ease of transportation, its safety in warm
climates, and its freedom from milk-borne in-
fections. In China, where the milk supply is
sa'd to be fit only for wallowing beasts, dried
milk products are used preferably for infant
feeding when breast milk is not available.
Many of the missionaries there tell us that
they use dried milk mixtures for the table.
A most interesting feature lies in the fact
that in the preparation of dried milk, the
nutrient value is not destroyed. The Vita-
mines — A, B and D, are preserved; and that
portion of C which is destroyed is readily re-
placed by the customary routine use of or-
ange juice. Although it is stated that some
of the mineral salts are reduced in solubility
by the drying process, nutrition does not suf-
fer as a result. By homogenization before
drying, the size of the fat globules is reduced
to such an extent that infants who cannot
digest the fat of fresh cow's milk, can readily
handle the fat in dried milk. The sugar con-
tent is unchanged by the drying process.
Protein, like fat, is made more digestible by
the drying process. Infants suffering from
allergy while taking cow's milk seem to toler-
ate dried milk very well.
Dried milk is simply fresh cow's milk from
which the water has been removed. In pre-
paring formulae, water is added, returning the
powder to its original state and nutrient
value. There are two systems whereby milk
is reduced to the powdered form.
The Just-Hatmaker sj'stem is the older.
Here the liquid milk is passed over heated
rolls, the water being evaporated, and leaving
the solids on the rolls. This is scraped from
the rolls, pulverized, and packed in contain-
ers. The outstanding brand of dried milk
treated in this way is dryco. It becomes a
partly skimmed dried milk as a result of this
method of preparation, being low in fat and
high in protein. As a result it is frequently
used where fat intolerance exists.
The other method of changing liquid milk
to the dried form is known as the Merrell-
Gere spray process. The liquid milk is
forced in spray form into a chamber through
which hot air circulates. The heated air re-
moves the water and the powdered milk re-
luUs. jMeade's whole m'\k and klim are ex-
amples of this system of treatment. It is to
be remembered that after adding water to the
dried m'lk, the resulting tluid is only cow's
milk, \\h ch cannot c<impare to breast milk in
its constituent qualities.
The following table is offered for compari-
son:
Hrra^l Milk
rnrbohvdratc bSO%
Protein _ 1.50%
fat 3.50%
Mineral Salts 20%
Klim
Dr\co
4,70%
3.35%
3.50%
.75%
5.75%
4.00%
1.50%
.87%
ORTHOPEDIC SURGERY
O, L Miller. M.D., E<Iil«r
Charlotte, N. C.
Foot .\ilments in Women and the Major
Cause
From a well known piece of literature
comes the intimation of how useless it is to
"kick against the pricks." This is particu-
larly true, it seems, in reference to habits in
footwear among the females of our species. I
don't believe I have ever heard a woman ad-
mit that she wore, what in her opinion was,
a high heeled shoe. It is needless to argue
that she does. She will sometimes admit
wearing a "modified heel." We do, however,
have very high heeled shoes built and sold to
satisfy the styles in dress for women. Style
February, 1029
SOUTHERN MEDICINE AND SURGERY
is not thought out along physiological lines,
therefore, we should not expect it to protect
the welfare of that important member — the
human foot.
The unreasonable things women wear on
their feet do contribute to ill health. It
seems, though, they reason that the beauty
of the footwear is worth the sacrifice, and
one hesitates to speak about it. I once
thoueht that the emphasis on defective feet
generally, as brought out by examination of
draft troops in the late war, might have some
influence in modifying the damaging footwear
used even by women. I don't think so now.
Men wear more common-sense shoes than
forrppi iy.
Since it is an unpopular chord to harp on.
I am going to quote from Dr. Elizabeth Van
Duyne, medical director of Goucher College,
who, writing in the January issue of Hygcia,
states that young women are loath to accept
evidence that shoes are the cause of most of
their foot troubles. Corns, calluses, warts and
bunions are undoubtedly nature's protest
against shoe insult.
Most eirls ard women, in spite of ridicule
and warnings, look on high heels, and even
spike heels, as things of beauty ardently to
be desired. Probably when silk-clad calves
begin to dwindle, dame fashion will call a
halt, but meanwhile feet can be permanently
damaged that might be saved for a youthful
old age.
Dr. Joel E. Goldthwait in Body Mechanics
and Health says: "High heels have always
received well-merited censure." He warns of
interference in circulation and nutrition in
the muscles of legs and feet, of bad effects on
spine and pelvis, and of flattening of the
arches of the feet.
It seems to be difficult for women to find
pood-lookinR, safe dress shoes. Because of
this fact, chiropodists and foot specialists in
shoe stores are making fortunes. .\ well
known weekly recently gave space to the fol-
lowing: "Do you want a new business pro-
fession of your own with all the trade you
can attend to? Then become a foot correc-
tionist and in a few weeks earn a big income
in service fees. Easy terms for home train-
in-^."
In a recent senior class at Goucher College,
s mpfiical interxiew brought out these points
on feet and shoes: Number of young women
in class — 212; number with apparently nor-
mal feet — 38; number with abnormal condi-
tions in the feet — 174. The main defects
were depressed anterior arches, calluses under
the anterior arches, calluses back of the
.Achilles tendon, bunions, warts, corns, in-
growing toe nails and contracted tendons.
.•\n astonishing fact in connection with these
findings was that few students would admit
discomfort or pain in their feet. ?^Iore than
half of them wore spike-heeled shoes for dress
occasions. Nearly all of them, for hiking and
athletics, had sports shoes with a straight in-
ner line, low broad heels, room for the toes
and flexible shanks. Further facts brought
out in this study were that of the thirty-
eight students with practically normal feet
thiry-seven, either did not wear high heels at
all or else worse them less than one-third of
the time. .According to the records forty-six
girls suffered with backache at intervals dur-
ing their college career. Of this number, 14
per cent did not wear high heels, although
several had tried them and found them too
uncomfortable.
Dr. Van Duyne's conclusions were as fol-
lows:
1. Many thickenings and calluses not pre-
viously observed have been noted at the back
of the heel since spike heels have been worn.
In a few cases it was found that the heel
tendon had contracted and the wearing of low
heels caused discomfort or pain.
2. The large number of lowered anterior
arches would seem to indicate that even the
wearing of spike heels for dress occasions may
be followed by damage to these arches.
3. Backache is likely to be increased by the
wearing of high heels.
4. The danger of injuries from falls is un-
questionably greater in high heels.
5. F'atigue, irritability and nervous condi-
tions appeared to be associated with the
wearing of high heels.
6. Dysmenorrhea seemed to he increased in
those who wore high heels more than half the
time and probably in many who wore high
heels only for dress occasions.
It is sufficient to say that the majority of
women's shoes are really crippling or poten-
tially so. It would we well to emanate all the
f)ropaganda we can to kee[) young girls in
sensible shoes, certainly the majority of the
time. If they must wear the so-called stylish
SOUTHERN MEDICINE \ND SURGERY
Fcl)ruarv, 1<)2P
shoes, try to influence them tn limit the prac-
tice as much as possible. This will make for
improved health, posture and comfort in later
life.
UROLOGY
For this issue, O. T. FiXKLEA, M.D.. Florencf, S. C.
^Ialformation of the Kidney
A malformation of the kidney is easily ex-
plained by its embryological development and
migration.
The kidneys first appear in the posterior
or lower end of the embryo, as a small bud
or mass of cells in the pronephros, one on
each side of the median line. Tliese buds are
on a level with the mid-sacral region. They
later unite with the ureter and begin to take
on definite form. At this stage the axis of
the kidney is vertical, while in the adult the
axis is lateral. About this time they begin
to migrate upward towards their final posi-
tion. In this migration these embryonic kid-
neys must of necessity come very close to
each other .especially is this true at the brim
of the skeletal pelvis. Should anything pre-
vent the migration or interfere with its prog-
ress, we find some malformation resulting.
For convenience we can divide the malfor-
mations into three general groups: as to num-
ber, as to form and as to position. The num-
ber of k'dneys may vary from a complete
abience in the monstrosity to three or more.
Usually when there is inoie than one on a
sde the supernumerary org:m is smaller and
is fused to the lower pole of the more normal
k'dney. The supernumerary kidney is a very
rare anomaly. The malformations of form
may be of several types: (a) lobulated kid-
ney, (b) aplastic kidney: (c) hypertrophic
kidney; (d) fused kidney. The fused kidney
may be either a mass kidney or a horseshoe
kidney. The most common form of fusion
is the horseshoe kidney. About 90 per cent
of these are fused- at the lower poles and in
the majority of cases the connecting is an-
terior to the abdominal aorta. The congeni-
tal polycystic kidney is also a type of this
group. It is always congenital as well as
bilateral.
The position of the malformed kidney may
be anywhere below the diaphragm. As a
usual thing the malposition is lower than the
normal level. It mav be within the true
pelvis as is seen in the case report to follow.
The fused kidney is always situated at a
lower level and nearer the median line. The
ectopic kidney must not be confused with
the movable kidney. In the ectopic kidney
there is a true misplacement and it is usually
fixed in this location.
The blood supply to the kidney may show
numerous deviations from the normal, the
principal one being supernumerary arteries.
The arteries usually come directly from the
abdominal aorta but may arise from the iliac
or mesenteric arteries.
The malformations are of interest and im-
portance because the\- favor disease develop-
ment. The malformed kidney usually causes
some interference with drainage: this means
stasis, and stasis will sooner or later lead to
infection. This faulty drainage may help the
formation of stones, hydronephrosis and
pyonephrosis. A chronic pyelitis is frequent-
ly found in the malformed kidney and tuber-
culosis is not at all an uncommon infection.
The malformations are important because
of the many departures from the normal
which may be found. Suppose there is a
solitary kidney: then the surgical procedures
employed must of necessity be very different
from those ordinarily employed. It is for
this reason, if for ro olhc'r, that every case
for renal surgery should have a complete
study by a competent urologist.
The malformed k'dney does not usually
give any symptomiS unless it becomes dis-
ccr.cd, in which case it is discovered during
routine urological study. The symptoms are
not those of the malformed kidney, but are
those symptoms found in a similar disease
of the otherw'se normal kidney.
The diagnosis of a malformation is usually
made by urography, or urography in conjunc-
tion with cystoscopy. In the earlier times
the malformations were diagnosed by palpa-
tion, but the greater number were found in
the autopsy room. When the misplaced kid-
ney is felt during an ordinary examination a
feeling of doubt arises and this is clarified
only by complete urological study.
Case Report: In 1920 I was the assistant
in the removal of an appendix from a girl
sixteen years of age. During this operation
the right kidney was found well within the
true pelvis. The shape was more rounded
February, 1929
SOUTHERN MEDICINE AND SURGERY
117
than niirnial, with the pelvis on the anterior
and superior aspect. At this time the kidney
showed no evidence of any infection or pres-
ence of a stone. The left kidney was in its
normal position. In 1925 this patient was
readmitted with acute colic in the lower right
abdomen. She was especially tender over
the location of the ectopic kidney. The .x-ray
and urological study proved a small stone
was present in the right ureter about midway
between the kidney and bladder. The right
pelvis showed some dilatation, holding about
fourteen c.c. of the opaque pyelographic fluid.
The ureter left the kidney pelvis well up to-
wards its superior border. The left kidney
was normal in every respect.
RADIOLOGY
John D. MacRae, M.D,, Editor
.•\sheville, X. C.
Pelvimetry With X-Rays
The female pelvis is rarely perfectly sym-
metrical. In a considerable per cent the lack
of symmetry amounts to a deformity which
is great enough to interfere with the normal
progress of labor.
Statistics designed to show what is the in-
cidence of contracted or deformed pelves are
unreliable. The men who hax-e compiled
them have arrived at very different conclu-
sions. These differences have occurred be-
cause of the different sources from which the
material has come and because the definitions
and classifications of "contracted pelvis" have
varied greatly.
Certainly the delivery of babies by means
of cesarean section is frequent enough to in-
dicate that seriously deformed pelves are
fairly common.
Measurements of the pelvic diameters
must be made as part of the routine manage-
ment of pregnancy except in multipara who
have already demonstrated their ability to
deliver themselves normally.
The most important pelvic diameters are
those of the superior strait. If these are nor-
mal those of the outlet are almost certain to
l^e normal also.
I'elvimetry accom|)lishcd by use (if instru-
ments and the fingers is admittedly unrelia-
ble. Of course gross deformity or contraction
will be recognized, but there is a wide mar-
gin of error. Internal pelvimetry is gener-
ail\-. postp<^»ned until late in pregnancy in or-
der to take advantage of the soft and relaxed
condition of tissues which facilitates the use
of instruments and which does not exist in
the early months. If there is pelvic contrac-
tion it is certainly desirable to know it earlier
than in the eighth month.
Out of many rather complicated methods
of x-ray measurement of the pelvic diameters
one has evolved which is simple enough for
every-day use. Inasmuch as the diameters
of the superior strait are those of greatest
importance this method concerns itself with
measurements in the plane of the entrance to
the true pelvis or superior strait.
.At any time before, during and after preg-
nancy a radiograph of the pelvis can be made
wiiich will clearly show its form. Then by
using a specially made scale its diameters can
be obtained and recorded in centimeters.
The patient is prepared for x-ray examina-
tion and placed above the film, sitting in a
semi-reclining position; the spine being arch-
ed forward and the plane of the sui^erior strait
parallel with the x-ray film. .\ Bucky dia-
phragm must be used because of the density
of the parts to be rayed.
The plane of the superior strait will be
parallel with the film when a point 1 cm.
below the upper margin of the symphysis and
another point posteriorly just below the spin-
ous process of the fourth lumbar vertebra are
equidistant from the film.
The patient having been placed as describ-
ed and the tube centered over the center of
her pelvis at a distance of thirty-six inches,
the exposure is made. The entrance to the
pelvis will appear clearly defined, but some-
what enlarged because of the divergence of
the rays as they spring from the center of
the tube target.
In or'der to avoid mistake in measurement
because of the enlargement, a special scale
is made. It is obvious that measurements
with a centimeter scale placed directly on the
film would be incorrect and misleading. This
is obviated by making a special scale. .\
strip f)f lead is marked at centimeter intervals
by filing notches in its margin and then an
\-ra\- picture of the lead strip at the same
distance above the film as was the superior
strait of the subject, being studied. When
this scale is ready it is applied directly to the
pelvic film and the measurements of the di-
ameters of the superior strait are made and
SOUTHERN MEDICINE AND SURGERY
February, 1029
recorded. They will be found to be accurate.
In the laboratory there should be a set of
scales for use in pelvimetry which will be
applicable for measuring the diameters of any
pelvis. They should be made by radiograph-
ing the lead strip at distances from the film,
varying from eight to eighteen centimeters.
INTERNAL MEDICINE
Paul H. Ringer, A.B., M.D., Editor
Asheville
Treatment of Lobar Pneumonia With
Concentrated Anti-Pneumococcus
Serum
Lobar pneumonia is a disease that is still
resisting our attempts at treatment. Its mor-
tality even in private practice still ranges
between 20 per cent and 30 per cent and,
therefore, any measure that can be brought
forward tending to lessen the inroads of this
infection must be welcomed with enthusiasm.
For several years treatment has been under-
taken with an anti-pneumococcus serum
which, however, up to this time has only
been of value in the treatment of the so-
called Type I pneumonia. The pneumococci
in the sputum are "typed"' and according to
their cultural qualities are classified as I, II,
III and IV, Class IV being composed of all
those pneumococci that do not come under
the cultural characteristics of I, II or III.
Latterly attempts have been made to develop
a polyvalent serum which would have anti-
bactericidal action against more than one type
of pneumococcus. Dr. Felton, of Boston, has
studied this matter from the laboratory
standpoint and has evolved a polyvalent se-
rum. In the Journal of the A. M. A. for De-
cember 29, 1928, there is a very excellent
article on the treatment of lobar pneumonia
with his serum by Russell L. Cecil and W. D.
Sutliff. This article is almost impossible to
abstract because different portions hinge so
closely one upon the other, and the tables
shown are of such value that one misses the
main point by giving simply an abstract. We
do not attempt so to do, but we simply wish
to emphasize some of the salient jxjints in
order to stimulate a careful reading of this
most e.xcellent contribution.
After describing the method of preparation
of the serum, the authors say; "Felton's
serum i.s therefore an aqueous sohifiop of
pneumococcuD anti-bodies --ontainine the
globulins and a few other inert substances."
With regard to the administrat'on of serum
they have the following to quote: "If sputum
was obtainable it was sent at once to the lab-
oratory for typing, but, as the type deter-
mination usually took twelve to eighteen
hours, it was deemed advisable to start treat-
ment with polyvalent serum without waiting
for the laboratory report on pneumococcus
type. In order to avoid anaphylactic actions,
each patient was first questioned as to pre-
vious injections of horse serum and as to hay
fever, asthma or hives. An intradermal and
ophthalmic test were then made with a one-
to-ten dilution of normal horse serum. If,
after fifteen minutes, the tests were both
negative, five c.c. of concentrated serum was
slowly injected intravenously; the rule was
to devote five minutes to the injection of
five c.c. of serum. If the patient did not
show any reaction to this first injection of
serum, a second injection of fifteen or twenty
c.c. was given intravenously from one to two
hours later, and this dose was repeated in
another two to three hours. An effort was
made to inject approximately one hundred
c.c. of serum during the first twenty-four
hours. One hundred c.c. was generally con-
sidered equivalent to at least 100,000 units
against Type I, and, to an almost equal
number against Type II. The potency of the
polyvalent serum against Type III has been
either nil or so low as to be of comparatively
small practical value."
Certain reactions were experienced, but
none of them of a serious nature. In almost
every instance the administration of adrena-
lin hypodernrcally relieved the patient of the
unpleasant symptoms. Cecil and Sutliff state
that serum sickness developed in 18-8 per
cent of the treated patients. "In .summariz-
ing the effects of the serum it may be stated
that the administration of the serum early
in the course of the disease frequently causes
a striking drop in the temperature and gen-
eral amelioration of the patient's symptoms."
From their studies in a large number of cases,
Cecil and Sutliff conclude that it would ap-
pear that if patients with Type I and Type
II pneumonia were admitted early and treat-
ed early with serum, the death rate for Type
I pneumonia could be cut to one-third of the
present figure, and that for Type JI to almost
one-half of the present figure. They feel
Februao', 1929
SOUTHERN MEDICINE AND SURGERY
that, although it is a debatable question
whether serum treatment should be instituted
before the pneumococcus type has been defi-
nitely determined, in order to save valuable
time, it is best to administer serum promptly
in patients with a frank lobar pneumonia as
soon as a clinical diagnosis has been made.
If, after the typing, the sputum shows I or
II pneumococcus, serum treatment should be
continued. If the case proves to be a Type
III or one of the miscellaneous group IV in-
fections, serum treatment should be discon-
tinued. At the present time there is no evi-
dence to support the use of serum in Types
III or IV. In asthmatic patients, or patients
who have previously received large amounts
of horse serum, it is doubtful whether serum
treatment should be employed at all. In pa-
tients who give a positive skin reaction serum
should be administered with the greatest cau-
tion. .\ positive ophthalmic reaction to di-
luted horse serum should be a definite contra-
indication to its administration.
Finally, as to their material, it seems that
in 441 cases of lobar pneumonia treated with
refined polyvalent serum the death date was
30 per cent, while in a controlled series of
444 cases the death rate was 39.2 per cent.
In a series of 153 treated, Type I cases, the
death rate was 20.9 per cent, while in the
control series of 157 untreated Type I
cases the death rate was 32.6 per cent. A
definite but less marked effect on the death
rate was observed in cases of Type II pneu-
monia treated with the serum.
.As said above, it is quite impossible to sat-
isfactorily abstract this paper. Every intern-
ist who has to deal with lobar pneumonia
should read it, and is advised to write to Dr.
Russell L. Cecil, 3i East Sixty-first Street,
Xew 'S'ork, asking for a reprint of this val-
unhle contribution.
1 Salvrgan in Edema
.Another excellent paper in the same num-
ber of the Journal of the A. M. A. is by M.
Herbert Barker and James P. O'Hare, of Bos-
ton, deals with this latest product for the re-
moval of fluid from the tissues. It is a ten
per cent solution of mercury salycilallylamide-
o-acetate of sodium. It has been used clini-
cilly as an antisyphilitic, as well as a diuretic.
1 !'«' inifal dosp is .5 r.c. intravpnotJ<;ly. Thj^
I- quickly 'aised to one and a half nr t«n c.c.
given once or twice a week. Bernheim states
that salyrgan is not less efficient than nierba-
phen, and in one thousand injections he has
not observed even the slightest toxic effect. In
almost all of Barker and O'Hare's patients
diuresis began in from one to four hours and
was complete in from eight to twelve hours.
The drug is therefore best given in the morn-
ing: otherwise the patient will lose much sleep
and rest from the frequency of urination. In
patients who respond poorly or not at all to
salyrgan, ammonium chloride or ammonium
nitrate were given in conjunction with the
mercurial. These drugs were used in doses
of from eight to fifteen grams a day, being
started usually from three to four days before
the salyrgan was administered. Barker and
O'Hare report several cases of different types
showing the excellent effect of this drug.
They conclude that it is a good diuretic with
a wide range of usage and is relatively non-
irritating. It has a particular value in circu-
latory failure and in the ascites due to cir-
rhosis of the liver and chronic nephrosis.
Salyrgan, like merbaphen, is much more ef-
fective in the presence of the acid-forming
salts, and the ammonium ion seems to be
most effective when supplied as ammonium
chloride or nitrate. By all means write to
Dr. James P. O'Hare, Peter Bent Brigham
Hospital, Boston, Mass., and ask for a re-
print of his and Dr. Barker's most valuable
paper.
Finally, the editor would refer his readers
to three papers in the November number of
the American Journal oj the Medical Sciences
which can in no way be abstracted, as to do
so would not convey their real value. The
first is "The Renal Lesion in Bright's Dis-
ease," by T. Addis. The second is "Renal
Function in Arterial Hypertension," by Ralph
H. Major, of Kansas City, in which a rela-
tively new functional test is set forth, where-
by a better idea of the ability of the kidney
to carry on excretory work can be obtained
than has hitherto been possible. The third is
entitled 'Differential Diagnosis of Surgical
From Xon-Surgical Jaundice by Laboratory
•Methods," by Lucius \V, Johnson and Paul
F. Dickens. No attempt will be made to
comment upon these three articles, save that
they have interested the editor very much
indeed, and that he feels thai any man will
fletue b<^nefit from reading them slowly, care-
SOUTHERN MEDICINE AND SURGERY
Februarv, 1029
fully and conscientiously. The first and the
last are not easy reading. They are not to
be indulged in as a sort of medical recreation.
One has to put on his thinking cap and get
down to brass tacks. But if it is done with
sufficient enthusiasm and with sufficient pa-
tience, the results obtained will well repay
the work that is undergone. Reprints of these
papers may be obtained by writing to Dr. T.
Addis. Stanford University School of Medi-
cine, San Francisco, California; to Dr. Ralph
H. Major, Medical Arts Building, Kansas
City, Mo., and to Dr. Lucius W. Johnson,
United States Naval Medical School and
Hospital, Washington, D. C.
SURGERY
Geo. H. Buxch, M.D.. Editor
Columbia, S. C.
Chest Injuries
The postman has this week brought us
from the -American College of Surgeons a
Symposium on Traumatic Surgery with the
report of a special board appointed by the
regents of the College for the Investigation
of Traumatic Surgery in the United States.
In 1927 there were 95,500 deaths from acci-
dents in the United States. There were 23,-
000 deaths from industrial accidents and
more than 23.000 deaths from automobile
accidents. Six per cent of all deaths were
from violence. There were 3,250,000 non-
fatal injuries received in industrial work and
doubtless as many more from automobiles.
The best way to care for the ever increasing
number of injured has become quite a prob-
lem to the medical profession. Typhoid fe-
ver, tuberculosis and syphilis no longer make
the most of medical practice as they did a
generation ago. Traumatic surgery requires
special training that medical schools have
heretofore largely ignored.
Because of negative pressure and the dan-
ger of lung collapse the chest has been the
last great region of the body to be entered
by modern surgery. It is of interest to note,
however, that there is the American Associa-
tion for Thoracic Surgery of 100 active mem-
bers, and that it took 400 pages of this
month's Archives of Surgery to publish the
fcientific papers read at the 1928 annual
meeting in Washington. The literature on
heart sutii.-e for stab wound is considerable.
More thaa 200 cases have been reported with
« i«9rta]ity of nearly 50 per cent, At the
last meeting of the Columbia Medical So-
ciety Doughty reported two cases with one
recovery. Tolbert had seen four cases. Ma-
guire, of Charleston, and Rhodes, of Au-
gusta, has each had a case to recover. Oper-
ation offers the only chance of recovery and
prompt exploration should be done when a
stab w'ound of the heart is suspected.
Shock, hemorrhage and infection are the
three great dangers of chest injury as of ab-
dominal injury. Of these shock should be
treated in the usual way with heat, morphine
and rest. If one of the large vessels is torn
or perforated the patient is apt to bleed to
death within a few minutes and surgical in-
terference and control of bleeding are im-
possible. Fortunately blood in the lung is
under low pressure and bleeding usually soon
stops if the patient be kept quiet. Infection
from chest injury if there is no gross con-
tamination from the outside does not occur
as often as might be supposed. Air in the
ung is not sterile, but pathogenic organisms
are few. Pneumonia does not usually follow
penetrating wounds of the lung if no foreign
body is left in the tissues. Only three cases
of abscess of the lung from penetration by
fractured ribs are on record.
The most common chest injury is fracture
of the clavicle or ribs, neither of which is
serious if there is not injury to the heart or
lungs. The x-ray is of service in determin'
ing the exact injury to the bone. The treat-
ment consists of reduction and rest maintain-
ed by suitable strapping. If the fractured
bone penetrate the lung, respiratory air es-
capes from the lung and infiltrates the tissues
causing emphysema which may extend from
the scalp to the ankles. Air in subcutaneous
tissue has a characteristic crackling feel on
palpation. The condition unless respiraticm
be mechanically embarrassed by the swelling
requires no treatment as the air is gradually
absorbed. If the emphysematous swelling
become too great, further escape of air into
the tissues can be stopped by collapsing the
lung by pneumothorax or by open operation
upon the lung and suturing the wound in it
Penetrating wounds of the chest are usual-
ly from gun-shot injuries and in civil prac-
tice have a rather low mortality if *he heart
or large vessels are not entered. Both air
and blood are apt to collect in the pleural
cavity. The bullet \TOund is small and th"
Fehruan'. 1039
SOUTHERN MEDICINE AND StJftGERY
131
tissues fall together and soon close it. Ac-
tive bleeding stops as the lung is put at rela-
tive rest b\- the increasing pneumothorax.
The blood in hemothorax is at first helpful
in splinting the lung and in controlling bleed-
ing, but later after several days when there
is fever from absorption the blood should be
removed from the pleura through a large
needle. Large wounds causing open thorax
should be immediatley cleansed and closed.
Foreign bodies should be removed if possible
at the primary operation for they result in
infection and abscess. Pierre Duval, of the
French army, reports 20 per cent mortality
in the world war of gun-shot wounds of the
lungs and pleura, while Moynihan {Surgery,
Gynecology and Obstetrics, December, 1917)
reports a mortality of about 45 per cent in
the English Army. In the Civil war the
mortality of penetrating wounds of the chest
was 62 per cent. In the Spanish-American
war it dropped to 27.5 per cent, to 14 per
cent in the Boer war and to only 3.5 per cent
in the battle of JNIukden of the Russo-Jap-
anese war. These variations in mortality are
due to difference in the nature of injury rather
than to improvement in treatment. In the
world war many wounds were from shrapnel
with extensive destruction of tissue.
In civil practice, unless the indication for
operation be positive, we advise and practice
conservatism. Morphine, immediate immob-
ilization of the chest with adhesive straps and
watchful waiting are the essentials of treat-
ment. After abdominal injury, if in doubt,
explore. After chest injury, if in doubt, do
not operate. Nature will cure most chest in-
juries without the aid of surgerj-.
PERIODIC EXAMINATIONS
Fkederick R. Tavlor, B.S., M.D., Editor
High Point, N. C.
Diseases of the Respiratory and Circu-
latory Organs Found in 271 Consec-
utive Health Examinations
Lungs and Bronchi
Cases
Bronchial asthma 2
Bronchiectasis (history suspicious, diag-
nosis previously made by x-ray) 1
Bronchitis, subacute _ 2
Emphysema ..— _. 1
Pneumokoniosis _ 1
Pulmonary tuberculosis, active 11
Pulmonary tuberculosis, arrested 8
■ Total 26
Blood
.\nemia, secondary 21
.\nemia, pernicious -- 1
Eosinophilia (over 4%) 7
Total 29
Heart and Blood-vessels
Angina pectoris 1
Aneurism, subclavian 1
Arteriosclerosis (middle aged people rath-
er than old ones examined in this
group) 1
Congenital heart disease — pulmonic sten-
osis and patent ductus arteriosus? 1
Extrasystoles 2
Functional murmur of heart 1
Heart, hypertrophied 1
Hypertension, essential _ 9
Hypotension, essential 4
JNIitral regurgitation 2
Mitral stenosis 1
Myocardial weakness — - 1
Paroxysmal tachycardia 1
Pleuro-pericardial adhesions - - 1
Raynaud's disease 1
Tobacco heart 1
Vagal attacks 1
V'aricose veins of lower extremities 13
V^asomotor instability, general 1
Total 44
Comment: Despite the rapid fall in tuber-
culosis mortality, active pulmonary tubercu-
losis is still a fairly frequent condition in
persons supposed to be healthy. Eleven cases
in 271 persons examined gives a percentage
of about 4.06. The data on circulatory dis-
eases show some peculiar features, some, at
least, of which, we suspect would be rather
radically corrected by figures taken from a
larger series of examinations. One would ex-
pect more cases of angina pectoris and of
arteriosclerosis. Especially would one exp)ect
a larger number of functional, and, for that
matter, other heart murmurs. We are inclin-
ed to look upon the small number found as
one of those strange coincidences that often
occur in medical work, which make individ-
ual data unreliable in some respects. We
know a doctor who is one of the fathers in
122
SOUTHERN MEDICINE AND SURGERY
February, 1929
our medical Israel, an able man of large ex-
perience, especially in g\'necologic work, who
says that he has seen only two undoubted
cases of carcinoma of the cervix uteri!
Percentages derived from one case are, of
course, perfectly useless. No doubt we might
make a thousand health examinations — per-
haps ten thousand, without finding another
case of subclavian aneurism. Here, too, indi-
vidual experience may mislead one in draw-
ing positive conclusions as well as negative.
In our own prWate practice, plus hospital
experience, plus health examination work, we
have seen no less than four cases of acciden-
tal smallpox vaccination, whereas we know
many men of much longer and more exten-
sive experience who have never seen a case.
These four cases were so interesting that we
might mention them here:
1. Child vaccinated as usual. Scratched
his vaccination, then scratched baby brother
under eye — vaccinia of lower eyelid.
2. Young bride vaccinated on elbow bj-
rubbing against husband's vaccinated arm.
3. Vaccinated child scratched himself, then
scratched mother on upper lip, giving vac-
cinia of lip.
4. Doctor started to vaccinate a child's
arm, dropped needle on to abdomen, vacci-
nating abdominal wall. Vaccinia of arm de-
veloped simultaneously.
From these figures, one might supix)se that
accidental vaccinia was a pretty frequent con-
dition, yet correcting individual experience
with group experience, we believe it is rather
rare. We need to have the pooled experience
of the profession in health examinations to
get the truest idea of the disabilities existing
in the apparently healthy of our state, and
it would be valuable if many physicians would
report the statistics of their work along this
line.
OBSTETRICS
Henry J. Lancston, B..\., M.D., Editor
Danville, Va.
Are We Practicing Obstetrics?
For seven years now we have been observ-
ing the practice of obstetrics from the stand-
points of both patients and physicians. Dur-
ing this period of observation many interest-
ing facts have been revealed, all of which
caused us to ask this question: "Are we
practicing obstetrics?" Physicians have par-
ticipated in this field only a short period,
and this short period, the past three hundred
years. If all of the facts were known it would
be discovered that even in this scientific age
physicians do a small amount of the obstet-
rics of the world. In countries like England.
France, Germany and America a little more
than one-half of the work in the field is done
by physicians. This fact in itself should
bring the matter of obstetrics into the fore-
front of our minds both in a professional
way and in a public way. Because of this
situation it is impossible to estimate the waste
of life, suffering, unnecessary morbidities and
economic factors which are placing burdens
on the shoulders of families, burdens which
could be removed.
First, we want to think of the practice of
obstetrics from the standpoint of the patient.
In discussing this problem with patients, it has
been revealed that physicians generally are
paying very little attention to the study of
the patient during pregnancy. We have talk-
ed with many women who have had from
one to ten babies and they say that they
have never been examined before delivery;
that their blood pressure has never been ta-
ken; that they have never been weighed, and
in most instances the urine has never been
examined; the pelvis has never been meas-
ured; the lungs and heart have never been
examined. .\lso they say that they have
never been informed as to how they should
take care of themselves sexually; they have
been given no information about the kind of
diet they should have. In fact most of the
information that they have had is informa-
tion given to them by older women. This
applies to city and country and represents the
majority of the women who are giving birth
to the babies who will occupy places of social
activity in the next generation. .Also these
women say that they are never examined
after the puerperium; they say the doctor
delivers them and comes back to see them
once or twice and maybe three times, and
they never see the doctor any more unless he
is called. How long will we allow this con-
dition to exist?
When we pick up any book written on the
theory, principles and practice of obstetrics,
we find this book gives us in a very decided
way principles which should be observed in
the finest manner possible. In our conversa-
Februan', 19^9
SOUTHERN MEDICINE AND SURGERY
12)
tions with, and observations of, physicians
in general practice we have been forced to
wonder how physicians do so well when they
are actually practicing so little the principles
of obstetrics. In urban and rural practice we
find very few physicians who have a pelvi-
meter of any kind. Any physician doing ob-
stetrics should have pelvimeters for both ex-
ternal and internal measurements. Any phy-
sician can in a short time develop a technique
for measuring the pelvis externally and in-
ternally. He will find in a short time that
he will become very accurate in this work.
By being able to accurately estimate the size
of the pelvis and of the baby he will be able
to anticipate the difficulties which he will
have with each case, and will thereby equip
himself for the difficulties by having present
as much help as necessary to bring the mother
through labor safely and to deliver a live
baby uninjured. We also find that very few
physicians are actually measuring, weighing
and carefully examining the babies they de-
liver to see if there are any abnormalities.
In many instances the physician returns to
see baby and mother and the mother calls
the physician's attention to something that
is not just right about the baby. This ought
not so to be. The physician should use his
hands, his eyes and his ears before he leaves
the house and know whether he leaves a nor-
mal or abnormal baby with the mother. If
it is abnormal the family should be so in-
formed.
Many physicians are not weighing their
mothers from time to time and studying their
weights; that they are paying practically no
attention to diet and to exercise. Also they
are giving very little attention to the mental
attitude of the expectant mother.
From both the public and professional
standpoints we are forced to admit that we
are not truly practicing obstetrics. We are
simply rocking along with the current of our
times. We are not growing mechanically, in-
tellectually, socially or spiritually as we
should. These fields of opportunity in the
physical, mental and spiritual life, well culti-
vated, would enrich and enlarge our own lives
and make us the most useful in all the world.
Doctors would gain the position in obstetrics
which should be theirs; mothers and their
offspring would have services from our hands
which would produce health, happiness and
peace of mind; much human waste and suf-
fering would be eliminated.
The family physician should keep up with
everything that is new in obstetrics. The
majority of physicians are reading compara-
tively little. We need to read everything that
is written on obstetrics — the things that are
good put into use and the things that are
bad discarded. The family physician by
keeping abreast of the times will grow and
will help the families under his care to grow.
These families will find that they can go to
their family physician and get proper and
scientific advice at all times; that he is hu-
manly interested in their health; that if all
members of the social group can be kept
healthy and happy, and have to a degree
peace of mind, we can grow a social order
that is safe and sound.
We are not truly practicing obstetrics, but
we feel hopeful of the future, and we think
that by calling our attention from time to
time to the importance of practicing the finest
principles in obstetrics we can help the social
condition and in proportion as we are able
to help the social condition in this important
field in that proportion we will in other
branches of medicine cope with various other
human ailments, eliminating preventable dis-
eases and t seating more accurately and effi-
ciently other forms of disease. Obstetrics
can not be separated from other branches of
medicine; they all interlock, but obstetrics
and other branches of medicine can be co-
ordinated, and by proper co-operation on the
part of the public and the profession we be-
lieve the day will soon come when every ex-
pectant mother in the nation will have a phy-
sician who observes and practices everything
that is good in obstetrics; that family phy-
sicians as a whole will be scientific in their
prenatal work, in the delivery and the care
of the patient during the puerperium, and
will turn back to the homes and husbands
healthy, normal wives and mothers.
We hope that each physician will answer
his question, "Are we practicing obstetrics?"
in the light of the theory and practice of the
principles of obstetrics and his experience,
and that he will begin to read everything that
is written on obstetrics, become thoroughly
acquainted with scientific obstetrics and be
just as up to date as the man who limits his
work exclusively to obstetrics.
m
SOUTHERN MEDieiNE ANC SURGERY
February, 1929
NEUROLOGY
Olin B. Chamberlain, B.A., M.D., Editor
Charleston, S. C.
Tumors of the Temporal Lobe
Only within the past two decades have
cHnicians evolved worth-while criteria to en-
able them to diagnose tumors of the temporal
lobe. Monographs on the subject have gener-
ally depended upon a very limited number
of cases. It is therefore of great interest to
study a paper in Brain written by an Ameri-
can, Kolodny, who is working at the National
Hospital, in London, under the direction of
Gordon Holmes.
Kolodny bases his report up<3n a series of
38 cases of tumor confined to the temporal
lobe, studied carefully while in the wards,
and minutely examined post mortem.
He analyzes the symptoms presented in or-
der of frequency, jxiinting out first that one
can divide the symptom-complex into those
resulting from intra-cranial pressure, from ir-
ritation of the neighboring areas, and thirdly,
from focal destruction of the involved region.
He then enumerates the symptom most com-
monly encountered, and compares the fre-
quency with which they are met in his series
with former accounts.
Kolodny insists upon the importance of
differentiating between headache and local-
ized pain in the head. Generalized headache,
which occurred in every case, had little diag-
nostic value. However, localized tenderness
in the head was observed in 10 cases, and in
8 it was present on the side of the tumor.
\'omiting, while present in 50 per cent of the
cases, presented no special features. Papill-
edema was seen in 86 per cent of cases. .\n
interesting point is here presented that only
in a few cases, and those very early, was the
comparative amount of swelling in the two
nerve heads of any value in deciding upon
which side the tumor was present.
The writer points out that incontinence is
much less frequent in temporal tumors than
in those located in the frontal lobe, and also
the inability to control the sphincters appears
later in the clinical course of temporal tu-
mors.
-As to psychic disturbances it is stated that
they may be grouped as follows: (a) defects
of memory found in SO per cent of cases, ( b )
change of character and temperament, in 21
per cent, (c) hypersomnia (prolonged sleep)
in 23 per cent, and (d) mental confusion,
found only in 3 cases.
"Fits occurred in 50 per cent of the cases,
but only in 40 per cent were they of localiz-
ing or lateralizing value. They were a rela-
tively early symptom, especially focal sen-
sory fits, which were observed in 32 per cent
of the cases. Uncinate fits and dreamy states
are of merely localizing value, but the visual
hallucinations that may accompany them are
of lateralizing importance when they occur in
a part only of the visual field. The visual
sensations which occasionally follow closely
on the uncinate aurae are of a complex na-
ture, and thus differ from the crude visual
phenomena occurring in fits associated with
lesions of the occipital cortex.''
Motor and sensory disturbances were ob-
served in 92 per cent of the series. In twelve
patients the whole contralateral side of the
body was affected; in seven there was weak-
ness of the arm and face only; in five a weak-"
ness of the face alone was seen, in three the
contralateral arm alone was involved; weak-
ness of the face alone was seen; in three the
instances, and in two patients there was pare-
sis of the arm and leg. The most constant
of the motor and sensory symptoms was a
contralateral lower facial weakness; it was
observed in 66 per cent of all cases of the
series. Kolodny remarks that the motor and
sensory disturbances rarely amounted to pa-
ralysis or anesthesia, and in the majority of
cases they were so slight as to require repeat-
ed examination before they could be regarded
as definite symptoms. The only reflexes
which could be said to have any value were a
loss or weakness of the contralateral abdomi-
nal reflex, seen in 39 per cent of cases, and
an extensor plantor reflex (positive Babinski)
seen in 45 per cent of the series.
Nothing worth-while das discovered by a
study of gait and balance. Kolodny 's find-
ings as to the visual fields does not bear out
Cushing's statement that "the perimeter as a
diagnostic aid in temporal lobe tumors is pos-
sibly the most important agent of all." That
aphasia was not of as great diagnostic im-
portance as one is led to believe from the
literature is evident from the fact that in
twenty-one right-handed patients aphasia was
a definite symptom in twelve cases only, and
was the first localizing sign in only four pa-
tients. As a rule, however, the disturbances
of speech produced in the early stages by tu-
mors of the temporal lobe are of the sensory
Februarv, lo:o
SOUTHERN MEDICINE AND SURGERY
12?
type and the most frequent symptoms are
loss of power to recall words and to name ob-
jects, places and persons.
As to cranial nerve involvement, "the com-
monest change is in the size of the pupil:
changes of shape were seen only four times.
.An early slight transitory recurrent ipsilateral
myosis is a relatively frequent sign. It is
due to involvement of the sympathetic fibres
accompanying the first division of the trige-
minus which innervate the dilator pupillae.
At about the same time the sympathetic fibres
accompanying the oculo-motor and supplying
the involufitary palpebral muscles may be in-
volved and ptosis result. Later in the disease,
when the constantly increasing pressure of
the enlarged temporal lobe leads to compres-
sion of the oculo-motor trunk proper, the
sphincter pupillae becomes paralyzed and
myosis gives way to mydriasis."
PUBLIC HEALTH
For this issue, E.wnix G. Williams, M.D.
Commissioner of Health of Virginia
The Newton Bill
There is now before Congress a bill known
as the Xewton Bill designed to carry on the
maternity and infancy work that was inau-
gurated under the Sheppard-Towner .Act in
1921.
When the Seventeenth .Amendment was
passed, giving suffrage to women, the first
move on the part of the women was to enact
some legislation that would be of benefit to the
women and children of this country. .As an
outgrowth of this Congress passed the Shep-
pard-Towner .Act, appropriating $1,000,000
to the Children's Bureau to assist the health
agencies m the various states and territories
in lowering the death rates of mothers and
infants, which was generally recognized to
be too high in our country.
The operation of the Sheppard-Towner Act
will come to an end June 30, 1929, and this
work will be seriously crippled in many states
unless Federal aid is continued. Mr. Xew-
ton, one of the representatives from Minne-
sota, realizing the benefit this work has been
to the mothers and infants, particularly in
the farming sections of the country, intro-
duced a bill to continue this activity of the
Federal Ciovernment.
There were certain features of this bill that
were objectionable and, when attention was
called to these features by the representatives
of the Conference of State Health Officers,
Mr. Xewton promptly agreed to amend the
bill to meet the objections. The health offi-
cers preferred that the work be placed under
the U. S. Public Health Service rather than
the Children's Bureau. It was suggested to
Mr. Xewton that the work be transferred to
the Public Health Service, as the health of-
ficers were of the opinion that this was the
natural agency of the government for all
public health activities. This suggestion was
not agreed to and the health officers did not
insist upon it, as they had to acknowledge
that the work had been most satisfactorily
conducted by the Children's Bureau of the
Department of Labor. In the states, how-
ever, all the work would be carried on through
the official state health agencies, as hereto-
fore.
The doctors who are familiar with the ma-
ternity and infancy work will agree that
much has been accomplished. The menace
of midwifery has been lessened by the elimi-
nation of many dangerous midwives and by
the instruction of the better type. The moth-
ers correspondence courses and the literature
that is sent to every mother emphasizes the
importance of employing doctors instead of
midwives, and instructs the mothers how to
care for themselves in the prenatal and natal
periods, and also how to care for the infants.
The instructions given through this depart-
ment to mothers has really increased the work
of the doctors by showing the importance of
securing the services of a doctor at times
when he can be of real benefit.
This is the work that the Newton Bill pro-
posed to continue and it is to be hoped that
the medical profession, as well as those or-
ganizations interested in the welfare of our
rural sections, will advocate it.
REDUCTION OF PAR.\PHIMOSIS
(Wehbein. in Urol, aiirl Culan Review) _.
The almost universally employed technique of
reducinq a paraphimosis is as follows: (1) Reduce
the edema by compression. (2) With the index and
middle fingers of each hand pull the constrictinR
hand forward while pushing the glans through the
ring with both thuml)s. .Ml text-books of urology
and general surgcr\ lon^uili'd were found to give
this technique.
The following method, published by Steinmann in
1026 and used in Enderlen's clinic as early as lOO-t,
has been found much more satisfactory: (I) Reduce
edema by compression. (21 Make traction on glans
penis with one hand and quickly slip constricting
ring over the elongated glans with the other hand.
«'^« SOUTHERN MEDICINE AND SURGERY
FINAL PROGRAM
February, 19J«
oj the
Thirty-first Annual Meeting
oj th'e
TRI-STATE
MEDICAL ASSOCIATION
oj the
CAROLINAS and VIRGINIA
"The medical society helps to keep a man 'up to
the times.' and enables him lo refurnish his mental
shop with the latest ivares It ketps his
mind open and receptive, and counteracts that ten-
dency to premature senility ivhich is apt to overtake
a man who lives in a routine So meeting
should be arranged without the presentation of pa-
tients The society should be a school in
which the scholars teach each other" — OSLER.
GREENSBORO, NORTH CAROLINA
February \9th-20th-21st, 1929
OFFICERS: SESSION \020
Dr J. K. Hai L, RiclimoiKi. \a. .. President
Dr. Ores- M(iore. riiarlolte. N C. Vice President
Dr. R. FisiFv C.AViE, JR.. Richmond. \a.
Vice-President
Dr. Dehitt Ki I Tiz, Clrcenville. S C. Vice-President
Dr. J. M. NuRTni.NC.Tox. Charlotte, \. C.
Secretary -Treasurer
E.xEcriivE Council
ONE ve.\r term
Eht. Warden T. X'avc.han. Richmond, Va.
Dr. M H. VVvmax. Columbia, S. C.
Dr. L G Be.\li.. Black Mountain, \ C.
n wo YEAR TERM
Dr. E S Boice, Rockv Mount, N. C.
Dr. F. B Johnson, Charleston, S. C.
Dr. R L. Payne, Norfolk, Va.
three year term
Dr. J Bolting Jones, Petersburg, Va.
Dr. D. .\. Garrison, Gastonia, N. C.
Dr. \V. R. Wallace, Chester, S. C.
LOCAL committee OF ARRANGEMENTS
Dr. R B. Davis, Chairman, Greensboro.
All sessions, except the public session, will be
held in the Ball Room, O. Heurv Hotel
PROGRAM
Dr. Parran
with
Dr.
The reading oj a paper shall occupy not more
than fijteen minutes and the individual dis-
cussion oj a paper not more than five minutes
Tuesday, February 19th, 10 A. M.
The .Association will he called to order by Dr. J. L.
Spruill, President of the Guilford County Medi-
cal Society
Invocation, bv Rev. J Clvde Turner, D.D., Pastor
of the First Baptist Church, Greensboro, N. C.
"Foreign Bodies in the .Air and Food Passages," bv
Dr. E. G. Gill, Roanoke, Va.
Discussion opened bv
Dr. C. N. Peeler, Charlotte. \. C.
"Pre- and Post-operative Care," by
Jnrboe. Greensboro. N C.
Discussion opened bv
Dr. Xuma Bitting, Durham. N. C.
"Continuous Irrigation of Wound Cavities
N'ormil Saline-Boric Acid Solution," by
Linu'ood D Keyser. Roanoke. Va.
Discussion opened by
"The Murphv versus the Ochsner Treatment." bv
Dr. J. E Rawls, Suffolk. \a.
Discussion opened by
"Chronic .Appendicitis as a Cause of Indigestion,"
bv Dr \f 0. Burke. Richmond, Va.
Discussion opened by
Dr. Robert C. Bryan, Richmond, Va.
"The New Perspective in Urologv." by Dr. C 0
DeLanev, Winston Salem. N. C.
Discussion opened bv
Dr. Hamilton W McKay, Charlotte. N. C.
"Stricture of the Female Urethra," bv Drs. Hamilton
W. and Robert W McKay, Charlotte, N. C.
Discussion opened by
Dr. J. W. Tankersley, Greensboro, N. C.
Luncheon — 1:00 O'Clock
Afternoon Session — 2:00 O'Clock
Clinic in Diseases of Children, by Dr. Edifards .4
Park, the Johns Hopkins Hospital, from 2:00 to
4:00.
"The Clinical Laboratory in the Diagnosis and
Treatment of Disease," by Dr. John A. Kolmer,
Philadelphia (Invited Guest).
"Serum Sickness." bv Dr. R. .1/. Pollitzer, Green-
vHle, S C.
Discussion opened by
Dr. J. M. Northingion, Charlotte, N. C.
"Sterility," by Dr. R T. Feriuson, Charlotte. N C.
Discussion opened bv
Dr. H. S. Lott, Winston-Salem. N. C.
"Iodine and Surgery in Goiter," by Dr. C. B. Epps,
Sumter, S. C.
Discussion opened by
Dr. 5. O. Black, Spartanburg, S. C.
"Earlv Pericardotomv," bv Dr. .4 G. Brenizer,
Charlotte, N. C. '
Discussion opened bv
Dr. R. F. Leinbach,' Charlotte, N. C.
Fcbruan-, lo^o
SOUTHERN MEDICINE AND SURGERY
157
■Arlerio-venou> Anfurysm," li\ Dr. W I. FfpU,
Richmond, Va.
Discussion opened by
Dr. G. P. La Roqiir. Richmond, \'a.
■A Mental Problem." by Pr. L. G. Bra!!. Black
Mountain. \. C.
Discussion opened by
Dr. Albert Anderson, Raleigh, N. C.
Dinner— 6:30 P. M.
Public Session— 8;00 F. M.
Auditorium North Carolina College for Women
(Broadcast)
His Eitcellency, O. Max Gardner. Governor of North
Carolina.
Presentation of gavel made nl timber from "Belroi,"
the ancestral home of Dr Walter Reed, in Glou-
cester County, \'irsinia, by Dr. J. .illison
Hodges. Richmond. \'a.
Acceptance, by Dr. Stuart McGuire, Richmond, Va.
Dr. Winjred Overholser. Boston, Mass. (Invited
Guest), Director of the Division for the E.xam-
ination of Prisoners of the Department of Men-
tal Diseases, — "The Psychiatrist in Court."
Dr. Joseph L. Miller, Thomas, W. Va. (Invited
Guest)--"Has Medical History .Any Value?"
Dr. Charles O'H. Laughingho>i\e, Health Officer »i
North Carolina, 'Preventive Surgery From a
Public Health Standpoint."
Dr J K Hall. Richmond, President of the Tri-State
Medical .Association of the Carolinas and Vir-
Wednesdav, February 20tm, 9:00 A. M.
Dr
Psychiatric Consideration of .Abortion.'
R. Finley Gayle, Richmond, Va.
Discussion opened by
Dr. J. H. Royster, Richmond, Va.
The History of the Introduction of the Vaginal
Speculum, by /)r. R F. .Seihels. Columbia, S. ('.
Discussion opened bv
Dr. H. A. Royster, Raleigh, N. C.
Broken Backs," by Dr. J S Gaul. Charlotte, N. C.
Discussion opened bv
Dr. W. F. Cole. Greensboro. N. C.
The Abdominal Symptoms of Extra abdominal
I-osions," by Dr. DeW'ilt Kltttlz. Greenville,
S. C.
Discussion opened by
Dr. Frank A. Sharpe, Greensboro, N C.
Repair of Tears," bv Dr 11 J LannUan. Danville,
Va.
Discussion opened by
Dr. M. P. Rucker. Richmond, Va.
Encephalocele." bv Dr. G. H Hunch. Columbia,
S. C.
Discussion opened b\
Dr. C. C. Coleman. Richmond, \a.
'Acute C'cllulitis of the Orbit," bv Dr
lell. Charlotte, N. C.
Discus.sion opened by
// C. Neh-
"Paroxysmal Tachycardia," by Dr. J. Morrison
llutcheson. Richmond, \'a.
Discussion opened bv
Dr. F. C. Rinker, Norfolk, \a.
"Gas Gangrene." bv Dr R H Davi<. Greensboro,
N. C
Discussion opened by
Dr. D. A. Garrison, Gastonia, N. C.
"Brain and Spinal Cord Conditions." by Dr A A
Parron. Charlotte, N. C.
"The Problem of the Small Ho-pilal in the Moun-
tains," by Dr Mm. C. Tale. Banner Elk, N. C.
Discussion opened by
Dr. C. O'H. Lauf^hinghouse. Raleigh, N. C.
.•Mlrrgv Clinic, bv Jlr Warren T Vauf.han. Rich-
mond. \a . 12:00 to 1:00 V M
Luncheon — 1:00 P. M.
.... .Afternoon Session — 2:00 O'Ci.ock
Clinic rn General Medicine, by Dr Thomas McCrae.
the lefferson Medical College. 2 00 to 1.^0
Clinic in Nervous and Mental Diseases, Dr Mich-
ael P Lonergan. Clinical Director, Manhattan
State Hospital, .New York. ,(:.!0 to 5:00.
"Nephrosis," bv Dr. J Garnelt Xehon. Richmond,
Va.
Discussion opened bv
Dr. W. deB. MacNider, Chapel Hill, N. C.
"Coronary Occlusion," by Drs. T. Deury Davis and
Douglas VanderHopj. Richmond, Va
Discussion opened by
Dr. J. M. Hutcheson. Richmond, Va.
"Obscure Deforming Bone Conditions." by Dr. A. L.
Gray, Richmond, Va.
Discussion opened by
Dr. W. T. Graham. Richmond, Va.
'Gongylenoma Hominis" (Report of a Case), by
Dr H. \V. Lewis, Dumbarton, Va.
Dr. J. K. Hall. Richmond, Va.
'Brain Tumors — Differential Diagnosis From Cere-
bral Vascular Disease," by Dr. J. G. Lyerly and
Dr. C. C. Coleman. Richmond, Va.
Discussion opened by
Dr. R. Finley Gayle. Richmond, Va.
"Chronic Duodenal Stasis — Its Causes, Symptoma-
tology and Treatment," by Dr. If. R. Graham.
Richmond, Va.
Pa'ening Session — 8:00 O'Clock
"Some Phases of Cardio-renal Disease," by Dr.
Thomas McCrae. Philadelphia (Invited Guest).
"Recognition and Treatment of Early Syphilis," by
Dr. .•!. Benson Cannon. New York (Invited
Guest I .
"Primary Tuberculous Infection in the Infant," by
Dr. F.dumrd'i A. Park. Baltimore (Invited
Guest ) .
"The Relation of .Atelectasis to Post-operative
Pneumonia," by Dr. Walter F. Lee. Philadelphia
(Invited guest).
Thursday, February 21st, 9:00 .\. M.
"Phrenic Avulsion," bv Dr. F S. Johns. Richmond,
Va
Discussion opened b\
Dr. Dean B. Cole. Richmond, Va.
"Fibroids," bv Dr. I M Procter. Raleigh, N. C.
Di.5cus.^ion opened by
Pr. R. L. Pillman, Fayetteville, N. C.
Ui
SOUTHERN MEDICINE AND SURGERY
Februarv, 1939
"Surgerv of the Prostate Gland and Bladder," by
Dr' J. D. Highsmitli, Fayetteville, N. C.
Discussion opened by
Dr. B. J. Lawrence, Raleigh, N. C.
"Drug Addiction. " by Dr. W . C. .islnrprlh. Greens-
boro, N. C.
Discussion opened by
Dr. C. M. Gilmore, Greensboro, N. C.
"Peptic Ulcer— 05 Cases," by Samuel Orr Blatk,
M.D., Spartanburg, S. C.
Discussion opened by
Dr. C. S. Lawrence, Winston-Salem, N. C.
Clinic in Skin Diseases, by Dr. A. Benson Cannon,
Columbia University, 10:30 to 12:00.
"Osteomyelitis oi the Frontal Bone," with Case Re-
ports, bv J P. Malheson M.D., and F.
Motley, 'm.D., Charlotte, N. C.
In Memoriam — For our Fellows who have died s
the 1928 meetmg.
Bu.^iness Session— Election of Officers.
Information
Mic U ll.i..> Hulel will l^c on,.,al l,ca,K,llullcl =
ol the .'"Lssociutioii. \\\ meetings, with the exception
of the Public Session (and possibly one or more
Clinics) will be held in the Ball Room of the hotel
Nearby hotels will also comfortably accommodate
members of the Association and their guests.
Physicians who contemplate attending the ap-
proaching meeting should ask at once for the reser-
vation of a room. Do this immediately.
Little time of the Association will be given over
to entertainments.
The members of the Association are .urged to bring
their wives with them to Greensboro. The wives of
the physicians of Greensboro will make their visit
pleasant. Many of the medical papers will be of
interest to them Many of them were educated in
Greensboro cir in Salem, .^n automobile ride of a
few minute;, would currs tlle^e alumnae back to their
Alma Mater.
Please be giving thought to the officers to be
elected at the meeting. The President is to come
from the North Carolina membership, and a Vice-
President from each of the three states. The Secre-
tary-Treasurer may be elected from any of the three
states. The meeting in f.^o will be held in South
Carolina.
The Clinics will be made especially attractive fea-
tures. Let's be on hand promptly to learn all we
can. Work up your cases well and bring in written
reports along with the patients.
Kindly notify the Secretary at once of any error
or omission in the program. If you are not on the
propram, present your ideas in the discussion of a
,/()aper.
Come to the Greensboro meeting. Bring your
medical neighbor. Whether he be a member of the
.Association or not, he will be gladly welcomed.
If your discussion is to be illustrated do not worry
he lantern or the operator. The Committee
of Arrangements are attending to this matter.
Please arrange to be at the 0 Henry Hotel not
later than 0 o'clock on the morning of Tuesday,
February 19th. The opening exercises will begin
exactly at 10 o'clock, and they will be characterized
by great brevity. Hear them. Arrange not to leave
until you have participated in the election of officers.
There will be ample time for the reading and the ■
discussion of each paper.
For additional information of any kind whatever
write to or telegraph the Chairman of Committee of
Arrangements in Greensboro, or
J AS. M. NOKTHINGTON, MD,
Secretary -Treasurer.
Charlotte, N. C.
NOTE. — Members arc particularly urged to look
nut for doctors who have recently located nearby
inil lo invite Ihem If none to llic nicTlini;
Kebruarv, lo'o
SOUTHERN MEDICINE AND SURGERV
NEWS
The annual meeting of the South Caro-
lina Pediatric Society was held January
ISth, at Columbia. Program: Clinics — Dr.
W'm. Weston, jr., chairman clinic committee:
Case reports — Dr. C. W. Bailey, Spartan-
burg, "Vincent's Angina"; Dr. E. W. Bar-
ron. Columbia: Dr. W. E. Simpson, Rock
Hill. "Serum Sickness, following toxin-anti-
toxin"; Dr. \Vm. Fewell. Greenville, "Hyper-
pnea": Dr. John I. Barron, York. Pajjers —
Dr. J. B. Sdbury, Wilmington, N. C, "Ex-
s.anguination Transfusion';; Dr. J. I. Waring.
"Beri beri in infants"; Dr. H. D. Wolfe,
Greenville, "Juvenile Pulmonary Tuberculo-
sis." Retiring officers — Dr. C. W. Bailey,
pres'dent, Spartanburg; Dr. P. V. jMikell,
v'ce-pres'dent, Columbia; Dr. R. M. Pollit-
zer. secretary and treasurer, Greenville. Of-
ficers elected: Dr. E. A. Hines, Seneca, presi-
dent: Dr. T. D. Dotterer, Columbia, vice-
president: Dr. R. M. Pollitzer, re-elected.
.-\ CONTRACT has been awarded for the erec-
tion of a BABY HOSPITAL at Roaring Gap, and
work is expected to be started immediately
with a purpose of having it ready for use by
Jure, the open'ng of the resort season.
The hospital will be a gift of Mrs. James
Gray, of Winston-Salem, and will be man-
aged by Dr. L. J. Butler, pediatrician of
Winston-Salem. The building will be 142
feet in length, the main section two stories
in height. It will be th()rf)ughly modern in
design and equipment.
Resolutions on Dr. J. F. Kinney
Whereas: We, the members of the Marl-
boro County Medical Society, desire to place
on record our testimony of the love and appre-
ciation in which Dr. Kinney was held by us.
Whereas: We wish to testify also to his
worth and standing in our community, there-
fore be it resolved
First: That in his death we have lost one
of our most devoted members, our town and
county one of its truest and most loyal citi-
zens.
Second: That Dr. Kinney exemplified in
h:s daily life all those principles that repre-
Jent the best in our medical profession; al-
ways looking to the interest and welfare of
his patients; never considering himself or
his own comfort, when he could do something
to relieve the sick and suffering. .\s a citizen
he was active and alert to everything looking
to the' advancement of the town and com-
munity; never shirking nor evading any duty
or obligation devolving upon him; never put-
ting off until tomorrow anything that could
be done today; always putting forth his best
efforts in anything he undertook.
Third: That a page in our minute book
be inscribed to his memory: th:il a copy of
these resolutions be sent to his family, the
Pec Dee Advocate, and the South Carolina
Medical Association.
CHARLES R. may,
DOUGLAS JENNINGS.
Committee from Marlboro County Medical
Societv.
Dr. L. L. Williams Elected Cu.mberlano
Health Officer
L. L. Williams, M.D., D. P. H., Houma,
La., has been elected health officer of Cum-
berland county by the county board of health
to succeed the late Dr. J. W. ;^.IcN"eill. The
post is now held temporarily by Dr. W. T.
Rainey, of Fayetteville.
Dr. Williams is a native of North Caro-
lina. His medical degree was obtained at
the University of Maryland, and he took the
degree of doctor of public health at Johns
Hopkins after his work as health officer of
Surry county had won for him the favorable
attention of Dr. W. S. Rankin and a scholar-
ship at Hopkins. He has served with the
State Board of Health as assistant director
of county health and has done work as a
health officer in Pitt and Surry count'es in
this state, in Spartanburg, S. C, and in L(niis-
iana.
The total North Carolina deaths due to
pellagra, which has been steadily decreasing
year by year, was 847 in 1928, according to
the State Board of Health. The 1027 roll
was 659.
During the past year the disease killed
mrw-e people in this stale than diwl from, the
130
SOUTHERN MEDICINE AND SURGERY
Fcbruarv, 1029
effects of typhoid fever, smallpox, diphtheria
and malaria combined. In addition to those
it killed, the disease sent hundreds to hospit-
als for the insane.
Dr. Joseph Treolar Wearn has been
chosen to head the Department of JMedicine
of the School of Medicine of Western Re-
serve University, Cleveland. Ohio. Dr.
Wearn was born in Charlotte in 1803, the
son of Mr. and Mrs. J. H. Wearn. He took
his A.B. degree at Davidson College in 1913
and later graduated at Harvard University
and secured his ^M.D. degree in 1917 at Har-
vard.
Dr. p. J- Klutz, of Maiden. X. C, died at
the home of his son. Representative L. F.
Klutz, at Newton. Among the survivors are
two sons who are doctors. Dr. Dale 'SI. Klutz,
who makes his home in New ^lexico. and Dr.
.-Xustin Flint Klutz, of Maiden.
Dr. S. a. Nathan, Chapel Hill, has been
made quarantine officer for Orange county.
Dr. Joseph Goldberger, of the U. S. P.
H. S., who has achieved world-wide fame for
his work in pellagra, died at the Naval Hos-
pital, Washington, D. C, January 16th, aged
54. '
Dr. H. L. Trantham, Salisbury's oldest
physician, died January 22nd, at the Salis-
bury Hospital. He had been in ill health
for several years and had retired from active
practice some years ago. He was born on a
plantation near Camden, S. C, 75 years ago,
came to Salisbury when a young man and for
years was one of the best known physicians
of the county.
Dr. Herbert Gorham, who for two years
has been connected with the city health de-
partment of Winston-Salem, has been elected
county health officer for Surry county and
will assume his duties February 1st. Doctor
Gorham succeeds Dr. W. A. Johnson, whose
resignation became effective several months
ago.
Post-Graduate Instruction at Gill ^NIe-
morial Eye, Ear and Throat
Hospital, Roanoke
.'\pril 8th to 13th there will be given a
course in ophthalmology, otology, rhinology,
laryngology, facio-maxillary surgery, oral sur-
gery, bronchoscopy and esophagoscopy, by
Dr. E. G. Hill, his associates and invited
teachers, .\mong those giving clinics, etc.,
will be Dr. W. P. Eagleton, Newark; Dr.
Walter Dandy, Baltimore: Dr. H. D. Scar-
ney, Roanoke: Dr. E. G. Gill, Roanoke; Dr.
C. G. Coakley, New York; Dr. R. H. Ivey,
Philadelphia: Dr. J. .\. Kolmer, Philadel-
phia: Dr. J. I. Ch(]rlog. Roanoke; Dr. H. S.
Hedges, Charlottesville: Dr. John M. Wheel-
er, New York; Dr. D. L. Poe, New York,
and Dr. C. E. McDannald, New York.
Write Dr. E. G. Gill, Roanoke, for pro-
gram.
The Highsmith Hospital, the oldest pri-
vate hospital in North Carolina, has identi-
fied itself with the Duke endowment through
a reorganization which makes the institution
a non-profit enterprise.
The hospital and equipment have been
leased to a board of prominent men, who
have retained Dr. J. F. Highsmith as gen-
eral superintendent and the entire medical
staff and personnel, so that the institution
will be conducted exactly as heretofore with
the advantage that the hospital will receive
from the Duke foundation one-third of the
cost for all charity patients.
Operating without profit, the hospital at the
end of each annual period will use all surplus
to reduce the costs to patients who are able
to pay.
Dr. John O. Daniel has located at Lau-
rens for the general practice of medicine.
Dr. C. M. Lents, .Albemarle, N. C, has
been re-elected county physician. After
much discussion as to the advisability of put-
ting on a full time health officer, it was
moved that the county board of health rec-
ommend to the county board of commission-
ers that the county co-operate with the State
Board of Health in putting on a full time
officer in the county. The motion was car-
ried.
Members present were: Dr. J. I. Camp-
bell, Dr. J. A. Allen, Dr. B. B. Monrp, M. J.
Harris and Jame? P. Sifford.
February, 1929
SOUTHERN MEDICINE AND SURGERY
Dr. jNIacXider's Harvey Lecture
The honor of an invitation to deliver one
in the series of Harvey Lectures has been
conferred on Dr. William deB. MacXider by
the Harvey Society. He delivered the lec-
ture at the .Academy of Medicine in New-
York the evening of January 17th.
Dr. Xoble Dick, Medical College of the
State of South Carolina, '21, formerly of
Sumter, is now associated with the Mason
Clinic. Seattle, Washington.
Dr. W. p. Herbert, .\sheville, is president
of the Buncombe County Medical Society for
1929. Dr. Matthew S. Broun was re-elected
secretarv.
Dr. George C. Andes, Medical College of
Virginia, "17, announces the opening of of-
fices with Dr. L. D. McPhail, 405-408 Pro-
fessional Building, Charlotte, N. C.
Dr. C. X. WvATT, after 16 months in the
Emma Booth Hospital, Greenville, S. C, has
associated himself with Dr. R. E. Hughes,
Laurens, S. C.
Dr. Paul C. Brittle, 49 years of age, one
of the leading professional men of Burlington,
d'ed at Rainey Hospital, January 29th, fol-
lowing an emergency operation performed
during the night.
XEWS—
Dr. Harold L. AiMOs is coming to Duke
University in 1930 as Professor of Medicine.
He has demonstrated outstanding clinical,
teaching and scientific ability. He was born
in Kentucky, received his academic training
at the University of Kentucky, and his M.D.
and D.P.H, at Harvard. He was at the Rock-
efeller Institute for ten years and for the past
seven years has been .Associate Professor of
Medicine at the Johns Hopkins. He has
made many contributions to medicine notably
on poliomyelitis and erysipelas.
The Xorth Carolina State Hospital
Association will meet at High Point, May
14th, 15th and 16th, it has been announced
by Dr. W. L. Jackson, member of the execu-
tive board.
The RuiHERfORD CoVMi' MfDiCAi, So-
ciety, meeting at the Rutherford Hospital,
January 31st, elected Dr. P. H. Wiseman, of
.Avondale, president; Dr. C. F. Glenn, of the
Rutherford Hospital staff, vice-president; Dr.
W. C. Bostic, sr., of Forest City (re-elected)
secretary-treasurer; Drs. W. A. Thompson, of
Rutherfordton, and George P. Reid, of Forest
City, censors; Dr. R. H. Crawford, of the
hospital staff, delegate to the State ^Medical
Society; Dr. W. C. Bostic, jr., of Forest City,
alternate.
Dr. William Crisp, of Roxboro, promi-
nent and respected physician, was found dead
in his bed F'riday morning, January 11th. Dr.
Crisp had been in his usual good health
Thursday night when he had retired and his
death came as a great shock to all.
Dr. T. D. Christian, jr., of Greensboro,
died at the Wesley Long Hospital, January
12th. Dr. Christian had been in bad health
for the past year. More recently he had con-
tracted influenza and the complication pro-
duced a condition of critical nature. He was
a native of Lynchburg, \'a., where he was
born December 24, 1897.
Dr. J. W. Warren and Dr. M. P. WicH-
ARD, Edenton, X. C, have completed a deal
whereby they became owners oi the Cason
office building on East King street.
They stated that the building will be re-
modeled with two complete sets of offices, as
they will practice separately.
Dr. George Fleming McLnnes died on
the evening of January 12, 1929, at the Baker
Sanatorium, Charleston, S. C, from injuries
received in an automobile accident. He was
born at (Sullivan's Island), Charleston, S. C,
.August 21, 1881, and was graduated from the
Medical College of the State of .South Caro-
lina, 1908.
Dr. J. H. .Anderson, of Tarl)oro, died at
his home, January 17th, in the 81st year of
his age. The deceased, an outstanding citizen
of his community, was well known through-
out the entire county. Just prior to his ill-
ness he had been engaged in the active prac-
tice of medicine in the upper section of Edge-
combe countv. Death was due to heart dis-
ease.
SOUTHERN MEDICI^fE AND SURGERY
Ffbruary, 1P29
Dr. J. T. BuRRUS, widely known surgeon
and ex-president of the ISIedical Society of
the State of North Carolina, is convalescing
from an attack of pneumonia.
for several years been a member of the gov-
ernor's advisory board on m?ntal h>giene.
Dr. a. William Lescohier, Detroit Medi-
cal College, '09, has been appointed general
manager of Tarke, Davis & Co.. according
to an announcement made publx on January
10th by Oscar W. Smith, president of the
company. Dr. Lescohier has been connected
with the company for the past twenty years
and has most recently occupied the position
of assistant to the president. From 1918 to
1925 he had charge of the production of se-
rums, vaccines, antitoxins, and other biologi-
cal products. In 1925 he became director
of the Department of Experimental Medicine,
and in that capacity was in constant touch
with physicians and scientific workers in the
Vnding hospitals and medical colleges of the
country. Dr. Lescohier is a Fellow of the
.American ^Medical .Association and a member
of the .American Therapeutic Society.
Dr. J. E. Person, Pikeville, College of
Physicians and Surgeons. Baltimore, '75, died
January 22nd. Dr. Person was prominent in
the affairs — professional, financial and politi-
cal— of Wayne county for 50 years, .\mong
the survivors is a son. Dr. E. C. Person. Med-
ical College of Virginia, '05. Pikeville.
Capt. George Tvcker Smith, of Char-
lottesville, Virginia, has been promoted to
the rank of rear admiral in the naval medical
corps.
Dr. W. .\. Wall.ace, 47, :\Iedical College
of Virginia, Ob, one of the best known prac-
titioners m Spartanburg, South Carolina, for
20 years, died January 31st.
Dr. W. V. Drewrv, Petersburg, \a., who
was for many years superintendent of the
Central State Hospital in that city, has been
made director of the newly created bureau
of mental hygiene of the state department
of public welfare.
Dr. Drewry, who is well known as an ex-
pert in mental diseases, is a former president
of the .American Psychiatric .Association, and
of the Medical Society of Virginia, and has
Increasing Weight With Insulin
Uiime. J Sli:i'..\ in Jm'nia! I.'ib >ralory and Clin'cal
.M,-ii:dnr)
Of seven cases of malnutrition treated with
insulin, all showed increased appetite and
some had intense food craving following in-
sulin; five showed definite gains in weight in
response to insulin : one showed no gain what-
ever but was slightly under the original weight
at the end of three weeks; one was not ob-
served a sufficient length of time. It is con-
cluded that insulin can be a valuable agent
for increasing weight in malnutrition. At-
tempts should be made to increase the fatty
as well as the starchy foods after the admin-
istration of insulin when malnutrition is
treated. Thirty minutes should elapise after
insulin administration before food is taken if
the optimum development of appetite is de-
sired. The insulin should be given three times
a day before meals in d.jses of 10 units more
or less according to ind v^dual indications.
.Albuminuria in Children
[Joseph K. Calvin, in Illinois Medical Journal)
We wish to direct attention to the danger-
ous practice of stressing the term albuminuria
too greatly to the parent or to the child. The
harm done psychically may be worse than the
condition physicalh'. .Albumin in the urine is
a dreaded occurrence among the laity, and
albuminuria neurotics can easily be created.
The "disease" often occurs only in the phy-
sician's test tube and in the mind of the pa-
tient. However, these simple benign album-
inurias must not be totally disregarded. .A
functional albuminuria should be regarded
much as a functional heart murmur. Every
case should be under the control or observa-
tion of the physician for a variable period,
certainly during the period of adolescence,
and for a short period following.
SOUTHERN MEDICINE and SURGERY
Vol. XCI
Charlotte, N. C, March, 1929
No. 3
The Apotheosis of the Individual
Beiny the Presidential Address
to the
Thirtv-first Annual Meeting of the Tri-State Medical Association
of
The Carolinas and Virginia
James K. Hall, ^I.D., Richmond, Va.
The pages of history are starred with evi-
dences that nothing is more immortal than
many of the exhibitions of mankind's poor
judgment. The errors that men make con-
tinue to walk the earth long after they them-
selves have passed behind the veil of oblivion
and have crumbled into the silence of for-
gotten dust. But I promise to detain you for
a moment only and to make as brief and as
light as p<issible the embarrassment and the
disappointment of those of you who in an
unwise emotional upheaval a year ago ele-
vated me into this position of momentary
pedestalization. ^ly natural timorousness is
exaggerated enormously by the duality of the
uniqueness of this strange experience. For
the first time since consciousness developed
within my calvarium as I toddled years ago
over the red hills of old Iredell I iind myself
engaged in an attempt to verbalize a presi-
dential message, and I find myself confronted
by a microphone. Words have become wing-
ed, indeed, and it behooves us as we release
them into the circumambient air to give
thought to the freightage with which we laden
them.
Surrounded as I am by the multitudinous
evidences of the tendency to mechanize our
modern life I am made mindful of the re-
sponse of the late Judge Bennett to the first
mimeogra|)hed letter that came into his hands.
His prompt and profane and fitting exclama-
tion was, "Damn this metallic age!" .\nd if
the intrusi(m of machinery into the intimacies
of personal corres[)ondence called forth such
a judical outburst more than a {|uarter of a
century ago, what would the gallant old Con-
federate colonel exclaim today if he still
walked the earth amongst us?
Largely because of the mechanizing of the
age in which we live am I increasingly im-
pressed by the enforced changes that are tak-
ing place in the functions of the physician.
Only little more than a century ago, I can
easily imagine, the doctor was seldom called
intfi the home until pain or physical illness
had fallen upon some member of th? family.
.\nd then the medical man was expected to
bring assuagement of the suffering and cure
of the disease. The doctor of the days gone
by had been taught to focus his thought upon
man chiefly as a physical mechanism, .^nd
such medical philosophy was in keeping with
the spirit and the necessities of the times.
]\Ian was a muscular organism who defended
himself against his environment largely by
personal prowess and who was compelled to
obtain his sustenance out of his immediate
vicinage by the employment of his own phy-
sical strength. Unless man were strong of
sinew and of muscle he perished. Xo better
vital statistics of Colonial days are available
than those furnished by the moss-covered
tombstones in the old graveyards. Most of
that pioneer po[)ulation succumbed in infancy,
and few survived beyond m'd-life. The weak
perished; the hardy endured only for a brief
period. The hard law of the survival of the
fittest was doing its deadly work long before
that epigram was coined.
Not so long ago man's body and the frames
of some of those lower animals domesticated
Ijy him were the chief sources of utilizabl;:
energy. Man tamed the beasts by his wit
and his wiles and by their strength and his
own he jjabulaled and defended himself an.l
transijorted himself and his wares.
It is not strange, therefore, that m;nikiiKl
invoked ujjon certain of his fellows the magic
or witchcraft or skill requisite to keep his
SOUTHERN MEDICINE AND SURUEKY
body free from pain and from the disabirty
and defenselessness caused by disease. Life
itself could not long be kept in a body racked
by pain and made impotent by sickness. The
inlluence of disease and of climatic unwhole-
someness is written emphatically and tragi-
cally in the records of the march. of civiliza-
tion. Had babyhood in the coastal regions
of the Southern States been prolonged into
robust manhood in the decades immediately
preceding the Civil War the disparity in the
numbers contending against each other at
Gettysburg and along the marshes of the
Chickahominy might not have been so great,
with the consequent result that a memorial
to Jei'ferson Davis might now occupy the
very spot upon which the Great Emancipator
looks down in marble grandeur upon the ad-
miring throng. Climate and health are much
more potent factors in personal and racial
history than individual destiny and all the
stars in the vault of heaven.
But the day of success based upon muscu-
lar power and physical strength is no more.
Never before in the world's history has
strength of muscle in man been of so little
consequence. ?.Ian is no longer looked upon
ch'efly as a motive mechanism. He has
caused the falling water, restless in its trou-
bled way to the sea, to do the work of myriad
men and countless beasts; he has compressed
the boundless and impalpable air so that it
does his bidding; from the spacious bosom
of Mother Earth he has brought forth the
limpid fluid that has made possible the inter-
nal combustion engine; out of the hidden re-
cesses of the mountain ranges man has
hoisted the lumpy blackness with which he
has supplied himself with heat, light and
power; and by this method and by that he
has generated the electric current which
serves his purposes in fashions so innumerable
and mysterious as to confound his under-
standing of his own handiwork. The cry of
the pioneer was; Give me power. The
prayer of his children of today is: Give us
knowledge of ourselves that we may be able
to develop the skill and the cunning in order
to make use of the boundless power at our
disposal.
Neither in this assemblage nor elsewhere
shall I permit myself to fall into speculation
about the origin or the nature of the mind.
Is it an essence of the physical being? a prop-
erty of matter? or does it merely make use of
bodily structures through which to make it-
self manifest? I know not. But I do know
that portions of the brain are projected as
far from the brain as their safety permits,
and that these brain out-posts we call the
£_~ec'al senses: the eyes, on the very front of
the head; the nose, even beyond the front of
the head; the ears, those ugly, out-sticking
protuberances: the tongue, mobile and far-
reaching, and often an evil member; and the
skin, the largest sensory organ of all. These
projections of the nervous system, these an-
tennae, pick up for us information about the
universe which surrounds us, and out of this
inllowing information is built up our concep-
tion of the universe and all the creatures and
other things that inhabit it. Through the
physical mechanism v.'e become conscious of
our surroundings and through the medium of
bones and joints and muscles and other or-
gans we are enabled to make response to the
objects around us. .A human being is, or
should be, e.xceedingly sensitive, and equally
as responsive, to sensations.
Living is almost entirely a matter of mak-
ing adjustments. Fitting response implies
wholesome living; inadequate adjustment
means poor living. The effort to keep our-
selves constantly in comfortable tune with
our individual universe embraces the whole
art of living. The personal universe is con-
stantly being enlarged. \\'e are obliged to
respond to millions of stimuli that were not
even in existence in the days of our ances-
tors. You know them — the irritating me-
chanical necessities of this metallic age — the
telephone, the telegraph, the typewriter, the
rad.o, the automobile, the flying machine, the
railway train, and all those countless mechani-
cal devices engaged in the fabrication of this
thing and that in factory and in shop.
Modern civilization has decreed that we
must each fit into some sort of mould that
has been adopted by the neighborhood; that
we must have the same sort of instruction in
order that we may be less unlike each other,
£0 that there may be a minimum amount of
friction as we go in and out amongst each
other. But the attempt to bring about a
sort of universal standardization has always
wrought mischief, and I hope it always will.
We have come to a bad pass if we can not
live our own lives, think our own thoughts,
and go our own way without the restraining
tug of law or of convention pulling back on
March, 102Q
SOUTHERN MEDICINE AND SURGERY
1,>S
our coat tails.
Most of the difficulty in iiKidern life is not
caused by our strugfjle with matter, but with
our own beliefs and our ow'n thousshts, and
with the thoughts of others. The field of
mans battle is within his own mind — with
his own instincts, his own thoughts, his own
feelings. His life is made constantly more
difficult, not only by the multitudinous de-
vices with which he has to work, but even
more so by the network of laws and "customs
with which he has entangled himself. Most
of the tragedies of lite are due to conllicts
between primitive ways and the demands of
civilization. Let us know ourselves as we
are. Does the causative factor of the failure
lie in the individual or in the complexities of
a social order that are too much for his fac-
ulties of adjustment? How much civilization
can w'e endure? May we not be fabricating
a social structure about us that may be un-
endurable?
Herein lies the importance of considerate
thought of that tabernacle of clay in which
our spirits for the moment must abide. The
immaterial part of man is the important fea-
ture of him, but the most immediate thing in
his environment is his physical body. That
body should be well developed, symmetrically
formed, wholesome, and free from avoidable
defects. Juvenal, the great Roman satirist,
urged his countrymen to pray to their gods
that they might have sound minds in sound
bodies. .\nd that was a majestic prayer for
a pagan philosopher. .A defective or a dis-
eased body gives a blurred and distorted con-
ception of the realities of life, even as a de-
fective lens gives a gnarled and twisted image
of objects within the range of vision. The
body is holy, and we should cherish it, by
keeping it free from infection, by attending
properly to its nourishment, by eliminating
poison from it, by working it in moderation,
and by giving it adec|uate rest. The mind is
keenly sensitive to intolerable conditions
within the body. Through an unwholesome
physical being the mind can not comprehend
clearly, nor can it react efficiently to the
mental receptions. Whatever is bad for the
body and the mind is immoral.
If unwholesome physical health affects the
mentality adversely I am certain that morbid
emotional states and un.sound intellectual at-
titudes are even more harmful. All of you
have seen crip[)les wh(j were happy, and phy-
sical giants who were unhappy and inade-
quate.
Fear, I have no doubt, is more hurtful to
our mental and our physical health than ail
the germs that have been catalogued. Fear
plays a bad part in the life of each of us. It
dominates many of us in the great philoso-
ph'cs of life — in religion, in politics, in eco-
nomics, in industry, and in that intimate in-
ner circle called home. Fear is the club too
often made use of in rearing children and in
dominating adults. It is generally the causa-
tive factor in warfare, and fear guides the
pen that formulates most of the peace treat-
ies. Children should be taught not to be
afraid. .Adults should be taught to under-
stand God and not to fear him. Citizens
should be taught either to obey statutory
laws, or to abolish them, but not to fear
them. It is a sad state when mankind comes
to fear his own formulations. Intolerance
begets personal unhappiness, and leads to un-
wholesome mental health. Let us not do
obeisance to human opinions, whether they
come from the printed page, from the doctor,
from the pulpit or from the supreme bench
itself. History demonstrates that most hu-
man opinions have been wrong. Charity
means love, but some things and some people
can not be loved. But we can, at least, toler-
ate them. Intolerance is, I feel, one of the
curses of our age. Too many of us would
mould the lives of our neighbors. I believe
there is too much moral tension in the world.
Physical relaxation is no more important than
relief from moral tension. In some individ-
uals the process of relaxation is brought about
by resort to alcohol or to some other drug.
I'nrestrained expression is natural in primi-
tive life, but repression is one of the prices
paid by us for our civilization. Practically
all disorders of conduct are manifestations
of failure in repression. We physicians should
each open a confessional. More of our atten-
tion should be directed to the emotional pur-
gation of our patients. Let us not be too
condemnatory. I sometimes think that all
of us at times do too much moral tip-toeing.
Truth, after all, may be largely an individual
and a relative matter. The thing that seems
to lie righl to Tiie may seem lo be wrong to
my neighbcjr. It is tragic to cNpect too much
of a mere mortal; we are made of dust, not
What, after all, is that summum bonum for
SOUTHERN MEDICINE AND SURGERY
March, 1929
which each is lifting high his hands? Mate-
rial wealth? The dollar has, perhaps, never
before been so influential in human history.
Those who have most of them are, I some-
times fear, formulating; our college curricula,
and controlling the admissions to the seats of
higher learning. But money is mobile, and
the dollar finally finds lodgement where it is
most needed. The wild striving for it ruins
much health, mental and physical, and the
loss of it causes much unhappiness. Charges
equally as grave can be lodged against the
desire to attain eminence — in wealth, in in-
dustry, in politics, in society — the craving to
stand up above the herd, head and shoulders,
as Saul stood up above the host. But, in
spite of his great stature, he went out miser-
ably.
Mental health comes out of right living,
and sound mental health makes right living
possible. Our lives are too filled with pur-
poseless movement and hurry: we demand no
time for deliberation and contemplation, and
for opportunity to live with our own medita-
tions. The very essence of the necessity of
individualization in the study of human con-
duct was set forth with majesty and beauty
more than si.x hundred years ago by the great
Persian poet:
"I sent my soul throush the Invisible,
Some letter of that After-life to spell;
And by and by my soul returned to me,
-And answered, "I myself am Heaven and Hell."
I am convinced that the mind can be
wounded by a harmful thought or by a bad
e.xperience, even as I believe that the physi-
cal body can be injured by an accident. The
minds of little children are often irreparably
damaged by the terrible tales told to them
by nurses and by others. Most of the great
fears that haunt human beings throughout
life were lodged in infancy. So-called psycho-
analysis is doing much to root out such fears
and other morbid mental states.
?*Iodern society interferes too much with
instinctive tendencies. There is too much in-
clination to regard all instinctive b?havior as
wrong. What is inherent and therefore nat-
ural can not be altogether bad. Practically
all statutory laws are antagonistic to natural
instincts. For that reason we are all essen-
tially lawless. .All great men have been law-
less. Too much respect for herd opinion im-
plies either individual ignorance or cowardice,
or both. All progress has its origin in the
minority. Every fundamental improvement
in civilization has been at first frowned down
upon and resisted by the great body of good
c'tizens — by the majority. The group is gen-
erally wrong. Herd opinion is so conservative
as to be deadening. Every helpful theory,
every great discovery, every revolutioniz'ng
invention had to be protected from the deadly
assault of the good citizen. Only the spirit-
ually adventurous and the restlessly discon-
tented make any permanent contributions to
human knowledge and human progress. All
great souls have made war upon the status
quo. .And not infrequently they have paid
with their I'ves for their assaults. I am little
concerned about the law-breaker and the
criminal. It is written that the wicked shall
perish. But I am troubled by the compla-
cency of the good citizen. The great menace
in modern life is not the criminal, but the
unwise legislator. A fully developed human
b?ing is the only immortal contribution civili-
zation has made to the ages. I object to all
agencies, however seemingly benevolent, that
interfere with individual development. If
every law-making body had some Socratic
consultant the courts would be less busy, the
prisons less congested, and mankind would be
happier. What a dangerous procedure it is
to set up obstructions to the natural outflow
of instinctive behavior 1 Have you read the
terrible indictment of our national law-mak-
ing body by the president of Harvard Uni-
versity?
Time must offer its own diagnosis of con-
duct. That conduct which has in it qualit'es
that make for the good of the race will sur-
vive: all other conduct is malignant and must
perish. I shall continue to have respect for
a certain degree of polite insubordination and
for certain e.xhibitions of civil disobedience.
A man's universe, after all, must consist
largely of hiinself and his God. There is little
else for which we need have respect.
Unless we be able and willing to go in
search of the Truth and to find it and to
stand by it after we have found it, then we
shall avail not, either as physicians or teach-
ers, lawyers or preachers, or any other kind
of citizens. But if we bring ourselves into
possession of the courage and the serenity
and the helpfulness that Truth alone can
give, then we .may e.xpect personal fulfilment
of the prophecy of the son of Amoz: .And
there shall be a pavilion for a shadow in the
day-time from the heat, and for a refuge and
for a covert from storm and from rain.
March, 1Q29
SODTftERN MEblCtNE ANt> SttROfiftV
13?
The Psychiatrist in Court*
WiNFRED OvERHOLSER, A.B., M.B., M.D., Bostoii, IMass.
Director, Division for the Examination of Prisoners, Massachusetts Department of Mental Diseases
Assistant Professor of Psychiatry, Boston University School of Medicine
W til frstressing frequency one reads in the
dr.'ly press accoimts of criminal trials in
wh'ch the defense produces alienists to prove
the defendant mentally irresponsible, while
the prosecution produces an equal or greater
number to establish the contrary. Editorial
castigations are administered to the luckless
"experts," and in that forum of democracy,
the smoking compartment of the Pullman
car, the verdict is pronounced that the expert
is a menace to society, and a coddler of the
criminal, if not indeed guilty of high treason!
That a widespread distrust of the expert ex-
ists cannot be denied. State crime commis-
sions and legislative committees are at the
present moment considering how best they
may cope with a situation which, as affecting
the administration of criminal justice, is
highly undesirable. Since the physician is one
who often has occasion to testify in an expert
capacity, it may not be inappropriate to ad-
dress to this representative group of physi-
cians gathered from three of the great and
progressive states of our country some re-
marks on the place of the psychiatrist in the
criminal courts. No attempt will be made
t(j deal with the subject of expert testimony
in civil cases'; the problem here, too, is se-
ricius, but the public is not a party, and so-
ciety is, therefore, not so intimately and
vitally affected as in matters having to do
with offenses against the group — in other
words. Crimes.
The English courts seem to have recognized
very early the existence of questions relating
to ^^cience or art upon which they were in-
competent to pass unaided. They did not
hesitate, therefore, to call upon skilled per-
sons to advise and assist them. In 1353, in
one of the earliest recf)rded instances of such
testimfiny, we find surgeons sent for to in-
form the court on the nature of certain
wounds in a case of alleged mayhem-. At
this time, and for several centuries subse-
quently, the "expert" was looked upon as a
♦Presented \,y invitation to the Tri St.ite Medical
Association of the Carolin.is and V'ircinia, Greens-
boro, N. C, February 10, 192'-).
friend of the court, whose knowledge and
special training were of value to the court on
subjects of which the ordinary jud,:je must
almost necessarily be ignorant. Gradually,
however, the status of the skilled adviser
changed, so that by the latter part of the
eighteenth century he had become a mere
witness to the jury. In this capacity, he was
presented by one party or the other, that is,
as a partisan. In spite of the general princi-
ple that a witness must have personal knowl-
edge and must state only facts, the expert
witness who had no such personal knowledge
of the facts was permitted to express his
opinion under the highly artificial guise of
an answer to a "hypothetical question,"
usually skilfully phrased to favor the pro-
pounder and calling for a categorical reply.
That expert witnesses should not always agree
was inevitable, — disagreements among the
learned are not unknown, even in the reason-
ably well-defined field of the law — but the
apparent differences could be magnified by
the rigid rules of evidence so as to make the
opinions seem diametrically opposed. The
attempt to make the witnesses' replies con-
form to arb'trary "tests" of insanity, most
of which are based with modifications (and
possibly even misapprehensions) upon the
psychological doctrines in effect in 1843, has
not tended to enable the expert to speak fully
with regard to scientific fact, and has not in-
frequently added to misundi?rstandiiTgs on
the part of the court and jury.
Let us not think that distrust of the testi-
mony of the expert witness is a new thing;
it d.d not require much time for the degen-
eration of his status to become complete once
it had begun. We have seen that the change
bigan in the late 1700's, yet as soon after
that as 1843 we find an English court .saying
"Hardly any weight is to be given to the
evidence of what are called scientific wit-
nesses; they come with a bias on their minds
to support the cause in which they arc em-
barked."-' As expressing the attitude of
.American courts at a very slightly later pe-
riod may be cited the dictum of the United
iii
SOtTttERiC MEDICINE AND SUkGEftY
March, 1929
States Supreme Court that "experience has
shown that opposite opinions of persons pro-
fessing to be experts may be obtained to any
amount," adding that the cross-examination
of such witnesses perplexes instead of eluci-
dating the questions involved.^ The present
disrepute of expert testimony, in fact, may
almost be said to be a tradition in the law,
although recently it has received a wider
publicity through the journalistic reporting of
criminal trials.
In all this welter of criticism the alienist,
or expert on the mental specialty of medicine,
psychiatry, has received the major share of
attention. Indeed, there are probably per-
sons who think that the alienist is the only
sort of expert known to the law I This mis-
apprehension is perhaps only natural. The
mental factor in crime was clearly recognized
at the common law, and was indeed an es-
sential element of many felonies. Long be-
fore Blackstone, it was settled law that a de-
fendant could not be arraigned or tried while
insane, and this principle still holds. When
the question is raised the court must first
satisfy itself that the accused is in suitable
mental condition to defend himself before the
trial on the merits can proceed. On some
occasions failure to observe this provision has
resulted in a reversal of the verdict.'' Still
more important than the question of triability
is that of responsibility, that is, the mental
capacity of the offender at the time of the
offense to conceive the necessary "criminal
intent." If absence of this mental capacity
can be shown, the defendant has committed
no crime, and must be acquitted by reason
of insanity." The defense of insanity has
frequently been offered in cases in which a
heavy penalty, even death, might be inflicted;
as these are cases which have attracted much
popular attention, the matter of mental alien-
ation has become unduly familiar to the pub-
lic. With this familiarity has come a tend-
ency to attribute to the alienist most of the
evils of the entire system of opinion evidence.
That mental disease is a measurable factor
in the incidence of serious crime cannot well
be denied, nor in making such a statement is
it at all necessary or desirable to go to the
lengths of some writers in claiming all crime
as a manifestation of mental disease. Such
claims sound suspiciously like a reductio ad
absurdum. As is well known, reliable crim-
inal data are almost non-existent for the
country at large, and no estimate of the inci-
dence of mental disease among persons ac-
cused of crime in the United States can be
offered. A review of the four hundred fifty-
four persons indicted for first degree murder
in Massachusetts in the past thirteen years
shows that fifty-four of them, or almost
twelve per cent, have been found by the
courts to be insane and have been committed
to mental hospitals. Certainly if one murder
out of eight is known to have been commit-
ted by a person suffering from a psychosis,
it must be admitted that mental disease plays
a considerable role as a cause of anti-social
conduct.
To these figures may be added the state-
ment that a close study of the convicted pop-
ulation of the Massachusetts county jails (a
study which deals with nearly six thousand
persons) has shown about four per cent of
the prisoners examined to be suffering from
mental disease, and about five per cent to be
mentally defective to such a degree as prop-
erly to call for institutional care. These in-
dividuals are the so-called "minor offenders;"
many of them, however, are confirmed recidi-
vists and constitute social problems of con-
siderable magnitude, especially as they con-
stitute ninety per cent of the commitments
to all penal institutions." The reports of ex-
aminations of the inmates of state prisons
and reformatories likewise tend to show that
mental disease and defect are found to an
appreciable extent among those guilty of what
the law considers the more serious offenses.*
These facts demonstrate that some prisoners
with marked mental abnormalities are dis-
posed of by the courts as if they exhibited
no deviations from the "normal." Praise-
worthy as the work of the various institution
psychiatrists unquestionably is, no prison
clinic is an adequate substitute for some
means whereby the court may have knowl-
edge in the first instance of the sort of hu-
man material with which it is dealing.
How, one may well ask at this point, is
the court to know what defendants should be
examined as to their mental condition? Here
we come to a weakness of the prevalent sys-
tem of selecting cases for examination. Ex-
cept in those instances in which the judge
himself notes something about the defendant
which arouses suspicion as to the latter's
mental soundness, his attention is called to
the accused by someone who has had official
March, 102q
SOUTHERN MEDICINE AND SURGERY
m
contact with the C2eo. This may be a court
officer, a jailer, the probation officer, or the
deferse counsel. Not one of these persons is
m:dcally trained, with the result that the
cases referred tend to fall in two general
categories — those which are so marked either
by their conduct while in custody or from a
hislory as obtained by the probation officer
aS to be obvious, and secondly, those in
which a "plea of insanity" may appear, for
one reason or another, to be sound legal
Ftrategy. A method of selection which de-
pends upon lay diagnosis must of necessity
fail to identify all cases of mental d'sease or
defect, with the result not only that the state
will be put to the unnecessary expense of
trying some persons who should hs committed
forthwith to a mental hospital, but that the
injustice will be done to some mentally ill
persons of putting them through an ordeal
which they should be spared.
It is presumably the duty of the prosecut-
ing officer, as representing the public, to
present the facts concerning the defendant as
he knows them, even though some of those
fasts may indicate innocence. He should,
therefore, if he believes the accused to be
insane, bring out the evidence to that effect.
We have, however, known of cases in which
the prosecutor, thinking his chances of re-
election the greater in proportion to the num-
ber of convictions he secures, has constructed
his case to suit his purpose, omitting the
points which might weaken it. Bias is not the
possession of the defense alone 1 The courts
have not always seen tit to rely on the facts
as presented to them, and have called upon
disinterested experts to report to them the
results of their examination. .Such a proce-
dure seems eminently hel])ful and certainly
not objectionable. The court presumably has
the right and even the duty to be informed
as to the mental status of the defendant. The
authorities and the weight of the decisions
favor such a practice'' and one court has even
said that the neutral status of such an expert
is a fair subject for argument to the jury as
affecting his credibility.'" The courts of last
resort of Virginia" and North Carolina'-
have both declared in favor of such a prac-
tice; on the other hand. Michigan''' and Illi-
nois'^, by decisions which seem obscurantist
in tone, and which are of doubtful snundness,
have stated that such appointment wnuld
serve as a certificate of credibility and migiu
thereby unduly affect the weight of the wit-
nesses called by one side or the other.
Some courts have appointed formal com-
missions to make inquiry and report. The
very formality of such an inquiry limits its
usefulness from a medical point of view, as
th s procedure savors too much of a trial on
the merits. The expense too attached to
some of these commissions has approached
scandalous proportions, and some of the ap-
pointees have seemed to be hardly the most
qualified of experts. .\s a means of securing
impartial information, the Colorado law of
1927''' is of interest, requiring the observa-
tion commitment of the defendant to a state
hospital whenever the plea of insanity is in-
troduced. There have been still other pro-
posals designed to overcome the evils attend-
ant upon expert testimony, such as limiting
the number of experts, and the amount of
their fees, or requiring experts for the two
s'des to make a joint examination and report,
or complicating the introduction of the plea
of insanity, as in California'". None of these
methods, however, even if we grant the legal
soundness of them all, obviates the great ob-
jection to the non-medical selection of cases
to be examined.
In those cases which have gone to trial
after the raising of a special plea alleging
insanity as a defense, the matter has been
presented to a jury of laymen, who have
often, in perplexity, disregarded the opinions
offered and have rendered a verdict on the
basis of "common sense," or as has sometimes
unfortunately happened, of a popular clamor
for blood. Twenty years ago the State of
Washington tried to rectify this defect by
leaving to the jury only the question whether
or not the accused comm'tted the act al-
leged; his mental condition at the time of
committing the act was to be determined by
the court. Unfortunately, this provision of
law was declared unconstitutional, the fact
of sanity being held material and therefore a
subject for the jury.''
The preceding remarks have iieen intended
in part to show that the primary cause of
the downfall of the expert was his develop-
ment into a partisan, and that the selection
of cases for examination is fortuitous, being
d?pendent upon non-medical persons. Fur-
ther, we have seen that courts and legisla-
tures have attempted to meet the issue of
partisanshiji, but that nunc nf the ])roposals
140
SOtlTfiERN MEDICINE AND SURGERY
March, 1020
so far considered has overcome the objection
relating to selection. It is, therefore, of some
interest to consider a provision which meets
in large measure both of the defects men-
tioned.
In 1921, Dr. L. Vernon Briggs, a promi-
nent Boston psychiatrist, secured the passage
by the Massachusetts Legislature of a law
designed to remedy the undesirable situation
into which expert testimony had fallen.'** By
this law, all persons indicted for a capital
offense and all persons bound over or indict-
ed for a felony who have been previously
convicted of a felony or indicted for any
other offense more than once are reported to
the State Department of Mental Diseases for
mental examination before trial. No pre-
sumption of sanity or insanity is required
for this examination or raised by it. The
defendant is examined by reason of the legal
category in which he falls, not because men-
tal disease is suspected or alleged. The ex-
amination, then, is routine, and within the
class defined by the statute is not based upon
selection, lay or expert. Furthermore, it is
impartial. The examiners are not retained
by the prosecutor or defense; • they are not
appointed by the judge. They are selected
by a non-judicial, non-political professional
branch of the state government which has
no interest except to arrive at the facts. The
court is thus relieved of the duty of finding
a specialist who is both qualified and dis-
interested. The attorneys for the defendants
have almost without exception encouraged
their clients to cooperate in the examination,
recognizing as they do the fact of the exam-
iner's neutrality and fairness. The report of
the examiners is forwarded to the clerk of the
court, and is accessible to the court, the dis-
trict attorney, and counsel for the accused.
The report itself is not admissible as evidence,
but the results of the examination may be
introduced by placing the physicians upon
the witness stand.
By means of this system, the district at-
torney may know in advance whether he
should proceed to trial or request the defend-
ant's commitment to a state hospital. The
expense of many needless trials has been
saved; since the release of prisoners commit-
ted to mental hospitals is thoroughly safe-
guarded; society has been protected; finally,
and most important, justice has been done
to the mentally ill defendant. The impartial
status of the examiners has been generally
recognized, and the courts have been inclined
to follow their suggestions. The disadvan-
tage of attempting to controvert their evi-
dence by that of partisan experts has been
seen, with the result that the "battles of
experts," which are far from unknown in
other states, have virtually disappeared in
Massachusetts. The expense of the adminis-
tration of the law has been almost infinitesi-
mal. Since 1923 a fee of four dollars has
been allowed to each examiner, so that the
total cost to date does not exceed the amount
which has been saved in any one of a number
of trials which would otherwise have taken
place. By means of this law justice has been
accomplished in an orderly and dignified man-
ner, with safety to society, fairness to the
accused, and respect for science.
A few facts as to the nature of the report^
may be of interest. Up to October IS, 1928,
seven hundred and forty-four persons accused
of felony had been reported for examination,
of whom five hundred and sixty-one were ex-
amined. One hundred and fifty-six of the to-
tal were on bail and not located, had been
previously sentenced or discharged, or for
some other reason were not available. Twenty-
seven others were found not to fall within
the provisions of the law. The indictments
against the five hundred and sixty-one exam-
ined were:
Murder (including six in the second degree) 237
Breaking and entering (including what is usually
termed burglary) _ _ _ 148
La rceny - 1 2 S
Sex offenses 30
Assault to kill or rob 20
Other offenses 54
Of these five hundred and sixty-one per-
sons, thirty-seven were reported as being le-
gally "insane"; fourteen others were recom-
mended for observation commitment; fifty-
five were considered mentally defective or
"defective delinquents"; and fifteen were
diagnosed as "psychopathic personality." In
all, then, one hundred and twenty-one or
twenty-one and one-half per cent of the total
were found to be clearly or suggestively ab-
normal mentally. A proportion of such di-
mensions certainly demands attention and
calls for inquiry as to the efficiency of our
present methods of peno-correctional treat-
March, 1929
SOttHERN MECtilNE AND StTRGERY
141
merit. On the other hand, in view of the ill-
founded objection sometimes offered that
psychiatrists if given a free rein would pro-
nounce all or at least most offenders psycho-
pathic or defective, it is worthy of note that
this group of psychiatrists, working without
bias or any obligation except of ascertaining
the truth, has made no such wholesale decla-
ration.
The legal distinctions between felony and
misdemeanor are entirely arbitrary, being
based im the type and severity of the punish-
ment which may be inflicted. It may well
be, of course, that one accused of felony for
the first time or even held to answer only
for a misdemeanor may be in need of mental
examination and may be in such condition
that he should be permanently segregated.
The "Briggs Law," however, was enacted
more or less experimentally with the intent
that the presumably most serious offenders
should be examined. It has proved its value,
and must almost inevitably be widened in
scope. For the present, it is one of the most
promising steps yet taken toward a practical
solution of the problem of psychiatric expert
testimony in criminal cases.
With the development of such individual-
ized procedures as probation and juvenile
courts, and of such special institutions as
those now existing in Massachusetts and New
York for defective delinquents, the courts are
gradually paying less attention to the crime
and more to the criminal. Some courts, of
which the Recorder's Court of Detroit is a
consp'cuous example, have indeed established
psychiatric clinics as general advisers in mat-
ters relating to the disposition of defendants
of abnormal makeup. The signs are multi-
plying that the courts are growing in a reali-
zation of the value to them of knowledge of
the mental constitution of persons coming be-
fore them for disposition.''' The recent pro-
posal of former Governor Smith of New
York-" that the entire matter of disposition
and duration of sentence be lodged in a board
of psychiatric and sociological experts, the
matter of guilt-findinu alone l)eing left with
the court, has drawn attention to the futility
and inconsistency of many of the sentences
Ija.sed u|)on the oki "penal equivalent" jihi-
losophy. It would seem that some such scien-
tific method must eventually replace the pre-
vailing random imposition of sentences of
predetermined duration which often bear lit-
tle or no relation to the social "formidability"
of the offender.
The day of vindictive justice is passing,
largely because it is being recognized that
justice of that sort is no justice at all and
makes no permanent contribution to the
common weal. It is only by a study of the
needs of the individual offender that the suit-
able treatment can be prescribed, with re-
sultant justice to the offender and a larger
measure of protection to society. Much study
of the offender and of correctional methods
is yet needed. Psychiatry lays no claims to
omniscience and does not pretend to offer a
panacea for social ills. It has, however, dem-
onstrated that even in its present state it can
materially aid the courts in solving some of
their difficult problems. By removing from
the sphere of partisanship the means of ad-
vising the courts on psychiatric matters, the
Massachusetts procedure has redeemed expert
testimony and has placed forensic psychiatry
on a much firmer basis. In this respect it
presages a time when the courts, society and
the offender may derive full benefit from the
services of trained social investigators and
psychiatrists.
REFERENCES
1. Henry VV. Taft: "Opinion Evidence of Medi-
cal Witnesses." X'ir^inia Law Review, XIV, No. 2,
Dec, 1027, pp. Sl-QO.
2. 4 WiKmore on Evidence (2nd Ed.) Section
1017, pp. 100-109.
■i. Tracv Peerage Case, 10 CI. and F., 154.
4. Win;ins v. N. Y. & Erie R. R. Co., 21 Howard
,SS (at 101).
5. For example. State v. Ossweiler, 111 Kansas,
.tSS.
b. See Hale, "History of the Pleas of the Crown,"
\'ol. 1, pp. M-ib (167S), Ed. Stokes & Ingersol,
Pub., Phil., 1S47.
7. See "Prisoners: lQ2,i" (U. S. Census), p. 24,
Table 0.
The Massachusetts Law providing for the rou-
tine examination of this group is found as Chapter
MO, Acts of 1024.
S. See, for example — A. VV. Stearns: "Survey
of One Hundred Cases at the Massachusetts State
Prison at Coarlejton." Bull, of the Massachusetts
State Board of In.=;anity, No. 16, December, 1015, pp.
SOL*. B. Cilueck: "A Study of bOS .Admissions to
Sing Sing Prison," Mental Hygiene, Vol. II, No. 1,
pp. 85-151, Jan., lOlS. Fernajd, Hayes and Uawley:
"Study of Women Delinquents in New \'ork Stale,"
pp. 4i,(-52.i, Pub. N. v., 1020. "Report of the So.
Car. Mental Hygiene Survey," 1022, pp. 26-27; "Re-
port of Rhode Island Mental Hygiene Survey." 1022,
|). 60; Pub. National Committee for Mental Hygiene.
"Summary of the Texas Prison Survey," Vol. 1, p.
47, 1024. Pub. Texas Comm. on Prisons and Prison
Labor.
0. See: 4 Wigmore on Evidence (2nd Ed), Sec.
1017, pp. 100-109. i Chamberlayne, Modern Law
142
SOWttERJJ MEbtCiNE AND StJRGEftY
March, 1924
of Evidence, Sec. 2376, pp. 3228-9. Thayer, Cases
en Evidence (2nd Ed.), p. 672, note.
10. Meek v. Wheeler, Kelly & Hagnv Inv. Co., 251
Pac. R?p. 1S4 (Kans).
11. Tugman v. Riverside and Dan River Cotton
Mills, 144 Va. 473,
12. State vs. Home, 171 N. C. 7S7.
13. People v. Dickerson, 120 N. W. Rep. IQP
(Mich.)
14. People v. Scott, 326 111. 327.
15. Ch. 90, Acts of 1027 (Colorado).
16. Ch. 677, .^cts of 1027 (California).
17. State v. Strasburg, 60 Wash. 106.
IS. Passed originally as Ch. 415, .Acts of 1021
(Mass.) Found in its present form (as amended)
as Ch. SO, Acts of 1Q27. For detailed description of
the law see: Sheldon Glueck: "Mental Disorder
and the Criminal Law," pp. 5S-72, Boston, 1Q25.
W. Overholser: "Practical Operation of the Massa-
chusetts Law Requiring the Psychiatric Examination
of Certain Persons .Accused of Crime." Mass. Law
Quarterly, Vol. XIH, No. 6, pp. 35-40, .Aug., 1028.
"Psychiatry and the Massachusetts Courts as Now
Related" to appear shortly in "Social Forces."
10. See W. Overholser: "Psychiatric Service in
Penal and Reformatory Institutions and Crimnal
Courts in the United States." Mental Hvgiene, Vol.
XII, No. 4, pp. S01-83S, October 102S.
20. "Governor's Message to the Legislature." N. Y.
Legi;lative Document No. 3, pp. 53-54 (L02S). S'lch
a proposal was made by Sheldon Glueck in 1025.
See "Mental Disorder and the Criminal Law," pp.
March, 1029
SoOtHfikN MEblClKfe AUt> StJROSRV
143
Has Medical History Any Value*
J. L. Miller, M.D., Thomas, W. Va.
I would be derelict in my appreciation of
the honor conferred upon me by your presi-
dent's invitation to speak to you on a sub-
ject that long has interested me, did I not
begin with an expression of thanks for your
courtesy and hospitality.
He set a task for me far beyond my knowl-
edge and ability when he requested that I
present to you, to cjuote his own words, "a
panoramic view of the medical procession
since the dawn of civilization in its awkward,
slow, tedious, halting, painful crawling up to
its present standing." Even the great Osier,
with his profound knowledge of the subject,
required more than two hundred printed
pages to record in "The Evolution of Mod-
ern Medicine," his "aeroplane tfight over the
progress of medicine through the ages" as he
called it.
While it is impossible for me to condense
into a dozen pages five thousand years of
medical history from the days of old Imho-
tep, that enlightened Egyptian physician in
the infancy of civilization, to the lusty giant
of modern medicine, I do hope I may be
able to tell you enough about medical history
to show that it does have value. If I can
do this and awaken an interest that will bring
more of you to the task of searching out and
recording the history of medicine in the
South, I shall be most happy.
Seventy-three years ago a young North
Carolina physician, who later became famous
in three continents, sa'd in an address to the
Medical Society of North Carolina: "Noth-
ing is more fruitful of evil to our profession
than the lack of, or improper, mental culture
of those who engage in its pursuit." This
need of a wider intellectual and cultural
f(jundation upon which the physician is to
build his technical education is today clearly
recognized, and demanded by the entrance
requirements of all medical schools: but,
strange to say, until within the past decade
none of the medical faculties considered or
attempted to continue the cultural side of
the student's education ;ifter he entered their
*Presi-ntetl liy invilaticn In Ihe Tri-Statc Medical
Association of (he Carcilinas and V'ircinia, (irccns-
boro, N. C., Meeting February 19, 20 and 21, 1929.
halls. Now, many of the medical colleges
are adding the chair of Medical History to
their faculties and searching the world for
the rare old medical classics to enrich their
libraries. While it was thought necessary for
the physician's pre-medical education to ac-
quaint him with the general history, literature
and ijhilosophy of the world, there was no
attempt to instruct him in the history, classi-
cal literature, and philosophy of his own pro-
fession. -And yet, no history is richer in the
story of human fallibility, of human search
for Truth; of unselfish, arduous work; of
great aspiration and lofty ideals; of danger
and persecution; of heart-breaking failure
and triumphant success, than that of medi-
cine in its progress from the dim and hazy
past to the blazing light of the twentieth
century.
The English historian, Edward Withington,
said: "The study of medical history makes
us acquainted with the most diverse forms
of thought, and brings before us every phase
of civilization," to which may be added the
words of Sir William Osier that, "In the
records of no other profession is there to be
found so large a number of men who have
combined intellectual pre-eminence with no-
bility of character ... In the continued re-
membrance of a glorious past individuals and
nations find their noblest inspirations."
The power, vigor and success of modern
medicine has engendered in the rank and file
of the profession of today, in their ignorance
of the past, the narrow and complacent feel-
ing that — "We are the men and knowledge
has come with us;" forgetting that in all
things each generation is but a link in a great
chain stretching from the past to the future.
A consideration of medical history shows us
that each age stands on the shoulders of those
gone before; it gives us a better perspective
of modern medicine; a clearer vision of the
possibilities of the future. It teaches that
the value of each age is not its own, but in
part, in large part, a debt not only to those
who went before, but also to those who fol-
low; and likewise, as the great .Alfred Stille
said, "Science itself is unstable. The science
ol the last century is the folly of today, and
144
SOtTHERN MEDICINE AND StftGEftY
Umh, 19i9
much of that on which we pride ourselves
as certain will be found in the lumber room
of the next generation."
The profession of medicine is today work-
ing under conditions never before present in
ihe world. No fanatical theological control:
w'der tolerance in every way; greater har-
mony and unanimity in its own ranks; more
intelligent understanding and public sympa-
thy for its aims and purposes; and necessary
moral and financial support from both state
and accumulated wealth. But in the marve-
lous advance of medicine in this golden age
we should not lose sight of the fact that
many of its discoveries and successes are but
the flowering of roots planted by generations
now gone; that many important facts in medi-
cine are but re-incarnat ons. Conceived and
born of thinkers in oth?r ages — coldly receiv-
ed, or stoned to death — forgotten, then reborn
from time to time; until, now in a more sym-
pathetic soil, they have attained that state of
perfection desired by their original fathers. .As
s'mple examples of this take two valuable
obstetrical procedures. Podalic version was
described and used in the second century A.
D. by Soranus of Ephesus, that master ob-
stetrician of the ancients, then forgotten
for nearly fifteen hundred years until brought
back to notice by the Rosengarten of Roslin,
who founded his book on obstetrics on the
work of Soranus; but it did not become a
viable part of modern obstetrics until de-
scribed and used by .Ambrose Pare more than
half a century later. Nine hundred years ago
.Albucasis, an .Arabian physician of Cordova,
described the obstetric posture which we
now know as Walcher's position — "Turn de-
cumbat mulier in collum suum, pedeantque
dorsum pedes, ejus, ilia vero in lectum decum-
bat, etc." Five centuries later Scipione Mer-
curlo, in the first Italian work on obstetrics
rediscovered, described and even illustrated
the same thing, but again it disappeared for
four hundred years until brought to light and
nam:d for .Alfred Walcher in 1889.
3.1edical history shows us many such inci-
dents proving the truth of Osier's dictum,
that — "The world affordeth no new accidents,
but in the same sense, wherein we call it a
new moon, which is but the old one in an-
other shape; and yet no other than hath been
formerly, old actions return again furbished
over with some new and different circum-
stances."
Medical science is no exception to all kinds
of natural phenomena. As geologists tell us,
th? world today is but the consequence of
prev'ous conditions and changes. Its plants
and animals are the product of ages of evo-
lution, but whose origin we cannot trace.
Just as present day civilization is the out-
come of thousands of years of continuous
effort of man to build up a social fabric, so
even is modern medicine th? resultant of the
laborious efforts of the phys'cians of past
ages to penetrate the secrets of nature for
the prevention and cure of disease. So for
knowledge of the physical, intellectual and
spiritual world we must turn to history, no
part of which has a more varied and richer
interest than that of medicine. Frankly, I
think no physician should cons'der himself
educated until he knows something of the
epochs and the men who have built up the
profession which has received Km as a mem- '
bcr. .A study of medical history shows us
that medicine is a cohesive correlation of the
work and d'scoveries of its devotees in past
ages — that l.ke the human body it studies,
it is a vital, living thing, ingesting, digesting,
excreting and secreting to the end that the
red blocd coursing through its arteries gives
energy, power and light to the world. That
no member of this living organism can or
ever has functioned alone.
It is commonly thought that such men as
Galileo, Harvey, Boyle, Pasteur were inde-
perident of past generations — that they de-
molished the work of their predecessors and
started afresh; making their epochical dis-
coveries either by accident or conceived en-
tirely by their own superior minds. But in
reality no investigator, not even the greatest,
is thus independent. If you will take the
trouble to look you will find some germinal
seed somewhere in the past even of our most
recent discoveries. The investigator is always
indebted to those who went before, not only
for their instruments of research and the
grains of truth they discovered, but also for
the errors of their work and conclusions.
They save him time and point to the roads
he should, or should not take. It has been
said that "error is a stage in the development
of truth," and that should the History of Hu-
man Error ever be honestly written it would
be the History of Human Progress.
Sometimes I wish that history might be
written backwards — that is, start with the
March, 102t)
SOUTHERN MEDICINE AND SURGERY
important event and trace it backwards to
show that it is the consequence of what ex-
isted yesterday, and before yesterday. Take
for example immortal Harvey and his mo-
mentous discovery. The closing years of the
sixteenth century saw him a student at the
old school of Padua studying anatomy with
Fabric'us, one of the greatest anatomists and
teachers of h's day. Four years b?fore Har-
vey was born Fabricius discovered the valves
in the veins; and twenty-one years before
this Michael Servetus, that "martyr for the
crime of honest thought," published in 1553
his d'scovery of the lesser, or pulmonary, cir-
culation in language so plain none could mis-
take— a gem of the first water. He wrote:
"The vital spirit is generated by the mixture
in the lungs of the inspired air with the sub-
tly elaborated blood, which the right ventricle
fends to the left. The communication be-
tween the ventricles, however, is not through
the m'dwall of the heart, but in a wonderful
way the fluid blood is conducted by a long
detour from the right ventricle through the
lungs, where it is acted on by the lungs and
becomes red in color, passes from the arteria
venosa into the vena arteriosa, whence it is
finally drawn by the diastole into the left
ventricle." Thirteen hundred years earlier,
that master of ancient medicine, Galen, de-
scribed the action of the valves of the heart
and the fact that the blood passed in only
one direction from them, but had no clear
idea of how it returned to the heart. Two
hundred years before Galen the old school at
Alexandria showed that air drawn in by
breathing was distributed by the arteries.
Had the Roman Catholic Church permit-
ted human d'ssection in the time of Galen,
and had not John Calvin and his protestant
fanatics buriied .Servetus at the stake in the
sani ■ year he published his great discovery
iif the pulmonary circulation, one or the
other of them might have been the discoverer
of the circulation and not Harvey.
It is unthinkable that Harvey did not
know of these things — that Fabricius, who
recognized Harvey's genius, failed to impart
to him his own discovery of the valves in
the veins, or the facts recorded by Servetus,
Galen and the professors at .Alexandria, for
in that day the ancient writers were held in
great veneration and their writings familiar
to all students. Can we say that Harvey
owed nothing to these men? Their discov-
eries were all links in the great oval road of
hiuiian life and energy and Harvey had but
to travel farther and connect them up, wh'ch
he d d not quite do, as it remained for ^lal-
p'f'hi to complete the circulat'on by his d's-
cov:ry of the capillaries.
r.Iedical h'story forces us to the conclusion
that had science been free of the throttlin';
c<Mitrol of ancient Christian theology, much
of the knowledge of today would have been
known centuries ago. A theology that forced
Galileo to recant on bended knee that the
world revolved on its axis and around the
sun — to turn away from the altar a broken
old man pathetically whispering to himself,
"but it does move."
That compelled Roger Bacon to spend fif-
teen of the best years of his life in prison
and to conceal the greatest of his discoveries
in a cypher that is only now being translated
after seven hundred years; thus forcing other
icekers three to six hundred years to redis-
cover the m croscope, many biologic facts, and
other th'ngs of the greatest moment, that we
now learn Bacon knew in the thirteenth cen-
tury.
That sent Servetus, the greatest man of
his age, whose "brain was the torch that
burned to enlighten the world," to the "Foun-
tain of all Truth" on a chariot of fire accom-
panied by all the copies of his great brain
child they could pile at his feet — only two
copies are now known, one in Paris, its edges
hxorchcd by the fire that consumed its author,
and one in Vienna.
That caused the death of th it other great
reformer, Vesalius, by banishment fmni Ku-
rope.
That hounded a still earlier medical re-
former, Paracelsus, from [ikice to place in
Europe and blotted out whole pages of his
books with hot irons, as I could show yciu in
my library.
In fact, it will shnw you that, as Col
Fielding Garrison says, "Ideas of l\vj greatesi
scientific moment have been throttled at
birth, or veered into a blind alley, through
some current theological prepossession, or de-
prived of their chance of fruition through
human ind.fference, narrow m'ndedncss, or
other accidental circumstances." "In many
instances resulting in even the very memory
of a pathway broken into the Land of Prom-
ise being obliterated, so that what seemed an
accomplished fact has had to be recreated
146
SOUTHERN MEDICINE AND SURGERY
March, 1920
by laborious work covering years, decades
and even centuries," as Karl Sudhoff, that
Nestor of Medical Historians, wrote some
years ago.
The study of medical history, as nothing
else can, shakes our smug complacency by
showing us that, in spite of our freedom from
such human slavery, and our boundless op-
portunities, we still are making progress
slowly, and there is much yet to learn.
It shows us the great diversity of ways
medicine has advanced, both as an art and
as a science. At times as a pure inductive
science, aiming toward the establishment of
the laws of life — of life both in its normal
state and as disturbed by disease. At other
times by laboriously methodizing into prin-
ciples the results of enormous experience.
Again it has made epochal progress by the
happy observation of a single fact, and its
mmediate application to practice, such as
ihe introduction of vaccination by Jenner,
from his observation that the m'lkmaids, ac-
c'dentally inoculated with cow-pox were
mniune to smallpox. The immediate use of
'nhalations of ether by Long, Morton and
Warren without waiting for the laboratory
to tell them the method of its action in ob-
literating the pain of surgery. The screening
of windows next to marshes in England as
early as 1800 to prevent malaria, and the
use of quinine as a specific in its cure, long
years before we knew th? part played by
mosquitoes in causing the disease, or the ac-
tion of the drug in curing it. To seize the
unknown truth in the known jact is the verv
essence of scientific discovery.
In fact as the study of medicine itself is
composite, so also has been its progress. It
has never been continuous, or even at all
times progressive. The ethnologists have
shown that in the development of every race
and nation, the healing art has played a con-
spicuous part. So through the ages the river
of medical evolution Hows on, undiverted by
the impedimenta of poverty, jealousy and
crude materials, and the opposition of igno-
rance and bigotry, slowly and surely widening
and deepening as each generation adds its
contribution to speed its progress toward that
ideal of all true physicians — the annihilation
of disease, and the lengthening of the span
of human life and activity.
A magnificent theme for a glorious epic —
but one that, as yet, no poetic genius has
attempted.
I'ermit me to urge you to embark for an
excursion down the history of this facinating
stream. From the trickling springs of primi-
t've healing, over the shallows of priest rid-
den Egyptian medicine, down the great Greek
rap'ds past the splendid temples of Aescupa-
I'us, Aristotle and Hippocrates, through the
whirling Greco-Roman maelstrom with its
jutting cliffs of Celsus, Dioscorides, Soranus,
Arestasus and Galen, into the great gloomy
lake of the Dark Ages — lightened only by
the fires of the great Arabian scholars, IMesue
(senior), Rhazes, Avicenna, Albucasis, and
Avenzoar guarding for the future, the treas-
ures of the past from its engulfing waters.
Thence 'hrough the Narrows of Supersti-
t'on into the clearer waters of the Renais-
sance, along whofe banks the grass begins to
grow beneath those giant oaks, Paracelsus,
Vcsalius and Pare, from whose acorns sprung
modern skepticism of unproven authority,
modern anatomy and modern surgery; round-
ing the Po'nt of Freedom into the bright
waters of the Seventeenth Century studded
with the glorious isles of Harvey, iMalpighi,
Lcewenhock, INIayow, Glisson, Lower, Willis,
the sturdy ships of iModern Physiology, Em-
bryolor'y, IMicroscopic, and Comparative An-
atomy and iModern Chemistry, Clinical IMedi-
cino ard Obstetrics. .A powerful array sailing
bryology, microscopic, and comparative an-
atomy, and modern chemistry, clinical medi-
cine and obstetrics. .\ powerful array sailing
cut to join the staunch old flagship. Anat-
omy, launched into the turbid waters of the
Rena'ssance and now leading the fleet into
th^ b.order reaches of the Eighteenth Cen-
tury, in whose beautiful inlets are waiting a
host of adventurous sailors, bearing gifts of
some great discovery, or clarifying procedure,
to join in the voyage to the shores of Mod-
ern JNIedicine.
What a host they arel iNIorgagni, Wolff,
Von Sommering, Albinus, Scarpa, Cheselden,
Winslow and the iMunros with many appren-
tices seeking service on the flagship; while
Petit, X'enel, Chopart, Heister, John Hunter,
Abernethy, Pott, Young and others preferred
to walk the deck of Surgery under the noble
banner of Pare. The guns of the great ship
sailing under the double flag of Physiology
and Chemistry were soon ably manned by
Boerhaave, Haller, Spallanzani, Hales, Hew-
son, Cruikshank, \Miytt, Galvani, V^olta, m
Marrh. 1020
SOUTHERN MEDICINE ANt) SURGERY
Black, Priestly and Lavoisier; while Clinical
Medicine, launched by Sydenham, attracts
such recruits as Lanc'si, Raniazzini, Frank,
Cullen, Withering, Heberden, and Prinjjle.
Close on the heels of these four great ships
of the line we see that leaky old tub Obstet-
rics, so recently captured from the Amazons,
and now being rapidly remodelled and newly
equ'pped by La ]\Iotte, Ould, Smellie, Levret,
Camper, Boer, \Vm. Hunter, Chas. White and
Baudelocque to advance her toward the first
rank of modern medical battleships.
As on they sail we see other craft mount-
ing strange guns appearing. Sailing under
their own captain's colors, but standing close
to the old ship Clinical Medicine — Auenbrug-
ger, sounding unknown depths: Jenner
mounting torpedo tubes against Smallpox,
captain of the Pirate Fleet. Passing on into
the wide spreading sea of the Nineteenth
Century to meet those great captains — Pinel,
striking the shackles from the slaves in the
galleys of Dis-reason; Laennec, listening to
the winds singing through the darkness of
the night: McDowell, invading the strong-
hold of the abdomen to drag away the crim-
inal h'ding there; Long, driving back the
sharks of pain with the subtle perfume of
ether: Holmes and Semmelweis, swinging
from their mast that foul murderer, Puerpe-
ral Sepsis; Pasteur, with eagle eye, seeking
the deadly octupus of pathologic fermenta-
tion lurking in the murky depths; Lister,
holding back the invisible armies of sepsis
with the deadly spray of his antiseptic gun;
Behring tearing the ghoulish fingers of Diph-
theria from their strangle hold on the throats
of the world's children. From the four
quarters of the globe they come — great
captains with strange new guns to join
the mighty fleet, sailing on to the harbor of
Twentieth Century Medicine. Here to tarry
while other splendid ships make ready to
join in the cruise on to the next harbor, and
the next, so long as the world shall last. Can
you think of a more inspiring and magnifi-
cent spectacle?
.As travelers in a strange country not only
visit its great buildings and beautiful gal-
leries, but also its crumbling ruins and
mouldy cemeteries, so should we voyagers
down the river of Medical History land here
and there to temper our prifle viewing the
ruins of once beautiful systems and philoso-
phies, and to cast a tear on the forgotten
grave of some earnest pilgrim who, though
se:king the light, paused in his labor ere the
ro?v dawn of his dream had brightened into
day.
.\s I sa'd before, the limitations of a paper
of this kind precludes any attempt at a com-
prehensive survey of medical h'story — one
can only present a phase, a nam?, or an inci-
dent snatched here and there from its broad
iwcep. In an abstract way I have tried to
bring to you the idea that med cal history
does have interest — does have value. To tell
you that you will find in it, sordidness, hero-
ism, poetry, romance, humor — heart-breaking
failures and triumphant successes. A story
of absorbing interest because it is the story
of humanity itself. That no h'story, no lit-
erature, no philosophy can better portray the
r'se and aspirations of the human race from
barbaric savagery to a high civilization.
I feel certain that, if those of you, unfa-
miliar with the record of the past of your
profession, will spend a few hours with Os-
ier's "Evolution of iModern iMedicine, "
Dana's "Peaks of iNIedical History," or any
other of the numerous books on the subject,
you will be convinced that Colonel Garrison
did not exaggerate in his introduction to the
first named work when he said: "It will be
to the aspiring student and the hardworking
practitioner a lift into the blue, an inspiring
vista, or Pisgah Sight of the evolution of
medicine, a realization of what devotion, per-
severance, valor and ability on the part of
physicians have contributed to its progress;
and of the creditable part whch our profes-
■'on has played in the general development
of science. That the slow painful character
of the evolution of med'cine from the fear-
some, superstitious mental complex of primi-
tive man, with his amulets, healing gods and
d'sease demons to the ideal of clear eyed ra-
tionalism is traced with faith and a serene
sense of continuty. " Years, ago Oliver Wen-
chll Holmes said it widens our horizon and
gives us a broader conception of the ideals
and purposes of our profession.
If I may h^ pardoned a per.sonal allusion,
I wish to say to those whose lives may be
bounded by the limitations of practice in
small communities, that nothing else helped
me so much to ward off the mal'gn influence
of thirty years' practice in a crude, isolated
mine village as the hours spent with these
old worthies and their contributions l(j the
148
SOUTHERN MEDICINE AND SURGERY
March, 1929
profession I love. The beneficent influence
of their lives and struggles I am sure made
me a better doctor, a more charitable man, a
worthier citizen. They taught me to not let
down but to keep in touch with the work of
the great world of medicine outside my own
small field — that, even if I made no discovery
and added nothing to its progress, at least I
could do the work at hand and feel worthy
of membershio in JNIedicine's great army of
unknown soldiers.
MEDICAL HISTORY IN THE SOUTH
And now for the real reason for my ac-
ceptance of Dr. Hall's invitation to speak to
you. It was not to try to tell you of the
interesting things I think medical history
holds for those who read, but to appeal to
your patriotism and to that filial love and
respect we should have for our own medical
.Tcestors. who to our shame have in large
measure been neglected.
For many years we have been wont to
complain that the south has not been given
her due by writers on American history, that
■•uch mention as thev make has often been
in the direction of slander and misrepresen-
t-^t'on. that New England is so persistently
plaved UP as the birthplace of the nation,
ard of all that is worthwhile in our American
government and institutions; thit even the
v,-,?rs that brought us freedom from England,
f"tend?d our territory, and miintained our
'Pflenendence were be^un, fought and won in,
aid by the Xorth. The reason for this ap-
parent bias of writers of Americnn history
was so thoroushly given by Dr. de Rulhac
Hamilton of the University of North Caro-
lina last year, and is so pertinent to what I
wi?h to say at this time that T can do no
better than quote or condense his thought as
a preface to my application of it. He said:
"The South has lived a life — social, eco-
nomir, industrial, political — as d'stinctive as
tint of any other section. It has played a
ixirt in national history second to none of
the others. Its contribution of leaders, par-
ticularly in the realm of political thought,
has been striking. Why has it not attracted
the historical investigator to the same e.xtent
as in other sections? When we know with
an infinity of detail the life of New England,
or the West, whv do we not know something
of how the Old South lived? A little, far less
than is usually realized, is known. Why do
we know more of the rather dull and austere
life of New England than we do of that of
the more colorful South? The true answer is
to be found in the different treatment accord-
ed to their records by the people of these
sections. Puritan New England, elected of
God, and acutely conscious of the fact re-
corded everything. It made careful records
of its thoughts and feelings on every conceiv-
able subject. It kept diaries with the utmost
particularity, in which were entered the re-
port of critical and unusually unsympathetic
study of other sections and people. It wrote
letters in profusion, personal and public, and
preserved them. It published books, pamph-
lets and magazine articles, on every sort of
question. It founded great libraries and used
them.
The same is true of the Far-West and to a
lesser extent of the Rliddle-West and the
South-west; they, too, have had regard for the
right of posterity to be informed of the past,
and to know all that is humanly possible of
its origin.
The historian has at his command the
enormous collect'o:is of historical material in
the John Carter Drown Library for New Eng-
land, the librarirs of New York and Phila-
delphia for the nrddle states; the Clement
and Burton libraries in J.Iichigan and the
L'brary of the Historical Society of Wiscon-
sin for the Middle-West; whle the Far-West
and the South-west, with their Spanish and
!Mex"can elements, are amply provided for
by the great Bancroft collection in California
and the library of the University of Texas.
But where is any great collection for the
South? What has been the story of the
Soulh? It has been, it must be admitted, a
very different one.
From an early date its people showed
marked and str.king disregard of the import-
ance of records. Careless in their making
ard more careless in their preservation. True
of both public and private papers. Public
records show numerous gaps; private papers
of the utmost historical value have not been
kept, or only for later destruction. Only
within comparatively recent years have there
been other than scattered attempts in the
South to save the material from which the
past can be studied and the story told. There
h:is been an incalculable waste of invaluable,
and often irreplaceable historical material.
Fire and water have taken their toll, and still
March, 1029
SOUTHERN MEDICINE AND SURGERY
take it. Rats and invading armies have suc-
cessfully rivaled the elements, man has been
horribly and criminally careless with records
. . but I ciuestion if the female of the species
has not in the main been more dangerous
than the male, whether they be rats persist-
ently gathering quantities of historical bed-
ding, or the meticulous house cleaners on the
ceaseless task of destroying 'trash.' The
result of all their combined efforts have been
most disastrous." Dr. Hamilton in his great
study of the question brings to light the im-
portant fact that "there still remains in ex-
istence a vast wealth of such material
throughout the south, and to a lesser degree
southern material in other parts of the coun-
try, and even abroad." He urges the collec-
tion of this as rapidly as possible, for no
owner dies, no old home of generations is
broken up, no family moves or goes through
the annual house cleaning, but it is accom-
panied by a holocaust of human records,
many of which are worthy to endure.
The cf)ndition described regarding the col-
lection and preservation of the records of the
social, economic and political history of the
South is far more true of her medical pro-
fession; and due to this, more distressingly
true of the two or three attempts that have
been made to write a history of medicine in
America. It is to do your part in remedying
this that I appeal to your pride, your patriot-
ism and your love of your profession. If
each and every member of this Association
would make it his duty, if not his pleasure,
to contribute his bit, you would be astonished
at the result in only a short time. Data could
be collected in each section of the three states,
where a member lives, for a sketch of the
medical history of that section, for biographi-
cal notices of the prominent physicians who
have preceded him in past generations in
ministering to the people in that locality. Old
books, pamphlets, letters, case and account
bt!()ks, portraits, etc., of the physicians of
the Old South could be brought together from
the closets and garrets of their descendants.
Many of them most valuable records of
southern medicine in the past. Then from
t'me to time let the more important of these
b'ograj'hical sketches and chapters of the
medical history of the state be published in
a collected volume; for no historian has the
time or patience to search through hundreds
of volumes of old journals and transactions
of societies, with their enormous mass of ma-
terial foreign to his subject, but he will seek,
in special collections of data pertinent to his
purpose, the information he desires. With
X'irginia and the Carolinas, always a trium-
virate of leaders in the south, blazing the
way a few years will see such a collection of
important data and original records of the
|irofession in the Old South as to assure her
of her proper place in the future history of
.American ^Medicine.
South Carolina should be proud of the fact
that one hundred and thirty-eight years ago
two of her broad-minded physicians, with a
vision of the future, and a high sense of the
duty of a physician to his profession, gave
their private collections of books as the nu-
cleus around which to found a great medical
library in the city of Charleston, the third
oldest medical library in the United States.
These public spirited men were Doctors Rob-
ert and Samuel Wilson, sons of a graduate
of famous old Edinburgh who came to South
Carolina nearly two hundred years ago. This
family has for five or six generations
upheld the lofty ideals of medicine in their
native state, but none more worthily than by
the great grandson and namesake of the foun-
der. Dr. Robert Wilson, Dean of the Medical
College of the State of South Carolina, who
has, and is giving his best to medical educa-
tion in the south and to the preservation of
medical history in his native state and her
ne'^ihbors. The three states represented here
today can well be proud of their medical
families that have passed down the mantle
of .Aesculpius further enriched by each gen-
eration to wear it. South Carolina has the
]\Ioultries and others of fewer generations,
but none the less distinguished to accompany
the Wilsons. North Carolina can claim the
oldest medical family with a continuous suc-
cession of physicians in the United States,
the De Rossets of Wilmington; and Virginia
is proud of her Cabells, !McGuires, McCaws
and others, where worthy sires have been suc-
ceeded by worthy sons.
South Carolina has a sjilendid medical her-
itage and I hope those who carry on the
trad'tions of their state will s|ieedily add to
the treasures already in her medical library
and museum many other records and relics
of her physicians of past generations.
I am happy to tell you that the Richmond
Academy of Medicine is soon to erect a suit-
I.'
ISO
SOUTHERN MEDICINE AND SURGERY
March, 1029
able home for itself and in conjunction with
th2 old Medical College of Virginia the estab-
lishment of what is hoped will eventually be-
come a great medical library in the south. I
wish to express here the hope that every pa-
triotic medical son of Virginia, both in and
out of the state, will make it h's duty, his
obligation to his profession, and to his state
to add to it, books, records, portraits and
other memorials, not only of his native state,
but also of the entire south. Nearly a cen-
tury ago. the old Medical Society of Virginia
began the collection of a library and museum
which had assumed creditable proportions
when dispersed and lost by the war. The
present medical society is to be commended
for the work it has begun of placing markers
at the birth places and graves of her notable
physicians which have never been marked;
also for its action at the last session in ap-
propriating several hundred dollars for the
collection and beginning of a medical history
of the state. They made a most happy selec-
tion of their committee for this work — "A
thing well begun is half done." Its chairman.
Dr. Wyndham Blanton, who also is president
of the Academy of Medicine, is greatly inter-
ested in medical history, and, looking to the
future, is inculcating in many of his students
at the iNIedical College of Virginia a love for
medical history that is sure to bear fruit.
To you of North Carolina, I can only say
that I have no knowledge of your plans for
the future, or of what you may already have
done. But I do want to say that you have
one of the oldest medical societies in the
south, your state has produced many worthy
disciples of Aesculapius, and it is a pleasure
to note your interest in local medical history
as shown by the papers in your transactions,
and by the establishment of a department of
medical history in your Journal of Southern
Medicine and Surgery. Permit me to urge
you to extend this interest and spare no pains
in collecting the records and surviving relics
of value of the profession in the Old North
State, which will not only be interesting to
you ,but most valuable to the future historian
of your state and of Southern Medicine.
With the great work already done by your
university in arousing the people of the state
to appreciate the historical value of the old
letters, papers and books stored in their clos-
ets and garrets, this should be easier for you
than for those of your sister states. All
honor to the University of North Carolina,
the oldest Southern State University, for the
preat task she has undertaken of remedying
the south's lack of a great library of southern
b':torical material. Already she has more
than forty thousand volumes of bound books
and pamphlets besides a great mass of man-
uscript material relating to the history of
North Carolina and her sister southern states.
Until you have a suitable library of your
own this would be a most excellent place to
deposit your historical collections.
Perhaps some may ask what, aside from
iNIcDowell, Long, Sims and Reed, did any of
the physicians of the older generations in the
South do, that we should bother to remember
them? An adequate reply would require
hours, and I have already trespassed too far
upon your courtesy, so can only say go to
such biographical records as now exist of the
physicians of the Old South and see for your-
self.
To say nothing of Georgia, Kentucky, Ten-
nessee, and the Gulf States — South Carolina
with such men as Lining, Chalmers, Garden,
Ramsay, Baron, King, Ravenel, Uickson,
Lawrence Smith, Glover, the Wilsons and
iMoultries and others too numerous to men-
tion; North Carolina with such outstanding
figures in medicine as Brevard, Bricknell,
Haywood, Strudwick, Warren, jNIurphy, Wil-
liamson, Wood and the DeRossetts and iNIc-
Leans; and Virginia with men like iNIitchell,
Clayton, Tennant, Baynham, Bennett, Arthur
Lee, Bland, James iNIcClung, Leigh, Mettauer,
the IMcGuires, Cabells and many others, can
show records of a high standard of work and
original thinking in the profession that will
equal at least any produced by the other
colonies and states. i\Iany of them are men
whose work entitles them to a place in the
story of American iNIedicine even more than
Eome whose names now blazon the pages of
Packard, Mumford and other historians of
medicine in .\merica. Their omission is no
fault of the historians named, but of the pro-
fession in the south who have not made these
records accessible.
.A study of the medical biographical history
of the South, and it is far, far from being'
complete, will surprise you greatly. Not con-
tent to be merely physicians and surgeons,
many of them added additional luster to their
names as Fellows of Royal Societies; corre-
spondents of famous old world scientists;
March, 102Q
SOUTHERN MEDICINE AND SURGERY
adventurers into unknown lands as explorers
and soldiers of fortune; statesmen helping to
build a great nation; investigators seeking
the secrets of nature for the benefit of their
own and allied sciences — a colorful picture
that some day some master artist will por-
tray.
Add to these the medical sons of Virginia,
the Carolinas and other states of the South
who went out beyond her borders to become
leaders in the medical thought of the nation
and of the world, and you have a record to
make any southerner glow with pride.
Here I wish to quote from one of your
South Carolina members whom I have men-
tioned before.
"I have purposely made no effort to treat
the subject with any degree of fullness; in-
deed, all I have attempted has been merely
to suggest the wealth of material that may
be found in the South. If I have succeeded
in stimulating in some degree an interest in
medical history in the South and aroused a
desire to gather together and preserve our
neglected records, I shall have done all that
1 set out to do."
Let us not forget — "the living present
owes a debt to the past."
It seems fitting to conclude with a sketch
of the life of one of the most remarkable men
of this state:
Edward Warren (1828-1893) of Tyrrel
County, North Carolina, "is one of the most
b'zarre and picturesque figures in the annals
of American medicine, having passed through
the successive transformations of country doc-
tor, professor, editor, surgeon general, Egyp-
tian Bey, and Chevalier of the Legion of
Honor, as he journeyed from the swamps of
Carolina and the shores of the Chesapeake
to the Xile and the Seine, practicing in three
continents and received everywhere with ac-
claim."— Howard Kelly.
Educated at the University of Virginia and
Jefferson Medical College, he began to prac-
tice at Edenton, X. C, in 1851, spent a year
in [lost-graduate work in Paris in 1854-55,
and in ISSb received the Fisk Fund prize for
his essay, "The Influence of Pregnancy on
the Development of Tuberculosis." Return-
ing h? settlefl in Baltimore and was professor
of Materia Medica at the University of Mary-
land, 1860-61, and editcjr of the Baltimore
Journal of Mrdieine.
In 1861 Governor Vance, of North Caro-
lina, appointed Dr. Warren chief surgeon of
the North Carolina Navy. Following the
transfer of this to the Confederate States'
government in July, 1861, he received his
rapid succession appointments as Medical
Director of Department of Cape Fear; Chief
;Medical Inspector, Department Northern
Virginia; Surgeon General, North Carolina
forces C. S. A. with rank of Brigadier General,
1861-65. After the war he returned to Bal-
timore and in 1867 reorganized the Wash-
ington University Medical School, serving as
its professor of surgery 1867-71; and in 1872
became one of the founders of the College of
Physicians and Surgeons and a member of
the faculty for two years.
Of a restless nature he sailed in 1873 to
Egypt and entered the service of Ismail Pasha
as chief surgeon. "Here he made a reputa-
tion by his dependableness, decision of char-
acter and common sense methods, with an
infusion of modern medicine; he was soon
fortunate enough to save Kassim Pasha, the
minister of war, abandoned by his regular
attendants and dying from a strangulated her-
nia." He was badly afflicted with ophthal-
mia, in 1875, went io Paris for treatment,
and stayed on in that city. Through Charcot
he was made a "licentiate of the University
of Paris" and practiced with signal success.
He skillfully discovered a case of arsenical
poisoning in a prominent Spanish lady and
was made a "Knight of the Order of Isabella
the Catholic" by the King of Spain as a re-
ward. He became a "Chevalier of the Legion
of Honor of France," and the university of
his native state conferred on him the degree
of LL.D.
In 1861 he published in RichnKjnd "An
F^pitome of Practical Surgery for Field and
Hospital"; in 1885, "A Doctor's Experi-
ence in Three Continents," which is "full of
charming personal and precious professional
reminiscences"; and from 1853 to 1871 sev-
eral scientific papers in the medical journals
of Baltimore, Philadelphia, \'irginia and
North Carolina, being editor of the latter
journal in 1857. His address before the Med-
ical Society of North Carolina, on May 14th,
1856, should be regarded as one of the class-
ics in the medical literature of that state.
In 1857 Dr. Warren married Elizabeth,
daughter of Rev. Samuel Iredell Johnstone, of
Edenton. He died in Paris, Sqjtember 16th,
1893.
152
SOUTHERN MEDICINE AND SURGERY
March, 1020
Goiter
J. W. Davis, M.D., F.A.C.S., Statesville, N. C.
Davis Hospital
Ihe imposing array of literature on the
subject of goiter and the various classifica-
tions of the different types have caused more
or less confusion.
A simple class'fication of goiter is rather
difficult to make, the following pathological
classification adopted by Plummer and others
is very satisfactory:
1. Colloid goiter.
2. .Adenoma —
(a) With hyperthyroidism.
(b) Without hyperthyroidism.
3. E.xophthalmic goiter.
4. Thyroiditis, syphilis, tuberculosis, malig-
nancy.
The colloid type of goiter is simple enlarge-
ment of the gland without toxic symptoms.
This is the type which sometimes becomes
very large. The gland is smooth and uni-
form. No nodules are either visible or palpa-
ble.
In adenoma of the thyroid there may or
may not be toxic symptoms. Where toxic
symptoms are present, they are due to an ex-
cessive quantity of thyroid secretion which
is normal in quality. This type of gland con-
tains nodules which are usually either visible
or palpable. Only a part of the gland may
be involved. The tendency of all adenomi-
tous thyroids is to become toxic.
In exophthalmic goiter the thyroid secre-
tion is abnormal both in quantity and qual-
ity.
The thyroid gland is subject to acute in-
flammatory conditions as is true of any other
similar structure of the body. Sometimes ma-
lignant conditions develop and these must be
kept in mind in making a diagnosis of any
thyroid condition.
The classical symptoms of hyperthyroid'sm
are:
1. Rapid pulse. (This is the earliest and
most common sign.)
2. Nervousness.
3. Fine tremors.
4. Loss of weight and strength.
5. Gastro-intestinal disturbance.
6. Sometimes low blood pressure.
7. Flushing of the face.
8. Flushing and sweating.
9. Exophthalmos.
10. Extreme susceptibility to shock or
fright.
11. Increased basal metabolic rate. (This
is always indicative — but not conclusive
evidence — of hyperthyroidism. )
In the very early stages the most charac-
teristic symptom is a persistent rapid pulse.
Cabot states that, "Loud heart sounds with
or without a systolic murmur should always
make us suspect thyroid poisoning."
On having the patient hold the arms out
with fingers spread a definite fine tremor
is usually present. In the more advanced.
cases the pulse is more rapid, the nervousness
greater and the tremor more pronounced. In
the exophthalmic type of goiter the eyes be-
come more prominent and as the condition
progresses this may become extreme and dis-
figuring. The enlargement of the thyroid
gland varies. In some cases, even with mark-
ed toxic symptoms, there is very little en-
largement. L^sually a clinical diagnosis can
be established beyond any reasonable doubt,
but in very early cases a basal metabolic rate
determination will aid greatly in establishing
a definite diagnosis and give us some idea as
to the severity of the thyroid disease present.
In the more advanced cases, particularly of
the exophthalmic type, there are certain eye
symptoms which have been described but
which, with the exception of the exophthal-
mos, are not particularly useful or necessary
in establishing the diagnosis.
In toxic goiter without exophthalmic symp-
toms the condition is sometimes overlooked
for a longer period of time. However, a
rapid pulse, nervousness, loss of weight, gas-
tro-intestinal disturbances and tremors should
in all cases warrant a very careful and thor-
ough examination to determine the exact
cause.
Basal metabolic rate determinations enable
us to determine with more or less accuracy
any hyperactivity of the thyroid gland and
in early cases this test should always be made.
A second test is advisable to check the re-
sults of the first. Even a third test may be
March, 192^
SOtJTHERN MEDICINE Akb SURGERY
i^i
required befor: a satisfactory standard is es-
tablished. (The metabolic rate determina-
tions are simply the accurate determinations
of the amount of oxygen used within a speci-
fied time.)
The discovery of the fact that iodine given
internally will counteract the to.xic action of
exophthalmic goiter has revolutionized the
treatment of this condition. The administra-
tion of iodine will also counteract to some
extent the toxic adenoma. Iodine is usually
given in the form of Lugol's solution.
The use of local anesthesia in thyroidec-
tomy has aided a great deal toward reducing
the mortal'ty in goiter operations.
Very important is an early diagnosis in
toxic adenoma or exophthalmic goiter. This,
however, must always be carefully differen-
tiated from the mild hyperthyroidism so often
found in young girls.
The use of iodine has become so universal
that a number of companies are manufactur-
ing table salt containing a certain amount of
iodine in the form of potassium iodide. A
word of warning should be sounded with re-
gard to its use. A simple adenoma of the
thyroid gland may, if enough iodine is given,
become toxic. In toxic adenoma of the thy-
roid gland iodine should be administered only
in small amounts and the results noted very
carefully, for this type of goiter is often mads
worse by the use of iodine, especially where
it is administered in considerable amounts for
any length of time.
Every case of suspected goiter should be
studied very carefully from every standpoint.
A complete physical examination, urinalysis,
complete blood count, blood urea, blood su-
gar and sugar tolerance should all be done.
.■\ wassermann or kahn test should be made
in all cases. A careful examination of the
eyes is essential. The vocal cords should al-
ways be examined to determine if there is any
paralysis or any weakness. Pressure on the
recurrent laryngeal nerve by an adenoma or
an enlargement of the thyroid gland may
cause paralysis of either vocal cord. For this
reason every patient should be examined so
that if there is a paralysis present the [)atient
can be told of this before operation and later
this paralysis will not be attributed to the
operation. When a patient who has a sus-
pected early hyperthymidism is being exam-
ined it should be carefully explained that the
examination will require a little time. Occa-
s'onally two or three days may be necessary.
Basal metabolic rate determinations should
be made preferably in the morning after a
good night's rest. No breakfast should be
taken the morning of examination. The
stomach should be empty.
The mortality in goiter operations is now
very l<nv. Early recognition has done much
to lower the mortality. The use of Lugol's
solution to counteract the toxic symptoms
and slow down the pulse has enabled us to
get patients in condition for operation in a
very short time. Cases which were formerly
inoperable can now be operated on with rea-
sonable safety, especially when operation is
done under local anesthesia.
It must be remembered, however, that up
to a certain point iodine is of the greatest
help in exophthalmic goiter, but if it is con-
tinued and there is no surgical interference
there will be a return of the toxic symptoms.
When this occurs it is a sign that the benefi-
cial action of iodine in that particular case is
at an end. The condition then becomes rap-
idly worse and usually operation is impossible.
Iodine should only be given in exophthalmic
goiter for the purpose of preparing the pa-
tient for operation. To carry this treatment
beyond this point is extremely dangerous and
often disastrous.
The preoperative preparation of a patient
for thyroidectomy should be carried out un-
der the most favorable circumstances possible
and must not be hurried. This preparation,
especially in the more severe cases, will have
a great deal to do with the success and favor-
able outcome of the operation.
The great advances which have been made
in the handling of thyroid patients have re-
duced the mortality to a very low point and
hastened the convalescence and recovery after
thyniidcctomy in a most remarkable way.
REFERENCES
1. Pliimnicr. H. S.: The Clinical and Pathological
Reiali(in-hip of Simple and Exophthalmic Goiter.
Am. Jour. Med. Sc. 131,f, CXLVI, 700-705.
.'. Hoothby, VV. M.: The Use of lodin in Ex-
ophthalmic Goiter. Endocr'niolniiw 1024, X'lII, 727-
745.
.(. Plummer, H. S., ami Koolhhy, VV. M.: The
Value of lodin in ExophthrUmir (loiler. Jour. Iowa
.Sliilr Med. Soc, 1024. \\\\ (i<v7.t.
4. Mayo. Charles H.: The Thyroid Gland. Bniii-
mi.itl Lrrlurr, IJelroit, Midi., January. 1025.
5. Crisler, J. A.: IJifferenlialion of Various Types
of Goiter. Sou. Mvd. Jour.. 102S, X.XI, .(ol-.*62.
(). Hume, W. I^.: Early Keco(;nilion of Surgical
Goiter. Kentucky Med. Jour., 102S, XXVI, 7,i-76.
7. Hertzler, A. E.: Pathology of Goiter. Endo-
154 SOUTHERN MEDICINE ANb SURGERV March, 10J«
crinology. 1027, XI, S28-S8S. Goiter. Surg., Gyii. and Ohs., 102S, XL, 716-17.
S. Bothc, Frederick A.: Some Surgical Aspects of 12. MacCarty, W. C: Goiter and Its Relation to
Hyperthyroidism. Jour. Med. Soc. N. J., 1927, Its Structural and Physiological Units. Surg., Gvii.
XXVI, 161-163. and Obs.. 1013, XVI, 406-411.
0. Stocks, P.: Influence of Iodine Administration 13. Blackford, J. M.: Thyrotoxicosis. Surg., Gyn.
on Goiter Incidence and Physical Growth in Adoles- and Obs., 1022, XXXIV, 185-1S8.
cent Girls. .4««. £«gfH/«, 1927, II, 382-304. 14. Crile, G. W.: The Thvroid Gland. W. B.
10. Graemiger, O.: Iodized Salt in Goiter Preyen- c- j ,- t^l-i j i u- ,ni,
lion, Schewiz. Med. Wchnschr., 1Q27. LVII, 1176- launders Co., Philadelphia, 1922.
1177, 15. Bartlctt, Willard: The Surgical Treatment aj
11. Foss, H. L.: The Treatment of .\dolcscent Goiter.^ C. V. Mosby Co., St. Louis, 1026.
MARION SIMS' START IN NEW YORK
In a small private dwelling in the year 1855, the Woman's Hospital was
launched upon its career. The protession oDjected to its existence on the ground that
the field ol .work in which it proposed to engage, viz., destructive injuries of the
vesico-vaginal septum, was too limited to warrant an institution for their special care
and treatment. Sims' experience, however, had awakened him to the realization of
the fact that throughout the land there had existed, lor many years, an accumulated
number of women made derelicts by this tragedy of child-birth; and still more im-
portant was the fact that the surgical staff of no institution then existing in New
Vork was capable of relieving a single victim of vesico-vaginal fistula. The element
of particular interest here is that the Woman's Hospital was organized solely for the
purpose of curing vesico-vaginal tistula, and the justification of its founding soon
became apparent, tor, as its reputation kept pace with Sims' and Emmet's remarkable
operative achievements, it outgrew its capacity and expanded into an imposing
structure, te be known wherever surgery was known.
That you may better visualize the sunerings of those whom Sims sought to relieve,
permit me to relate briefly the story of Mary Smith, the first patient upon whom
Sims operated at the Woman's Hospital. She had but recently arrived in America
as an immigrant from the Western Coast of Ireland, a pitiable, ill-smelling, repulsive
creature, with an extensively excoriated vulva, the result of a continued escape of
urine. When the anterior vaginal wall was exposed, a greyish mass came into view,
projecting well into the vagina. It appeared to be a very large stone, but on exam-
ination, after its removal, it proved to be a wooden float irom a seine, about the size
of a goose egg; this had been introduced into the bladder, through a large vesico-
vaginal opening, by her medical attendant at home, to support the superior surface
of the bladder and to prevent it from protruding through the fistulous opening; and
it formed, with the intestines, a true vesical hernia. The float was, of course, in-
crusted with phosphatic deposits, and its removal was thereby rendered difficult and
extremely painful. Most ot the base of the bladder and of the urethra was destroyed,
but, through the combined efforts of Sims and Emmet, these tissues were reconstructed
and restored to function, and for six years or more this woman was employed as a
helper in the hospital.
During the first year of the hospital's existence, its surgical records were kept with
indifference. This failure, however, soon became apparent to Emmet, who possessed
hospital training, and to him is due the credit for their eventual accuracy and for the
invaluable information which may be garnered from them today. When reviewing
these statistics from a numerical standpoint, it should be remembered that before the
work on vesico-vaginal fistulae was systematically begun, it was generally considered
too restricted for special consideration; also that the hospital was closed for three
months of the year, for reasons then thought valid, viz., that wounds did not heal well
during the summer.
Emmet states that during his early career as a surgeon in the Woman's Hospital,
1856-1861, he operated for the repair of vesico-vaginal and urethro-vaginal fistulae
on an average of twice a week. But a better idea of the actual number of cases which
came under his care is obtained through his report at a later date, 1867, analyzing
275 cases of injuries to the vesico-vaginal septum.
— From an Address by Dougal Bissell, to the Section on Obstetrics and Gynecology of the Royal
Society of Medicine of England, published in its Proceedings.
karch, 1929
SOUTHERN MEDICtNE AND StRGERV
isi
The Ketogenic Diet in the Treatment of Epilepsy in
Children
T. D. Walker, jr., iSI.D., Winston-Salem, N. C.
Although epilepsy has been known for
many centuries and has been the subject of
much speculation and thought, it is still a
condition not understood and as a conse-
quence no specific treatment has been devel-
oped for the group of symptoms which bears
its name. Widely varying types of cures
have been advocated, praised and eventually
d scarded. Surgery has given relief in some
instances, but drugs and various forms of diet
have been the main form of therapy used in
most instances. The greatest success has
been claimed for luminal, which has largely
replaced the bromides.
The interest in low protein and salt-free
diets has diminished and, although the various
methods of treatment have all been attended
with some measure of success, the proportion
of failures has been so great that any treat-
ment which gives better results is welcome.
It is recognized that the most satisfactory
method of treatment has been by diet. Va-
rious experiments have been made with d'ets
and at the Massachusetts General Hospital a
group of epileptic children were put on a diet
sufficient to maintain life but not sufficient
to carry on normal metabolic function. The
attacks were lessened while on this diet, but
the attacks returned when the regular diet
was resumed. In a colony of epileptics in
New Jersey the same experiment was carried
out with the same results. In 1921 R. M.
Wilder of Mayo clinic, starting with this
hypothesis, worked out a diet for the treat-
ment of epilepsy, which produced somewhat
similar changes in the body as the starvation
diet, but at the same time maintained normal
growth and development. This diet he called
the "ketogenic diet," because it produced a
ketosis by reversing the ratio of carbohydrate
and fat in the nf)rmal diet and at the same
time gave the minimum amount of protein
that woulfi maintain nitrogen equilibrium. If
the carbohydrate in the diet is decreased and
the fat is increased a point is reached where
there is not sufficient carbohydrate to burn
the fat, with the result that incomplete prod-
ucts of combustion, as acetone and other
ketones, appear in the blood and urine.
When the ketones occur in the blood in
sufficient concentration the epileptic seizures
are lessened in frequency and severity and
often disappear entirely. This is thought to
be due to the anesthetic effect of the ketones
upon the nerve centers, similar somewhat to
ether anesthesia from the affinity of ether
for lipoid cells.
That portion of the diet which tends to the
production of ketones is fat; while the p<ir-
tion which tends to prevent the production
of ketones is principally carbohydrate. Pro-
tein is slightly anti-ketogenic.
Of the normal diet carbohydrate forms
about 50 per cent, fat 35 per cent, protein 15
are not produced, but if the ketogenic ele-
ment— fat — is increased over the anti-keto-
genic elements — carbohydrate and protein —
in the ratio of 2 to 1, 3 to 1, 4 to 1, or possi-
per cent. If this ratio is maintained, ketones
bly 5 to 1, a point is reached where a ketosis
develops. The ratio is expressed in grams of
cooked food.
TYPES OF CASES TO BE TREATED BY THE
KETOGENIC DIET
A\. first it was thought that only cases of
epilepsy of unknown origin should be treated
by this diet. Later good results have been
reported from the use of the diet in cases in
which there was definite pathology of the
central nervous system. Best results are to
be expected, however, when there is no defi-
nite brain injury.
EFFECT OF DIET ON GENERAL METABOLISM
Growth and development are not interfered
with. Blood sugar is slightly lowered to 60
to 80 mg. per 100 c.c. The alkaline reserve
is slightly lowered, also uric acid; i)ut there-
is no marked change in the non-protein nitro-
gen, phosphorus, calcium, or chlorides. So no
harmful effect has been observed. On the
other hand, the color of the skin and general
condition improve.
TREATMENT
Co-operation of parents and [xiticnt must
1S6
SOtJtHEkN MKmClNE! ANt) SURGfiftV
March, I9i«)
be obtained, for the diet must be followed
carefully for many months. Hospitalization
is necessary in the beginning of treatment in
order that the services of a dietitian may
be had, and that a parent or nurse may learn
the diet; then the patient may return home.
A change from the normal diet to the keto-
genic diet should be slowly made. A slight
reduction in carbohydrate and a slight in-
crease in fat is the first change to be made,
making a ratio of about 1 to 1; 1 grm. F.
to 1 grm. P. plus — 1 grm. F to 1 grm P plus
1 grm. C. After a few days the ratio is in-
creased 2 to 1, 3 to 1, 4 to 1, 5 to 1, as rap-
idly as the appetite of the patient will permit.
The urine should be examined daily for the
appearance of ketones. A ketosis usually de-
velops on a ratio of 4 to 1; at times it may
be necessary to increase the ratio to 5 to 1.
When a ketosis is produced to the extent
that the epileptic seizures are controlled the
diet remains unchanged. After the patient
has been free from convulsions for six to nine
months a return to a normal diet may be
begun. This is done by decreasing the fat 5
to 10 grms. once a month — and increasing
the carbohydrate 10 to 20 grms, -the caloric
value of fat being twice that of carbohydrate.
Protein is increased 5 grms. a month until
the normal amount is reached. Usually when
a normal diet is reached the convulsions do
not return.
The growing child needs 15 grains of cal-
cium daily for the growing bones. There is
that amount of calcium in twenty ounces of
milk, so, as a precaution when the milk is re-
duced below that amount, calcium lactate ten
to fifteen grains three times daily should be
given. Constipation should be overcome by
giving mild laxatives, magnesia, cascara, etc.
Other drugs, such as pheno-barbital and bro-
mides are not necessary if a sufficient ketosis
is produced.
CALCULATION OF DIET
The first thing to be done in the calcula-
tion of the diet is to determine the caloric re-
quirement. In adults this can be done by
determining the basal metabolism, which is
not practicable with children. The simplest
way of arriving at the caloric requirement is
to use a metabolic table, by Du Bose, based:
upon age, height and weight ratio. To this
caloric requirement is added 50 per cent for
growth. Given a child 6 years old, height
40 in., weight 36 lbs., the caloric require-
ment would be 36 (lbs.) X 22 (calories per
pound) = 792 calories + 50 per cent =
1188 calories.
1 grm. of protein per kilo (2.2 lbs.) of
body weight will maintain nitrogen equilib-
rium, so this amount of protein in the diet is
all that is necessary and remains constant
throughout treatment.
The number of grams of fat and carbohy-
drate to be used may be arrived at in several
ways — by Woodyatt's grm. ratio formula,
fatty acid to glucose, or Shaffer's molecular
ratio. The simplest method is to multiply
the caloric requirements by known coeffecients
which will give any ratio desired.
For instance: child 6 years of age, height
40 inches, weight 36 lbs. — caloric require-
ment 1188 calories. Multiply 1188 by coef-
ficients .045, .035, .025, .015, .010, to deter-
mine carbohydrate grms. Multiply 1188 by
.08, .09, .10, .11, .12 to determine fat grms.
1 grm. protein per kilo of body weight =17
grm. P.
1188 X -045 = 53 grm. C.
1188 X -08 = 95 grm. F.
17 + 53 = 70 grm. P + C.
95 grm. F to 70 grm. P -|- C, gives a ratio
of 1 1-3 grm. F. to 1 grm. P -|- C.
1188 X -035 = 42 grm. C.
1188 X -09 = 107 grm. F.
17 + 42 = 59 grm. P -f C.
107 grms. F to 59 grm. P -|- C gives a
ratio of 1^4 F to 1 P + C.
So by using the coefficients any ratio de-
sired may be determined.
Diet— Total Calories 11S7— Ratio I.I4 Fgm. to
1 grm. P. + C.
Carbohydrate 42 grm.
Protein IS. 7 grm.
Fat IDS grm.
Breakfast
Grm,
, C
P
F
Calories
Bran cakes
2
0
0
0
0
Cornflakes
10
8
0
1
4
0
o.s
2.5
1.0
2.0
0
8
7.5
12.0
0
12.5
35.2
Bacon
15
77.5
Cream 40%
30
116.0
Fruit 10%
60
24.0
Butter - „
15
112.5
13
6.3
32.0
365.2
Dinner
Broth lean meat-
9
0
2.4
1.5
23.1
Vegetables 5% —
60
2.0
1.0
0
12.0
Cream 40%-
______ 30
1.0
1.0
12.0
116.0
Fruit 10%
„.._ 30
2.0
1.0
0
12.0
Butter
22
0.0
0.0
18.3
164.7
Uneeda Biscuits
_._.. 2
10.0
1.0
1.0
53.0
15.0 6.4 32.S 3S0.S
March, 1029 SOUTHERN MED1CIN6 AND SURGERY iSt
Supper VI. A simplified method of calculating the
Vegetables S7c -_.... 60 2.0 1.0 0 12.0 diet makes the method more practical.
Cream 40% 60 2.0 ^" ^'" '"" ^
Unecda Biscuits 2 10.
0
12.0
24.0
232.0
2.7
24.3
13.3
110.7
1.0
53.0
Cheese 7^ 0 2^0 2^7 24.3 VII. The ketogenic diet will cure many
Butter 16 0 0 13.3 11Q.7 cases of epilepsy of unknown origin and will
benefit, others with definite brain pathology.
14.0 6.0 41.0
BIBLIOGRAPHY
CONCLUSION 1. Talbot, Fritz B., Metcalf, Kenneth M., Mor-
I. The ketogenic diet fulfills all require- ^"V; M^f.*"-et E.: 'Clinical Study of Epileptic
Lh.lnren Treated l)V Ketosenic Diet. Boston Med.
ments for growth and development. „„^ siirn. Jour., Jan., 1027.
II. A ketosis maintained for many months 2. Taloot, Eritz B., Metcalf, Kenneth M., Mor-
does no harm, but, on the other hand, im- ''^'^''-''Tf ^,'- J^7^'^'f"f -'""''' ■'• '^^- ■^"
' rcD., I'J//, \ 01. 33, pp. zlo-Zzo.
proves the general condition of the patient. 3. Talbot, Fritz B.: "The Treatment of Epilepsy
The systematic care may be partly responsi- »'" Childhood by the Ketogenic Diet." Rluni,- island
ble tor this. 4 vVilder, R. M.; ".\ Primer for Diabetic Pa-
III. Varying degrees of ketosis may be nee- licnts."
essary in various patients before improvement 5 Tallxt, Fritz B., Hendry, Mary, Morwaty,
Margaret: "The Basal Metabolism of Children with
"'^'^"''^- Idiopathic Epilepsy." Am. Jour. /)«. 0/ Ch.. Oct.,
IV. The diet has to be rigidly enforced to 1024, \'ol. 2S, pp. 4IQ-420.
produce results.
X. Indiscretion in diet such as eatinj;
Talbot, Fritz B.: "The Ketogenic Diet in
Epilepsy."
7. Food \aluci. V . S. Gov. HuUrthi No. 2S.
sweets, may precipitate a convulsion. Star- S. Carter, Home, and Mason: Clinical Dietetics.
vation for a day or two and rigid enftirce- "• Atwaier, VV. O., Bryant, ^. P.; "The Chemi-
^ r J- . -11 . f 1 1 cal Compositions oi .American Food Materials. Pub.
ment of diet will prevent further attacks. j; 5 Oept. oi .■iRricuUure
ME.^NING OF HEART MURMURS
In 1,106 patients 127 accidental heart murmurs were discovered, while 39 (i.3 per
cent) of them, showed murmurs indicative of organic valvular disease. .All of the
accidental murmurs were systolic in time, and 84 per cent of them were heard at the
base of the heart. Transmission of accidental murmurs is relatively rare. Nine and
four-tenths per cent of the murmurs so classified were transmitted to the axilla, and
only 0.8 per cent upward from the base. Cardiac hypertrophy was encountered in
association with accidental murmurs in 8.0 per cent of the cases, hut in every instance
it was pfissible to account for the hypertrophy independently of the murmur. Cardiac
hypertrophy is a necessary part of organic valvular disease. .Accentuation of the
pulmonic second sound is heard in connection with accidental murmurs of the inor-
ganic type, but is not to be expected with other types of these murmurs. Other evi-
dence than that afforded by a muimur must be found before a heart is assumed to be
diseased.
—Or Ileyward Giblies. in 7"/;c Anuyi<:an Heart Joiinia'. February, 1029.
.-MDS TO DELIVERY
In the magical group we have such performances as those of loosening girdles, opening locks
and doors, and other actions suggestive of freedom. Another variety takes the foetus as its
objective, presupposing that the unborn child ijarticipates in the movements that bring it into the
world, an idea which lingered long in official medicine. Money is jingled, chains are rattled (Scot-
land), guns are fired (Siberia), in order to stimulate the activity of the child in the uterus. One
variant of the same magic is seen in cases where the husband approaches the mother and turns
away from her again, in orflcr to entice the child to follow him.- ,M.\I)11.I., "The Infancy of Mid-
wifery," The Irish Journal oj Medical Science, Feb., '20.
SUIHING AS A DIAGNO.STIC SIGN
In effort syndrome without heart disease excessive sighing is very frec|uent (80 per cent of 100
cases). When effort syndrome or marked nervousness is combined with organic heart disease,
excessive .sighing is common (74 per cent of 50 cases). It is evident from the date previously
cited that in these cases the sighing comes from the nervous stale anrl not from heart disease.
Frequent or constant sighing is a symptom of nervous origin, not fleprndent on disease of heart,
lungs, kidneys, or thyroid glanil. When it is present one should delcrmine the degree of respon-
sibility of the nervous svstem in the production of a stale iil ill luillli that mav exist. — WHITE
and IIAHN, in Am. Jour. Med. Sc, Feb., '29.
158
SOttttERN MEDtClNfi AKt) SURGERY
March, 192^
Some Applications of the Laryngoscope and Bronchoscope
G. C. Cooke, IM.D., F.A.C.S., Winston-Salem, N. C.
Since Chevalier Jackson so widely intro-
duced the bronchoscope to the profession by
hs ingenious methods in removing foreign
bodies from the food and air passages, we
have recognized its invaluable position in the
doctor's armamentarium and are not reluctant
in giving him praise for such a pioneering
feat; but the profession has been pathetically
slow in recognizing the value of per oral
endoscopy in other diseases of these passages
not due to foreign bodies: and more espe-
cially slow in learning that men other than
Jackson and his immediate associates have
become skilled in this new and useful art.
The air and food passages may become
affected by any disease which other mucous
membranes may suffer, including neoplasms;
also affections peculiar to their structural
characteristics, such as spasm of the sur-
rounding musculature and strictures due to
scar, which on a flat surface would not cause
serious change in the physiology.- In all these
conditions in which per oral endoscopy may
better render an accurate diagnosis or the
best means by which a cure may be effected,
we may passingly admit its usefulness. In
many conditions we will surely be guilty of
neglect or incompetency if we deprive our
patients of the benefit which may be so
gained.
The use of the laryngoscope and broncho-
scope in the hands of well informed and rea-
sonably skilful surgeons is not dangerous or
difficult. Since we first begun the use of
laryngoscopy and bronchoscopy after visiting
Jackson's clinics a year ago at the Univer-
sity of Pennsylvania and Jefferson Hospital,
we have done ninety-one laryngoscopies, fifty-
two bronchoscopies and ten esophagoscopies
including the removal of five foreign bodies,
without mortality or morbidity, and we feel
sure that we have not only had some wonder-
ful results but have saved several lives.
The first condition that I wish to mention
as requiring the use of the laryngoscope is
laryngeal diphtheria. I have been impressed
and alert to the value of intubation in this
disease for eleven years and during that time
I have not once had the opportunity of seeing
it used effectively; and I have witnessed sev-
en deaths that I recall from that malady. In
the past year we have had three cases, one
in a patient who was almost moribund and
the others gravely ill, whose lives I feel sure
were saved by aspirating a tenacious mucus
from the trachea through the laryngoscope.
In neither of these cases could there be hope
for relief by intubation, as antitoxin had been
given in them all and the obstructions were
due to a liquefying fibrin which would oc-
clude the tube if it were introduced, rather
than by a dry membrane which could be held
open by a tube. Not only is laryngoscopy
imperative in this type of case, but every
case of laryngeal obstruction should have the-
benefit of direct and indirect observation be-
fore blind probing with a tube or tracheotomy
is resorted to, except of course in certain
emergencies. Should intubation become nec-
essary, it can be done through the laryngo-
scope much more effectively, more quickly
and with less trauma, than blindly.
Secondly, examining and aspirating the
larynx free from blood clots or mucus follow-
ing tonsillectomy is an easy procedure, which
Vi'ill not only give the operator opportunity
to keep his hand and eye trained in this form
of examination but will undoubtedly often
make the patient more comfortable when
awakening and probably go a long way in
preventing post tonsillar lung complications.
Immediately after the tonsil operation is over,
one may take the laryngoscope which has
been prepared routinely with the oth;r in-
struments and raise the epiglottis, see if there
is blood or mucus in the larynx or upper
trachea and if so, in a minute, aspirate it dry.
The use of the bronchoscope of course re-
quires more skill, and one is apt lo consider
the average clinic or private practice to be so
lim ted in conditions necessitating broncho-
scopy that one would not have enough of the
work to do to keep in practice; but there
are enough conditions to be benefited by
bronchoscopy so that the average fifty-bed
hospital should be able to have at least one
regular bronchoscopy period each week, if
these patients are only referred to that de-
March, l<)29
SOUTtttkM MEbtCtkt A^ StftGEftV
159
partment. One of the most harassing condi-
tions to be seen fairly frequently, which can
sometimes be entirely relieved by one treat-
ment and which most always can be markedly
benefited by a series of regular treatments,
is asthma. Most frequently the cases of ex-
piratory dyspnea, that we so often hear of as
being so severe that the patient had to sit
up in bed or sit by the window in the middle
of the night for breath, are not conditions
of allergy or pollen sensitization at all but
allergy or pollen sensitization at all but an
acute congestion of the bronchial mucous
membrane superimposed upon old chronic
bronchitis. If these patients will submit to
bronchoscopy frequently numerous dry,
tough, fibrinous bands may be seen stretched
across the lumina of the bronchi appearing
as spider webs. These webs hold within
their meshes much secretion of varying com-
position. When these webs and their con-
tents are removed through the bronchoscojje,
the cough is allayed, the rattling and dyspnea
relieved, and we have had many patients tell
us that they not only don't have that tight
feeling in their chests, but they think they
breathe more freely than before the attack.
Some patients are permanently relieved by
one or two treatments. While others may
not be entirely cured by several treatments,
they can be made comfortable if the treat-
ment is continued at one to two week inter-
vals or when an attack appears imminent. Of
course this does not remove the necessity for
searching out and removing all foci of infec-
tion. There are cases in which we would
hesitate to use a general anesthetic for re-
moval of focal infections or for other opera-
tions on account of an asthmatic tendency,
who, in absence of other disease may be made
quite goofi anesthetic risks by bronchoscopy.
.Another condition where your patient will
be most grateful for the use of the broncho-
scope and you may even save life, is the post
anesthetic formation of tough mucus, which
a harassing cough fails to dislodge. This is
seen most frequently in excessive smokers.
Especiallv is bronchoscopy at times impera-
tively indicated in order to save life in mas-
sive lung collapse or atelectasis following
ether aneUhesia.
Another condition of rather frequent oc-
currence in our practice has been stricture of
the esophagus, due to scar tissue, inflamma-
tory tissue or spasm of the cardia. Because
of the danger with which blind dilatation
is fraught, it is apparent that it should not
be done before a visualization of the actual
obstruction has been made. In one case diag-
nosis of spasm of the cardia had b?en made
and, when the area was viewed through the
esophagoscope, it was seen to be a rough,
ragged, ulcerated and indurated carcinoma-
tous stricture. Enough of the scar tissue was
bitten away by means of forceps so that ra-
dium was placed into the ulcerated area and
held in place for twelve hours by a rubber
tube leading out to the mouth. The growth
cleared up rapidly and the patient gained
twenty pounds in weight in two months.
Even though a definite spasm of the cardia
has been diagnosed the spasm should be
viewed through the esophagoscope before di-
latation is attempted, because in some of
these cases an enlarged lymph node or some
other pathological lesion may be present
which is causing the cardia spasm, forcible
dilatation of which may cause serious trou-
ble.
These are by no means all the conditions
which call for the use of peroral endoscopy,
but merely a few which are of such frequent
occurrence as to require greater consideration
of the procedure by the profession generally.
NEGRO HOSPIT.\L
(.Advertisement in Charleston Medical Journal,
1855)
The unfiersiyned have opened a HOSPIT.AL for
the treatment of sick NEGROES, laboring under
Medical or Surgical diseases*, at CHISOLM'S MILL,
west end of Tradd-street. Every attention will be
paid to Nezrocs entrusted to their care. Experi-
enced Nurses are provided. The usual Medical and
Surgical fees will be charged. Board, with nursing
$2 per week.
'Excepting Small Po.x.
J. J. CHISOLM, M D
F. PEYRE PORCHER, M.D.
.AND FLEES IS FLEES
But Flee Hill had euphony. It told its own story,
that years ago when that part of Cumberland county
was wild and woolly the animals used to gather
under the stilted church and leave their flees for the
worshipers on Sunday morning, — Hickory Record.
\\. a certain Sunday school the subject of the les-
son for the day was "Arise, take the young child and
its mother and flee into Egypt." The Ics.^on was
illustrated by cards distributed to the little fellows.
One seized his card eagerly, scrutinized it carefully,
then announced disappointedly: "Well, I can see
the baby and the papa and the mama anri the little
mule; but where 's that flea?"
163
SOtrt«fiftN MEMClNe AND SCtlGfiRV
March, I9i9
PRESIDENT'S PAGE
Tri-State Medical Association oj the Carolinas and Virginia
—CYRUS THOMPSON
It is said that the AjKistle Paul was not
much for personal appearance: that so far
cs one could tell by looking at him he was a
rather insignificant Jew. His learning and
h!s wisdom, however, are well attested by his
letters which are of record. One of his wise
sayings was that we be "not forsaking the
assembling of ourselves together." He knew
what the effects of association would be upon
the spiritual character of the saints individ-
ually, and what it would be on the zeal of
the saints in the aggregate. He knew that
isolation meant death to the individual saint
and the decadence of the religion for which
th?y stood. I have always felt that doctors
on the average were as saintly as the saints
and that St. Paul's admonition might well
have been addressed to the medical profes-
sion. Certain it is that the best men in the
profession are the men who stand for medical
organization and medical association.
At the meeting last year at Virginia Beach
the question was raised whether there was
place and use for the continued existence ot
the Tri-State. The Greensboro meeting made
joyous answer to this anxious inquiry. Under
the presidency of Dr. James K. Hall, the Tri-
State at Greensboro rose to h'gh water mark,
both in the excellence of the program and in
the number and character of the men in at-
tendance upon the meeting.
Next February the Tri-State goes to
Charleston, S. C, rich in historv, rich in cul-
ture, rich in medical tradition and education.
We are expecting in the matter of program
and in attendance to make the Charleston
meeting as great and gratifying to the pro-
fession as was the Greensboro meeting. The
president and secretary and official members
of the Tri-State cannot succeed in this with-
out the help of the proud men in the profes-
sion of the three states. I am, therefore, at
the beginning of the year, endeavoring to stir
up your righteous minds to take part in this
great work. We must have a record program
ard a record attendance and a meeting of the
h'^hesl usefulness. We must demonstrate in
C harlcston the placefulness and the usefulness
of the Tri-State as a medical organization.
.■\ doctor in his prime said to me at Greens-
boro: "When we go to Charleston, you must
let us dance one night," and I said to him:
"We will." The meeting is going to be of
interest to men of all ages. Those who are
mature in years and whose activity lies main-
ly in the head will be satisfied, and those of
younger years whose activity is not only in
the head but throughout the whole body will
have an opportunity to enjoy themselves and
m:ikc their pleasure evident even if it must
be made pcdijest — shown with their feet.
Let us have a great time, an enjoyable time
for every age, at Charleston in February,
1930, the Thirty-second Annual iNIeeting of
the Tri-State.
March, 1029
SOUTHERN MEDICINE AND SURGERY
Southern Medicine and Sur§erp \
I iri-S(;ilt' .Midiciil Assdciiitiiiii ol' the Caroliiias ami X'ii'iiiiiia I
Official Organ of ^ ^,,,^,.,.^,, g^,,.,^,,^ ^,,. „,,, g,^,,^. ^^^ ^,,,.„, (,,,.,,,i„^, \
James M. Xorthington, M.D., Editor
Depar
James K Hall, M.D. _
Frank Howard Richardson, M.D.
W. M. RoBEY, D.D.S —
J. P. Matheson, M.D.
H. L. Sloan, M.D
C. N. Peeler, M.D
F. E. Motley, M.D
\'. K. Hart. MD
F. C. Smith, M.D
The Barret Laboratories
O. L. Miller, M.D
Hamilton W. McKay, M.D
John D. MacRae, M.D..
tment Editors
.-Rkhmonri. Va. Human Behavior
-Uhifk Mmiiit:iin, N. C - - Pediatrics
.-Charlotte. N. C. Denlistry
Charlotte, N. C. -.
Diseases of the
Eye, Ear, Nose and Throat
Laboratories
Joseph .\ Elliott, M.D
PAri, H Ringer, M.D
(;eo. H. Bunch, M.D
Federick R Taylor. M.D
Henry J. Lancston, M.D
CiiAS. R. Robins, M.D
Olin B. Chamberlain, M.D
I, oris L. Williams, M.D
Various .-Xuihors ----- — —
_Charlotte, N. C
Gastonia, N. C. Orthopedic Surgery
ICharlottc, N. C. .- - Urology
..\sheville, N. C Radiology
.Charlotte, N. C - Dermatology
_.'\shcville, N. C Internal Medicim
.Columbia, S. C. — Surgery
_High Point, N. C. Periodic Examinations
Danville, Va — - Obstetrics
.Richmond, Va Gynecology
Charleston, S. C Neuro'ogy
.Richmond, Va Public Health
Historic Medicine
Appreciation
I doubt if any secretary of the Tri-State
Medical .Association ever before placed before
the membership of that body a program so
engaging as that of the recent meeting in
Greensbonj. The papers were up to the usual
hijjh level of excellence. The eagerness with
which the members attended the clinics con-
vinced me that the clinical features of the
annual meetings have come to stay. Even on
the last morning of the session, when adjourn-
ment was near at hand, the clinic of Dr. Can-
non in diseases of the skin was crowded.
From many sources I have had assurances
that the outstanding features of the convoca-
tion were the clinics. Not the least interest-
ing and instructive element of the clinics was
the thoroughness with which the doctors of
Greensboro had selected and assembled mate-
rial for demonstration purposes. It is to be
remembered, too, that few of the doctors in
Greensboro who made the clinics possible are
members of the Tri-State. I am certain that
the members of our organization join me in
thanking those physicians for their splendid
spirit of helpfulness. And the meeting clearly
established the fact that Greensboro is an
ideal town in which to hold a medical assem-
blage. Our membership could not have been
better cared for in any other place.
The program was too long. A number of
papers were not read for lack of time. Long
before the next meeting the secretary should
have helpful advice from the members about
the ma.ximum number of essayists that can
appear on the program. The opinion has
been offered that a two-hour period is too
long for one clinic. But I doubt it. Not
many clinical conditions can be jiresented and
interpreted in a shorter time.
The next meeting goes to Charleston. Cor-
dial invitations came, also, from Columbia,
Sjjartanburg, Greenville, and Florence. Our
meetings in South Carolina are always well at-
tended. I can think of no city in which I would
rather make a visit than Charleston. Life there
is quiet and dignified and serene, and I admire
the Charlestonian unostentatious disdain of
the noisy industrialism of the outside world.
Everywhere in Charleston are the evidences
of a brave and patient people. The citizens
of that city have dared to have opinions and
to assert them, and to be without apologies
162
SOUTHERN MEDICINE AND SURGERY
March, 1029
for them even to this dy. I can well believe
that the quality of individualism exhibited
by the citizens of Charleston throughout the
years has had an enormous influence on our
national life. That city is rich in medical
history. The medical college there is one of
the oldest in the United States, but long be-
fore it was opened some of the practitioners
of Charleston were known throughout the
world. I shall look forward with unabating
interest to our next meeting in Charleston.
I have missed no meeting of our organiza-
tion since 1910 when I joined the Tri-State
in Richmond. My thanks go out to all those
who helped to make our recent meeting in
Greensboro so satisfying. I am deeply grate-
ful to our invited guests who came with such
splendid helpfulness. They have stimulated
our belief that we can make a genuine post-
graduate school of our organization. And I
am placed under lasting obligations to our
secretary, Dr. Northington, for his unwearied
industry in making such a program possible.
He has made the impossible possible.
Right here in the heart of the South, where
sociability dominates all organizations, he has
succeeded at last in eliminating from our an-
nual assemblages every single thing that does
not have to do with the art of preventing and
healing disease.
The family doctor has not disappeared. Dr.
Cyrus Thompson, our president, is the ideal
family physician. Few pschologists know
more about the functioning of the normal
mind, and no psych'atrists know more about
the perversities of the disordered intellect
than Dr. Thompson. His personality is an
unceasing delight to all those who know him.
He and Charleston will have fine appreciation
of each other.
—Jas. K. Hall.
Lay Control of Medicine
In the February issue of th's journal is
published an address of the president of our
State Medical Society which should be given
the earnest attention of every doctor into
whose hands it comes. Dr. Kitchin is not a
visionary seeing bogeys. He is a highly in-
telligent, far-seeing doctor and medical edu-
cator; occupying a strategic position from
which to view the field; concerned for the
welfare of medical men in general; anxious
that the students whom he teaches shall, when
they become doctors, not find the post of
doctor shorn of most of its prestige and emo-
lument ; and possessed of the courage to speak
out against the agencies insidiously working
toward just that end.
His urging that "public-spirited citizens
must be brought to realize the real and im-
mediate danger," and that with their aid doc-
tors, individually and collectively, must con-
stantly teach the whole public that, in mat-
ters of health, salvation is of the doctors, is
w'se and timely.
The extent of the encroachment on the
field of medicine by non-medical organiza-
tions, little realized as it is by most of us, is
truly appallinp;. Ponder his words: "All
that medical men have discovered, developed
and accomplished is in danger of being capi-
talized and exploited by men who have no
connection with the profession;" and: "In
many instances the buildings are furnished
by philanthropy and physicians give their
t'me and talents, but the non-medical man-
agers and overseers are well paid both in
money and in glory. '
That this evil does not exist only in our
state and in the eyes of Dr. Kitchin is rather
startlingly evidenced by publications from
various sections of the country coming to our
exchanr-e table within the past month.
Dr. John \. Hartwell — an invited guest at
the meeting of the Tri-State four years ago —
in his address' as incoming president of The
New York .'\cademy of Medicine, said this:
"We ought not to stand by in an unconcerned
attitude while any portion of the community
rests its faith in health matters on the teach-
ing of 'gnorance." And this: "Medical men
in th's city and in the entire country are
faced with grave and important questions of
economics. These questions must be solved
in such a way that the health of the public
and the individual is safeguarded. This must
be accomplished by means that will neither
deprive the physician of just compensation,
nor lower the dignity and influence of his
calling."
The ever alert Journal oj the Indiana State
Medieal Association can always be counted
on to stand up for doctors. Its issue for
February carries a powerful editorial,
".'\gainst .Abuses of iMedical Charity." Fol-
lowing a line of reasoning which we have used
frequently and to which we hold tenaciously.
Dr. Bulson says: "iMedical and surgical ser-
vices are just as much a necessity as food,"
March, 1020
SOUTHERN MEDICINE AND SURGERY
Ic)
and asks pertinently: "Why should the phy-
sician be expected to donate his services, and
his knowl dge, which is his stock in trade,
any more than the merchant furnish his goods,
or the pkimber furnish his time?" His ra-
tional suggestion for correction of such abuses
is that medical charity be placed absolutely
urder the control of a unified medical pro-
fession, and he is convinced that unless this
froblem is solved by doctors "another link
will be added to the chain of evidence being
welded by certain individuals [and many or-
ganizations.— Ed. I in behalf of state medi-
cine."
The leading article in Calijoniia and
Western Mcdieine, February, is entitled "The
Menace to INIedicine." .Ats author is Dr.
Rexwald Brown,- of Santa Barbara, Califor-
nia. His opening paragraph, as true as dra-
matic:
".\ new note has been introduced by ob-
serving and thinking medical writers into the
I'terature of medicine. This note is a com-
bination of anxiety, distress and even fear.
The medical profession is undeniably disturb-
ed by movements in the social structure
whose waves, with ever increasing vigor, are
beating against a medical position which has
existed for centuries, a position which has
seamed unassa lable. The present commer-
cializcy age .... is reaching out to engulf
the medical profession and compel it to bow
to the supervisional management of its high-
powered votaries."
(Jn the Pacific as well as on the .Atlantic
it is evident that, "All too soon, if physicians
do not unite to thwart the menace, they may
be relegated to the positions of employees of
organizations using the knowledge which has
been so laboriously dug by medical men from
nature's storehouse," and doctors be "pawns
rather than guides."
Dr. Brown offers a remedy, and it is the
same as that urged by Dr. Kitchin — constant
instructicm of the public in the truths of
medicine. It is recognized to be a colossal
task. But medicine must undertake it and
carry it through.
.Some because of inertia, some from the
sloth of fatness, some by reason of incredul-
ity will toss this aside with a shrug. Some —
and among them many who have much
money and, therefore, influence — will tend to
think somewhat on this wise: My practice
will last as long as I will want it; why should
I concern myself? But there are few doctors
who do not have a son, a so^i-in-law, a
reph-^w, or a young associate in whose wel-
fare they are vitally interested. When doc-
tors generally are made aware of the extent
of the encroachment on the rights and privi-
leges of doctors, which have been made in
recent years by various agencies, — some al-
tru'st'c and misguided, and some entirely
sord'd — the doctors of this section will rilly
to Dr. Kitchin's banner, repel these invaders
and force the leaving of med'cal matters to
medical men, to the great advantage of all,
including even the "uplifters" themselves.
The fact that Dr. Kitchin's term as presi-
dent is soon to come to a close will not lessen
his interest or abate his zeal in this great
CHuse. It is our hope, and confident predic-
tion, that he will stress this problem in his
Pres'dential address; and that under his fine
leadersh'p, the Medical Society of the State
of North Carolina will be the first organiza-
tion in the field to recapture lost ground, to
the end that we may maintain the rights and
d'gnities which belong to doctors while we
live, and transmit them unshorn to the doc-
tors who come after us.
'January Jrd, 1929, Bulletin X. Y Acad, of Med.
-You are urged to write Dr. Brown requesting a
r?prlnt. The whole article should be read atten-
tively.
The Thirty-first Tri-State Meeting
The letters which follow will constitute the
major part of our comment on this meeting.
In these letters may be seen expressions of
enthusiastic appreciation of the fitting climax
of the administration of the president under
whose inspiring leadersh'p the Tri-State has
set a new high mark.
Our distinguished invited guests, the doc-
tors of Greensboro and its vicinity, the mem-
bers who contributed essays — all these and
many others wrought mightly toward the suc-
cess of the meeting. It d sparages the.^e no whit
to pay highest tribute to our retiring presi-
dent. His industry, his resourcefulness, his
[latience, his pwwers of persuasion, his savoir
faire — all these were drawn on ceaselessly;
with what result those who were present saw
and heard for themselves, and those less for-
tunate may learn from these letters and from
the printed record as it is unfolded in the
pages of this journal.
President Hall's meeting reached its acme
SOUTHERN MEDICINE AND SURGERY
of felicity when he welcomed President
Thompson and turned over to him the gavel
of office.
As soon as the Sage of Jacksonville can be
induced to make a choice of the likeness in
which he wishes to appear before the readers
of the journal, we promise it, along with
some words appertaining to the original.
Here and now is pledged him our best sup-
port, and the whole Fellowshio is urged to
read carefullv the messages which will be car-
ried on the ''President's Page" from month to
month.
While the details of this meeting are fresh
in your minds, make memoranda, and soon
let us have your suggestions and recommen-
dations.
Of the kindly words said for the secretary-
editor, he is most appreciative.
The President's .\ddress was of the stuff
to gladden hearts which, despite the craze for
standardization, hold high hone that the Ford
Fra is but a transient phase: and that it is
not vain to look for a return of the time
V hen every man may live and love and dream
"under his own vine and under his fig tree,"
and no snooper shall make him afraid.
Charlotte, X. C,
March 5, 1929.
My Dear Doctor Northington:
For the first time in five years I attended
a meeting of the Tri-State Mcd'cal Associa-
t'on, the Greensboro meeting. To Dr. Hall
as president, and to you as secretary ol the
.Association, I wish to express my thanks for
the high character of all the features of this
meeting. I have often heard it expressed by
others, and have felt myself, that too large
a part of the time at med'cal ni?etings was
given up to the reading of long, tiresome and
uninstructive papers, for which there was no
earthly excuse — save the attempt of some
man to advertise himself.
The average medical or surgical man, leav-
ing his home and practice and going to a
medical or surgical meeting, would like to
attend clinics led by well informed men. I
am confident the Tri-State Association will
be made one of the most popular and largely
attended of medical gatherings in this section
of the country if you will use your influence
to have fewer papers and more teaching clin-
ics in the future.
Thanking you again for your part in what
I consider a fine meeting at Greensboro, I am,
Sincerely your friend,
JOHN HILL TUCKER.
Florence, S. C,
INIarch 1, 1929.
Dear Dr. Northington:
The Greensboro meeting was one of the
most delightful of the Tri-State Association
thit 1 have ever attended. The general pa-
pers were fine and the clinic feature was an
innovation of greatest instructive value and I
trust that future programs will include this
feature.
The Tri-State Medical Association is ful-
filling its purpose: teaching and exemplifying
scientific med cine. The members of the As-
sociation are due its officers a vote of appre-
ciation for the splendid Greensboro meeting.
With kind personal regards, I am.
Sincerely yours,
' F. H. McLEOD.
Charleston, S. C,
Feb. 26, 1929.
Dear Dr. Northington:
Ever t'lrxe getting back from the meeting
in Greensboro, I have been thinking with
great pleasure of what a splendid clinical
meeting we had, and hope that you and Dr.
rhcmpson, with what help we can give you
here, will succeed next year in getting off as
iiHc-C t nj a meeting.
Yours very truly,
FRANCIS li" JOHNSON.
Roanoke, Va.,
Feb. 22, 1929.
Dear Dr. Northington:
Just a note to tell you how very :nuch I
c:ijoyed my brief stay at Greensboro. Th's
is the first time I have attended the meeting
of the Tri-State Medical Society and I wish
to say that it is the best I have ever attended.
Vou may put me down next year as one who
will attCi d and stay the entire session. You
are certa'.nly doiag a great work. I hope we
can have this society meet in Roanoke in
ir.51.
I am, with kindest regards,
\'ery sincerely yours,
E. G. GILL.
SOUTHERN MEDICINE AND SURGERY
16S
Richmond, Va.,
March 1, 1929.
Dr. James M. Northington,
Secretary and Treasurer,
Charlotte, N. C.
Dear Doctor Northington:
I liked the papers, I liked the clinics, and
I liked the doctors — in fact, I was delighted.
The special feature of clinics was especially
delightful and instructive, and the clinic on
skin diseases, a subject little known to most
of us, and less understood as a rule, was an
eminent success, and I believe inspired and
instructed others, as well as myself.
If I had any criticism to make at all, as
you recjuested, it would be that we had a
little too much of these goods things, but in
the language of the newspapers, all we had to
do, was to "reach for a fag," and be prepared
for our ne.xt good luck. As a whole, the
meeting was a great success and all those who
contributed by their co-operation, are to be
most heartily congratulated.
With best wishes,
Sincerely yours,
J. ALLISON HODGES.
pers were all very fine. The officers of the
Tri-State Medical Association are to be con-
gratulated.
With kindest personal regards, I am,
Sincerely yours,
JAMES W. DAVIS.
Raleigh, N. C,
Feb. 28, 1929.
Dear Dr. Northington:
The recent session of the Tri-State Medical
.'Association of the Carolinas and Virginia, in
my opinion, was one of the most interesting
and instructive medical meetings which I
have ever attended. I enjoyed every minute
of my stay. It was refreshing to get away
from special society meetings and to hear
read and discussed papers bearing upon the
various branches of medicine.
The "dry clinic" furnished real feature, and
I think should be kept up at future sessions.
My only suggestion is that the limit be set
to the number of papers to be put on the pro-
gram each year, so that there would be no
crowding and no postponing.
Yours sincerely,
H. A. ROYSTER.
Asheville, N. C,
March 9, 1929.
Dear Doctor Northington:
Judging from the various comments from
those attending the meetinj^ of the
Tri-State Medical Society recently held at
Greensboro, and from my own observation
every one, I am sure, will agree it was a most
successful meeting from beginning to end.
The program was well arranged and the pa-
pers interesting and stimulated free discus-
sion. The most outstanding feature of the
meeting was the clinics held by our visiting
guests. This feature of the meetings should
be encouraged whenever plenty of clinical
material can be obtained as we had at
Greensboro. Clinics should be encouraged
not only by visiting guests but by all our
own members. Perhaps there were a few
too many papers on the program, necessitat-
ing some very good ones to be read by title
only.
The officers and those taking part in the
meeting are to be congratulated.
Very truly yours,
CHAS. C. ORR.
Statesville, N. C,
Feb. 28, 1929.
Dear Dr. Northington:
The Tri-State Medical Meeting in Greens-
boro was one of the best medical meetings I
have ever attended.
The clinics were a great help and the pa-
What a Doctor Should Carry Regularly
Last fall this journal sent out forty-five
letters as follows:
"Dear Dr. :
"All of us have been confronted with emer-
gencies when we wished that we had thought
to provide ourselves with a certain drug or
appliance.
"Many of us have had a feeling that we
lost a patient because we did not have with
us the means of meeting the critical need.
"I am writing a number of representative
doctors asking that they write me letters on
this subject and send along a list of drugs,
instruments, appliances, etc., which they
would recommend that every doctor keep
packed ready at hand, for meeting emergen-
cies, and carry with him on all night trips
and other trips which put him out of a few
minutes touch with a supply house.
"Think about this and give the patients of
SOUTHERN MEDICINE AND SURGERY
our doctors the benefit of your experience and
your thoughtfulness. Yours."
The replies, as was anticipated, were not
many. But, if only the one here reproduced
had come, the time, labor and money spent
in making the incjuiry would have been well
expended.
Here is the letter:
"My Dear Doctor:
"While I am deeply appreciative of your
inquiry re-rarding the medicines, instruments,
etc., that a doctor should have with him in
emergency cases, yet the fact that I am a few
days (rather than a f ew fuinufcs) out of
touch with a supply house, makes me loath
to attempt an answer. However, as a country
doctor, I shall append a list which I have
found almost indispensable:
"One flashlight, for auto repairs, throat ex-
aminations, and an occasional instrumental
delivery.
"Sterile cotton and gauze, needles and su-
tures (including a threaded obstetrical ten-
don).
"Adhesive, bandages and rubber gloves.
"A small instrument case containing at
least two hemo'^tats, a pair of scissors, a
probe, a combination male and female ca-
theter (steel); a pickup forceps and a knife
with renewable blades (Bard-Parker handle
with two or three different blades).
"A hypodermic syringe (Luer with two
needles, long and short).
"One rubber catheter (may be used in
laryngeal obstruction from diphtheria or for-
eign bodies or a portion of rubber from
stethoscope may be inserted in tracheotomy
cases).
"A stethoscope with no loose parts, and a
blood pressure instrument in good condition.
"A good speculum and tenaculum and a
cervical dilator, with a dressing forceps
thrown in with these.
".Axis traction forceps (may be used for
h'gh, mid or low deliveries).
".'\nesthetics— a tube of ethyl chloride and
a can of ether or chloroform.
"One rectal instillation outfit for the mag-
rcsium sulphate-quinine-ether method of
Gwathmey; many operations may be per-
formed with this— currettement, forceps de-
livery, trachelorraphy, etc.
"Drugs: a few — aromatic spirits of ammo-
nia; an vj-iaic for hypodermic use; 10,000
u'.iiti diphtheria antitoxin (State Board, cost
25 cents); an ampoule of LaPenta's hemo-
static scrum (P. D. & Co.) A bottle of su-
prarenal extract (preferably P. D. & Co.'s.,
Adrenalin, which may be used locally, sub-
culaneously, or intravenously — or immediate-
ly after death into the heart itself. (No good,
in the few trials I have given it). A form of
oral and intravenous digitalis (d;galin — Hoff-
man-LaRoche).
"With these drugs and instruments a prac-
titioner should be able to meet the usual
emergencies of ordinary practice until he is
able to secure more drugs or more professional
help.
"It has been my observation that the com-
mon run (or garden variety) of country doc-
tors are adaptable and equipped naturally to
meet the ordinary exigencies of general prac-
tice adequately. Have seen one take a dress-
ing forceps, bend the end at right angle and
do a curettage. On another occasion, take
a pair of scissors and a section of stethoscope
and complete a tracheotomy, saving a neg-
lected laryngeal diphtheria patient.
"This equipment takes up very little room
and may be carried by any practitioner in
one case, any time, and anywhere.
"Sincerely and fraternally,
"J. F. NASH."
St. Pauls, N. C.
This letter shows thoughtfulness and re-
sourcefulness of a high order, and that solici-
tude for the welfare of his patients which
provides appropriate appliances and sugges-
tions for meeting acute emergencies with im-
provisiations. It is fine, too, to note the con-
fidence which the writer reposes in the fam-
ily doctor. No finer or more deserved tribute
could be paid to his medical neighbors, nor—
though paid unconsciously — to himself. Per-
haps sitbconscioiisly would be the better word,
the subtle inlluence being exerted through
the name 5/. Paul's, and Dr. Nash being In
all truth "a man that is a Roman," "a citizen
of no mean city," "brought up at the
feet of Gamaliel."
Dr. Nash's letter will saves lives. Many?
A great many if every doctor who reads the
journal will, from day to day, from month to
month, from year to year, carry out his sug-
gestions.
March, 1929
SOUTHERN MEDICINE AND SURGERY
167
Our Idea of Propriety
We can not praise everything newspapers
do. Sometimes we are constrained to lift our
voice in protest against their way of doing
things. However, when excellence shows up
I we gladly acclaim it.
Every decent doctor deplores sensational
reports of cures brought about by himself or
his friends. Sometimes a reporter urges that
he must give the name of the medical man
in order to make a readable story. Here is
proof that this is not necessary. We make
our manners to the surgeons and newspaper
folks responsible, and pass this report on as a
model :
CHILD GOES TO HOSPITAL WITH
^ SAFETY PIN IN THROAT
U* (Special to Daily Ncu's)
Durham, Jan. 12. — With an open safety pin
lodged in her throat, the 10-months-old in-
fant daughter of Mr. and Mrs. A. J. Best, of
Burlington, was brought to a local hospital
Thursday for surgical treatment. The child
swallowed the pin Thursday morning, though
it is not known exactly how this happened.
The hospital surgeons were unable to ex-
tract the pin, but succeeded in pushing it
down into the stomach. The pin is not a
large one. and the child's condition is not con-
sidered critical. The child will be retained at
the hospital for several days, where doctors
will watch for any developments.
Shall Ultraviolet Rays Be Generally
Used to Complement Winter
Sunshine?
(Editorial, New Ent^land Journal of Medicine,
January 31st)
Recently a physician called this office and
asked whether a certain institution engaged
in using various forms of physiotherapy is
reputable and explained that a person was
considering sending a group of students to
be subjected to violet rays for the purix)se of
supplying the winter deficiency of sunlight.
There was no question of specific evidence
of the need of ultraviolet rays in the ensuing
conversation, but the question was asked why
not use violet rays if prolonged exposure to
the summer sun at bathing resorts is benefi-
cial.
Now comes the report of the warning in
the report given out by the New York Acad-
emy of Medicine published in the New York
fimes of January 9, 1929, based on the state-
ment that "expcriinental confirmation of the
well-known fact that cancer of the skin is
mijie frequent among those exposed to exces-
sive sunlight"' a warning is issued as a part
of the statement of three important steps
made in the study of cancer; the first and
second relating to the behavior of cells under
certain conditions and the third, which is en-
dorsed by some physicians, to the effect that
in certain cases "ultraviolet rays increase
rather than retard the effectiveness of the
agent producing cancer."
We are of the opinion that apparently
healthy children should not be subjected to
artificial ultraviolet rays and that this form -
of therapy should be under the control of com-
petent physicians. We are in an age when
all new therapeutic resources are overempha-
sized in the newspapers. We know that the
valuable properties of electricity have been
perverted to unwise uses. Enthusiasts as well
as quacks have been guilty of playing to the
imagination of the laity in many fields in the
improper use of many therapeutic agents.
LTltraviolet rays have become popular with
some doctors and are especially alluring to
the laity. Here as in many other depart-
ments of medicine a little knowledge may be
dangerous. We appeal to the profession to
urge the laity to refrain from using ultra-
violet rays unless advised and controlled by
physicians. Good ventilation and active ex-
ercise out of doors will, even in the winter,
make the use of artificial ultraviolet rays un-
necessary in the great majority of young peo-
ple who are without evidence of certain defi-
nite diseases.
I
More Quackery Squelched
(liditorial Wesl Virginia Medical Journal)
Below will be found two stories. The first
is an advertisement that appeared in a Wheel-
ing newspaper on February 5, 1929, inserted
by Dr. Robert .\. Patterson, "the cancer spe-
cialist of Philadelphia." The second is a
Ixnia fide newspaper story concerning the ac-
tivities of Dr. W. H. McLain, Ohio COUNTY
HEALTH OFFICER. [Italics ours.— S. M.
& S.] The two items in themselves tell a
much better story than could be worked out
by the editorial board of this journal. They
follow:
"Dr. Robert A. Patterson, the Cancer spe-
cialist of Philadelphia, will be at the Hotel
McLurc, Wednesday and Thursday, Feb. 6
SOUTHERN MEDICINE AND SURGERY
March, 192g
and 7, to consult with any person afflicted
with Cancer and to give a demonstration of
his method of treatment, by means of photo-
graphs of actual cases.
"On Oct. 26, 1916, The Evening Telegraph,
of Philadelphia, published a six-column arti-
cle pertaining to Dr. Patterson's method of
treating Cancer. Out of a large list of names
of cured patients submitted to the Telegraph,
twenty-six were selected for investigation.
"These people were interviewed by a rep-
resentative of the Telegraph. Twenty-five
reported that they had been permanently
cured, many of them after other methods had
failed, and one reported that he had been
benefited.
"Dr. Patterson has offered his treatment
for Cancer to the Rockefeller Institute for
Cancer Research. He will be especially glad
to demonstrate his method of treatment to
physicians."
* * *
"Dr. W. H. McLain ordered Dr. Robert A.
Patterson, Philadelphia, to cease practicing in
this city without a state license or he would
be arrested by health officials. This notice
was issued to Dr. Patterson following the ap-
pearance of an advertisement in an evening
paper of Tuesday, which carried a caption,
'Philadelphia Cancer Specialist Coming to
Wheeling.'
"Dr. Patterson was located at the McLure
Hotel Wednesday at noon by Deputy Sheriff
John G. Hammer. Deputy Hammer brought
the man to the county building, where Dr.
McLain interviewed him about his cancer
cure. Dr. Patterson stated he had a Penn-
sylvania license but he could not produce it,
while he also stated that he did not believe
that he needed a West Virginia license. He
denied any intent to violate the law in any
way.
"All the personal effects that the doctor
had, in a professional way, was a small
satchel of tools. Ajter receiving the warning
jrom Dr. McLain, the Philadelphia specialist
vhllcd the ojjice oj the newspapers and or-,
dered his advertisements 'killed.' [Italics'
ours. — S. M. & S.] There will be no charges
placed against him."
word for a 25-word summary of his adminis-
tration.
— 0. J. in Greensboro Nen's.
The Stanly News-Herald carried in a
recent issue an article of unusual interest to
doctors. Two slaves were executed in 1864
for the murder of the wife of their owner,
IMr. J. E. Austin, of Union County, N. C,
and their bodies were sold, for dissection, for
?100 each to Dr. Tabner Threat and Dr. Eli
Huntley, respectively. Thus we see that the
increase in their labors and the depiction of
their purses, combined, did not quench the
ardor of these country doctors in their quest
for knowledge of medical science.
Dr. Wm. H. Taylor taught us that often,
if the ancients could say )thing to us mod-
erns, "they would say something crushingly
uncomplimentary."
Manganese Butyrate in Furunculosis
E. L. Touby, after a clinical investigation
of about four years in the Duluth Clinic,
found that 2 hydopermic doses (1 and l.S c.c.
each) of a 1 per cent solution of manganese
butyrate, given at 4 or 5 day intervals, suf-
ficed to cure most cases of furunculosis.
About 70 to 80 per cent of his cases respond-
ed favorably, particularly if the blood sugar
was not too high and the patient had no other
obvious constitutional handicaps.
The manganese butyrate treatment was
just as effective for deep carbuncles as for
the superficial ones. The comfort of the pa-
tient was enhanced immediately, and incis-
ions and drainage were generally unnecessary.
— Clin. Med. and Surg., 1928, v. 35, via
Jour. Chemotherapy, Jan., '29.)
We reckon it would depend on how much
one needed an editorial writer as to how large
one's offer to President Coolidge would be.
Now -.ic d iliuught of tendering him a cent a
Woman Doctor Elected President
Dr. Norma P. Dunning, resident physician
of Winthrop College, has accepted the post
of president of the York County Medical As-
sociation to which she was elected by the
membership this week at a meeting held in
York. She succeeds Dr. W. G. Stevens, of
York.
Dr. W. C. Whitesides, of York, was cho-
sen vice-president and Dr. IMcGill, of Hick-
ory Grove, secretary and treasurer. Dr. E. E.
Herlong, of the Fennell Infirmary staff of
Rock Hill, was elected a member of the asso-
ciation.
March, 1020
SOUtltEkN MEbtCli^ AKb StJRGEkY
i6^
CORRESPONDENCE
Chadboiirn, N. C,
Feb. 27, 1929.
Dr. J. 'SI. N.irthington,
Ed tor, Soiitlicrn Medicine and Surgery,
Charlotte, N. C.
Dear Doctor Northington :
I wish you would investigate and find out,
if you can, who operates an automobile with
N. C. License Plate No. 261-272. The State
Department advises this number is registered
in name of M. L. Friedman, care Charlotte
Hotel, Charlotte, N. C.
Two parties have been operating a car in
this section with the above license number
and have been posing as doctors. They call-
ed on one party and one of these men went
into this party's house and told him he was
traveling in the interest of the state, examin-
ing eyes. He examined this party's eyes
and told him that he could not do anything
for him but that he had an expert in his car
that could remove cataract with radium and
that he would call him in. This party in the
car goes in and tells our man that he could
remove it but he was in right much of a
hurry, as he was on his way to Charlotte to
speak before the Medical Association, that
it would cost $300.00 for him to remove the
cataract which he attempted to do.
I e.-varnined this party's eye today and I
find th.at this party did not have any cataract
at all. The party posing as a doctor is a
crook and should be slopped. The party here
gave him $300.00 for Ih's fraud operation.
The man posing as the doctor gave his name
as T. B. Long. The car in which he traveled
is listed with License Bureau as M. L. Fried-
man.
I believe this party is operating out of
Charlotte in the rural sections and not in
Charlotte. I think the police could locate
him and that he would be most likely to be
there on week-ends. This party is very nicely
dressed. White, age alxjut 35 years, slightly
stout, slightly red complexion, about 5 feet
S inches, about ISO or 160 pounds.
If you can locate these parties I think some
action should be taken and I would be glad
tu have you advise me at once. I only gave
one of the parties' description, as I did not
Know the other.
With kind personal regards, I am,
Yours very truly,
W. F. SAHTH.
GOOD IDEAS FOR THAT TIME AXD THIS
(The following three cxiracis are jnmi I he Charies-
luit Mcdiail Journal, 1856.)
Tiie physicians of Allegany, Michig.in, have
adopted a set of rules, one of whicli we would like
to SLe tried on. They mutually pledge themselves
not to attend a patient unless the physician pre-
viously in attendance shall have been "regularly dis-
charged and satisfactorily compensated for his at-
tendance." And in case the patient refuses to settle
his back scores, they decline to attend him alto-
gether. Being sick is a luxury. If some folks had to
pay for it punctually they would indulge in it less
frequently.
* * * *
The address of Dr. Edward Warren is brilliant in
conception and polifhed in style. He is imbued with
lofty ideas of the dignity and usefulness of the pro-
fession, and he is a warm advocate of Medical Re-
form. Would that many more of the profession of
our country were ready and determined to carry out
his views. He felicitously eulogizes those gallant
h;roes who battled so manfully with the .'Vngel of
Death in the stricken cities of Norfolk and Ports-
mouth ; ^nd he pays a splendid tribute to the mem-
(ry of those who fell victims on that occasion; but
his cvuljcrant benevolence has led him to require
mi re of medical men than the experience of all who
h.ive practiced for many years will be willing to en-
dorse. Although he acknowledges the value of the
services of the physician, he denounces in the strong-
est term;; him who requires payment from his pa-
tients in proportion to their ability to pay. A few
years' experience will convince him that he never
rliinild have penned those lines which .nppear on
page 2.3 of the Transactions to which we have al-
luiled. 'Tis .said in Scripture, that "all a man hath
he will give for his life." Nowadays in our cities we
find that a man will pay every one else to whom he
m ly be indei)ted, before he thinks of paying the
physician who has been in Irumental in preserving
h's life. The members of the profession in our cities,
who sink beneath the level of respectability, are
guilty nf the very practice which the benevolence of
Dr. Warren would exalt into a virtue. The dignily
of the medical profession never can be obtained until
the community feels that their services are to be
rep.. id, not by gratitude only, but by the payment
of liberal fees. Men always undervalue that which
costs them nothing, and in proportion to the price
they pay, they estimate the .services they receive.
Hy the unanimous vote of the Society it was re-
s.lved to eslabli,h a Medical Journal in North Car-
oKn.i, under the auspices of the Society, if the re-
quisite number of subscriber? ran be obtainerl to
defny the expense-, of publication, and an Editor's
snlarv of ."MOO. The Journal is to be a bi monthly
of I2.S pages.— 7"r«HS. Med. Soc. Stale oj N. C, 18S6.
1^0
SOUTHERN MEDICINE AND SURGERY
March, 1024
DEPARTMENTS
HUMAN BEHAVIOR
James K. Hall, M.D., Editor
Richmond, Va.
Liquor and Lawlessness in Virginia
Doctor — I believe he is a physician — J. M.
Doian, Prohibition Commissioner of the
United States, has called upon His Excellency,
Harry F. Byrd, Governor of Virginia, for
information about the enforcement of the
prohibition law by the State of Virginia, and
the reply of Governor Byrd has given the
Commissioner and all the people of the state
something to think about. The figures made
use of by Governor Byrd refer to the differ-
ent courts of Virginia, and not to the United
States Courts.
In 1928 there were 15,297 convictions for
vilation of the prohibition law in Virginia.
In 1918 there were 1,717 convictions; in 1921,
3,184; in 1923, 5,438 convictions, and in 1926
there were 12,017 such convictions.
The tabulated report of the prosecutions
for violation of the prohibition law are even
as interesting. In 1928 the prosecutions
amounted to 20,005 cases; in 1918 there were
only 2,400 such prosecutions, but tlie number
increased each year, and since 1921 the in-
crease in prosecutions has been rapid.
The foregoing figures have reference only
to violations of the prohibition law. But the
data that follows immediately has reference
to commitments to prisons for all causes. In
1918 there were 21,631 commitments to jails,
and 452 commitments to the penitentiary. In
1921 the commitments to jails had increased
to 27,248, and to the penitentiary to 856.
And in 1928 the total number of prisoners
sent to jails had reached the astounding num-
ber of 39,254, and commitments to the peni-
tentiary had gone up in the ten-year period
from 452 to 1,036. The news story in one
of the Richmond dailies states that one Vir-
ginian out of every sixty of the population
was imprisoned in 1928, and that in that
year those convicted in the courts for having
violated the prohibition law alone would make
up a marcliing column about nine miles long.
Doctors of tlie art of medicine are not in-
frequently invited to make an interpretation
of statistical data. What is the medical
opinion about criminality so coldly recorded
above? We have heard that if the prohibi-
tion law were enforced violations of it
would cease. But in Virginia convictions
have not been followed by a lessened or a
lessening number of violations of that specific
law. Nor have there been fewer violations
of other laws. The statistical figures would
tend to indicate that prohibition such as
exists today in the Commonwealth of Virginia
has not brought along with it fewer violations
of other laws. If prosecutions and convic-
tions be looked upon as valid criteria the
people are becoming more and more lawless.
One wonders if whisky were as free and as
cheap and as accessible to the people as wa-
ter is in the Chickahominy flats what the
figures would be. And I personally wonder
what an accompanying financial table Wdul.i
disclose. What was the totality of the fines
imposed in all these convictions? What sums
were collected by prosecuting attorneys as
fees in these convictions? And what amounts
went to apprehending officers, office attaches,
and all others, as concomitants of these prose-
cutions and convictions? It is scarcely UkeW
that such figures will be published. But is it
not a fact that prosecuting attorneys wax fat
upon such convictions? Do they not receive
a sizeable fee for each such successful prose-
cution? And if more than fifteen thousand
citizens of the mother commonwealth were
convicted of violating the liquor law only last
year, may one not surmise with some degree
of accuracy that at least twice, treble,— or
not less than 100,000, or perhaps as many as
200,000 citizens did some violence to the pro-
hibition enactment? Such is the retrogressive
progress of a great reform. But if the viola-
tions of the Ten Commandments could all be
tabulated since their promulgation the figures
would likewise be depressing.
The Ecclesiastization of Tobacco
Time was in this country of ours when the
manufacture, sale, and personal use of alco-
holic beverages were in less bad standing
than in these latter days. I can recall out
of the days of a boyhood not many decades
distant that reputable citizens in North Car-
olina and in Virginia unblushingly distilled
whisky and offered it for sale to the neighbor-
March, 1020
SOUTHERN MEDICINE ANt) StJRGEkY
ih
ing public. Srme of the founders of our re-
public made it and used it, and the cheering
glass had its place in almost every hospitable
home in the South until after the Civil War.
Not infrequently I find myself wondering
about the cause of the change that has taken
pl.^^e with reference to the personal use of
alcohol as a stimulating drink. A generation
ago I heard a distinguished North Carolinian
rrmark that no one could have to do with it
in any way without being tarnished by it.
Rut his damning speech was voiced at the
conclusion of a brief spree. He himself was
a periodic drinker.
I have little doubt that the present-day
objection to alcoholism is largely economic
in origin. Our civilization has become mech-
anized and industrialized. Studies of the ef-
fect of alcohol upon the human body and
the mind tend to convict it of lessening effi-
ciency and of impairing judgment. Even the
slightly toxic individual is out of place in the
midst of machinery. Such a situation may
endanger his own life and place in jeopardy
the lives of others. Steam and gasoline and
electric currents may place enormous power
in drunken hands. Automobiles are engines
of death when steered by toxic drivers. The
cab of a locomotive is not the proper habitat
for an alcoholic engineer. The instruments
made use of in an operating room become
tremulously dangerous when manipulated by
shaky fingers. Care and precision and re-
straint are not listed amongst the psychologi-
cal effects of alcohol.
But the social status of whisky has been
damned by those who made it and marketed
it. Throughout the South at least the saloon
became more or less of a hovel and gentlemen
toiild not patronize it and come out of it
uiidarnaged. And whisky has been made use
of in the most cold-blooded fashion to bring
about personal degredation and to interfere
with proiier political activities. Those who
have had to do with alcohol have not kept it
in such repute as it enjoyed a century ago.
Then it was produced and enjoyed by the
nobility. And abroad good whisky must still
have such high a.ssociations. The manufac-
turers of ardent spirits in the United States
have been poor psychologists. Their appeals
have been made to the lower levels of society
and to the lower instincts in the individual.
They have not known how to secure the ap-
proval of good people. They have been ex-
ceedingly poor advertisers.
But not so has it been with the manufac-
turers of tobacco. In my boyhood schooldays
I studied a little volume on physiology in
which a final chapter was devoted to con-
demnation of the use of alcohol, opium, and
tobacco. But I doubt not at all that tobacco
has now been removed from membership in
that tripod of bad things. Tobacco has be-
come ecclesiasticized. Those who profit from
its sale pay just as careful attention to the
]Mi])lic attitude toward tobacco as they do to
the manipulation of the weed itself. The
tobacco manufacturers have become our chief
philanthropists. Without their considerate
care certain educational institutions would
suffer, orphans would hunger, hospitalization
of sick folks would be interfered with, mis-
sion causes would atrophy, church activities
would be lessened, and many elderly minis-
ters would miss some of the comforts brought
to them through philanthropists who are pay-
ing such careful attention to public opinion.
1 can easily remember when | ecclesiastical
organizations frcrjuently recorded their strong
disapproval of the ministerial use of the weed.
.^lul it was once thought as reprehensible for
a decent young woman to- smoke cigarettes
as for a man to sniff cocaine. But the psych-
ologists in the advertising bureaux of the to-
bacco industries have adroitly made it not
only decent but actually commendable in
young women to smoke cigarettes. Why not?
Is not every user of a cigarette a contributor
to the United States Treasury and to various
ecclesiastical and eleemosynary causes? Could
n:/y causes so beneficent and god-like in their
purposes as christianizing the heathen, hos-
pitalizing the poor, educating the ignorant
and ministering to the aged servants of the
Lord rest upon any basis other than solid
virtue itself? The use of tobacco has indeed
become sanctified.
Liquor would probably have as many
friends today in sanctified circles as tobacco
if the beer barons had been more ecclesiasti-
cal-minded. Every cause that is to succeed
must have the approval of good people,
whether the cause be Henry the Eighth, the
consumption of whisky, or the use of tobacco.
Governor McLean's Opinion of Dr.
Aldert Anderson
His Excellency, Angus W. McLean, retired
from the governorship of North Carolina on
112
SOtrrttEkN iiEMCiNfe and StJRGfERV
Marcli, 1020
January 11th. During the trial of Dr. Albert
Anderson in Wake County Superior Court in
November last I am certain that if Governor
McLean had been a witness his testimony
would have declared his strong disapproval
of the methods adopted for the investigation
of Dr. Anderson's conduct as superintendent
of the State Hospital on Dix Hill. Governor
McLean has unfortunately misinterpreted
some of my remarks as reflecting my opinion
that he had lent his approval to the prose-
cution. Such a thought never entered my
mind. Governor McLean has declared him-
self as entirely out of sympathy with the
prosecution of Dr. Anderson, and I have no
doubt that he thinks Dr. Anderson was con-
victed upon charges so frivolous as to be
ridiculous. Now that Governor McLean is
out of office I wish there might be a legisla-
tive investigation of the superintendency of
Dr. Anderson and of those carrying the prose-
cution through. The testimony of Governor
McLean before such a committee would be
illuminating. I am wondering if the Solici-
tor is going to prosecute Dr. Anderson fur-
ther? And if so, one wonders if the office of
the Attorney General will participate in the
next trial.
A good many people have assumed that
Dr. Crane, of the faculty of the University,
who lent his presence to the entire trial, is a
physician. I am informed that Dr. Crane is
not a doctor of medicine. He is a member of
the department of psychology in the Univer-
sity. I presume that he practices psychome-
try — a measuring of the intellect. The scope
of that work bears about the same relation-
ship to the practice of psychiatry that optom-
etry bears to ophthalmology. But a good
many lay people are engaging in the practice
of medicine.
The people of the State of North Carolina
may rest assured that Governor McLean feels
certain that a miscarriage of justice has taken
place in convicting Dr. Anderson upon frivol-
ous charges. The people of the state are en-
titled to know also that Governor McLean
has full confidence in the integrity of Dr.
Anderson and that he regards Dr. Anderson
as a highly competent public servant who is
rendering the state splendid service.
Many think of influenza under the name as com-
paratively modern but it is not. On a tombstone
in the cemetery of the Episcopal church at George-
town, S. C, the inscription in 1759 reads: that the
deceased died of jnlluenza. — Pee Dee Advocate.
PEDIATRICS
Frank Howard Richardson, M.D., Editor
Black Mountain, N. C.
Schick Test
The discovery of the to.xin test was made
by Schick, but the development of a practical
toxin-antitoxin remained for Park and his as-
sociates to work out. If an individual pos-
sesses no less than l/30th of a unit of anti-
toxin for each c.c. of blood, he has a natural
immunity to diphtheria. LTpon the injection
into the skin of 1/SOth of the dose of diph-
theria toxin required to kill a 250 gm. guinea
pig, the injected material acts as an irritant
and produces a local reaction, provided the
individual does not possess a natural immun-
ity. In case a natural immunity does exist
the injected toxin will be neutralized.
Zingher stated that percentage figures for
susceptibility vary widely. It is the belief
of many physicians that the new-born child
is Schick negative, but Schick states that 7 '
per cent are positive. The first six months
of life present about 30 per cent positive re-
actions, followed by a rapid increase to 50
per cent at the end of the first year of life.
The peak of susceptibility is reached by the
end of the second year, at which time about
70 per cent are positive. A gradual decline
then appears in the curve to the fifth year
when about 60 per cent are positive. At the
tenth year about 30 per cent of the children
are still positive.
It is interesting to note that children living
in congested districts show more negative re-
actions than do children living in the less
congested districts. The same holds true in
clinic work over private practice.
When three injections of toxin-antitoxin
are given at weekly intervals, at least 95 per
cent immunity results. This immunity may
develop within a few weeks but more prob-
ably in 10 to 12 weeks after the injections.
A Schick test may be safely done any time
after three months in order to learn whether
or not the child has been sufficiently pro-
tected. Should the test at this time be posi-
tive, two more injections of toxin-antitoxin
may be given to practically assure a negative
reaction. Prominent authorities feel that an
immunity so obtained will last for life.
An attack of diphtheria does not confer an
immunity to this disease as do scarlet fever,
smallpox and whooping cough. Children who
have recently had diphtheria should be given
March, 102y
ik)Utfi£kM UfibtCtKt AND StJkOERV
m
Pos.
Neg.
7
9
2
13
3
3
the Schick test following convalescence and,
if the test shows the necessity, they should
be given toxin-antitoxin, even if the diphthe-
ria had been treated with antitoxin. Chil-
dren who develop diphtheria despite the
toxin-antitoxin can be given a second series
of toxin-antitoxin should the Schick test be
positive following the attack.
In preparing to administer the Schick test,
the solutions should never be used if they
were prepared more than 24 hours before.
The solutions must be injected into the skin
and not under it. The reactions are to be
read after 48 hours as at that time the pseudo
reactions have begun to fade. The presence
of horse serum in the Schick toxin solution
cautions against the use of the test in children
who are subject to asthma and other condi-
tions in which anaphylactic or allergic reac-
tions are feared.
A recent private practice Schieck test done
on a group of 37 children showed the follow-
ing report:
Children who had had nothing
" " t. a-t.
" " " " antitoxin
The ages of the children who had had no
protection were 7, 4, 8, 2, 3, 6 and 2 years;
all these had positive reactions. Those in the
negative group were older — 9, 10, 12, 5, 3,
12, 13, 8 and 16 years of age. This finding
agrees with the statement that a natural im-
munity is acquired with age. The two chil-
dren who had had toxin-antitoxin and were
still positive were 8 and 7 years of age, both
having had three injections of toxin-antitoxin
more than a year ago. The ages of those
who were protected against diphtheria, as in-
dicated by Schick tests, were — S, 3, 14, 5, 6,
7, S, S, 9, 2, 4, 7 and 9 years. All of these
inoculations had been given at least six
months previously. The children who had
received antitoxin were evenly divided. None
of these children had had diphtheria, but
they were inoculated because of contact with
the disease. It is not felt that the dose of
antitoxin which any of these six children had
received had any influence on the outcome
of the Schick test, since the shortest interval
between the time they had received the anti-
toxin and the Schick test was four years.
A recent experience might be cited at this
time. \ child of a family in which there
were four other children, all younger, devel-
oped diphtheria. She was given 10,000 units
of antitoxin, and each of the other children
was given 1,000 units at the same time.
Three weeks later one of the children who
had been protected with the 1,000 units de-
veloped diphtheria, despite strict isolation of
the patient and two negative throat cultures.
The protection conferred by the 1,000 units
had expired. The second child was treated
with antitoxin, no untoward reaction occur-
ring from the administration of the second
dose of antitoxin.
EYE, EAR, NOSE AND THROAT
For this issue, V. K, Hart, M.D., Charlotte
Charlotte, N. C.
Vertigo as a Warning in Middle Ear
Disease
For this issue, V. K. Hart, M.D., Charlotte, N. C.
The sudden onset of marked dizziness dur-
ing any stage of middle ear disease sh(Hild
immediately demand close attention. It is a
warning of inner ear involvement — extension
to the labyrinthine structures. Hence its
name, labyrinthitis.
Consider a patient who has had a discharg-
ing ear for two or three weeks. Suppose there
is a precipitate attack of vertigo, compelling
the patient to lie on the sound side. He fears
to move his head. There is probably vomit-
ing and a nystagmus to either side or both.
The hearing is impaired on that side out of
all proportion to an ordinary middle ear con-
dition.
Here we have the picture of an acute laby-
rinthitis. There may be very little tempera-
ture and no external evidence of mastoiditis.
Nevertheless, the shrewd medical man will
not be thrown off his guard. The syndrome
is a clean-cut indication for an immediate and
careful mastoidectomy, freeing the semicir-
cular canals from overlying diseased bone,
and getting thorough posterior drainage from
tlie middle ear. There is usually considerable
mastoid involvement.
The appearance of this syndrome during a
chronic otitis media of long duration is also
an indication for immediate interference. In
this case a radical mastoid operation is done.
The actual opening of the semicircular ca-
nals and cochlea (lal)yrinthectomy) is rarely
undertaken in this country. What would
justify such a procedure? An impending or
m
SOUTHERN MEDICINE AND SURGERY
Kiarch, lo:'o
frank meningitis as shown by the clinical pic-
ture and spinal fluid findings. It should be
remembered, however, that many patients
with an increased spinal fluid cell count re-
cov:-r following appropriate mastoid surgery
alone.
'J he imperative need of interference with
such a picture is obvious, i. e., to prevent a
meningitis. The labyrinth having been at-
tacked there are three avenues to the sub-
arachnoid space: (1) by the nerve fibres
through the internal auditory meatus, (2) by
the aqueductus cochlearis from the perilymph
space of the cochlea, (3) by the aqueductus
Vestibularis from the vestibule to the saccus
ci;dolymphaticus.
Whether or not the labyrinthitis is to.x'c
(perilabyrinthitis from ovci lying diseased
boiic), or infective (direct break in one of the
canals, commonly horizontal, or passing
through the oval or round window); and
v.hether it is serous or suppurative, are ques-
tions of academic interest to the aurist and
not to the general medical man.
To epitomize: a sudden, intense attack of
vertigo during middle ear disease is a grave
warning. That patient should be an imme-
diate candidate for appropriate mastoid sur-
gery. If one waits until a frank meningitis
supervenes, finis is usually written.
LABORATORIES
For Ihh issiit', Nan.sie IM. S.\nin, M..\.
Charlotte
The Blood in Purpura
Rosenthal presents a classification of pur-
pura, as a result of his stud yof 172 cases
showing purpura as a primary or secondary
symptom. Basing his classification on the
clinical study and the study of the blood pic-
ture of his cases, he divides purpura into three
main groups:
1. Thrombocytopenic purpura or purpura
as a result of the diminution of blood plate-
lets.
2. Chronic thrombasthenic purpura in
which the blood platelets are normal in num-
ber but are altered in quality.
3. Purpura as a result of alteration of the
capillaries.
In addition to the estimation of the hemo-
globin, the enumeration of red and white
blood cells and platelets and the differential
count, the coagulation time, the bleeding time,
the clot retraction test and tourniquet or
capillary resistance test were done on all pa-
tients. Acute thrombocytopenic purpura,
chronic thrombocytopenic purpura and the
pupuras associated with acute and chronic
aplastic anemia, leucemia, subacute bacterial
endocarditis, pernicious anemia, tuberculosis,
carcinoma, typhoid fever, Banti's disease,
Gaucher's disease, and purpura as a result of
the intake of drugs belong to the first group.
In acute thrombocytopenic purpura there
is a reduction of hemoglobin and red cells in
projxjrtion to the loss of blood. The white
and differential blood counts are normal.
There is a marked reduction in the number
of platelets. The coagulation time may be
normal or somewhat prolonged. The bleeding
time is greatly increased, the tourniquet test
is positive and there is absence of blood clot
retraction.
The chronic cases of thrombocytopenic pur-
pura differ from the acute cases only in their
course. The blood picture in the chronic
cases is very similar to that of the acute cases.
The diminution of blood platelets is be-
lieved to be due in some cases to disease of
the bone marrow and in other cases to an
increased destruction of the platelets in the
spleen. In cases in which the reduction in
numbers of the platelets is due to disease of
the bone marrow, there is, after removal of
the spleen, a preliminary increase in the plate-
let count, but this is followed by a return to
the former low level. In cases in which the
reduction in numbers of the platelets is due
to destruction in the spleen the platelets re-
turn to normal after splenectomy.
The blood platelets in this disease are
changed in quality as well as reduced in num-
bers.
Cases of chronic aplastic ancnr'a showed
attacks of purpura with reduction of the
platelet count, prolonged bleeding and coagu-
I.ition time, positive tourniquet and absence
of clot retraction. Chronic aplastic anemia
dllfers from thrombocytopenic purpura in the
course which the disease takes but the blood
picture of the two diseases is very similar
except that in chronic aplastic anemia there is
a low white count with lymphocytosis.
The blood picture of acute aplastic anemia
shows a marked reduction of all the formed
elements of the blood. The bleeding time is
prolonged, the tourniquet test is positive and
there is absence of clot retraction.
March, 1929
SOtrrSERN MEblClNE AND StJRGERY
l«
Purpuras associated with leucemia show
platelet count, bleeding time, tourniquet test
and clot retraction test typical of thrombocy-
topenic purpura. In cases which show a nor-
mal white count, the differential blood count
showing the presence of immature cells, is
practically the only differential point in the
diagnosis of the two diseases.
Cases of subacute bacterial endocarditis
which showed purpura had low platelet
counts. Some cases showed normal bleeding
times, tourniquet tests and clot retraction
tests. In other cases the bleeding time was
prolonged. The tourniquet test was positive,
and there was absence of clot retraction. The
purpura in these cases was thought to be due
to capillary change as well as alteration of
the platelets.
Pupura associated with Banti's disease and
with Gauchcr's disease show blood pictures
very like that of thrombocytopenic purpura.
One case of acquired hemolytic jaundice
with pupura showed a low platelet count, but
the platelets were normal in quality as the
bleeding time and tourniquet lest and clot
retraction were normal.
Five cases of pernicious anemia showed
purpura with a marked diminution of blood
platelets. The equalitative change in the
platelets is not as great as in cases of throm-
bocytopenic purpura.
Purpura associated with two cases of tuber-
culosis showed a blood picture typical of
thrombocytopenic purpura.
True purpura as a result of the intake of
drugs was found in two cases. As a result
of the injection of quinine hydrochloride there
was a profuse purpura with reduction of
platelets and increase in the coagulation and
bleeding time. The tourniquet test was posi-
tive. Purpura observed in one case after the
injection of salvarsan showed the blood pic-
ture typical of thrombocytopenic purpura.
Purpura of this type was also found in a
case of carcinoma, typhoid fever and in a
patient who had a dermoid cyst of the ovary.
The second type of purpura, the chronic
thrombaslhemic, is differentiated from hemo-
philia by the presence of a prolonged bleed-
ing time and the absence of clot retraction.
This condition is found in both males and
females. The coagulation and bleeding times
were prolonged in two cases which Rosenthal
observed, but the platelets, the clot retraction
and tourniquet tests were normal.
The third group of purpuras is due to con-
ditions which affect the capillaries, as hyper-
tension and nitrogen retention, jaundice,
scurvy and Schoenlein-Henoch's purpura.
Five cases showing hypertension and nitrogen
retention associated with purpura showed re-
duced platelet counts and increased bleeding
times. Purpura associated with jaundice was
observed in four cases. These showed normal
platelet counts with prolonged bleeding and
coagulation times and positive tourniquet
tests. In scurvy the blood picture is normal
in cases with purpura except for a [wsitive
tourniquet test. Anemia may occur after ex-
cessive loss of blood.
Schoenlein-Henoch's pupura associated with
joint involvement shows a normal bl(jod pic-
ture except for the positive tourniquet test.
ORTHOPEDIC SURGERY
O. L. Mn.LER, M.U., Editor
Cliarlutlc, N. C.
Further Comments on Foot Ailments
When the average adult presents himself
complaining of distress in his feet, there is a
tendency to label his ailment "flat-foot,"
and relcr him to a neighboring shoe store for
some commercial arch supports. So great
has this tendency grown that people are now
inclined to go to the shoe store when they
have any kind of foot pain, and prescribe
arch supports for themselves or have them
prescribed by the shoe salesman. This prac-
tice has built up a great business in commer-
cial arch supports and prompted many shoe
stor^-s to more or less enter into the practice
oi medicine by having one salesman become
recognized as somewhat of a doctor for the
diagnosis of various foot defects, and for pre-
scribing various shoes and arch supports.
The main function of any store is to sell —
sell for prolit and sell to please the customer.
FLAT-FOOT
The condition, llat-foot, is a common thing.
Iherc arc many, many people who have llat-
foot but do not have any fool trouble. An
x-ray is not needed to make the diagnosis of
tli.s condition. Flat-foot is thought of as a
deiiiLSsiun, lo some degree, of either the long-
itudinal or lateral arcli of the fool, or the
tran.sverse arch beneath the heads of the
melatarsal bones. Flat-foot is an unfortunate
Uiin to use in describing a pathological con-
dition, since the arches may be depressed and
m
SOUTHERN MEblClNS AND StftGEftV
March, I9i0
be normal for certain individuals, or at least
painless. "Foot strain" is better terminology.
When there is pain in the arches of the
feet, it is due, in the majority of cases, to
prolonged or sudden strain of the muscles
aixl ligaments supporting the arches. One
should reason that, if the ligaments and mus-
cles have been properly exercised and cared
for, they will stand the stress of weight-bear-
ing without damage. Unfortunately, how-
ever, v»-hen an individual begins to wear shoes
so sriug that the foot muscles cannot function,
or walk so little that they do not function, a
fertile field is being prepared for foot strain.
Foot strain may come on gradually after
months of weight-bearing in ill fitting shoes,
or it may appear suddenly, following a hunt-
ing trip or an extra walk by an individual
whose foot muscles have not been kept con-
ditioned. Arch supports, under such circum-
stances, are merely crutches, as these feet
have every potentiality for being strong and
well. Wearing arch supports permanently to
lift feet whose muscles and ligaments are re-
laxed and without tone, represents a type of
laziness.
A foot with symptoms of strain in the lat-
eral arch may be supported a few days by
the well known strapping with adl)esive plas-
ter. This strapping should be of the simple
"stirrup" type, pulled a little tighter on the
inner side of the ankle. The adhesive strips
should be at least one inch wide and reach
from about six inches up the leg on the outer
side to eight inches up the leg on the inner
side. This will relieve pain in the acute stage
of foot strain. After the acute stage is passed,
the patient should be taught to tone up his
muscles and ligaments supporting the arches.
The muscles to emphasize in foot exercises
are the anterior and posterior tibial muscles
and tlie flexors of the toes. To exercise the
foot muscles means consistent practice for a
few minutes, several times daily, of active
forced adduction of the fore-foot and forced
flexion of the toes. It is an exercise that
would bb represented by picking up marbles
with the toes and dropping them into a con-
tainer between the feet. This simple proce-
dure will make strong, competent feet out of
the great majority of weak feet, or feet
known to be suffering from chronic strain. It
is understood that the patient will wear a
strong, common-sense walking shoe.
A weak anterior arch or depression of the
metatarsal heads is treated by placing a small
felt bad just behind and beneath the meta-
tarsal heads and snugly strapping it against
the sole of the foot with adhesive. The strips
should reach almost around the fore-foot and
several pieces of tape should be used. This
strapping temporarily reconstructs the arch
and the pad takes weight-bearing off the sen-
sitive m-talarsal heads. Again this strapping
should be applied only through the sensitive
phase of anterior arch trouble, and the pa-
tient should be taught the exercises suggested
above to tone up his normal foot musculature
and thereby make a competent and permanent
arch for himself.
Morton's toe
The condition known as Morton's toe is in-
terpreted as a depression of the anterior arch
of the foot where only one metatarsal head
is giving symptoms. This is frequently very
painful and often obstinate. The metatarsal
head irritates the nerves going to the pha-
lanx, and a burning sensation is referred alon<'
the toe. ''
The treatment is practically the same as
that outlined for the treatment of foot strain
localized in the anterior arch of the foot. It
will be necessary to protect the toe for quite
a period.
Of course, some arch supports are neces-
sary arid allowable, but the point I wish to
make is that if a foot condition is definitely
diagnosed and properly treated, very few
arch supports need be prescribed, and, if pre-
tcribtd, they will be built especially' for an
nidividual and usually worn temporarily.
BUNION AND HALLUX VALGUS
A bunion is the reaction of a metatarso-
phalangeal joint to the constant trauma of a
tight shoe. A bunion is often (he forerunner
of hallux valgus deformity. Hallux valgus is
hypertrophy of the inner aspect of the first
metatarsal head and various degrees of deflec-
tion, outward, of the great toe with conse-
quent deformity of its associated soft struc-
tures. (A very excellent article on hallux
valgus was published in the last edition of
this journal.)
The treatment of bunions and hallux val-
gus consists of wearing shoes which do not
press severely on the offending areas, until
the condition demands operation— and oper-
ation is usually and finally indicated if cor-
rection is obtained. Foot exercises, metatar-
March, 1929
SOUTHERN MEDICINE AND SURGERY
?al pads and bakinc; of tender areas about a
bunion may help. There is necessarily a dis-
turbance of the anterior arch in hallux valgus.
Quite a reservation exists in the lay mind in
re;);ard to having operations for hallux val-
gus. The few bad results which have follow-
ed some of the well known operations seem
to have been widely circulated. Statistics
favor the operation.
HEEL SPURS, BURSITIS AND ARTHRITIS
Right under the weight-bearinp; aspect of
the OS calcis is a favorite site for a small os-
teophyte to grow, or a small area of perios-
titis to occur. This is known as a heel spur.
It hurts offensively. It has been thought to
be quite often associated with gonorrheal
arthritis. It occurs in many patients who
have escaped gonorrhea.
The treatment of a heel spur is practically
the same as for an arthritis. It is usually
arthritic in origin. In the acute stage put
adhesive straps around the heel and a soft
pad in the shoe under the heel. As a rule,
they gradually smooth over and get better
with time. If the heel spurs persist, they may
be excised and the operation is attended
by the possibility of recurrence of even larger
processes.
r.ursitis and arthritis occur in the foot as
t!i(-se conditions occur in other parts of the
body. Arthritis is a rather common affection
of this member, and causes real discomfort.
Even though it is in the foot, it is still arth-
ritis, needs to be treated as such, and will
probably not respond very encouragingly to
the application of a pair of high priced arch
supports.
UROLOGY
HA^^Ir.T^^• W. Mc Kay, M D., F.ditor
Cliarlottc, N. C.
The Significance of Pyuria
Pus in the urine is an objective symptom
of great importance or it may be of no value
except to becloud the diagnosis. The proper
interpretation or significance can be placed
on this finding only when the following fac-
tors are definitely known:
1. Sex.
2. State of external genitalia.
?,. Technique, methods, and technical
terms.
4. A thorough knowledge and insight into
the manner in which the specimen is collected
and carried to the laboratory.
Unless we thoroughly understand and ap-
preciate all of these imp<irtant factors, jire-
liminary to the examination itself, we need
not proceed further with a discussion of ques-
tions like these: What is considered a pyu-
ria? Is it often of sufficient importance to
nnke a thorough investigation necessary to
fii d out the source of the pus?, or can the
examining physician argue to himself that
the pus in the urine is probably due to a
mild cystitis and dismiss the patient with a
prescription for urotropin? What does pus
in the urine mean to you?
To me it can mean much if I am assured
of the way in which the specimen is collected
and the way in which it is examined. At
other times I pay very little attention to the
report "pus in the urine." What is the use
to attach any significance to the report of
pus in the urine from a female child or adult,
v-.ho brings you a voided specimen of urine?
You do not even know if the bottle is clean,
to say nothing of the receptacle that the pa-
tient voided into at home. It is our custom
to invariably tell female patients, both chil-
dren and adults, that we prefer to collect a
fresh specimen of urine at our offices. In this
way we are assured not only of getting an
uncontaminated specimen, but we have an
opportunity to examine the external genitalia
and lower urinary tract. We can not empha-
size too emphatically a careful examination
of the urethra in girls and women with pyu-
ria. Given a female, child or adult, with pus
in the urine, if we carefully wash out the
urethra with boric acid or a normal salt solu-
tion, then pass a catheter, we are able to
obtain much information from this procedure
alone. If the washings from the urethra con-
tain pus and the cathetcrized urine from the
bladder is clear, we conclude that the trouble
is below the bladder or in the urethra. Much
information can also be obtained from wash-
ing out the anterior urethra of the male. I
have dwelt at length on the faultle.ss tech-
nique that should be employed in procuring
.'^pecimcns of urine for laboratory examination
and have insisted I hat in female children and
adults the physician should collect the speci-
men of urine himself, where it is possible for
him to do so.
]\Iany girls and women could be spared the
inconvenience, cost and discomfort of a com-
plete urological study if the proper collection
178
SOUTHERN MEDICINE AND SURGERY
March, 1929
of the specimen of urine and a careful inspec-
tion of the external genitalia, as is outlined
above, were made.
It is generally accepted that a few leuco-
cytes may be found in the urine of individ-
uals, apparently healthy and without symp-
toms. Whether these cells are physiological
or are the evidence of some pathological proc-
ess, not producing symptoms, is not known.
The fact remains, that a few leucocytes in a
specimen of urine do not necessarily mean
disease, which fact makes it necessary to de-
fine the normal limits, either by counting the
number of pus cells in the h'gh-power field or
by actual count of the cells in a counting
chamber. For practical purposes we gener-
ally accept from one to ten leucocytes to
each high-power field as a normal urine, ten
pus cells to each high-power field being the
upper limit of normal. Dr. Cuthbert Dukes
advocates the use of the Fuchs-Rosenthal
counting chamber in estimating the actual
count of pus in the given specimen of urine.
Ilis experience teaches that a count of more
than a hundred leucocytes per c. mm. points
to disease of the genito-urinary tract and jus-
tifies the designation of pyuria. So we must
be in close touch with our pathologist and
understand his arbitrary terms, as: a very
few pus cells, few pus cells, a " moderate
amount of pus, many pus cells, pus abundant.
To summarize: a carefully collected speci-
men of urine, examined fresh, by or under
ibe supervision of a competent co-operative
pathologist, are absolutely necessary factor.5
in determining what the significance of pus
in the urine has, and what should be done
about it. If we wish to avoid many pitfalls
we should make it a custom to inspect the
external genitalia and cathcterize all female
children and adults ourselves.
INTERNAL MEDICINE
Paul H. Ringer, .\.B., M.D., Editor
AshcviHc, .N. C.
A HOSPIT.AL OF 1S67
To most of us the very name of Thilip II
of Spain is anathema. He is thought of as
spending his time in working out new devil-
tries to be perpetrated by the Spaaish Inqui-
sition, as glorying in the burning of heretics,
as applauding the horrible cruelty of the
Duke of Alva in the Netherlands, and all
those things he did — and many more besides.
The building of the enormous palace of the
Escorial and the inclusion therein of the mon-
astery of San Lorenzo was the work of Philip
ITs mind and the realization of one of his
great ideas. He loved this palace — lived and
d:cd in it, having a small window cut into the
wall of his room so that at any time he might
look through' it and see the monks celebrating
mass at the high altar. For a brief but
graphic description of Philip's death the
reader is referred to Streachy's recent and de-
I'ghtful book, "Elizabeth and Essex."
Louis Bertrand of the French Academy in
a recent number of the Revue dcs deux
Momlcs writes fascinatingly upon Philip II
and the Escorial. During its construction a
hospital was built for the care of sick and
injured workmen. The details of the man-
a.:;emcnt of this liospital are so interesting
that the editor has translated several passages
and submits them here without further com-
ment.
".\s long as the construction oi San Lo-
renzo lasts there will be a temporary hospital
for the workmen and employees that are sick
or wounded. This was the first matter to
receive the attention of the King. Later, after
tlie building is completed this hospital will
become [vrmanent and will be open to pa-
tients from the surrounding country."
"The document on this subject is a model
of organization of wisdom and of humanitar-
ianism, v.hich today could well be carefully
ttud cd by our boards of public charities. The
duciunent is certainly the work of the monks,
but it was submitted to the king who read it
and apiiruved every detail, if indeed, he did
not ii.s.jae it in its totality. It is interesting
to peruse it, if only to discover therein a
Philip II far different from the one that is
u.,u->l]y thought of. It is evident that in his
est mation the salvation of souls takes the
firtt place. We perceive in the midst of these
lengthy pages filled with meticulous instruc-
tions the persevering desire and the noble
wish to lift the poor people, that will come
to file hospital to suffer and to die, above their
earthly miseries. Those that are to care for
them must be filled with this idea, must treat
them with gentleness and must secure for
them creature comforts which they would be
unable to find at home. 'In the first place,'
s:iys the document, 'the clerk, the orderly,
the cook and all others who are to wait \i[yo\\
the sick must have much love and patience,
Marrh. 1030
SOUTHERN MEDICINE AND SURGERY
they must he very zealous for cleanliness and
very careful, all these things being indispen-
saiile for the patients' welfare.' "
"Patients will fust be seen by the doctor
who will set apart those suffering from con-
tacious or incurable diseases. These will- be
cared for elsewhere (a very wise measure con-
S'dcring the agglomeration of workmen which
swarmed over the Escorial during the years
necessary for its completion). Patients ad-
mitted to the hospital will be urged, if strong
enough, to go to confession and to receive the
Holy Communion 'so that they will not die
like bea-^ts.' Before putting them to bed
they will be washed and if necessary their
hair and beard will be clipped. They will
be (riven clean shirts. Their clothes will be
washed so that they will be clean upon the
patients' d'scharge from the hospital. Those
who have open wounds will be segregated in
order not to infect others and in order not
to annoy them by the bad odor of their
wounds * * * when the Holy Sacrament is
brought in the ward must be in good order
and perfumed (with incense) * * There will
be a separate mom for the administration of
extreme unction to the dying in order that
other patients may not be disagreeably af-
fected by this ceremony * *. When a pa-
tient is about to die the bell will be tolled so
that prayers mav be said for him in the mon-
astery and in the village in ord^r that he
shall not d'e like a beast * *. Finally the
priest who has charge of the patients must be
a man of far-reaching charity, patience, pru-
dence and humility * * *."
"When a patient dies the mattress and bed
linen must be disinfected at once * ♦ *.
Chicken and fresh eggs must always be avail-
able for fel)rile patients who may not be able
to eat at the regular meal hours * *. Toilets
for pat'ents, who are strong enoueh to be
able to use them, must be cleaned twice a
day and disinfected each time that the hos-
pital is disinfected. Bed pans and urinals are
to be scalded and thoroughly washed each
week. They must always contain clean wa-
ter * *. Patients able to be up must have
sh'ppers and bath robe at their bedside * *.
Sheets, p'llows, shirts, handkerchiefs and all
other linen must be changed each week in
summer and every fortnight in winter and
tnorc often if necessary * *. When a patient
has taken a cathartic the orderly will give
him chicken or mutton broth in accordance
with the doctor's orders * * *. When the
doctor prescribes an early breakfast for con-
valescents they will be given in summer c'lcr-
ries. prunes or a slice or two of good melon,
and in v.intcr dried grapes or dried fi^s * * *.
The orderly will boil all water used and in
summer he will be careful to b')il it in small
quantities at a time lest it should become
contam nated and he will further see that it
is kept in jars that are scrupulously ckuin.
Dclwcen each two beds tliere will be a cur-
tain, a little medicine closet and a cuspidor
* *. Patients will have a bed table so that
they may eat comfortably while in bed and
at the foot of the bed there will be another
curtain so that otlicr patients will not see the
dying or those attending to the duties of
nature * * *. In cases of hyperpyrexia a
piece of oil cloth will be placed between the
fheet and mattress in order to cool and com-
fort the patient * *. Braziers will be pro-
vided to keep patients warm in winter and
incense pots to keep the air in the ward
pure * *. Finally( a picturesque and touch-
ing detail) there will be a gill cup for the
administration of medicines."
"We offer no excuse for calling the attention
of the reader to these details of hospital man-
agement and human suffering which the Cath-
olic king deemed worthy of his closest atten-
tion. If we consider the rough ways of the
times (1567) and that this hospital was or-
ganized for workmen, masons, carters, hos-
tlers and the like, we must be surprised to
find such concern not only for their souls but
for llicir physical hygiene, their comfort and
tlicir bodily cleanliness. What we particular-
ly with to stress is the strikingly modern
character of this document, and, if we add
th:it there was a pharmacy connected with
this hospital, managed by a monk who was
a true chemist, we will get a better idea of
one of the essential thoughts of its founder,
namely: to incorporate in the Escorial the
sum total of the science and art of his time
and to make it a sort of monumental encyclo-
pedia in which all knowledge and all techni-
cal methods will direct their supreme effort
and their uttermost ramilications toward the
(levclo)iment of one single idea."
Every coin has its obverse and its reverse.
So has every personality and as tliat of Philip
1 1 has been mainly viewed from tlie obverse,
tlie foregoing pages give a iitllc-known pic-
ture of the reverse.
SOUTHERN MEDICINE AND SURGERY
March, 1929
SURGERY
Geo. H. Bunch, M.D., Editor
Columbia, S. C.
Brain Injuries
Althousih addinsj but little new information,
the volume of William Sharpe, of New York,
on Brain Injuries, published in 1920, has
been the means by which understandinij of
the chancjes taking place in brain tissue after
trauma has become more general amonc; phy-
sicians. With understanding has come more
intelligent treatment. Indeed the treatment
of brain injuries has become crystallized so
that it is essentially the same in most modern
hospitals. We now know that unless the in-
dividual be killed outright at the time of in-
jury the pathology in the injured brain de-
velops by stages, each of which has charac-
teristic symptoms making its recognition pos-
s'ble. Experience has proved that proper
treatment varies with the stage of pathology.
Treatment that may be curative in one stage
may be fatal in another. In these patients
there may be a time for watchful waiting, a
t'me for medical treatment and a time for
active surgical interference.
Brain tissue is the most highly organized
of all the tissues, and nature has been lavish
in her efforts to protect the brain from trau-
mi. The arches of the feet, the curves of
the long bones, the curves of the spine, the
intervertebral cartilages, the cerebro-spinal
fiu'd, the skull itself — all serve to protect the
brain from jarring and from injury. Frac-
ture of the skull is of importance only as it
affects the brain. Tearing of a meningeal
artery is of serious import only because of
increased intracranial pressure caused by the
extravasated blood. Tlie delicate brain can-
not function if under increased pressure. Im-
mediate death from liead injury is due to
actual destruction of brain tissue by trauma
but death coming later is most apt to be
from intracranial pressure.
.Vfter every severe brain injury there is
shock with an increase in pulse rate and a
fall in blood pressure. The patient may or
may not be unconscious. He is pale and in
a i.old sweat as he is brought into the hos-
pital. He should be put to bed and kept
warm. If restless morphine should be given.
No detailed examination or x-ray study should
be attempted until he has recovered from
shock. The time of reaction will depend upon
the severity of the injury. If trauma to the
brain is too great death without reaction is
inevitable. It is a common mistake after head
injury to place the patient in a car and tc^
rush him over rough roads to a hospital.
Such a /n^") only intensifies the trauma arjd\
deepens the shock. It costs more lives than
saves. After admission the treatment of this
the first stage after head injury is rest. Re-
action from shock is indicated by a return of
the pulse rate and of the blood pressure to
normal. Now — and not until now — should
complete examination of the patient be made
and the extent of the injury, so far as possi-
ble, determined.
The patient may recover after reaction
from shock or may enter into the second
stage, medullary compression, marked by a
progressive increase of blood pressure, a pro-
gressive fall in pulse rate, a progressive rise
in cerebro-spinal fluid pressure as shown by
the spinal manometer, and by edema of the
optic d'sc as shown by the ophthalmoscope
In this stage active measures should be taken
to prevent increased cerebro-spinal pressure.
Rejieated spinal tapping is useful. If the
patient can swallow, dehydration from yi
ounce of saturated solution of magnesium
sulphate by mouth every 2 hours, is advised
by Dowman of .Atlanta in the Southern Mlcd-
<Val Journal, May, 1925. He says that if
water is denied the patient, purging is not
e.\cessive. If unable to swallow, the patient
may be given a hypertonic solution of mag-
nesium sulphate or sodium chloride by rectum,
or into a vein. It is remarkable what a fall in
intracranial pressure dehydration will produce.
Frequent observations must be made and,
if, in spite of measures to control it, intra-
cranial pressure continues to rise, subtempora'
decompression is imperative to save the lif*-
of the patient. Under local anesthesia this
simple operation may be done on one or both
sid.s with very little shock. When the dura
is opened, if a brain is under great pressure,
its soft consistency may allow of its being
forced through the opening and thus injured.
This may be prevented by draining the lat-
eral ventricle with a brain trocar or needle
before incising the dura.
The third and last stage of development
after brain injury is medullary edema — the
so-called wet brain. There is a falling blood
March, 1029
SOUTHERN MEtdCINE AND SURGERY
181
pressure, a rising pulse rate, and a continu-
ously rising intracranial pressure. The pa-
tient is essentially moribund and ultimately
dies no matter what treatment is given.
E.xperience teaches the wisdom of conserv-
atism in the treatment of brain injuries.
Operation is only useful in the second stage
and only then if other treatment fails to con-
trol intracranial pressure. A symptom-free
interval after injury followed by unconscious-
ness means e.xtradural bleeding from the mid-
dle meningeal artery. The skull should be
opened and the vessel tied.
PERIODIC EXAMINATIONS
Frederick R. Taylor, B.S., M.D., Editor
High Point, N. C.
Abdominal and Rectal Conditions Found
IN 271 Consecutive Health
Examinations
Condition No. of Cases
Very lax abdominal wall
Visceral adhesions
Chronic appendicitis 26
Subacute appendicitis
Bacillary dysentery
Convalescence from cholecystectomy and
appendectomy
Mucous colitis
Obstinate constipation
Chronic diverticulitis
Epiplocele
Chronic gall bladder disease 1
Functional gaseous distention
Chronic gastritis
Bilateral femoral hernia
Bilateral inguinal hernia
rnilaterai inguinal hernia _ 1
Umbilical hernia
Cirrhosis of liver
Carcinoma of liver, secondary
Tuberculous peritonitis
Chronic sigmoiditis
Carcinoma of rectum
Hemorrhoids _. 3i
Polyp of rectum
Tendency to prolapse of rectum
.'>lricture of rectum
Tiital 120
Comment: To those who have been fol-
liiwing these reports from month to month,
it will be obvious that the figures here pre-
sented are peculiarly open to question. There
are a number of reasons for this. In the first
place, a remark once made by Ur. David
Riesman in one of his great clinics at the
Philadelphia General Hospital applies with
peculiar force, and that is, that chest diagno-
sis is child's play compared with abdominal
diagnosis. Not that chest diagnosis is liter-
ally child's play, by any means — it may be
exceedingly difficult, but relatively speaking,
abdominal diagnosis, especially in the non-
acute cases such as one usually encounters in
health examinations, is full of pitfalls into
which even the very elect will often plunge
headlong. We wish, therefore, to state at
the outset of this discussion, that in this list
will probably be found a larger ratio of wrong
diagnoses than in previous lists. Then an-
other factor is operative, and that is this: a
few of the persons examined whose cases are
included here were not strictly health clients,
as they had some definite symptoms, yet they
were included here for reasons that will be
given in discussing their individual cases.
Let us now consider a few of the items
that may be considered more or less contro-
versial.
Chronic appendicitis: There seems to be
an increasing tendency to deny the existence
of this condition. Dr. Carnett, of Philadel-
phia, recently expressed a view of this sort
in the Journal oj the A. M. A. It is a rather
accepted viewpoint at Harvard. We do not
wish to argue the point on the strict etymolo-
gic derivation meaning an actual inflamma-
tion of the appendix, though perhaps we
should. The point we wish to make is that
we believe there is a condition characterized
by various types of chronic indigestion, with
tenderness over the appendix, more or less
constant, that is cured by appendectomy. The
opponents of the diagnosis seem to deny the
value of apjjendectomy in such so-called
cases. We freely confess that many mistakes
are made in labelling certain conditions as
chronic appendicitis that have nothing what-
ever to do with the appendix, and after oper-
ation the last state of such patients is worse
than the first, yet we have .seen too many
persons cured of abdominal distress that had
persisted for years, not to believe that there
is a chronic clinical entity, the pathology of
which is in the appendix, be it inflammation,
obstruction, adhesions, kinks, or what not,
curable only by appendectomy.
Bacillary dysentery: This was a mere co-
incidence— an apparently healthy man had
182
SOUTHERN MEDICINE AND SURGERY
March. 1020
been asked to come to the clinic by his doctor
during prel'minary arrangements, and the day
he was examined had been seized with a mu-
cous bloody diarrhea that clinically had all
the earmarks of an acute intestinal infection
— onset with chill, fever, etc.
C/iionic diverticulitis is a risky diagnosis to
make on clinical findings only, without an
x-ray study, and of course may be wrong.
The picture of a left-sided chronic appendi-
citis in a person who does not have an ob-
vious transposition of viscera is what led us
to this tentative diagnosis in two cases.
The patient whom we thought had second-
ary carcinoma of the liver seems worthy of
mention. He was very cachectic, looked very
sick, had lost about 40 pounds, had a large
knobby liver, yet insisted that he wasn't par-
ticularly sickl The primary focus was not
found, but was suspected to be in the stom-
ach.
Tuberculous peritonitis seems a weird diag-
nosis in an apparently healthy person, yet the
two patients examined who seemed to give
evidence of this did not consider themselves
sick to amount to anything. Vague doughy
masses throughout the abdomen such as are
found in the plastic type of this disease,
were the main basis for the diagnosis. Slight
fever and general abdominal tenderness were
also present.
The patient with carcinoma of the rectum
was obviously sick, but is included in these
figures for a particular reason. She was a
physician's sister, and was supposed to be
healthy except for an antral sinusitis, for
which she was being treated by a specialist.
She was cachectic and had lost much weight.
She had previously stated that she was con-
stipated, and the statement was accepted
without elaboration. On further questioning,
however, she stated that defecation was pain-
ful and often accompanied by blood, and
that this condition seemed to be getting pro-
gressively worse. Rectal examination showed
a large mass that made even a digital exam-
ination extremely difficult and painful.
A stricture of the rectum is, of course,
I'kely to be specific in origin. As previously
stated in this department, however, we do
not attempt to collect figures rega^'ding syph-
ilis, as when we send in blood the report
comes back to the patient's doctor, and we
rarely hear from it. We d'd, however, hear
a startling thing that sounds too good to be
true. We took routine wassermanns on the
boys of the Eastern Carolina Training School
at Rocky Mount. .\t that time we expressed
the view that one of the 67 boys examined
piobably had clinical congenital syphilis. If
the report from one of the teachers there is
correct, that one boy was the only one who
showed a positive wassermanni A larger se-
ries would no doubt have a healthy chasten-
ing value for our diagnostic pride, but we
have been humbled diagnostically so often
that we see little cause for inflation of the
ego because of an interesting coincidence
such as the above.
OBSTETRICS
Henry J. Lancston, B.A., M.D., Editor
Danville, Va.
Pregnancy Complicated With
.Appendicitis
Pregnancy complicated with appendicitis is
a very common condition. INIany practition-
ers meet with it every week of the year. It is
apparent that we follow the conservative prac-
tice in managing this condition.
I have followed the conservative practice
of watching and waiting and treating the pa-
tient palliatively, namely, by keeping her in
bed, ice cap to side, small quantities of water
by mouth and warm soda enema daily. Many
cases have bsen brought safely through the
attack by this method, and I was able to de-
liver these patients successfully. Several of
them since having babies have had their ap-
pendices removed. This conservative princi-
ple was practiced until three years ago, at
which time a patient seven and a half months
pregnant, had an acute attack of appendi-
citis, which I felt was a case for operation
and urged operation. Patient refused opera-
tion. She was treated palliatively and re-
covered from the attack. Six weeks later,
almost simultaneously with the advent of la-
bor, there came an acute attack of appendi-
citis. She had nausea and vomiting, pain in
her right side and fever, added to the pains
of labor. Her baby was delivered without
difficulty: but before the delivery something
had happened in the abdomen. Her temper-
ature went up and she developed symptoms
of peritonitis with nausea and vomiting. With
this condition the question was what should
be done. Again a conservative principle waj
followed by ice caps to abdomen. Fowler's
position and rectal feeding. After five days
March, 1Q29
SOUTHERN MEDICINE AND SURGERY
she (lied of general peritonitis as a result of
ruptured appendix.
This experience forced nie to take a dif-
ferent position in the matter of appendicitis
complicating pregnancy. The way we pro-
pose to answer the above question is in this
manner:
After a definite diagnosis of appendicitis
has been made we cannot justify ourselves
scientifically in treating the patient pallia-
tively. The dangers are too great. Operation
is indicated, for appendicitis and pregnancy
do not keep good company. The period of
pregnancy makes little difference. These pa-
tients do better if they are operated on under
spinal anesthesia. Wonderful relaxation is
obtained, there is practically no nausea and
vomiting following operation, and it does not
irritate the kidney, central nervous system
or lungs. A recent case in my own practice
illustrates the principles involved. This pa-
tent was seven and a holf months pregnant.
The attack was typical with a leucocytosis.
Consultation was held and the consultant ad-
vised watching. This principle was followed
for a few hours, after which time the patient
was operated on under spinal anesthesia. The
appendix was found badly infected and was
easily removed. Recovery was uneventful. Re-
cently she was delivered of a full term baby;
today she is up on her feet and is able to look
after her baby and is enjoying a most satis-
factory convalescence.
.Many times during the past two years I
h-ive found it necessary to remove an acute
appendix where patients were pregnant. Not
one of these cases aborted or miscarried; all
of them recovered from the operation; many
of them have already been delivered, and
there are a few yet to be delivered. The
(|uestion may be raised as to the difficulties
which one may encounter at delivery follow-
ing an appendectomy. If the patient is prop-
erly managed during the prenatal period and
is brought up to the hour of labor in first
class physical condition, even though she has
h:.d to have her appendix removed, delivery
can be effected as easily and as safely as in
cases where there has been no operation.
The solution to our problem may be regard-
((! as radical in a sense, but it is safe and
round, provided each patient is thoroughly
■■■tudied and the principles of practice applied
after projjer conclusions have been reached.
We are losing a great many young women in
the United States annually from appendicitis,
and no doubt a great many of these lose
their lives during the period of pregnancy or
immediately following delivery as a result of
appendicitis and its complications. We can-
not be too alert to recognize this condition
and treat it properly wherever possible.
NEUROLOGY
Omn B. Chamberlain, B.A., M.D., Editor
Charleston, S. C.
.\ Case for Diagnosis
It is well recognized that the problem of
epilepsy becomes more complicated and far-
reaching as we learn more about it. It is
becoming increasingly apparent that the
chance of arriving at a simple formula, ex-
pressed either in metabolic or psychic terms,
by which we can explain the genesis of every
case of repeated convulsive attacks, is almost
impossible. It is likewise better understood
today that there are many recurrent phenom-
ena of widely varying nature which have a
relationship and fundamental similarity to
epilepsy — or as one says nowadays, the epi-
lepsies.
Psychic equivalents refer to mental epi-
sodes which occur at intervals and replace the
spells of unconsciousness or convulsions.
These episodes are generally of such short
duration, and so frequently does one obtain a
history of at least a few frank convulsions,
that the diagnosis is seldom in much doubt.
At times, however, the period of excitement
or automatism may last for several days or
weeks. Diagnosis will not be so simple. If,
in addition, no satisfactory history pointing
to the possibility of convulsive seizures or
petit mal attacks can be obtained, the situa-
tion is much more obscure.
A case which the writer has under obser-
vation illustrates the difficulty of a decision
under such circumstances:
A young man of thirty was first seen in
consultation six months ago. He was then
in a hospital restrained in bed. He was ex-
cited, somewhat confused, and evidencing a
marked negativism. He talked almost con-
stantly, showing much verbigeration and
stereotypy. The history was meagre and the
tentative diagnosis of dementia precox was
advanced. The excited condition cleared up
in a few days — and the patient was not heard
from again until lately when he was trans-
184
SOUTHERN MEDICINE AND SURGERY
March, 1929
ferred to the writer's care for observation and
diagnosis. When he presented himself at the
office he was entirely rational. He gave an
accurate and clear history which may be sum-
marized as follows: During childhood he
was regarded by his family as being "nerv-
ous." Upon analysis this seemed to mean
that he was easily embarassed, and rather
introspective. He suffered a great deal from
night terrors. He did not like school and
began work early. He was a steady worker,
but d'd not learn a trade. He became a semi-
skilled laborer. His se.xual life, does not, on
the surface, appear to be abnormal. For sev-
eral years he has been a tailor and he is able
to have normal intercourse.
Ten years ago he had his first mental epi-
sode. The attack came on suddenly. For a
day or so he felt depressed and he then
quickly went into a state similar to that in
which the writer had first seen him. The
attack lasted five days, leaving him almost
suddenly. He returned to work and was per-
fectly normal until about two years later when
he had another attack. He has had eight in
the past ten years. The shortest lasted three
days, the longest three weeks. One attack
came on suddenly with a "fainting spell." He
has little memory of what happens during
one of these episodes. His only definite rec-
ollection is that he seems to be under some
strong impulsion to resist anything anyone
wishes to do for him. He has never tried to
harm anyone, and if left alone will wander
around the house, talking continually to him-
self. He refuses food and medicine and is
very weak when the attack is over.
Physically he is well developed and pre-
sents no organic defects. His intelligence is
average. He has never drunk to excess. Be-
tween attacks he is energetic, a willing work-
man, and he leads a quiet respectable life.
It is apparent that the case might well be
considered a psychoneurosis, with an emo-
tional complex in the background. Space does
not permit the writer to bring out the con-
s-derations which incline him away from
such a diagnosis. It seems most likely to
him, however, that the condition is probably
that of epileptic psychic equivalent of an
unusual type.
"Was the Thomas Christmas party a success?"
"Was it! I wore home a wreath of holly and
they had my hat hanging in their window for three
days!" — Colorado Medicine.
HISTORIC MEDICINE
For this issue, Robert W. McKay, M.D.
Charlotte, N. C.
Ephraim Brevard
In 1765, after the revocation of the ed'.ct
of Nantes, there left France a young Hugue-
not, whose name was John Brevard. After
fleeing his country, he settled in the northern
part of Ireland, among the Scotch-Irish, who
were also exiles from their native land be-
cause of religious prejudice.
When the Scotch-Irish of his immediate
vicinity decided to emigrate to America, John
Brevard left with them and on the long voy-
age across the Atlantic he fell in love with a
daughter of a Scotch family, by the name of
iXIcKnitt, who temporarily diverted his mind
from the free lands of the new continent.
After reaching the new country they married
and the young couple settled in Cecil county,
of what is now the state of INIaryland.
Of this union there were born five sons '
and one daughter. Three of the boys and
their married sister joined the flood of im-
migrants which was pouring down into the
Carolinas from the North, and they settled
between the Yadkin and Catawba rivers in
1747. The eldest of these three brothers was
also named John Brevard. Before his emi-
gration from ]\Iaryland he had married the
daughter of a Scotch-Irish doctor by the name
of Alexander iMcWhirter.
Previous to this emigration E])hraim Bre-
vard was born in the state of iMaryland and,
at the time of the family's moving to North
Carolina, he was three years old. On
the long and arduous trip South, he had the
misfortune to lose an eye. The cause of this
misfortune is not known.
Ephraim grew up near what is now IMt.
iMourne, on the main highway between Char-
lotte and Statesville. His early education was
very carefully looked after. He was taught
at home and at a community school organ-
ized by the colonists. At the conclusion of
the Indian war in 1761, he was sent to a pre-
paratory school in Virginia, and, after this
preparation, along with some of his neigh-
bors, he entered Princeton College in 1766.
In those days the curriculum was quite short.
He was graduated in two years and taught
in the state of iMaryland, "reading medicine "
the while under Dr. David Ramsey. After
acquiring a certain degree of proficiency in
March, 1020 SOUTHERN MEDICINE AND SURGERY hi
#<tg 20:2 1775 ^ ^
llTCj6<>luca— - (!.l\t\l rohosiumer »UrrcU^ or mdlrrcltg aWtc or \n rtu\) wni' form i»r
turtuncr. aun\lc«rt«i-f3 Ihc umaoion of ot>r rigjtts.ns allrmplfd bg&r ^arltararul of fircalSnl-
iimisnu I'urm^lohiftrotmlr^lOcArofrira.rttuI tWnq,Ms ofwuxn.
Ilrsoluri} — ^hal voclKr r%r»\3 of^ttfrWcttbor^cotrnti^ilokrcVi) dtswlur Ihc
political Ixtiids which have ronncclcil t>5 nirththc nmlher cotmlrg.nad absolwc oursclocs fmm
all rtllcinauci- lolhc^JnUsh croumahjnrtn^ all jioliUcol conncclimi toilKo uahonlhal bar.
wanloiils Irainplcil on ovv rights ami Ubfrhes omhnhwniftntgsWdlhc imioccnl blooil of
-Awcncans al IV.vini^lcin
■tti'solwpil — ^hal \v( ilo hfYcbi^ ilcclarr cujrscbf s a free nnd indcjjtnUml people,
ihni tvr arc nnjl of vio.hl otniUl to bo, a soticrcign and sflf-^oxrertiin^pieopkpuclerthcpoin-
cr o( Jjioil am' the i)f ureal JfAnirtrcsGilo Ihc mntnlftiftUT? ofrohui imdcpnulfttce wc liolcimnlu
^Icilo/ 1o each olhtv oor luulwrtl co cjjerolion.mjr hws, oor tortonrs.cmdOTnr loosl sacrcit honor
^ic'iohu'il — - ^irti tv? Uo hereby onlaitx and aAopi Mvoki ot «jn(lncl,aU an»l each ol owr
fovincr IftWo rturi Uic cvoiun o! pi»vcat|!?nlatn cannot be cotisiilfredhrrcallcr as holding
aui] vi*ihts primU'iH's or imniDutlic3 amougdl v)$
^^o<;oliTCil — fTUrtt all afhccrs.tiolbi'ivil (indTOiUlar^mlhiscomili] be eulillcdlo
e.rcrriee Ih: sjomc );ioi>>erG n«d «wlhonlif4 a« heretofore ; tUat eoct^ wiember of\hi6 dclc-
v^ulion shall brnccf orlh be a etpil officer, and exercise the f)otxicr$ of a justice of Ihe peace
issne process hear and delertnme e\ndronerdtr;9 acrordm^tolanj.preserne peace ttnion
<x\n\ harmony u\ Ihr cxJijnV^.and osf eoer^ cvttUon to spread the lone of UbtrVg and ot
coonlrg unltl a wore ^iwral and belter orqanyed system gt^onemnicnl be CAtablishcd.
^i^eooKicd — ^ihftl a copjE^ ot these resolnltons be transnxttled b\) cjcpres's lo tbe^res-
ident of iW jff 0 rihncxital p>0TXgre5a acstmhltA inPitladelphui to beloid before tbnt bod^ .
ItpVirOim Htnxrr.! — •" M" »»■»»"*>»
lArjr6»oh 31 JBaUV ffhaiUs AlexAadflc
Into yWtr Tottltire lUiIson
Ik." <t ««.ri5 — -".^^ UJoljiililin Atitj
VohnVotil _ ^ (Ilr.Uli»ii,1H'l'l""
UlAatii8«rjj Will inotr,...
V«..rvj'>"~ «eib<il J)<u,l«
\UAUvn Ct.km^ j}.. J «.«,-
TfiajstilaH ftWiowfltr Piebmil UokK
Pbomas Pfflft.
Dr Eplirnim Rri-v:irrl was tlic author of the above "Mecklenburg Declaration of Indepcmlence."
Ill- urolc- il llic ni^lil (il May lu, 1775. His signature appears the first from the left.
186
SOttTMEfeM MEUlClMfi ANt) StftGEftV
March, 1920
Dr. Ephraim Brevard, so tradition has it, is buried in a corner of the yard of the "old" court-
house— third from the original log structure, in which the Declaration was made — shown above.
Upon this site formerly stood the old Queen's Museum, which he helped to found and with whose
history he was so closely connected. Soon after the Declaration the name of Queen's Museum
was changed to Liberty Hall. Some consider our present Queen's College, of Charlotte, a lineal
descendant of the Museum, established in 1773 by the people of Charlotte, despite refusal of the
Colonial Government to grant them a charter.
the medical sciences, and since Dr. Ramsey
was moving back to South Carolina, he came
back to Mecklenburg county, Xorth Caro-
lina, for the purpose of practicing medicine.
He soon came to be much respected among
the colonists because of his learning and mar-
ried a daughtef of the celebrated Colonel of
^Militia, Thomas Polk, one of whose descend-
ants became President of the United States.
He became greatly interested in the educa-
tion of the young, and we find him a teacher
in Queen's Museum which had been estab-
lished soon after the settlement was made on
Sugaw creek.
When the perilous revolutionary times
came on he becam? a Regulator and we have
a record of his leading a band of nineteen
patriots against the troublesome Tories of the
Cape Fear district of the state, in February,
1776. On May 20, 1775, we find him acting
as secretary of the ^Mecklenburg Convention,
which met to discuss the continued encroach-
ment of the British king on the granted lib-
erties of the .American colonists. During the
progress of the convention, a messenger ar-
rived bearing news of the serious happenings
around Boston. This was the deciding fac-
tor in stirring up the colonists to such an ex-
tent that they were willing to draw up reso-
lutions disclaiming British sovereignty.
The leaders of the colonists thought so
highly of Dr. Brevard's ability and judgment
that they gave to him the task of drafting
the famous Declaration of Independence,
karch, 1029
SOUTHERN MEDICINE ANt) SURGfekV
I8t
vviixh led ihc sta'e of Xorth Carolina into
open strife with England at that time, and
has led to so many arguments with sister
states since then.
The Mecklenburg Convention adopted the
Declaration of Independence, and Ephraim
L'rcvard's s?;nature was affixed to it. When
res 'tance against the British became organ-
i-ed, we find him entering the Southern rev-
clulionary army as chief surgeon. He had
the m'sfortu'je to be under the command of
ih? ill-starred General Lincoln and, as a re-
sult of stupidity in high command, he was
cinturcd wiih the army in the surrender of
Cnarleston in 17S0.
On board a prison sh'p in the harbor of
Charleston he contracted a disease, the nature
of which is not known. Perhaps it was some
enteric condition of which so many soldiers
in similar c'rcumstances died. When the
British saw that he was a doomed man they
released h'm from prison and he started back
(in the long road to the home of his boyhood.
When he reached the outskirts of Charlotte,
he found that he could go forward no longer,
and there entered the home of his devoted
friend, John iMcKnitt Alexander, in whose
hcime was kept the original copy of the doc-
ument that he himself had penned.
In the last few days of his life he must
have repeatedly re-read this original docu-
ment that was the child of his brain and that
was destined to make his name immortal. He
did not rally at all, rapidly went down hill,
and breathed his last in the spring of 1781,
at the age of thirty-seven years.
Trad'tion has it that he is buried in the
righlhand corner of the square in Charlotte,
where now stands "the old courthouse" (third
of the four to be erected in Mecklenburg
county). On this square once stood the
Queens Museum (later Liberty Hall) that he
had helped found, and in its shelter was prob-
baly written the Mecklenburg Declaration of
Independence. His tomb is unmarked, but
the products of his brain live on.
Careful search has revealed no portrait of
this illustrious patriot. F^erhaps collections
::mong the Scotch-Irish in Colonial days were
the same as they are at the present time, and
we have no indications that he was possessed
of any wealth.
His son, true to the traditions of the fam-
ily, joined the American army during the
Mexican war and was killed in the siege of
IMexico City. Honor to whom honor is due.
"Familiarity breeds contempt," as well
of diseases as of individuals. We are prone
to neglect the commonplace, even though it
is the commonplace, in the very nature of
things, which offers the greater opportunities
for service, and provides us with our means
of livelihood. Evidently the Chairman of the
Section on Pediatrics for the last meeting of
the Medical Society of the State of Pennsyl-
vania, sensed this inappreciation of the im-
portance of the snub-nosed diseases, for he
arranged a Symposium on Measles.' It's hard
to beat (or even equal) the Dutch.
^The Pennsylvania Medical Journal, January,
1Q20.
"A Bill of Fare for the Barber Surgeons
and Wax and Tallow Chandler Company
[Xewcastle-on-Tyne| , October 28, 1478, m
the reign of Edward IV': — To 2 loins of veal,
8d.; do. beef, 4d.; 2 legs mutton, 2^ d.; 1
pigg, 6d.; 1 capon, 6d.; 1 rabbit, 2d.; 1 doz.
pigeons, 7d.; 1 goose, 4d.; 1 gross eggs, 8J/2
d.; 2 gallons wine. Is. 4d.; 18 gallons ale. Is.
6d." — The Urologk and Cutaneous Review.
Two legs mutton for a nickel, one gross
eggs for 17 cents, a gallon of wine for 16
cents and ale at 2 cents a gallon! Here's
hoping civilization goes more in cycles.
Xew Vork 1928 Liquor Deaths Increase
256
Dr. Charles Xorris, chief medical examiner,
says that alcoholic drinks caused 256 more
deaths in 1928 than in the previous year in
Xew Vork. The total figures for the year
were 1,565.
Dr. Xorris attributed a large number of
deaths in motor accidents, homicides and ac-
cidental death from falls to poison liquor.
'While only 130 alcoholic deaths are re-
corded for the year," he said, "there was
marked increase in homicides, motor accidents
a:.d accidental deaths from fall. iNIost of
these are directly traceable to poison alco-
hol.
The medical examiner said there is as much
drinking now as when saloons were running
and that the licjunr now being served is most-
Iv bad,
SOUTHERN MEOiCme AND SURCJERV
March, 1920
NEWS
To Erect Marker to Noted Physician
The Durham-Orange Medical Society will
erect a marker to the memory of Dr. Edmund
Strudwick, famous Hillsboro surgeon of pre-
vious generation. The society had planned to
erect the monument to Dr. Strudwick in
Hillsboro, with a number of other historical
markers as a part of its program of work,
but since the new Duke University campus
will extend into Orange county, a plan is now
being considered by the medical men of Dur-
ham and Orange counties to erect the marker
on the new Duke campus.
Sterilization Bill Passes N. C. Senate
The bill to require the sterilization of the
feeble minded inmates of state, penal and
charitable institutions was passed at second
reading after considerable debate. On ob-
jection by McMullan, of Beaufort, the t^nal
vote will be delayed until tomorrow.
The author of the bill. Senator Millner,
Republican of Burke, in speaking for his
measure cited other states which had similar
laws, and declared it would be of great bene-
fit to future generations.
Senators Johnson, of Robeson,- and Alder-
man, Democrats, and Ivey, Republican of
Wayne, a physician, supported him. Gallo-
way, Democrat of Transylvania, opposed the
bill.
The bill would require the recommendation
of the state health officer, the commission of
public welfare and two state physicians be-
fore a patient could be subjected to the oper-
ation. It also authorizes the sterilization of
other defectives upon the recommendation of
four state officials and the agreement of the
ne.xt of kin.
Johns Hopkins Gets $3,000,000
An anonymous gift of $3,000,000 to be
used for the maintenance of the medical and
surgical clinics has been announced by Dr.
Frank Goodnow, president of Johns Hopkins
University.
Two other gifts, one of $60,000 from Fran-
cis P. Garvan to be used in cancer research
and another of $10,000 bv Dr. Emanuel Lib-
man to establish a lectureship in the depart-
ment of history of medicine, have also been
announced.
Medical College of Virginia Given
Grant
The Chemical Foundation, Inc., of New
York City, has made a grant to the Medical
College of Virginia, Richmond, to make it
possible to employ for a three-year period a
full time expert to enlarge its present pro-
gram of research in chemistry as related to
medicine, surgery, and dentistry. The spe-
cial laboratory for this work will also be con-
siderably enlarged.
Richmond Academy of Medicine Raises
Dues From $4 to $25
At the meeting held on January 22nd, the
Board of Trustees submitted the following
from the minutes of the Building Commit'^
tee:
"1. That the committee inform the Board
of Trustees that in order to proceed with the'
building, it appears necessary to increase the
annual dues.
"2. That the committee recommends that
all funds over and above the current expenses
of the Academy be turned over to the build-
ing fund.
"3. That the revenue available for the
building from the above source should be not
less than $5,000 per annum.
"4. That it is the belief of the committee
that if funds can be provided as outlined
above, the building operations can be begun
within the year of 1929."
With the above in view it was noted that:
"The annual dues of active members shall
be Twenty-five Dollars ($25.00), payable
semi-annually in advance, except that the
annual dues of active members shall be Ten
Dollars ($10.00) so long as they have been
m active practice less than three years. Dur-
ing the year of election, dues shall be pro-
rated.
"The annual dues of associate members
shall be Ten Dollars ($10.00)."
A four-story addition to the Charlotte
Sanatorium will be erected in the immediate
future, according to decision reached by of-
ficials of the institution and announced by
Dr. J. P. Munroe. The addition will contain
20 rooms and be for obstetrical cases exclu-
sively.
March, 1029
SOUTHERN* MEDICINE AND SURGERV
isa
Gill Memorial Eye, Ear and Throat
Post-Graduate Course
Following are the names of the doctors who
registered for the course to be given April
Sth-13th:
Drs. C. G. Butler, Gainesville, Ga.; S.
Kirkpatrick, Selma, Ala.; \'. C. Dail, Knox-
vlle, Tenn.: A. M. Walker, Tuscaloosa, Ala.;
Martin Crook, Spartanburg, S. C; Thos. W.
Davis, Winston-Salem, N. C; E. Vermillion,
Welch, W. Va.; W. W. Perdue, Mobile, Ala.;
E. L. Sutherland. Lynchburg, Va.; Wallace
Gill, Richmond, Va.; L. W. Hovis, Charlotte,
X. C; Karl S. Blackwell, Richmond, V'a.;
Carl Bi.shiip, Plainfield, X. J.; R. W. Petrie,
Lenoir, X. C.; J. R. Perkins, Winston-Salem,
X. C; J. R. \'erm:llion, Princeton, W. Va.;
y. F. Crouch, Winston-Salem, N. C; J. Sid-
ney Hood. Gastonia, N. C; E. G. Campbell,
Johns'jn Cit_\-, Tenn.; — . — . Ogg, Johnson
Citw Tenn.
Dr. Joseph R. Latham, of New Bern, has
been elected president of the Craven County
Medical Society, to succeed Dr. Harvey B.
Wadsworth, and Dr. E. L. Bender has been
named secretary, succeeding Dr. D. E. Ford.
Dr. Thomas R. Harding, 73, prominent
and beloved physician of Yadkinville, died
February 6th. The deceased had been a
practicing physician for forty years, had
served his county as health officer and as its
representative in the state legislature. Death
was due to cerebral hemorrhage.
President Edwin \. .Alderman, of the
L'niversity of Virginia, will deliver the prin-
cipal address at the ninety-first commence-
ment of the Medical College of \'irginia,
Richmond, on Tuesday, May 28, 1929.
Dr. J. E, Dowdy, of Winston-Salem, be-
cause of an infection just above the wrist,
had his right hand amputated P>bruary 25th.
His general condition is reported as favor-
able.
The (Joi.dsboro Extension Clinic of the
.\orth Carolina Orthopedic Hospital is to
ha\e a permanent home if the recommenda-
tion of the state budget commission, now in
I lie hanfls of the (ieneral .Assembly, goes
through.
Cancer Inoculation of Criminals to be
Sought
Legalized cancer inoculation of criminals
condemned to death, so as to discover a possi-
ble method of curing or eliminating the dis-
ease from mankind, is to be discussed before
the Cuban .Academy of Science by Dr. Matias
Duque, chairman of the National Board of
Health.
Dr. E. B. Gray, formerly house surgeon to
the Manhattan Eye, Ear and Throat Hospital,
Xew York City, announces the opening of his
office at 909-910 Montgomery Building, Spar-
tanburg, S. C, for the practice of ophthal-
mologv.
THE TRE.\TMENT OF A SORE FINGER
Keep it dry. Protect it from squeezing by a
thimble or celluloid guard. If a thorn is still in do
nut squeeze. Take a safety razor blade and slice off
the overlying epithelium; this will drag the torn
out and, should the spot suppurate, the denuded area
will provide an easy exit for pus and so limit inward
spread. If the linger is throbbing relieve the tension
by an incision and then apply a moist dressing at
body temperature. It is not easy to place these
small incisions with accuracy or to avoid the annoy-
ance of secin'j the abscess burst two or three days
later I mm. from the line of incision. Use of the
razor blade in the horizontal direction will show up
the site of puncture and greatly assist in correctly
placin.: the incision. For accurate localization of an
p.bscers the method adopted by Mr. Frank Jeans is
well worth remembering. In kindly thought for his
patient he does not brandish a probe, but takes the
more homely match. If the center of the brawny
swelling shews a maximal point of tenderness a
small collection of pus may be expected. If two
maxima are encountered then a larger collection may
1 e expected and the incision must be made between
thee two points. — R. Kennon, in The Lancet, Jan-
uarv 26th.
.1 GIFT TO A FRIEND
A ^ijt to a friend ; a year's subscription to
Southern Medicine and Surgery — especially
appropriate because the proceedings oj our
fine meeting are now being published — $2.50;
notice oj the gijl sent to recipient jrom oui\
oflice. A hundred or so extra copies oj the
March issue are being laid by.
Errata
Il'r regni that, in the article by Dr. E. IF.
Schocnhcit in the issue jor February, the cuts
7e'ere misplaced as jollows: The cut shown
in figure 6 should be in the place oj figure 2;
figure 2 should be where figure 3 is; figure 3
should be where figure 6 is, and figure 8 is
upside down.
i9d
SOUTHER!^ MEDtClisrE AND StRGERV
Marcli, 19i9
REVIEW OF RECENT BOOKS
TEXTBOOK OF CLINICAL NEUROLOGY, by
M. Nnistaedter. M.D.. Ph. D., X'isitin:; Ncurolog'st,
Central Neurological HcspHal, Welfare Island; for-
merly Lecturer in Neurology, University and Belle-
vue Hospital Medical College; Clinical Professor in
Neurology, New York Polyclinic Medical School and
Hospital ; with an introduction by Edzvard D. Fisher,
M.D., Professor Emeritu:. of Neurology, llnivers'ty
and Bellcvue Hospital Medical College, New York,
with 22,S illustrations, some in colors. F. A. Davis
Co., Philadelphia, 1020. ,S6.00.
The opening paragraph of the introduction
is encouraginp;: "A new text-book
should possess certain essential qualities. It
should be distinctly different from other books
dealing with the same topic."
Very welcome is the presentation of mate-
rial as it actually occurred and will repeatedly
occur in medical practice. Very tiresome and
d'scouraging are statements that you mav
find or may try this or that. If medical au-
thors will tell other students of medxine,
graduate and undergraduate, what they did
and do find and try, and with what result, the
students can be depended on. to supply their
own mays. Usual'y, always and never are
words found with gratifying frequency
throughout.
The reviewer e.xpects to learn much from
this book, which he heartily recommends for
its plain teaching from a basis of experience
with patients and with authors who havj little
grasp of the necessity for clearness, brevity
and unadorned facts.
CONSECR.ATIO MEDICI AND OTHER PA-
PERS, by Harvey Cushing, M. P., Surgeon-in-Chief
of the Peter Bent Brigham Hospital; Professor of
Surgery in the Harvard Medical School. Little,
Brown & Co., Boston, 1028. $2.50.
The address which gives this volume its
title was given to the graduates of Jefferson
in 1926. It sounds a high note of devotion
to great cause. Especially delectable is "Dr.
Garth, the Kit-Kat Poet," and, whether or
not it is true that Dr. Garth delivered a fun-
eral oration on Dryden "with much good na-
ture from the top of a beer barrel th? head
of which fell in during the course of the pro-
ceed ngs," we enjoy the tale. Other "papers"
as the author modestly styles them are on
subjects of such great interest as: "Reali'?;n-
ments in Greater Medicine," "William Osier,
the Man," "The Personality of a Hospital,"
"The Physician and the Surgeon," "The Clin-
ical Teacher and the Mcd'cal Curriculum,"
"The Doctor and His Books," and "Emanci-
pators."
From his broad experience of life, no less
than from his deep education in matters to
be found in books, a student and thinker has
learned many deep things, wh"ch things arc
here set forth in admirable style.
RECENT ADVANCES IN OBSTETRICS AND
GYNECOLOGY, by Aleck W . Bourne. B.A.. MB..
B.Ch. (Camb.), F R.C.S. (En-.), Obstetric Surgeon
to Out-Paticnts, St. Mary's Hospital; Senior Ob-
stetric Surgeon, Queen Charlotte's Hospital; Sur-
geon, Samaritan Hospital for Women; Consulting
Gynecologist to the Willesden General Hospital; Ex-
am'ncr to the Society of .Apothecaries, and Central
Midwives Board. Second Edition, with 67 illustra-
tions. P. Blakiston's Son & Co., Philadelphia, 1028.
That advances have been urgently needed
in obstetrics over the past thirty years is gen-
erally admitted and deplored. The death rate
from childbearing has mounted while that of
every other acute condition constituting a
major problem has fallen.
A cons'derable advance has been made in
reducing the number of cases of eclampsia,
this largely through ante-natal care by indi-
vidual doctors and special organizations. It
is recognized in England as well as in this
country that the improvement of the training
in obstetrics of the medical student is the
main hope of reducing the number of deaths
from sepsis.
It has been learned that many of the fetal
deaths in breech presentation which have
been attributed to asphyxia, are really due to
brain injuries inflicted by attempts at rapid
delivery for the prevention of asphyxia.
In gynecologic treatment it is said' that the
March, 19J9
SOtJTttEftK MEfttClNfi AMD SUftGERV
191
greatest advances have been made in the use
(if radium and x-ravs.
much in stimulating and fixing interest.
PRACTICAL CLINICAL LABORATORY DIAG-
XOSiS, by Chas. C. Bass, M.D.. Dean and Professor
of Experimental Medicine, and Foster M. Johns,
M D., Assistant Professor of Medicine and Director
cf the Laljoratories of Clinical Medicine, the School
of Medicine, Tulanc Univcr.:ity of Louisiana. Illus-
trated with 134 black and white te.xtual figures and
20 plates, Q of which are in colors. Third Edition,
ccniplctcly revised. Williams & Wilkins Co., Balti-
more, IQ-'O. S7.50.
Only one test for ascertaining any one
tli'n'i is given. That, in itself, is sufficient
recommendat'on, for it assures a prospective
purchaser that the plan of the work was con-
ceived by men well acquainted with the sub-
ject and its practical application in the hands
of doctors in general.
The size is convenient, the type large, the
arra,i,f<ement excellent ,and the illustrations
numerous and of the kind that teach. Few
doctors could spend to better advantage than
in a purchase of th's back.
PARTNERSHIPS, COMBIN.^TiONS AND AN-
TAGONISMS IN DISEASE, by Edward C. B. Ibol-
sou. M.D. (Lond.), B.S.. Fellow Royal Society of
Medicine, London. Illustrated. IQiO. F. \. Davis
Co., Philadelphia. S.i.50.
The author recognizes that the knowledge
of these subjects is elusive and, in many in-
stances, contradictory. His discussions are
general and often unconvincing. He is grop-
ing toward satisfactory correlation of many
isolated observations. He says that many
more observations are needed and expresses
the hope that many others will make investi-
gations over a large number of patients, and
that analysis of these gathered facts will prove
illinninating.
A DOCTOR'S LETTERS TO EXPECTANT
PARENTS, by Frank Howard Richardson, M.D.,
F.i.C.P The Parents Children Magazine and W.
W Norton & Co., Inc., New York, .^l.TS.
This series of letters is written after an
original plan and in an entertaining style. It
will be ncilfd that they take note of the fact
that a father is a parent and that he should
have some instruction in his duties during the
period of expectancy. The drawings used,
fur illustration, are cleverly designed to aid
THE PR.\CTICAL MEDICINE SERIES, com-
prising eight volumes on the year's progress in Medi-
cine and Surgery.
OBSTETRICS AND GYNECOLOGY
OnsTf:TRi(S, Edited by Joseph B. DeLee. A.M..
M D., Professor of Obstetrics, Northwestern Univcr-
fity Medical School; Attending Obstetrician and
Medical Director, Chicago Lying-in Hospital and
Dispensary, and J. P. Greenhill. B.S., M.D., F.A.C.S.,
Attending Obstetrician, Chicago Lying-in Hospital
and Dispensary ; Attending Gynecologist, Cook Coun-
ty Hospital, .Associate in Obstetrics, Northwestern
University Medical School. Gynecolog/i, Edited by
John Osborn Polak, M.D., Professor of Gynecology,
Long Island College Hospital, Brooklyn, N. Y. Series
102S. The Year Book Publishers, Chicago, .S2..=;o.
An excellent feature of the books of this
series is the arrangement bv which an article
is abstracted and frequently the editors ap-
peiid criticisms, favorable or unfavorable.
In discussing the various methods for the
d'agnos's of early pregnancy the fact is em-
phasized that the student should be taught
the usual symptoms and signs appreciable
without elaborate equipment. Never forget
that salvarsan and neosalvarsan are more
dangerous in pregnancy than at other times.
Hypothyroidism is one of the causes of ha-
bitual abortion.
From a study of a series of 499 cases of
eclampsia early and quick delivery is advo-
cated for all such patients who can be deliv-
ered easily by the natural passages. Support-
ing the perineum is shown to be a fallacy.
When the perineum stretches readily the head
is allowed to be born sp(mtaneously and lac-
erations repaired immediately. If the perine-
um does not distend easily, incise medio-
laterally at height of pain, thus getting a
wound with smooth edges for immediate, ac-
curate repair.
An article is quoted at length which tends
to refute the idea that there is any synergism
between magnesium sulphate and morphine.
Today a cesarean section is more often a con-
fession of ignorance than an expression of
sound obstetric judgment, say the editors.
There is a detailed, excellent abstract on ac-
ciput posterior after engagement. Never pull
on the cord to deliver the placenta. The par-
turient should not be discharged from obser-
vation for a year after confinement (sic).
Remember that lactose may a[)pear in the
urine of a nursing woman and a mistaken
m
SOUTHERN MEDICINE AND SURGERV
Marcii, i<ii^
diagnosis of diabetes made because of it. The
greatest care needs to be exercised that babies
may be properly identified. Before using
quinine the patient should be questioned as
to idiosyncracy.
The section on gynecology opens with an
account of the organization of a gynecologi-
cal and obstetrical clinic from which many
excellent points may be gained. Endocrine
therapy is summarized. Gonorrhea is a self-
limiting disease and persistence and cleanli-
ness will cure it whatever gonococcocide is
used.
There is a detailed plan outlined for the
organization of a Sterility Clinic.
Pedhtrics, by Isaac A. Abt, M.D., Professor of
Pediatrics, Northwestern University Medical School,
.Attending Physician St. Luke's Hospital, Chicago,
Children's Department, with the collaboration of
Arthur F. Abt., M.D., Assistant in Pediatrics, North-
western University Medical School, Assistant Attend-
ing Physician, St. Luke's Hospital, Chicago. Series
102S. The Year Book Publishers, Chicago. $2.25.
Some of the more conspicuous features will
be noted.
A brief sketch is given of the growth of
interest in JNIaternai and Infant Hygiene in
the United States. The reduction in infant
mortality in the first year of life has been
more than SO per cent in the past 27 years;
but, between 1918 and 1925 the death rate
from injuries at birth increased more than S
per cent per year. Asphyxia in the new born
should not be treated by skin stimulation but
by gentle lung inflation with o.xygen and car-
bon d'oxide for 2 or 3 seconds, 3 or 4 times
a minute. There is a report of a congenital
cancer which caused a death at 11 months
frf)m a general carcinomatosis.
Initial purgation in the treatment of in-
fantile diarrheas is condemned. .Mways be
on the lookout for intussusception when an
infant appears to have sudden, severe pain,
soon followed by vomiting and prostration.
The opaque enema with fluoroscopic control
is recommended for reduction. Epinephrin
is strongly advised in malignant and neglect-
ed cases of diphtheria, along with the anti-
toxin. Mumps is said to involve the testes
in one-third of the males who have the dis-
ease, one-half these testes becoming atrophied.
The disease also has such serious neurologic
complications as meningitis, encephalitis, and
polyneuritis of cranial and spinal nerves.
Intradermal vaccination against smallpox is
advised. Symptoms attributed to thymic en-
largement are most often due to other causes.
General Medicine, Edited by George H. Weaver,
M.D.; Lawrason Brown, M.D.; George R. Minot,
M.D.; William B. Castle, M.D.; William D. Stroud,
M.D.; Ralph C. Brown, M.D. Series 1528. The
Year Book Publishers, Chicago. $i:M.
The names above given are a guarantee of
the worth of the volume. The introduction
comments on the number and importance of
the infectious diseases which owe their origin
to animals.
Rabies is considered one of the most im-
portant of health problems, and it is on the
mcrease. A map showing incidence gives all
the southern states in solid black. Malta fe-
ver and tularemia are serious diseases which
are on the increase. Each year adds at least
one drug for treatment of whooping cough.-
This year's contribution is ephedrin. Atten-
tion is invited to an improved method of vac-
cination against smallpox.
The abstracts contained in the part dealing
with diseases of the lungs are particularly
instructive, and the editorial comments apt.
Recently acquired knowledge of the anemias,
particularly pernicious, makes the dealing
with the blood and its makers of especial in-
terest. The constantly rising death rate from
cardio-vascular-renal disease gives appeal to
that excellent section.
International Clinics, Edited by Henrv W.
Cattell, A.M., M.D. Volume 4, thirty-eight series,
1028. J. B. Lippincott Company, Philadelphia.
.^mong the many subjects which arrest at-
tention are: "Digestive Problems of Old
Age," by Dr. Thos. R. Brown, Baltimore;
"Postponement of the Processes of .Aging,"
by Dr. Linsley Williams, of New York; "The
iModern Physician's .'\rmamentarium," by Dr.
S. Solis Cohen, Philadelphia; "Circulatory
Insufficiency in Obesity," Dr. L. F. Barker,
Baltimore; "The Problem of the Epilepsies,"
by Dr. Samuel Brock, New York; "Differen-
tial Diagnosis of Some Syphilitic and Non-
Syphilitic Eruptions," by Dr. Howard Fox,
New York; and "Luke: Th3 Physician and
His Writings," by Dr. Howard Kelly, Balti-
more.
March, 1Q29
SOUTHERN MEDICINE AND SURGERY
193
PROCEEDINGS
OF THE
THIRTY-FIRST ANNUAL MEETING
OF THE
TRI-STATE MEDICAL ASSOCIATION
OF THE
CAROLINAS AND VIRGINIA
Greensboro, N. C, February 19-21, 1929
The Tri-State Medical Association of the
Carolinas and \"irginia convened for its thirty-
first annual meetins! in the ball room of the
O. Henry Hotel, Greensboro, N. C, Tuesday
niornin?, February 19th, at ten o'clock.
Dr. J. L. Spruill, President, Guilford Coun-
ty Medical Society, Jamestown, N. C:
tientlemen, the thirty-lirst annual meeting
of the Tri-State Medical Society of the Car-
olinas and Virginia will now come to order.
Dr. Turner will make the invocation. All
will please stand.
INVOCATION
Rev. J. Clyde Turner, D.D., Pastor First
Baptist Church, Greensboro, N. C:
Our gracious and loving Heavenly Father,
we feel Thou art supremely interested when
a group such as this comes together in a work
which is at once theirs and Thine. We re-
member how Jesus went about laying His
hands on the suffering and giving them heal-
ing and health and strength; and this group
has gathered here today to advance this great
work. May the spirit of Him who went about
doing good be here, and in all the plans that
are made and all the discussions that are held
do Thou guide and direct them. We ask Thy
blessing on these men. Be gracious unto
them. Watch over those in their homes. We
shall be satisfied, our Heavenly Father, if we
are doing the things which are pleasing in
Thy sight, if we are ministering to them of
whom Jesus said, "If ye have done it unto
one of the least of these, ye have done it unto
me." We ask it in Jesus' name. Amen.
Dr. Si'ruill:
(ientlemen, as President of the (Juilford
County Medical .Association 1 extend to all
of you the warmest welcome and our best
wishes for the most profitable meeting that
this society has ever had. The President will
now take the chair.
Dr. James K. Hall, President:
Mr. President and Fellow Members: I
thank you. Dr. Si)ruill, for your most cordial
welcome. I am glad we are meeting here in
Greensboro. This city must be about the cen-
ter of the territory of this organization.
Greensboro is throbbing with the spirit of the
renaissance that has taken hold of this state.
You have a very active medical profession in
North Carolina. Those of us who come into
this state from neighboring states are bene-
fited always by our contacts with you medi-
cal men in North Carolina. We are glad to
be here, and we expect to have a hippy and
successful meeting. I thank you, sir.
ESS.WS, CLINICS, ETS., OCCUPIED THE
TIME OF THE .\SSOCL-\TION IN THIS INTER-
\AL.
BUSINESS SESSION
February 21st
Dr. James K. Hall, President, in the
chair.
Dr. Marion H. Wvman, of Columbia, S.
C, extended an invitation to the .Association
to meet next year in Columbia, S. C.
.\t the request of the President, Secretary-
Treasurer North inoton read the names of
the members who had died during the past
year, the audience standing:
Dr. J. H. Miller, Cross Hill, S. C; Dr.
W. L. Dunn, Asheville, N. C; Dr. C. L.
Summers, Baltimore, Md.; Dr. H. M.
Stucky, Sumter, S. C; Dr. A. Murat Wil-
lis, Richmond, Va.; and Dr. G. F. McInnes,
Charleston, S. C.
Dr. C. C. Orr, Asheville, N. C, read the
memorial on Dr. W. L. Dunn prepared by
Dr. M. L. Stevens.
Dr. J. Allison Hodges, Richmond, Va.,
read the memorial on Dr. A. Murat Willis
prepared by Dr. C. C. Coleman.
Dr. Francis B. Johnson, Charleston, S.
C, read a memorial on Dr. G. F. McInnes,
of Charleston.
Other memorials were filed with the Secre-
tary-Treasurer for publication in its offxial
journal.
President Hall:
In opening the business session, I think I
might read some notices that have come to
me. The first is a telegram from Dr. I. P.
Battle, of Rocky Mnunt. 1 have also a tele-
gram from Dr. Rdberi Wilson, of Charleston;
a telegram from Dr. John T. Burrus, of High
Point, N. C, who is now in Spartanburg con-
SOUTHERN MEDICINE AND SURGERY
valescing from pneumonia; a telegram from
Governor Gardner; a note from Dr. Tom
Anderson, of Statesville; and a letter from
Dr. William H. Cobb, of Goldsboro.
Dr. D. T. Tayloe, jr., moved to send tele-
grams to Dr. Thos. E. Anderson and Dr.
John T. Burrus expressing regret ihat they
could not be here and hoping that they may
be present next year. Motion seconded and
carried. It was also moved and carried that
telegrams be sent Dr. Thomas IMcCrae, Phila-
delphia, and Dr. Thomas E. .\nderson, States-
ville, expressing the Association's concern
about their illness; and to Dr. Wm. DeB.
MacXider, Chapel Hill, conveying our sym-
pathy in the illness of his mother.
Secretary-Treasurer Xorthington re-
ported that he had telegrams from Dr. Lin-
wood D. Keyser, Roanoke, Va., and Dr. C.
B. Epps, Sumter, S. C, and a telephone mes-
fage from Dr. A. ^NIcX. Blair, of Southern
Pines, N. C, expressing their regret that they
could not be present.
The report of the Secretary-Treasurer was
read by Dr. Xorthington.
REPORT OF COUXCIL
The Secretary-Treasurer re;5orted as follows
for the Council:
We had applicat'ons from 94 physicians,
and all of these were elected to membership.
We have invitations from Floreice, Char-
leston, Greenville. Spartanburg, and Colum-
b'a. Charleston is the recomme::dation of the
Council.
It was moved that at the end of one year
the journal cease to go to a Fellow in arrears,
but that he be carried on the rolls for two
years as a member, after which time his ac-
count will stand on the books of the Associa-
tion: $5.00 dues for first year, $3.00 per year
dues for second and third years — total
."^ILCO; no Fellowship shall be renewed until
all arrears are paid in full. This motion
v.as carried and made retroactive for three
years as to arrears.
It was also moved and carried that the
initiation fee be d'scontinued.
Three vacancies on the Council were filled
by the Council, Dr. Dean B. Cole, of Rich-
mond, Dr. R. E. Seibels, of Columbia, and
Dr. C. C. Orr, of .Asheville, being the new
members of the Council.
The .Auditing Committee, composed of Dr.
Oren Moore and Dr. Warren T. Vaughan,
approved and indorsed the report of the Sec-
retary-Treasurer.
It was moved that the Secretary-Treasurer
print in the journal all changes in the by-
laws since their first promulgation, and this
was carried.
On motion of Dr. M. H. Wyman, duly sec-
onded and carried, the reports of the Secre-
tary-Treasurer and the Council were accept-
ed.'
Dr. F. B. Johnson, Charleston;
I just want to say, in behalf of the city of
Charleston, that we are glad you are coming
and we hope you will have a good meeting.
I do not know whether we shall have as
rplend'd clinics there, but we will do our best
to have gsod clinics.
President Hall:
In recognition of the cordiality and help-
fulness of Dr. Homer W. Starr, Medical
Director of the Pilot Life Insurance Company,
I am going to present him to you.
Dr. Homer W. Starr, iNIedical Drector, Pi- "
lot Life Insurance Company, Greensboro,
N. C:
Ladles and gentlemen, the directors of the
Pilot Life Insurance Company request your
attendance at a luncheon at the home office
of the crmpany, wh'ch is seven miles out, at
Sedg; field. We shill have buses out in front
to take you and shall be very glad to have
you with us.
Secretary-Treasurer Xorthington read
the following resolution of thanks, which, on
motion of Dr. i\I. H. Wyman, was adopted.
ELECTIOX OF OFFICERS
Secretary
On motion of Dr. M. H. Wyman, Dr.
Ja.mes iM. Xorthington was re-elected Sec-
retary-Treasurer.
Dr. J. BoLLiNG Jones, Petersburg, Va.:
I just want to say a word of appreciation
of the work being done by Dr. Xorthington
lhrou,r;h our journal. I hope that we all read
our journal. We in the three states want to
keep in touch with each other, and we can di
it best by reading each issue, going through
it. We can gain many points from it. I hope
we all read it as carefully as possible, and I
know we appreciate the work that Dr. Xorth-
ington is doing.
Appreciation of the work of Dr. Xorth'ng-
ton as Secretary-Treasurer of the Association
ar.d Ed. tor of the Official Journal was voted
with enthusiasm.
Mardi, Io:'3
SOUTHERN MEDICINE AND SURGERY
Vice-Presidents
Dr. F. B. Johnson nominated Dr. W. R.
Wall.ace, of Chester, as vice-president from
South Carolina. Nomination seconded by
Dr. M. H. Wyman, who moved that the nom-
inations be closed. This motion was carried,
and Dr. Wallace was elected.
Dr. Wvman nom'nated Dr. Wm. E. War-
RFN, of W'll'amston, as vice-president from
North Carolim. Nomination seconded.
Dr. J. E. S. Davidson, Charlotte:
I rise to nominate a distinguished member
of a verv illustrious family. He is a son of
one of North Carolina's most distinguished
physicians, and his grandfather was also a
ohysician. I place in nomination Dr. Julian
IM. Baker, of Tarboro, N. C. Nomination
seconded.
Dr. Julian M. Baker, Tarboro:
Mr. President, I thank my friend verv
much for nutting me in nomination but I ask
h'm to withdraw it in favor of Dr. Warren.
Dr. Wyman withdrew Dr. Warren's name
in favor of Dr. Baker and moved that the
nc^nvnations be closed. Motion seconded and
carried, and Dr. Baker was elected.
Dr. F. C. Rinker, Norfolk, nominated Dr.
Frank S. Johns, of Richmond, as vice-presi-
dent from Virginia. Nomination seconded.
On mot'on of Dr. Wyman, the nominations
were closed, and Dr. Johns was elected.
President
Dr. J. .Allison Hodges, Richmond:
Gentlemen, it has been my fortune to live
in various parts of the world, but it has al-
ways been my pleasure to feel that my first
love was North Carolina. I say that today
with more than usual fervor, because it has
been demonstrated to me within the past hour
that there is a nobility of soul in its people
thit is seldom equaled. It came to my knowl-
edge that in this forensic campaign that is
but natural, for there must be a head to this
great organization, there were two men, both
of whom live in the great eastern section,
both of whom are neighbors, and, better still,
both of whom are friends. When I felt per-
sonally that I did not know whom I would
[)rcfer tn see prcs'dent of this great organiza-
tion 1 called ihcm together a few moments
ago in the lobby and asked them to solve the
problem for me and for their many friends.
One of the gentlemen spoke up before the
other could speak and said: "I would prefer
that he have such an honor rather than my-
self." That gentleman was Dr. Jul'an M.
Baker. That is the spirit, gentlemen, that we
are proud to have our own; that is the splr t
that makes such an organization as th's e iter-
prising and prospering and succ:ssful and
makes the world get higher ard better in the
march towards the end. So it is a pleasure,
then, for me, and a double pleasure to nom'-
nate to you as president of this Association
that other friend. Dr. Cyrus Thompson.
(Applause.) He has served long and faith-
fully in the practice of his profession and
has not been one of these high-brow scientific
specialists that we now appreciate, but has
been always a country doctor, with all that
that means, full of experience, full of science,
full of work, and full of love for his patients.
For h'm who has done so much for others I
should be pleased if this Association would
do something in honoring a life that has been
conspicuous in the profession and in the com-
munity and in civil life as always striving
for higher and better things.
The nomination was seconded by Dr. Ma-
rion H. Wyman, who moved that the nom-
inations be closed. Dr. John Q. Myers also
seconded the nomination. Dr. Wyman's mo-
tion was carried, and Dr. Thompson was
unanimously elected.
Cries of "Speech!"
Dr. Cyrus Thompson:
Mr. President and Gentlemen: I think you
wll bear me witness, and the society also,
that 1 have been unusually quiet in this meet-
ing. 1 have had practically nothing to say
because in a meeting of such splendid attain-
ments I felt very much as if 1 knew nothing
to say, and I sat by as an interested learner.
^^'h■le I have said nothing in the society here,
the President, who loves me and whom I love,
has had me out on two occasions. For in-
stance, he sent me with Dr. Overholser over
to the State College to talk to some two thou-
sand women. I did not know anything to
say, and I let Overholser be presented and
speak first, and then. Dr. Hodges, I spoke
along the same line that he spoke on. .And
when we were coming away I said to h'm:
"\"()U ard I have been very fortunate. We
liave come out here and we have talked to
two thousand girls. D'd it ever occur to you
how much more agreeable it was to us to talk
to two thousand girls than to have two thou-
sand girls talk to us? " Then last night I
196
SOUTHERN MEDICINE AND SURGERY
March, 1029
went out to dinner with my beloved friend,
and he had me talk some out there. But
with you all I have been very quiet, not that
I was said, but that I was ignorant and was
trying to learn.
You know, I am getting now into the sere
and yellow leaf. Perhaps I feel as young as
many of you; but yet I know, and I am not
gloomy on account of it, that the places that
know me now will soon know me no more
forever. It is not a thing to be sad about. I
have lived my three score and ten and four
naturally and happily. My ideals through
life have always been hich, and my purposes
have always been healthy. I have never
hated: I have loved all my life where I could
love; and where I could not love I have left
absolutely alone. The thing that has aston-
ished me in my life perhaps more than any-
th-'ng else is that so much love has been pre-
Fented to me. Now, th's is a manifestation
of your love for me; I know that; and I am
overwhelming by it; and I thank God in
these declining glows of my sun that you feel
that way about me. It makes lifs sweeter.
and it stimulates me to love you and to love
mankind and to go ahead and do whatever I
can so that when my time com-^s and they
say: "This is where you get off," I get off
I'ke a gentleman and say I have had a very
pleasant ride.
Xow, 1 know I shall not be able to be
president of this Association Ike my friend
who comes from a feeble-minded institution
in Virginia, but with the help of you and with
the help of him and with the help of our d's-
t'nguished secretary over here we shall go
down next year to the city of Charleston and
have a meeting while not perhaps as good as
this yet perhaps a littb bit better.
I appreciate this honor, and when I go
home my wife will appreciate it, and my chil-
dren will appreciate it. I know my friends
will be proud of it, and I am glad to say I
have no enemies. I thank you, gentlemen.
(.Applause.)
President Hall:
Dr. Thompson, I think, sir, that many spe-
cific statements are untrue and that a great
many more general statements are untrue.
.Amongst the latter I would list the frequently
heard assertion that the family doctor has
disappeared. Here is an uncrowned, seventy-
four-year-old, worthy illustration in refutation
of the statement that the family doctor is no
more. Here beside me is as perfect a speci-
men of the family doctor as William Mac-
Lure, himself of "Beside the Bonnie Brier
Bush." .Although Ur. William MacLure had
to die, you remember what a splendid, mag-
nificent death he died, and that the great
surgeon from Edinburgh shook hands with
h'm and told him he was an honor to man-
kind and to the medical profession. The fam-
ily doctor can never d'sappear until the hu-
man race has disappeared, but I am very
much afraid that the particular kind of fam-
ily doctor that Dr. Cyrus Thompson has been
for the past fifty years will disappear from
North Carolina at his death forty-six years
from now. I love him as Jonathan, the son
of Saul, loved David, the son of Jesse. There
is no member of this body to whom I should
have been momentarily unwilling to pass on
the torch of this organization, but there is no
member of the organization to whom I would
more gladly pass the torch. I congratulate"
the organization, sir, and I shall see you in
Charleston next year and shall be at the
meeting of this organization every year after-
wards as long as th? Lord lets me live. God
bless you, sir. (.Applause.)
The following resolution offered by the
Secretary-Treasurer v/as carried unanimous-
ly:
Resolved, That we express and record in
our minutes our thanks:
(1) To our distinguished invited guests:
Dr. Edwards A. Park, Baltimore; Dr. John
A. Kolmer, Philadelphia; Dr. Winfred Over-
hoLer, Boston; Dr. Joseph L. iMiller, Thom-
as, W. Va.; Dr. iMichael P. Lonergan, New-
York; Dr. A. Benson Cannon, New \'ork;
and Dr. Walter E. Lee, Philadelphia.
(2) To Dr. Joseph L. Spruill, President of
the Guilford County iNIedical Soccty, the
otiier orficers and members of this society.
(3) To Dr. R. B. Davis, Chairman, and
Drs. S. R. Ravenel, R. E. Perry, W. C. Ash-
worth, Frank Sharpe, J. A. Keiger, B. E.
Rhudy, R. N. Harden, Marion Y. Keith, W.
M. Jones, J. T. Taylor, Brookton Lyon, R. M.
Buie, Fred Patterson, C. W. Banner, C. M.
Gilmore, .A. D. Ownbey, his Associates on the
Committee of .Arrangements.
(4) To the doctors who provided patients
for the Cl'n'cs: Drs. W. C. Ashworth, S. F.
Ravenel, C. M. Gilmore, R. O. Perry, J. A.
March, 1P29
SOUTHERN MEDICINE AND SURGERY
Keiger, M. V. Keith, H. R. Parker, F. A.
Sharpe and R. B. Davis, of Greensboro; Dr.
J. P. Rousseau, of Winston-Salem: Dr. J. S.
De Jarnette, of Staunton, Va.; and Dr. .Al-
bert .Anderson, of Raleigh.
(5) To Dr. A. D. Ownbey, who has so
freely sacrificed his time and talents in oper-
ating the machines for illustrating the essays.
(6) To Dr. J. I. Foust, President North
Carolina College for Women, for affording the
Association the use of the college audito-
rium.
( 7 ) To the Reverend J. Clyde Turner for
his service in inaugurating our session with
an invocation.
(8) To the Greensboro Daily News and
the Greensboro Daily Record for their under-
standing, considerate and efficient reporting
of the meeting and the advance publicity
given it.
(9) To the management of the O. Henry
Hotel for their most satisfactory functioning
as hosts.
(10) To the Medical, Civic and Commer-
cial bodies of Columbia, Spartanburg, Char-
leston, Florence and Greenville, S. C, for
their cordial invitations to the Association to
meet in their respective cities in 1930.
President H.all:
Before we adjourn I want to say T love
every member of this organization. So far as
I know, every member has been helpful in
making this meeting successful. I now want
to thank the doctors in Greensboro and Dr.
R. B. Davis, especially, the very efficient
chairman of the local committee, for his help-
fulness. Dr. Davis has been very quiet and
unobtrusive with his help but very constantly
helpful. I thank the other doctors, many of
whom arc not members and do not ex[>ect to
become members. The doctor who helped
with the skin clinic is a very good illustration.
I thank all of you for your co-operation dur-
ing the past year. Let us make the meetings
hereafter better and better.
There being no further business, the meet-
ing then adjourned sine die.
THK JEFFERSON MEDICAL COLLEGE
AUXILIARY TO THE TRI-STATE
(Supplied by Dr. D. W. Holt)
During the meeting of the Tri-State So-
ciety in Greensboro a number of the Jeffer-
son Medical College graduates in attendance
met at the King Cotton Hotel for an alumni
dinner.
The meeting was arranged for by a trio of
the alumni living in Greensboro — and every
one of the more than 50 present was high in
his praises of the success of the initial meet-
ing of its kind by the Jefferson men in the
Carolinas and Virginia.
The meeting was presided over by Dr. Oli-
ver L. Sharpe, of Greensboro, and Dr. D. W.
Holt, of Greensboro, was secretary and treas-
urer pro tem.
No little prestige was added to the occa-
sion by the presence of Dr. James K. Hall,
of Richmond, president of the Tri-State Med-
ical .Association, and Dr. Thurman D. Kitch-
in of Wake Forest, president of the Medical
Society of the State of North Carolina — both
alumni of Jefferson. Dr. Cyrus Thompson,
of Jacksonville, subsequently elected presi-
dent of the Tri-State, was a guest of honor.
.After a very sumptuous dinner was served,
impromptu speeches, of a very enthusiastic
nature, were made by Drs. Jas. K. Hall,
Thurman D. Kitchin, W. P. Beall, Greens-
boro; Oliver L. Sharpe, Greensboro; .A. R.
Wilson, Greensboro; D. W. Holt, Greens-
boro; Wingate Johnson, Winston-Salem; and
Chas. C. Hubbard, Farmer.
Deep regret was expressed by all present
over the fact that Dr. Thos. McCrae, Pro-
fessor of Medicine at Jefferson, who was to
have sat at the head of the table, was absent
owing to illness. .A special message of sym-
pathy, signed by all present, was sent to him;
a similar message of condolence was also sent
to Dr. Thos. E. .Anderson, of Statesville, who
was unable to attend.
So well attended and so thoroughly enjoy-
ed by each one of the members in attendance,
was the first meeting of the alumni of its
kind in these parts, that it was voted and
passed unanimously to make this a perma-
nent organization as an auxiliary to the Tri-
State Medical .Association. Officers for the
coming year were elected as follows:
Dr. Jas. K. Hall, Richmond, Va., Presi-
dent; Dr. D. W. Holt, Greensboro, N. C,
Secretary and Treasurer; Vice-Presidents:
Virginia— Dr. Jno. J. Neal, Danville; North
Carolina— Dr. Thurman D. Kitchin, Wake
Forest; South Carolina— Dr. Hugh Black,
Spartanburg.
The new officers are already at work look-
ing forward to a great meeting next year at
Charleston.
SOUTHERN MEDICINE AND SURGERY
iilarch, igjy
OUR ANNUAL MEMORIAL SERVICE
Dr. W. L. DUiNN
By Dr. jM. L. Stevens
Asheville, N. C.
A history of great physic'ans, if written,
would necessarily include an important chap-
ter on Dr. William LeRoy Dunn, of .Ashe-
ville, X. C, who died May 24, 1928, at
Mount .Alto Hospital in Washington. Such
a chapter is already written in the minds and
hearts of those who were privileged to know
him well.
He graduated in medicine at the University
of ^Michigan, the tirst institution of learning
to establish a chair of Bacteriology, and he
became much interested in this branch of
study. Later he devoted several years to
study in the medical centers of Europe. Hav-
ing decided to specialize in the treatment of
tuberculosis, he came to Asheville to the
Winyah Sanatorium, which was then probably
the largest private institution for the treat-
ment of this disease in the United States.
There he had abundance of clinical material
for study, and in the laboratory connected
with the institution he was associated with
Professor Klcbs in e.xhaustive research work
directed toward the finding of a successful
method of immunizing against the disease.
Although success was not attained, this work
done by h'm was the best of the pioneer
work done in that line.
His aspirations were to contribute some-
thing to the lengthening of the average span
of human life and to merit the respect of
h'mself as well as that of his fellows, and
richly were these aspirations realized. H he
had a harmful habit it was too much work.
In his desire to gain the mastery over a dis-
ease which most physicians looked upon as
incurable, he studied his cases by day and
the work of other phthisiologists far into the
night with no vacations and few recreations.
His relations with his confreres were al-
ways above question. Do unto others as you
would have them do unto you — was his code
of ethics. His competitors were his friends
and it was of their virtues, not their faults,
that he spoke when discussing them.
From the time he began the independent
practice of his specialty in 1901 his patron-
age steadily grew and his merited fame ex-
tended. His clientele was from many states
n'd countries. Few, if any, in his line have
done a greater work, and none has done it
better.
His improved methods of diagnos's and
treatment of tuberculosis influenced favorably
the work of other practitioners thus e.xtend-
ing his sphere of influence to sufferers who
were not under his care.
He was never too busy to consider the pub-
I'c health needs of his city and country, or
the welfare of his profession or that of the
disabled veterans of the \\'orld War. He was
a member of h's city's first board of health
and offered the service of his well equipped
laboratory for its use. His contributions to
the programs of the various med'cal societies
of which h? was a member were classics. His
local society valued his wise counsel on all
matters of professional interest and recog-
nized his influence in promoting that feeling '
of friendship and fellowship that prevails
among its members.
During th; late war he was ch'ef of medi-
cal service of Base Hospital 102 located in
Itah'. In appreciation of the service render-
ed there the Italian government commission-
ed h'm colonel in the Italian .Army and he
acted as military ambassador between the
.American and Italian forces. .After the war
the cause of the disabled veterans received
much of his time and attention. The \'eter-
ans' Bureau sought and profited by his wise
counsel and congressional committees b?fore
which he appeared were always impressed by
his opinions regarding proposed legislation
affecting the welfare of the disabled veteran.
He was influential in the changing of the Vet-
erans' Hospital at Oteen from a temporary
to a permanent hospital and in the establish-
ment of the diagnostic center at Mount .Alto,
Wash'ngton. While a patient in that institu-
tion shortly before his death, with full knowl-
edge of the hopelessness of his disease, he
collaborated in arranging the program for the
ne.xt meeting of the .American Climatological
and Clinical Association of which he was then
pres'dent and the membership of which in-
cluded many of his dearest friends.
He was a great man, a great physician.
The heritage of his work makes all mankind
his debtor.
\larch, 1Q:9
SOUTHERN MEDICINE AND SURGERY
Dr. G. F. McInnes
By Dr. F. B. Johnson
Charleston, S. C.
George Fleming McInnes was born in
Charleston, S. C, on August 26, 1881, the
son of Dr. Benj. McInnes and Mary Kater
McInnes: married July 10, 1922, to Miss
Ruth Ward, of .\tlanta, Ga.; died January
12. 1929.
When six years old he received an injury
which resulted in the development of a le-
sion in his lumbar spine, from which he be-
came paralyzed. During many years he had
to wear a jacket to support his spine. His
education was under the leadership of a pri-
vate tutor, he having to use a rolling chair
in order to get around. Later on he was able
to walk, but only with a great deal of diffi-
culty, and was able to attend a private school
in his native city. When twenty years old,
due to the lesion in his spine becoming fixed,
he was able to discard his brace, and grad-
ually regained the strength in his limbs, so
that he could walk naturally.
He entered the Medical College of the
State of South Carolina in 1904, graduating
in 1908, during which time he served his sum-
mer vacations in hospital work. In 1908 he
was appointed on the Roper Hospital staff,
after which time he began an active practice
in the city of Charleston. He was associated
first with Dr. T. Prioleau Whaley, who at this
time was one of the few men doing genito-
urinary work, and was one of the first to
have an x-ray machine. In 1911 he opened
his own office, associating himself with his
brother, Dr. Kater McInnes, specializing in
genito-urinary surgery and x-ray. His suc-
cess in this line was recognized by the medi-
cal profess'on. He was a member of the Ra-
diological Society of Xorth .\merica, and of
the Urological of South Carolina. His inter-
est in medicine in all of its branches was keen
and active, he was held in the highest esteem
by members of his profession. He held mem-
bership in the Medical Society of South Car-
olina, the South Carolina Medical Asso-
ciation, the Tri-State Medical Society, the
-American Medical Association, in all of
which he was active and contributed the
fruits of his experience and research.
On January 11, 1929, just after returning
from a medical meeting in the upi^er part of
the state, in coming to his evening office hour
he met with an automobile accident, which
resulted in his death the following day, due
to a ruptured liver.
Suffering under the handicaps of extreme
physical defects he was always unusually
cheerful in disposition with a keen mind
which was always active in the profession
which he followed.
Dr. McInnes' untimely death removes from
South Carolina one of the most useful citi-
zens of brilliant professional attainment, and
who was endeared to hundreds who knew him
intinvitely in personal and professional rela-
tionships.
Dr. a. M. Willis
By Dr. C. C. Coleman
Richmond, Va.
Dr. J. Allison Hodges, Richmond, Va.:
Mr. President, in speaking thus for my
friend. Dr. Coleman, I feel I would be untrue
to the memory of my friend. Dr. Willis, did I
not say here how much I appreciated his life
and his services and how much I admired him
as a man and a physician. He was one of
the few men I looked upon as a knight errant
of surgery: brave, fearless, yet with the gen-
tleness and sweetness of a woman. He lived
for his profession, and I am glad that his
last moments were spent at the table where
he had served so many others with aiiounding
skill. This Association will join with many
others in honoring the memory of Murat \\'il-
lis.
On January 3rd of this year the public
and profession of Virginia were shocked into
the realization of the fact that the useful
career of Murat Willis had come to an un-
timely end. The brief remarks that I shall
make on this occasion will be but a feeble
expression of the high esteem in which he
was held by his many friends and associates.
For nearly twenty-five years I knew him
well, and during much of this time there was
a close personal association. In dwelling
upon some of the striking features of his
aggressive and forceful personality, one
thinks immediately of his loyalty to his
friends: his candid, straightforward way of
meeting situations, and the energy and en-
thusiasm he gave to any measure which en-
listed his interest or sympathy.
We, who knew Willis well, wondered at
200
SOUTHERN MEDICINE AND SURGERY
March, 1Q29
his tremendous phys'cal endurance, and I
can recall no occasion on which he referred
in the slightest way to the fact that he felt
tired or overworked. His ability to make and
hold friends was an outstanding feature of the
man. He made many friends and lost few,
because in his friendships, as in his work,
he gave of himself freely. His judgment in
everyday problems, in matters of surgery
and in business affairs was equalled by that
of few men of the profession, and his counsel
was freely used by his friends. Many a young
doctor will recall the advice and material
help in many ways which he received from
Dr. Willis upon leaving his hospital training
to start in practice.
This is not the time nor occasion to attempt
any detailed account of his influence upon
surgery. His scientific honesty was outstand-
ing. His surgical work was backed by con-
viction, and he waited and studies h"s patients
until he got a conviction before sending them
for operation. The safety and value of sur-
gery along such lines are being more and more
appreciated.
.As a teacher of surgery for many years, he
emphasized in no uncertain way the rights of
the patient and the high value of surgical
judgment. His judgment in surgery, like that
of his distinguished chief. Dr. George Ben
Johnston, was superb, and it was supported
by a proper conservatism which gave excel-
lent practical results. Any reference to the
accomplishments of Murat Willis would be
incomplete if it failed to emphasize his abil-
ity as an organizer of hospitals and other
medical institutions. His vision of the devel-
opment and progress of medicine was clear
and penetrating. He threw his full support
to specialization in medicine and surgery,
realizing years ago what has since become ob-
vious, that satisfactory progress would come
only through men highly trained in special
I'ncs. He even encouraged and believed in
reurological surgery fifteen years ago, wh?n
to most surgeons it looked as if such a spe-
c alty had no future.
To his individual work I shall make only a
brief reference, feeling assured that his
achievements will be memorialized more ca-
pably by others. While abdominal surgery
was naturally the field in which he e.Ncelled,
he made important contributions to other
branches of surgery, such for example, as in
the excision treatment for burns. His analy-
sis of the rising mortality of appendicitis,
ftcmach ulcer, goitre and other surgical con-
d't'ors, v,h'le not flattering to the profession,
was d'stinctly beneficial, and is often quoted
in Ihc literature.
As a close friend and warm admirer of
Murat Willis, I think of him as one upon
whose unswerving loyalty his fr'ends could
always depend; a man of conviction and per-
sonal force; of tireless energy; candid, fear-
less and honest. I remember him as having
a refreshing sense of humor: keen-witted and
entertaining. His organizations will live and
flourish as monuments to his vision, judgment
and energy. His influence will live in th?
friendships he made, and in the sol d achieve-
ments of his medical career.
Dr. C. L. Summers
By Dr. J. L. Hanes
Pine Hall, N. C.
Dr. Charles Lee Summers, Professor of
Pediatrics in the University of iMaryland,
died on July IS, 1928, at the age of sixty-
four. His association with the University
began in I9I8, when he was appointed Clini-
cal Professor of I^ediatrics, and he continued
his active administration of his clinic almost
to the day of his death. During those years,
Dr. Summers, who was not in active prac-
tice, gave himself untiringly and wholly to
the difficult task of organizing, supporting
and administering the Babies and Children's
Clinic. Few men of his age have retained
the energy and enthusiasm which in his case
led him for ten years to subordinate all his
interests to the accomplishment of one pur-
pose. These ten years of devoted work were
repaid by the growth of the clinic from the
days when Dr. Summers, laboring alone in
a small cellar room under the hospital, saw
five or six children brought in each week, to
the present time when the large quarters of
the clinic frequently are crowded by over a
hundred infants and children a day; when
the staff of physicians numbers twenty-three;
when three social service workers are re-
quired for the follow-up work in the homes;
and when sixty-six lad es are enrolled as vol-
unteer nurse-aides to assist in the nursing in
the clinic.
This busy and beneficent center of child-
welfare work is the crowning achievement of
a long and varied career. Dr. Summers was
Marcti, 1020
SOtJtiiEfeM iifibtCiMfe AMD stRGfifeV
m
born at Statrsv'lle. N. C, the son of Charles
and Sarah ]\Iurdoch Summers. He received
his early education in private schools, at Bing-
ham Military Academy and at Davidson Col-
lege in North Carolina. In 1866 he matric-
ulated in the University of Maryland and
received his degree of Doctor of Medicine in
1887. Following his graduation he did post-
graduate work in pathology at the Johns
Hopkins ]kledical School. In 1890 he en-
tered practice at Winston-Salem, N. C, and
remained there, except for some years abroad,
until his return to Baltimore in 1916. Dur-
ing this period in Winston-Salem he served
for a number of years as Division Surgeon
for the Norfolk and Western Railroad.
In 1895 he married Miss Bessie Carter
Hall, of Charlotte, N. C. They had two
children who died in infancy. It is probably
to this loss that may be traced the origin of
much of both Dr. and Mrs. Summers' deep
feeling for children.
In 1911 Dr. Summers first turned from
general practice to specialization in Pedia-
trics. He went abroad in that year and en-
tered von Pirquet's clinic at Vienna, where
he remained until the following year when
he went to Berlin to study under Finkel-
stein. Dr. Summers" association with the
Children's Hospital of the University of Vi-
enna resulted in a close friendship with Pro-
fessor von Pirquet. When the latter visited
Baltimore in 1923 he was entertained by Dr.
Summers, and spent a morning with him vis-
iting the Babies and Children's Clinic. That
Dr. Summers' services to the Children's Hos-
pital in \'ienna were noteworthy is shown
by the fact that when, in 1920, a tablet was
placed in the walls of that institution naming
those who had done most for the children
of .Austria, the only Americans listed were
Herbert Hoover and Dr. Summers.
Following his return to .America there were
a few more years in Winston-Salem, and
then in 1916 Dr. and Mrs. Summers came
to live in Baltimore. From that time on he
devoted himself entirely to Pediatrics, work-
ing for several years in the Harriet Lane Hos-
pital and in the Robert Garrett Hospital.
Finally in 1918 he was appointed Clinical
I'rofessor of Pediatrics in the University of
.Maryland in the department of Professor
kuhrah.
On coming to the University of Maryland
he was given charge of the Children's Dis-
pensary ill the University Hospital: a small
bare room in the cellar of the hospital. Such
paucity of facilities would have chilled the
ardor of most young men, especially if they
had previously had the experience of working
in some of the largest and best equipped chil-
dren's hospitals in the world. But Dr. Sum-
mers at fifty-four was only stimulated to a
greater activity. Possessed of sufficient means
to enable him to restrict his private practice,
he was able to devote most of his time to
h's university work. He gave long hours to
the growing clinic — he sought out assistants
among the younger physicians — he besieged
the medical school authorities for equipment
and supplies, and when these could not be
provided in the measure he felt necessary, he
vifent about among his friends and raised the
money needed.
In 1920 the clinic had grown to the point
where it was impossible to house it any longer
in its cramped quarters, and it was moved
across the street into the old gymnasium un-
der the library. These were especially lean
years in the finances of the medical school
and beyond the space, its heating and lighting
and janitor service, the university could do
little to help the new clinic. Dr. Summers,
however, was quite equal to the task, and he
was most ably seconded by Mrs. Summers.
Together they built up the Babies and Chil-
dren's Clinic Aid Society, a corps of devoted
ladies who ever since have worked daily in
the clinic, weighing, measuring, taking tem-
peratures, and assisting the physicians in ex-
aminations. The active financial support of
philanthropic individuals, of the North Caro-
lina Society of Baltimore, and of fraternal
organizations was obtained so that, as the
clinic grew, social service workers, secreta-
ries, supplies and equipment could be pro-
vided. The Babies and Children's Clinic be-
came the favorite charity of many people in
Baltimore.
Dr. Summers was especially interested in
the nutritional problems of infancy and child-
hood. !Much of the work of the clinic lies
along these lines. Situated, as it is, in a con-
gested district, largely inhabited by the for-
eign born and the colored race, the clinic has
served yearly many thousands of mothers in
this district, anxious to learn how to bring
their children safely through the dangers that
202
SOtTHERK MEDICINE AND StJftGERY
March, 1929
beset their first years. It has been an educa-
tional agency whose teachings have saved the
lives of innumerable little ones.
The students of the medical school work
in the clinic in groups throughout the term,
and there has always been an active and
growing staff of graduate physicians. The
continued and rapid increase in the number
of patients as well as the scarcity of available
hospital beds prevented the complete devel-
opment of many of the opportunities for spe-
cialized work afforded by the clinic. Dr.
Summers had many ambitions for its future,
and those who must carry on the work realize
that there is much to be done; yet as it stands
today, it is a most valuable institution and a
living memorial to the ability and the philan-
thropic spirit of the man who created it.
Through the difficult and laborious task of
organizing and administering the clinic, Dr.
.Summers was constantly assisted by his wife.
She worked daily with him; he teaching and
examining patients and she directing the vol-
unteer nursing staff. Her illness and death
in 1927 saddened his last year, but he cou-
rageously continued at work until his own
health gave way. Even then in the last few
weeks of his life he was active in directing
the |X)licy of the institution. His death is a
great loss to the university and to his many
friends. He has left behind to younger phy-
sicians an example of single-minded devotion
and of accomplishment, and to the children
of Baltimore he has left a heritage in the
Babies and Children's Clinic.
Dr. J. H. Miller
By Dr. R. E. Hughes
Laurens, S. C.
Dr. John H. Miller, a native and life-long
resident of Cross Hill, Laurens county. South
Carolina, was not only a fine type of gentle-
man, but as a physician, a business man and
a churchman his rank was high. Strong in
his convictions, with courage always to back
them, he was unusually popular and entirely
loyal to his ideals and friends.
He twice represented his county in the
House where he was highly honored and es-
teemed for his constructive vision, sane judg-
ment, forcible speaking and convincing logic,
He was a charter member of this society,
also a member of the South Carolina, South-
ern, and American ^Medical Associations, and
was a regular attendant. He took a number
of post-graduate courses in this country and
abroad and was abreast with the progress of
modern medicine and surgery.
Besides being a successful physician, he was
also a merchant and farmer, leaving an im-
mense estate.
Dr. Miller died December IS, 1927, aged
70, leaving no children, rich in the plaudits
of a grateful and appreciative public. Mrs.
Miller has since passed, so the book is closed
and "finis" is here recorded of our valued fel-
low member, friend, neighbor and colleague
whom we honor reverently, affectionately and
sincerely — Requiescat in Pace.
Dr. H. M. Stucky
By Dr. C. B. Epps
Sumter, S. C.
In the death of Dr. Henry Mortimer
Stuckey, the Sumter County Medical Society
lost one of its most faithful members. He
was probably absent from its meetings less
often than any other member.
Dr. Stuckey was born in 1867, graduated
from the JNIedical College of the State of
South Carolina in 1891, and licensed the same
year. Doctor Stuckey was president of his
local medical society for one or more terms,
and acted as delegate to the State .Association
at various times. In the medical life of his
community he was ever ready to take an
active part, and strove to maintain friendly
relations between the members of his profes-
sion.
Beside his activities in the profession. Dr.
Stuckey took a most active part in the busi-
ness and social life of Sumter. As an official
of one of the leading banks of the city, and
as a successful farmer, he did valuable work
in the advancement of his community.
His passing was sincerely mourned by his
fellow physicians, and his happy, cheerful
presence is sorely missed at our monthly
meetings. In his long, faithful attendance,
he has set us a splendid example in loyalty
to our medical society.
March, 102^
SOUTHERN MEDtClKE Akfi StJRGfiRV
JOJ
Miscellany
RPXiISTRY OF TECHNICIANS
(Outline supplied by Dr. Fniiicis B. Jnlinsoii of
Outline supplied by Dr. Fniiicis H. Johiium of
Charleston)
In accordance with the trend of the times,
th? practice of medicine is utilizing more and
m:)re the services of trained lay help. The
advent of the laboratory as an indispensible
ad to the diagnosis of disease has created a
pew specialty in medicine; that of clinical
piithology. In order to carry on the numer-
ous technical tests required in scientific diag-
nostic procedures, the laboratory director has
found it necessary to train the technical per-
sonnel. With the standardization of hospitals
and the urgent call for qualified laboratory
a.ssistants there has arisen a demand for
proper standard requirements as to prelimi-
nary education and technical training of those
enrolled in this new profession.
There has also been a desire on the part of
those engaged in this useful calling to raise
their status, similar to the evolution of the
trained nurse of the generation ago. This
want is now being taken care of by a national
organization consisting of a body of men who
are most vitally interested in elevating the
intellectual and technical status of laboratory
workers. The American Society of Clinical
i'athologists has taken u[)on itself the task of
organizing a Registry of Technicians with
rules under which those qualified by educa-
tion, technical instruction, and moral charac-
ter will receive a certificate.
The subject is of interest to physicians in
every field of endeavor as many of them are
desirous of securing the services of techni-
cians to carry on the routin? laboratory pro-
cedures.
There is no doubt that the elevation of
the laboratory technician to the status of a
respected and useful calling will be a great
help to the medical profession, to the patient,
and to the scientific practice of medicine.
The headquarters of the Registry of Tech-
nicians of the American Society of Clinical
I'athologists are located in the .Metro|xiiitan
Hii Iding of Denver, Colorado.
.Another very desirable feature of the Reg-
istry is the facilities it offers in finding suit-
able placement for registrants and in aiding
physicians to find desirable applicants.
The following is a proposed working scheme of
the Registry of Technician; of the American Society
of Clinical Pathologists.
TJic Registry oj Technicians oj the American
Society oj Clinical Pathologists
Proposed Working Schcmi
I. Name
1. The Registry shall be known as the
Registry of Technicians of the .American So-
ciety of Clinical Pathologists, and shall be
directed by a Board of Registry of si.x mem-
bers appointed by the Society.
II. Objects
1. The objects of the Registry shall be:
a. To establish the minimum standards
of educational and technical qualifi-
cations for various technical workers
in the clinical, research and public
health laboratories.
b. To classify them according to these
standards.
c. To receive applications for registra-
tion and issue a certificate of regis-
tration to those who meet the mini-
mum standards of requirements.
(1. To register schools which offer an ac-
ceptable course of laboratory train-
ing.
e. To conduct a placement bureau for
registered laboratory technicians.
f. To cultivate a high ethical standaril
among laboratory technicians in ac-
cordance with the code of ethics es-
tablished by the American Society of
Clinical Pathologists.
III. Board ok Registry
1. The Board of Registry shall be com-
posed of six members elected by the .Ameri-
can Society of Clinical Pathologists, two
members to be apfxjinted by ballot to serve
for three years at each annual meeting of
the Society or until their succe.ssors have been
elected. The first board shall consist of six
members, two of whom shall be elected for a
term of one year, two for a term of two year*
204
SOtJTHERN MEDICINE AND SITRGErV
March, 1910
and two for a term of three years. It shall
elect its own chairman from among the hold-
over members and Secretary-Treasurer.
2. The Board of Registry shall be author-
ized to employ a director who is empowered
to manage the affairs of the Board.
3. The duties of the director shall be to
administer the office of the board by taking
charge of registration of technicians, issuance
of certificates and conducting a placement
bureau and such other business as may be
necessary to carry out the functions of this
board. He shall be directly responsible to
the board.
I\'. Classification of Laboratory
Technicians
1. Technical workers in the clinical re-
search or public health laboratories shall be
classified according to their education, train-
ing and experience, as follows:
a. ^Medical Technologist.
b. Laboratory Technician.
2. Medical Technologist shall signify one
who possesses a university degree with at
least one year in basic sciences including
chemistry, bacteriology, physiology and path-
ology with laboratory demonstration or credit
equivalent to the same as determined by the
board and at least one year of practical ex-
[jerience in a recognized laboratory, devotes
himself wholly to the technical work of a
medical laboratory, and has rendered a val-
uable service in the field of laboratory medi-
cine through research, teaching or other scien-
tific endeavors. Medical Technologists shall
be elected annually by the unanimous vote of
the Board of Registry. A laboratory techni-
cian who possesses no college degree but who
has rendered a long and faithful service in a
recognized clinical, research or public heaith
laboratory in a responsible capacity, may be
eligible to this designation.
3. Laboratory Technician shall signify one
who is fully qualified to render general or
special technical service in a clinical, research
or public health laboratory under the super-
vision of a qualified director, and shall exhibit
the following minimum preparation and quali-
fication:
a. Graduation from an accredited high
school.
b. One year of didactic work in basic
sciences including chemistry, bacteri-
ology, physiology and pathology, to-
gether with laboratory demonstration,
or credit equivalent to the same as
determined by the board,
c. Six months of actual experience in a
recognized clinical, research or public
health laboratory.
4. Laboratory Technician or Medical
Technologist who limits his work in a certain
special field shall be so designated as Bacteri-
ological Laboratory Technician, Chemical
Laboratory Technician, Public Health Labo-
ratory Technician, etc. in the case of labora-
tory technicians and Bacteriologist, Serolo-
gist. Parasitologist, etc., in the case of Medi-
cal Technologists.
y. Registration of Technicians:
Certificate
1. Candidates shall properly fill out an ap-
plication blank of the Registry and file with
the director of the Board of Registry.
2. A registration fee of three dollars shall
accompany the application. This will be
returned if the application is rejected.
3. Annual renewal of the certificate is re-
quired for which a fee of one dollar is charged.
4. Upon the receipt of application the di-
rector shall conduct a preliminary investiga-
tion of each applicant and the result shall be
filed with the application. Certification of
applicants shall be done by the Board of
Registry at the annual meeting.
5. \ certificate of registration shall be is-
sued to all applicants accepted by the Regis-
try.
6. A certificate may be revoked at any time
for cause by order of the board. A hearing
may be granted on request.
VL Examination
1. A formal examination may be deemed
necessary by the board to determine the qual-
ifications of an applicant in which case, writ-
ten, oral and practical examinations shall be
conducted at a place and by a member of
this Society as arranged by the director of
the board.
2. An additional fee of $10.00 to cover
the expense shall be charged the applicant.
VH. Registration of Schools for
Laboratory Technicians
1. The board shall investigate, classify and
periodically inspect through an accredited
representative, the schools and laboratories
which conduct a training course for laboratory
technicians.
2, These schools and laboratories may reg-
March, 1929
SOUTHERN MEDICINE AND StlRGERY
JOS
ister with this board and receive an annual
certificate of registration provided the course
of training given meets the approval of this
board. An annual registration fee of one
dollar shall accompany the application.
\'III. Pl.acement Bureau
1. Registered technicians and technologists
may, upon proper application, be placed
through this bureau operated by the board.
2. A fee equivalent to five per cent of the
first month's salary shall be charged to the
technician who obtains employment through
this bureau.
IX. Code of Ethics
1. All registered technicians and technolo-
gists shall be required to strictly observe the
Code of Ethics as defined by the American
Society of Clinical Pathologists, namely, that
they shall agree to work at all times under
the supervision of a qualified physician and
shall, under no circumstances, on their own
initiative, render written or oral diagnoses
except in so far as it is self-evident in the
report, or advise physicians and others in the
treatment of disease, or operate a laboratory
independently without the supervision of a
qualified physician or clinical pathologist.
REGISTRY OF TECHNICIANS
American Society of Clinical Pathologists
256 Metropolitan Building
Denver, Colorado
pyorrhoea in middle life. Of the reasons for this
prematurity in the victims of pyorrhoea we are still
iRnorant. They may act either directly on the tooth-
supporting structures, predisposing them to atrophy
and absorption, or they may act by encouraging the
deposit of calculus, the most vital of the exciting
causes. They probably signify some biochemical
change in l.me metabolism, perhaps due to an altered
endocrine activity. In this connection F. W. Broder-
ick and Weston Price have made some interesting
sugfiestions, pointing out that pyorrhoea becomes
more common as caries become less common — a con
trast that applies not only to the age incidence, but
to the type of tooth most severely attacked — and
that pyorrhoea is a disease of lime e.xcess in the
blood, caries one of lime deficiency But a coherent
explanation of these matters has still to be worked
out, and for the present we must be content to
realize that there is undoubtedly some unknown pre-
disposing cause which helps to determine why
amongst individuals in whom the exciting causes are
equally operative some are attacked by pyorrhoea
nd other.; remain immune.
PREDISPOSING CAUSES OF PYORRHOEA
(Humphivys in The Lancet, January lOth)
The first of these is the essentially transient and
temporary nature of the teeth and iheir supporting
structures, a physiological fact due to the evolution-
ary history of the mammalia. The reptiles from
which they sprang are polyphyodont — that is, they
have a succession of teeth limited in numbers only
by the life of the individual; each set after a short
period of use is cast off and replaced by another. In
that class of reptiles (the Thcriodontia) from which
it is believed that mammals were evolved we see
that the life of each set of teeth became more and
more prolonged, till in some species two sets were
sufficient for the normal life of the individual. This
arrangement became stereotyped in mammals, and
all the sets of teeth after the second were suppressed.
But throughout the mammalia, if an animal lives
much beyond its normal allotted span, there is a
tendency for its teeth to become lost, till it finally
becomes edentulous. The exceptions are teeth of
persistent growth, and if they are so arranged that
no wear reduces their size these teeth continue to
grow larger throughout life — for example, the tusks
of elephants.
The loss of the permanent teeth due to wear and
the atrophy of the tooth-supporting structure is.
then, a normal feature of old age, and there is no
clinical difference between the loss of teeth as a
normal senile change and their premature loss from
OUR LEAST CONCERN
(New York Herald -Tribune via New Yorh State
Jour, of Med.)
I'm told that fifty-dollar bills
Are brittle when they're new
And should be laid away in tills
A year, or maybe two —
That when this trifling time has passed,
Their fibers will grow strong,
.And one will find that they will last
A hundredfold as long.
This statement may be true or false,
But I shall never know.
For I have neither tills nor vaults
In which my bills to stow.
And be they frail or be they strong,
All those I ever see,
.'\ssuredly will last as long
.As they abide with me.
Though old and worn or crisp and new
With backs of gold or green.
They tarry briefly in my view,
Then vanish from the scene.
They have to go for this or that;
Bright butterflies are they
Which touch my hand to leave me flat
.And flutter on their way.
.And if they crack or tear across
.As on their flight they fare,
Some other man must stand the loss
.And little do 1 care.
So let them brittle be, or tough,
The few I ever see
Will certainly last long ent^ugh
To take away from me!
206
SOUtttERN MEDICINE ANO StRGERY
March, m9
MEMBERS TRI-STATE MEDICAL ASSO-
CIATION OF THE CAROLINAS
AND VIRGINIA
N on- Resident
Barker, L. F. (Hon.) Baltimore, .Md.
Sharpe, William (Hon.) New York City
.Stirling, \V. C Washington, D. C.
Tovvnsend, M. L Washington, D. C.
White, Chas. S Washington, D. C.
White, Wm. A. (Hon.) ..Washington, D. C.
CaudiU, E. L Elizabethton, Tenn.
South Carolina
Abell, Robert E. Chester
Allison, J. R. Columbia
Baker, A. E., sr. (Hon.) ..Charleston
Baker, A. E., jr. Charleston
Barron, W. R. Columbia
Black, H. R. Spartanburg
Black, H. S. ..Spartanburg
Black, S. O. . Spartanburg
Black, W. C. Greenville
Blackmon, W. R. . Rock Hill
Blackwell, W. G. Parksville
Brockman, Thomas Greer
Bunch, G. H. Columbia
Burnside, Alfred F. Columbia
Cannon, Joseph Henry Charleston
Carpenter, E. W. .......Greenville
Cathcart, R. S. (Hon.) Charleston
Coggeshall, Julian T. Darlington
Corbett, J. W. Camden
Davis, T. McC Greenville
Durham, Frank M. Columbia
Earle, C. B. Greenville
Epps, C. B. . Sumter
Evatt, Clay . Greenville
Finklea, O. T. Florence
Finney, Roy P. Spartanburg
Foster, Carl A. Columbia
Foster, Ralph K. ..Columbia
Fouche, James S. Columbia
Furman, Davis (Hon.) Greenville
Guerry, LeGrand (Hon.) Columbia
Horger, E. L. Columbia
Hughes, R. E. (Hon.) ..Laurens
Jefferies, J. L. Spartanburg
Jennings, Douglas Bennettsville
Johnson, F. B. Charleston
Jordan, Fletcher Greenville
Kinney, P. M. Bennettsville
Kluttz, De Witt Greenville
Kollock, Chas. W .(Hon.) Charleston
Lander, Frank SI. Williamston
Lyles, W. B. .Spartanburg
Lynch, Kenneth M ...Charleston
:\IcGill, Waldo Knox Clover
Mcintosh, J. H. (Hon.) Columbia
McLeod, F. H. (Hon.) _..._. Florence
Maguire, D. L. Charleston
.Mauldin, L. O. Greenville
?ilay, Charles R. Bennettsville
^Montgomery, B. McQ. Kingstree
Pitts, Thos. A. Columbia
Pollitzer, R. M. Greenville
Ravenel, James J. Charleston
Reeves, T. B. Greenville
Rhame, J. Sumter Charleston
Routh, Foster M. Columbia
Seibels, Robert E Columbia
Shealy, Walter H. Leesville
Sherard, S. Baskin Gaffney
Smith, D. Herbert Glenn Springs
Smith, Hugh Greenville
Smith, Josiah E. Charleston
Smith. Thos. H. .- Bennettsville
Smith, W. Atmar Charleston.
Smith, Zach. G. Marion
Smyser, John D. Florence
Steedly, B. B Spartanburg
Stuart, Garden C. Eastover
Stuckey. T. M. Cope
Taylor, J. H. ... Columbia
Timmerman, W. P. Batesburg
Walker, R. R. Laurens
Wallace, Wm. R. Chester
Ward, W. B. Rock Hill
Weinberg, Milton Sumter
Wilkinson, Geo. R. Greenville
Wilson, L. A. Charleston
Wilson, Robert, jr. (Hon.)..... .Charleston
Wolfe, H. D. Greenville
Wyman, Hugh E. Columbia
Wyman, M. H. Columbia
Zimmerman, W. S. Spartanburg
Virginia
Anderson, P. V. Richmond
Andrews, C. J. Norfolk
Barnett, T. Neill Richmond
Baughman, Greer Richmond
Bear, Joseph . Richmond
Blackwell, Karl S Richmond
Brown, Alex G. _ Richmond
Bryan, Robt. C. (Hon.) Richmond
Budd, S. W. Richmond
Burke, .AI. O Richmond
Bu.xton, J. T Newport News
Call, Manfred _ Richmond
Clarkson, Wright Petersburg
Cole, Dean B Richmontj
Marcb, 102«
SOWHERN MEDICINE AND SURGERY
M7
Coleman, C. C. - _ Richmond
Culpepper, James H. Norfolk
Darden, O. B. Richmond
Davis, John Wyatt Lynchburg
Davis, T. Dewey „ Richmond
Dodson, A. I. Richmond
Drewry, W. F. Petersburg
Dunn, John Richmond
Ennett, N. Thomas Richmond
Faulkner, D. McKenzie Richmond
Fowlkes, C. H. _. Richmond
Gayle, R. F., jr Richmond
Gayle, E. M. Portsmouth
Geisinger, J. F — Richmond
Graham, J. T. Draper
Graham, VV. R Draper
Gray, A. L. Richmond
Hall, J. K. (Hon.) Richmond
Hamlin, P. G. Williamsburg
Hamner, J. L. Mannboro
Harrell, D. L. Suffolk
Hazen, Chas. M. Bon Air
Hedges, H. S. . University
Henderson, Esteell H. Marion
Henson, J. \V. Richmond
Hiden, J. H. Pungoteague
Hill, Emory Richmond
Hodges, A. B. _...__ Norfolk
Hodges, Fred M. Richmond
Hodges, J. Allison (Hon.) Richmond
Horsley, J. S. Richmond
Howie, Paul W. Richmond
Hughes, T. E. Richmond
Hughes, T. J. Roanoke
Hunter, J. W., jr. Norfolk
Hutcheson, J. M. Richmond
Jameson, Waller Roanoke
Johns, F. S. . ^ Richmond
Jones, J. Boiling Petersburg
Jones, Thos. D. Richmond
Keyser, L. D. Roanoke
King, J. C. Radford
Langston, Henry J. Danville
Leigh, Southgate (Hon.) ..Norfolk
Lyerly, J. G. Richmond
McGavock, E. P Richmond
McGuire, H. H Richmond
McGuire, Stuart (Hon.) Richmond
McKinney, Joseph T. Roanoke
Masters, Howard R. Richmond
Mauck, H. I'age Richmond
Michaux, Stuart Richmond
Miller, C. M , Richmond
Monroe, A. C Richmond
Nelson, Garnett Richmond
Nuckols, M. E Richmond
Payne, R. L. Norfolk
Peple, W. L. (Hon.) Richmond
Porter, W. B. Richmond
Preston, Robt. S. Richmond
Price, L. T. Richmond
Rawls, J. E. Suffolk
Righter, Frank P Richmond
Rinker, F. C. Norfolk
Robertson, L. A. Danville
Robins, Charles R Richmond
Royster, James H. Richmond
Rucker, M. P. Richmond
Sherrill, Z. V. Marion
Smith. James H. Richmond
Spencer, H. B. Lynchburg
Tabb, J. L. Richmond
Taliaferro, E. C. S. ....Norfolk
Talley, D. D., jr. Richmond
Terrell, E. H. Richmond
Thomas, C. W. Floyd
Tucker, B. R ..Richmond
Turman, A. E Richmond
VanderHoof, Douglas Richmond
Vaughan, Warren T. Richmond
White, Jos. A. (Hon.) Richmond
Williams, Carrington Richmond
Williams, L. L., jr. Richmond
Williams, J. P. Richmond
Wilson, Franklin D. Norfolk
Woolling, R. H. Pulaski
Wright, R. H. Richmond
North Carolina
Allan, William ...Charlotte
Allgood, R. A. Fayetteville
Ambler, C. P. Asheville
Anders, McTyeire G. Gastonia
Anderson, Albert (Hon.) Raleigh
Ashworth, W. C. Greensboro
Averitt, Kirby G. Fayetteville
Baker, Julian M. Tarboro
Barret, Harvey P. Charlotte
Barron, A. A. _.. Charlotte
Battle, L P _ Rocky Mount
Beall, L. G. .....Black Mountain
Beam, Hugh M Roxboro
Beam, Russell S. Lumbcrton
Biggart, W. P _ ......Charlotte
^'8'"- V. L. Kinston
Blair, A. McNiel ..Southern Pines
^"'ce, E. S Rocky Mount
Bosf, Thomas C Charlotte
Brackett, Wm. E. Hendersonville
Brenizer, Addison G. Charlotte
i6A
SOUTHERN MEDICIKE AND StRGEftV
March, l9i^
Brooks, R. E. Burlington
Burrus, J. T. High Point
Burt, S. P. Louisburg
Carroll, R. S. Asheville
Carter, T. L. Gatesville
Chester, P. J. Fayetteville
Cole, \V. F. Greensboro
Cooke, G. Carlyle Winston-Salem
Coppridge, \Vm. M. Durham
Council, E. E. Angier
Crowell, A. J. (Hon.) _.... _..._.Charlotte
Crowell, L. A. Lincolnton
Daniel, N. C. ^Oxford
Davenport, C. A. Hertford
Davidson, J. E. S. Charlotte
Davis, Francis M Canton
Davis, James W. Statesville
Davis, Richard B. Greensboro
Davison, W. C. Durham
Dawson, W. W. Grifton
DeLaney, C. O. Winston-Salem
Dickinson, E. T Greenville
Dixon, Guy E. Hendersonville
Dixon, G. G. Ayden
Dixon, W. H. ._ Kinston
Elliott, Joseph A. Charlotte
Elliott, W. F. Lincolnton
Faison, Yates W. Charlotte
Ferguson, R. T. '. Charlotte
Fleming, M. I ...Rocky Mount
Fox, P. G. Raleigh
Gage, L. G. Charlotte
Garrison, D. A. Gastonia
Gaul, J. S. Charlotte
Gibbon, Jas. W. ..Charlotte
Goodman, A. B. Lenoir
Green, Thomas j\L ..Wilmington
Griffin, M. A. Asheville
Griffin, W. Ray Asheville
Hardin, R. H Banner Elk
Harper, J. H. Snow Hill
Hathcock, Thos. A. Norwood
Highsmith, J. D .....Fayetteville
Highsmith, J. F. Fayetteville
Highsmith, Seavy Fayetteville
Hill, W. Lee Lexington
Hipp, E. R. Charlotte
Holt, Wm. P. Erwin
Holmes, A. B. ..Fairmont
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Jackson, W. L ....High Point
James, W. D. Hamlet
Johnson, Chas. T. Red Springs
Johnson, Thos. C. Lumberton
Johnson, Wiley C. Canton
Johnston, J. G. Charlotte
Julian, C. A. Greensboro
Kapp, Henry H. .Winston-Salem
Kelleher, L. B. Charlotte
Kelly, Luther W. Charlotte
Kennedy, John P. Charlotte
Kerr, J. D. Clinton
Kinlaw. W. B. Rocky Mount
Lafferty, R. H. Charlotte
Laughinghouse, Chas. O'H. (Hon.)... Raleigh
Lawrence, Chas. S Winston-Salem
Leak, Wharton G East Bend
Lee, Thomas L. Kinston
Lilly, J. i\L Fayetteville
Love, Bedford Roxboro
Mahoney, A. F. Monroe
Mangum, Charles P. Kinston
Martin, M. S. Mount .Mry
Martin, W. F. Charlotte
^Nlatheson, J. P. Charlotte
Miller, O. L. -. Charlotte
Moore, A. Wylie Charlotte
Moore, Oren Charlotte"
Moore, R. A. Charlotte
Motley, F. E. Charlotte
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MacNider, Wm. deB. (Hon.) ...Chapel Hill
McBrayer, L. B. Southern Pines
McCampbell, John Morganton
IMcFadden, Ralph H. Charlotte
^IcKay, Hamilton W. .....Charlotte
.McKnight R. B Charlotte
McLean, E. K. Charlotte
.AIcMillan, R. D. ....Red Springs
McPhail, L. D. ....Charlotte
McPherson, S. D. Durham
Nalle, Brodie C. Charlotte
Nance, Chas. L. Charlotte
Nash, J. F Saint Pauls
Neal, Kemp P. Raleigh
Newton, Howard L Charlotte
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Orr, Chas. C Asheville
Parker, J. R. Burlington
Parker, O. L. Clinton
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Peery, Vance P. .....Kinston
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March, IQ.'o
SOUTHERN MEDICINE AND SURGERY
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Robertson, J, N .— Fayetteville
Royster, Hubert (Hon.) Raleigh
Royster, T. S. Henderson
Russell. Jesse M Canton
Scott. Chas. L. Sanford
Scruggs, W. M. -- „ -Charlotte
Shirley, H. C Charlotte
Shore, C. A. „Raleigh
Shull, J. R. - - Charlotte
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Sloan, Henry L. Charlotte
Sloan. \Vm. H. , Garland
Smith, C. T __ Rocky Mount
Smith, O. F. Scotland Neck
Smith. Owen High Point
Smithwick, J. E Jamesville
Sparrow, Thos. D Charlotte
Spicer, R. W. .Winston-Salem
Squires, C. B. Charlotte
Stevens. M. L. Asheville
Tate, W. C Banner Elk
Tayloe, David T. (Hon.) Washington
Tayloe. David T.. jr. Washington
Tayloe, Joshua, 2nd Washington
Taylor. E. H. E. Morganton
Taylor, Wm. L. Oxford
Thomas, W. N. Oxford
Thompson. Cyrus __- Jacksonville
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Todd. L. C Charlotte
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\\'h!taker. F. S. Kinston
Whitaker. Paul F. Kinston
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Wooten, W. I. Greenville
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Yarborough, R. F. Louisburg
NEW MEMBERS ELECTED TO FELLOWSHIP AT GREENSBORO :MEETING
C M. Gilmore
Parran Jarboe
P A. Shclburne
Robert E. Rhvne .....
R. H. Crawford
J. W. Fauntleroy
C. H. Fryar
F. A. Sharpe
T. T. Watkins __
G. A. Torrcnce
.1 ddres:cs
Greensboro, N. C.
.Greensboro, N. C.
..Greensboro, N. C.
Gastonia, N. C.
G. D. McGregor
C. S. McCants __
L. P. Thackston ....
J. VV, Dickie
C. R. Tov
G. P. LaRoque _..
J. G. Murray
E. A. Hines
0. E. Finch _..
O. D. Ba.\ter
R. P. Kelly
.\. B. Greenwood
H. B. Thomas
J H Bnulware
Furman Angel
H. \V. Lewis
I-. N, We.st _....
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Reccmmendrd by
VV. C. Ashworth
W. C. Ashworth
W. C. Ashworth
McG. Anders
Vm. Allan
Robt. C. Brvan
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R. B. Davis
C. 0. DeLaney
R. F. Gavle
L. W. Kelly
DcWitt Kluttz
C. A. Moblev
L. B. McBraver
W. deB. MacNider
Richmond, Va W. L. Pcpic
Greenville, S. C. __R. M. Pollitzer
Seneca, S. C __ R. M. Pollitzer
Raleigh, N. C. van Procter
Raleigh, N. C. van Procter
Lynchburg, Va. W. T. X'aughan
Asheville, N. C. . (. VV. Vernon
Whitmire, S. C W. R. Wallace
Winnsboro, S. C. _.W. B. Lvlcs
'■"ranklin, N. C. _. J. K. Hall
Dumbarton, Va _ J. K. Hall
Raleigh, N. C. ). K Hall
Greensboro, N. C J. K. Hall
._Rutherfordton, N. C.
...Zirconia, N. C.
. .Oak Ridge, N. C.
...Greensboro, N. C.
._Clemons, N. C.
_Hot Springs, Va.
. Charlotte, N. C. _
...Winnsboro, S. C.
-Orangeburg, S. C.
...Southern Pines, N. C.
...Chapel Hill, N. C
.\. O. Spoon
S. B. Woodward
C. \. Mobley
P. VV. Flagge _
Petersburg, Va. J. K. Hall
Roanoke, Va J. K. Hall
Greensboro, N. C. _. J. K Hall
Davton, Ohio ]■ K. Hall
_ Orangeburg, S. C. J. K. Hall
High Point, N. C J. K. Hall
210
SOttHERN MEDICINE AND SURGERY
March, 1929
M. S. Brent
J. K. Corss -
J. S. Dejanuette
E. T. Harrison
B. F. Eckles.
G. L. Carrington
Robert \V. McKay
C. R. Wharton
Anna M. Gove
O. O. Ashworth
W. M. Love
T. D. Houck „„
W. L. Grantham
J. J. Post
F. W. Griffith _ ..
H. L. Denoon, jr.
B. W. Page
H. C. Neblett
J. VV. White
L. M. Fetner
F. R. Tavlor
C. E. Reitzel
R. O Lyday
C. W. Banner __
R. C. Mitchell -
T. D. Kitchin
J. W. Tankersley
G. C. Andes
F. C. Smith
H. H. Ogbum __
L. J. Butler
C. D. W. Colby _
R. F. Leinbach _
\'. K. Hart
W. G. Smith
T. O. Coppidge ..
H. H. Foster _.
G. L. Fuquay — .
J. VV. Martin
Petersburg, Va.
Newport News, Va. „
Staunton, Va
High Point, N. C.
Galax, Va ,..
Burlington, N. C.
Charlotte, N. C.
Ruffin, N. C.
Greensboro, N. C.
Richmond, Va.
Monroe, N. C. —
Timmonsville, S. C. ..
. . . . -.\sheville, N. C.
Greensboro, N. C.
.\sheville, N. C.
Richmond, Va.
. Trenton, N. C.
Charlotte, N. C _.
-Greenville, S. C -
..Charlotte, N. C.
._High Point, N. C. .
—J
—J
—J
—J
—J
—J
—J
—J
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—J
—J
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-J
-J
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-High Point, N. C. .
....Greensboro, N. C. .
Greensboro, N. C. ,
Mt. Airv, N. C.
. -... Wake Forest, N. C
. Greensboro, N. C.
J
I.
-J
-J.
J.
Charlotte, N. C J.
... ...Charlotte, N. C J.
Greensboro, N. C. J.
Winston-Salem, N. C. J.
Asheville, N. C. J.
Charlotte, N. C. J.
Charlotte, N. C. J.
Wendell, N. C. J.
Nashville, N. C. J.
Norlina, N. C. J.
Coats, N. C. J.
Roanoke Rapids, N. C. J
W. D. McClelland Gastonia, N. C. J.
W. J. Moore Ashcboro, N. C J.
F. M. Patterson _Greensboro, N. C. J.
F. L. Potts \anceboro, N. C J.
A. B. Sloan Mooresvillc, N. C. J.
J C. Tayloe Washington, N. C J.
P. H. Wiseman .^vondalc, N. C. _ J.
I. T. Mann High Point, N. C .T.
T. D. Walker Winston-Salem, N. C. J.
R. L. .Anderson Richmond, \'a. J.
R. L. Noblin O.xford, N, C ".
W. D. Rogers Warrenton, N. C E.
K. Ha
K. Ha
K. Ha
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M, No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
M. No
W. W. Green
A. T. Thorp
H. G. Lassiter
D. B. Cobb _
G. H. Sumrell
C. R. Young
C. N. Wyatt
W. H. Prioleau
R. \. Moore
Graham Harden
R. H. Courtnev
_Tarboro, N. C.
„Rockv Mount, N. C.
..Weldon, N. C
.Goldsboro, N. C.
_^^•den, N. C.
..Angler, N. C.
..Laurens, S. C
.Charleston, S. C.
.Farmville, Va
.Burlington, N. C.
.Richmond, Va.
J. H. Wheeler
E. B. Beasley
Henderson, N. C.
Fountain, N. C.
seman
M. N
M. N
M. N
M. N
M. N
M. N
H. W
S, Bo
S. Bo
S. Bo:
S. Bo
S. Bo;
H. D
L. Fuquay
E. Hughes
B. Johnson
S. Martin
M. Patterson
T. Price
S. Royster
I. Wootcn
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
ngton
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SOUTHERN MEDICINE and SURGERY
Vol. XCI
Charlotte, N. C, April, 1929
No. 4
Recognition and Treatment of Early Syphilis*
A. Benson Cannon, M.D., New York City
Associate Professor of Dermatology, CoIIcrc of Physicians and Surgeons, Columbia University
Attending Dermatologist, City Hospital
I have always the same theme when I think
or talk syphilis, the plea for an early diag-
nosis and for continuous and adequate treat-
ment in order to prevent cardiac syphilis,
neurosyphilis, and other distressing sequelae
of this d'sease.
extragenital chancres
Most physicians are well acquainted with
the appearance of the typical syphilitic lesion
as it occurs on the genitals, but when it de-
velops elsewhere, as on the fingers, lips, ton-
sils, or anus, or when it is obscured by the
presence of a mixed infection, it is often not
so easily diagnosed.
Case 1. Lip Chancre. — A woman, aged
25, a child's nurse, was referred to me for a
sore on the lip and a rash over her body. Six
weeks previously she had gone to a hospital
d'spensary to be treated for the sore which
was diagnosed and treated as a herpes. When
she returned to the clinic eight days later, the
lesion was much larger and crusted, but after a
consultation with three other doctors, her
physician assured her again that it was only
an unusually severe fever sore. A few days
later she ncjticed that the glands on the right
s'dc of her neck had become very large;
a short while after that a rash appeared over
her body. During this time she had felt per-
fectly well. Examination showed a large, in-
durated, nodular, ulcerated, hazel-nut sized
swcjjin;; on the vermilion side of her right
lower lip: the right submaxillary glands were
grc.illy swollen, and all of her superficial
glands were palpable. There was a general-
Fig. 1
Chancre of the lip.
♦Prr.scntcd hy invitation to the Tri-Statc Medical
As>'.K;alion of the Carolinas and Virginia, Greens-
boro, N. C, February. 19, 1929.
Fig. 2
The same case showing a secondary macular and
papular eruption.
iiy
SOUtHERN MEblClME ANt) StftGEftV
April, 1929
ized maculopapular eruption. Spirochetes were
demonstrated in a dark iield examination of
the secretion from the sore and her wasser-
mann was four plus. {Figs. 1 and 2.)
Case 2. Tonsil Chancre. — Last week, a
young man 24 years old was sent to me com-
plaining of pea to dime sized, red, bald spots
over the scalp, with loss of hair. His atten-
tion had been called to the spots five days
previously by his barber. I found his right
anterior cervical glands as large as a hen's
egg and slightly tender; the right tonsil en-
larged and ulcerated. He stated that the ton-
sil and gland had developed about two months
previously and both had improved consider-
ably. All the superficial glands were palp-
able; circinate and annular, red, scaling, ma-
cular and slightly raised lesions were over
the scrotum and penis; the pupils were un-
equal, irregular in outline, the left reacting
sluggishly to light. The arm reflexes, ab-
dominal and cremasteric were hyperactive and
equal on the two sides. The left knee and
ankle jerks were hyperactive. There were
several scars where scrofulous glands had been
removed at intervals since the patient's in-
fancy. He had also been operated on for
bone tuberculosis of the left hand and right
foot. The patient had had no constitutional
symptoms. His wassermann was four plus.
Case 3. Anal Chancre. — Late in Decem-
ber a man, 26 years old, was referred to me
for an eruption of the body and face, of one
his physician had sent him to a surgeon who
had operated on him for hemorrhoids and a
fissure two weeks before I saw him. A week
after his operation, a rash had appeared over
his bodv and face and his throat had become
week's duration. A month previously he had
noticed pain and soreness in the rectum and
Fig. 4
The same case showing enlarged gland in the left
inguinal region and a macular and papular eruption.
sore. L^pon examining him, I found that he
had a generalized maculopapular and squa-
mous eruption most marked on the face, soles,
palms and flexor surfaces; a pharyngitis; a
mucous patch on his right tonsil; enlarge-
ment of all sujjerficial lymphatics, especially
pronounced in the right inguinal region; and
a chancre on the right side of the anus. Dark-
field examination of secretion from chancre
showed numerous spirochetes and his wasser-
mann and kahn precipitation tests were both
strongly positive. It is interesting that in
January I saw two additional patients each
with an anal chancre, one of whom had also
been operated on for hemorrhoids. (Figs. 3
and 4.)
CHANCRE COMPLICATED BY OTHER LESIONS
We probably see the chancroidal compli-
cation most frequently, the ulcerations being
usually soft, necrotic, and sometimes causing
considerable destruction of the parts, with a
suppurating inguinal adenitis and a demon-
stration (microscopically) of Ducrey's bacil-
lus and repeatedly negative dark-field exam-
inations. In such instances the discovery of
the presence of syphilis is detected only by
frequent blood wassermanns or by the devel-
opment of a secondary eruption. We have
often found a chancre complicating gonorrhea
either at the meatus {Fig. 5) intraurethral or
hidden by a phymosis. Syphilis may not
even be suspected until the development of
adenitis or other evidences of secondaries, or
a positive wassermann report. {Fig. 6.)
April, 1929
SOUTHERN MEDICINE AND SURGERY
Fig. 5
Chancre of the meatus and prepuce with phymosis
complicating gonorrhea. Note the presence of en-
larged gland in the left groin and secondary lesions
on the thighs.
A phagedenic chancre with marked destruction of
the prepuce and portion of the glans penis and in-
duration of the right side of foreskin.
Case 4. Herpes. — Occasionally one sees a
chancre develop at the site of a herpes pro-
genitalis. A short while ago a young man,
twenty-eight years old, consulted ms for
penile lesions. He stated that over a period
of ten or eleven years he had had frequent
severe herjjes progenitalis. Six weeks pre-
viously, he had an unusually severe outbreak
of lesions on the prepuce and glans penis,
which instead of disappearing in two or three
weeks, hud gradually become markedly ulcer-
ated with enlargement of the inguinal glands,
generalized eruption and sore throat. Exam-
ination showed eight indurated ulcerations on
the glans penis and prepuce, superficial ade-
nopathy, more pronounced in the inguinal re-
g'on, generalized maculopapular eruption and
pharyngitis. Spirochetes were demonstrated
in serum taken from sores and his wassermann
was four plus with all methods.
Both the primary and secondary lesions in
syphilis may be so obscured by scabies and
an additional pus infection caused by scratch-
ing that again syphilis is not considered as a
diagnosis until the development of mucous
patches, or some of the constitutional symp-
toms of this disease such as headaches, fa-
tigue, and indefinite pains over the body.
Case 5 — On November 27, 1928, I saw in
consultation a man, ii years old, who com-
plained of severe constant occipital headaches
and stiff neck of two weeks" duration. In
the previous December he had developed a
generalized itching eruption with sores on the
penis which were diagnosed as scabies. He
obtained relief from the itching after using a
sulphur salve for about eight days although
the sores on the penis persisted. About Jan-
uary 6th the rash reappeared and this time
he had a diagnosis of ringworm and was given
a violet ray treatment. By January 20th the
penile lesions were large, ulcerated and cjuite
painful, and swellings had ap[5eared in the
inguinal regions. Spirochetes were demon-
stater in the secretion taken from the sores
and his blood wassermann was reported 3
plus. On January 30th, he began treatment
and took eight injections of neoarsphenamine
and eight of mercury salicylate at weekly in-
tervals. After a three weeks' rest, his was-
sermann was reported negative. He continued
the rest period for an additional two weeks
when he developed occipital headaches and
stiff neck. These symptoms became intensi-
fied and on May 24th, while in conference
with a business associate, his left arm and leg
began twitching, he was unable to speak
clearly, and in a minute he became tense and
fell to the floor unconscious. He was in a
hospital for two weeks with weakness in his
left arm and leg. His blood was.sermann was
reported two plus and his spinal fluid nega-
tive. He was given eight more injections of
neoarsphenamine and eight of mercury after
which his blood wassermann was again neg-
ative. .After a three weeks' rest he took five
additional injections of each drug. After a
further two weeks' rest he began to have se-
vere, continuous general headaches, most
marked in the occipital region and unrelieved
by opiates. His symptotns were attributed to
an excessive amount of arsenic.
When I examined him, I found that his
pupils were unequal; all the deep reflexes
214
SOUTHERN MEtJl(?lNfi AND SURGERY
April. IQ-'a
hyperactive; the left arm, abdominal, epigas-
tric, cremasteric, patellar and ankle jerks
were more active than the right. There was
a double babinski and ankle-clonus, most
marked on the left foot. His blood wasser-
mann was strongly positive and his spinal
fluid was 4 plus to 0.1 c.c, cells 58, globulin
3 plus, gold sol. 5555432100.
Up to this time, he has had six intraspinal
injections of Swift-Ellis serum, seven injec-
t'ons of neoarsphenamine, seven of tryparsa-
mide, and fourteen of mercury salicylate. The
first intraspinal treatment relieved the head-
aches, he has remained free from symptoms
and has gained fourteen pounds in weight.
Granuloma inguinale is sometimes easily
confused with the initial lesion in colored
people; but we usually are able to diagnose
it by the persistence of the lesion, its lack of
infiltration, the absence of the spirochete and
by demonstrating the Donovan bodies. {Fig.
7')
Fig. 7
Granuloma inRuinalc of the prepuce somewhat re-
semblins an initial lesion but showinp; a characteris-
tic granuloma inguinale ulceration of the right in-
guinal region.
I have seen carcinoma involving the glans
penis mistaken for a chancre, but the pres-
ence of a leukoplakia, the rolled borders of
the ulceration, absence of the spirochete, and
finally, the biopsy report enables one to estab-
I'sh the true diagnosis there.
Realizing the tremendous importance of
making an early diagnosis in syphilis and the
flifficulty one often e.xperiences in being able
to recognize the initial lesion, especially in
extragenital cases, we make it a practice to
suspect syphilis always until it has been defi-
nitely excluded by repeated dark-field exam-
inations, biopsy, and blood wassermanns.
INTERPRET.ATION OF THE DOUBTFUL
W.ASSERMAN REACTION
It is a s.'mple matter to decide that a pa-
tient has syphilis when a properly controlled
wassermann is found to be strongly positive,
four plus; but when the test is doubtful, one
antigen giving a moderately or strongly posi-
tive wassermann and the other reporting neg-
ative, or practically so, and especially when
the patient has a negative physical examina-
tion and venereal history, the diagnosis be-
comes more of a problem. In such instances
as the latter, we have found it necessary to
study the conditions under which the wasser-
mann reaction was made and to have it re-
peated every few weeks for several months,
having it controlled by the kahn precipitation
test. Many laboratories use only the was-
sermann reaction while others depend exclu-
sively on the kahn precipitation test. INIany
methods are used in doing wassermanns, and
kahn precipitation tests but the possibility of
error is so great that we feel it is safer to
use both tests, each as a check on the other.
Case 6. Doubtjul Wasscnnuiiii. — A child,
twenty-seven months old, was referred to me
three years ago this month with a rash over
her body and a wassermann negative with
alcohol and four plus with cholesterin anti-
gens. The child's nurse was just recovering
from a severe secondary syphilitic eruption
with mucous patches in her mouth and throat.
Examination of the child showed a typical
pityriasis rosea eruption, slight enlargement
of the superficial glands and a slight conges-
tion in her throat. Our first wassermann re-
port agreed with the previous report she had
had. A week later, her wassermann was neg-
ative with both the antigens and with the
kahn precipitation test and seven other was-
sermann and kahn precipitation tests made
on her blood during the succeeding six months
were all negative, as was also her spinal fluid.
Twenty-two months later the child developed
an unsteady club-footed gait and syphilis was
again suspected, but all tests were negative
and her case was diagnosed by competent
neurologists as being infantile paralysis.
Not infrequently we find a four plus cho-
lesterin antigen, the alcoholic antigen being
negative as is also the kahn precipitation
test. We also see patients from whom we get
a negative venereal history, a slightly positive
or entirely negative serology and with vague
April, 192^
gOtJTttERN tHEDICiNE AND StJRGERY
its
or indefinite physical symptdms yet with a
strongly positive spinal fluid. Again we oc-
casit)nally encounter a patient who, without
a clinical history or physical signs of syphilis,
has had a routine blood wassermann which
was rejxirted four plus but whose blood in
subsequent tests we find repeatedly to be neg-
ative.
Case 7. — Mr. M.. aged 61, was referred to
me on September 22, 1925, with conflicting
wassermann reports. A year previously, he
had been badly beaten by the waves while
in swimming and his muscles had become
sore. He stated he had not felt well since;
his vision had been poor and his gait un-
steady; he had had dull, frequent headaches;
had lost sexual power; had felt generally run
down. A few weeks after the onset of his
symptoms, during the course of a routine e.\-
amination by an insurance company, the pa-
tient suggested that they make some blood
tests. The report of his wassermann was
four plus with cholesterin antigen and nega-
tive with alcohol. Following this he consult-
ed seven very able physicians, all of whom
gave him a written report stating that he
was physically normal. Six of them found
that his wassermann test was entirely nega-
tive while one reported a wassermann two
plus with cholesterin. He denied initial le-
sion and secondaries but admitted gonorrhea
forty-three years previously. When I saw
him his examination showed slightly unequal
and irregular pupils; his right arm refle.xes
greater than the left; his abdominal, epigas-
tric and cremasteric absent; patellar and the
ankle jerks hyperactive, the left more marked
than the right. There was a babinski of the
right foot. His heart was slightly enlarged,
the aortic second sound was greater than the
pulmonary second and faintly accentuated.
Blood pressure was 160/100. His liver was
a little enlarged. His blood wassermann was
four plus cholesterin, three plus alcohol, two
plus kahn precipitation test. His spinal fluid
was four plus to 0.2 c.c, cells 25, globulin
four plus. We gave him twenty-four injec-
tions of neoarsphenamine, ten injections of
tryparsamide, forty-two injections of mer-
cury and bismuth, and six intraspinal injec-
tions. This treatment was followed by a dis-
appearance of his symptoms and a negative
serology.
Case 8.— A man, .igcd 51, was brought to
me by his physician in April, 1927, with the
following history: He denied initial lesion
and secondaries, admitted gonorrhea thirty
years ago. His present illness began on Feb-
ruary 17th with a severe pain in the sacro-
iliac joint three days after he had driven
about three hundred golf balls. The pain
gradually increased and many kinds of opiates
gave no relief. Two days after onset of pain,
he ran fever from 99 to 104. From an x-
ray picture of the joint, he had a diagnosis
of metastatic carcinoma, probably secondary
to the prostate; however, the prostate was
found normal. Blood wassermann in two
laboratories was found four plus. He was
given a filtered dose of radium and potassium
iodide by mouth and his symptoms cleared
up within four or five days. We found no
evidence of syphilis in his physical or neu-
rological examinations. Fourteen wasser-
manns over a period of four and one-half
months by a number of different laboratories
were reported anti-complementary, the kahn
precipitation test negative, and the koimer
reaction negative. We gave him ten injec-
tions of neoarsphenamine, fourteen of mer-
cury, and potassium iodide.
In the past year and a half, he has had
several acute attacks of pain and swelling in
the joints, with high fever, and sometimes
rales in the chest. Each attack has lasted
about a week. We made a diagnosis of in-
fectious arthritis.
We believe the interpretation of doubtful
wassermanns in cases which have had no
treatment whatever, should depend chiefly on
the physical findings; that p(jsitive or nega-
tive physical evidence of syphilis in such cases
is far more trustworthy than the indefinite
laboratory tests.
In treated cases, a dinibtful wassermann is
of prognostic value, especially in determining
the influence of the anti-syphilitic drug on the
infection. For this reason we always advo-
cate a wassermann test at the beginning and
at the conclusion of each course of treatment.
WASSERMANN-FAST CASES
There has been a great deal of discussion
about the wassermann-fast cases. It is well
known that a few cases of tertiary syphilis,
and occasionally a case of syphilis in the
secondary stage of the disease where no evi-
dence can be found of the focus of infection,
will remain strongly [positive even after pro-
longed treatment. In many instances these
cases have been treated intermittently or uth-
SOUTHERN MEDICIME AMD StRGEfeV
216
erwise ineffectively. I have treated nineteen
such cases continuously with neoarsphena-
mine, mercury, bismuth or mixed treatment;
and although in several instances the treat-
ment had to be prolonged for four years, I
was able to obtain a negative wassermann in
all cases — so far without a relapse, in some
patients as long as eight years.
Case 9. — Ten years ago I saw a man aged
46 who complained of a persistent four plus
wassermann. A year previously, while visit-
ing a friend's laboratory to have a blood
count done because of a slight anemia, he
asked to have a wassermann made also. The
report was four plus. He was treated inter-
mittently for a year with injections of mer-
cury and twelve injections of arsphenamine,
but his wassermann was unchanged. In the
absence of symptoms, his physician suggested
that he ignore the test, taking only a little
mixed treatment spring and fall. He worried
over the positive wassermann so we placed
him on continuous treatment for a period of
five years, during which time he received
thirty-two injections of arsphenamine, sev-
enty-five of mercury, fifty of bismuth, and
potassium iodide by mouth at intervals. He
has remained negative for five years without
further treatment. His spinal fluid and phy-
sical examinations have always been negative.
SELECTION OF DRUGS
So many drugs are advocated for the treat-
ment of syphilis that the physician who treats
only an occasional case is often puzzled to
know what drugs to select. Many try first
one and then another without any particular
routine or course of medication. Because of
the simplicity with which neoarsphenamine
can be administered, and the comparatively
mild reactions, more physicians use this drug
than any other.
Keidel and Moore of Johns Hopkins
strongly prefer old arsphenamine, as does also
Stokes of the University of Pennsylvania.
Stokes goes so far as to state that he believes
that the use of neoarsphenamine is responsi-
ble for most of the wassermann-fast cases. It
is interesting that neo is employed almost ex-
clusively in the treatment of syphilis in the
European clinics.
With the idea of comparing the effective-
ness of old and neoarsphenamine I began,
more than two years ago, to treat equal num-
bers of early secondary syphilitics with the
two drugs. To date, we have treated more
April, 1029
than one hundred with each drug, the treat-
ment being intensive and continuous. We
carefully recorded the results of the wasser-
manns taken before all treatments, and our
records show that blood tests of cases
treated with old arsphenamine, usually be-
came negative slightly sooner than those
of corresponding cases treated with neo-
arsphenamine. We noted further that sul-
phur-arsphenamine and mercury were cor-
respondingly more effective than were
silver-arsphenamine and bismuth. While all
of these drugs may be indicated in certain
types of syphilis, it would seem much better
that the man treating only a few cases of
syphilis would acquaint himself thoroughly
with one arsenical and one mercury and bis-
muth preparation, rather than try one drug
and then another. We have found that oc-
casionally, when a person is unable to take
old arsphenamine, he can tolerate neo with
little or no trouble. We have also observed
the same to be true of silver and tryparsa-
mide.
But, after all, I believe that the choice of
any particular arsphenamine is of minor im-
portance when compared with the carefully
formulated plan of continuous treatment.
For early cases, our plan includes a minimum
of thirty injections of old or neoarsphenamine
and forty-five injections of mercury, these to
be given continuously at regular intervals
over a period of ten or eleven months. We
have found it advisable to give at least one
course of ten injections of arsphenamine and
one course of fifteen mercury injections after
the patient's wassermann has become nega-
tive. As a part of the routine examination,
every patient before being discharged as cured
must have a spinal fluid examination. I have
never known a patient, who has begun treat-
ment within nine weeks after his initial in-
fection and who has taken the prescribed
course of treatment, to have a positive spinal
fluid or any symptoms of syphilis. It is a
well known fact that most of the cases of
syphilis with tertiary manifestation, who
bring a history of previous treatm.ent, have
either had rest periods between each course
of medication or else have had too small a
dosage of arsphenamine with too long inter-
vals between each injection.
Here I return to my original theme: In
order to avoid neuro, cardio-vascular, and
order to avoid neuro-, cardio-vascular, and
is imperative that we diagnose the infectioR
April, m^
§6tJtttSRJJ MEDICINE A^rt) SURGERV
iif
in its early stages, and give the patient ade-
quate and uninterrupted courses of anti-syph-
ilitic treatment.
SUMMARY
1. Extragenital chancres often go unrecog-
nized unless the patient develops evidences
of secondary syphilis such as enlargement of
the superficial glands, rash on skin, alopecia,
or constitutional symptoms.
2. The character of the initial lesion may
be so obscured by a chancroid, gonorrhea,
herpes, or scabies as to cause one not to sus-
pect syphilis until the patient develops symp-
toms of secondary syphilis, or until a routine
wassermann test is found positive.
3. The interpretation of a doubtful wasser-
mann def)ends up)on a knowledge of the tech-
nique used, the history and physical findings
in the case, and sometimes upon observation
of a patient over a period of months or years.
4. VVassermann-fast cases, where a deep-
seated focus of infection can not be found,
probably may be the results of intermittent
medication, inadequate dosage, or too long
intervals between treatments. Such wasser-
manns will usually become negative if the
patient takes medication continuously over a
period of several years.
5. While careful selection of the particular
arsphenamine, mercury or bismuth is import-
ant, it is much more necessary to give the
treatment continuously at frequent intervals
and in the proper dosage. It is better to be-
come thoroughly familiar with one drug
rather than to change from one to another.
6. Every early secondary case of syphilis
should be given at least thirty injections of
arsphenamine without interruption. Each pa-
tient should receive — at least — a course of
ten injections of arsphenamine and fifteen in-
jections of invaluable mercury and have a
negative wassermann of the spinal fluid be-
fore being discharged.
2IS
SOUTHERN MEDICINE AND SURGERY
April, 1929
Presentation of Gavel Made of Timber From "Belroi"*
J. Allison Hodges, M.D., Richmond, Va.
In this presentation, :Mr. President, I wish
to speak briefly of heroes, not of war, but of
science.
A review of the history of Medicine reveals
that few physicians have been acclaimed as
heroes of science. Their daily lives, both in
the prosaic paths of medical duties and in
the more intricate problems of scientific re-
search, have been so quiet and unassuming
that their discoveries and accomplishments
have been little noticed, or appreciated by
the general public.
In the pursuit of science, that humanity
might live, the physician has often chanced
death in his lair while hunting the cause of
death, yet in this grim battle, there has been
nothing to grip the imagination of the people
nor stir their souls, nor hold their continuing
and abiding interest. The issue has been
joined; the fight has raged; it has been lost
or won, and the result is accepted without
question, and frequently without action.
The public, however, usually knows but lit-
tle of these struggles, and occasional sacri-
fices by the scientist, for if it did, it would,
we believe, better appreciate this courageous
spirit and this devotion to service beyond the
line of common duty that characterizes his
work, and would regard it as a record of he-
roic achievement, that is at times as romantic
as drama, and as appealing as fiction.
To accomplish such things for the benefit
of science and the love of mankind, there
must be in the profession some inborn or in-
bred inspiration for higher and holier life-
values, and we believe that this basic senti-
ment is nowhere better expressed than in the
inscription engraved on the statue of Dr.
Crawford W. Long in our National Hall of
Fame at Washington, and whose words should
be as immortal as is the fame of their author:
"To me, my profession is a divinity from
God."
Neither time, nor the occasion permits that
the entire Romance of Medical Martyrdom,
lU. S. Government Report.
♦Presented by invitation to the Tri-State Medical
-Association of the Carolinas and Virginia, Greens-
boro, N. C, Meeting February 19, 20 and 21, 1929.
and especially the unusual scientific contri-
bution of the South to this record, be told,
but the classic case of Dr. Walter Reed, Ma-
jor and Surgeon, United States .Army, and
his associates, stands out preeminently as
high types of simple and sublime courage as
heroes of science, who gave given their lives
freely that others might live, and "greater
love hath no man than this." ; '■'
"The results of the work of iNIaj. Walter
Reed, and the Yellow Fever Commission, of
which he was president and the masterful
mind, have been so beneficial and far-reach-
ing that its importance is considered second-
ary to no other scientific achievement."
The experimental work of this commission^
cannot be told here, neither its failures, its
triumphs, nor its tragedies, but the roster of
Dr. Reed's illustrious colleagues must be
called, for immortal is the work and the
names of Drs. James Carroll, Jesse \Y. La-
zear and .Aristides .\gramonte.
This commission appointed in 1900 proved
conclusively how yellow fever is transmitted,
and Major Reed thus removed for all time
the old threat of this disease as a pestilential
plague from all sub-tropical ports, and from
our own .\tlantic Seaboard as well, making
himself a conqueror of disease, and mankind
his lasting debtor.
Major Reed's life was short, but eventful.
He was born at "Belroi," Gloucester County,
Virginia, September 13, 1851, and was a
graduate of the Medical Department of the
University of Virginia in 1869, at 17 years
of age, and Bellevue Hospital Medical Col-
lege, New York, in 1872. He was appointed
assistant surgeon. United States .\rmy, June
26, 1875, and, through successive promotions,
was, at the time of his death, November 23,
1902, aged 51, first in the list of majors in
the Medical Department of the United States
Army.
Such is the brief life-history of the gallant
gentleman and soldier of Science whom we
would honor tonight, and when your commit-
tee was appt)inted at the last meeting of this
.Association at X'irginia Beach, the spot where
it was organized thirty-one years ago, to pro-
April, 1929
SOUTHERN MEDICINE AND SURGERY
219
vide an official commemorative gavel for its
proceedings, it was at once decided to link
the history of our Tri-State Association of
the Carolinas and Virginia with the name of
that distinguished X'irginian who has left us
an enduring inspiration in his life-work, and
a daily challenge to higher accom[3lishments,
for the contemplation of such deeds as his
lifts men to godlike stature.
Furthermore, Mr. President, this union of
professional spirit and scientific endeavor
seems eminently appropriate for the following
reasons:
First, because of the family ties that bind
us, Dr. Reed's father and mother having come
from North Carolina to Virginia, and he hav-
ing gone to that State at the age of twenty-
five to claim as his wife Miss Emilie Law-
rence, some of whose ancestors lived in South
Carolina;
Second, because his scientific discovery a
brief quarter of a century ago, has banished
from our three largest sea-coast cities, Nor-
folk, Wilmington and Charleston, all rav-
ages and remembrance of that dread disease
that had slain so many of their inhabitants
and left the survivors dumb with dismay and
d. stress; and,
Third, because it gives us, as medical men
and as an Association, an opportunity to fos-
ter and aid the Walter Reed Memorial Com-
mission for the Encouragement of Research,
to be established at the University of Virginia
by the Medical Society of that State, so that
never again in our home land shall there be
"the pestilence that walketh in darkness, nor
the destruction that wasteth at noon-day,"
and the glad day shall be hastened when pre-
ventive medicine shall come into the full
beauty of its own fruition.
.As a slight token and symbol for the future,
and through the courtesy of Dr. Clarence
Porter Jones, the zealous and most efficient
secretary and treasurer of the Walter Reed
Memorial Commission, I present to the As-
sociation this gavel, wrought from the haud-
hewn framing of "Belroi," the ancestral home
of Major Reed, built about 1720.
If, however, this does not satisfy, and you
would have your scientific ardor quickened,
your love for the idealism of your profession
strengthened, or your veneration for Walter
Reed, as man and physician, made more real
and vital, go, then, and visit Belroi Shrine,
from which this gavel comes, commune with
his spirit, and learn anew the lesson that
dominated and emphasized the life-work of
this great soldier-scientist, embodied in the in-
scrtpion that is over the Government Hospital
at Washington; "Duty is stronger than love
or life."
Dr. Stuart McGuire, of Richmond, ac-
cepted the gavel in a brief speech after his
usual happy, facile manner.
220
SOUTHERN MEDICINE AND SURGERY
April, 1924
Some Medical Problems*
Thurman D. Kitchin, M.D., Wake Forest, N. C.
President, Medical Society of the State of North Carolina
Dean, Wake Forest Medical School
Before Troy fell, a Trojan Prophetess, Cas-
sandra, foretold in melancholy accents its
tragic fate. Every age has its Cassandra, dis-
pensing gloom and foreboding. The age in
which we live, like every preceding age, be-
l-eves that the world is rapidly growing worse.
If we are to believe the abundant literature
of despair, the universe is riding at break-
neck speed into chaos.
Concerning certain inatters there may be
just grounds for this apprehension and we
should take note of every sort of warning
and exert every effort to prevent the fulfill-
ment of such dire prophecies. However all
this may be, there is no room for pessimism
for the adherents of scientific medicine.
Glance, if you will, at the past with its
plagues, pestilences, and diseases of filth and
ignorance which wrought such havoc among
the people, at times practically wiping out
civilization, so that disease was considered a
visitation from the .Almighty; and compare
this with the fruits of modern medicine, the
plagues and epidemics having been controlled
and every part of the world made habitable.
Even those regions that were once the death
bed of men are now veritable health resorts as
compared with the so-called healthy portions
of the world in the past.
But this has not been attained by a stroll
along the primrose path of ease. The first
stage of the development of the science of
medicine was long, slow, and very little prog-
ress was made from the dawn of history until
the si.xth century, when Bacon's inductive
philosophy and Descartes' principles of scien-
tific methods tended to free the mind and
loosen the shackles from science. From
Galen (130 .A. D.) until the fifteenth century
is truly the ".Age of Coma " in medicine. Dur-
ing these fifteen hundred years men studied
the works of Galen and not nature. The six-
teenth century saw Vesalius, Paracelsus,
Pare, Sylvius, Fabricius, and Eustachius lay
the foundation of medicine, which developed
♦.Address before Forsyth County Medical Society
Winston-Salem, N. C, February 12, 1929.
rapidly during the next century when human-
ity reached that state of intellectual freedom
which so characterized the seventeenth cen-
tury.
Some of the causes which retarded the
growth of medicine were the ancient preju-
d'ce against dissection of the human body,
efforts to convert medicine into philosophy
and thus reach conclusions by pure reasoning
rather than by observation of the human
body, and the inborn horror of sickness and
death in the primitive mind, which made
mysticism and quackery easier to accept than
research and reasoning concerning such mat-
ters. The discovery of the circulation of the
blood by Harvey in the first quarter of the
seventeenth century marks the beginning of
rational medicine. (Harvey published has
"De Motu Cordis" in 1628, but he had been
teaching his pupils the correct idea of the
circulation of the blood for ten years. More
important to medicine than the actual dis-
covery of the circulation of the blood was
that Harvey taught that the way to learn
about the body was to study the body itself
and not books.) The destruction of the idea
of sp<intaneous generation by Pasteur, about
the middle of the nineteenth century marks
the beginning of modern medicine. After the
destruction of this theory he established the
germ theory of infectious diseases. The real
birthday of modern medicine was May 31,
1S82. It recorded the most thrilling field ex-
periment of all time. .At this time the cattle
and sheep industries of France were almost
destroyed and thousands of people were dy-
ing annually from anthrax. Pasteur announc-
ed that he had isolated the germ and had
produced a vaccine that would prevent anth-
rax. Scholars and philosophers scoffed at the
idea. Finally, Pasteur accepted the challenge
of the French \'eterinary Society to prove his
claim. .Accordingly, on May S, 1882, at a
farm near Melun, Pasteur vaccinated 25 sheep
against anthrax and on May 17th a second
and much stronger dose of the vaccine was
administered, the strength of the seconc} (Jose
April, 1020
SOUTHERN MEDICINE AND SURGERY
m
given sometime before, probably it would
killed half the sheep. He returned on May
31st and inoculated these 25 sheep and 25
other sheep which had not been previously
vaccinated, with virulent virus from an ani-
mal then dying of anthrax. He stated that
he would return on June 5th, and that the
25 sheep which he had vaccinated would not
be sick and the other 25 which had not been
vaccinated would be dead. As he drove into
sight en the morning of June 5th cheers went
up from the great crowd that had gathered
at the farm, hats went into the air and Pas-
teur was received with great acclaim. Not a
single one of the 25 vaccinated sheep was
sick while 22 of the unvaccinated were dead,
two died in a few hours and the other one
died during the night.
Another eventful day was July 6, 1885,
when Joseph Meister, a nine-year-old boy
who had been severely bitten by a mad dog
was brought into Pasteur's laboratory by his
mother. It had been heralded through the
country that Pasteur had produced a vaccine
that would immunize dogs against rabies. But
it had never been given to a human being.
Mrs. Meister, frantic with the knowledge that
death was certain, implored Pasteur to try
the experiment on her boy. The inoculations
were begun that evening. Imagine the anx-
iety of both Pasteur and the mother as they
watched day in and day out for symptoms
of hydrophobia to develop. But nothing hap-
pened: the boy remained well, and the Pas-
teur treatment for rabies is one of the crown-
ing achievements of medicine. .At the same
time Koch was doing nKjnumental work on
culture media, the bacillus tuberculosis and
other micro-organisms in Germany, playing
an important part in laying the foundation
for modern bacteriology. Lister applied the
germ theory of disease to surgery. Oliver
Wendell Holmes in this country and Semmel-
weis in Austria applied this new concep-
tion of micro-organisms to obstetrics. Soon
the medical world accepted the important
place that pathogenic organisms played in
disease.
Until 1900 yellow fever stalked upon the
face of the earth leaving death, sadness and
destruction of communities in its path. In
that year the Yellow Fever Commission made
its investigation in Havana into the cause,
transmission, and prevention of yellow fever;
and Doctors Reed, Carroll, Lazear, and Agra-
monte offered their liveiS on the altar of
science for humanity, Lazear and Carroll dy-
ing as a result of allowing mosquitoes which
had previously bitten yellow fever patients
to bite them. The commission convicted the
mosquito and thus made it possible to put
an end to yellow fever epidemics.
With such a triumphant past, we are apt
to think our task is done, but in reality it has
just begun.
Medicine has advanced until today, with
the conquest of infectious and transmissible
diseases practically assured, the profession is
already focusing its chief attention upon the
health of the individual. And after all this
is the essential element because the general
health of a people is the sum total of the
health of the individuals. And this work is
not the work of the various public health
departments. Neither the municipal, county,
state, nor national health departments or bu-
reaus can do this type of work. // can only
be (lone by the private physician dealing with
the individual patient.
The fact is, public health officers must ad-
mit that from now on unless the private physi-
cian co-operates, public health work must
suffer. Public health departments can control
epidemics, do protective vaccinating on a large
scale and look after general sanitary condi-
tions, but that vast army of degenerative
diseases that develop at and after middle life
and all of those so-called individual sicknesses
cannot be handled without the private physi-
cian.
Even preventive medicine is shifting from
compulsory protection of large groups of the
population to the education of the individual
and the stimulation of the individual to apply
this newly acquired knowledge. That is, the
importance of preventive medicine is shifting
from mass protection and sanitation to per-
sonal hygiene.
In matters of public health, between the
duties of the state and the duties of the family
doctor, there is a twilight zone in which the
two merge so imperceptibly that no man can
say where the province of one begins and the
other ends. But in order to establish a work-
ing basis there must be a line of demarcation.
Rightly or wrongly the medical profession
believes that the province of the state is the
prevention of disea.se, that of the doctor treat-
ment of disease, and in this treatment not
the least important factor is the study and
222
SOUTHERN MEDICINE AND SURGERY
April, 102^
treatment of the individual harboring the
disease. There is more to th; practice of
medicine than detecting diseases and intro-
ducing measures to combat them: it is com-
monly true that the patient and not the dis-
ease needs examination and treatment. Con-
sequently, the physician must have a heart
as well as a head.
One of the duties of the Government, as an
agency of the people, is to furnish such pro-
tection to the people as they cannot provide
for themselves. Consequently, the State is
well within its right and is fullilling its duty
in providing institutions for the insane, blind,
feebleminded, the tuberculous, etc., because
here not only is there protection but the fur-
nishing of an environment and a type of care
which can not reasonably be provided in pri-
vate homes and general hospitals even under
the direction of competent physicians. But,
even here, those financially able to do so
should pay a reasonable part of the cost of
their care.
Measures of a general character, such as
instruction in sanitation, and even wholesale
examinations and vaccinations, are in a group
which can be handled by the state. But
matters that require individual treatment be-
long to the private physician because here
treatment must be followed up arid varied
according to the needs of the individual
patient.
The State can only justify such an under-
taking as the tonsil and adenoid clinics among
children on the ground of its educational
value, as a demontration to arouse interest
interest and enthusiasm in the community as
to the value of such treatment. In my opin-
ion, these clinics can not be justified on the
usual ground that children who need their
tonsils and adenoids removed are backward
and deficient in their school work and that
after the removal of these tonsils and adenoids
the children improve and then keep up with
their work. This is an argument for the value
of these operations but I doubt the validity
of it as an argument that the State should
perform such operations.
Unless some principle of this kind is agreed
upon, the activities of the State in regard to
the schools would have to extend to food,
clothing, housing, as well as to the other ills
of the school child, all of which affect the
efficiency of the child as a student.
It is not always easy to determine where
prevention ends and treatment begins. But
there need be no waste of time in splitting
hairs over this, because there is enough to
keep the public health man and the private
doctor both busy with the material at hand,
each finding himself occupied with the tasks
which are unmistakably his.
.Another problem the physicians must face
and attack is the one of adjustment between
the individual and the time in which he is
living. The brain is the crowning achieve-
ment of nature, the last and most delicately
adjusted addition to man. It is, therefore,
the part of man most sensitive to adverse
conditions. Yet, while much has been done
to adapt the environment to meet the needs
of the physical body — by means of clothing,
housing, diet, exercise, protection from ex-
tremes of heat and cold, etc. — little has been
accomplished in the matter of adjusting our
mental life to the altering conditions. These
past fifty years have been positively kaleido-
scopic. There have been more changes dur-
ing this period than in all previous time. The
whirling life of today entails stress and strain
on the very part of the body least able to
stand the pressure — the brain. Consequently,
abnormal nervous and mental conditions are
on the increase.
The increasing number of demands impos-
ed by the surging life of today is making it
increasingly difficult for people to maintain
their poise, much less to meet these demands
and to keep their footing. It so happens that
many people who, in the quiet backwaters of
civilization would be able to live simple, nor-
mal lives, are swept off their feet by the
swiftness of the current. The result is, they
are classed either as subnormal or abnormal
persons. Such people are forced to spend
their strength, not in constructive effort in
behalf of themselves and their families, but
in a bewildered struggle to keep their old
ideas from being swept downstream, without
having been able to seize life-preservers in
the shape of new and practical ideas from
the wreckage. We must furnish a basis for
this class of persons to stand on, a basis which
will give room to coordinate old ideas with
the new, and give safety and breathing time
while the process is going on. This must be
done if we are to stem the tide of nervous
troubles which are menacing the life of our
people today. .Xnd this adjustment cannot
be made on the wholesale plan. It must be
April. 1020
SOUTHERN MEDICINE AND SURGERY
223
the work of the personal jihysician with the
private patient.
Finally, with so many and such varied
problems to face, never before has any pro-
fession demanded such a well rounded man,
one so abounding in vitality and ada|3tabil-
ity, as does the practice of medicine demand
today. Never before was it so necessary to
consider the practice of medicine a profession
and not a trade.
As a profession, it must deal primarily with
people and not with things. Contacts estab-
lished must be social rather than material.
Accordingly, we must assume our social obli-
gations and opportunities. We must know
more of the world that we live in than what
is contained in our medical libraries and in
the medical journals that come to us from
day to day. We must not think of this world
as if it were a dismal prison-house. One who
had reached a ripe old age wrote concerning
the world:' "It has indeed got all the ugly
things in it but there is an eternal sky over
it: and the blessed sunshine, the green pro-
phetic spring, and rich harvests coming."
.\nd we must know more than our own field.
We must broaden our horizons, realizing that
we are no less citizens because we are doctors,
but we are citizens with added responsibilities
and consequently the task before us is to pre-
pare ourselves to the limit of our ability to
assume these responsibilities, and to perform
them with all the grace and enthusiasm and
cffic'ency our manhood can bring to bear upon
Iheni. Vou will agree with me that medical
jjroblems themselves, broadly speaking, often
may reciuire for their solution judgments
based upon general knowledge as well as u[X)n
medical knowledge proper, and so to be well
rounded in the profession, as well as a citizen
of broad interests and deep sympathies and
ripe wisdom, the physician must have general
knowledge as well as technical knowledge and
skill. We must remember that the medical
profession deals with a thing so complicated
as to stagger the imagination of the wisest^
human life. Especially then is it incumbent
on the physician to cultivate the most lib-
eral spirit and a sympathetic mental attitude.
224
SOUTHERN MEDICINE AND SURGERY
April, 1929
Repair of Fresh and Old Lacerations of the Cervix and
Vagina*
11. J. Langston, M.D., Danville, Va.
HISTORICAL NOTE
The study of women who hive sjiven birth
to babies gives abundant ev'dence that wo-
men have received birth injuries from the
beginning. It is apparent that the majority
of the women who have been delivered un-
aided receive lacerations of both the cervix
and the vagina. Up until now th? teaching
has been opposed to the repair of the cervix
unless hemorrhage demanded stoppage. The
early teaching was against repair of the pel-
vic floor and, even now, many physicians
leave extensive lacerations of the vagina of
recond and third degree to be repiired by the
fuvgeon or gynecologist. Current literature
p'ves us some evidence of a change of atti-
tude. No part of human anatomy is so
rrossly neglected and so roughly treated as
the cervix and the vagina of the women of
child-bearing age. Women who have borne
children and those who are bearing children
are suffering more from the injuries received
at child-birth than probably any other one
th'ng. The cost in money due to the inabil-
ity of these women to perform their fuH du-
ties cannot be estimated, and the amount of
money spient annually for such treatments
and operations is enormous. Too, many
cancerous conditions that appear on the cer-
vix are found at the site of old lacerations.
It may be that we shall eventually find that
the laceration is primarily responsible for the
appearance of the cancerous growth. Among
those who have written splendid papers on
the repair of the cervix and the pelvic floor,
some dealing with the repair of the cervix
only and others with that of the cervix and
the pelvic floor are: Dr. Norman Harris Wil-
liams, Dr. J. B. DeLee, Dr. Irvin W. Potter,
Dr. W. C. Danforth, Dr. J. L. Nubis and Dr.
Robert P. Kelly.
It is interesting to read these papers and
note the changes that have taken place in
this important field. I shall not review these
papers otherwise, but simply want to call your
•Presented by title to the TrI-State Medical
.^sjociation of the Carolinas and Virginia, Greens-
boro, N. C, Meeting February 19, 20 and 21, 1929.
attention to them and those of you who have
not read them will find it worth while to do
so.
There are two reasons why I desire to call
the attention of the profession to birth in-
juries. The first one is, after studying most
carefully my first five hundred deliveries in
private practice, I was struck most forcibly
with the ev'dence of so many women who
had lacerations of the cervix which should
have been repaired. These lacerations occurr-
ed in natural deliveries, where forceps were not
used, pituitrin was not used and no form of
external pressure was applied. Most of these
patients had been given morphine and chlo-
roform during the second stage of labor; some
of them had been given rectal anesthesia ac-
cording to Gwathney technique; the cervices
were not examined at the time of delivery
but were examined after six weeks. I fol-
lowed the principles I had been tau';ht of not
exanrning the cervix unless there was hem-
orrhage. The second reason is that while I
was a resident physician I saw a high forceps
delivery. The physician who did the delivery
was a good man. Immediately following de-
livery his patient bled profusely, even alarm-
ingly. The cervix was caught by sponge
sticks, both the anterior and posterior lips,
and it was brought well down out of the va-
gina. It was immediately discovered that
there was a rent on each side extending high
up; that on the left side extended into the
lower uterine segment and the uterine artery
was spurting. This was caught by a sponge
stick. The cervix was repaired with 20-day
chromic catgut, interrupted sutures. It took
only a few minutes to repair the cervix on
each side; the hemorrhage ceased. The pa-
tient had lost enough blood to be so pale that
the matter of transfusion was discussed; but
after reaction from the anesthesia it was de-
cided that she be watched and if the occasion
should demand a transfusion would be done.
She was g.ven 500 c.c. of saline in the vein.
This patient made a most wonderful recov-
ery; not running any temperature; did not
develop any complications whatsoever. The
April, 192P
SOUTHERN MEDICINE AND SURGERY
physician told me later that he examined the
patient and found her cervix to be in perfect
condition and the uterus in good position and
well involuted. This one case impressed me
by reason of the fact that the cervix was re-
paired and the vagina was not packed and
there was no bleeding other than normal after-
ward. Of course it may be said that my
second reason for reading a paper on repairs
is premature, but we will let time jud ;e that.
ETIOLOGY
Lacerations of the cervix and the vagina
are due to these parts not being able to adjust
themselves to the passage of baby by natural
birth, or to delivery by the use of such agen-
cies as pituitrin or forceps, version and ex-
traction.
PATHOLOGY
Old cervical lacerations left unrepaired re-
sult in hypertrophy with extensive granula-
tions which tend to increase with age, with
development of a profuse leucorrhea. New
lacerations after the patient has passed
through the puerperium produce hypertro|)hy,
with patulousness, and the appearance of sub-
acute, low grade inflammation with a mild
leucorrhea. Leucorrhea increases with age.
Frequently there is subinvolution and retro-
displacement of the uterus; in case the peri-
neum has not been repaired properly, recto-
cele or cystocele with relaxation.
SYMPTOMATOLOGY
Common symptoms are relaxed vagina
with retrodisplacement of the uterus and ad-
nexa, leucorrhea, backache, dragging down
feeling, general discomfort and poor health.
Lacerations can be divided into two groups:
( 1 ) The old lacerations, bilateral, unilateral
or stellate, which have occurred with each
delivery, each time the laceration making the
mechanical and physical condition of the
pelvis of the patient worse. (2) Fresh lac-
erations that have just occurred with the first
delivery, these being bilateral, unilateral or
stellate.
TREATMENT
Immediately after delivery is the best time
to repair old lacerations. The placenta hav-
ing been expelled the patient is thoroughly
cleaned, redrapcd. and the nurses who are
supporting the limbs may now flex the thighs
on the abdomen. This tilts the pi-lvis and
throws the uterus down so that the cervix
appears just to the inside of the vulva. With
a single blade speculum introduced both lips
of the cervix can be seen and caught and.
with very gentle traction, drawn out of the
vag'na. These cervices appear very ragged
.vd sometimes there is an abundance of cysts
in Ihese ragged areas. The cervix is now
tr'mmed up on each s-'de most carefully. I
prefer scissors for th's. .\ftcr a side is
f'mmird it is immediately reiiaircd with 20-
day chronv'c catgut. Continuous lock
suture has jjroved most satisfactory in my
work. I find it takes from three to five min-
utes to do a repair of an old lacerated cervix.
Immediately after the repair is finished, with
a sterile sponge on the fingers the uterus can
be lifted high into the pelvis and the limbs
of the patient lowered. Following this work
the pelvic floor can be repaired if there is a
fresh or old laceration.
For an old laceration of any conse-
quence, the technique I use is as follows:
Incise beginning as nearly as possible at
the site of the old laceration following
the muco-cutaneous juncture, separate the
structures and dissect up the posterior
wall of the vagina and locate the levator
ani muscles. This d'ssection may have
to go back about two or three inches.
Bring the soft structures together by inter-
rupted sutures tied loosely. The levator ani
nui.'=cles are now caueht and brought together
with cither intenuptcd or continuous sutures,
being careful not to get them too tight. The
skin edges can be brought together either with
2C-diy chromic suture or with skin suture,
mucous membrane brought to the edges of
th-? skin and loosely sewed, approx'mating the
ed-'es evenly so there will be no puckerng.
An old th'rd degree laceration requires
more dissecting. Incision is made just as de-
scrbed for second degree tear until the region
of the sphincter ani is reached. Here I make a
cross as in th? capital letter // by going down
on each side of the anus until a good ilap is
made and a good exposure of the sphincter
ani obtained. At this point the posterior wall
of the vaginia is dissected up until the levator
ani muscles and the soft parts back of these
muscles have been exposed, so that they may
be brought together to make a good pelvic
floor. The next steps are dissecting out the
ends of the divided sphincter ani, bringing
SOUTHERN MEDICINE AND SURGERY
April, 192Q
them together with three to four interrupted
20-day chromic catgut sutures. The struc-
tures back of the levator ani muscles and the
muscles themselves are now loosely tied. This
skin is brought together, well covering the
sphincter ani, the mucous surfaces of the pos-
terior wall of the vagina are brought down
to the skin and loosely sewed. The two lac-
erations of this nature that I have had re-
quired approximately twenty minutes each to
do the repair. Both of them healed nicely
and the results were most satisfactory.
NEW LACERATIONS
The cervix of every patient I deliver is
examined and the fresh lacerations, if there
is any necessity for doing so, are trimmed
up. This is not always necessary. The edges
are approximated and sewed with a continu-
ous lock suture just as in an old laceration.
LACERATIONS OF THE VAGINA
For some time now I rarely ever get more
than a first degree laceration of the vagina
and sometimes I do not get any. These are
repaired with continuous suture chrom'c 20-
day catgut. I do not bring the sutures tightly
together. The mucous edges of the vagina
are brought together by continuous lock su-
tures, and the skin edges are approximated
and sutured with an interrupted chromic 20-
day catgut.
The technique is very simple and in case
of fresh lacerations it takes about five to eight
minutes to repair them. Old lacerations re-
quire ten to twenty minutes. The delivery
of the average case in the hospital and repair
of the cervix and vagina takes approximately
40 minutes. After the patient has reacted, the
head of the bed is elevated to about a 45-
degree angle, and I try to keep her in this
[Dosition most of the time for seven or eight
days. Five per cent solution mercurochrome
is put into the vagina once a day with a
sterile catheter. My belief is that this helps
to keep down the process of multiplication
of bacteria and it prevents the lochia from
having an odor.
All my patients delivered and repaired by
this technique up to date number ninety-five.
I have not had any septic infection. All have
made uneventful recoveries. These patients
tell me that they feel perfectly well; those
who never had a baby before, and those who
have had babies and have had trouble before
tell me they are now well. In the case of
each of these patients the uterus is in good
position, well involuted; there is no leucor-
rhea; the vagina is not relaxed; there is no
backache or dragging down feeling.
CONCLUSION
( 1 ) This method of treatment of lacera-
tions of the cervix and the vagina is safe.
Dangers of infection from repair of the cervix
and vagina in my judgment are nil.
(2) This method of treatment of women
of child-bearing age eliminates worlds of suf-
fering and morbidity and, if universally prac-
ticed, would save many lives and incalculable
suffering and avoid the necessity for expend-
ing quantities of money, which, in most in-
stances, can be ill afforded.
(i) That we will have young mothers who
are capable physically of looking after their
household affairs and raising their children.
(4) This method of handling obstetrical
cases appears to be a great step forward,
leaving women in better physical condit'on,
and probably reducing the incidence of can-
cer.
(5) It is hoped that the profession at large
is going to open its mind and make more
progress in taking care of women at the time
of the birth of their little ones.
REFERENCES
Williams, \. H.: Am. Jour. Obs. and Gviie.. Sept.,
DcLce, J. B.: Am. Jour. Ob.'., and Gviir.. Oct.,
1Q27; 40Q.
Potter, Irvin W.: Am. Jour. Obs. and Gvne.,
Mar., 102S; i.'.b.
Danforth, W. C: Am. Jour. Obs. and Gvnr.,
April, 1Q28; .S05.
Bubis, J. L.: Am. Jour. Obs. and Gvnc, July,
1028; 57.
Kcllv, Robert P.: Virginia Med. Monthlv, Feb.,
1928; 713.
April, 1Q2P
SOUTHERN MEDICINE AND SURGERY
227
Stricture of the Female Urethra*
Hamilton \V. McKay, M.D., and Robert W. McKay, M.D., Charlotte, N. C.
INTRODUCTION
In order to intelligently discuss stricture of
the female urethra, it is necessary that we
recall the close relationship of the urethra to
the bladder and upper urinary tract, which
exists through the sympathetic nervous sys-
tem. It is important to recognize that the
trigone and the urethra are practically one
continuous structure. It is at once evident
that pathological lesions in various portions
of the upper urinary tract and bladder may
produce symptoms similar to the condition
under present consideration. We desire to
confine this discussion to stricture of the
urethra, alone, and purposely omit lesions of
the bladder and upper urinary tract, such as:
1. Renal and ureteral lesions, without blad-
der pathology, but causing urethral and blad-
der symptoms, namely, renal infections, tu-
berculosis, and stones.
2. Infiltrations and strictures of the lower
end of the ureter, tuberculosis of the ureter,
and simple ureteritis.
,5. The elusive bladder ulcer group.
4. Acute and chronic urethritis, with or
without trigonitis.
Many urologists look upon the female
urethra simply as a tube through which we
pass a cystoscope to search for pathology
higher up in the urinary tract. In general, the
urologist and gynecologist is so intent on
searching for the more spectacular lesions in
the upper urinary tract and bladder, that the
relatively short and seemingly less important
urethra is neglected. Thus, stricture of the
urethra is often not discovered by the urolo-
g'st, is often overlooked by the gynecologist,
doing urology, and is seldom considered by
ihe general practitioner in attempting a diag-
nosis.
The objects of this discussion are two:
First: to emphasize the importance of the
routine examination and calibration of the
urethra in females with urinary .symptoms.
Th s should be done with bulbous or olive-
tipped bougies. Second: to discuss, clinically,
str cture of the urethra.
•Presented to the Tri-State Medical Association of
the Carolinas and Virginia, Greensboro, N. C, Meet-
ing February 19tb, 20tb and 21st, 1929.
HISTORY
Lisfranc, in the year 1824, was the first
to describe urethral stricture in the female.
The research work of \'an de Warker and
Otis, in the year 1887, is outstanding. They
emphasized the importance of stricture in the
urethra of females, as an entity, and of the
varied reflex symptoms, produced by such
lesions. Of the present-day writers, Stevens
and Hunner deserve most of the credit of
stressing the importance of stricture of the
urethra in the female. The chapter on the
female urethra, by Stevens, appearing in
Lewis' System of Surgery, is the only modern
work of importance, with which we are fa-
miliar.
INCIDENCE
Stevens thinks that we frequently overlook
stricture of the female urethra, since most
consider this condition to be rare. Pugh, in
1922, in the examination of three thousand
gynecological and urological records, finds
four cases diagnosed as stricture. Graves, in
the second edition of his textbook, states
that "stricture of the urethra is not a com-
mon affection in women,'' while Norris also
says, "it is a comparatively infrequent occur-
rence." Stevens, analyzing one hundred and
sixty-nine female urological cases, finds ure-
thral stricture in ninety cases, or 55.4 per
cent. He also finds urethral stricture present
in his series of ureteral stricture in 54.5 per
cent. In his series of ureteral stricture, he
finds urethral stricture present in 46.1 per
cent. Hunner says that urethral stricture is
present in more than 60 per cent of his ure-
teral stricture cases.
ETIOLOGY
The factors producing stricture in the fe-
male urethra are many. We believe the fol-
lowing are the most important:
1. Infections of the urethra (gonorrhea
leading the list).
2. Traumatism from chil(ii)irtli.
3. Congenital malformations.
4. Operative procedures, application of
caustics, and ulcerations.
Hi
SOUTHERN MIEWCINE AND SURGERY
April. 1020
Hunner thinks that focal infections play
an important role in producing urethral stric-
ture.
PATHOLOGY
Little is known of the actual gross or micro-
scopic pathology of stricture in the female.
Early elastic infiltrations of the urethra are
known as "soft strictures," and are usually
of large calibre. Later these progress to form
the hard, fibrous stricture, greatly narrowing
the tube. The soft, infiltrated, inflammatory
area is the primary process of fibrous stricture
formation.
TYPE AND LOCATION
The most common and most important
type is the fibrous annular stricture, involv-
ing the external urinary meatus. The ante-
rior third of the urethra is commonly the site
of stricture formation in the female. Infil-
trated patches may occur in the urethral
glands, surrounding the urethra, about
Skeen's glands, or about the so-called third
gland, which lies in the roof of the urethra,
near the external urinary meatus.
SYMPTOMS
In many patients the symptoms are quite
confusing and difficult to elicit. These vague
symptoms are responsible for much confusion
in diagnosis and unnecessary upper urinary
tract investigations. The woman usually
complains of the well-known triad of urinary
symptoms — frequency, pain, and burning on
urination. In this particular type of indi-
vidual, we frequently suspect a neurosis, but,
after a careful history is taken and the pa-
tient carefully observed, one is immediately
impressed by the genuine urinary discomfort
which the patient is suffering. The catheter-
ized specimen of urine may show a few pus
cells, or it may be entirely negative.
DIAGNOSIS
A thorough history, a careful inspection and
palpation of the urethra with the thumb and
forefinger of the left hand, and the intelligent
use of bulbous and olive-tipped, flexible bou-
gies, will settle the diagnosis.
The urethra may be inspected with the
endoscope for diagnosis or treatment. The
normal female urethra is 7.5 mm. in diameter
and a measurement of 26 F. is considered
normal. Infiltrations or conditions narrowing
the tube to less than 26 F. scale may cause
symptoms. Thus the necessity for calibration
becomes apparent. Frequently inspection
with the endoscope will establish a diagnosis
and save our patient being put through the
urological mill, cons'sting of cystoscopy and
double ureteral catheterization pyelograms.
TREATMENT
The technique consists of anesthetizing th3
urethra with a 4 to 10 per cent solution of
cocaine on a cotton swab. After anesthesia
is produced gradual dilatation can be effect-
ively carried out. Dilatation should begin
with the graduated, flexible bougie, later fol-
lowed by metal sounds. Dilatations should
take place about five days apart, using a dila-
tor or sound of the next larger size every week
or ten days. The instrument should be left
in the urethra for ten minutes. In the fibrous
annular type of stricture, occurring about the
external urinary meatus, it may occasionally
be necessary to do some cutting procedure.
The following cases of ours will illustrate
what can be found out and accomplished by
carefully observing the female urethra:
Case L — A woman of 51, referred to us
October 1, 1928, complaining of fullness in
the region of the bladder, frequency, and
terminal dysuria.
Previous Medical History: She has had
no previous renal or bladder trouble until an
illness, five months ago, at which time she
had a mass in the upper right quadrant, sus-
pected of being due to gall-bladder disease.
Laparotomy was done, and a large right kid-
ney was found.
Present Condition: The present urinary
symptoms have been present, intermittently,
for the past nine months. She complains bit-
terly, of a fullness in her bladder, urgency,
frequency of about fifteen minutes, and ter-
minal dysuria. Repeated examinations of her
urine have been negative.
Examination reveals a fibrous stricture,
surrounding the external urinary meatus,
drawing the urethra upward. The passage of
a 24 F. sound causes severe pain. The
right kidney is about twice the normal size, is
fixed, is irregular in outline and of a stony
hardness to the examining fingers.
Diagnosis: In this case, the diagnosis was
stricture of the urethra and enlarged right
kidney (new growth).
Treatment: Gradual dilatation of the
urethra, with observation.
It is interesting to note that the patient
was at first completely incapacitated, as she
April, 1Q20
SOUTHERN MEDICINE AND SURGERY
229
had the desire to void every fifteen minutes
when erect. She now is treated once a week
and her bladder symptoms have disappeared.
She, however, has a large right kidney, which
we believe to be malignant, with stone for-
mation (inoperable).
Case 2. — A woman of 30 presented her-
self for examination February 4, 1929, com-
plaining of unbearable frequency of urina-
tion, sensation of fulness in the bladder
and pain and burning at the end of urination.
Previous Personal History: She had an
appendectomy eight years ago. Influenza in
1918. She has always been extremely nerv-
ous, and rather unstable in her thoughts and
actions.
Present Condition: Three years ago the
patient slipped on the ice and fell. She was
told by a surgeon that she dislocated her right
kidney at the time. This is her real reason
for consulting us. She wished to know if we
advised fixation of her right kidney.
Examination revealed an atresia of the va-
';inal outlet, with a funnel-shaped pelvis. On
calibration of the urethra with a 26 F. flexi-
ble, bulbous bougie, we detected a d'stinct
hang in the outer third of the urethra. Fven
this gentle examination was followed by
bleeding, showing definitely that the patient
has a soft stricture of large calibre. In con-
genital malformations one should always
search carefully for abnormalities of the ure-
thra.
Treatment: Gradual dilatations are pro-
ducing markedly beneficial results.
Case 3. — A woman of 46 came in .August
7, 1928, seeking relief from a scratching,
burning sensation in her vulva. This scratch-
ing sensation was confined to the left labium
minus and major.
Previous Medical History: She had a la-
parotomy, in 1910, at which time her apjien-
d'x, both tubes, and one ovary were removed.
Since this operation she has been perfectly
well, until the present time.
Present Condition: Two years ago she
noted a scratchy, burning feeling in the left
sid • of the external genitalia. She has been
continually treated since 192 7 for cystitis,
although only occasionally was there found a
small amount of pus in the urine. The exter-
nal genitalia were repeatedly examined and
pronounced normal. The discomfort made
her nervous and miserable, and was sufficient
to completely incapacitate her. She became
despondent about her condition.
Examination: Calibration proved her to
have a fibrous annular stricture of the urethra.
This undoubtedly produced the referred sen-
sations in her external genitalia.
Treatment: Dilatation successfully reliev-
ed her of the referred sensations.
SUMMARY
1. Stricture of the female urethra is a com-
mon lesion in women who complain of urinary
symptoms.
2. The urethra should be routinely exam-
ined and calibrated before cystoscopy and ex-
tensive urinary tract investigation is carried
out.
3. The common symptoms of stricture are:
frequency and pain and burning on urination,
although the symptoms may be referred to
the external genitalia, as is illustrated by one
of our case reports.
4. The diagnosis should be established with
the bulbous or olivary type of bougie and
the endoscope.
5. Calibration of the female urethra should
always be done before investigation of the
urethra and upper urinary tract.
DISCUSSION
Dr. J. W. Tankersley, Greensboro:
Dr. McKay has been very thorough. This
subject was brought to my attention some
years ago accidentally, before I ever heard
of stricture in the female urethra. In making
cystoscopic examinat'ons and gynecological
examinations I found the urethra frequently
so small I could not introduce the ordinary
cystoscope; very often I had to dilate. Fre-
quently the symptoms disapp>eared. I tried
to puzzle it out to my own satisfaction and
decided it must be stricture of the urethra
that was causing it.
I want to say now that these pains do not
always come down along the thigh but fre-
quently are referred to the region of the
ovary. Dr. McKay calls attention to stricture
of the ureter occurring with stricture of the
urethra. I believe that the infection causing
these strictures is carried by the lymphatics
from the urethra up to the ureter. Occasion-
ally I find a stricture in the membranous por-
tion of the urethra, that portion lying in the
folds of the triangular ligament. Dr. Mc-
Kay mentioned that his strictures have been
nearer the bladder. Mine have been more
frequently in these folds. Whether vou use
3M
SOUtttfekM MfebtCtNfc ANt) StbGERV
April, 1929
a bulbous sound in finding these strictures or
use an ordinary catheter, a great deal de-
pends upon your sense of touch. I believe in
a large number of those cases the mMd infec-
tion is introduced at childbirth into the ure-
thra, and possibly a good many of them are
specific. We have tended to overlook the
fact that an old, attenuated infection, mild
at the time, getting into the glands of the
urethra, develops infiltration around the
glands, and then you get your stricture. The
external urethra looks as though it has been
puckered up with a draw-string; there is a
hard, fibrous, firm ring around the meatus.
I «vish to take exception to one thing that
Dr. McKay said, and that as to cotton on an
applicator. .Anyone who uses cotton on an
applicator in the urethra is going to have
trouble sooner or later. Some time that cot-
ton will get into the bladder, and you will
have trouble getting it out. I never use cot-
ton on an applicator; when I use it I put it
in a suitable forceps.
In my experience, these patients have al-
ways been of middle age or above, more fre-
quently around forty-five or fifty. We never
find it in younger women. They are always
above thirty-five, around anywhere from
forty-five to fifty years of age and even older.
One patient sixty-five years old I relieved by
gradual dilatation of the urethra, and she
comes in every now and then to thank me
for it.
Finally, T might say that we specialists
have developed the habit of taking care of
these holes in the body, but we should not
forget the body as a whole.
Dr. M. H. Wvman, Columbia;
Dr. Hamilton McKay is associate editor,
I think, of Southern Medicine and Surgery,
and he calls on different ones of us for articles
occasionally. A few months ago I wrote on
residual urine in the female bladder. Occa-
sionally that retention is caused by stricture
of the urethra. .After having borne a certain
number of children, a certain amount of tone
of the bladder is lost and even though the
urethra is open complete emptying can not
be accomplished.
As to caruncle, from a surgical point of
view our observation has been that it has not
been cured as readily as we hoped by high
frequency current. In fulgurating it is hard
to know when you have done enough. It is
important to follow it up; don't fulgurate a
patient, then let her get away from you, be-
cause sometimes she will come back in a year
with a strictured urethra. I follow up these
cases, have them come back, and frequently
dilate them, until they get weU.
Dr. Wm. R. Barron, Columbia:
I report a case because it is in a child so
young, a little girl of five, brought in by a
country practitioner from fifty miles away,
with acute retention and a great deal of pain.
The child would not let us touch her, so we
gave her a general anesthetic. When we tried
to cystoscope her we found her urethra prac-
tically closed. The history was that she had
voided pretty well up to that time. Finding
we could not introduce the cystoscope, we
used a number three ureteral catheter, a bulb-
tipped catheter, in order to start dilatation.
Dilatation under anesthetic up to what we
thought was a reasonable size relieved her,
and her doctor never brought her back; he
reported she was cured.
Frequently I find the urine entirely nega-
tive in such cases. A graduate nurse who
was never free from symptoms presented such
a case. We look for the big things often,
as Dr. McKay brought out, and overlook the
little things. I dilate at intervals of from
five to seven days. I think it takes that long
to get over stretching mucous membrane.
Dr. McKay, closing:
I am glad the subject of the cotton came
up, because it brings up a very ludicrous sit-
uation to my mind. I remember in the first
case I ever cystoscoped I quite clumsily
pulled off the cotton. My instructor said:
"Well, I suppose we shall have to operate on
this man tomorrow because of your extreme
clumsiness." The next day the man came
back, we injected some sterile oil, told the
man to void, and out came the cotton.
Dr. a. J. Crowell, Charlotte:
May I have just one word? In regard to
the mop, one nurse fixes all those mops of
cotton and turns them to the right. If you
will, in doing the endoscopy, turn them al-
ways to the right you will not be troubled
with the cotton coming off. If it does, you
can follow the procedure Dr. McKay has
mentioned, inject oi', and have no trouble.
April, 1929
SOttHER^ iklfebtci^fe Akb StftGfeftV
Ml
Clinic in Diseases of Children*
Edwards A. Park, M.D., Baltimore
Johns Hopkins University
President Hall:
It is a great pleasure and a great honor
to me to be permitted to present to you Dr.
Edwards A. Park, Professor of Pediatrics in
Johns Hopkins University. I was just saying
to Dr. Park that he has the honor of carry-
ing on the first clinic in the history of this
organization, now thirty-one years old. Dr.
Park will hold a clinic in diseases of children,
and tomorrow night he will give us a paper
on diseases of children. Dr. Park has been
professor of pediatrics in Johns Hopkins for
.the past two years; prior to that, for six or
eight years he was at Yale University; and
prior to that he was at Hopkins. Dr. Ed-
wards A. Park.
Dr. PARK:
It is a great pleasure to be allowed to come
to the meeting of this society. I had my
first glimpse yesterday and the day before
of the southern part of Virginia and North
Carolina, and I had no idea previously how
very beautiful it all is.
I hope the result of this clinic, which I am
informed by Dr. Hall is the first to be given
before the society, will not be that it is the
last. 1 am indebted to Dr. Robinson and
Dr. Parker and Dr. Ravenel for my cases.
Case 1. — I first want to show you a little
girl aged six years, and I shall summarize
for you what I learn from the mother in an-
swer to questions. The child has always been
a perfectly healthy and normal child. .At one
year of age she had a very mild case of
whooping cough (had the serum) and had
measles at four years, followed by a mild
case of scarlet fever. She had fever only one
day when she had scarlet fever, and there
were no complications. Apparently she re-
covered entirely. During the course of the
attack of scarlet fever she had no arthritis,
no inllammation of the joints. Two weeks
ago the child was taken with acute pain in
the hip joint; no |)ain anywhere else, but
fever. A week before that she complained
of soreness or pain in the bottom of the feet
•Given before the Tri-State Medical Association
of the Carolinas and Virsinia, meeting at Greens-
boro, .\. C, February l^tli, 20tb anU ^Ist, 1929.
when she got up, when she would get out
of bed and begin to walk. She had a sore
throat when she was taken with this hip
pain; the mother had not noticed this until
the morning of the day when the child com-
plained of her hip in the afternoon. The pain
in the feet occurred every morning for about
a week, but the child had no pain in the
ankles or elbows or anywhere else. The acute
pain in the hip lasted for two days; it then
disappeared entirely. The temperature went
up to 103; the fever lasted from Monday
until Thursday; no fever since then. The
child was in bed for fourteen days. The
temperature was taken once a day; there
has been no fever since the first few days.
Dr. Ravenel told me he looked at her throat
and the throat was extremely red; there was
no exudation. She is a healthy-looking little
girl excellently nourished. I have looked at
her throat previously and want to look at it
again. She has very much enlarged tonsils,
with very uneven surfaces. The tonsils are
red, and I think that there is some inflamma-
tion of the pillars of the fauces. Her throat,
I think, shows tonsils which you would all
admit are the seat of inflammation, and I
think you will all admit that her throat also
is at the present time slightly inflamed. Dr.
Ravenel tells me that the inflammation in
her throat has been rapidly diminishing.
When we palpate her neck we find that the
peritonsillar lymph nodes on both sides are
quite large. They feel to me as if the en-
largement of the nodes is not of the last few
days only; I get the impression that she has
had the enlarged nodes for some time, on
account of their hardness.
Now we come to the examination of the
heart. In examining the heart in children
one has to remember that the apex impulse
is found at different places at different ages.
In the newly-born child the heart is horizon-
tally placed, and the heart changes its posi-
tion with the assumption of the erect posture.
From birth to the first year the apex impulse
is in the fourth interspace about a centimeter
to the left of the sternum. With the assump-
tion of the erect posture the heart falls more
an4 more downward; the apes impulse reacj^es
Hi
SOUTHEfeN MEblCiNE AM) StRGEftV
April, 19^9
the nipple line, in the average child, at about
the fifth year; and in the fifth year the apex
impulse is in the fourth or the fifth inter-
space and in the nipple line. By the tenth
year the apex impulse is found in the fifth
space and about a centimeter internal to the
nipple. In this child at the present time I
think it is in the fifth interspace and just
outside the nipple line. When I percuss the
heart I find essentially no extension of the
dullness to the right; I think the heart shows
a slight enlargement toward the left and pos-
sibly downwards, but the evidence of enlarge-
ment of the heart is extremely slight. When
I listen I find that the heart action is regu-
lar; it is not increased in rapidity; I should
think that it is about one hundred to the
minute or a little less. The sounds are all
clear; I think that there is no pathological
accentuation of the sounds. At the apex is
a blowing systolic murmur. Now, the mur-
mur at the apex has a soft quality, and it is
transmitted to the left; it is not very well
transmitted — at least, it is not very loud;
one has to listen rather carefully to hear it
in the axilla and also to hear it in the back.
I do not bring out that point now but I
have listened to the child's heart previously,
and from the back in the interscapular space
one can hear it. The pulse is of normal qual-
ity. Otherwise I think the physical exam-
ination is normal. The lungs are clear; the
abdomen is not abnormal; the spleen is not
enlarged; and there is no evidence at the
present time of any inflammatory condition
in the joints.
So here we have a little girl who was per-
fectly well until about three weeks ago, when
she was taken sick with a sore throat and
she complained of pain in her feet when she
got up in the morning, which was foreign to
any previous experience; and then she com-
plained of pain in the hip. With the sore
throat and with the pain in the hip she had
a temperature of 103, which fell to normal
at the end of three days and has since been
normal. Now we find her with a normally sized
or possibly slightly enlarged heart, with a
blowing systolic murmur at the apex. I think
there is no doubt as to what she had; she
has had a very mild attack or a mild attack
of inflammatory rheumatism. Dr. Ravenel
told me, I thaik, that the temperature came
down quite abruptly with salicylates — with
aspirin. Now we find a blowing systolic
murmur at the apex.
Some interesting points are at once raised
by the case of this little girl. In the first
place, in regard to the significance of a sys-
tolic murmur at the apex, if one turns to
some of the German text books on pediatrics
one reads that functional murmurs are ex-
ceedingly rare in children. On the contrary,
functional murmurs are exceedingly frequent
in children and very, very common in babies,
from the very beginning of life. From the
very beginning of life functional murmurs
are exceedingly common. Possibly the most
common area in which functional murmurs
are found in children is the pulmonary area,
as in adults, the area which Dr. Osier, I
think, called the area of romance. They are
also very common between the pulmonary
area and the ensisternum. I do not know
to what they are due, but they are very com-
monly discovered in healthy boys and girls.
The murmur sometimes is rather typical in
that it does not begin with systole and has
a peculiar quality, the sort of noise that a
saw makes in going through wood — a slightly
musical quality. They are not transmitted.
Now, one very commonly finds functional
murmurs over the apex of the heart. I per-
haps ought not to call them functional mur-
murs, but they are murmurs which are not
produced by disease of the heart valves.
They are soft, are systolic in time; they are
poorly or fairly well transmitted; often they
are due to dilatation of the mitral ring; and
dilatation of the mitral ring without disease
of the mitral valves is exceedingly common
in childhood. I fancy that it is far com-
moner than it is in adult life.
I call attention to the existence of those
murmurs because they do not mean neces-
sarily that the heart is diseased. Now, under
what conditions do we find those murmurs?
We find them, I think, in children who are
anemic; it is a very common thing in the
child who is anemic and whose muscles are
flabby to have the lack of tone extend to the
heart itself, with a resulting relaxation of the
mitral ring and a corresponding leakage. It
is common to find them in children who are
run down — I do not know how to express it
otherwise — children who perhaps have no
very definite disease but who are below par,
whose skeletal muscles are flabby; and one
is led to suppose, as I just said, there is a
April, 1929
§6UtttERK MEtlidiME ANt> SURGERV
Hi
general condition of hypotonia. For instance,
it is not uncommon to find murmurs like this
in children with orthostatic albuminuria.
Second, it is quite frequent to find murmurs
of this kind in children who have just re-
covered from acute infections, and of the
acute infections I should put infiammatory
rheumatism first in the order of frequency.
It is a very common thing for children who
are suffering from or have just recovered from
infiammatory rheumatism to show mitral sys-
tolic murmurs which are due to dilatation of
the mitral ring. Now, it is a very difficult
thing to determine whether a murmur such
as this child shows is due to vegetations on
the mitral orifice, to deformity of the mitral
cusps, or whether it is due to a relative dila-
tation of the mitral ring. Sometiijes one can
recognize murmurs which are made at the
mitral orifice on account of their quality. In
general, I think organic murmurs tend always
to be present. They are present with changes
in the position of the patient, and they are
present at different times in the history of
the patient. Functional murmurs show much
more variability. A murmur which is pro-
duced by vegetations on the valves shows
much more constancy than a murmur which
is produced by a d.latation of the mitral ring
— that is, an expansion of the heart muscles.
Then sometimes one can be perfectly sure
that a murmur is an organic murmur because
of its loudness. So far as I am aware, func-
tional murmurs are usually not very loud.
They certainly never develop the intensity
which is characteristic of the murmurs of
acquired heart d.sease. They are never musi-
cal. Sometimes the murmur in acquired heart
disease, as everyone knows, is musical. Func-
tional murmurs are never diastolic in time;
if one hears a diastolic murmur, one knows
it must be produced as a result of an organic
lesion of the heart. But the trouble is that
in early rheumatism and early chorea the
murmur, so far as I am aware, is never musi-
cal and is frequently not very loud and from
the murmur alone one is wholly unable to
say whether the valves of the heart are the
.seat of vegetations or whether one is dealing
with a rela.xation of the heart muscle only.
.\t one time when I was at New Haven I
tnok charge of the cardiac clinic for a m(mth
in the absence of the man regularly in charge,
and I began seeing in the card.ac clinic chil-
dren whom I had seen previously in the wartls
and on whom I had made the diagnosis of
rheumatic heart disease, and I was astonish-
ed to find out the number of children whom
I had discharged from the hospital with the
diagnosis of rheumatic heart disease who
came back to the dispensary without any
evidence of disease of the heart whatsoever.
Since that experience I have been much more
careful in making the diagnosis of organic
heart disease following rheumatism than I
had been previously. It is a very common
experience in the case of children with chorea
to find that as they become active, as their
muscular contractions become increased, a
systolic murmur develops at the apex which
is very loud, sometimes is quite well trans-
mitted to the axilla, and is heard in the back,
and to have that murmur in a few weeks,
with recovery, entirely disappear. The mur-
mur, I think, is due to the fact that the heart
muscle is affected as a result of the rheuma-
tism or the chorea and the murmur itself is
induced by the dilatation of the mitral ring
as the result of the physical exertion imposed
upon the child by the choreiform movements.
It seems to me that time alone will tell
whether this little girl whom we have just
seen has an endocarditis or whether the mur-
mur is due to the relaxation of the mitral
orifice which I have just been discussing.
Sometimes the murmur is valvulitis — rheu-
matic valvulitis — begins in the course of the
rheumatism and never disappears. In other
words, the murmur does not develop until
months or years after the subsidence of the
infection. That is particularly true of the
murmur of mitral stenosis. The individual
may give no evidence of mitral stenosis for
years after the attack of inflammatory rheu-
matism; and the purring murmur of mitral
stenosis, which immediately precedes the first
sound, is very rare indeed in childhood.
Wlien seen in childhood it is limited to oJder
children, who have had their rheumatic fever
and the injury done to the heart years pre-
viously.
There was a time when I used to think
that if a systolic murmur was at the back,
as is the case in this child, the murmur was
organic in nature. 1 think perhaps that may
hold in adults; I do not know; but in chil-
dren 1 call your attention to the fact that
functional murmurs can very easily be heard
in the back, as a result of the thinness of the
chest wall, Undoubledlj', then, this little girl
m
SOUtttERN MEDICINE AMD StJRGEftY
April, 1929
has had acute rheumatism; and undoubtedly
the heart has been affected; and we do not
know whether the affection of the heart has
extended to the valve or whether it has been
limited to the muscle. If I were to make a
guess it would be that the murmur which
this little child shows will disappear in the
course of a few weeks. Whether it will be
followed by a murmur due to an affection
of the heart valves, as I have indicated, I
can not say.
Formerly the conception of rheumatic fe-
ver was essentially one of inflammation of
the heart valves. Our ideas in regard to
rheumatic fever have changed materially in
the last few years, and if we compare rheu-
matism with any other disease at the present
moment we will compare it with tuberculo-
sis. When a child becomes infected with tu-
berculosis the infection may be over in a
few weeks; it may be over in a few months;
it may be over in a year or two; or the child
may never recover from the infection at all.
The same thing, I think, applies to rheuma-
tism. The child may recover in a few days
or a few weeks; the child may recover in a
few months; the child may recover in two
or three years; or the child may never re-
cover. We have come to regard rheumatic
fever, then (and my understanding is that
you see very much less of it in the South
than we see in the North), as an extremely
chronic infection and that its danger, I think,
is the same kind of danger which exists in
regard to tuberculosis — that it never leaves
the patient, or is apt not to leave the patient,
until severe damage has been done. Instead
of the disease being limited to the heart
valves, as we used to think, we find the dis-
ease most widespread all through the body.
The heart muscle, for instance, is extensively
involved. One finds all through the heart
muscle, in the connective tissue and around
the blood vessels, what are known as the
.Aschoff's bodies. They are ill-defined collec-
tions of round cells, and among them giant
cells are found. They are an indication, so
far as I know, only of rheumatic fever. One
finds those lesions scattered in the blood ves-
sels of the body, and some New York
doctors have reported their presence in
the pulmonary vessels, in the lungs.
In other words, the disease of rheumatic
fever is not limited to the heart valves
nor to the heart muscle, but the le-
sions are scattered around throughout the
body. Now, from time to time, in the North,
we see patients having rheumatic fever ac-
companied by rheumatic nodules. Dr. Rave-
nel tells me he has not seen any rheumatic
nodules since he has been in Greensboro.
They are apparently far more common in
England than in this country and are appar-
ently far more common in New England and
in Baltimore in this country than they are
here. In the course of rheumatism little no-
dules appear on the tendons around the joints
of the body. They appear under the skin,
and it is easier to see them than to feel them.
By stretching the skin tight they form little
white places where the blood is squeezed out.
Favorite places are the olecranons, over the
patella, along the tuberosity of the tibia,
sometimes along the tendons of the feet and
the backs of the hands; rarely one sees them
along the tendons of the wrist and over the
spine of the scapula; and sometimes one finds
them on the back of the head. Usually they
are as large as a £ shot or BE shot, but
sometimes they reach a huge size; on the
back of the head they have been found as
large as walnuts. Quite often they last only
two or three weeks, but quite often they last
five or six or seven or eight weeks. They
come in crops. When they come the signifi-
cance is that of an extremely severe infec-
tion, and the prognosis is a bad prognosis. I
mention them because the structure of the
lesion they compose is identical with the
structure of the Aschoff body, and it is just
another indication of how widespread rheu-
matism is pathologically speaking. Dr.
Thayer, not long ago, examined a section of
the heart in all cases of rheumatic diseases
in which autopsies had been performed in
Johns Hopkins Hospital, and I think he found
.Aschoff bodies in perhaps eighty per cent of
the hearts. I call your attention to this fact
because it indicates how long a time the virus
of rheumatism (or whatever it is) exists in
the body, because in many of these cases the
acute disease had occurred ten, fifteen, or
more years previously.
Now, what is the prognosis in regard to
this little patient, and what ought we to do?
If a child has had rheumatic heart disease
or if a child has rheumatic heart disease
think the immediate prognosis is good,
mean if a child has acute rheumatism I think
the prognosis as to the rheumatism is good
the child recovers from the rheumatism al
April, 1924
SOUTHERN MEDICINE ANt) SURGERY
as
most immediately. I think the prognosis as
to the rheumatism is better than in older chil-
dren; but as regards the heart, as you know,
the prognosis is always doubtful. Probably
sixty per cent of the subjects of acute rheu-
matism go on to the development, sooner or
later, of rheumatic heart disease. As regards
the heart, the prognosis in acute rheumatism
is always a very dubious question. The
younger the patient, I think, the more serious
is the prognosis. In general, in very young
patients rheumatism affects most the heart
muscle — in children three or four years old.
In children from five to ten it seems to affect
the joints and the valves, particularly; and in
adult life it is most common, I think, for the
disease to affect the joints and for the heart
to escape. .As regards the heart, then, the
prognosis varies with the age and is the
more serious the younger the child.
Now, what ought to be done in a case like
this? What ought we to do when we are
confronted with acute rheumatism and rheu-
matic heart disease in a child? We think of
the case — or at least I try to think of the
case — very much as I would think if the
ch.ld were the subject of an acute tuberculo-
sis. What would you do if the child were
the subject of an acute tuberculosis, if you
knew it? We are so familiar with tubercu-
losis that we would at once put the child to
bed and keep the child in bed until the dis-
ease left. We would keep the child in bed
for days or for weeks or for months or for
years. Certainly we would keep the child in
bed as long as we thought the disease was
remaining in an active state. How should we
know whether the disease is remaining in an
active state, or not? We would be guided
by the fever, for instance; we would be
guided by such a symptom as the cough; we
would be guided by the physical examina-
tion; if rales persist we would feel fairly
sure that the disease is active. We would be
guided also by the general condition of the
child; if the child was gaining weight, if the
child became stronger, we would feel fairly
sure that the disease was leaving. We have
exactly the same attitude in rheumatic fever,
and we are guided very much by the same
criteria. What we attempt to do first and
the cardinal principle in the treatment of
rheumatic heart disease, then, is to give the
child rest. We i)ut the child to bed and
keep the child in bed. We put the child to
bed with the expectation of keeping the child
in bed for an indefinite period of time, until
the evidences of disease absent themselves.
Xow, what are those evidences? Fever is
one of them. They are very prone to have
fever for three or four weeks; then the tem-
perature becomes normal for three or four
days; then the child has another bout of
fever. .\ prominent New York pediatrician
keeps the child in bed until the fever has
been below 99.4 for a period of one week.
.\nother valuable symptom is the pulse. Per-
haps, when the heart is affected in acute
rheumatism, we get as much information
from the pulse as anything else. There is
nothing more favorable than to have a pulse
of 120 or more slow down to a pulse of 90
or 100; it is always a favorable sign or al-
most always a favorable sign when under bed
treatment the pulse resumes its normal rate.
We are influenced also, by the weight of
the child. It is a very striking thing in se-
vere cases of rheumatic fever to find that as
the case progresses the marked improvement
is coincident with a sudden increase in
weight. Dr. Marriott, for instance, in his
clinic in St. Louis, lets his children out of
bed when they have begun to gain weight;
and when they begin to lose weight they are
put back to bed again. One has to be care-
ful, of course, to be sure that the gain in
weight is a true gain and not due to edema.
Then one has to be governed by the physi-
cal condition of the heart itself. If new
murmurs appear, if there is anything indica-
tive of a pericarditis, why naturally the dis-
ease is in an active state. One takes into
consideration the signs of congestive heart
failure; they indicate that the heart is still
the seat of disease. We watch — not murmurs,
as we used to — but the heart action. What
these patients suffer from is the lack of driv-
ing force in the heart, not from leakage, so
it is always the heart muscle which we have
in mind in estimating the severity of the dis-
ease, and not the injury to the valves.
Having put a child like this to bed, we
get the child up every gradually, the severer
the case the more gradually. Now, this is
a very mild case, and I would surmise that
the child would stay in bed just a short time
and the process of getting the child out of
bed would be abridged. But in a severe case
we let the child stay up the first day for five
minutes, the next day for ten minutes, the
ii6
SOtTttfeft^J MEDICINE AND SURGERV
April, M<i
next day for fifteen minutes, then a half hour.
On getting out of bed we let the child first
rtand for a minute, then walk a few steps,
then walk two or three times the length of
the room, all the time watching to see that
the reactions are favorable. If we find that
the disease is still present we put the child
back to bed again and resume the original
treatment. Now, we not only try to give
these children rest, as we do in tuberculosis,
but we try to improve the general condition
of the child, as we would do in tuberculosis,
in every possible way. We go over the diet
with great care and make sure the diet is the
best possible one the child could have; we
go over the habits of the child, the hygiene,
and try to make everything the best possible.
Our thoughts are not alone on rest and on
improvement of the child's state as much as
possible but are also fixed on the avoidance
of a recurrence of the acute rheumatism. How
can we avo'd a recurrence of the acute rheu-
matism? Well, we can not avoid it but can
do something towards it. We can do some-
thing by the removal of sources of infection,
and what we turn to first is the throat. This
child, for instance, has diseased tonsils. I
think the removal of the tonsils in this case
is indicated. Dr. White, of Boston, always
removes the tonsils in rheumatic heart dis-
ease, irrespective of what the tonsils are like
or what the history of infection of the tonsils
has been. It never seemed to me that that
is a rational procedure; but it seems to me
we ought to err, in rheumatic heart disease,
on the side of removal of the tonsils. If the
tonsils are diseased they ought to come out,
certainly. If the child has repeated attacks,
the tonsils ought to be removed. When ought
they to be removed? When the disease has
become quiescent. By that I do not mean
the intlammation in the joints but the disease
as a whole, particularly as it affects the mus-
culature of the heart. But we sometimes can
not wait for that to take place. It seems to
me that in general children with rheumatic
heart disease tolerate well the removal of the
tonsils; I think they tolerate the removal of
the tonsils better than children with chorea.
In general, I think we can take out the ton-
sils in children with chorea with impunity,
but from time to time one sees a marked
exacerbation of the chorea, and I have some-
times seen fatal result follow. In rheumatism
I have seen children exceedingly sick when
the tons'ls were removed and no reaction fol-
lowing their removal at all. In rheumatism,
if we can wait until the rheumatic fever is
quiescent before the removal of the tonsils,
then we do so. If, on the other hand, we
can not wait, if the disease goes on week after
week, then we remove the tonsils anyway.
Children, I think, are not so prone as adults
to infections of the sinuses, but in all cases
of rheumatic heart disease we examine the
sinuses by x-ray and through examinations
of the nose and transillumination to make sure
that no disease of the sinuses exists. If dis-
ease of the sinuses exists, it is treated as
under other conditions.
We also examine the teeth. I think that
ulcerations of the teeth — root abscesses — are
far less frequent in children than in adults,
but they occur sometimes.
As far as drug treatment is concerned in
a case like this, it is absolutely useless; and
there is no indication for any drug treatment
whatsoever. The indications are those which'
I have mentioned.
Case 2. — This little girl, I think, is four-
teen years old and was taken sick first when
she was ten or eleven years of age, when she
had a sore throat which was followed by pain
in the joints. The joints most affected were
the ankles. She was sick and was kept in
bed for some little time. Six months or so
later she had another attack of tonsillitis;
th's was accompanied, again, by pains in the
jo'nts. Following her second attack of acute
rheumatism (for that is what she obviously
had), she was kept in bed, as I am sure she
should have been, for a number of months;
and her tonsils were removed. Since her last
attack (about four years ago) she has had no
further recurrence of her rheumatic fever.
That, in substance, is the history.
We find her teeth in excellent condition;
her tonsils have been completely removed;
her throat is in good condition; her lungs
are normal; there is nothing to be found any-
where on physical examination except in her
heart; and her heart has the following char-
acteristics. The apex impulse is in the fifth
space and about in the nipple line, and is
exceedingly powerful. From a mere palpa-
tion one would know that the heart is very
much hypertrophied. The right border is en-
larged slightly to the right of the sternum.
When one listens one finds an exceedingly
loud systolic murmur at the apex, wJiicJi js
April, 1920
SOUtHERN MEDICINE ANt) §URGERY
iil
transmitted into the axilla and is heard pow-
erfully in the back. The pulmonary second
sound is slightly accentuated; the aortic sound
is normal. .At the ape.x one hears what some
call the murmur of mitral stenosis and what
some call the third heart sound. So far as I
am concerned, I do not know. I am quite
sure most people would call it the early mur-
mur in mitral stenosis. As to whether she
has a mitral stenosis of any moment, I do not
think she has. She might possibly have some
thickening of the valves, narrowing of the
orifice; but certainly there is no typical sten-
osis of the mitral orifice present.
I have already called your attention to the
fact that mitral stenosis we rarely see in
children, and when we do see it, it is in the
older child. It is not a sudden development;
it is a slow development; it is due to a cica-
tricial growth of the orifice or union of the
valves; the orifice is unable to grow. That
has been ignored somewhat, I think — that,
due to some injury, the orifice is not able to
grow as the child grows.
Now, what about this little girl? She has
some damage to her valves. I think her heart
muscle is in excellent condition. She can
jump and and down and does not get short of
breath, does not complain of palpatation or
anything at all. But she has leakage. Her
heart is hypertrophied, and I think it has
taken care of the leakage. It is not as good
■ a pump as yours, but it is a pretty good
pump, and if the rheumatism never lights up
again I think she is in no danger. Of course,
there is always the danger to the heart mus-
cle: it is the lesion to the heart muscle which
is important and not the lesion of the valves;
but the lesion to the valves may be so marked
that the individual suffers from it. That is
notably the case in mitral stenosis. If the
mitral orifice has been reduced to a mere
.-^lit. how can the individual get along? The
hole is not large enough to admit the passage
of sufficient blood. The same thing applies
to aortic regurgitation. It may be mild, or
it may be so serious that on account of the
serious leakage which occurs at the aortic
orifice life is no longer compatible. But if
Ihe damage is not great, particularly if there
is only a mitral regurgitation present, the
child may have a (comparatively .speaking)
perfect state of health. Now, just because
this child has a loud murmur, just because
this child from the standpoint of physical
examination has nine or ten times the involve-
ment of the heart that the other child had,
are we going to put this child to bed or limit
this child's activities? I answer in the nega-
tive. The child's heart is in good condition;
she has recovered from her rheumatic fever.
We will allow this child to lead a natural
existence; we will not make an invalid out
of her. We will watch her and try t(j guide
her in her life in such a way that she will
never be exposed to extreme degrees of jihysi-
cal exertion, but beyond that point we would
do nothing.
Rheumatism manifests itself very differ-
ently in children than it does in adults, and
I shall just call your attention to some of
our experiences with rheumatic fever in the
child and particularly the young child. You
are more familiar than I am, probably, with
the manifestations in the older child and in
the adult. The child usually develops a sore
throat, and it is quite common to have the
rheumatism develop about ten days later.
Sometimes the rheumatism develops coinci-
dently with the sore throat, as in our first
case; or it may even precede the sore throat;
but it is quite common to have the sore
throat preceding. Then the joints light up;
rheumatism goes from one joint to the other,
from the shoulder to the thigh, to the ankle,
to the knee joints and the small joints of
the fingers, etc. As the rheumatism subsides
in one joint it goes to another joint. You
are all familiar with the picture. Sometimes
there is temperature with it — fever of 104
or 105. After a few weeks the fever sub-
sides, and then the individual recovers en-
tirely or else is left with rheumatic heart dis-
ease.
Let me recapitulate. The text books state
that rheumatic fever does not occur under
the fourth year. I think it is perfectly prob-
able that rheumatic fever is uncommon under
the fourth year; but it occurs, and it occurs-
much more frequently than we have been in
the habit of thinking; it is apt to occur in a
masked form. I think sometimes it occurs
as fever and only as fever; there are no joint
manifestations; there is nothing to attract
the attention of the physician to the fact
that it is rheumatism; it is simply a fever.
Not infrequently the joint symptoms are very
mild. The child may come in with
a temperature of 103, and on physical exam-
238
SOUTHERN MEWClMfi AND StRGERY
April, 19^9
ination you find nothing; the next day one
joint may be red and swollen. The inflam-
mation in that joint lasts twelve to twenty-
four hours and then entirely disappears. I
have seen that happen again and again. I
think in very young children sometimes the
heart alone gives evidence of disease. Some-
times the joints are skipped entirely; it is as
if the disease went immediately to the heart;
and I am under the impression that in very
young children it is the myocardium which
is involved rather than the valves. One finds
very great enlargement of the heart ; the heart
may fail to pump the blood around the body,
and yet there may be little or no evidence of
disease of the heart valves.
You are all familiar with the child with
growing pains, which may be manifestations
of rheumatic fever. Quite frequently one gets
a history, in a case of rheumatic fever, of
growing pains. It is not at all easy to be
sure those growing pains were rheumatism
and not of some other origin.
How early can rheumatic fever appear?
We have seen rheumatic heart disease some-
times in babies two years of age, and I have
seen it in children one and a half years of
age. Sometimes the rheumatic heart disease
in two-year-old children is apcompanied by
arthritis; sometimes not. .After the fourth
year rheumatism becomes quite common, and
after the fourth year the manifestations are
typical rheumatic manifestations — the kind
of picture vou are all familiar with in adult
life.
Case 3. — This boy presents what to me is
a more complicated problem. He was a pa-
tient of Dr. Robinson's. He is fifteen years
old now, and his mother states that he has
had three attacks of influenza and that with
his last attack of influenza he had an arth-
ritis. At the time of the second attack of
influenza, when he had a pneumonia. Dr.
Robinson examined his heart and recognized
that his heart was the subject of disease.
That, in short, is his history. The last at-
tack of influenza was accompanied by rheu-
matism; but Dr. Robinson was able to rec-
ognize that his heart was diseased at the
time of his second attack of influenza, so-
called, which I think was four years or so
ago.
When we e.xamine him we find his heart
is where my finger is. He is very long-chest-
ed, and one would exp>ect that his cardiac
impulse would be low. It is in the fifth space,
and it is about in the nipple line. The dull-
ness extends out about a centimeter beyond.
There is not a very marked extension
of dullness to the right. We get no
thrill. When we listen to his apex impulse
we hear a very curious murmur. The first
sound is a very sharp sound, such as we hear
in mitral stenosis. I think it is due to over-
action of the heart, due to e.xcitement, though
I am not sure. It begins after a very per-
ceptible interval after the first sound. It is,
however, I think, the characteristic murmur
of organic heart disease; it has not the char-
acteristics of a functional murmur. It is not
particularly loud but very harsh. When we
listen in the fourth and third spaces, to the
left of the sternum, we hear a diastolic mur-
mur, an unmistakable blowing diastolic mur-
mur; and it means only one thing. We can
trace it up easily to the third space and can
hear it in the second space following the
second pulmonary sound. I could not hear
it over the aortic area. The pulse is not a
typical collapsing pulse; I think if I were
perfectly honest, I think if this hand were
stuck through a hole in the sheet and I felt
the pulse and was asked what the trouble
was I certainly could not make the diagnosis
of aortic regurgitation; and yet the pulse is
certainly somewhat suggestive of aortic re-
gurgitation. Now, it may be my imagination,
but it seems to me there is slight enlargement
of the thyroid gland. I can not be sure about
it, but I can not bring that into relation with
anything else my little friend shows. The
hands and ears are cold and are cyanotic.
Certainly the cyanosis and coldness of the
hands are not connected in any way with dis-
ease of the heart; I think it is probably a
familial trait. His twin brother, it seems to
me, when I saw him had cold hands, too.
This boy has undoubtedly had rheumatic
heart disease, and he has mitral regurgitation
and also an aortic regurgitation, and the en-
largement of his heart is very great. As
nearly as I can discover, he is not short-
breathed from exertion. His mother does not
let him exercise very much, and his general
condition seems to be fairly good. He looks
pale, but his brother is also pale. He is not
very well nourished, but neither is his brother,
who is entirely healthy. On account of the
systolic murmur, which almost disappears
April, 1929
SOttMERN MEWCtNfi AND StRGERV
when the boy takes a deep breath and which
is loudest at the end of inspiration, one won-
ders (or at least I wonder) whether he could
have an adherent p>ericardiuni. I do not be-
lieve he has an adherent pericardium; I look-
ed him over for adherent pericardium; I look-
ed for Broadbent's sign. That is a great
help, but its presence does not nec-
essarily mean adherent pericard'um. I
put a great deal of emphasis on the
point whether the heart shifts very
much. In this boy the heart shifted very
little, not more than a centimeter, indicating
that the heart is fixed. That sign, however,
certainly does not establish the diagnosis of
adherent pericardium, though it makes one
suspect it. But I am quite sure that the boy
has not adherent pericardium; by which
term I mean the parietal and visceral layers
are attached, but that the external layer of
the pericardium is attached to the chest wall
in front. I am quite sure that he has not
adherent pericardium, because he does not
seem sick enoueh and the heart is not large
enough. I think adherent pericardium gives
rise to the greatest degree of hypertrophy of
the heart we know. With adherent pericar-
dium I should expect his heart to come to
the right of the sternum, and I am quite sure
that adherent pericardium is not present.
Here, again, what shall we do with this
boy, and what is the prognosis? I think the
prognosis on this boy is not quite so good as
in the other two cases. He has a lesion, we
know, of two orifices, and in aortic regurgi-
tation the condition is almost always a serious
one. We know that the heart is badly af-
fected. On the other hand, at the present
time it is functioning in a fairly satisfactory
way. What are we going to do with a case
like th's? We should do everything we can
to build up his general health and maintain
it at the highest point. As to recurrence of
his rheumatism, the foci of infection have
been eliminated as well as they can be. We
would allow this boy to take ordinary exer-
cise; we certainly would not make him an
invalid; but we would prevent com[>etitive
sports or any kind of exertion which brings
strain upon the heart; and we would be very
patricular to choose an occupation which
would put as little strain on his heart as
possible. I think his case should have further
study.
239
Case 4. — I have one more case to show you.
Now, this little boy I have never seen be-
fore ,but I have been informed what he has
and have seen x-ray pictures taken at the
age of five months. The x-ray will show you.
In taking an x-ray of a child of this age one
looks at the heart to see whether it is of
normal size and shape; then one looks at the
mediastinum to see whether it is broadened
or whether there are any irregularities in the
med'asinum, and then one looks at the lungs
to see whether the shape is abnormal or
whether they present any abnormal condi-
tions.
In this child I think the outline of the
heart is normal. The mediastinal shadow ap-
pears to be thicker. Is it due to enlarged
shadow or due to something else? On this
side the outline is indistinct. We would have
to be quite sure it is not due to enlargement
of the thymus. When we look at the lungs
we find this fringed-out shadow from the
lungs, which we recognize to be tuberculosis.
By looking at the x-ray picture, without much
doubt, we could make a diagnosis of tuber-
culosis. He was only five months old when
the picture was taken, and here the boy is
at the present time. Certainly he is up to
the normal in nutrition, if not up to the nor-
mal in height and other respects.
From this x-ray picture one could go fur-
ther than to make a diagnosis of tuberculosis.
The child. I think, without much doubt, has
tuberculosis of the tracheal lymph nodes.
He has involvement of the nodes at the bi-
furcation of the trachea, or we would not see
thrm; they would be covered by the shadow
of the heart; but he has involvement of the
nodes that run along the trachea — the para-
tracheal nodes. That, I think, has more
serious significance than involvement of the
nodes at the bifurcation, because involvement
of the nodes at the bifurcation comes first
and of the paratracheal nodes second. So I
would judge from this picture the boy had
fairly extensive tuberculosis at the age of five
months.
I am going to talk about tuberculosis for
fifteen minutes tomorrow night, so I shall
not say a great deal about it now, but per-
haps I shall mention the tuberculin tests.
Those of you who are interested in pediatrics
are familiar enough with the value of the
tuberculin test, but those of you who are in
SOUTHERN MEDICINE AND SURGERY
April, 1020
adult practice may not be familiar with it.
The tuberculin test is of very little moment
if done on you or done on me, because prob-
ably all of us are infected and would Rive a
positive tuberculin reaction: but it is of very
great moment when done on children under
three years of age. After that age it begins
to lose its value. What does it mean? When
I first went to Johns Hopkins, Dr.
taught that a positive von Pirquet on chil-
dren under two years of age meant the death
of the children, von Pirquet himself taught
that. But it was soon found that that was
not borne out. The more we study tubercu-
losis in infants, the more convinced we are
that very many children infected with tuber-
culosis under one year recover. I can not
give you statistics in regard to it; I do not
think statistics exist: but probably fifty per
cent of children infected under six months
recover and probably seventy-five per cent
of those infected under a year: and the prog-
nosis of children infected at three is very
good.
Now, tuberculosis in infants is active. In
older children it may be inactive and may not
be the cause of the symptoms from which
the child suffers, but in infants it is active
and likely to be the cause of the symptoms
from which the child suffers, because it is a
very active state. In New York City prob-
ably from one to two per cent of babies under
one year of age give a positive tuberculin
test. Probably in Greensboro a smaller per-
centage would give a similar tuberculin test.
In St. Louis forty per cent of children at ten
years of age give a positive tuberculin test,
in Greensboro probably a smaller percentage.
Hence I would think the tuberculin test would
be of greater value in Greensboro than in
New York City.
A negative test is of great value. A child
comes in suffering with encephalitis or some-
thing else we can not determine. We do not
do a von Pirquet test any more; we inject
intradermally .1 mgm., then .2 mgm., then .3
mgm. If we get a negative result, then we
may be sure the child has not tuberculosis.
When we look at this boy's arm (this is a
Pirquet test) we see that the tuberculin test
is markedly positive.
It is extraordinary the extent to which tu-
berculosis can exist in infants and recovery
take place. This child does not show a very
extensive tuberculosis but shows a fairly ex-
tensive tuberculosis. One of the most dis-
tinguished physicians of Paris states that if
there is involvement of the glands bordering
on the paratracheal nodes death will take
place, yet this child had involvement of those
glands and death did not take place. Now,
this picture which was made a few days ago,
is extremely interesting to me. I should like
to see it repeated, because it shows a suspi-
c'ous lesion. The greatest extent of
the lesion at five months ot age was on the
right side; now, at three years of age, there
is what appears to me to be a little scar there.
I think that little scar indicates a primary
focus. What happens in these children is
that the tubercle bacilli are ingested, are ta-
ken up by the blood stream, are carried ta
the lungs and lodged somewhere, and the
point at which the primary focus takes place
when healing occurs becomes calcified and
persists. I am inclined to think that this
little scar which you see denotes the primary
lesion in this little boy's case.
I shall not say anything further except that
the second x-ray picture shows that tubercu-
losis has disappeared; the shadows of his
early tuberculosis have gone; and I do not
doubt that recovery has taken place. Never-
theless, he is like the child with rheumatic
heart disease I have shown you; the tubercle
bacillus is present in his body— present, very
likely, not only in one place but in a number
of places, because children are 1 kely to
have not only tuberculosis of the bronchial
lymph nodes but of the abdominal lymph
nodes and of other parts. Wh'le I think th?
prognosis is excellent and that he will not
have tuberculosis any more, that the disease
will not break out again, yet it is ixjssible it
may break out. We are at present engaged
in a study at Hopkins to find out whether
these little children who arc infected with tu-
berculosis are the ones predisposed to have
recurrences of early tuberculosis following
adolescence and in early adult life.
April, lo:<J
SOUTHERN' MEDICINE AND SURGERY
Allergy Clinic*
Warren T. \'augiian, M.D., Richmond, \'a.
The subject of allergy should be of interest
to all who are practicing medicine, in view
of the fact that fully ten per cent of all in-
dviduals are allergic and in allergic families,
of course, the percentage is very much high-
er, and allergic individuals may suffer from
several different manifestations of the dis-
ease.
I am going to devote most of my attention
in this hour or half hour to the technic and
interpretation of the test. You will find on
the backs of the boxes in which you get your
proteins from the manufacturer directions for
use. They are very brief, and it looks so
simple that if you do the test and get a neg-
ative result you will have entire confidence
in the result. But as a matter of fact there
are many, many tricks to the technic which
you will find in no book; I have not found
them in any book, and I do not know of any
article that has come out giving the minute
details of the technic and the interpretation
of findings with any degree of accuracy. You
will find a lot of books on allergy; in fact,
the market is being flooded with them now.
There is renewed interest in asthma, because
of the allergic factors in asthma, but they
keep their technic a little to themselves. Take
Duke's book; you can not find any technic
in it; and the same is true of all the rest
e.xcept for a brief presentation of technic. If
we are going to try to do allergy we must
have a technic that is reliable. We can get
a lot more out of the reactions than most of
us do when we use the ordinary commercially
described technic.
The protein extracts of the foods — the com-
mercial preparations — are reliable and are
much better than we can make unless we
have a tra'ned chemist who has specialized
in food chemistry for years. What prepara-
tion is best? .Arlington, Squibb, Mulford,
are all reliable so far as I can determine.
There is a paste put out by another firm
which has several of the proteins; you squeeze
a little of the paste on the scratch. That
♦Given before the Tri-State Medical Association
of the Carolinas and Virsinia, meeting at Greens-
boro, N. C, February IQth, 20th and 21st, 1929.
increases the possibility of the negat've re-
action. I have shown thit very definitely
in my own work. You will get enough false
relative reactions when you are dealing with
iust one protein, so you do not want to com-
plicate the matter by having several proteins
in. It is a different matter when you are
trying the intradermal reaction; then you
know you are putting the protein directly
into the skin. In the scratch method you
are putting the dry protein on the skin; you
are using a solvent to carry it into the scratch;
and you hope enough of it will get in to
cnuse a reaction. On the other hand, with
the intradermal test you put it directly into
the skin. We are now working on a group
method; for instance, the bean and pea fam-
ily. The proteins are so similar that even if
the pat'ent is not sensitive to green peas on
the scratch test but is sensitive to lima bean,
nevertheless that patient may have trouble
from green peas. That family includes green
pea, lima bean, string bean, kidney bean,
lent'l, etc., and peanut.
The proteins put up by manufacturers are
in a dry state and keep indefinitely. Most
fcllis use the .Arlington preparat'on; whether
it is a matter of habit, or not, I do not know.
The .Arlington people co-operate well in any
research one wants to carry on.
So far as the pollens are concerned, the
three per cent pollen extract, five c.c, costs
.'i'lO.OO. That is the usual standard price. If
you have the facilities for making up your
own pollen extract you can get a very satis-
factory product. This is the ragweed pollen;
if you are subject to hay fever, do not open
it. That is the ragweed pollen as it looks
when collected and separated from dirt and
other impurities. The dry powders for prac-
tically any of the pollens that you want to
u'^e — trees, grasses, even the very rare pol-
lens— can be procured from the Greer Pollen
Gardens, Marion, Virginia, or from the
Knapp & Knapp Pollen (Jardens, North Hol-
lywood, California. They are very much
cheaper than the [xillen extract; and, pro-
vided your preparation of the pollen extract
f:cm the dry powder is good, you can get
242
SOUTHERN MEDICINE AND SURGERY
April, 1929
better results, because you can always make
it up fresh and have a standardized prepara-
tion.
With the pollens, never use the intrader-
mal test; there is danger of a systemic re-
action. With foods, when you have reason
to suspect that there is a food sensitization
and the scratch test is negative, always do
the intradermal test; but never do it without
having done the scratch test first. Your pre-
I'minary scratch test with negative findings
safeguards you against a systemic reaction,
which is very embarrassing, may be serious
to the patient, and once in a long, long while
may be fatal.
There are some patients here who have
been kind enough to come up for test. This
boy is five years old. He has had asthma
since he was nine months old. Now, I have
rot asked his mother whether he was breast
fed, or not; but when asthma begins at the
age of nine months, always suspect that it
came on about the time of weaning and that
it may be a food allergy. There is one im-
portant point in the history; allergy begin-
ning about the age of nine months is usually
a food allergy. He has had it steadily since
about nine months old and is now five years
old. These tests were made a coiiple of hours
ago, and the reactions have faded. I can
bring out one or two points. First, when
you have more than one or two tests to do,
use the back rather than the arm. One ad-
vantage in using the arm is that th? patient
does not have to do any stripping, and it is
the easiest part to get to; that is the reason
for using the arm for smallpo.x vaccination.
The back is a much better place, for the
following reasons; First, it does not show;
second, especially in a child like this, he can
not see it when you are doing it, and the
psychic factor of fear is to a great extent
eliminated. He does not see it, and it does
not scare him. Third, there are fewer sense
organs in the back than in the arm; it act-
ually does not hurt as much. Some time ago
I tested some cases on the arm, forearm, back,
and thigh, and I got as good or better reac-
tions on the back than anywhere else. I
used the scratch test, because we were using
that in the routine work. .Alexander, of St.
Louis, has carried out this work in much more
detail. He has used the same areas and also
used the abdominal skin, accurately meas-
ured. He finds that, while there is some
variation, you are more apt to get positive
reactions on the skin of the back and the
skin of the abdomen than elsewhere.
Case 1. — This boy has had thirty-nine tests.
We have not put him through the regular
routine, because we just wanted to bring out
what was probably positive. His asthma is
worse in the winter and in rainy weather.
That always suggests the probability of su-
perimposed bacterial infection, sinus infection,
bronchitis; and that will be followed up.
Here is something related to that; this boy
has fever with his asthma. That looks as
if there is a bacterial factor, also. We find
some positive skin reactions, but there is
probably a bacterial factor also. Now, this
bacterial factor may be a simple pyogenic
infection of the [peribronchial lymph glands,
may be a sinusitis; but whenever you get an
asthmatic child running fever with h's at-
tacks, have him examined to rule out tuber-
culosis. I am not indicating that he has
tuberculosis, but he should be examined to
rule it out.
Here is another thing about this boy, the
possibility of a food allergy. He had eczema
before he had asthma, and that is a frequent
sequence in food allergy.
Going into the family h'.story, in over fifty
per cent of allergy you will get a positive
family history; in the rest you will not; but
they are allergic, all the same. But wh?n
you get a family history you are more posi-
tive you have a true allergy. This boy's
grandmother had asthma and migraine; his
father had migraine. The manife-lations
come in different ways, allergy, migraine, hay
fever, etc.
This boy can not eat wheat bread. Bread
at night will cause allergy before morning.
He can eat rye crisp, which is put out by
the Ralston Company, St. Louis, and is the
only pure rye flour bread you are able to
purchase. .All the rye bread baked in Rich-
mond has some white flour in it. Here is
an interesting thing about little Homer, why
he can not eat the fresh rye bread as pur-
chased at the bakery, but after it has been
kept for three or four days and has been
toasted he can eat it without asthma. Some
people who can not eat wheat bread can eat
shredded wheat biscuit, because the thorough
cookir.g has broken down the protein. He
can not eat jellies and preserves very well.
He can not eat chocolate candy but can eat
April, 102Q
SOUTHERN MEDICINE AND SURGERY
other home-made candies. In infancy eggs
made him vomit.
It is not all protein sensitization. The fel-
low who treats them purely on a basis of
protein sensitization will not get as good re-
sults in as large a proportion of cases as the
man who treats each case on its individual
merits, taking into considerations problems
such as constipation, overeating, overeating
at night, especially in persons who are apt
to have trouble at night, other dietary indis-
cretions, such as a high fat diet, alcoholic in-
toxication, etc.
Now, this boy has a reaction to eggs, feath-
ers, and to dog hairs. His mother is going
to watch him for reaction to the dog. He
would probably be better off without a dog;
it is better for persons who are allergic to
avoid having pets of any sort. The same is
true of toy horses, etc.; toy horses have
manes made of rabbit hair. Rabbit hair is
a frequent offender, because it enters into
felt, in felt mattresses, etc. About feathers;
of course, he should be taken off feathers.
What pillow is his mother going to put him
on? She can get a kapok pillow. Kapok
grows on a tree in South .America and India.
It is a much drier fiber than cotton, because
while it is a hollow fiber like cotton both
ends are closed, so dampness can not get in
ihe fiber. Now, she can get a kapok pillow,
but she has to open it and make sure there
are no feathers in it. In Richmond I have
made arrangements with one of the uphols-
terers, and he makes kapok pillows or silk
floss pillows for my patients, on order. Silk
floss is simply ravelings of silk and makes a
very comfortable pillow. People, of course,
can be sensitive to kapok or silk, but not so
often.
This boy is plus-minus to horse protein.
He is also sensitive to wool. Wool rarely
ciu'es asthma but may cause eczema and
may have been the cause of his childhood
eczema. He is plus-minus to wheat. We
have done only one-third of a test. It should
l)e read at the end of a half hour, at which
time the test may be negative; should be
read at the end of si.x hours; and should b?
read agiin at the end of twenty-four hours.
One should pay consideration to all three
readings in relation to each other.
Case 2.— Here is a little boy who was up
to see me a couple of years ago. He had an
eczema and was definitely sensitive to eggs
and also gave positive reaction to beets, sweet
potato, and orange juice. He was kept away
from eggs, and his eczema has cleared up
entirely. We tested him this morning, and
he gives a plus-minus to whole egg. I would
advise his mother to keep him off eggs for a
while yet. His mother has very little trouble
keeping him off eggs. Most of our trouble
in keeping patients off wheat or off milk or
off eggs is with the cook or the parents, but
one or two or all three of them may be avoid-
ed without undue trouble to the cook. This
boy knows what it will do, and he will not
take it. In the majority of cases there is no
difficulty about getting them to avoid it. I
have a boy of my own who is wheat- and
chocolate-sensitive, and when he goes to the
neighbors you know what they offer him —
chocolate cake and candy, but he will not
touch it.
Case 3. — This boy is six years old. His
asthma began at the age of two years and
began in the fall. All these reactions are
negative in the present state. Most of the
text books say make the scratch one-sixteenth
to one-eighth of an inch long, but that is
not long enough if you are going to pay any
attention to the delayed reaction. ]\Iake it
one-fourth of an inch to a half-inch long, and
there is no objection to making it longer;
the more protein you get in contact with the
skin the better the test will be. This boy
has had forty-five tests. His attacks come
on in the fall of the year, every two or three
weeks, come on at night; but here, as in the
first case, they are apt to be worse in damp
weather and in cold weather. They are worse
at night. We tested him to feathers; he
was plus-minus to feathers, but when you
have an asthmatic you would rather find a
positive reaction and know there is a rationale
for taking tfiem away. He might become
sensitized, so take them away and use kapok
pillows. We do not know why he is worse
at night. There are lots of asthmatics who
are worse at night. I do not know whether
it is because of sinus involvement and the
change of p)sition; I have had lots of asth-
matics and have had my full share of tho.se
who are worse at night and do not know
why it is.
This boy is two-positive to dog hair, and
he should have no pets. There is usually a
group reaction; for instance, if you find a
reaction to one cloven-hoofed animal you
244
SOUTHERN MEDICINE AND SURGERY
April, 1929
usually find a reaction to other cloven-hoofed
animals. Usually, if you get a positive reac-
tion to dog hair you will get the same reac-
tion to cat hair, though not always. He did
not, neither did the other boy. Xow, he is
distinctly positive to wheat. He had treatment
a year ago, without improvement so far as
the asthma was concerned. He never has
been free from asthma more than a month
since he was two years old. His sinuses and
chest were x-rayed yesterday. The sinuses
were clear; some peribronchial shadows but
no evidence of tuberculosis. He does not
run a temperature with his asthma. There
is no family history of asthma, hay fever, or
epilepsy. The mother has migraine. He
drinks lots of milk. Pay attention to food
likes and dislikes; they may give you a lead.
He is definitely sensitive to wheat. Xow,
when we are leaving wheat out, what do we
eat? Does that mean he can not eat any
wheat bread? Yes, it does. Here is the
usual list of what the child or patient can
eat, and a large number of people who think
they have been off wheat have not been, when
you go over the list. They can not eat bread,
cake, pies, pastry, cream of wheat, macaroni,
spaghetti, dressing, gravies thickened with
flour, salad dressings thickened with flour.
Wheat flour can get into a tremendous num-
ber of things.
This boy also gave a positive reaction to
egg yolk and ovomucoid, and he is also posi-
tive to rabbit hair. That raises the question
whether he has any toys with rabbit hair as
fur, or whether he is sleeping on a felt mat-
tress. I am not attempting to make a thor-
ough study in any of these cases but am sug-
gesting points of departure.
Case 4. — This boy shows two things. He
has been tested intradermally with white of
egg and illustrates the intradermal reaction.
We tested him a couple of hours before, and
he gave perhaps a little better reaction. They
have faded now. If they are positive to-
morrow, they will be read just like a pxisitive
tuberculin reaction. This boy has his asthma
only in the ragweed season and at no other
t'me. He is fifteen years old and has had
asthma and hay fever for the last seven or
eight years, coming on in the middle of Au-
gust and lasting until the middle of Septem-
ber or later. We have tested him out with
ragweed and will test him with other pollens.
It is not enough to test just with ragweed.
Whenever you start to desensitize a ragweed
case, test him with the dilutions first, to de-
cide in what dilution to start your sensitiza-
tion. Use that dilution that causes no re-
action.
How many injections are you going to
give? That is one danger in using these
treatment sets that are put up ready for
use; you use the fifteen treatments and stop.
One of my patients has had the fifteen treat-
ments but says it did no good. If you give
just fifteen doses, you might desensitize h'm
just up to here. So during the ragweed sea-
son test again with these dilutions and see
if the different dilutions are negative. We
run the desensitization up until all four dilu-
tions are negative; then we expect to get
results. If some of them are positive, we
know before-hand we shall not get perfect
results.
Case 5. — Here is our prize package. This
little boy took everything, and we did not
get a sound out of h!m. He has had some
eczema. The scratch tests were negative, so
we did intradermal tests, and they are nega-
tive, too. We used the foods to which they
.ire more likely to be sensitive, the wheat,
eggs, milk, etc. and used those things that
he is eating now, milk, orange juice, bacon,
cereal, spinach, carrot, beet, etc., but did not
get a positive reaction. That does not nec-
essarily mean that he is not an allergic case.
We also tried him with silk and wool. It
would mean that he should have more test-
ing, more intradermal testing with the foods.
In other words, don't turn him down as a
non-allergic case yet until you have made a
more thorough study.
Case 6. — This gentleman is an asthmatic;
he has had asthma for thirty years. He also
is sensitive to ragweed. I just want to show
you how our routine sensitization test works.
Here are ninety-nine tests, done in about a
half hour, at one sitting, with no discomfort
to the patient whatsoever. You have a black-
board to read from, instead of a rounded
surface, as on the arm. You would have to
do that at several sittings, on the arm. He
gave several reactions; cotton-seed oil is one.
How could he come in contact with cotton-
seed oil? Well, Wesson oil is cotton-seed oil;
and that is, of course, used more frequently
than any other oil in salad dressings. If a
person is sensitive to cotton-seed oil, use olive
oil; if sensitive to that, use Mazola oil, which
April, IQ-'O
SOUTHERN MEDICINE AND SURGERY
24S
is corn oil. Most prepared lards are made
from cotton-seed oil, and if you are sensitive
to cotton-seed oil you will have to go to the
butcher and ask for pure hog lard. Cotton-
seed oil also enters into soap.
This patient is one-plus sensitive to milk.
It may be that is his predisposing factor.
Vou may take milk all the time and not have
asthma and have another cause superimposed
on that, constipation, acute head cold, fatigue,
superimposed on that, and have asthma. Take
milk out (if the diet, and he will not have
asthma.
Clinic in General Medicine*
I. Garnett Xei.son, M.I)., Richmond, \'a.
.\ssociatc Professor of Medicine, Medical College of Nirginia
Case 1. — This patient his chronic mitral
disease, with mitral stenosis and mitral re-
purg'tation and tachycardia. I do not mean
to say that I have made a proper examina-
tion. Xo one has studied the heart sounds
properly without taking into consideration
posture and effort, as when the murmur is
present when the patient is standing, but not
when he is in bed in the hospital or recum-
bent on your examining table.
The questions of occupation and habits arc
questions of fundamental importance with
him. It is possible that he can be taught
how to do his work, how to lift even heavy
weights and have no tachycardia and no
dyspnea and no evidence of the heart's re-
serve being overtaxed. If he can not do that,
then his occupation should be changed. I
notice on the chart that he is a married man
and take for granted he has children whom
he wishes to support and to educate. That
will require of him that he live for twenty
or twenty-tive years longer. He is not going
to do it with that heart unless he protects it.
If he cleans up what infection he has and
protects what reserve he has, he may live as
long as you and I and perhaps beyond.
II. J. Morrison Hutcheson, M.D., Richmond, V'a.
Professor of Therapeutics, Medical College of Virginia
Cases 2 and ,^. — Gentlemen, I have two
patients whose conditions are more or less
identical. If anyone wants to listen to the
heart or feel the pulse, I feel sure they will
be glad to submit to that: otherwise I shall
not undress them.
Xow, the young lady here is twenty-two.
She is a teacher and director of a gymnas-
ium: in other words, her daily pursuits re-
quire a considerable amount of physical ex-
ercise. She complains of a recent attack of
influenza, tires easily, and has palpatation,
wh'ch means that at times she is conscious
of her heart beating. Her past history is es-
sentially negative except for rather more fre-
quent attacks of influenza than the average
person h:is. I do not kn<jw whether that is
•(liven Ijcfore the Tri-Stale Medical Association
of the Carolinas and Virginia, meeting at Greenj-
boro, N. C, February 19th, 20th and 21st, 1929.
true, though. She had an attack last fall
and again in January. In 192.'5 she was ex-
amined for some reason and her heart found
to be irregular. This irregularity seemed to
disappear after tonsillectomy. She was ex-
amined by Dr. Gilmore in January of this
year, during an attack of pharyngitis and
influenza, and he made a note that the pulse
is rather rapid and irregular. Because of
this, and the fact that she had recently had
an infection, she was advised to rest for some
time, which she did with good results. Those
symptoms improved. Xow an examination
at the present time, which was made hastily
by me but was sufficiently extensive to sat-
isfy me of her general situation, shows a heart
of normal size and a rhythm that is irregular,
but the irregularity consists of a normal
rhythm which is interrupted from time to
time by a dropped beat. This dropped beat
occurs from every four to six contractions.
246
SOUTHERN MEDICINE AND SURGERY
April, 1020
The fluoroscopic examination of the heart,
which was made recently, shows no abnor-
mality in shape and size, and the aorta ap-
pears normal. The pulse rate is said to vary
from 90 to 110. There has been no further
examination made. I have simply noted the
character of the irregularity and the fact
that the heart is normal in shape and size.
The fact that she carries on her regular du-
ties, teaching and giving instruction in the
gymnasium, without discomfort, is as good a
functional test as I could possibly give. I
am sure that the response to reasonable ex-
ercise is good.
The second patient is a young man of
twenty-four. He complains of palpitation and
irregularity of the heart beat. His past his-
tory showed that he had something which
might have been rheumatism in 1914. He
has been well since that, has gone to school,
engaged in athletics, and led an active life.
Recently he has gone to work and has been
working hard and has been conscious of his
heart beat and thinks that it has been irreg-
ular. He was put to bed for a time and felt
better. He found, however, that even after
being in bed for a while, if he would get up
and go to the bathroom or stir around just
a little he would be conscious of his heart.
Recently, however, he decided to try it out,
to be reckless, to do something devilish, and
found out after a little dissipation his heart,
instead of misbehaving, seemed better.
There is nothing in the history, really, ex-
cept palpitation. He has been a little doubt-
ful about his response to exercise, inasmuch
as he is conscious of the palpitation a little
more when stirring around than when he lies
still, but he does have it when lying .still.
P'or instance, when he gets up and goes to
the bathroom and goes then back to bed, he
has it a little more after getting back into
bed than when up. The normal rhythm is
interrupted from time to time by a dropped
beat. E.xercise sufficient to speed up the
heart abolishes the irregularity. I had him
hop a while and quickened his pulse up a
1 ttle, and his dropped beat disappeared, to
reappear when the rate came back to normal.
I might say in both these cases there is a
slight variation of the heart rate with res-
piration, a slight waxing and waning, which
!3 intensified by holding a deep breath; I find
that in both of these patients, in addition to
the rather frequent dropped beat.
No fluoroscopic examination has been made
in this case. So far as I can make out, the
heart is normal in shape and size. Dr. Nel-
son intimated in his remarks a little while
ago that estimation of the size of the heart
by percussion is rather approximate. I th;nk
it is worth doing if we have no other means
of estimating it. An electro-cardiogram has
been made in this case. Now, the electro-
cardiogram is the court of last appeal in ir-
regularities. It is not, however, necessary;
usually we can arrive at a satisfactory con-
clusion as to the nature of the irregularity
without an electro-cardiogram. It shows
what you would expect, a fairly frequent pre-
mature contraction, chiefly in the right ven-
tricle. You will notice a series of beats of
the same kind, which are normal beats, and
then a high ventricular wave breaking over,
which means a premature contraction.
Both of these cases have a combination of
s'nus arrhythmia and premature contraction.
The sinus arrhythmia would probably not be
noticeable had the premature contraction fiot
occurred. Sinus arrhythmia is common in
young people. The premature contraction is
what attracted the attention of the patient
and then the physician. They are sometimes
rather annoying things to decide about. I
believe, however, that the heart in both in-
stances is essentially sound.
Just a word about the diagnosis of irreg-
ular heart. In this day it is not enough to
know that the pulse is irregular or that the
heart is irregular or even very irregular. We
have enough knowledge, gained chiefly from
electro-cardiographic studies, to enable us
with our ordinary senses to classify the ir-
regularities which we ordinarily encounter
and to assign it its proper place in prognosis
and treatment. That is the chief thing, after
all, in the examination, to know what the
irregularity means to the patient. Does it
indicate severe cardiac disease; is it a handi-
cap in itself to good cardiac function? If so,
is there anything we can do to correct it?
Now, in order to consider an irregularity
in an orderly way, we are bound to keep be-
fore us a picture of regular heart action. We
must think of what goes on when the heart
beats regularly, just as when we examine a
chest we have in our minds what a normal
chest is like. We must remember that in the
normally beating heart the impulse to con-
April, 192^
SOtJtttfeftJJ MfibtCttCfe Aiib SUfeGERV
U1
tract starts at a definite place in the heart^jj,
muscle and travels toward a definite objec-
tive. A number of things may occur ii' the
heart to break up this order. As a mat-
ter of fact, comparatively few things occur.
We do not. then, have to consider many pos-
sibilities. Sinus arrhythmia, premature con-
traction, and auricular fibrillation are the ir-
regularities we commonly come across. Sinus
arrhythmia occurs in young individuals who
are otherwise normal and is probably a vagus
affair. Occasionally the sinu arrhythmia is
so marked that the patient is conscious of
the irregularity, and the heart may appear
very irregular. If it is a vagus affair it needs
no treatment. It can be influenced by atro-
pine if treatment becomes necessary. I have
seen no case where it did become necessary.
Premature contraction is primarily due to
an overexcitability pf the heart muscle. They
usually occur in the ventricle. Where they
do. they break in upon the normal rhythm.
That is, before the normal impulse can get
down to the ventricle, an impulse starts in
the ventricle itself. If it catches the ventri-
cle in a state of responsiveness, it responds;
it throws out a beat right in the middle of
the heart sound. The beat coming down from
the auricle finds the ventricle in a refractory
state and is lost: consequently there is a
pause until the ne.xt normal beat comes down.
So there is a qu'te characteristic phenomenon.
They may be very frequent and may arise
from several different foci at the same time
and may be confusing, but ordinarily if you
listen at the apex you get a normal beat, then
a premature contraction, then a pause, then
a normal beat, as I just described.
In auricular fibrillation you get a heart that
is i-ntirely irregular. There is no rhythm;
I he jiace-maker is out of commission. Now.
if you are considering the difference, if you
are trying to differentiate between premature
contraction and auricular fibrillation (and
that is what the question usually is), if you
will exercise the patient a little bit it will
frequently help a lot. If it is premature con-
tractions, they disappear; if it is auricular
fibrillation, they get worse. Another sign is
a pulse deficit: you can hear more beats at
the apex than you can feel at the wrist.
As to the significance of these irregulari-
ties, as I said, sinus arrhythmia need not be
considered. It is not heart disease, and the
less we think about it in thsk individual case
the better. Premature contraction is a thing
that is bound to bother us somewhat. As a
matter of fact, premature contraction is found
more frequently in diseased hearts than it is
in normal hearts; but it does occur in normal
hearts very, very frequently — that is, hearts
that are normal according to our standard of
what is normal. We may change our stand-
ards some of these days, when we know more
than we do now. But according to our pres-
ent-day standards, premature contractions
are compatible with what we consider a nor-
mal heart. If we find a heart normal in
shape and size, with good valves, and respon-
sive to exercise, then we may forget the pre-
mature contractions. Treatment, so far as
the premature contractions is concerned, is
not often necessary. As a matter of fact,
few people with premature contraction need
treatment ; they often need more work on the
part of the doctor than people with real heart
disease. I am sure that the idea of heart
disease in the patient's consciousness results
in more unhappiness and disability than real
heart disease, sometimes. In other words, a
man can get along better and with more real
comfort in life with a damaged mitral valve
than he can with palpitation: it is a thing
that you can not dismiss hastily. He sees
someone else, and the more doctors he sees
the more unhappy he becomes. If you are
in doubt, reassure him; you can make him
happy for a time, anyhow; and there is not
mucn you can do on the other side. Reassur-
ance and explanation pay; conservation on
the part of the doctor is often a great help
to these people. It really does them some
giMid and is worth our while.
So far as medication is concerned, 1 think
sedatives do more good than anything else,
in premature contractions. I doubt if they
help th.- contractions, but they make the pa-
tient less sensitive and help him to bear his
burden. Occasionally premature contractions
become so frequent and so annoying that we
are tempted to try to stop them. Quinidine
will sometimes stop them but sometimes fails.
Fibrillatiton is a very different matter;
fibrillation means real heart disease. Wheth-
er we can find any lesion to go along with
it, or not, we are justified in presuming, when
we encounter fibrillation, that we are dealing
with a damaged heart. We may assume that
the fibrillation itself, the disordered action.
w,ll become a factor in breaking down the
248
SOUTHERN MEDICINE AND SURGERY
April, 19i9
myocardium. If we can control the fibrill a-
tion, we may assume we are doing some good
in making the heart last longer. Fibrillation
occurs with a failing heart. In most of the
cases with fibrillation, digitalis does good.
For the fibrillation itself, digitalis only suc-
ceeds in slowing the ventricular rate and al-
lows the heart to work better; but digitalis
itself does not, so far as I know, abolish
fibrillation. Fibrillation itself can be abol-
ished by quinidine. In cases where the com-
pensation is good, quinidine is indicated; and
in a considerable number of cases it will
abolish the fibrillation.
DISCUSSION
Dr. F. C. Rinker, Norfolk, Va.:
I do not want to delay this discussion to
any great extent but to say there is one point
brought out by Dr. Hutcheson I feel par-
ticularly interested in, and that is the psych-
ological care of the individual who has pre-
mature contractions. I think I can more
quickly bring this out by a diagram showing
what does occur in these cases. Roughly, if
we think of the right auricle here (indicat-
ing), the pace-maker at this point, impulses
sent out to the auricle, the node at this point,
the impulses coming down here, right and
left bundle branches to the pace-maker. Sup-
pose something comes along and punches the
ventricle at this point or punches the auric-
ulo-ventricular septum or division; then there
is going to be an impulse that is thrown in
too early, and we have premature contrac-
tion. The reason I drew that is simply to
say this — I think many times we can relieve
our patients and ease their minds by showing
that if a telegraph operator is sending out a
message and I step up and touch his button
before he is ready to send the ne.\t dash,
there would be a premature contraction which
would not be due to the operator himself.
That is frequently a method of relieving the
an.xiety of the patient about his heart condi-
tion.
Dr. F. R. Taylor, High Point, N. C:
I have h;!d very little personal experience
with quinidhe but I have seen one case in
which it was given in which it knocked the
patient cold. Something happened: I do not
know what; but I have had a very healthy
respect for quji.dine since. At the Peter Bent
Brigham Hospital in Boston I heard a very
interesting conversation in which one partici-
pant was advocating the rather frequent use
of quinidine. The other asked: "Granted it
will stop the fibrillation, what have you gain-
ed?" It came down to this — in ambulatory
patients in whom the consciousness of the
arrhythmia is the thing that is bothering the
patient most and doing the most damage,
quinidine is worth while; but unless the actual
consciousness of the arrhythmia is the essen-
tial factor in the disturbance, the quinidine
had better be left out. I do not offer my
own views on that, of course, in opposition
to Dr. Hutcheson: but that was the outcome
of the debate between the two men, with
more or less of a compromise as the conclu-
sion.
(Dr. Porter was asked to continue the
clinic by quoting some of the work he has
been doing in liver feeding.)
Dr. W. B. Porter, Richmond, Va.:
We had no patient that presented any' of
the characteristics of anemia, and I told Dr.
Lane it might be of advantage to this group
if I discussed some of the basic principles
involved in this matter, which is attracting
so much attention at this time — namely, the
management and care of patients who have
anemias by the administration of liver or
some preparation of liver.
For at least fifty years the question of per-
nicious anemia has revolved around the mat-
ter of hemolysis, and practically all teachers
have felt that the hemolytic aspects of these
primary anemias were of the greatest import-
ance. However, we note in the literature
several keen observers who have questioned
this and who felt that the real, fundamental
nature of [pernicious anemia was a disturb-
ance in blood formation. I refer particularly
to Ehrlich.who described the bone marrow as
being a reversion to the embryonic type, and
refer to the late William Pepper ', of Phila-
delphia, and several others. But the hemo-
lytic aspect has more or less dominated the
field, and it remained for the present era to
change some of our conceptions, and I
thought it might be interesting to compare
some of the fundamental differences between
addisonian anemia, on the one hand, and so-
called secondary anemias, on the other.
.As you know, the bone marrow is the
source of the red cells and also of
the polymorphonuclear leucocytes. It is also
April, I9i9
SdtJTHERM MECiClNE ANtJ StRGERV
M
the source of the blood platelets. In dealing
with secondary anemias we have a condition
of the bone marrow which is quite character-
istic. If I may ilkistrate on the board some
of these characteristics, I think we may carry
away a conception of the whole problem
which will be of some help to you in the
therapy of these cases and of some help in
understanding why secondary anemia, as such,
does not respond dramatically to the feeding
of liver or liver fraction, and why addisonian
anemia, on the other hand, does respond to
liver feeding and improves under its influ-
ence.
If we take a section of bone marrow as
presented by a microscopical field, we find a
good deal of fat scattered through normal
bone marrow. If you look at it closely, you
will find them as little red-looking specks;
these represent what are called erythroblastic
islands. Under the microscope these islands
look like an irregular group of cells. In the
center we find a cell with a nucleus, an ordi-
nary normoblast, which is the precursor of
the normal erythrocyte as we see it in the
blood stream. As we come to the surface,
we begin to get cells at a point in the mid
zone, which, when stained will be seen to
have reticuli — the so-called reticulocytes. As
we get to the surface we get a normal-looking
cell without the reticulum, which is the nor-
mal erythrocyte just getting ready to pass
out into the circulation. Bunting and several
other observers have pretty well shown that
that is the mechanism of normal blood for-
mation.
Now, in an anemia which is secondary to
some other cause, such as the loss of blood,
what do we note in this? The only thing
we note in this field is that there is an in-
crease in the number of normoblasts, these
nucleated red cells which are normal in size;
and we find that these reticulocytes and nor-
moblasts are beginning to migrate toward the
border, showing that the stimulus of the ane-
mia, the demand for new blood, is whipping
up the bone marrow, so that not infrequently
following hemorrhase we get into the circu-
lation nucleated cells; and these cells we call
reticulocytes. Now, if the blood is stimu-
lated by the hemorrhage, it is quite illogical
to think we shall ^ive a substance which will
further stimulate the bone marroyv. The
logical treatment is not something to stim-
ulate but something to relieve that overta.\ed
bone marrow — food with a high percentage
of iron, sunshine, rest, stopping of the hem-
orrhage, and, if the hemorrhage is sufficiently
severe, replacement of the lost blood by a
transfusion. That is the logical treatment.
What is the situation in pernicious anemia?
A very different picture. If, in [pernicious
anemia, we take a section of the bone mar-
row, we find in the first place that instead
of the bone marrow looking yellow with a
few little red specks scattered through it, it is
red, quite red, a gelatinous-looking substance
which has a neoplastic appearance. What
do we see under the microscope? We see a
cross section of this marrow that looks like
a tumor. It looks exactly as Ehrlich described
it — embryonic bone marrow. It looks like a
mass of cells, cytoplasm, rather pale-yellow
bone marrow filled up with these large red
cells: in between we find other large cells,
pale cytoplasm; the whole thing is a home-
geneous collection of cells — very young red
blood cells. The bone marrow is literally
packed full of these very young cells, red
cells and white cells.
Now, what has that to do with treatment?
What is the fundamental thing that is appar-
ently happening in pernicious anemia? Ap-
parently it is not a destruction of red cells;
the increased amount of pigment in liver and
spleen may be the normal amount of pigment
being thrown aside because of insuffiicient
number of cells to take it up. What is ap-
parently happening in pernicious anemia is
that there is lack of the substance necessary
for the maturation of these red cells. In
other words, there is a standing army, but
something has happened to the soldiers
for the time being, and they can not come out
into the circulation. When we give liver or
l.ver fraction, there is a substance in it which
unites, probably — probably, I say — with that
immature cell, allowing that cell to mature.
.As soon as that occurs the blood stream be-
comes Hooded with these young cells. Con-
sequently, these cells being matured from the
very young red cell, the result is that they
get out into the circulation in a premature
state, still retaining, probably, a fragment of
the nucleus, which can be stained by a vital
stain and produces this little reticulum, giv-
ing the cell the name, a reticulocyte. After
we treat the patient and his blood count goes
up to normal, about 3,000,000 or 2,700,000,
the reticulocyte disappears.
iSd
SOUTHERN MEDICINE AND SURGERY
Aprit, 19«
Why did we start off with a lot of reticu-
locytes and then they disappear? For this
reason; at that particular stage when we get
to the 3,000,000 mark, if we study the bone
marrow we find it has been converted into
the state typical of normal bone marrow. In
other words, it has been changed from this
hyperblastic bone marrow to the normoblastic
bone marrow; it has changed to the state
where we get these erythroblastic islands em-
bedded in fat.
So we feel now that it is absolutely funda-
mental for one to make, as far as possible, a
diagnosis of a so-called megaloblastic anemia
before treatment is started, for if a patient
has a megaloblastic anemia, addisonian in
character, and he starts liver and gets well,
that patient is supposed, so far as we can
tell, to maintain liver feeding indefinitely;
otherwise he will relapse. Consequently the
proper diagnosis of a megaloblastic anemia
or addisonian anemia is just as important as
a diagnosis of syphilis. If you treat your
anemias in a haphazard fashion you will be
unable to tell whether the patient was cured
by the feeding of food high in iron or by the
liver. In one type of anemia liver is specific,
in the other non-specific. I believe that ex-
plains the difference between the two diseases,
and I believe that explains why in one ane-
mia we get results and in another we do not.
April, 1920
SOtJtttfiRN MEDICINE AND StRGERV
iSl
The Psychiatric Consideration of Abortion*
R. FiNLEY Gayle, jr., M.D., Richmond, \'a.
Westbrook Sanatorium
Associate Professor of Nervous and Mental Diseases, Medical College of Virginia
Every physician is consulted at some time
for his opinion concerning the advisability of
producing an abortion upon a pregnant wo-
man because of her mental condition. The
psychiatric ramifications of the subject are
manifold and have far more to do with the
c|uestion than simply the advice for or against
the procedure. There are many pregnant
women suffering with frank psychoses, as will
be subsec|uently discussed, who should be al-
lowed to go to term. Conversely there are
those in like condition without classifiable
psychosis in whom it may be thought wise to
empty the uterus before the embryo is viable.
The incidence of abnormal mental states in
pregnancy, which vary from the mild psycho-
neuroses and an.xiety states through the men-
tal scale to the obviously insane, is very com-
mon. Cole states that fewer than one per
cent of pregnant women develop frank psych-
oses. The personality, however, of every
pregnant woman is altered to some degree.
This is particularly true of the primipara.
The emotionally unstable and the constitu-
tionally psychopathic and neurotic ones near-
ly always demonstrate some psychopathology.
The indications for abortion because of
mental disease are primarily to preserve the
life of, or to prevent or to cure severe mental
or physical disease in the nKjther or the child.
Kach case is an individual one and there can
be no dogma concerning any particular group
of symptoms which at a given time are in-
dicative of the termination of pregnancy.
The whole psychiatric picture in reference to
the mother and the future of the child must
lie regarfied on its merits. We must not allow
our sympathy to be unduly extended and
thereby warp our judgment. The older phy-
sicians were apparently more likely to abort
a woman because of mental disease than is
the psychiatrist of today, probably for the
reason that heredity as the causation of men-
♦Presented to the Tri-State Medical Association of
the Carolinas and Virginia, Greensboro, N. C, Meet-
ing Februar>' 19th, 20th and 2lst, 1929,
tal disease was more firmly believed in for-
merly than it is now.
It is an almost universally accepted fact
that disease in the mother affecting the em-
bryo, brain hemorrhage at birth, the infec-
tious diseases of childhood, and bad environ-
ment during the developmental period are the
dynamic forces in the production of mental
disease. Among these we include the psycho-
neurotic or the "nervous"; the psychotic or
the insane; the feeble-minded; the psycho-
pathic inferior and the epileptic. If the fore-
going be largely accepted we do not of neces-
sity allow ourselves to become panic-stricken
simply because a pregnant woman shows
mental symptoms even if profound in degree
though she may have had a psychosis during
a former pregnancy or there had been some
insanity in her family. Heredity, of course,
plays a part in the production of these abnor-
mal mental states but we must not allow our-
selves to forget that many mental character-
istics considered as influences of heredity are
in reality products of environment. To illus-
trate: a child is a natural imitator of every-
one and particularly of its parents. It is not
likely that a high-strung, hyserical mother
who at no time inhibits nor attempts to con-
trol her emotions, who gives vent to her af-
fects and feelings will be imitated by her
offspring or, possibly, the child may go to the
other extreme and repress its emotions and
become "shut in" and of the praecoid type.
An unstable nervous system is fertile ground
in which any of the diseases of affectivity
may grow, even to the degree of profound
psychosis. The fear that an offspring will
develop manic depression or some other in-
sanity because the mother was so affected,
even while pregnant, is not, as a rule, well
founded. If the training of the child can be
regulated away from the hypomanic or de-
pressed influences of the mentally diseased
relatives or parents it does not of necessity
follow that the child will be of similar cyclo-
thymic personality. On the other hand, when
there has been a long line of manic de|)res-
sive types in the family with many suicides
Hi
SOUTHERN MEDtCtNE AND StJRGERV
April, m^
and possibly a defective or abnormal child
by a former pregnancy, in which the mother
was mentally disturbed, the relief of preg-
nancy here may be more seriously considered.
Even with the epileptic and feeble-minded we
are yet without sufficient eugenic data to say
that the progeny will be likewise affected.
It is probable that the manic depressive
group is much the largest. They are an emo-
tional class who practically always marry and
become pregnant. Fortunately the dementia
praecox individual usually withdraws from
society and shuts himself in before he has
had much opportunity for matrimony. For
that reason these cases are not as great a
psychiatric problem. The paranoiac usually
becomes definitely disturbed mentally towards
the end of the child-bearing period and ob-
viously they, as a type, are not as great a
problem.
The expectant young mother who has not
had previous experience with pregnancy is
naturally beset by many conflicting thoughts
which necessarily upset her normal mental
tone. Most often these erroneous thoughts
are readily compensated for and no psychic
disturbance of note is a problem either to the
patient, her family, or to the doctor. The
unstable nervous ones, on the dther hand,
who have neither the background, the intelli-
gence, nor proper environmental influences,
are mentally miserable. Fear is the motivat-
ing influence of most of the psychoneuroses
and it is not hard to conceive of the anxiety.
apprehension, and fear a young mother must
experience in the anticipation of going through
the ordeal of childbirth. This is especially
true of those who have been taught to dread
the pain and suffering of the experience or
of those who have been misinformed as to
the procedure. The same reaction is often
present in the neurotic mother who has had
a previous difficult labor and who is mentally
unwilling to again subject herself to the suf-
fering incident to labor.
The psychoneurotic reacts usually by dem-
onstrating the instability of the emotions
with tears, mild depression, irritability, and
fears of death. Other symptoms of the func-
tional neuroses as insomnia, abnormal sug-
gestibility, social maladjustment, various mo-
tor and sensory disturbances (including pain
and weakness), and evidences of major hys-
teria which may simulate convulsive seizures,
paralyses, blindness, deafness and dumbness,
may be encountered in most any combination.
These mild mental disorders usually clear up
either before the end of the period of gesta-
tion or shortly afterward. It is seldom ad-
visable to recommend abortion in these cases.
They may desire the operation, but it is
cjuestionably how often this procedure relieves
completely the mental state and it has not
infrequently happened that the performance
of an abortion has added materially to the
previous mental conflicts of the patient. This
is especially true in those who have had a
rigid religious background and in others whose
religion frowns for any reason upon the oper-
ation.
The most common psychosis of pregnancy
is the depressive phase of the manic depres-
sive type. The degree of depression and the
other symptoms of psychosis vary greatly in
different individuals. Some of them exhibit
only a mild depression with worry, restless-
ness, insomnia, tears, and physical and mental
fatigue. It is often difficult to differentiate
these from the more pronounced psychoneu-
rotics and we can only do so by making a
survey of the patient's whole mental life and
taking into consideration the personality type
to which she belongs. It is seldom, if ever,
advisable to terminate pregnancy in this type
of individual. The more profound cases of
depression exhibiting a decided delusional
trend (at times concerning the parentage of
the child), marked insomnia, suicidal tenden-
cies, refusal of food, and negativism give the
consultant much more concern; but even here
we do not deem it advisable to interfere in the
majority of cases especially in the first preg-
nancy. If a woman is of a family in which
there has been much insanity or other evi-
dence of mental abnormality and she has had
a mental disorder in other pregnancies or has
previously had a defective or abnormal child,
it is at times advisable to abort her.
The maniacal type of manic depressive in-
sanity is occasionally encountered but it
is not nearly so frequent as the depressed
type. Because of the intractability of this
group and the danger they are to themselves
and to the foetus they, of necessity, must be
institutionalized during the psychosis. .Abor-
tion is seldom indicated in these cases unless
the situation is similar to that set forth above.
.Against abortion in this type of case is also
the fact that the psychosis usually persist?
April, 19^9
SOtTHfiRN MEDlClNfi AND SURGERV
m
for a time regardless of the termination of
pregnancy.
Every institution handling mental cases
has in its files records of these types of psych-
osis in women whose pregnancy was not in-
terfered with and who have borne healthy
children and have recovered mentally. I have
particularly in mind a woman who was very
delusional and maniacal during most of her
pregnancy. She repeatedly attempted to de-
stroy herself and the embryo because of a
delusion that the father of the child was a
negro. The pregnancy was allowed to con-
tinue. She recovered, has since lost her hus-
band, and the child, who is healthy and ap-
parently mentally well, is her one pleasure
in life and probably helps in her mental ad-
justment.
We are more sympathetically inclined to-
ward advising abortion in the group of men-
tally sick comprising the feeble-minded, the
epileptic, and the dementia praecox, because
hered'tary factors are more potent in this
group. But even in these types we must
weigh in the balance the incidence of similar
mental disorders in the family and of men-
tally abnormal children of previous pregnan-
cies. We must bear in mind that occurrence
of the above mentioned mental abnormalities
may not be of hereditary genesis but may
have resulted from cerebral disease in utero,
at birth, or in the developmental period of the
individual.
Mental abnormalities resulting from the
to.xemias of pregnancy are rare compared to
the dsorders of affectivity which are precipi-
tated friim like cause; but they are, neverthe-
less, often confused. In fact most mental up-
sets at the puerperium are diagnosed puerpe-
ral psychosis when in reality the majority of
them are simply emotional dis(jrders and
might have occurred at some period regard-
less of [)regnancy. The true toxemias of preg-
nancy giving rise to mental symptoms are due
to ne[)hritis with nitrogenous retention in the
blo(jd and hepatic insufficiency, and to infarcts
or other pathology in the placenta. The in-
dications for abortion in these cases do not
depend upon the mental condition of the pa-
tient, but upon structural pathology in the
mother and its likelihood of causing death to
the mother or the foetus.
The question »i sterilization must be con-
sidered when abortion, because of mental dis-
ease, is discussed. There pmbablv is no UKjre
dangerous procedure than promiscuous legal-
ized sterilization. However, it is our opinion
that sterilization must be considered when-
ever abortion is done because of a mental
or nervous disease. We do not mean to leave
the impression that we advocate this proce-
dure in all cases where abortion is done on
account of mental disease, but in some of
them it is indicated. We seldom advise abor-
tion and we less seldom advise sterilization.
.As we have said before each case must be
considered on its merits.
Pregnant women have been known to feign
mental disease in the hope that they may
arouse the sympathy of their physician and
thereby have their pregnancy interrupted.
The malingerers can usually be detected if
they are observed closely enough and every
case of suspected mental disease should be
watched over a sufficiently long period to
make one certain of his diagnosis.
The question of mental disease in the fa-
ther must be given consideration. This point
is seldom raised, but it is almost as important
a one as mental disease in the mother if we
are to consider the factor of heredity. It is
our opinion that pregnancy in this instance
should not be terminated unless the same
factors of heredity are present as were men-
tioned formerly and there have been mentally
abnormal children by previous pregnancies in
a healthy and mentally well mother.
The advice which should be given a moth-
er concerning future conception, who has
gone through a pregnancy in which she was
mentally upset, is of prime importance. It is
grossly unfair to her to openly advise her
against future pregnancies, because if you do
give such advice the patient will most likely
become mentally disturbed should she again
conceive and you will certainly be called
upon to recommend an abortion. Such ad-
vice gives the patient a sense of security in
that she knows where she will go for help
when she is again pregnant. Only recently
we had to advise that in our opinion an abor-
tion was not indicated in a woman who had
been told by her physician that under no
circumstances should she become pregnant for
fear of doing damage to her mental health.
We have no right to interfere with a nor-
mal |)regnancy simply because a woman is
unwilling to face the ordeal of pregnancy even
though she has had frequent jiregnancies. In
the mild cases, after a commonsen.se talk with
^S4
SOUTHERN MEDICINE AND StRGERV
April, 19J9
the patient and her husband, we are often
able to clear up the situation and get the
patient reconciled to allow her pregnancy to
continue. Guidance, suggestion, reassurance,
and the various forms of psychotherapy are
not infrequently helpful in the successful
h:indliiig of these cases. Suicide must always
be guarded against even in the nvldly depress-
ed ones, and institutional care must be re-
sorted to in others.
In Germany, Austria and Switzerland cer-
tain organizations are attempting to legalize
abortion before the third month of pregnancy
regardless of the physical or mental condition
of the mother. Many physicians and soci-
ologists in England and on the Continent con-
tend that the woman should be the mistress
111 .he situation. The German view is that
the loeti's is not an independent human be-
ing a!id that every woman by the virtue ol
the right over her own body should decide
whether it should become one. We are noi
in accord with this view and we sincerely
hupe that it will not gain ground in .America.
-'12 West Franklin Street.
DISCUSSION
Dr. J. H. RoYSTER, Richmond:
I have enjoyed listening to Dr. Gayle's pa-
per. All forms of nervous and mental dis-
eases are met with in pregnancy and the
puerperal state. It certainly brings no im-
munity, but it is not a cause, and I do not
believe if you do an abortion it is going to
relieve the mental state, which is frequently
a complication rather than a result of this
condition. I am in entire accord with Dr.
Gayle's views on this and think that thought
should be given to it. .Much harm can be
done these patients, and I believe as many
mental conditions are precipitated by abor-
tions as are relieved, and I think that they
should be given very careful consideration.
Each individual case is peculiar unto itself,
and certainly no rules can be laid down fot^
inducing abortions in any class of mental or
nervous disorders.
President Hall:
Dr. Lonergan, whom I am about to pre-
sent to you, is the director of the largest hos-
pital in the world, the hospital on Ward Is-
land, New York, which has seven thousand
mmates. Dr. Lonergan is going to conduct
a clinic this afternoon on mental and nervous
diseases, which constitute, as you know, a
great problem. There are more beds in the
insane hospitals than in all other hospitals.
Dr. Lonergan, I may say, is associated in
his work in the state hospital on Ward's Is-
land with Dr. George Kirby, a son of the
former superintendent of the state hospital
at Raleigh. Dr. George Kirby is one of the
best known men in mental diseases not only
in this country but in the world. He has re-
cently been made professor of psychiatry at
Yale University. I present to you Dr. ^iich-
ael P. Lonergan.
Dr. iMicHAEL Lonergan, New York City:
I had not thought of speaking to Dr.
Gayle's paper and hoped to defer this intro-
duction by the president until later.
In the first place, I agree with Dr. Gayle's
paper. I think it is quite conservative. We
in the hospitals, of course, do not see these
cases in the early stages. When they do de-
velop severe mental symptoms they are sent
to us. What do we do then? Do we call a
surgeon or an obstetrician to relieve them of
their burden? No. Of course, each case
has to be considered by itself; but our usual
procedure is to make a complete e.xamination,
and then send her to the hospital ward where
we do have such cases. We let her go through
her pregnancy and when the child is born
take care of that. If the patient is a chronic
case and to remain in the hospital, we send
the child either to a foundling hospital or
to some of the relatives.
In regard to the type of psychosis which
a pregnancy may precipitate there is a dif-
ference of opinion. We get a type of persons
who have manic-depressive attacks; some of
them recover before the delivery takes place.
Of course, that is a very happy solution.
With those who are upset about this con-
dition and do not want to go through the
term of pregnancy, of course the attending
physician has to pass judgment. I was won-
dering how we look upon our responsibility
there. Should the psychiatrist be consulted?
I think so, especially when it borders on a
psychosis or a psychoneurosis.
Some of our patients that come because of
pregnancy come after pregnancy. Perhaps a
day or two after delivery the patient devel-
ops a mental reaction. It is not very typical.
Many of them are somatic conditions;' there
is a clouded state. Very often there is am-
April, 1020
SOUTHERN MEDICIXE AND SURGERY
2SS
nesia. There is a very good prospect for re- Gayle's paper, not having expected to speak
covery. :Most of them stay only one or two gj^^^jj ^ -pj^jg afternoon, I hope to say
or three months, manv of them not as long , • x- ^- ■ t
,, , ■ something about our work in Aew \ork. 1
as that. "^
I have nothing more to say about Dr. am, of course, substituting for Dr. Kirhy.
Encephalocele*
George H. Bunch, M.D., Columbia, S. C.
A cephalocele or encephalocele is a con-
genital tumor of the head consisting of men-
inges, cerebro-spinal fluid and often of brain
t'ssue, pro'ectin^; through a congenital defect
of th? skull and covered by attenuated skin.
When there is a continuation of one or more
ventricles of the brain into the tumor the
condition is known as cystencephalocele.
?Iost lame congenital tumors about the head
are of this type and are peculiar in that they
are found only in the midline. They usually
arise from the region about the root of the
nose or from the occiput where there is apt
lo be error in the development of the skull
about the foramen magnum. Tumors below
the tentorium having brain tissue come from
the cerebellum; those above the tentorium
involve the cerebrum and may spring from
either fontanelle.
There is no positive knowledge about the
cause of these tumors. The common belief
is that through some developmental error the
skull fails to properly enclose the fetal brain
so that a portion of it and its membranes re-
main extracranial. The closure of the me-
dullary tube, according to von Bergmann, is
usuilly completed at the second week of fe-
tal life so that the origin of the deformity
must be in the very earliest period of cmbry-
ological life. iNIost infants with cephalocele
also have congenital hydrocejihalus and it is
not improbable that increased cerebro-spinal
pressure from some incomplete obstruction to
the circulation of the cerebro-spinal fluid may
cause the brain and the m-^ninges to protrude
from the embryonic skull and make the tu-
mor mass.
Von Bergmann estimates that cephalocele
♦Presented to the Tri-.Slalc Me.lical A s^ciation of
the Carolinas and Xirginia, Greensboro, X. C., Mecl-
ing February 19th, 20th and 21st, 1929,
occurs once in 3,500 to 4,000 new burn chil-
dren. Records are not available but a d 'fi-
nite percentage of these must d'e in delivery
from injury to the brain. At birth children
with cephalocele are apt to have more or
less congenital deformity of the extremities
and impairment of function. They are apt
to show stigmata of degeneration and be both
physically and mentally subnormal. Many
of them d'e within the first few hours or days
of life. Others succumb later by accidental
rupture of the attenuated skin covering the
tumor, or from its ulceration and infection
of the underlying brain.
Of 144 cases of encephalocele, not operated
upon, reported by Reali, only 7 reached adult
life and of 39 cases in Moskow reported by
iVIiller none lived a year. As early as 1893
Diakonow from the literature reported 17
recoveries out of 27 cases ojjerated upon, and
in 1898 Lyssenkow found ii recoveries in
62 operative cases. Von Bergmann in his
System of Surgery, 1904, reports having oper-
ated upon 10 cases with only 2 deaths. He
gives 4 contraindications to operation: (1)
cxencephalus in wh'ch the whole brain is in
the tumor; (2) occipital encephalocele with
attachment through the foramen magnum;
(3) unm'stakable hydrocephalus; (4) defor-
mities in other parts of the bjdy which are
themselves soon fatal. Fraser in "Surgery of
Childhood," 1926, says, "(1) The oj^eration
fhould not be performed until the child is
three months old, (2) The child must b'
progress'vely gaining in weight at llie tiiii ■
of operation, (3) ."Xny suspicion of coini ident
hydrocejihalus should be accepted as a inn-
traindication to operation." For the opera-
tion he gives ether by intrapharyngeal in-
sufflation and keeps the head low to jirevent
ip\] in cerebro-spinal pressure, .\fter making
an elliptical incision around the base of the
256
SOUTHERN MEDICINE AND SURGERY
April, 192Q
tumor and excision of the mass he closes the
defect by a plastic operation in which he uses
meninges, skull and skin, bem^ careful to pre-
vent a leak of cerebro-spinnl flu'd which he
says may never close. He quotes Reinhart's
report of 200 cases with a mortality of 7 per
cent. This and the previous series of cases
show surprisingly good results from opera-
tion and are obviously composed of cases
carefully selected for operab'lity.
]My experience with encephrloceb consists
of but a single case. On November 2, 1927,
with Dr. Rhodes, a colored physician of Co-
lumbia, I saw a colored baby whom he had
delivered without forc?ps the previous day.
The mother was a young worn in who had
one healthy child a year old. She hd never
had a miscarriage. The newborn infant was
a nine-pound boy with a large cystic mass
attached to the head by a prd'cle with a base
about 4J/2 inches long and 1 inch thick ex-
tending forward along the top of the head
from the posterior fontanelle. The mass was
not translucent. It did not pulsate but it did
become distended when the child strained or
cried. iManual pressure upon it caused the
chid to stop breathing and to have a hard
convulsion. It consisted of two portions alike
in character but one much larger than the
other and both attached to the head by a
common pedicle. The mass was covered with
skin which soon became thin and without
hair. The head was tower-shaped with the
pedicle forming the top of the tower. The
child was poorly nourished but had no de-
formity of its body or extremities. It nursed
and moved its body in a normal way. The
tumor was larger than the head.
The father was told that the tumor was an
extension of the linings of the brain and per-
haps of a part of the brain itself through an
opening in the skull. The tumor was cov-
ered with skin that was so thin it must soon
ulcerate or tear, causing death. Operation
in one so young and so weak would be a
serious undertaking with the probability of
the child dying on the table. .\nd even if
the child survived the operation it would
probably be mentally deficient. But an oper-
ation offered the only chance for the child.
I had never operated upon such a case nor
had I ever seen one operated upon. The fa-
ther insisted upon operation.
The next afternoon I removed the tumor
from the three-day-old infant in the simplest
possible way, feeling that extensive operation
would surely kill the child from hemorrhage
and shock. Every possible drop of
blood must be saved. Leakage of cerebro-
I. Child before operation
spinal tluid must be prevented. Infection
must not occur. Bleeding, continuous leak-
age of cerebro-spinal fluid, or infection would
cause death. The region about the ped'cle
was carefully shaved and painted with half
strength tincture of iodine. Without any an-
esthesia, through and through interrupted
mattress sutures of silkworm gut were put
through the base of the pedicle as close as
possible to the skull. These were not inter-
locked but were placed close together and
carefully tied. .■\s each suture was tied I
feared th? child might die but it showed no
ill effect from the manipulation. Then with-
out bleeding the pedicle was removed with
a knife a half or three-quarters of an inch
beyond the mattress sutures, the central por-
tion of the pedicle base being cupped out so
as to leave the skin margins long enough to
be approximated over the meninges without
tension with interrupted silkworm gut sutures.
Much to my surprise there was no evident
shock. The operation lasted ten minutes and
the patient was apparently none the worse
for it.
Th? wound healed without infection. The
silkworm sutures were removed the tenth day.
There was never leakage of cerebro-spinal
fluid. The child is now 14 months old and
in gocd heakh although poorly nourished. It
April, 1929
SOUTHERN MEDICINE AND SURGERY
still nurses the mother but is also fed with
milk out of a bottle. It weighs only 8 pounds.
It has two teeth. It is too early to say defi-
nitely what the mental status of the ch'ld
will be. The mother thinks he is mentally
deficient. Although immediately after the
wound healed the shape of the head was more
nearly normal, it has now become somewhat
tower shaped again. The x-ray shows a lirge
opening in the skull, a congenital absence of
skull over this area. There is quite a fullness
of the scalp here as if the cephalocele were
partially reappearing. We believe this is the
result of hydrocephalus and the scalp is being
forced outward by it. When the child is older
and stronger, if it be deemed best, perhaps a
plastic operation of some kind can be done
to close the defect in the skull. For the pres-
ent it seems the part of wisdom to await de-
velopments. In the meanwhile the child has
been placed under the care of a competent
pediatrician who, by proper feeding, will en-
able the little patient to overcome the effects
of malnutrition and to grow more advantage-
ously.
This case is reported because of the great
size of the tumor, of the early age of the pa-
t'cnt at the t'me of operation, of the operative
technique used and of the final good result.
II, Child 14 months after operation, showing re-
current deformity from hydrocephalus
We consider this a cystencephalocele with
meninges, brain tissue and ventricele occur-
ring in the tumor mass. Unfortunately the
child was not weighed after operation so that
the weight of the tumor is conjectural. There
was considerable brain tissue removed but
ventricles could not be grossly identified in
it. Even in spite of hydrocephalus the pa-
tient has survived operation.
258
SOUTHERN MEDICINE AND SURGERY
April, 1Q2Q
PRESIDENT'S PAGE
Tri-State Medical Association of the Carolinas and Virginia
—CYRUS THOMPSON
The assertion might be too broad to say
that every philosopher should be also a doc-
tor, but it is easily within bounds to say that
every doctor should be also a ph'losopher.
John Locke, the philosopher, was first a doc-
tor and then a philosopher; and though his
reputation stands upon philosophy rather
than medicine he still held on to medicine
and thought of it philosophically. Late in
the seventeenth century, writing to a kins-
man, he said: "One thing has come into my
mind relating to your son's health, and which
may perhaps be of use to you a'-^o, which is
that I would have him go constantly to stool
once a day. I expect that y u should think
it strange that I propose this as if it were in
his or anybody's power else, and I think in
great measure it is, and more perhaps than
you imagine. I myself being naturally cos-
tive, and considering a great part of our dis-
eases come from a want of due excretion, cast
about for a remedy. Laxative d'et is neither
always to be had nor always to be used. I
first, then considered that a great many mo-
tions of our body that seem natural and al-
most wholly involuntary, might yet, by a use
and constant application, in a good measure
be made obedient, and particularly that of
the peristaltic motion of the guts, wh'ch cause
that e.xcretion, I saw might be restrained.
Therefore, after my first eating, which was
seldom till noon I constantly went to stool,
whether I had any motion or no, and there
stayed so long that most commonly I attain-
ed my errand; and by this practice in a short
time the habit was so settled that I usually
feel a motion; if not, I, however, go to the
place as if I had and there seldom fail (not
once in a month) to do the business I came
for. This is one of the greatest secrets I
know in physic for the preservation of health,
and I doubt not but it will succeed both in
you and your son, if with constancy and pa-
tience you put it into practice."
Locke's remedy for constipation, if this jazz
age could take time to try it out, would be
found better than nujol, agarol, phenoltha-
lc!n, and the whole brood of intestinal lubri-
cants and peristaltic activators.
After all, every organic thing is but the
equation of its environment, and what we call
heredity is but environment oft-repeated un-
til crystallized, so to speak. So in all our
bodily functions we are just bundles of hab-
its, good or bad. This was Locke's concep-
ttion of life, of living.
So, too, thought Solomon the many-wived
and much-concubined splendid King of the
Jews; of whom the Queen of Sheba was sat-
isfied that not the half had been told. David,
I suspect, besides the burden of his kingly
duties, trod rather too much the primrose
path of dalliance to devote as much time to
the training of his son as he should have given
h'm; but Solomon had enough philosophy in
his make-up to say that if you would train up
a child in the way he should go, when he was
old he would not depart from it. That is to
say, that we do what we are in the habit of
doing, and that we can get into good habits
or bad habits by long-enough repetition of the
act.
Some year.^ ago, before some form of gaso-
line cart became the ubiquitous mode of
travel, I was called out into the woods one
Sunday afternoon to see an old lady with a
Colles' fracture on one side and a badly
bru'sed and wrenched elbow on the other.
"How did all this happen?" I asked. "Jerry,"
she said, "was taking m? to meeting with the
mule and buggy; the mule got scared, dashed
over a stump and pitched me out." She was
suffering acutely. By way of reviving her
spirits, I said, "If I were Henry, and you
couldn't do any better than this, I wouldn't
let you go to meeting any more." She saw
no semblance of humor in my remark, but
with an intense air of religious longing, she
sadly sighed, "I couldn't get along without
my meeting!"
That's the way the medical men in the
bounds of the Tri-State ought to feel about
it. Pilany of them do, and they are all the
better for their habit. What of the others?
Let them come along and meet with us every
yeir. It is the finest way in the world to
cure yourself of that dulling constipation of
ideas. Make up your minds to try it — form
the habit.
April, 1929
SOUTHERN MEDICINE AND SURGERY
Southern Medicine and Sur§erp
j Tri-S(ii((' Mcdiciil AsMtciadiin (if (he CMnilinas and \°ir<|iiiia
Official Organ OF 1 ,, ,. , ^. . , ,. ,, „, , .. ^. ,, ,,
I Slcdical .So! icl.v (it (hi- Slate <>l Nortli Carolina
James M. Xorthington, M.D., Editor
Department Editors
James K. Hall, M.D Richmond, Va
Frank Howard Richardson, M.D Black Mountain, N. C.
W. M. RoBEY. D.D.S Charlotte. N. C.
J. P. Matheson, M.D -v
H. L. Sloan, M.D.
C. N. Peeler, M.D I Charlotte, N. C. -.
F. E. Motley, M.D f Eye,
\. K. Hart. M.D...._ I
F. C. Smith, M.D.
The Barret Laboratories . _Charlotte, N. C
O L. Miller, M.D. Gastonia, N. C
Hamilton VV. McKay, M.D Charlotte, N. C..-
John D. MacRae, M.D Asheville, N. C —
Insrpii A. Elliott, M.D. „ Charlotte, N. C —
"Pa! r H Ringer, M.D .■\sheville, N. C _
C.Fo H Bunch, M.D Columbia, S. C. -
Feperick R. Taylor. M.D. High Point, N. C. .
Henry J. Lanc.ston, M.D Danville, Va
Chas R. Robins, M D. Richmond, Va.
Olin B. Chamberlain, M.D
i.ouis L. Williams, M.D
V.'.RIOUS .^riHORS ...
....Charleston, S. C
Richmond, Va
Human Behavior
Pediatrics
Dentistry
Diseases of the
Ear, Nose and Throat
^Laboratories
Orthopedic Surgery
Urology
Radiology
..Dermatology
Internal Medicine
. Surgery
-Periodic Examinations
_ Obstetrics
Gynecology
Neurology
Public Health
Historic Medicine
The President of the Tri-State
Cyrus Thompson — Family Doctor, Scholar,
Philosopher
It was fitting that the Tri-State IMedical
Association of the Carolinas and X'irginia
should make the choice it did for its presi-
dency.
On many hands we hear the lament, the
old order changeth; particularly and insist-
ently doleful are the jeremiads of those who
mourn the passing of the family physician.
Wherever we look we see the efficiency man;
practicality is lauded from our rostrums and
in our papers and magazines in the language
(if the go-getters.
The pernicious inlluence of these agencies
on the med'cal profession is manifest. Those
in tlie profession most widely quoted, courted
and advertised who have accumulated vast
wealth are more often envied and emulated
for and in their successful financial methods,
than for their contributions to Medicine. Take
account of the subjects which prominent
doctors bring up for discussion in clubs, din-
ing rooms and smoking cars, and note the
jnoportion which tells of how much money
is being made by the speaker or somebody
else. Compare articles in the current monthly
medical literature with old copies of the
Charleston Medical Journal, the Virginia
Medical Monthly, or the Boston Medical and
Surgical Journal, and see how poorly the aver-
age medical article of today compares in
clearness of expression — to say nothing of the
grace and elegance which should characterize
the writings of members of learned jjrofes-
sions — with one written 50 or 75 years ago.
Ur. Cyrus Thompson is a living refutation
of the contention that the office of family
doctor has fallen low, and a living rebuke to
those whose financial and cultural aspira-
tions are those of the professional promoter.
Last year Dr. Thompson rounded out a
half-century of service (what a pity that
boosters rob our richest words of all mean-
ingl ) to his people in the capacity of family
floctor, guide, philosopher and friend. This
is not a statistical account, so no enumera-
ti(m will be attempted of the babies he has
brought into the world and through measles,
whooping cough, dysentery, malaria and ty-
2 60
SOUTHERN MEDICINE AND SURGERY
April, 1029
phoid, to fine, glowing manhood and woman-
hood; of the extra years of happiness and
usefulness in his community because of his
wise and patient endeavor; of the bodily ease
and mental comfort he has afforded as he
made smooth the downward course he was
powerless to stay.
Dr. Thompson enjoyed the opportunity,
rare in the years soon succeeding the War
between the States, of being well instructed
in the classics before entering on his medical
studies; and no one who knows him can
doubt that he can say with a beloved teacher,
"From my youth all along to my declining
years, literature has been the delight of my
happier hours, and the precious solace of my
days of sore affliction." From his home in
Jacksonville he has taken mental excursions
at will to Rome and .\thens and communed
with the shades of Cicero, Virgil and Marcus
Aurelius; of Homer, Socrates and Plato. He
has delighted in the sheer loveliness of Keats,
loved with Byron and Shelley, laughed
and wept over Dickens, learned history and
life and methods of setting them forth from
Carlyle, and enacted dark tragedies with
Shakespeare; but his boon companion has
been Michel de Montaigne, to whose deft
comments on human life our new president
owes much of his own geniality and felicity
of expression; indeed, one might venture to
say that ^lontaigne holds next place in Dr.
Thompson's affections to the King James Ver-
sion— that matchless bit of literature on
which attempts at improvement are made by
those who would paint the lily.
Dr. Thompson is a member of the State
Board of Health; he has been president of
the Medical Society of his state; he has been
North Carolina's Secretary of State; but the
office which most delights his heart and stim-
ulates his pride is that of family doctor to
his people in Jacksonville and rural Onslow.
Many have been the attempts to induce him
to move "to a better location." He says
there is no better location, in fact none so
good. He knows his people and loves them;
"they know me" — these are his words spoken
many years ago — "and look with charity on
my faults; where could I hs as useful and
find such happiness"?
The family doctor who exerts himself in
promoting the health and well-being of his
families as does Dr. Thompson will not find
himself forsaken though a specialist set up
at every cross-road. He who makes friends
with the mighty geniuses, dead and gone
these hundreds or thousands of years, will
feel no need of a weekly or semi-weekly even-
ing at a picture-show; and his gregariousness
will manifest itself only at intervals — not con-
stantly, as is the case with negroes and mules.
Let us each take as much as we can appro-
priate to our uses from this living lesson;
the more of it we can assimilate the more
useful and the more happy will we be — and
the more successful; for success is but an-
other name for happiness.
Will President Hoover Tell Us How.?
In public health the discoveries of science have
opened a new era. Many sections of our coun-
try and many groups of our citizens suffer from
diseases the eradication of which are mere mat-
ters of administration and moderate expenditure.
— Hoover.
The paragraph above quoted is from our
President's Inaugural .Address, as sent out by
the Associated Press. It is not an isolated
statement taken out of its setting; it is every
word said on the subject.
Of course the words "administration" and
"moderate" admit of wide interpretation; but,
considering all this, we must regard the Pres-
ident's statement as rhetorical only.
Taken at its face value, the pronounce-
ment is an indirect, but caustic, criticism of
Public Health officials. Surely they are set
up as administrators, they draw salaries as
administrators; and funds are placed in their
hands from which they can make moderate
expenditures.
It is no new thing for a layman to make off-
hand dogmatic assertions as to how health
problems which have been puzzling the best
minds in medicine for decades can be solved
overnight.
The discoveries of science have placed in
our hands means of eradicating many dis-
eases— provided we could persuade or force
all the people to accept these means. Per-
suasion is much hampered by the activities
of Bernaar ]\Iacfadden (fancy spelling not
guaranteed), the Eddyites, chiropractors, ct
al., duly licensed and touted by legislators.
Our general intelligence level is too low to
admit of the compulsory putting into effect
of all the preventive measures with which
scientific investigators have made us ac-
quainted. Witness the thousands of deaths
April, 1029
SOUTHERN MEDICINE AND SURGERY
261
from smallpox in these United States each
year.
In 1798, Edward Jenner. a small town doc-
tor in England, published to the world a
cheap and harmless method of preventing
smallpox. (Previous to that time the Turks
and other Eastern peoples had inoculated
with the virus of smallpox itself — about 25
per cent as dangerous as the disease acquired
in the usual way. It was this method that
Lady ^Montague introduced into England, and
which came thence to the Colonies.) There is
evidence that within ten years after Jenner
published the results of inoculation with cow-
pox Bavaria had put into effect a compulsory
vaccination {vacca=ci cow) law; all the Ger-
man states soon compelled vaccination and
revaccination of their soldiers — a fact which
contributed largely to their successful war-
V. aging; and, since 1874, the German Empire
has enforced a law requiring vaccination be-
fore the end of the second year and revacci-
naton at the 12th. With what result? For
many years not a case of smallpax has oc-
curred in the person of a native of Germany;
while our death rate from the disease is the
hghest of any country in the world, save
only India! In 130 years we have been un-
able to induce our people to be protected
against a disease which is loathesome. costly,
dangerous and disfiguring; when the means
at hand is, by the most ready [iroof. cheap,
harmless and effectual.
If the President knows his statement to be
true, he must necessarily know in detail how
the diseases to which he refers may be eradi-
cated; and it is certainly his bounden duty
to give this information the widest possible
publicity.
We ask that he please tell us how.
A .Secretary of Health at Washington:-'
Cver a number of years there has been
considerable agitation for the creation of a
Department of Health, headed by a Secre-
tary in The President's Cabinet. Nearly
twenty years ago a prominent club-woman
claiped her hands and raised her eyes in
rhapsody in telling us how "wonderful' it
would be; nor would she stop at that; there
must be, also, an indejiendent, co-equal De-
partment of Babies. When we mildly sug-
gested that a butler, throwing wide the door
and announcing "The British Ambassador";
"The Secretary of Babies" would certainly
add to the merriment of nations, the rebuke
was ready and severe: that, too, would be
"wonderful."
Recently the American iNIedical Editors'
Association has sent out letters urging that
there should be such a Department of Health.
From our copy we could ascertain no reason
advanced beyond the argument that the pres-
tige, or dignity, or something of the sort, of
the profession of medicine would be thereby
enhanced.
This journal is energetically opposed to the
creation of any such office. We have three
Surgeons-General, who, with the President's
personal physician thrown in on occasion,
should satisfy the most requiring. Swank
they give us, no end.
We have not been able to obtain recent
official figures giving the proposition of our
whole population which derives its livelihood
from public office, but, inquiry among the
best informed of our acquaintances bolsters
our own opinion that figures have been com-
piled showing that the ratio is about that of
our grape-juice econimist's famous shibboleth
— 16 (workers) to 1 (office-holder).
Th''s journal is heartily in favor of reduc-
ing, rather than multiplying the number of
public officials. If the nation were to vote
tomorrow on this ticket and voting were com-
|)ulsory:
1. For incrcasinc the number of public officials
10 per cent,
2. For fiecreasins the number of public officials
25 per cent;
our vote would be cast without hesitation for
Xo. 2.
This journal believes firmly that we are
entirely too much governed, and that entirely
too large a proportion of that too-much gov-
ernment comes from Washington. It also
recognizes the fact that it is far easier to
create an office than to abolish it. When a
group of men and women become attached to
the public pay-roll, it is usually "from now,
on '; and usually the ranks are heavily re-
cruited at short intervals by "deserving"
henchmen and henchwomen.
With the aid of the County and State Med-
ical .Societies, our County and State Boards
of Health can attend to our public health
needs adequately. .Mecklenburg County
knows her own health problems better than
i62
SOUTHERN MEDlCtNE AND SURGERY
April, 1929
Buncombe knows them, and is more capable
of solving them; and Buncombe knows and
solves hers far better than Mecklenburg does
or could. Dr. Charles OH. Laughinghouse
knows North Carolina's health problems bet-
ter than any Secretary of Health at Wash-
ington could ever know them.
This mania for creating more and more of-
fices, departments and bureaus: and for vest-
ing all px)wer in the Federal Government has
carried us much too far already. The burden
of proof lies with anyone proposing the crea-
tion of a new office, attaching even one more
person to the public pay-roll.
We should set ourselves firmly against the
enfeeblement of County and State, and teach
the younger generation the principle of local
self government as applied to all affairs, pro-
fessional and lay.
CORRESPONDENCE
Spartanburg, S. C,
March 11, 1929.
My Dear Doctor Northington:
In reference to the Tri-State meeting in
Greensboro, I think it was a yery fine meet-
ing— splendid papers, well discussed. The
only criticism that I have to make is that I
think that two days would be sufficient in-
stead of three to hold a meeting, and have
heard several doctors express themselves in
the same way.
With kindest regards, and best wishes, I
am,
Yours very truly,
H. R. BLACK.
Norfolk, Va.,
March 12, 1929.
Dr. James M. Northington, Sect.,
Tri-State Medical Association,
Charlotte, N. C.
Dear Doctor:
I was much interested in the Greensboro
meeting and feel that the meeting as a whole
was a real success and that those in charge
should be congratulated.
Since you have asked the question, I am
glad to take the opportunity of offering what
I consider some constructive criticism of this
meeting.
In the first place, the program was too long
and required a great miny men who had
prepared papers to leave the meeting without
having the opportunity of presenting their
work.
In the second place, there was too little
time devoted to discussion of the papers, to
the extent that an individual who wished to
discuss a paper felt almost like a criminal
when he asked to be recognized on the floor.
Third, the clinics consume entirely too
much time on account of the fact that they
were presented at a time when papers should
have been read and discussed. Clinics natur-
ally are called on time because of clinical
material.
I believe the following suggestions are not
out of place:
1. That in the future no papers be sched-
uled in the morning or afternoon at the time
that clinics are to be held.
2. That there be a time limit of 45 min-
utes for clinics.
3. That each paper presented should have
at least 30 minutes set aside on the program
for its presentation so that a paper ranging
from fifteen to twenty minutes could have a
free discussion of ten to fifteen minutes there-
after.
Again I wish to say that I enjoyed the
meeting and am looking forward to another
next year.
With kind regards, I remain.
Sincerely yours,
F. C. RINKER.
.Allowance had been made for the usual
proportion of those on the program to fail to
appear. Holding essayists and discussers
strictly to the time limit, with the time made
available by absentees added, would have
given time for the whole program. However,
while the meeting was in progress, the Sec-
retary was making notes for use in arranging
future meetings, and one of these was to
allow 30 minutes for each paper, with a view
to encouraging free discussion. Very soon
these notes will be published with request for
further suggestions. The ideas and sugges-
tions sent in so far have been most valuable.
— T/ic Editor.
April, 10i9
SOUtHERM MEDtCtNE AND StJRGERY
i6i
Miscellany
Resolutions on Dr. J. W. McNeill
Ur. James William McNeill, distinguished,
faithful and beloved physician; public spir-
ited, unselfish Christian gentleman and citi-
zen; kind and hospitable friend; for more
than fifty years a faithful and devoted mem-
ber of the First Presbyterian church, died at
his home in Fayetteville N. C, on January
7, 1929. Nature smiled in all her glory with
not one cloud to be seen in the beautiful sky
on the morning of his death. When he start-
ed out on his daily professional routine, he
was suddenly called to the reward that await-
ed him in the Great Beyond, coming in pos-
session of the daily deposit that he had in
store in eternity with the assurance that God
is just and will reward his laborers.
Dr. McNeill was born near Fayetteville,
N. C, at "Ardulussa," the beautiful home of
his family, on June 28, 1849. He graduated
from Bellevue Hospital Medical College in
1876, and in May, 1876, he began the prac-
tice of medicine and joined the North Caro-
lina Medical Society, of which he was elected
president in 1892. At the time of his death
and for many years prior thereto, he was the
health officer of Cumberland county. Well
might we take to heart the example set by
him as a pattern for our lives, and in that
spirit we should strive to remember him for
to such as he does the practice of medicine
owe its encomium, "The Noble Profession."
After working his way through school, Dr.
McNeill began the practice of medicine under
conditions that do not e.xist today. He was
easily one of the most prominent physicians
in North Carolina. As a citizen of Fayette-
ville and Cumberland county, he was one of
the leaders. Though his interest was univer-
sal, his chief goal was to go about relieving
the suffering, and his treasures were stored
with those who suffered. For more than fifty
years in the general practice of medicine he
gave untiring, faithful and loyal service to his
patients, never counting the cost to himself
in time or money, but thinking only of what
he might do for the alleviation of the pain
and suffering of the sick and afflicted.
Throughout all this time no man ever [as-
sessed a happier spirit or more sanguine tem-
perament. He loved everybody in the world
and his very being was a constant spring of
good will, good cheer and good fellowship. In
the death of Dr. McNeill the profession has
sustained a loss that will be difficult to re-
store. There could be no greater objective,
no greater goal in the life of any young man
in the profession than to strive to fill this
vacancy — an inspiration, a vision, a dream!
Therefore be it resolved. That the Cumber-
land County iMedical Society express its sin-
cere and heartfelt sympathy for his loved ones
in their sorrow, and that a copy of this reso-
lution be spread on the offiicial minutes of
the Cumberland County Medical Society, and
mailed Southern Medicine and Singer v for
publication.
Respectfully submitted,
J. F. Highsmith, Sr.,
W. S. Jordan,
Col. David Baker,
COMMITTEE.
Withal, Wakley [founder and first editor
of The Lancet — Editor. | was a wit and could
be engagingly droll when he desired. To my
mind ore of the prize passages concerns a
certain Dr. James Johnson who changed his
place of residence. The news was published
in 7 he Lancet under the heading: "Pathologi-
cal Intelligence — Metastasis of an Extraordi-
nary Fungus." — Dr. Thurston Welton in
Long Island Medical Journal.
in the cause of Verity: many from ignorance of these Maximes, and an inconsiderate
Zeal unto Truth, have too rashly charged the Troops of Error, and remain as Trophies
unt(j the enemies of Truth.
Sir Thomas Browne: Keligio Medici.
264
SOUtHERN MEDICINE ANt) SURGERY
April, 1925
DEPARTMENTS
HUMAN BEHAVIOR
James K, Hall, M.D., Editor
Richmond, Va.
WiLLEBRANDTING IN RaLEIGH FaILS
The Supreme Court of the State of North
Carolina has reviewed on appeal the case of
Dr. Albert Anderson, superintendent of the
State Hospital at Raleigh, and the conclusion
of fhe matter is, in the opinion of the high
court, that the case should not have gone to
the jury. The result is that Dr. Anderson
has been cleared entirely of the charges. In-
ferentially, is it not true also that those en-
gaged in the prosecution have been rebuked?
The fair-minded and intelligent citizens of
the state who are acquainted with the great
work done in that hospital under the leader-
ship of Dr. .\nderson know that he is one
of the most useful servants of the state. He
has made of the hospital on Dix Hill one of
the best institutions for the treatment of
mental diseases in this country. The pro-
nouncement of the court is a recognition of
that fact. The opinion of the court e.xpresses
also the feeling of the better people of the
state, both in regard to the conduct of Dr.
Anderson, and i n regard to the methods
adopted by his prosecutors to debase him
and to oust him from office. From beginning
to end the investigation constitute an out-
rage.
The charges should have been carried be-
fore the oard of Directors of the hospital.
The Governor, the Attorney-General, the
District Solicitor, the Commissioner of Pub-
lic Welfare, and even Dr. Crane, of the fac-
ulty of the University of North Carolina,
could have occupied seats at such a hearing.
If those high officers of the state had reach-
ed the conclusion that the investigation was
biased, or that it lacked in thoroughness, then
the matter could have been taken into the
Superior Court. The Supreme Court's deci-
sion confirms the expressed opinion of former
Governor ^McLean — that Dr. Anderson was
convicted upon frivolous charges. Yet the
defense has cost Dr. .'\nderson twelve or fif-
teen thousand dollars, and there is nothing
at all frivolous about such an amount of
money even to a man as rich as some people
think Dr. Anderson is.
The cold fact is that those who undertake
to deal with the mentally abnormal subject
themselves eventually to the dangers of as-
sault— assaults upon their bodies and upon
their motives and their characters. The his-
tory of psychiatric work in North Carolina
certainly, and throughout the country prob-
ably, is confirmation of that statement. Crit-
icism originating in a mind occupied by high
motives is beneficent and helpful, but spring-
ing from any other source criticism is malig-
nant and destructive.
SURGERY
Geo. H. Bc.nch, AID., Editor
Columbia, S. C.
Spinal Anesthesia
Anesthesia is of paramount importance to
the surgeon for operative work must be done
under some form of anesthesia. General an-
esthesia has progressed wonderfully since
"ether frolics" were social functions and Long
of Georgia recognized the anesthetic qualities
of ether and in 1842 successfully removed a
tumor under ether anesthesia. We of the
present day can scarcely realize the revolu-
tionary importance of Long's discovery. In
1884 the history of local anesthesia began
when Roller, recognizing the anesthetic quali-
ties of cocaine, suggested that it be used for
surgical purposes. From the application of
the drug to mucous membranes infiltration
anesthesia came, to be followed by nerve
block and regional anesthesia. In 1894 Corn-
ing published an account of his experience
with injecting the anesthetic solution into the
spinal cord in the region of the cauda aequina
and Bier in 1899 published the record of a
number of operations done by anesthesia from
this method. In general surgery cocaine has
been replaced by novocaine and other less
toxic derivatives.
Largely because of the immediate and pre-
cipitate fall in blood pressure after the injec-
tion of the solution spinal anesthesia has not
met with a cordial reception from the medical
profession. Although anesthesia was satisfac-
tory after injection into the lumbar canal the
method was considered too dangerous and was
abandoned except by Babcock and a few
other devoted spirits. Sporadic reports from
Apfit, m
§6ttttEkK iiEblClNfe AND StRGfeRV
M
rhem are found in the literature. Burrus of
High Point in Southern Medicine and Sur-
gerv, yiay. 1927, after an experience of 100
cases advocates the method in selected cases.
The spinal anesthesia number of the Ameri-
can Journal of Surgery, December, 1928,
treats the whole subject comprehensively giv-
ing 12 special articles and an editorial on it.
The alarming fall in blood pressure in spi-
nal anesthesia has heretofore been combated
by giving adrenaline solution intravenously.
Because of the well known transient thera-
peutic effect of this agent the services of a
skilled man were necessary during anesthesia
to take the blood pressure frequently and to
administer adrenaline when necessary. Now
ephedrine has been isolated from ma huang
which has been well known in Chinese medi-
cine for 5,000 years. Ephedrine, when given
hypodermically several minutes before the in-
traspinal injection, by stimulating the sym-
pathetic nervous system raises the blood pres-
sure and maintains it for two hours or longer
so that after its administration there is no
alarming fall in blood pressure in spinal an-
esthesia. This makes the method safe and
we predict for it a constantly increasing pop-
ularity as its many points of advantage over
general anesthesia become better known.
Our experience with spinal anesthesia began
about ten years ago but because of the great
drop in blood pressure -we practically quit
using it until about six months ago. Since
this time we have used the Pitkin method in
about 75 cases with entire satisfaction. After
acquiring the proper technique of adminis-
tration we believe with Pitkin that the method
is safe, in many cases much safer than ether.
If the shoulders be higher than the pelvis the
cerebro-spinal tluid gravitates into the space
about the cauda aequina and distends the dura
so that one is not so likely to get a dry tap.
One should familiarize himself with one solu-
tion and with one method rather than experi-
ment with several. A dry tap with the shoul-
ders higher means that the needle is not in
the subarachnoid space. Fluid can always be
obtained if the needle is properly placed, and
if the soluti(m is really injected into the sub-
arachnoid space one gets anesthesia in every
case.
Under spinal anesthesia there is absolute
relaxation; respiration is quiet and unlabored.
There can be no straining or evisceration. A
hypnotic is given before injection and the
patient often sleeps through most of the oper-
ation. Injection should be made between any
two lumbar vertebrae and should always be
be'ow the termination of the cord and the
beginning of the cauda aequina. The anes-
thetic solutions of Pitkin are either heavier
or lighter than the cerebro-spinal tluid so that
the height of anesthesia can be regulated by
elevating or depressing the head. One should
be sure not to get confused about which solu-
t.on is being used, for if the solution is lighter
than the cerebro-spinal fluid, the head is
raised too much, or the patient inadvertently
sits up, death will result.
We have observed but few after effects from
spinal anesthesia. Headache does not often
occur and soon passes off. Catheterization
is not more often necessary than after
ether. One elderly patient had an inconti-
nent bowel for four or five days. Post-oper-
ative distention is less than after general an-
esthesia, spinal anesthesia being the most ef-
fective way of treating paralytic ileus. Res-
piratory and kidney complications that occur
are independent of the anesthesia.
Spinal anesthesia we find peculiarly adapt-
ed to work in the pelvis and lower abdomen.
Hysterectomy, whether vaginal or abdominal,
appendectomy, herniotomy and prostatectomy
are operations readily done under it. We
have found it satisfactory in several cholecys-
tectomies, in two resections of the stomach
and in an abscess of the pancreas. We are
sure there are positive indications for it and
think that perhaps in the near future it may
become the anesthetic of choice for most ab-
dom'nal surgery.
UROLOGY
Fur this issue, Lawrknci. T, Phicf., M.D.
Richmond, V'a.
The Problem of Sexual "Neurasthenia"
Every practitioner of medicine, from time
to time, has some patient who is disturbed
about h'mself from a sexual standf)oint, or
has a multitude of vague symptoms that are
due to sexual irregularities. There is no class
of patient who has been so much abused from
lack of recognition and of knowledge of how
to manage the case. It is not an uncommon
thing to see a young adult on the verge of
a mental breakdown, who has been through
the hands of many general practitioners, a
i66
SOUTHERN MEDICINE AND SURGEftV
April, 19i9
neurologist and probably a sanatorium, where
some very high toned diagnosis has been made
and much treatment given by way of mas-
sage, hydrotherapy, exercise, tonics and many
conversations. Many hundreds of dollars
have been expended, the family terribly dis-
turbed, and the patient is (mly the more dis-
couraged and despondent. An example fol-
lows :
Young man, 26, son of a most aristocratic
family, who had been raised in a broad and
commonsense manner, with the possible ex-
ception of over indulgence in money. His
habits would be taken as better than the
average — does not use alcohol, smokes cigar-
ettes moderately, never participated in athlet-
ics, was an average student in school and col-
lege. This young man stated that because of
remarks made by his boyhood associates, his
sexual desires were excited at the age of 14,
but because of fear of contracting a venereal
disease he had refrained from intercourse un-
til he was 18. He learned from his associates
about masturbation at this time, and practic-
ed the act from two to ten times a week until
he was 18, at which time he undertook to
break himself of the habit; but, because of
premature ejaculations and night emissions,
he did not seem to be able to feel satisfied,
and after six months of strenuous effort on
his part he returned to the habit of mastur-
bation, but not as frequently as formerly.
After 18, intercourse was practiced about
twice a year with unsatisfactory experiences.
At 20 he found that unless he masturbated
upon retiring his sleep would be restless and
he would get up in the morning feeling tired
and worn out, invariably having had an emis-
sion. He found that he was unable to con-
centrate his thoughts. His association with
ladies was very difficult because of embarrass-
ment which he could not control. His appli-
cation to reading or to individual work of
any kind was most difficult because of the
inability to concentrate his thoughts. He
became very restless, never being contented
to be in one place. With a very strenuous
effort he again refrained from masturbation
and made h'mself seek companionship with
friends of the family. He met a girl he
thought he 1 ked, and during their first year
of friendship his general viewpoints changed,
he became much more steady in his acts, his
power of concentration improved, and he ac-
cepted a position in a bank.
His visits to this young lady would be
three or four times a week, and upon each
visit ungratified sexual excitement would be
experienced and nocturnal emissions would
invariably occur the night following his visit.
He begun to observe a clear meatal discharge,
particularly after going to stool, and in the
mornings. His restlessness and lack of in-
terest in his position became more marked;
it was with the greatest effort that he could
apply himself to his work, and he frequently
found himself forgetting to do some of his
work. He could not look any one in the eye
during conversation, and ultimately gave up
his position because he felt that his manner
was noticeable. When he would see some of
his fellow workers engaged in conversation he
suspected they were talking about him, and
he gradually retired from associating with any
one, including his girl friend. He was treated
by his family physician for nerve depression,
he was sent out on a farm for six months,
was sent to several diagnosticians, and finally •
spent two months in a sanatorium for nerv-
ous persons. In the meantime he had lost
considerable weight and had arrived at a point
that he believed that he had an incurable
disease, in spite of all of the examinations and
diagnoses of various kinds, but functionally
his examinations were essentially negative.
He had never admitted masturbation and the
question of his irregular sexual life apparent-
ly did not occur to any of the physicians.
A congested hypertrophied verumontanum
was found, which responded beautifully to ap-
plications of silver nitrate solution, and dur-
ing the treatment, psychoanalysis was carried
out and a gradual replacement of sane ideas
and thoughts, with physical occupation. The
results being that after three months there
was a complete re-establishment of a normal
sensible person. The normal sexual act being
performed once a month with no irregulari-
ties of any kind.
This is an aggravated case of a great num-
ber of sexual neurasthenics that a urologist
sees frequently.
A congested verumontanum is always
found in a masturbator, also in chronic pos-
terior urethritis of long standing, and after
persistent withdrawal at intercourse, the use
of irritating injections and repeated instru-
mentations. The verumontanum being large-
ly composed of blood vessels, it can easily
become chronically congested, which conges-
April, 19i0
SOUTHERN MEDICINE AND SURGERY
i6l
tion may increase sexual desire. The sensory
nerve supply is very abundant, and relief is
obtained by ejaculation which temporarily
empties the blood vessels and relieves the con-
gestion.
["Congestion" is an easy diagnosis, not
readily susceptible of proof or disproof. We
greatly fear this patient is neurological as
well as urological, and confidently predict
that the neurological element will become
manifest. — EDITOR of the Journal.]
HISTORIC MEDICINE
For this hsur. Robert E. Seibels, M.D.
Columbia, S. C.
Theophrastus Renaudot
.'\ntimony was the center of a debate in
medical circles which became exceedingly bit-
ter, and the history of the controversy is
associated with many interesting people. The
metal was known as stibium and was e.xten-
sively used as a medicine in the sixteenth
century by I'aracelsus, but its wider medical
use was brought about by the publication of
Currus Triumphalus Antimonii which was
written by Johann Tholde, a Thuringian
chemist writing under the pseudonym of the
monk Basil Valentine. The author of this
work states that he observed some thin pigs —
possibly the ancestors of our own razorbacks
— which had eaten food containing antimony
and thereafter became very fat. Encouraged
by the result of this accidental experiment,
he tried its effects on some monks who, as a
result of prolonged fasting, had become very
emaciated and the result was even more
astounding— they all died! Stibium was re-
placed as a name by .Antimoine, on account
of its antagonism to monks. It is difficult
to discover on what therapeutic grounds the
metal was used as, like many of the drugs
of the time, its virtue seemed to be varied.
Its chief interest to us lies in the famous ver-
ba! duel between Guy Fatin and Theophras-
tus Renaudot, physicians of Paris.
Patin was a physician of the old school and
belongs as nearly as we can classify him to
the latro-Physicists. He was a member of
the Faculte de IMedicin and became its Dean
in 1050. He seems to have been incapable
of .seeing good in anything which had not
the stamp of time; thus though he refers to
Harvey's De Motu Cordis, it is only in con-
nection with the binding of the book, and
not its contents. Antimony was to him a,
poison and he could not believe that a drug
which was capable of producing death could
possibly benefit the human constitution.
Renaudot is one of the most interesting fig-
ures in medical history. He was born at
Loudon about 1586 and received the degree
of Doctor of Medicine at Montpellier in 1606.
He became acquainted with the Marquis de
Tremblay (Joseph Francois Leclerc) more
usually known as Pere Joseph, Cardinal Rich-
elieu's familiar and secretary, and apparently
the only human being in whom the wily Car-
dinal had unbounded confidence. In 1612
Renaudot took up his residence in Paris and
brought with him the strongest recommenda-
tion from Pere Joseph to Richelieu. It is
not surprising then to find that he received
the appointment of Physician-in-Ordinary to
Louis XIII. Under the King's protection
and with his permission, Renaudot establish-
ed a Bureau of Addresses, or sort of employ-
ment agency, and to this he added a pawn-
shop, and, most important of all, a news-
paper— the first number of which appeared
on May 30, 1631.
The paper consisted of two numbers week-
ly, one entitled Gazette and the other Non-
velles Ordinaires. Supplements were issued
from time to time containing individual nar-
ratives, court news, and offcial documents
communicated by Richelieu, and it has been
asserted that the King himsdf was an occa-
sional contributor. The Gazette had foreign
correspondents in Ireland, Scotland and Eng-
land.
In addition to these activities, Renaudot
continued to practice medicine and brought
in physicians from the University of Mont-
pellier to assist him in the distribution of
certain secret remedies. He established a
free clinic, and invited persons of a scientific
turn of mind to discuss subjects announced
beforehand in his advertisements, and printed
reports of these discussions in his paper.
Renaudot ran afoul of the Faculte de Med-
icin in Paris, but whether because he was
not a member of it or whether because he
used .Antimony is not clear. Antimony had
been condemned not only by the Faculte but
in 1566 by the highest legal authority, the
Parliament. Patin led the attack again.st
Renaudot and lost no opportunity to ridicule
him, terming him a "nebulous braggart" and
"The (Jazeteer," and went to great trouble
to belittle him and express his contempt for
i6i
SOtJtttfiftM MEDICINE AND SURGERV
April, 19ia
his methods of treatment. Certainly in Guy's
case there could have been but little profes-
sional jealousy, as he seems to have had all
the honors for which he wished and a more
than sufficient incorne: his hatred of Renau-
dot was based not only on his use of anti-
mony but also because he was graduated from
Montepellier. Patin felt that the faculty at
that university had granted many degrees ir-
regularly and claimed that their fams was
due to their knowledge of Arabic medicine,
his pet aversion. The argument culminated
in the trial of Renaudot and his friends and
in December, 1643, they were forbidden to
hold meetings. On Renaudot's appeal to a
higher court (the Parliament) his appeal was
rejected and, in addition, his pawnshop was
his Gazette and conduct his registration of-
fice.
One of the most interesting associations
with Patin is his friendship for Gabriel
Naude. Naude was a physician born in Paris
in 1600 but did not practice medicine and
devoted h'mself entirely to books, becoming
first librarian to the President de Mesmes,
then librarian and secretary to Cardinal de
Bagny and at his death took a similar posi-
tion with Cardinal Barberini and afterwards
with Richelieu. He assumed charge of the
wonderful collection of Mazarin and was the
principal purchaser and inspired genius of
the library forming the College de Quatre
Nations. Naude's method of buying books
was certainly original. He bought them in
quantities by weight and measure instead of
by title and volume. His method was to offer
the dealer so much per pound or foot for a
row of books and to pay no apparent atten-
tion to individual volumes and it may well bs
that the famous Mazarin Bible was bought
in this manner. It would be interesting to
know what Naude would think of the recent
purchase of a "forty-two line Bible" for Har-
vard University for $120,000.00.
OBSTETRICS
Henry J. Langstoh, B.A., M.D., Editor
Danville, Va.
Long Labor — Its Dangers
The so-called long labor test has been prac-
ticed since the early days of the human race.
In conservative practice this test still holds
sway. The resulting human suffering and
death to babies and mothers afford a sad
tommentary on our scientific knowledge and
skill. In many cases the woman stays in la-
bor for days. She comes to the end of labor
exhausted. There are many cases which
terminate with babies dead; in other cases
the molding of the head produces destruction
to brain tissue and blood vessels which causes
death to babies within a few days. In other
cases the baby survives and develops epi-
lepsy.
If one studies these cases carefully he finds
himself in the position of realizing that for
a physician to force a patient to go through
the test of long labor is most inhuman. iMany
of our cases of maternal deaths and morbidi-
ties fall in this group. Of course, someone
will say immediately that he has had in his
practice many cases of labor lasting for days
that have come through with live babies and
mothers in fair condition. A very close study
of these cases will reveal conditions in the
pelvis which are almost beyond repair; there
is destruction to the cervix and destruction
to the vagina which bring on symptoms in'
this region of which the patient rarely recov-
ers. We believe that it is reasonably easy
and safe to dispense with all of these long
test cases of labor. So we offer the follow-
ing suggestions and ask that you allow time
to prove or disprove our points:
1. Study the pelvis and birth canal in sucti
a manner as to have at your finger tips knowl-
edge that assures of the exact conditions that
prevail in the birth passage.
2. Accurately estimate the size of baby and
keep informed oi the rate of its growth and
weight.
3. Study the relationship of the baby to
the mother regarding the weight.
If we have these three things clearly be-
fore us and there is any disproportion be-
tween the baby and the birth canal, then we
should ask the questions;
If the patient goes into labor how long will
it take for the cervix to be dilated?
.After the cervix is dilated how long will it
takj the baby to pass through the cervix and
how much will be required of the uterus to
force the head through the vagina?
If we have these questions well in front
of our minds, and can answer them by saying
that the head will not have to go through a
very long period of molding and the soft
parts will not unduly resist the passage of
baby, then we can say with certainty that we
will not have to put this patient through 4
April, 1929
SOUTHERN MEDICINE ANi) SURGERY
264
long test of labor.
On the other hand, if, after study of the
birth canal, the patient's weight and the
baby's size, we find there is disproportion be-
tween the birth canal and baby which will
cause much damage to the birth canal:
that the uterus will probably exhaust itself
in an effort to expel baby; that in event we
have to use much external force to bring the
baby through the birth canal, with great risk
to the baby and to the canal; taking into ac-
count the fact that general exhaustion opens
wide the door of opportunity for bacteria to
develop producing infection and probably
death; we are challenged to re-study with an
open mind the horrible dangers of the long
test of labor. I recommend that this chal-
lenge be answered in the following manner:
.After we have studied our cases thor-
oughly and are certain that the patient can
not deliver herself with reasonable speed, re-
st)lve that we will not allow her to reach
term with these disproportions, this to be ac-
companied in one of two ways:
a. -As the patient approaches eight
months and two weeks, at which time we
find the lower uterine segment effaced in
part, the internal os open, the external os
open to the extent that it will admit easily
one or two fingers, we will take the patient
into the hospital and induce labor with a
No. 5 Voorhees bag. The bag can be
Cju'.ckly inserted into the cervix without
much difficulty, filled with sterile water, a
I'ght weight attached after the patient has
been put back to bed, and in from six to
eight hours you will find that the cervix
has been completely dilated. Soon after
the bag is expelled from the cervix the head
will usually follow and delivery can be
effected without the long test of labor.
I). The other way out of a difficult test
of labor is to let the patient go to term,
and when labor has dilated the cervix to
about the size of a silver dollar, deliver by
cesarean section. The next case of preg-
nancy with such patients may require sec-
tion provided there is disproportion between
the birth canal and the baby, or the pa-
tient may prefer to have labor induced be-
fore the hour of term and be delivered by
the birth canal.
Someone will probably say that this is too
dangerou.s — this interference. We will an-
swer this by saying that if the interference is
guided by educated intelligence and that hu-
man sympathy which has as its objective the
bringing the mother safely through labor with
no complications and deliver her an uninjur-
ed baby, — to say nothing of saving the mother
hours and days of agony which it is doubtful
if a man can imagine — the results of inter-
ference will more than satify these persons
who feel that we are doing things contrary
to nature.
M this time we are only opening the door
for discussion on the so-called long test of
labor. We shall in a later editorial discuss
the merits and demerits of this prevailing
practice because many of us see a great many
patients who have had to go through the long
test of labor and whose conditions now do not
comment favorably upon such test.
ORTHOPEDIC SURGERY
0. L. MiLi.EK, M.D., Edilor
Charlotte, N. C.
Unreduced Posterior Dislocation of the
Elbow-
As a rule, dislocation of the elbow is easily
recognized. The deformity around the joint
is characteristic, the olecranon process riding
upward and backward. Occasionally, dislo-
cation is complicated by some type of frac-
ture but, fortunately, this is not often the
case. A diagnosis can usually be made by
manual examination, and immediate reduc-
tion accomplished. It is best, of course, to
reduce a dislocation early, as it is then easily
done and leaves less aftermath of disturb-
ance of joint function. In this day, with the
general convenience of the x-ray machine, all
procedures having to do with the management
of fractures or dislocations should be checked
as early as possible, and as often as neces-
sary by roentgenograms. This practice is
safer both for the patient and the doctor.
.Although the clinical |)icture of elbow dis-
location is rather definite, a few cases, for
one reason or another, get by unreduced. Com-
mon causes of failure to recognize dislocation
are:
1. Confusing dislocation with a supracon-
dylar fracture at the lower end of the hu-
merus.
2. So much swelling being present that
anatomical landmarks are lost, and the sit-
uation not checked by an x-ray.
3. Certain cases not iircsenting iheiiiselves
to a doctor at all.
210
SOttHERN MEblClNfi AND StftGERV
April, i9ii
When an elbow dislocation has gone un-
reduced for as long as three weeks, it is con-
sidered irreducible by closed manipulation. In
this time the strong triceps muscle has con-
tracted to such an extent that the olecranon
fossa can not be made to pass around the end
of the humerus, without evulsing the triceps
tendon or fracturing a joint element. Other
periarticular structures also obstruct reduc-
tion and the olecranon fossa soon fills in with
extraneous material. The elbow joint be-
comes rather fixed in extension and this con-
stitutes a very unhandy position for any
practical use of the arm and hand.
If elbow dislocation has existed for as long
as three weeks, open reduction should be re-
sorted to. By this method only, can one
expect to recover normal function or ap-
proach normal function of the joint. If the
operation does not promote joint function, it
will at least put the elbow in a more favor-
able posture for practical use, and the joint
elements in better relation for a possible
arthroplasty later.
The best operative procedure for the cor-
rection of old, unreduced elbow dislocations
is one described by Campbell and Speed. The
operation consists of a free posterior incision
extending from four or five inches above the
joint to approximately two inches below it,
exposing the triceps tendon and doing a V
tenotomy of this structure; then a subperios-
teal resection of all the structures attached
to the epicondylar ridges and the condyles
themselves. The ulnar nerve should be iden-
tified early in the operation and carefully re-
tracted. After the joint has been exposed
and muscle attachments freed as described,
the olecranon fossa should be cleared of ex-
traneous material and, with gentle traction,
the ulna and radius should be carried down-
ward and forward until they engage with the
articular process on the end of the humerus.
The wound is then closed layer by layer and
the arm dressed in a right angle splint.
Careful passive joint motion should be
started in about two weeks and soon active
motion, this encouraged until the patient gets
the maximum range of motion from the pro-
cedure.
EYE, EAR. NOSE AND THROAT
For this issue, Henry L. Sloan, M.D.
Charlotte, N. C.
Changes in Refraction After Sixty
Many patients are told, when they have
reached sixty years of age, that they will not
again need their glasses changed. This ad-
vice has been given so often that people have
come to look upon this as true. As a result
of this false advice, they often neglect their
eyes after they have reached the good age of
three score years. The truth is that there are
as many changes in refraction after sixty as
during any other period.
During this period many changes in re-
fraction may take place. Hyperopia may in-
crease or decrease. Myopia may likewise in-
crease or decrease, with a greater tendency to
an increase. Astigmatism may increase or
decrease in amount, or the axis of the cor-
recting cylinder may, and often does change,
with the tendency of the axis to change to
the horizontal (inverse astigmatism). "As
to the changes that occur in later life," ac-
cording to Dr. Edward Jackson, "we are
forced to believe that these changes are
chiefly, almost entirely, lenticular. Since
Priestly Smith observed the increased size of
the normal crystallines lens from 25 to 65
years of age," the same author continues,
"and suggested this was probably the cause
of the increasing hyperopia of later life, no
more probable hypothesis has been offered."'
In later life there is a tendency to sclerosis
of the lenticular mucleus, which produces
large degrees of myopia, the "second sight"
of old age. Old age is a period of inactivity.
More genuine pleasure is derived from good
vision than any other one thing. Old pjeople
who cannot read are usually miserable.
In conclusion let me quote Dr. Edward
Jackson: "We know that the refraction of
the eye changes. ***** Such changes be-
come more common, more prominent, more
harmful in later life, when there is less ac-
commodation to overcome them, and when
the overcoming of their effects is more im-
portant for good vision."'
The largest piece of ivory in the world has
been found in Alaska and is on its way to
Washington without being elected. — Sumter
(S. C.) Item.
1. Jackson, Dr. Edward: Changes in Refraction
of the Eye. Transaclioii of the A. A. Oph. and Oto-
Ln., 102S.
April, 1929
SOUTHERN MEDICINE AND SURGERY
271
NEUROLOGY
Omn B. Chamberlain, B.A., M.D., Editor
Charleston, S. C.
Concussion of the Brain
All of us are interested in head injuries,
particularly if they be of the borderline type
where symptoms of cerebral injury are only
mildly present. There has been much con-
fusion over the terms used to indicate Ih?
extent of cerebral malfunction. We ordinari-
ly differentiate between concussion, contusion
and compression. The term concussion, or
commotio cerebri, is generally used for cases
in which there are no demonstrable micro-
scopic changes. It is supposed that there has
occurred a physico-chemical molecular altera-
tion.
The clinical picture presented by a case in
which gross cerebral injury is not apparent
is generally not very severe. The loss of
consciousness is relatively transient and no
need arises for formidable operative interfer-
ence. In a few hours or days the acute
symptoms clear up. It is with the sequelae,
however, that the interest is concerned. The
points of view concerning the causative fac-
tors in the subsequent manifestations differ
widely. These complaints are largely subjec-
t ve and consist of headaches, easy fatigue,
insomnia, inability to work, memory defects
and so on. Since they are subjective it is
hard to determine whether they depend upon
structural or physiological cerebral changes,
or whether, on the other hand, they are
pschogenic.
The question of law suits so frequently en-
ters into the case that there is an easily rec-
ognized, motivating factor for a neurosis. In
fact we may put the problem concisely, by
saying that we are faced with the decision
of saying whether the patient suffers from
traumatic encephalitis or compensation neu-
rosis. It is probably true that the ex[>eriences
of the war inclined the pendulum to swing
to the neurosis side. It is also fair to point
out that the increased knowledge of human
pathological motivations which has arisen
fnim the studies of Freud and his school in-
clined medical opinion away from the struc-
tural point of view and towards the import-
ance of psychogenic factors. "Shell-shock,"
so commonly diagnosed in the early days of
the great war, and esteemed to be due to at-
mospheric vibrati(jns, became an.xiety and fear
neuroses.
There are many indications that the pen-
dulum is swinging back to the organic and
structural point of view. This change is evi-
denced by several articles which have attract-
ed much attention. I refer particularly to
the article entitled "Punch Drunk," by Mait-
land, in the Journal of the A. M. A. of Octo-
ber 13lh, 1928. He points out that Osnato
.-rd G 1 berti in 1927 concluded as result of
the study of 100 clinical cases.
"Anatomic and clinical investigations seem
to show definitely that our conception of con-
cussion of the brain must be modified. It is
no longer possible to say that concussion is
an essentially transient state which does not
comprise any evidence of structural cerebral
injury. Not only is there actual cerebral
injury in cases of concussion but in a few
instances complete resolution does not occur,
and there is a strong likelihood that second-
ary degenerative changes develop. When this
happens, we have a condition which, clini-
cally at least, resembles some of the reactions
seen in encephalitis. We feel, therefore, that
the postconcussion neuroses should properly
b? called cases of traumatic encephalitis."
Maitland states that not only may tiny
punctate hemorrhages occur, but in other
cases of cerebral concussion the symptoms
may be attributed to hydraulic shock to the
neurons by distention of the perineuronal
spaces. If this is true he says, "there is a
purely morphologic lesion as the basis of
many cases of postconcussion neuroses and
psychoses. A replacement gliosis or even a
progressive degenerative lesion may be the
late manifestations of these former hemor-
rhages While the establishment of these
facts is of enormous importance to the courts
and to labor compensation boards in |ilacing
many cases of cranial injuries on a firm path-
ologic basis, it will also have its disadvan-
tages. A very great field is opened for the
so-called expert testimony, in which malin-
gerers and those suffering from various forms
of psychoses and neuroses may claim undue
compensation."
Maitland's prediction about the joy with
which these data will be received by damage
suit lawyers is, unfortunately, apt to be real-
ized. Juries are often willing to award huge
sums even when the allegation that organic
injury exists can receive no reputable scien-
tific backing. If it is freely admitted, even
by the experts for the defense, that a blow
pnducing only transient loss of conscious-
ness, is very apt to produce structural
2?2
SOUTHERN MEDICINE AND SURGERY
April, 192Q
changes, and worse than that, progressive
degenerative phenomena, it is rather apparent
that corporations are in for a bad time.
INTERNAL MEDICINE
Paul H. Rinc.fr, A,B., M.D., Editor
Ashcville, N. C.
Early Diagnosis of Tuberculosis
The National Tuberculosis Association is
inaugurating an Early Diagnosis Campaign
and it behooves all medical men to co-operate
therein. In the past twenty-five years much
has been accomplished along this line but en-
thusiasm must not be allowed to flag for the
enemy is ever at our doors.
The average practitioner sees tub?rculosis
but casually in the mass of general work.
Despite all the instruction that has been
broadcast, too many patients are still seen for
the first time by the "chest man" in a mod-
erately advanced or far advanced condition.
Many of these have been to one or more
physicians and have been dism'ssed with
some palliative. .'\t the risk of being consid-
ered dogmatic, the editor proposes to lay
down certain rules which if followed will tend
to earlier recognition of the disease.
1. Every cough of three weeks' duration
demands a searching chest exam latlon.
2. Rales in the upper lobes persisting after
cough are to be looked upon as of tubercu-
lous origin unless they can be proven to be
otherwise. Basal rales are to b? considered
non-tuberculous until proven to b^- otherwise.
,1. Every such patient having sputum should
have that sputum examined for tubercle ba-
cilli by a competent laboratory worker.
4. One negative sputum examination means
simply that further sputum examinations are
necessary. Xo physician should feel that he
has done his full duty with regard to the
sputum until sLx negative examinations have
been recorded.
5. No chest examination can be considered
complete, in the absence of definite chest
findings or of the finding of tubercle bacilli
in the sputum, without stereoscopic x-ray
films. These films must be well taken and
must be interpreted by a qualified examiner.
The following can be accepted as a true state-
ment: In the absence of rales and of tuber-
cle bacilli in the sputur.i a pair of good stere-
oscopic films interpreted by one fully quali-
fied, and pronounced negative, constitute a
strong argument against the presence of tu-
berculosis.
6. The expectoration of as much as a tea-
spoonful of blood must be considered as evi-
dence of tuberculosis until the contrary can
be proven. Do not be misled by the frequent
statement that "the blood came from the
throat." It very rarely does. Pharyngeal
varices do exist and may bleed, but this is
at once apparent. Gums that bleed easily do
not cause the expectoration of bright blood
or a dark clot. Tubercle bacilli are very, very
rarely found in the expectorated blood. Their
absence is no argument against the presence
of the disease. Make sure by carefully ex-
amining the chest and the sputum, and take
an x-ray.
7. A pleurisy with effusion not associated
with pneumonia or an injury to the thorax
should be looked upon as of tuberculous or-
igin, and the patient carefully watched for a
year or two.
8. Undue fatigue on relatively slight exer-
tion coupled with progressive, if not marked,
loss of weight should arouse suspicion of tu-
berculosis and consequently entail a careful
examination.
9. Fever from whatever cause unless its
origin be most obvious, e. g., acute tonsillitis,
acute appendicitis, demands a careful chest
examination.
examination of contacts
If and when an open case of tuberculcs's is
discovered it is most important to examine
carefully all members of the househ )ld and
especially all children. These latter are well
known to be most susceptible to infection
and by finding evidences of early disease in
them steps may be taken to prevent the prog-
ress of the disease. The physician should in-
sist on these examinations, though many fam-
ilies will rebel because of the time and ex-
pense involved; the end, however, justifies
the means. Young children should have a
von Pirquet test done which, if negative, will
be strong evidence against infection, and, if
positive, will pave the way for further |)re-
ventive measures, such as hyperalimentation,
sun baths, definite hours of rest, extra time
in the open air, the correction of an existing
anemia.
instruction to patients
The ird vidual phthisiologist and all con-
nected with sanatoria for the tuberculous will
April, 1929
SOUTHERN MEDICINE AND SURGERY
273
naturally give detailed instruction to patients
regarding the prevention of the spread of
infection. Every physician, however, upon
diagnosing a case of tuberculosis, should in-
struct that patient with regard to five things:
1. Disposal of sputum. (Use of sputum
cup which is to be burned with its contents.)
2. Covering the mouth with gauze (not a
handkerchief) when coughing or sneezing to
eliminate the possibility of droplet infect on.
3. The use of separate dishes, silverware,
napkins and towels.
4. The washing of these separately from
those used by others.
5. The importance of sleeping alone.
Three weeks ago Dr. Linsly R. Williams
published a very interesting paper in the
Journal oj the A. M. A. in the nature of a
statistical investigation based on 1499 pa-
t'ents diagnosed tuberculous with regard to
instruction received on Numbers 1, 3, 4 and
5. It was startling to find that 42 per cent
of these patients had had no instruction given
by the physician first diagnosing the case or
the disposal of sputum — the most important
f'ngle item. The physician failing to give
instruction under this head very naturally
la led under the other heads as well. This
study shows that too many of the profession
are as yet not sufficiently alive to important
preventive measures. \'erbum sap.
Early diagnosis of tuberculosis is not a new
.subject. To many of us it is an old subject
that has been worn almost threadbare; yet
the necessity for constantly urging it still
exists and it is for this reason that the Na-
tiimal Tuberculosis Association is making the
campaign at present, and that the editor has
written this brief summary.
PERIODIC EXAMINATIONS
Frederick R. Tavior, B.S., M.D., Editor
High Point, N. C.
In General
Wc ha\'e little to say in this issue on our
subject, for the reason that we are in the
midst of compiling data from a larger num-
ber of e.xam'nations than we have previously
used in giving statistics. iHowever, in analyz-
ing 400 consecutive health examinations, we
have found little to change the d:ita obtained
previously in 271 examinations. Refractive
errors and bad teeth continue to be over-
whelmingly the two most frequent defects
found. A much higher number of orthopedic
defects are noted in this series than in the
smaller group and this would be expected, as
strikingly few were rejxirted before, apparent-
ly just a coincidence. In the main, however,
the essential facts regarding conditions found
in apparently healthy persons stand as evi-
dent as they seemed to be in our earlier work.
In the 400 cases we have noted 1,380 defects,
an average of 3.45 defects p>er person.
\\'e have found one individual with no evi-
dent physical defects, but his habit defects
were sufficiently marked to cause his commit-
ment to the Eastern Carolina Training School,
and from the standpoint of the health exam-
iner such things are just as important as bad
teeth or tonsils. We are, therefore, still
searching for the apparently mythical perfect-
ly healthy person, and our search seems about
as futile as that of Diogenes with his lan-
tern.
We hope to have more of interest to report
when we have entirely covered the state and
can give really statewide statistics with a
critical analysis of the meaning of them —
mere statistics mean very little unless we ana-
lyze them and draw careful conclusions from
them.
News of Nurses' Meeting
District No. 8 of the North Carolina
Nurses' .Association met in regular monthly
session March 12th, at Wilson, with the Wil-
son nurses hostesses to about fifty nurses
from eastern North Carolina.
The meeting opened with a business ses-
son, over which the president of the district,
M ss Marie Farley, of Goldsboro, presided.
Reports from various committees were made
ar.d after a business discussion, the president
presented Miss Mary N. Miller, field repre-
sentative of the eastern branch of the State
Orthopedic Hospital, Gastonia, who .spoke of
the work being done by the State of North
Carolina through the eastern branch of the
State Orthopedic Clinic. The eastern branch
has but recently been established, with head-
quarters in Goldsboro, yet the monthly clin-
ics have grown so that there is every reason
to think that great and permanent good will
result.
Miss Mary \\ Laxton, of .■\sheville, presi-
dent of the North Carolina Nurses' .Associa-
tion, was presented by the president and in
a very charming manner spoke on Organiza-
SOUTHERN MEDICINE ANt) SURGERY
April, IP:"?
Miss Laxton reviewed the organization of
Nurses' Associations, going back to its infancy.
She easily made those present feel the neces-
sity of organization and membership in the
district association, which automatically
means membership in the National Associa-
tion. She sfKike of the protection against
those less qualified, given by membership. In
explaining that the Nurses' Association
stands for metropolitan legislation, she told
how North Carolina was the first state to
have a bill in the legislature for professional
women. The association is in federation with
other women's clubs, therefore enabling the
nurses to come in close association with other
phases of life. Miss Laxton reviewed the
work of the relief committee, state and na-
tional, advising that North Carolna has a
relief fund of $13,000. In reviewing the work
of the grading committee, she spoke very
confidently of the ultimite good which
she feels will be accomplished, .^fter appeal-
ing to those present for co-operation in all
activities of the State and National .Associa-
tions, she said there is much to be done and
that since the Nurses' .Association is the larg-
est body of professional women in the world,
she feels that we are equal to the task. Miss
Laxton delighted those present by reading a
letter from Miss Clara D. Noyes, chairman,
advisory Committee, .American Nurses' Me-
morial School of Nursing, Bordeaux, France,
who said that North Carolina was the first
state to go "over the top" with her quota. In
conclusion she urged the nurses to subscribe
to and read the Journal, advising that it is
the official organ of the nursing profession.
The president turned the meeting over to
Miss ^lartha Newman, of Wilson, who pre-
sented Col. John F. Bruton, president of the
First National Bank of Wilson, who in very
fitting words spoke on "Independence." He
urged his hearers to look into the future and
prepare for the days to come by investing
their savings, which should be at least one-
tenth of gross income, in non-ta.\able, con-
vertible stocks or bonds.
.After luncheon the president of the district
expressed, in behalf of the visiting nurses,
her appreciation for a very profitable and
enjoyable meeting.
The next meeting of the district will be
in Greenville, April 9, 1929.
Mrs. Walter C. Denmark,
Secretary.
NEWS ITEMS
Two Southerners .Appointed to Chairs in
School of Medicine of Duke
Dr. Julian Deryl Hart is coming to Duke
in 1930 as Professor of Surgery. His clinical,
teaching and scientific qualifications and his
personality are excellent. He was born in
Georgia, graduated from Emory University
and the Johns Hopkins Medical School and
has been a member of the Department of
Surgery of the Johns Hopkins Medical School
and Hospital for the past eight years.
Dr. Wiley Davis Forbus has been appoint-
ed Professor of Pathology. He has had a
splendid training in General and Surgi-
cal Pathology. He has demonstrated marked
ability and has been very cordially received
by the members of the profession who have
met him. Dr. Forbus was born in Missis-
sippi, received his academic training at Wash-
ington and Lee and his M.D. at the Johns
Hopkins. He has been a member of the De-
partment of Pathology of the Johns Hopkins
Medical School and Hospital for the past six
vears.
Post-Graduate Work at Bordeaux
Our office has just received word thit there
will be a post-graduate course in Ear, Nose
and Throat Surgery for .American phys'cians
at the University of Bordeaux, France, com-
mencing July 22, 1929.
Dr. Leon Felderman, Philadelphia, Pa., is
in charge of registering the .American physi-
cians for this course.
Dr. ?tIoNT Royal Farrar d'cd in a Char-
lotte hotel March 30th. Funeral services
were conducted from the late home at
Greensboro, at 2:30 o'clock Monday after-
noon, .April 1st, by Rev. J. Clyde Turner,
pastor of the First Baptist church. Pallbear-
ers were R. D. Covington, Dr. E. R. Mich-
aux, Dr. J. H. Boyles, W. E. Walker, J. B.
Barnes, P. W. Nielson, J. A. Hodgin and T.
Settle Graham. Interment was made in Green
Hill cemetery.
Dr. Farrar was a veteran of the world war,
having attained to a captaincy in the medical
corps of the United States army during the
hostilities with Germany, and was stationed
at several army hospitals after the end of the
war. While overseas he was presented the
Croix de Guerre ot tne i-'reiicii government for
gallant service.
April, IQ29
SOUTHERN MEDICINE AND SURGERY
21S
The Fifth District (N. C.) ^Iedical
Society — President, Dr. A. H. McLeod; sec-
retary. Dr. O. L. McFadyen — met at South-
ern Pines April 4th. Features of the program
were papers on "Disturbances of the Cutane-
ous Circulation," Dr. F. L. Knight, Sanford;
"Some Experiences with Pellagra and Tuber-
culosis," Dr. M. Eugene Street, Glendon;
"Diagnosis and Treatnunt of Acute Osteomy-
elitis," Dr. R. L. Pittman, Fayetteville; "Re-
lationship of Rest and Compression Therapy
in the Treatment of Tuberculosis," Dr. J. W.
Dickie, Southern Pines; "Treatment of Pneu-
monia in Infants," Dr. J. F. Foster, Sanford;
"The Value of Pressure in Surgery," Dr. H.
.■\. Royster, Raleigh; "Relation County Med-
ical Society and Personnel to Whole Time
Health Department," Dr. Chas. O'H. Laugh-
inghouse, Raleigh; Luncheon; L'fe Extension
Clinic, Dr. F. R. Taylor, Raleigh; "Potential
Worth of Electricity in Med'.cine and Sur-
gery," Dr. G. L. Sykes, Salemburg.
dent; and Dr. W. C. Whitfield, Grifton, sec-
retary.
Second District (N. C.) JMedical So-
ciety met at Kinston, March 28th. It was
called to order by the president. Dr. Charles
P. Mangum, Kinston, welcomed by Dr. W. T.
Parrott, Kinston, the welcome responded to
by Dr. M. T. Frizzelle, Ayden, and invoca-
tion made by the Rev. Eugene C. Few.
.\fter dinner came the scientific program.
Dr. Chas. P. Mangum, Kinston, "The Thy-
mus Gland as the Cause of Convulsions" —
Dscussion opened by Dr. V. L. Bigler; Dr.
Gabriel Tucker, Philadelphia, "Cases of Gen-
eral Medical and Surgical Interest from
Chevalier Jackson Bronchoscoplc Clinic,"
with slides and moving pictures — Discussion
opened by Dr. J. M. Parrot and Dr. Frank
.Sabiston; Dr. H. A. Royster, Raleigh, "The
Technique of Thyroidectomy," lantern slides
— Discussion opened by Dr. Dave Tayloe,
Jr., and Dr. M. D. Thompson; Dr. Spencer
P. Bass, Tarboro, "The Rheumatic Child" —
Discussion opened by Dr. R. Duval Jones;
Dr. Paul F. Whitaker, "Summary of the Prin-
ciples Involved in the Treatment of Diabetes
Mellitus" — Discussion opened by Dr. L. C.
Sk'nner; Dr. Thos. L. Lee— "The Treatment
of the Convulsive Toxemias of Pregnancy" —
Discussion opened by Dr. W. W. Whitting-
ton.
.\pprriximately 120 ductors were present.
Dr. M. I". Frizzelle, .\yden, was chosen presi-
The ISIecklenburg County Medical So-
ciety held a regular meeting March 19th.
A medical clinic by Dr. R. F. Leinbach; a
surgical clinic by Dr. .Addison Brenizer; and
a discussion of foreign bodies in air and food
passages, by Dr. C. X. Peeler, made up the
program.
The Mecklenburg County Medical So-
ciety held a regular meeting April 2nd. Case
reports were made and patients exhib-
ited by Dr. James R. Alexander and
Dr. Howard L. Newton. The greater part of
the meeting was given over to an address on
Periodic Health Examination, by Dr. F. R.
Taylor, for the State Board of Health. Dr.
Taylor's recommendations were received most
favorably, and a decided sentiment developed
for the members of the society leading the
movement by being examined themselves.
Dr. J. G. Reynolds, 68, Marion, X. C,
died at his home March 14th. Dr. Reynolds
was born and reared in Madison county. He
located for practice in Marion in 1915.
Dr. W. E. Simpson, of Rock Hill, was
elected president; Dr. A. M. Wylie, of Ches-
ter, vice-president, and Dr. J. R. Desportes,
of Fort Mill, secretary and treasurer, of the
Fifth District (S. C.) Medical Society, held
at Chester, March 26th.
Dr. J. W. Tankersley, Greensboro, spoke
to the student body of A. and T. College,
.April 3rd, carrying out the national negro
health week program. Dr. S. P. Sebastian,
chairman of the health committee of the col-
lege, presented Dr. Tankersley, who spoke on
the subject of "Periodic Health Examina-
tions."
Dr. W. W. McKenzie, Jefferson '92, for
thirty-five years a physician oi Salisbury, died
.April 2nd, at the Salisbury Hospital following
a stroke of paralysis he suffered March 31st.
Dr. John W. Wallace, Maryland '91,
Covington, Va., died in a Charlottesville hos-
pital .April 1st.
2)6
SOUTHERN MEDICINE AND SURCfeftV
April, 1929
Dr. 0. E. Finch, Raleigh, is taking special
work in Philadelphia. On his return he will
limit his practice to gastro-enterology.
Dr. Perry H. Wisem.an, Avondale, N. C,
is suffering a severe attack of influenza.
Dr. James Cornelius Braswell, Mary-
land '82, prominent citizen and fraternal
leader, of W'hitakers, died of heart disease
April 5th at a Baltimore hospital, where he
had gone about five weeks ago for treatment.
Dr. Braswell represented Nash county for
several terms in the General .\ssembly. He
was a past grand master of the North Caro-
lina Grand Lodge of Masons, a past poten-
tate of Sudan temple of the Shrine and at
the time of his death was an imperial repre-
sentative of Sudan temple.
Among the survivors is a son. Dr. J. C.
Braswell, jr., of Tulsa, Oklahoma.
Dr. I. T. Mann, High Point, has moved
into his new suite of offices, 409 Commercial
National Bank Building.
Dr. Joseph L. Burke, M. C. of Va., '95,
Chief Surgeon of the Seaboard Air Line Rail-
way, died at his home at Norfolk, Va., .April
5th. Among the pallbearers were Dr. John
Mann, Norfolk, and Dr. J. W. Palmer, .Alley,
Ga. A surviving son is Dr. Antonio Burke,
of Norfolk, and another son, Dr. Aulick
Burke, of Petersburg, died several years ago.
Dr. J. T. Burrus, High Point, N. C, has
been appointed to membership on the Govern-
ing Board of the State Hospital for the In-
sane at Morganton.
DOCTOR 18 yrs. located in town 11,000 Piedmont
Carolina — 6 doctors, 2 not very active — WANTS
CAPABLE DOCTOR to share reception room, take
care of his practice when he is away. Vieii.' to part-
nership lalrr. Address: T. R. J., care Southern
Medicine and Surgery, 804 Prof. Bldg., Charlotte,
N. C.
Joties was never an early bird at the office. One
morninR his boss exclaimed: "Late again. Have
you ever done anything on time?"
"Yes, sir," was the meek but prompt reply. "I
purchased a car." — Moiorland.
Atsrotiotner (to his wife): My dear, congratulate
me. I've discovered a star of hitherto unheard-of
density, and I'm going to name it after you. — TH-
Bils.
PEDIATRICS
Frank Howard Richardson, M.D., Editor
Black Mountain, N. C.
CROUP
High in the list of those maladies of child-
hood that make mothers spend wakeful nights
and that cause doctors to lose much needed
repose, stands croup. For a disease that is as
a rule perfectly benign, so far as any serious
permanent results are concerned, croup can
be about as terrifying in its manifestations as
a mother or any doctor cares to see. And
always lurking in the background is the fear-
some thought, in the mind of the mother,
that some other mother's child of her acquaint-
ance died of croup; and that this may be the
same kind of croup and her child may die,
too. Nor is the appearance of a child in the
throes of a sharp attack of croup such as to
reassure the mother who entertains such
thoughts; for croup that is quite simple as to
prognosis or sequelae, can be far more fright-
ening in its manifestations than many an ac-
tually fatal disease.
One of the unfortunate circumstances at-
tending the onset of an attack of croup is just
this uncertainty in the mind of the mother, —
and not infrequently, until he has had an
opportunity of examining the child and getting
a satisfactory history, in the mind of the
doctor, — as to which kind of croup he is deal-
ing with. For one form is this non-fatal mani-
festation, laryngeal or spasmodic croup; if
the child has this, there is call for no anxiety,
but simply for prompt and energetic combat-
ive measures of a sort that will shortly cause
relief. If, on the other hand, the condition be
proved to be the other form of croup, known
to the laity as membranous croup (usually
with the accent on the second syllable, which
seems to give it an extra thrill of horror!), the
sooner the word croup can be dropped from
the discussion, the better. For such a child is
suffering from a very serious, and not uncom-
monly fatal, localization of the Klebs-Loeffler
bacillus, which has chosen the larynx as a
place of residence, and so has hidden himself
where he can do the most harm with the least
likelihood of being detected. Such a child
needs diphtheria antitoxin in the biggest doses
that the courage of the doctor will permit,
and in the most direct way possible, intra-
muscular injection, unless conditions are such
that the intravenous route can be employed,
in which case the latter is by all odds the
April, 1029
SOUTHERN MEDICINE AND SURGERY
277
avenue of choice. Even this may fail to save
the child's life: for a diphtheria that has gone
undetected so long that it is causing symptoms
of laryngeal embarrassment grave enough to
be confused with an attack of laryngeal croup,
may easily have done so much harm that even
heroic doses of antitoxin may fail to save him.
We must remember that the potency of anti-
toxin to neutralize the toxin of the disease de-
creases very rapidly in direct proportion with
the length of time from the onset of the
disease; and of course it possesses no power
at all to undo the end results of the toxin of
the disease.
The diagnosis of membranous croujD — which
is a term that should be abolished from the
working vocabulary of every doctor, and re-
placed by its more exact and scientific syno-
nym, laryngeal diphtheria — is for the most
part simple. The history of exposure to
d'phtheria; the slow, progressive onset of the
symptoms, as contrasted with the sudden on-
set of an attack of the non-specific, spasmodic
or catarrhal croup; and its failure to improve
rap'dly under the administration of the croup
measures to be enumerated shortly, all com-
bine to make the diagnosis easy in most cases.
There is always, however, the small residue
of cases in which the diagnosis is most dif-
ficult, which will cause much anxiety to even
the most careful diagnostician. Of course the
surest diagnostic point is the appearance or
lack of appearance of a true diphtheritic mem-
brance on the vocal chords, as seen by direct
inspection of the larynx. But simple as the
practitioner's of this relatively recent refine-
ment of examination would have us believe
it to be, (or are their assurance merely a mani-
festation of a sort of mock-modesty that in
reality deceives no one, nor is intended to do
so!), there are not many of us who include
ihis as an easy and simple part of every
physical examination; so that we need not
rely upcjn this is the vast majority of in-
stances. Nor will there be time for any
laboratory examination of artificially induced
expectoration; it is quite probably too late
evci for immediate injection to save the child,
and certainly a delay of twelve or twenty-
four hours for a laboratory report if ever
justifiable is not so at such a crisis.
It may seem unsportsmanlike and "I-told-
\()u-so "-ish to mention the fact here; but it
is certainly the case that the doctor who uses
his divinely appointed prerogative of minding
the business of his patients to the extent of
getting all his youngsters immunized by the
administration of toxin-antitoxin, will not
often have to make this decision as to the
presence or absence of diphtheritic infection.
Especially is this true if he checks up on his
toxin-antitoxin administrations by giving a
Schick from none to twelve months later; for
he will then know whether his immunization
is only probable, or is actually in effect.
Catarrhal croup may come on out of a
clear sky; in which case the child who has
gone to bed perfectly well, awakes from a
normal or perhaps a troubled sleep gasping
for breath, with a strangling cry that brings
his parents to him on the run, with a spasm
of terror that is not allayed by the sight of
an almost strangling child. It is more com-
mon, however, for this occurence to follow
a slight cold, perhaps beginning the day pre-
ceding the night of the attack, and not infre-
quently little considered by the parents. How-
ever it begins, it presents a very real situation
to be dealt with. The child may be in such
distress that he seems to be strangling, with a
hoarse, raspy attempt to cry that is accom-
panied with a real inspiratory stridor and the
drawn facies of strangulation. This is the
most severe type; it may vary from this to
a much milder manifestation, of harsh brassy
breathing and an occasional crowing cough.
The usual physical e.xamination reveals noth-
ing, though direct inspection of the larynx
would show swollen edematous mucous mem-
brane, and the vocal cords swollen and dis-
torted.
What is the first thing to do for such a
child? Obviously, he needs to get air down
through this inflamed, swollen mucous mem-
brane; and the easiest way to get it there,
next to the heroic measures of intubation or
tracheotomy, is by getting moist warm air
(steam, in other words), into the neighbor-
hood. The easiest, simplest, and quickest way
to do this is to bring a steaming kettle from
the stove to the side of the baby's crib, over
which a sheet has been thrown like a tent, and
introduce the nose of the kettle under one
edge of the sheet. If the baby is lying in a
bed, or has been taken into his mother's arms,
an umbrella over his head may form the
framework for the sheet tent. This steam
inhalation may be sufficient to quiet the child;
it is quite unnecessary to add the hazard of
possible fire by actually boiling the kettle at
21i
SOUTHERN MEDICINE AND SURGERY
April, 1929
the bed side, in the neighborhood of the
swinging sheet edge, which in ths excitement
of the moment invites such a catastrophe.
Cold compresses applied to the outside of the
Irynx may aid the action of the steam in calm-
ing down the swollen mucous membrane. Just
why or how this works, it is not easy to say;
the fact that it does seem to help in tiding
over this very acute and painful crisis, will
be quite sufficient to recommend it to the
sorely tried physician and the agonized par-
ents of a child in the midst of an acute, fulmi-
nant attack of spasmodic laryngeal croup.
Still another arrow in the quiver that may
perhaps be used is an emetic dose of ipecac.
This is not often necessary; but it may have
to be used before relief is afforded. As a gen-
eral thing, before the other two methods have
been given time enough to demonstrate their
need of further means of relief, the sorely be-
set youngster will have dropped off into an
uneasy doze, which passes over into a natural
sleep that lasts until morning.
It is unfortunate that we have nothing of
proven value that can be said in regard to
the prevention of croup in susceptible chil-
dren, except that very bromidic bit of advice,
"keep them from having colds." The mother
or the doctor who knows just how to carry
out this bit of advice, that is so often given
with such wise-seeming and ponderous gravi-
ty, can have a place in this column that will
take precedence over any other communica-
tion that seems likely to be received by its
editor. A rich prize will be given such a
contributor, just as soon as said preventive
for colds is proven efficacious. Until then, the
mother of a child who occasionally has croup
will do well to keep the kitchen fire going with
the kettle filled with water; she may need it
at any time on desperately short notice.
[Syrup of ipecac was the highly efficacious
remedy kept constantly on hand for immedi-
ate application in the person of Editor oj the
Journal.]
"How many miles have you driven?" asked the
official.
"Fifty thousand miles — and never had hold of the
wheel!" interposed her husband, stepping up.
She got the license. — Detroit Motor News.
PUBLIC HEALTH
For this issue. G. M. Cooper, M.D., Raleigh
Director Bureau of Education, State Board of Health,
North Carolina.
Department of He.alth Education,
North Carolina State Board
OF Health
The part of the work of Health Education
for which the undersigned director is respon-
sible embraces three broad divisions:
First, responsibility for preparing material
for the Monthly Health Bulletin, a thirty-
two page periodical issued each month by the
North Carolina State Board of Health. This
material is prepared and selected with a view
to presenting in understandable language the
essential principles of the advancing evolu-
tion of public health. An endeavor is made
to present each month the A B C"s of ele-
mentary hygiene and sanitation. \ particu-
lar effort is made to present these matters in
such a manner as to be interesting and in-
structive to the readers of the Bulletin, which ■
comprise all classes of the population. As
many of the grade schools and high schools
of the state use the Bulletin as supplementary
reading for special class room work, the in-
formation about disease prevention and such
matters as school health is presented in as
clear a manner as possible.
Second. The miscellaneous medical corre-
spondence coming to the State Board of
Health is attended to in this division. Briefly
speaking, this work comprises the answering
of personal letters, giving detailed personal
information, when requested, on a wide va-
riety of medical, surgical, and public health
subjects. This part of the work is a distinctly
personal hygiene service.
Third. This department is beginning the
issuance of a Weekly Health Letter which
will go to the local board of health officials
throughout the state with the view of reach-
ing as many readers of local papers about
matters of public interest as possible. This
Weekly Health Letter is sent to the local of-
ficials with the understanding that they may
request publication in their local papers of
any part or all of such communications as in
their judgment are desirable in the advance-
ment of public health work.
Sambo — .\h needs pertection, suh; ah done got a
unanimous letter saying: "N'igger, let mah chickens
alone I"
Chief — Why protection? Just leave the chickens
alone.
Sambo — How's I gwlne ter know whose chickens
to leave alone? — Carolina Motorist.
PARTICULARS DESIRED
Hubby: "What's good for my wife's fallen
arches?"
Doc: "Rubber heels."
//.: "What'll I rub 'cm with?"— Nebraska State
M. J.
April, i9ii
gOttHERM MEblCiKfi AJJb StRGfeRV
REVIEW OF RECENT BOOKS
3>0
THE GLANDS REGULATING PERSONALITY
A study of th; Glands of Internal Secretion in Rela-
tion to the Types of Human Nature, by Louis Her-
man, M.D.. Associate in Biological Chemistry,
Columbia University. Second Edition Revised. The
MacMi'hm Company. New York, 102S, S.^.SO.
Personality is here used to designate "'the
sum of one's qualities of body, mind and
character" — certainly something very differ-
ent from the loose, common usage.
Starting with the conception that man is
close akin to his brethren of the sea, the
jungle, the forests and the fields, it necessa-
rily follows that a legitimate method of in-
vestigation is that of experimentation on
these kinspeople, as well as observations on
humans deprived of a part or the whole of
the secretions of one or more glands, by lack
of development, injury or disease.
The introduction lays a broad foundation
from profound knowledge of science and his-
tory, and on this is ingeniously built a solid
structure. The account of the work of The-
ophile de Bordeu, physician to Louis XV and
tiie first individual known to have entertained
the idea of an internal secrettion. The mon-
umental achievements of Berthold, Claude
Bernard, Addison and Brown-Sequard — at
one time Professor of Physiology in the Med-
ical College of \'irginia — are fascinatingly de-
picted.
The glands are treated of separately and
as parts of an interlocking directorate. There
is a chapter on "Some Historic Personages,"
which discusses Xapoleon, Xietzsche, Dar-
win, Florence Xightingale and Oscar Wilde
in a manner reminiscent of the brilliant i\Iac-
Laurin's, "Post-iMortems."
Dr. William H. Taylor's pupils will have
their old teacher brought frequently to mind,
for Berman, too, is one of those rarities of
rarities, a scientist whose writings are literary
delights.
This product of one who is a doctor, a
chemist and a master of English composition
is a constant delight. Every medical man is
urged to dust off his dictionary (it will be
needed) and read this inasterpiece atten-
tively.
THE DIAGNOSTICS AND TREATMENT OF
TROPICAL DISEASES, A Compendium of Tropi-
cal and Other Exotic Diseases, by E. R. Still, A.B.,
Ph.G., M.D., Sc.D., LL.D., Rear Admiral, Medical
Corp;, U. S. Navy ; Graduate, London School of
Tropical Medicine, formerly Surgeon General, U. S.
Navy ; President National Board of Medical Exam-
iners; Commanding Officer and Head of Department
of Tropical Medicine, U. S. Naval Medical School;
Professor of Tropical Medicine, Georgetown Univer-
sity ; Professor of Tropical Medicine, George Wash-
ington University. Fifth edition, revised, with 249
illustrations. P. Blakiston's Son & Co., Philadelphia,
1029. .SO.OO.
It is pointed out that no disease of any
great consequence is strictly limited to the
tropics. It is of great interest to note that
the author finds strong evidence for the iden-
tity of syphilis and yaws. History is regard-
ed as the first consideration and epidemiology
of great importance because it points the way
to future research.
X'ew chapters have b?en added on "melio-
dosis," "food injuries and vitamin deficien-
cies," "injurious plants," "helminthic infec-
tions" and "poisonous snakes."
The importance of the subject of "tropi-
cal" or — as Dr. Stitt prefers to call them —
"exotic" diseases, is usually very much under-
estimated. A knowledge of these conditions
is indispensable to proper medical practice in
the South Atlantic and Gulf States. The au-
thor is admirably fitted for supplying this
knowledge and admirably has he done this.
Sections are on: Diseases due to Protozoa,
Diseases due to Bacteria, Diseases caused by
Filterable Viruses and Rickettsias, Nutri-
tional Disorders, Diseases Not Satisfactorily
Grouped, Diseases due to Fungi and Injuri-
ous Plants, Animal Parasites, and General
and Statistical considerations. There is an
important -Appendix with Sections on Clinical
Diagnosis, Laboratory Procedures and Tropi-
cal Hygiene.
INJECTION TRE.\TMENT OF INTERNAL
HEMORRHOIDS, by Marion C. Pruitt, M.D.,
LRC.P.. S. (P:d.) F RC.S., (Ed.) F.A.C.S., Asso-
ciate in Surgery, Medical De|)arlmcnt, Emory Uni-
versity ; formerly Resident Surgeon, Westminster
Hospital, London, Eng. Illustrated. C. V. Mosby
m
SOUTHERN MEDICINE AND SURGERY
April, 1029
Co., St. Louis, 19-'0. $3.00.
The author is very much in earnest about
putting into the hands of his brother practi-
tioners a volume containing all that is need-
ful to know on this subject and nothing more.
This he achieves to a striking degree.
It is an orderly work, illustrated all that is
necessary, clearly expressed. Eleven case re-
ports show what the method recommended
has done.
This reviewer would prefer that no more
solutions, operations, signs, or instruments be
designated by men's names; but one can not
have everything.
INTERNATIONAL CLINICS, A Quarterly of
Illustrated Clinical Lectures and Especially Prepared
Original Articles, edited by Henry W. Cattell, A.B.,
M.D. Vol. 1. Thirty-ninth Series, 1929. /. B. Lip-
pincotl Co.
Dr. Lewellys F. Barker has two clinics on
subjects of such great interest as "The Nature
and Treatment of Maladies that Cause Head-
aches" and "Chronic Alcoholism and ....
Methods of Preventing the .^buse of Alco-
hol."
"Pellagra of Today," by Dr. Stewart Rob-
erts, of Atlanta; "Diagnosis and Treatment
of Latent Amoebic Infection," by Dr. C. F.
Craig, of Washington; "Hyperlipochromia,"
by Dr. Hugh S. Stannus, of London; and
"The Use and .'\buse of Forceps," by Dr. A.
H. Bill, of Cleveland, are contributions which
attract special attention.
THE TECHNIC OF LOCAL ANESTHESIA, by
Arthur E. Hertzler, A.M., M.D., Pit. D., LL.D.,
F.A.C.S., Professor of Surgery in the University of
Kansas. Fourth edition, with 146 illustrations. C.
V. Mosby Co., St. Louis, 192S. $6.00.
The field of local anesthesia is constantly
widening; as more and more doctors become
convinced that there is no such thing as a safe
general anesthetic, and as greater knowledge
and greater attention to details make it pos-
sible to do more and more e.xtensive opera-
tions painlessly, under the influence of a local
anesthetic.
From the simple, direct text and the ad-
mirable illustrations any surgeon may readily
enlarge his capacity for usefulness and learn
how to reduce the proportion of his cases in
which he has been accustomed to deem a gen-
eral anesthetic indispensable.
TUBERCULOSIS AND HOW TO COMBAT IT,
A Book for the Patient, by F. M. Potlenger, A.M.,
M.D., LL.D., F.A.C.P. Second edition. C. V. Mos-
by Co., St. Louis, 192S. ¥2.00.
The author says frankly that in preparing
this edition he has not found it necessary to
make any great change from the first. How-
ever, knowledge gained in the interim has
been recorded and a chapter added, entitled
The Will to Get Well.
Other chapters are on What Is?, Who May
Have?, Source of Infection, Seriousness of
Early, What to Do, Air, Rest, Exercise,
Foods, Baths: Water, Sun and Air, Climate,
Tuberculin, the various symptoms and acci-
dents. Worry, Sanatorium, Home Treatment,
Time, Friends and Relatives, etc.
It is gratifying to see that the author has
the sense to recognize the fact that most tu-
berculous patients are obliged to be treated
in their homes and to urge that doctors fa-
miliarize themselves with the principles of .
treatment so as to be able to surround the
patient with conditions as near ideal as possi-
ble.
Another evidence of accurate observation
and sound reasoning is his saying there is no
specific climate and the disease can be treat-
ed successfully anywhere.
These excerpts may be taken as fair sam-
ples of the wholesomeness and reasonableness
of the book. It is heartily recommended.
THE YOUNG MAN AND MEDICINE, by
Leivellys F. Barker, M.D.. L.L.D., Professor Emeri-
tus of Medicine Johns Hopkins University. The
MacMillan Company, New York 192S. $2.50.
Dr. Barker condems the haphazard method
of drifting into our life occupation as wasteful
of human resources. He urges an early choice
and systematic life-long work toward a defi-
nite end. He regards the tendency of natural
gifts to run in families as a matter of im-
portance.
He purposes helping those who have not
made a choice to compare the advantage of a
medical career with those offered by other
occupations, and to guide those who have
chosen medicine toward success. He discusses
the services which may be rendered, through
practicing medicine, through teaching medical
subjects, through medical discoveries, preven-
tion of disease and enhancing vitality, through
writing, and through organization and medi-
cal statesmanship.
April, 193«
"The rewards and satisfactions of medical
workers" make an absorbing cliapter. Per-
sonal qualifications for the different phases of
medicine are gone into, as are consideration
in the choice of a medical school, post-grad-
uate studies and helpful reading.
Voung men uncertain as to starting on a
medical career, or those who have made such
a decision, and doctors and other intelligent
parents and guardians of sons and wards who
are pausing at the threshold of medicine will
here find valuable material the which to
ponder.
EPIDEMIOLOGY OLD AND NEW, by Sir
William Hamer, M.A., M.D., FRCP.; Vice- PreM-
dent of the Epidemiological Section, Royal Society
of Medicine ; Formerly Medical Officer of Health
and School Medical Officer, County of London. A
Volume in The .Anglo-French Library of Medical
and Bibological Science, edited by F. G. Crook-
slumck. M.D.. FRCP., (London and Rene Cruchet
(Professor in University of Bordeaux). The Mac-
Millan Company, New York, 1029. .<;3.50.
Comparison is attempted between the epi-
demics in and from London in the past four
decades. The prolegomena point out the fact
that epidemics of 1915 bear a striking re-
semblance to those following soon on 1673,
bring again into prominence the importance
of soil as well as of seed, and give much space
to the prophetic conceptions of Sydenham.
.\ report is quoted to the effect that cere-
bro-spinal fever (meningitis) may be regard-
ed as a complication or sequel of influenza.
A section each is devoted to the severe in-
fluenzas on the crest of the pandemic wave
of 1918-1919, and the trailers of this pande-
mic. Contrasts and resemblances of old epi-
demics to new epidemics are painstakingly
enumerated.
For the chapter on The German Theory a
broad and intricate background is laid deal-
ing with increases in populations as influ-
enced by famines, and epidemics — particu-
larly of Black Death; with the periodicity
of waves of outpf)ut of e.xceptional intellect-
ual products; with the .\ge of Professionalism
"on the downward slope of Pnjf. Whitehead's
third wave."
The final chapter deals with epidemiology
during the past hundred years and is entitled
"Hack to Hippocrates."
it is a striking — at times startling, instruc-
tive, thought-provoking work.
SOtJtttEfeN MEDICtNfi ANt) StJRGERV 281
DISCUSSION OF DR. H. J. L.\NGSTON'S
PAPER
Dr. M. p. Rucker, Richmond:
Dr. Langston is to be congratulated on his
excellent presentation of this question that is
now so often discussed in obstetrical and gy-
necological societies. The aim of the obste-
trician should be to leave the birth canal in
as anatomically perfect condition as possible
after delivery. If we do that, we add a great
deal to the future happiness of our patient
and her family. It is a health measure of no
mean importance and is probably a very im-
portant step in the prophylaxis of cancer of
the cervix. The subject naturally falls into
two parts: consideration of the perineum and
consideration of the cervix. I think we all
agree that laceration of the perineum should
be repaired at once. Dr. Ilirsh, of Philadel-
phia, is about the only authority who differs
on that point. He believes that repair should
be done on the fifth day, when the edema has
subsided and the discharge is less. When Dr.
Hirst first published his paper, I was in ac-
tive charge of an out-patient service. His
plan suited our scheme admirably, for it is
difficult to keep up with two sets of students.
Under the new plan we could do the repairs
at a time that was convenient to all parties.
Unfortunately, we found that the patients
would not consent to an operation five days
after delivery. Theoretically it is all right,
but practically we found we had to do our
repairs right after delivery before the patient
woke up from her anesthetic. Often we went
to the house with an anesthetist and a bag
of tools only to be sent away. I think it is a
very good plan, if it can be followed out. At
any rate it is a comfort to know that you
can do it five days later if for any reason you
can not do it at once.
When we come to the cervix, that is a new
field. Of course, we all repair bleeding cer-
vices to stop the bleeding, but as a routine
procedure that has not been the custom until
quite recently. On the other hand, the ar-
gument for immediate repair of the cervix is
the good anatomical result afterwards, but
over aga'nst that you have to consider the
prolongation of anesthesia and some added
risk to the patient. 1 think we should remem-
ber that we can do a great deal for these
cervices that have been neglected by office
care and the cautery. So it is a question in
each individual case what we should do, but
I do think it is a field too often neglected.
Hi
SOUTHERN MEDICINE AND SUUGERV
A PAGE OF CHUCKLES
April, 192g
ENFORCEMENT
When Herbert Hoover succeeded
Where Upchurch and TurUngton tried,
When North Carolina's conceded
To be absolutely bone-dried,
Shall we drink city water and like it,
Coca-Cola imbibe without sigh.
And then as we moter or hike it
Watch the road for sign of Ne-Hi?
Well, those who love klim shall be happy.
They shall sit in a folding chair
On any country club verandah,
Pav five cents to draw to a pair
And watch dubs as they hobble showerward,
Sore in muscle and sorer in soul.
Knowing there's nothing in their lockers
To help play the nineteenth hole.
— "O. J." in Greensboro News.
If Democrats ever expect to win in a national
election in this country they have got to put up more
boodle, and — dammim — when a Democrat gets the
booddle he usually turns Republican. — The Inde-
pendent, Elizabeth City.
DUNDER UND BLITZEN
Nurse: "Bobby, I have a surprise for you."
Bobby: "I know all about it, I even know their
names."
"How?, Bobby."
"When the doctor told pa he said 'Twins, hell
and blazes'." — Nebraska State M. J.
CUTTING INTO THE RESERVE
Druggist: "Say, doc, can you fix this twitching
eye of mine?"
Doctor: "Is it troubling you much?"
Druggist: "Well, yes. in a way. You see every
time I wait on a man and he sees that twitching he
says, 'Don't care if I do'." — Brooklyn Eagle.
NO CIRCUMLOCUTION HERE
Doctor: "About nine patients out of ten don't
live through this operation. Is there anything I
can do for you before we begin?"
Dusky Patient: "Yessah, kindly hand me mah
hat." — Yorkshire Post.
"A thorough gentleman, the most polite man I
ever met."
"Yes, .'Mgernon. Jenkins was that."
"But he died unhappy, very unhappy."
"So, .'\lgernon, so?"
"Yes, he was afraid his relatives would think his
last gasp for breath was a hiccup and he wouldn't
be able to excuse himself." — Michigan Gargoyle.
A serious-looking stranger called upon Mr. Biggs,
shook his hand limply and remarked:
"I am representing the Association for the Sup-
pression of Profanity. I want to take the evil lan-
guage clear out of your life."
"Come here, Maria!" yelled Mr. Biggs, "here's a
man wants to buy our car." — Duluth News-Tribune.
"I would like to see the latest shades in silk hose,
please."
"Yes, madam, her: is our exceptional value, priced
at six dollars a pair."
"My, they come high, don't they?"
"Yes, madam, but you are a very tall woman." —
Colorado Medicine.
Susan admits, that generally speaking, women are
generally speaking.
There is no use to try to joke with a woman. The
other day Jones heard a pretty good conundrum and
decided to try it on his wife.
"Do you know why I am like a donkey?" he
asked her when he went home.
"No," she replied promptly. "I know you are,
but I don't know why." — Exchange.
Old Lady: "I suppose when you grow up you
want to do something for humanity."
.Ingel Tot: "Yes, ma'm, I want to be a bad ex-
ample."
Teacher — Who was king of France during the
Revolution?
Confused Student — Louis the Thirteenth — no, the
Fifteenth^ — no, the — well, anyhow, he was in his
teens. — Yale Record.
"No, thank you, sah," said the old man. "Ah
reckon mah old laigs will take me 'long fast enough."
"Aren't afraid are you, uncle? Have you ever
been in an automobile?"
"Nevah but once, sah, and den ah didn't let all
mah weight down." — The Wheel.
It was along a beautiful stretch of highway and
the telephone line along the way was in the hands
of repair men. She was driving and cooing, when
of a sudden she spied the men climbing the telephone
poles. "Elmer, just look at those fools," she ex-
claimed; "do thev think I never drove a car before?"
—The Wheel.
Lady (to druggist): Have you any Life Buoy?
Druggist: Just set the pace, lady. — Punch Bowl.
"Dat goil I innerdooced yer to wuz a Southerner."
"Yeh, I wuz wise to dat foist thing fr'm de fierce
way she has o' p'nouncin' her woids." — rf.Tas Ran-
ger.
Little Mary was in church with her mother. Sud-
denly, putting her hands to her mouth, she said,
"Mamma, I'm getting sick."
"This is no place to get sick, Mary ; hurry out to
the church yard."
In a few moments Mary returned and said, "I
didn't have to go outside, mamma. In the back of
the church I saw a little box with the sign on it,
'For the Sick'." — Colorado Medicine.
Parson: "And which of all the parable.? do you
like best ?"
Tommy: "The one where somebody loafs and
fishes."
"Johnny," said the minister, reprovingly, as he
met an urchin carrying a .string of fish one Sunday
afternoon, "did you catch those today?"
"Ye'es, sir," answered Johnny. "That's what they
get for chasin' worms on Sundav."
SOUTHERN MEDICINE and SURGERY
Vol. XCI
Charlotte, N. C, May, 1929
No. 8
The Doctor and Citizenship
Being the Presidential Address to the Seventy-sixth Annual Meeting
of the
Medical Society of the State of North Carolina
Thurman D. Kitchin, M.D., Wake Forest, N. C.
It is not time wasted, perhaps, to close our
ears occasionally to the din of a complicated
modern world as it beats against our doors
and windows, and to turn our attention to
an era when society was simpler than it is
now. It was simpler because there were
fewer people to inhabit the land, and these
cime together less often. Their wants were
more eas'ly satisfied, for the standard of liv-
ing had not reached the point where things
reem dominant, nor had been heard the
clamor for diversion by voices which would
rot be quieted. Such words as moderation,
austerity, and integrity were [peculiarly ap-
plicable in that less complicated era. I do
not mean to convey the impression that I
am dissatisfied with the era in which we are
row living; well do I realize how futile it
is to "cast leaves and feathers in last year's
rest." We all understand that "to change
and change is life, to move and never rest,"
and not one of us, if he could, would elect
to go back to that earlier time. But as we
strive to gather the full meaning of life today,
and face the problems with which our pro-
fession is beset, we may find that the light
of other days will serve to make the present
day clearer.
Descartes writes that . . . "The preserva-
tion of health is without doubt, of all the
Ijjessings of this life, the first and fundanien-
lal one; for the mind is so intimately de-
rerdcnt upon the condition and relation of
the organs of the body, that if any means
can ever be found to render men wiser and
more ingenious than hitherto, 1 believe that
it is in Medicine they must be sought for."
This is merely a succinct statement of an
axiom which explains in large measure why
the physician has always played such an im-
portant part in the development of the indi-
v'dual and of society at large. .\n important
element in the practice of medicine has al-
ways been the personal relationship between
the doctor and patient. Before the mere
fact of living became such an intricate proc-
ess, before the days when a physician must
needs establish a buffer between himself and
an ins'stent outside world in order to conduct
his work without fear of constant interrup-
tion, before the time when even the most
insignificant matters came to the medical
man tied with endless red tape, there was
more opportunity for this relationship. The
pat'ent was then an individual unit, was an
individual sharply distinguished from other
patients; his idiosyncrasies were known and
considered by the doctor. The [latient took
comfort from the fact that the family physi-
cian "knew his constitution." There was
something touching and beautiful in the con-
fidence and devotion — even approaching rev-
erence— which the whole family accorded him.
.And in his turn there was a spirit of undying
loyalty and sympathy, and a will to serve
whch never knew shadow of turning. Medi-
cine dealing with the masses was almost un-
known. The only gestures in that direction
were such simple ones as quarantine against
infection at Ih? ports of entry and wholesale
vaccinations. .As I mentioned before contacts
between indiv'duals were few, and therefore
health measures which dealt with people at
large were neither necessary nor desirable.
What was true of medicine in earlier days
was in a measure true also of religion, the
284
SOUTHERN MEDICINE ANt) StRGERY
May, IP^o
simple tenets of which a Christian sought to
follow by visiting the fatherless and widow
in their affliction and keeping himself un-
spotted from the world; and, it may be add-
ed, honestly striving to "give himself with
his alms."
The history of our government also may
be traced back to simple and unpretentious
beginnings, its main duties being such ele-
mentary functions as collecting taxes and
keeping the peace, so that it did not require
an expert in political science to be familiar
with the diversified nature and intricacy of
its ramifications.
Today, however, we are living in a crowded
society, swarming with human beings who
jostle each other at every turn. The serenity
of those earlier days is invaded by a mad
desire for speed. It is said that whereas in
olden times a person missing the stage coach
would wait patiently a whole week for the
next stage coach, now a person chafes with
vexation if he must wait for the next section
of the revolving door. Well may we implore
the Almighty to "forgive our feverish ways!"
In the present state of society each person is
in close relationship with every other person.
Remoteness is a term seldom applied now-
adays. We can take down the telephone re-
ceiver and in an incredibly short time be in
conversation with a friend across a continent,
or beyond the ocean. W'e are given reason
to believe that soon we shall see a friend as
well as hear his voice while the telephone con-
versation is going on. The air routes are
making the distant reaches of the world as
accessible as adjoining states used to be.
Through the magic of the radio we stride on
ten-league boots from New York to Dallas,
from IMiami to St. Paul. Thus society is
today a network of human relationships
which weaves the fabric of our social garment.
In the intricate design of this closely woven
cloth is it to be wondered that individual
threads are lost? Perhaps this is one reason
why to the unthinking individual this has
brought about a sense of lessened responsi-
bility and a tendency to shift personal obli-
gation by thrusting emphasis on society as a
whole.
And not only through improved methods
of travel and communication. Added to these
are the present day methods of producing
and distributing the materials of the world
and the new intellectual freedom — all these
and such as these are directly or indirectly
traceable to modern science. Science has
made life at once simple and complicated;
simple, because it has furnished appliances
for ease and comfort; complicated, because
it has fired mankind with a desire to play
with the toys which it furnishes, to test the
machines which are themselves only a little
less than human. Yet the tendency has
been for these very machines to become des-
pots in the commercial world. This robot
rule tends to take from the workman the sat-
isfaction of weaving his individuality into his
product and by monotonous operation has
lessened individual satisfaction in work. The
human element is being lost from business.
The prestige of custom has dwindled. Mass
production has made life more rapid but less
adventurous for the individual. Civilization
has become so hurried and so flurried that
sober thought is difficult and rare. Indeed,
there are schools in operation now whose busi-
ness it is to teach to a panting world the
lost are of reflection! If the world be domi-'
nated by machines, and society be controlled
by money and the power of the herd, is it
any wonder that the individual atrophies and
the crowd hypertrophies!
With the world about us in a state of flux,
it is inevitable that traditions which have
stood as bulwarks since early days should
show signs of tottering. The home is threat-
ened by the clamor of new and daily increas-
ing outside attractions; the searchlight is be-
ing trained on religion, and its shortcomings
are picked out in an unbecoming glare of
publicity. The so-called intellectual freedom
sends men out with a keen eye for these de-
fects. "Ye shall know the truth and the
truth shall make you free" — this is their
battle-cry. All of which is well and good if
the truths they parade are not ^a//-truths,
and if this freedom is not exchanged for
license. Even if there is not evident an
actual letting down of morals and diminish-
ing of ideals, there is a change manifest in
the methods of the church, a re-direction of
its activifes. No longer does it concern itself
as formerly with the individual devil and the
lurid horrors of hell, offering redemption as
a sort of fire insurance, but in the case of
the individual is wont to emphasize the re-
strained life, the sacrificial life, faith with
works — spirituality plus altruism. In dealing
with the masses religion enters the field of
May, 1020
SOUTHERN MEDICINE AND SURGERY
28S
Eocial service and we have the institutional
church, the denominational hospital — all man-
ner of schools, homes and the like. In like
manner the government has left its elemen-
tary functions and spread its tentacles in all
directions, until there is constant, if not con-
scious, dovetailing of the various activities.
Health measures are no longer matters for
the doctor alone but are questions for society
at large.
This brings us to consideration of the part
which the doctor is to play in this new drama:
for whether the medical profession likes it
or not, this is on the boards to stay — that
is. the government and philanthropic organi-
zations are going to do more and more for the
health of the people and concern themselves
more and more with medical education and
medical jjractice. This will be to the advan-
tage of all if the particular thing undertaken
can be handled in mass and if the scenery
and stage-setting can be made to conform to
the whims and idiosyncrasies of the actors,
but it will be a failure if it is lacking in either
of these points. Manifestly the scene must
be viewed from all angles, and consideration
given to the producer, the cast, the onlookers,
and even the stage-hands without which the
machinery would not function. It must be
v'ewed not alone from the angle of the pro-
fessional reformer; it also must be looked
at with a view to consultation on all subjects
touched on and all factors involved if the
play is to move successfully. Necessarily the
doctor is one of the most important factors
but not the only factor. When health meas-
ures are uppermost in the minds of the peojile.
the lawyer, the minister, the experienced
business man must be consulted, and the
ta.xpayer, and others. Kew projects affecting
society at large are apt to impinge upon the
rights of many, and must be subject to nmdi-
licati(m and alteration, for the human equa-
tion must be taken into account at every
turn. The doctor must realize that physical
ills may be due to social and economic con-
ditions as well as to physical, and that ine
proper treatment may be social adjustment
rather than medicine or a surgeon's kn'fe.
That is, he must study social pathology in
relation to physical pathology. Conversely,
the emjjloyer must realize that social and
economic ills may arise from untoward phy-
s cal conditions affecting employees, and that
better housing and instruction in the laws of
health may prove the most beneficent sort
of arbitration: that is, he must know some-
thing of the elements of physical pathology
in relation to social pathology.
.\gitators and professional reformers are
useful in dragging to light matters which
might otherwise continue to lurk in dark
corners, but these peojile are rarely so well
balanced as to determine what methods should
be used and to bring them forth, and what
percentage of the ultra-violet ray of publicity
is necessary to nurse them to full health.
Also there is the question of timeliness to be
cons'dered. Details of reform work should
be worked out by consultation and by co-
operation of all the agencies and factors in-
volved.
Unfortunately many of our laws are made
and executed in a spirit of class interest. The
laws are passed because some set of people
are particularly set against this or that thing,
rather than after mature deliberation and
study. Especially as regards the laws con-
cerning the health of our people, both intelli-
gence and humane insight, coupled with co-
operative specialization, must be employed, if
we are to avert disaster in the impending
crisis. The Government — federal, state,
county, and municipal — is going to do more
and more in a medical way for the people,
csi^ecially for groups as against individuals.
We must be prepared, then, to accept this
provision with a good grace and not only to
co-operate but to co-operate intelligently and
efficiently: likewise we must be prepared to
l^rescrve the amicable relations which have
always existed between the medical profes-
sion and the state and to exert our influence
toward outlining the correct part to be played
by each. We cannot afford to do the work
and carry out in detail something created
without our participation or without a voice
in its control. Precautionary measures are
essential both for our own good, which is
the narrowest view, and for the good of man-
kird.
The chef a'ms of society are: First, legal
organ'zation for protection, laws and regu-
kit'ons, establishment of property and indi-
V dual rights — in short government: second,
religion or the spiritual welfare; third, medi-
cal or physical welfare. But it is inevitable
that the spheres shall overla[), therefore each
specialized group cannot limit its attention
to its own business to the exclusion of the
286
SOUTHERN MEDICINE AND SURGERY
Mav. 1929
interest of others. Each group must have
a broad outlook in order to function and
co-operate efficiently and wisely. This atti-
tude of lett'ng each group attend to its own
field exclusively is responsible for many of
(he anomalies in our laws and social life
tcday; also the practice of passing a law
and then sitting complacently down and tak-
ing for granted that the thing has been ac-
complished goes far to explain, not only the
law's delay but the law's ineptitude. Laws
fhould be studied without bias and scientifi-
cally by all the groups in order to formulate
statutes that will be wise and likely to ac-
complish the results intended. Such laws will
not, of course, bring about such drastic and
radical reforms as to satisfy the professional
reformer, but the reaction against such laws
will be less and a foundation will be laid
upon which the envisaged structure can be
built. Here again is the inter-dependence
manifest and as science progresses in social
relations the doctor becomes more essential.
The spheres are inter-dependent and each
should rely upon the other for technical detail
in order to arrive at the best results, but as
a matter of fact this is not being done. To
illustrate, our legislature has recently passed
a law to steril'ze the feeble-minded. This is
a step in the right direction: but those who
think that such a law will materially lessen
the number of the feeble-minded in the state
have disillusionment in store because such
factors as these must be considered: (a) of
the estimated 60,000 feeble-minded in the
state only about 600 are identified and these
are already segregated and cannot reproduce:
thus sterilization would have no practical
effect upon the number of feeble-minded re-
produced; (b) this 60.000 is only an estimate,
rince they have not been identified and with
the present state of our knowledge it is abso-
lutely impossible to do so. The man does
not live who can go about in th's state and
put his finger upon people who m'ght be car-
rying in themselves cells capable of produc-
'ng either a gen'us or a feeble-minded crea-
ture. When even the greatest alienists differ
as to the sanity of an individual, what kind
of an imagination is requ'red to fancy
that science can select from among appar-
ently r.ormil people those who m'pht produce
the abnormall; (c) it is a matter of every-
day observance that a large percent.Tze, if
not the majority, of those feeble-minded in-
d'v'duals who have come under our personal
observation have been born of parents who
wou'd never have been considered subjects
for sterilization on any known basis: (d)
Normal-mindedness is a dominant factor
wh'le feeble-mindedness is a recessive factor.
Consequently, if a normal-minded person
mates with a feeble-minded person, the first
generation will all be apparently normal-
mmded and will have average intelligence.
They will, of course, have in themselves the
recessive factors but these cannot be detect-
ed. Therefore sterilization would catch none
of this generation. Now, if a member of
this generation mates with a member of a
generation having the same inheritance, then
about three-fourths of the resulting offspring
will be apparently normal-minded and about
one-fourth will be feeble-minded. That is,
sterilization would catch only twenty-five per
cent of the offspring from this mating, (e)
As'de from the difficulties in determining who
would be subject to such operations any at-
tempt by law to determine those of sufficient*
mentality to justify marriage and reproduc-
t'on would meet with such insuperable obsta-
cles when attempt was made to put it into
actual practice that it would fall to pieces,
(f) The predictable characters from any
matings are so extremely few that to attempt
to breed a certain type of individual is ab-
surd, to say nothing of the difficulties arising
as to who should be the judge of the stand-
ard we are to produce and of what the stano
ard should be and of how long that partic-
ular standard should be in style! (g) Final-
ly, sterilization which only prevents repro-
duction without interfering with the sexual
life, certainly in the type of patient for which
it is prepared, would be license for immor-
al ty and this blow to morality would offset
any good that might accrue to the physical
man. Furthermore, is it not possible that
this process m'ght be used as much by the
upper two per cent of the population to pre-
vrt reproduction as by the lower two per
cent? It must be remembered that authori-
I'cs consider and class as feeble-minded the
two per cent of the population that occupies
the lowest level of intelligence. Thus we will
.ilways have this proportion of feeble-nvnded-
ncjs regardless of how high our general aver-
a'-c "f '"telligence might develop.
.Aprther example of the point in question —
i. e., the anomalies in our laws and social life
Mav, 102Q
gOtJtHfefeN kMbtdtkfi ANb StJkGfifeV
iif
tcday, is the Volstead act. Everybody ad-
mits th? desirability, nay the necessity, of
resjulations imposed on physicians to prevent
the use of alcohol as a beverage, and to pre-
\ent the doctor himself from becoming a
bootlengerl But such a law should be
stud ed from an unbiased standpoint and not
regarded from a partisan or sentimental point
of view, nor yet through the blue spectacles
of th? reformer. It should be so framed as
not to prevent the legitimate use of alcohol
in the practice of medicine. (I hope doctors
will not be allowed to prescribe alcohol as
long as I practice medicine but this is a
narrow selfish view — the very sort I am ar-
guing against.) That many of our ablest
doctors think that alcohol has no place in
the physician's armamentarium does not in-
validate the principle, because the same is
true of many other remedies in use today.
Lorn; are praised for one property by one
j)hysician and for an entirely different prop-
erty by another physician. The real aim of
the law is to prevent the social and economic
evils that result from the use of alcohol as a
beverage. But unfortunately alcohol for bev-
erage purposes and alcohol for medicinal pur-
poses have become interchangeable terms.
And it is a reflection upon intelligent special-
ization and co-operation that the terms can-
r t be dissevered both in theory and in prac-
tice.
The narcotic problem, too, is one that can
hardly b^ solved by legislation alone, no mat-
ter how stringent the laws against the drug
handler, nor can it be solved by the estab-
I'shment of narcotic farms. Its roots have
gone too deep; it is a medical rather than a
penal problem. Every drug addict is not a
criminal, nor is every criminal a drug addict.
The same abnormal tendencies which predis-
],ose to the drug habit may predispose to
crime, the drug habit being a manifestation
of an ind vidual abnormality. And the addict
lakes drugs in an effort to adjust himself to
his world. The maladjustment may be
classed as a disease, and the addiction is a
: pecies of self-medication for the purpose of
lelieving the condition, for substituting
pleasure for jiain, seeming success for failure,
liope for despondency. It is practically al-
ways begun for the purpose of bettering the
(.xisting conditions either imaginary or real.
That it fails to accomplish this does not
make the victipi a criminal. The same ap-
plies to most self-medication through the use
of which the victim in his ignorance thinks
he is helping himself but in reality is doing
harm. Drug addiction is simply a shining
example of misguided self-medication.
Just recently a bill was introduced in the
legislature of one of the great states of the
Union to establish a state narcotic hospital
to treat the drug addict. It provided that
any citizen could report the addict, then if
two physicians agreed that he needed treat-
ment, the addict would be committed to the
hospital for not less than eight months nor
more than two years, and then discharged on
such conditions as the department of public
welfare might establish. That is, he must
stay eight months regardless of how much
sooner he might be cured, and when released
he could be compelled to rejxirt periodically
the rest of his life to some welfare official.
This problem should be studied by all the
interested groups and the findings pooled in
order to reach the sound principle. The
economist, th; humanitarian and sociologist,
the criminologist, the doctor, the psychiatrist,
the moralist, all these might be expected to
find it a fertile field for study. Even the
fact that the drug factories produce annually
more than ten times the amount of narcotic
drugs necessary for the world's legitimate
needs might be taken into consideration.
Another problem for society to face is that
of quackery in medicine. Laws against
quackery, of course, are necessary but educa-
tion must be the final solution. The partic-
ular type of treatment employed in a given
case should rest with the doctor in charge,
but the law should see to it that every per-
son who treats the sick is prepared for
this responsibility by meeting those edu-
cational and clinical qualifications which are
required of regular doctors of medicine, be-
cause the foundations of these requirements
are based on the pure sciences, adapted
by the accumulated experience of all time
and accepted as sound by the intelligent peo-
ple of the world.
The more the public knows about disease
the higher value it will set upon the service
of an able physician, because health education
does not mean that lay persons will become
doctors. Rather it means that people will
be taught such fundamental facts as knowing
that the bcjdy reacts according to certain
laws, that these laws must be observed or
288
SOUTHERN MEDtClNE AND SURGERY
May, 19^^
harm will result, that the body requires skill-
ful management and repairs when it fails to
function properly — these principles will serve
to impress the fact that when the body is out
of fix an expert — that is, the physician —
should be called, and not a quack or a devo-
tee of patent medicines. We do not carry
our watches when they need repairing to an
unskilled mechanic; should the exquisite
mechanism of the human body deserve less
consideration than a watch? They will real-
ize that bad health conflicts with the consti-
tution of the United States which guarantees
life, liberty, and the pursuit of happiness for
"disease robs us of life, takes our liberty,
and makes happiness impossible." And yet
compare the amount of money spent by the
government on the army, the navy, and va-
rious other departments compared with what
is spent upon the health of the people 1
And what a spectacle in this day, when
everybody recognizes that the proper solution
of affairs depends upon making use of all
available knowledge from whatever source, to
see that the appropriation authorities of a
great state say that a doctor's views should
not be considered in connection with the ap-
propriations for the state health department
in general and the State Laboratory of Hy-
giene in particular, because forsooth the doc-
tor is vitally interested in that department
of the state's work. The inference is that
views, opinions, and suggestions would be
considered if coming from any class of per-
sons whatever, provided it knows nothing
concerning the problem at hand. Shall such
policies be settled in terms of expert book-
keeping alone? Shall they be settled without
regard for the very thing they are intended
to foster — human welfare? What a negation
of specialization with co-operation, which is
the mudsill of intelligent progress.
An eminent physician with broad humani-
tarian interests has said that the time will
come when the culture of a nation will be
estimated according to the mutual relations
between medicine and the people and that
we must strive to improve man individually
and collectively, by scientific research into
the wants and needs of mankind, and apply
preventives and remedies for mankind's phy-
sical, intellectual, and moral dangers and
defects and through this medicine can create
that power which alone protects individuals
against despair and saves nations from wreck-
ing.
The newer developments in our field such
as government aid, free clinics, institutions,
etc., meet a certain demand and the public
will use them and, unless we provide and
control the handling of this practice of medi-
cine in the mass, it will probably be forced
upon us by the public ever ready to welcome
what appears to be something for nothing.
So our real problem is to work out a
method whereby these agencies will not con-
stitute an unfair discrimination against the
medical profession; and at the same time we
must preserve for the people the best that is
in them. In the long run anything which
operates to the detriment of the medical pro-
fession will be hurtful to the public interests.
Therefore, we must prepare to enlarge our
usefulness and perform our service to the
public in such a way that our value as phy-
sicians and our influence as citizens may be
preserved and enhanced.
There is never any danger that the doctor
may work himself out of a job by advocating
such methods of education and co-operative
legislation, because, even if there were a cure
for every disease, the variations in individuals
would still require the services of a doctor.
This is true because no two individuals will
ever react in exactly the same way to the
same stimulus and, moreover, every one saved
is a potential patient. Then, too, the wear
and tear in the individual and the ultimate
death preceded by complications will always
require the service of a physician. And it
may well be true that geriatrics may super-
cede pediatrics. The slogan "save the baby"
may have to share its ix^pularity with
"Grow old along with me I
The best is yet to be.
The last of life for which the first was made."
The variation in the individual which so
sharply marks it off from the machine-made
product, which demands intellectual ex-
ercise and individual judgment and adjust-
ment in each and every case, is the very point
which makes our profession so interesting and
absorbing. The very fact that our education
is never finished and that as long as there
are patients there will be new things to learn
is a challenge to the best there is in man.
Our profession must work to advance our
civilization because society, as has been well
May, I9i4
gbttttfeft^f Mfebtctkfe kUb stfeGfcfeV
isi
said, is like the bicycle rider "feeling safe
only if moving and satisfied only when ad-
vancing.''
But we must take care that the progress
so much longed for is accomplished without
radical and destructive measures and with-
out an endless program of campaigns to make
the world safe for this and safe for that, until
the very defences we throw out to protect
ourselves prove stumbling blocks and hin-
drances to progress. Instead, we must adopt
the method of growth which appreciates and
encourages the conservative and the construc-
tive, instead of well-meant but clumsy devices
which fail to achieve the purpose for which
they were intended. Our particular field is
to increase mental and physical health, for
by doing so we are improving thought and
life and are building for a greater day. It is
especially necessary in our comple.x society
that our mental health be conserved because,
like any other delicately adjusted machinery,
our social life must be properly co-ordinated.
In view of what I have said about the
changes which have taken place in all depart-
ments of life, what I am about to say now
may seem paradoxical, but I wish to empha-
size the point that the bedrock foundations
upon which our civilization was founded still
remain. I am thinking now especially of the
old personal relationships of the doctor with
the patient. These may be half hidden by
that which is ephemeral in the new order,
and may appear now and again under a new
guise, but remain nevertheless. Indications
are that medicine for the masses will be done
more and more in a general way by the so-
cial agencies, but this can go only to a cer-
tain point. This should relieve the doctor
of an enormous amount of perfunctory rou-
tine work, and release him for the study and
practice of individual medicine, which is pe-
culiarly his sphere. This should add pres-
tige to the profession and zest to the work,
because the doctor would have real cases,
and sufficient time and incentive to study
them. When our society was simpler than
it is now the direct relationship between the
teacher and the pupil was the pivotal point
of the educational system, but the method
of our progress and the demand for standard-
ization have made necessary a vast deal of
machinery, some useful and some useless,
operating between the teacher and pupil.
Now the pupil is supervised by the teacher
and the teacher is supervised by the princi-
pal and the principal is supervised by the
county agent, and the county agent is super-
vised by the state supervisor, with apparatus
all along the line. But with it all the inter-
est of the sympathetic teacher in his pupil is
the essential thing. Despite committees and
boards and a multiplicity of organization and
detail in the churches, nothing ever has yet
taken the place of personal reverence and
personal faith. And so it is in medicine:
nothing can supplant the personal relation-
ship of the doctor and his patient. After all
is said and done, this will remain.
For society to continue onward and up-
ward, there must be specialization with co-
operation, therefore it is important that the
knowledge of the specialist and the findings
of the research man should be co-ordinated
and pooled for the common good. Research
is essential, and the conscientious research
worker will always be the vitamine of scien-
tific progress. In a large number of matters
the physician must rely up<3n the research
man for technical information concerning his
problems, but the technical expert often sees
only a narrow angle, and it is the duty of
the practitioner to mediate between the man
absorbed in the purely scientific atmosphere
of laboratory and library and the public ab-
sorbed in the practical atmosphere of every-
day affairs. The doctor then must be pre-
pared to interpret the important and useful
findings of the exponent of the world of
science in terms which may be of service to
society at large. Surely the alert and dis-
cerning physician who applies these discov-
eries to the benefit of mankind deserves to
share with the researcher some of the credit
and glory which is the just due of both.
However, the present day program which
practically demands that all teachers in medi-
cal schools do research work seems arbitrary
and unwise. For work of this kind only a
few are qualified, for research workers, like
poets, are born and not made. When teach-
ers are forced to do this work, it is usually
done at the expense of the teaching of the
student. In many instances such research is
only a type of expensive advertising. For
research by medical students, there is even
less justification. In the first place, there is
enough knowledge already at hand fully to
occupy their time. In answer to the argu-
ment that it stimulates a student's interest
200
SOUtMERN MEDICINE AKt) SURGEkV
iViav, IQ.'a
in his work and encourages original effort,
implanting a desire to search beyond the
limits of the known, let it be said that if
properly taught there will be sufficient in-
spiration and furthermore, every experiment
he performs in the regular medical laboratory
courses is a research problem for him, from
which he should derive the stimulus and
broadened outlook which is claimed for re-
search.
Physicians have been so busy diagnosing
and treating and preventing disease that the
individual harboring the disease has almost
been forgotten. Of course it is presupposed
that doctors should know all there is to be
known about the scientific side of medicine,
the latest in diagnosis and in treatment; but
even this is not enough since the reason for
any of it to be done at all was, is, and always
will be the patient. To focus so much atten-
tion on the patient is not a contraction of
our horizon because every individual is a unit
in society and the saving of this unit con-
tributes to the ultimate saving of society as
a whole. Undoubtedly we have in our scien-
tific studies strengthened the tangible things
in diagnosis and treatment. We must guard
against the danger that the intangible, that
is, the human element, may be lost. With
the test tube in one hand and the microscope
in the other we have had no hand left for
the patient. We must strive to develop an
imaginary third hand. Without lessening the
strength of either the test tube hand or the
microscope hand this emanation from the
heart, from the spirit may help the patient
to keep up his courage and fight his way on.
With all of our modern success and manifold
accomplishments we can well turn back and
take a few leaves from the doctors before the
birth of our modern medicine. And from
them the paramount lesson to be learned is
that we must study the individual as a whole
and understand his reaction. Amiel, writing
in his Journal in August, 1873, gave expres-
sion to a text from which we might well
preach today. "Doctors make mistakes," he
says, "because they are not sufficiently in-
dividual in their diagnoses or their treatment.
They class a sick man under some given de-
partment of their nosology, whereas every
invalid is really a special case, a unique ex-
ample Every illness is a factor simple
or complex, which is multiplied by a second
factor, invariably complex — the individual
who is suffering from it, so that the
result is a special problem, demanding a spe-
cial solution."
As civilization advances and science erases
boundaries and increasingly difficult human
problems and adjustments are pressing for
solution, the physician must be more and
more versed in the affairs of the world. He
must guard against a narrow outlook, he
must take an interest in the great issues of
the day and when possible play an important
part in deciding them, for it goes without
saying that he must shoulder his part of the
general responsibility. In whichever direc-
tion the world is advancing the doctor must
be on the firing line.
I have tried to sketch for you in hasty
outline the times in which we are living —
these breathless times in which we are hurled
from one phase to the next; the changes
which have taken place; the miracle of mod-
ern inventive power, which turns our world
topsy-turvy, while science says in triumph:
"Behold, I make all things new." I have
touched upon certain problems which legis-
lation seeks to solve; I have tried to impress
the need for specialization plus co-operation,
especially in our own profession. And last
of all, I have sought to bring home to you
the truth that in spite of seeming chaos in
these whirling times, basic things remain. To
a person on a swiftly moving train objects
seen from the window seem to be rushing
pell-mell in the opposite direction; the trees
of the forest might be an army in rapid re-
treat. Yet if the train should stop he would
find the trees standing firmly rooted, as they
have been for decades, their roots going ever
deeper and deeper into the sustaining soil.
Does the motion of the train cause the leaves
to tremble? Does soot and dust settle upon
those nearest the steel rails? What then!
The whole world knows that the rate of the
train's speed, no matter what its velocity,
affects in no way the roots of these denizens
of the forest. The analogy is, I hope, clear
enough not to need amplification; certainly
we must believe that the speed with which
we are living today is not undermining those
fundamental principles upon which our civili-
zation is based. We must realize that
"through the ages one increasing purpose
runs" and that the purpose is a wise and
constructive one. Our part is to work with
a will and to keep faith. Does the future
May, 1020 SOUtHERK MEDICtNfi AMt) StJftGEftV J91
seem dark? Take heart, the morning is com-
ing—
"And not by eastern windows only
Where daylight comes, comes in the light
In front, the sun climbs slow, how slowly,
But westward, look, the land is bright!"
There are today lying all about, as yet uncorrelated, many if not most of the raw
materials for a vast system of state medicine or its equivalent in the corporate medi-
cal activities of industries, insurance companies, and the like. Now, personally, I
dislike to see fall into the hands of government any activity that can be done equally
well or better by one of the great functional groups of men as they go about their
daily work in their trades or professions. And so, I raise the question: Is private
medicine to be swallowed up by state medicine or its equivalent? The answer to this
question will, I think, depend entirely upon the quality of medical statesmanship
displayed by the medical profession during the next few years.
— Glenn Frank, President, University oj Wisconsin.
From The Wisconsin Medical Journal, April.
Ci^^^
292
SOUTHERN MEWCtMfi KUti SURGERY
May, 1929
President Hall:
Now you are going to hear for a little while
Dr. John A. Kolmer, Professor of Bacteri-
ology in the University of Pennsylvania, who
is going to stand here and answer what ques-
tions you want to ask him.
The Clinical Laboratory in the Diagnosis and Treatment of
Disease*
John A. Kolmer, M.D., Philadelphia
Professor of Bacteriology, University of Pennsylvania
The subject assigned to me by your good
president is a very comprehensive one, but
with the aid of lantern slides I hope to be
able to cover it in a brief manner.
We hear a good deal nowadays of the art
versus the science of medicine. Very fre-
quently I hear the criticism voiced that the
present-day tendency is to rely probably too
much upon the laboratory for the diagnosis
and treatment of disease. But this is not
true. Clinical medicine should always receive
our first consideration in the diagnosis and
treatment of disease, but the wise and the
well-trained physician will know when to call
upon the laboratory for aid in diagnosis. P'ur-
thermore there are some diseases which can
not be diagnosed except in the laboratory. I
need but mention syphilis in its so-called lat-
ent stage — which should be called its conceal-
ed stage, because syphilis is never latent — in
which diagnosis can not be made by physical
examination or from the history of the pa-
tient, and in which the serum tests may be
the only means at the command of the phy-
sician in making the diagnosis. Also diabetes,
in which diagnosis by blood-sugar determina-
tion should be the aim of the physician before
the disease has progressed to the stage where
sugar appears in the urine. There is indeed
a midway position, which, like so many
things in life and in medicine, would appear
to be the correct one.
It is scarcely necessary to speak upon the
importance of technic in relation to laboratory
diagnosis. Laboratory diagnosis can be of
no aid unless the methods are correctly con-
ducted; therefore the value of a laboratory
♦Presented by invitation to the Tri-State Medical
Ass.M'iation of the Carolinas and Virginia, Greens-
boro, N. C, February 19, 1929.
depends a great deal upon the training and
the experience of the individuals who are con-
cerned in this phase of medicine.
The data returned by laboratory exam-
inations must be interpreted very broadly,
and the better educated the physician is
the more likely he is to interpret the data
correctly. It is always to be kept in mind
that a diseased organ may still be functioning
and that the results of a laboratory examina-
tion may be even normal and yet the organ
itself be the seat of disease. We see this
particularly in the case of the kidneys, so
that a so-called negative report from the lab-
oratory should never override clinical judg-
ment. Positive reports from the laboratory
therefore command more attention, but both
the positive and the negative should be inter-
preted in the light of clinical experience.
I might briefly refer to the examination of
tissues removed at operation. It is scarcely
necessary to emphasize the importance of
their microscopical examination, particularly
if the question of malignancy is involved.
Xeither should I need to emphasize the
importance of autopsies in the acquisition
of medical knowledge. I hope very much
that in the hospitals of your city there is a
goodly percentage of autopsies and that ar-
rangements are made to bring at least the
results of one autopsy before each meeting
of your medical society. I know of no better
way to check up medical opinions and prac-
tice than by autopsies, and it is those com-
munities where autopsies are made most fre-
quently that are furthest advanced in medical
science.
Not infrequently physicians are aware of
the value of laboratory examinations but can
not avail themselves of them because of the
May, 1920
SOUTHERN MEbtClNE AND SURGERY
i9i
expense involved. But now it is quite possi-
ble in your towns and cities to have one man
who is trained as a pathologist and for him
to take care of your institutions in a sui>er-
visory capacity and have much of the techni-
cal work of the institutions done by well
trained technicians, this being a new field
for young women. When the work is grouped
the proper spirit of co-operation.
(Lantern slides.)
The first four slides summarize the useful
general blood examinations:
1. I wish to refer in this slide to a new
method for conducting the differential blood
count. You will probably recall that there
are the six principal kinds of leukocytes found
NO. 1
BLOOD EXAMINATIONS
*Hemoglobin estimations
*Er>throcyte count
♦Leukocyte count
Platelet count
♦Differential leukocyte counts
Variations in size, staining and shape of erythrocytes
♦Color index
♦Volume index
Malaria and other parasites
Sedimentation Time
Fragility of Erythrocytes
♦Routine
NO. 2
DIFFERENTIAL BLOOD PICTURE (NORMAL)
Total leucocytes: 6000-8000 per c.mra. (adult)
Usual (old) Method ' A'"'' (^'"7' '" '*■/' ) Method
Small lymphocyte
Large lymphocyte or
monomiclear 2%
Transitional
Polymorphonuclear
67??.
Eosinophile
3%
Basophils
1%
Small lymphocyte
Monocyte
Metamyelocyte
(young J none
Metamyelocyte
(old or banded)
Nj<'^_\ Polymorphonuclear
^ ^J 63%
Eosinophile
3%
Baaophile,
in this manner the cost can be made corre- in the blood: The small and large lympho-
spond'ngly less, so the great bulk of the mod- cytes, which are so frequently increased in
ern technic of the laboratory can be made chronic infections and in the lymphat'c leuke-
available in any community where there is mias; the polymorphonuclear leukocytes;
294
sottiitikK MEDicme and strkG6ftV
May, 1920
the eosinophiles; the basophiles and the
myelocytes. Now, a new method of conduct-
ing the differential blood count has been
evolved, largely in England and in Germany,
which has been called the Shilling or "shift
to the left" method, in which the polymor-
phonuclear cell is studied with more care.
We find that this cell has its origin in the
bone marrow and first appears as a cell with
a single nucleus and a slight indentation,
which is known as the young metamyelocyte;
that the slightly older cell is known as the
older metamyelocyte, and that the matured
cell is the ordinary polymorphonuclear. In
acute infections we find that the greater the
infection the more the stimulation of the bone
marrow and the greater the number of these
metamyelocytes. I will show you a slide to
illustrate this.
2. We recognize here that we have a pa-
tient who is very acutely infected, because
the blood count shows a great increase of
these metamyelocytes, which are the progeni-
tors of the polymorphonuclears, indicating
that the individual has a bone marrow which
is profoundly disturbed by the presence of
acute infection. We have found by this new
method, then, that we get more information
from the differential leucocyte count by ap-
plying this newer knowledge of the leucocyte
and counting these metamyelocytes than from
the older way. We think a better plan is to
judge the degree of infection by the total
leucocyte count and by the percentage of
metamyelocytes that are in the peripheral
blood rather than by the percentage of poly-
morphonuclear cells.
cell anemia, which I doubt not is to be found
in your community and particularly among
negroes as a familial tendency; in the diag-
nosis of chlorosis and in the diagnosis of that
terrible disease known as agranulocytic an-
gina. These patients have a severe sore
throat in which one e.xpects to find a total
leukocyte count of 10,000 to 12,000 or higher
but finds it down to 1,000 or less. The eti-
ology of this condition is still unknown and it
is always fatal; it is called agranulocytic an-
gina because of the sore throat and the ab-
sence of the granular leukocytes like the poly-
morphonuclears, eosinophiles, etc., in the dif-
ferential leukocyte count.
We also resort to this examination in the
diagnosis of polycythemia and in the diagno-
sis of the leukemias. Please do not forget
that many of these leukemias first manifest
themselves as gingivitis. Then the blood ex-
amination is also valuable in the diagnosis of
purpura hemorrhagica and is also of some
value in the diagnosis of Banti's disease. It
is also of some value in the diagnosis of
whooping cough due to the presence of a
leukocytosis because of a sharp increase of
the small lymphocytes. You have to keep in
mind that a child's total leukocyte count is
higher than in adults and that a child also has
a larger percentage of small lymphocytes but
in the catarrhal stage the blood count is fre-
quently of value, particularly because in this
stage the disease is most contagious.
4. Serological blood examinations summar-
ized in No. 5 are also of distinct value. No
one would think of doing a transfusion, ex-
cept in gross emergency, without typing both
NO. 3
HEMOGRAMS
'elocytes -.
. ig " "
. 14 " "
None
12 "
. .. _.. . 61 " "
63 "
1 "
1 "
Leukocytes
Small lymphocytes
Monocytes
Young me
Old metamyelocytes
Polymorphs
Eosinophiles
Basophiles
3. In what diseases can a general blood
examination be of value in diagnosis? Well,
we have the secondary anemias, where there
is a reduction of erythrocytes and hemoglob-
in, in such conditions as malnutritions after
severe infections, and in chronic poisonings.
Then there are the primary anemias, such as
pernicious anemia; in the diagnosis of sickle-
Pelvic
Suppuration
20,000
S per cent
1
Mild
Appendicitis
8000
16 per cent
donor and recipient,
tination tests of value,
only in the diagnosis
typhoid fever but also
to infection with the
abortion of cows and
course somewhat simi
The agglutination test
There are also agglu-
And particularly not
of typhoid and para-
of undulant fever due
bacillus of infectious
apt to run a clinical
lar to typhoid fever,
is also of value in the
Mav. 1029
SOUTHERN MEDICIiVfi AND SLRGKUV
Sccondar>'
Anemias
SO. 4
DIAGSOSTIC VALVE OF BLOOD EXA.UIXATIOXS
Malnutrition
Acute and chronic infections
Hemorrhage
I Malignancy
Chronic poisoning
Pernicious anemia
Sickle-cell anemia (negroes; familial) ' '' , '
Chlorosis
Acute aplastic anemia
Agranulocytic angina
Polycythemia
( Acute lymphatic
Leukemia ■. Chronic lymphatic
' Spleno-myelogenous
Purpura hemorrhagica
Hodgkin's Disease; Banti's Disease; Gaucher'? Disease
Whooping Cough
Helminthiasis (Hook-worm)
NO. 5
SEROLOGICAL EXAMLWi TIONS
Blood Compatibility Tests for Transfusion
Agglutination Tests for:
Typhoid and Paratyphoid Fevers and Carriers (Widal Test)
Undulant Fever
Tularemia
Complement-Fixation Tests for:
Syphilis
Gonorrhea
Typhoid Fever
Echinococcus Disease
Tuberculosis
Arthritis
Precipitation Tests for Syphilis
dagnosis of tularemia, that disease of rabbits
and other rodents transmissible to man. Now
every case I'.egative to the Widal test is run
through th"s test. Infectious abortion is very
common among cows in this country; there
is scdrcely a dairy herd that does not have
this disease in its midst, and since it is trans-
missible to humans this test is of great value.
The Wassermann test remains the best sin-
gle means of the diagnosis of syphilis after
I he primar\' stage and may be the only means
in the tertiary and so-called latent stages of
the d scase. We may also use the comple-
ment-fixation test for the diagnosis of gon-
orrhea and of typhoid fever: indeed, in the
latter it far outranks the Widal test as a
means of diagnosis. We also use it in the
diagnosis of echmococcus disease of the liver
and spleen, in tuberculosis, arthritis, etc.
There are also the various precipitation
tests for svfihilis. I recognize the value of
the Kahn test but think it is unsafe to rely
upon it e.xclusively in the diagnosis of syph-
I's. Too much emphasis has been placed
upon its so-called simplicity. It is not a
s^imple test and the impression that has gain-
ed ground that the doctor can do it in his
corner laboratory is not true; when properly
done it is technically almost as difficult as
the Wassermann test.
5. I now wish to consider an imp<irtant
subject in laboratory diagnos's known as
ijlocd chemistry (No. 6.) Th's 's particularly
of value in the practice of internal medicine.
We can make various determinations in blood
chcm'stry, but probably th? most important
are those listed in the table. We all carry
from 85 to 110 milligrams of sugar per 100
c.c. of blood. In diabetes sugar does not
usually appear in the urine until it is in-
creised from 110 up to about 170, so it is
or.ly by means of blood chemistry that we
can detect d'abetes in the early period and
before sugar appears in the urine. We
;'lso get information of value as to the
ron-protein nitrogen and the creatinine and
also in the estimation of chlorides, particu-
larly in the differentiation of the two chronic
types of nephritis. We also get valuable in-
formation in the estimation of cholesterol,
particularly in cases of gall stones. There i;5
also value in estimating the calcium of the
blood, particularly in the diagnosis of idio-
pathic tetany of children. These points will
be brought out in subsequent slides.
206
SOUTHERN MEDICINE AND SURGERV
May, 1020
6. I wish to point out in this graph (No. 7)
another valuable type of laboratory examina-
t'on of aid in the differential diagnosis be-
tween diabetes mellitus and so-called renal
glycosuria. You probably have in your prac-
tice individuals who will show traces of sugar
in the urine but with a perfectly normal blood
sugar. This is called renal glycosuria and is
believed to be due to some congenital defect of
the kidneys which permits sugar to pass
through the kidneys without increase of the
normal blood sugar. Insurance companies are
especially interested in this type of test, be-
cause renal glycosuria is not recognized as
being diabetes, and urine examination alone
can not differentiate.
In conducting the sugar-tolerance test 100
grams of glucose in lemonade are given after
a fast and the blood and urine examined at
intervals. In a person with renal glycosuria
the blood sugar will rise rapidly from about
tion known as acidosis (No. 8). We meet
with it in severe diabetes and also in children
with severe starvation states due to vomiting
or diarrhea; also in the vomiting of preg-
nancy. Acidosis might be d'agnosed clini-
cally by dilatation of the pupils, an apathy
of the face, the odor of acetone on the breath,
etc., but it may be done in the laboratory
even more satisfactorily.
We sometimes have a condition the oppo-
site of acidosis, known as alkalosis, due to
increased bicarbonate in the blood. We some-
times see it in children who are transferred
over from acidosis to alkalosis by excessive
doses of bicarbonate. We may also find it in
children (and in adults, too) as the result of
pernicious vomiting, in which there is lack of
absorption of hydrochloric acid from the
stomach. In the diagnosis of acidosis and
alkalosis these examinations of the blood and
urine are essential, and the diagnosis of the
NO. 6— BLOOD CHEMISTRY
Normal 0.08.=;-0.n0
Mild diabetes 0.1,^0-0.150
Severe diabetes 0.200-1.100
Chronic nephritis
Uremia 0.100-0.200
Gout
Tetany
80 or 85, which is normal, to about 160 and
sugar appears in the urine, .^t the end of
two hours it is down to normal. In an indi-
vidual with mild diabetes it will also travel
up but less rapidly, sugar appears in the
urine, and it does not come back to normal
quite so readily. In an individual with well
marked diabetes the blood sugar goes up
markedly but still less rapidly and comes
down much more slowly. Diabetes being,
therefore, a disease of the pancreas in which
there is a deficiency of insulin production, the
individual is not able to metabolize large
amounts of sugar. This sugar-tolerance test,
then, gives valuable aid in the differential
diagnosis between renal glycosuria and true
diabetes. It is also of value in estimating
the severity of diabetes.
7. We also find blood chemistry of value
in the diagnosis of disturbances of acid-base
equilibrium, especially in that clinical condi-
o e .5
a, I .S
Mgms. per 100 c.c. of Blood
10-20 25 -30 1-1.5 1-3
15-50
30 -SO
1-3
2-5 0.540-0.750 0.150-0,300
80-300
120-350
4-34
5-15 0.480-0.640 0.170-0.350
3.5-6 0.170-0.350
5-7
milder types can not be made without labora-
tory aid.
8. Uric acid (No. 9) is not increased in
acute rheumatism but is usually increased in
chronic arthritis. We also find it increas-
ed in various dermatoses, particularly itching
dermatoses, of which eczema is a type. We
also find uric acid increased in chronic ne-
phritis and sometimes in toxemias of preg-
nancy and also in sciaticas and lumbago, but
the main value of the test is in its differen-
tiation of rheumatism from gout.
Relative to blood calcium 9 to 11 milli-
grams per 100 c.c. of blood is the normal.
(No. 10). It is markedly reduced in so-
called idiopathic tetany in children, and it is
a common thought that the blood calcium is
reduced in rachitic disease in children. This
is not true; there may be a normal amount of
calcium in the blood, but the absorption is
reduced in some way, probably because of a
May, 1529
.260-
.240 •-
.220.
.200-
SOUTHERN MEDICINE AND SURGERY
.ISO
,140--
,120-- •
j_ Renal
Threshold
Hours -^
Normal curve
Severe diahrlrs
Mild diabetes
d sturbancc of the proportions of d'ffusible
a! d non-diffus'ble calcium. This determina-
tion is also useful in cases of gall stones and
for those practicing otology. In deafness the
blond calcium is sometimes increased in oto-
sclerosis.
We also have basal metabolism determina-
tions, which are very valuable in the various
types of goiter (Ko. 11). This determination
2 ^2
\SCE CURVES
s also of value in relation to thyroid adminis-
tration. Basal metabolism is now a recogniied
part of laboratory work in relation, particu-
larly, to the practice of internal medicine.
9. Urine examinations are probably con-
ducted by every doctor more or less routinely,
and yet the information that we get from a
routine urine examination is oftentimes rather
298 • ^ - SOUTHERN MEDICINE AND SURGERY May, 1929
NO. 8
DISTURBANCES OF ACID-BASE EQUILIBRIUM
(1) Acidosis: a defect in the body's power to deal with carbohydrates. May be met with in:
(1) Severe diabetes mellitus
( Vomiting of pregnancy
(2) Starvation due to < Diarrhea of infants
' Cyclic vomiting
(3) Disturbed fat metabolism in children
(4) Anesthesia
(2) Alkalosis: due to increased bicarbonate in the blood or withdrawal of acids. May be met
with in;
(1) Individuals receiving too much bicarbonate
(2) Carbon monoxide poisoning
(3) Hot baths
(4) Withdrawal of acid as in vomiting
(3) Blood tests for these ' C02 combining power of blood
' C02 content of alveolar air
(4) Urine tests for these ' Excess of Ammonia
' Acetone, diacetic acid, etc. (ketone bodies)
NO <5
BLOOD URIC ACID AND GOUT
Normal: 1.0 lo 3.0 mgm. per 100 c.c. blood
Average 2 mgm.
Not increased in rheumatism
Usually increased in:
Gout
Various dermatoses and especially eczema
Chronic nephritis
Toxemias of pregnancy, pneumonia, etc.
Sciatica, lumbago, etc.
. . NO. 10
BLOOD CALCIUM
Normal: Q lo 11 mgm. per 100 c.c. blood
Reduced in:
. Idiopathic tetany of children
Certain skin diseases (eczema, acne)
Azotemic nephritis
Increased in:
Gall stones
Arthritis deformans
Otosclerosis
No change:
Tetany due to alkalosis
Rickets
NO. 11
BASAL METABOLISM
Average calories per hour per square meter of body surface. Normal values:
14
to
20
years=43
to
40
20
to
40
years = 39
to
37
40
to
60
years=3S
to
36
60
to
SO
years=36
to
ii
Simple goitre: No increase
Hyperthyroidism: increased with fluctuations
Toxic adenoma: increased (steady)
Hypothyroidism (below 40)
Of value in relation to thyroid administration
Hyperpituitarism: increase
Hypopituitarism: decrease (increased by pituitary extract)
meager (No. 12). But if done properly every- min, always remembering that a patient can
thing has its value: the color, for instance, as have chronic nephritis and present no albumin
very light-colored urine in chronic nephritis in the urine. Then sugar; and if sugar is
and in diabetes mellitus: the sediment: the present, look for ketone bodies. Remember
reaction, if taken freshly after the urine has that sugar may be present, and yet the pa-
been passed; the presence or absence of albu- tient may not have diabetes; this diagnosis is
May, 1029
SOUTHERN MEDICINE AND SURGERY
A'O. 12
URINE EXAMINATION
♦Quantity; *Color; ♦Sediment; *Reaction; *Sp. Gravity
♦Albumin
♦Sugar; if present: acetone; diacetic acid; oxybutyric acid
Chlorides (normal 10 to IS gm. in 24 hours)
♦Urea (20 to 35 gms. in 24 hours)
*Indican
Bile
♦Blood
♦Pus
♦Casts
♦Crystals
♦Epithelium
Bacteriological
Tubercle Bacilli
Gonococci
Catheterized: B. coli, etc.
NO. 13
ACUTE NEPHRITIS
Chief value of test:
( estimating severity
s < " progress
prognosis
/ Decrease at first ; increased with recovery
1 Protein (albumin) increased
I'rine \ Blood
I Casts
^ Urea and chlorides diminished
( High urea nitrogen
Blood \ High total non-protein nitrogen
I High creatinine
NO. 14
CHRONIC NEPHRITIS
(1) Azotemic type — nitrogen retention
(chronic interstitial or Bright's disease; commonest type)
(2) Hydremic type — chloride and water retention
(chronic parenchymatous and relatively rare)
(3) Mixed type
Azotemic Type
Urine: polyuria; low sp. grav. ; albumin slight or absent; reduced urea; chlorides normal;
casts (granular and hyaline)
Blood: in early cases may be no changes but high nitrogen retention in majority
Hydremic Type
Urine; reduced; large amount of albumin; urea normal or nearly so; chlorides reduced;
casts.
Blood: usually little if any nitrogen retention; increase of cholesterol characteristic.
not justified unless the blood sugar is also
increased. The presence of chlorides, of
urea; the presence of blood or pus; the detec-
tion of tubercle bacilli, of gonococci, etc., etc.
10. I have summarized here (No. 13) some
of the outstanding changes in the course of a
case of nephritis. The blood chemistry in this
d'sease yields information also of value.
11. Chronic nephritis, as you doubtless
know, we divide into two types, the azotemic
type and the hydremic type (No. 14). In the
first type, if we do the blood chemistry we
find no change in the early cases but high
n'trogen retention in the majority. In the
hydremic type the urine is reduced in amount
instead of being increased, there is a large
amount of albumin instead of a slight amount,
urea normal instead of being reduced, the
chlorides are reduced instead of being nor-
mal, casts are also found. The blood shows
very little if any nitrogen retention, but there
is an increase of chlorides in the blood (No.
15) and also a sharp increase of cholesterol
(No. 16) in the blood, so the diagnosis be-
tween these two types can be done only by
laboratory procedures.
12. The so-called renal functional tests (No.
17) are of special value in surgery of the uro-
genital tract. Probably the majority of urolo-
g'cal surgeons depend most upon the urea
nitrogen, the normal being 20 or less milli-
grams per 100 c.c. When a patient shows from
20 to 45, he h:is moderate retention; when be-
yond 45 he has marked retention; and when
SOUTIIKUN Mr:DICIN'K AND SURGERY
Mav, 1020
(a)
(b)
NO. IS
BLOOD UREA NITROGEN
Normal: 10 to 20 mgm. per 100 f.r. blood
Renal inefficiency but no increase of urea because of polyuria
Renal inefficiency but no increase of urea because of very low protein diet.
(c) Urea increase by physiological causes
Low fluid intake
High protein
Hot weather
Excessive vomiting
Diarrhea
(d) Urea increase by pathological causes
\ Excessive protein metabolism (acute infections)
- Circulatory defects — cardiac
I Nephritis
NO. 16
BLOOD CHOLESTEROL
Normal: 130 to 100 mgm. per 100 c.c. blood
Increased in:
Cholelithiasis (60% gall stone cases)
Obstructive jaundice (not in hemolytic jaundice)
Some cases of diabetes
Parenchymatous nephritis
Reduced in:
Severe anemias (especially pernicious anemia)
Prostatic enlargement with urinary obstruction
(related to low resistance to infection)
NO. 17
RENAL FUNCTION TESTS
Maclean's Urea Concentration Test (15 gm. Urea in 100 c.c. H20)
Phenosulphonephthalein Test of Separate Kidneys
Normal: 50% elimination in 1 hr.; 70% in 2 hrs.
Moderate: 40-25%
Marked: 10-25% .
Inorganic Phosphorous of Blood:
Normal: 3.7-5 mgm. per 100 c.c. blood
Blood Cholesterol:
Increased in hydremic nephritis
Low cholesterol in prostate cases = poor resistance
High urea and low cholesterol=bad surgical risks.
Urea Nitrogen:
Normal: 20 or less mgm. per 100 c.c.
Moderate: 2S to 45
Marked: 45 to 70
Ambard's Coefficient of Urea Excretion;
Normal: O.OQO or less
Moderate: 0.116 to 0.220
Marked: 0.221 to 0.350
it gets up around 80 there is danger of his
developing uremia. I dare say there are no
urological surgeons in your community who
would remove th? prostate of an elderly man
without first estimating the functional capac-
ity of the kidneys for estimating the surgical
risk.
13. Liver function tests (Xo. 18) were also
of great value. Unfortunately, though, these
tests have not yet hx.i placed upon nearly as
satisfactory a basis as the k!dney functional
tests, because the liver is so complicated an
organ. But we can estimate its capacity by
estimating its metabolic functions, etc. We
abD m2y corduct tb; levulose-tolerance test,
very much as the sugar-tolerance test for dia-
betes is conducted, and also Widal's hemo-
clastic liver test for estimating liver function.
14. But today we rely most of all, prob-
ably, upon the estimation of the bilirubin in
the blood. All of us carry a certain amount
of bilirubin in the blood. If it increases be-
yond a certain point, latent jaundice is likely
to be found; if it is still increased, clinical
jaundice w^ll develop. We can also differen-
tiate between hemolytic jaundice and obstruc-
tive hepatic jaundice, and this test als<i aids
in the d'agnosis of catarrhal jaundice.
Then I have also listed here cholecystogra-
phy. So we do have aic} in arriving at the
May, 1029
SOUTHERN MEDICINE AND SURGERY
Tests of
Metabolic
Functions
Tests of
Pigmentary
Function
NO. 18
LIVER FUNCTION TESTS
(Metabolic; Pigmentary; Excretory; Antitoxic; Hemopoietic)
(1) Failure of deamination of amino acids with:
Increase of amino-nitrogen in blood and urine
Decreased urea formation
Decreased urea in blood and urine
(2) Levulose tolerance:
Normally no increase in blood sugar
Disease of liver: increase in blood sugar due to failure of storage
in liver
(3) Widal's leukocyte test:
Normally leukocytosis in 40 minutes after 7 oz. milk
Dysfunction: no leukocytosis or leukopenia
Two varieties of bilirubin A
B
^ 0.1 to 0.3 mgm. per 100 c.c. serum or
°"^^ 0.2 to 0.6 unit (unit is 1 in 200,000)
Renal Threshold: 4 units
Jaundice appears: 20 units or over
Latent jaundice: 4 to 20 units
Excess of A
Hemolytic Jaundice Positive direct
No excess in urine
Excess B
Obstructive Hepatic Direct negative or delayed
Jaundice Indirect positive
Urine positive
Toxic Hepatic and , „ , ,,
.4 or c or both
Catarrhal Jaundice
Tests of
Excretory-
Function
Phenoltetrachlor|)hthalein test (5 mgm. per K)
Normally all excreted in 1 hour
Dye in blood longer than 1 hr. = dysfunction
Cholecystography (tetraiodophenolphthalein)
NO. 19
SPUTUM EXAMIN.iTIONS
♦Quantity; *Color; *Consistency
I Epithelium
*Kind of cells • l"^. ^.,
1 Eosmophiles
' Blood
t Smear
♦Tubercle ■. Antiformin concentration
Bacilli ' Guinea pig inoculation
, Increase of spirochetes
I Pneumococci — typing in pneumonia
Other Bacteria Streptococci
I Staphylococci, etc.
Vaccines (chr. bronchitis and asthma)
Chemical: increase of albumin
♦Routine
functional capacity of the liver, not by any
one test but by the combination of two or
more. The most valuable at the present time
is the Van den Ber^h test for bilirubin.
IS. Sputum examinations (Xo. 19) are also
of value. I presume they are best known in
relation to the detection of tubercle bacilli in
the diagnosis of tuberculosis of the lunj^s. Of
course, we all know that the absence of tuber-
cle bacilli in a single specimen of sputum does
not exclude this disease; several examinations
should be made.
We may also examine the sputum for other
orsran'sms; for instance, for increase of spi-
rochetes in that condition known as pulmon-
ary spirochetosis. I need but refer to the
typinp; of th? pneumococcus in pneumonia,
v.hxh is not an aid to the diagnosis of the
dsease. for that is easily possible by physical
examination; but to know the type of pneu-
mococcus is of great value in arranging the
treatment of the disease from the standpoint
302
SOUTHliRN MKDICINL AND SURGERY
May, 1929
Physical
Microscopical
Acids in
Diagnosis of
NO. 20
GASTRIC ANALYSIS
Amount of residuum
Mucus
liile
Blood
, Free hydrochloric acid (fractional method)
I Total acidity (fractional method)
(a) according to amount of HCl secreted
I (b) according to regurgitation of alkaline fluid from the intestine
' Lactic acid (retention and fermentation)
J Opplcr-Boas bacilli
retention
Sarcinae and yeast
Digestion
Rate of emptying
Achlorhydria true (no secretion of HCl apparent)
(neutralized by regurgitation; relaxation of pylorus)
(a) Dyspepsias of phthisis, neurasthenia, etc.
(b) Cancer stomach
(c) Chronic gastritis
(d) Pernicious anemia
(e) Subacute combined degeneration of spinal cord
(f) Acne rosacea
(g) Dyspepsias of phthisis, neurasthenia, etc.
ulcer of pylorus
Spasm of pylorus reflex stimuli
Kyperchlorhydria stenosis
Excessive secretion of acid
(a) Found in S% normal men
(b) Duodenal and gastric ulcers
(c) Some cases appendicitis and cholelithiasis
NO. 21
DUODENAL CONTENTS
Pancreatic Ferments
Bilirubin
Urobilin
Bacteriological exam, of bile
Microscopical exam, of bile
.\mylase
Lipase
Trypsin
Lyon Method
Blood
( Gross
NO. 22
FECES EXAMINATIONS
Form; Color; Mucus; Parasites; Food, Curds
Microscopical
Bacteriological
j Digestion
I Pus
^ Epithelium
I Fats
Ova and parasites
( Tubercle Bacilli
I Typhoid, etc.
SOtJtttEkM kRblCtMfe ANb StjRGfiRV
ioi
S £ a. 1/2 H w X
'^ o ^
'7i -^ to
9 i I
=38
OS
i E
E .a
rz '5, '&
tic E
^c .S
Is''
m
SOtTMERN MEDlCtNE AND StkGEkV
May, 1$29
of serum therapy. We also examine the
sputum for bacteria in allergic asthma, so the
examination of sputum is by no means con-
fined to the tubercle bacillus.
16. Ne.xt comes examination of stomach con-
tents (No. 20). We examine them for the total
acidity, etc., and also examine for lactic acid,
its presence being an indication of retention
and fermentation. We also make microscopi-
cal examinations. The rate of emptying of
the stomach is also of value. Also, these de-
terminations may demonstrate achlorhydria,
where no hydrochloric acid is found. We
may also, by means of gastric analyses, detect
hyjjerchlorhydria. So you can see that an
examination of the gastric contents is not
confined entirely to the diagnosis of cancer
of the stomach; when properly conducted and
the data properly interpreted it lends dis-
tinct aid to the diagnosis of other gastric
conditions.
17. Examination of duodenal contents (No.
21). I do not know whether Dr. Lyon's meth-
od enjoys a good reputation in your commu-
nity or not. It aids, in my opinion, because
I think it is perfectly possible by this method
to obtain bile for direct examination as an aid
in the diagnosis of gall-bladder and biliary
disease.
18. The examination of feces can be passed
over very rapidly (No. 22), but even the study
of the form and the color, the presence or ab-
sence of mucus, etc., are valuable. Some-
times parasites are found; and we also ex-
amine for the presence of blood, the presence
or absence of pus, etc. Bacteriological ex-
amination is also valuable in cases of tuber-
culous enteritis and of typhoid fever. The
examination of the feces is also useful in the
diagnosis of ulcerative colitis.
19. A great deal of information can be ob-
tained from examination of the cerebro-spinal
tluid (No. 23). An examination of the spinal
fluid permits a diagnosis of so-called menin-
gismus. Then the examination of the spinal
fluid is absolutely essential for the exact diag-
NO. 24
BACTERIOLOGICAL EXAMINA TIONS
Nose I Diphtheria (smear and cuUure)
and \ Vincent's angina (smear alone)
Throat ' Streptococcus, ppeumococcus and staphylococcus (culture)
i Tubercle bacilli
Sputum ■ I'neumococcus typing (pneumonia)
( Vaccines
Pleural and
Peritoneal Fluids
j Tubercle bacilli
• Streptococcus
I I'neumococcus, etc.
Genital Organs
Gonococcus
Spirocheta pallida (dark field)
( Typhoid fever
\ Dysentery
' Ulcerative colitis (Bargen)
^ Septicemias; pneumonia, etc.
Spinal Fluid
I Meningococcus (epidemic meningitis)
■; Pneumococcus
I Streptococcus
Conjunctivae
i Koch-Week's (pink eye)
■■ Pneumococcus, etc.
' Before operation
( Spiro-fusillar gingivitis (smear)
•' Amebic gingivitis (smear)
I Bacterial gingivitis (culture)
Teeth
Apical infections (streptococci)
Way, lOid
§6tTHERN MEDICINE AND SURGEkV
m
r.csls of meningitis, whether the meningitis is
due to the tubercle bacillus, the meningococ-
cus, the streptococcus, or the influenza bacil-
lus. We also get from it information of great
value in encephalitis and in poliomyelitis, also
in syphilis. Indeed, an examination of the
spinal fluid should be done in every syphilitic
at some time during the course of the disease.
Sometimes we are able to detect paresis be-
fore it becomes apparent otherwise. We also
may obtain aid in the diagnosis of some tu-
mors of the spinal cord, etc.
20. Bacteriologies^, e.xaminations (No. 24).
Here the laboratory also can render great aid,
particularly in the diagnosis of diphtheria.
-\o physician can hope to have enough clinical
experience to always differentiate diphtheria
from non-diphtheri;ic anginas without the aid
of the laboratory. Indeed, my experience is
that the physicians H-ith the most clinical
experience are the ones who call most upon
the laboratory for aid. We can not hope
always to diagnose Vincent's angina without
the aid of the laboratory.
I have already referred to bacteriological
study of the sputum. Bacteriological study
of the pleural and peritoneal fluids; also bac-
teriological examination for gonorrhea and
syphilis. It has been my experience that the
chancre can not be always diagnosed by the
eye alone; the diagnosis is best made by re-
ferring the patient to the laboratory for micro-
scopic examination for the spirochete itself.
Also, bacteriological examination and blood
cultures in pneumonia are very valuable, and
bacterial examinations of the spinal 'fluid
and of the gums, of the tonsils, of extracted
teeth, etc., in relation to the diagnosis of
focal infections.
DISCUSSION
Question: Do you know of any cases of
agranulocytic angina which have recovered?
Answer: I know of no case that has re-
covered. The two in my own practice died
within forty-eight hours.
Question: Do you know of any signifi-
cance between the so-called available calciums
and those not available?
Answer: The values I gave on the board
are the diffusible and non-diffusible calcium
In rickets the fault is not in a deficiency of
calcium but in a deficiency of utilization of
calcium due in some way to a deficiency of
the antirachitic vitamine, the body is not
capable of utilizing the available calcium a:id
depositing it in the bone^.
Question: What advantage has the Shill-
ing blood count over the .Arnett blood count?
Answer: The Arnett blood count has
much the same value but is much more time-
consuming.
Dr. Garrison: What is the best method
of diagnosing pelvic and abdominal infections
by the general practitioner when he can not
get to the microscope? I mean, the sedimen-
tation test being so simple, would it be better
to use that as a quick method rather than
make a blood count?
Answer: That is a very important ques-
tion. I doubt whether we should choose be-
tween the two; I think both should be em-
ployed. A rapid sedimentation of the blood
would be a clearer indication of severe infec-
tion than a total leucocyte count, but a better
way would be to make a total and differential
leucocyte count as well.
Dr. Hines: Alay I ask if the laboratory
is the court of last resort in the diagnosis of
undulant fever, and if not, what are the
sources of error?
Answer: Where undulant fever is sus-
pected, a blood culture is to be thought of
first. The B. abortus is very frequently found
in the blood culture. But if the blood cul-
ture is sterile, as may occur if tha person has
been ill for a week or ten days, there may be
found in the blood of the individual an ag-
glutination for this bacillus. I do not know
of any way of diagnosing undulant fever with
certainty without the aid of the laboratory
examination.
Question: i\Iay I ask what is the most
recent reliable procedure for provoking a posi-
tive Wassermann reaction in a patient sus-
pected of having syphilis who shows negative
blood and spinal-fluid reactions?
Answer: There is still a lack of uniform-
ity for the procedure in the so-called provo-
cative test for the diagnosis of syphilis. Each
one will have to answer this according to his
own experience, and my experience has been
as follows; If a patient with chronic syphilis
presents no demonstrable lesion of the disease,
provocative stimulation probably can not be
induced. If the individual, however, presents
a lesion which may be .syphilitic, then provo-
cative stimulation can be produced and may
be of value. Therefore provocative stimula-
tion should be done only on selected indiyjcj.
^66 ^OtjfMERN MEDICINE \kt> SURGERV May, 1020
uals, and if it is decided to do it, my practice blood count of from 12,000 to 20,000 over a
is to administer 0.6 or 0.9 of neoarsphena- period of months, irrespective of the time of
mine and do a Wassermann twenty-four hours taking food, can there be some other cause
later. If negative, I give a second injection for that than a focus of infection?
and repeat the Wassermann If negative I Answer: I should say that is too high for
give a third injection, and if still negative I , , . , , ,. . ,
.J. J 1 1 » c normal; too high, even, for digestive leucocv-
repeat the procedure a week later. So you & . - r y
see it is far from a simple procedure. I per- *°S'S- ^" ^V opinion, an adult running from
sonally have no confidence in the so-called 12,000 to 20,000 leucocytosis over a period
single provocative test in syphilis. of time should certainly be looked upon as
Question: In a patient running a white harboring some type of chronic infection.
Following is an Advertisement cut from the Charlotte Medical Journal of July, 1894:
ST. PETERS HOME AND HOSPITAL
CHARLOTTE, N. C.
This Hospital is under the control of a Board of Lady Managers, who visit the
patients regularly, and make every effort to render them comfortable.
Private rooms may be secured for $3 to $5 per week. Charity cases will be re-
ceived into the wards after examination by the Hospital Physicians.
No contagious diseases admitted.
For further particulars address —
Medical and Surgical Staff,
Drs. C. H. MEISEXHIUMER
and R. L. GIBBON.
HOW TO MAKE EXECUTED CRIMINALS USEFUL
(From Southern Clinic. 1804)
An exchange reports that the blood of those poisoned with hydrocyanic acid can
be used as an excellent red ink, and that this will not require antiferments nor any
other preservative. If this is really so, then jails might have an ink factory run in
connection with their judicial life endings: but as the after-life of the converted
would be a respectable and cheerful sort of a lot, the hydrocyanic route should be
only chosen for such as the court would feel were entitled to some clemency. Political
thieves, boodlers, and such should, in their turn, be converted into glue, gelatine,
vaseline, and such other menial compounds. Bottles containing this crimino-
anthropological red ink, with the manufacturer's trade-mark and a view of the taking-
off place of the victim upon them, would have a beneficial and restraining effect upon
the morals of bank officials, prospective defrauding cashiers, and others who use red
ink.
The vasomotor effect of atropine may produce apparent fever. The less common
central effect of atropine may produce real fever, which occurs within a variable
length of time after the administration of the drug has been started, but which dis-
appears promptly when the drug is discontinued. In spite of the occasionally strik-
ing by-effects of atropine, it remains a safe drug for use in the vagogenic gastro-entero-
spasm or "colic" of early infancy.
— Park J. White, St. Louis, in Am. Jour. Dis. Child., April.
May, 1029
gOttHERN MEbtCiKE AND SURGEftV
36?
Medical Problems — Present and Future
Presidential Address to Tenth District (X. C.) Medical Association Asheville, April 10th, 102Q
W. B. Robertson, M.D., Burnsville, N. C.
It would be presumptuous for me to try
to cover in so short a time all the different
phases implied by my subject; and I want
to assure you in the very outset that I shall
confine my remarks to but two of what seem
to me to be the most important problems that
organized medicine has to face, and offer —
or rather hint at — possible remedies.
I. The Problem of Feeble-Mindedness
It has been estimated that in fifty years
from now the United States will have a pop-
ulation of 200,000,000, and there are regis-
tered now in foreign ports 1,500,000 seeking
entrance to the land of freedom.
There are 8,000,000 foreigners in the
United States who are not naturalized; we
also have within our domain 7,000,000 mo-
rons. .About four per cent of our population
is dependent from one cause or another — •
costing from 150 to 200 million dollars per
year. Statistics indicate a marked increase
of defectives, with a relative decrease, or very
slow increase, of the normals. This might
account for the fall of nations in the past,
and this gives us cause for serious reflection.
Today, in one of the greatest states in the
Union one-sixth of all moneys appropriated
goes to the support of institutions for the
care of the feeble-minded and insane. In
1910 there were more feeble-minded and in-
sane being cared for in our institutions in the
United States than there were students in
all our colleges, or men enlisted in the stand-
ing army, the navy, and the marine corps
combined! In 1880 in the United States there
were 183 insane people per 100,000 popula-
tion. In 1903 there were 225 insane [3er 100,-
000 population. The same increase is shown
in leeble-mindedness, imbecility, idiocy, and
moronity; and God only knows the number
between the moron and those considered nor-
mal. It is from this last named class of ab-
normais that we get a large percentage of our
criminals.
What I have said about degeneracy in the
United States is equally ap[)licable to most
countries across the seas. In England, for
example, the percentage of the feeble-minded
is increasing twice as rapidly as the normal
population.
Our chief source of pauperism, degeneracy,
and crime is from the mentally abnormal;
and all our great philanthropic effort in their
behalf only tends to foster and favor the
multiplication of the unfit. Heredity is the
chief factor in determining the future lot of
the offspring. This applies to physical de-
fects. I do not in any sense refer to moral
traits or characteristics, for morally we are
largely governed by environment, and can
acquire many most excellent moral character-
istics; as a result of which, the environment
of today may become the heredity of tomor-
row.
Some of the diseases which are inherited,
or a tendency to them transmitted to the off-
spring, are tuberculosis, syphilis, cancer,
deaf-mutism, albinism, color blindness, hem-
ophilia, brachy- and poly-dactylism, diabetes,
chorea, mental deficiency and insanity.
Mental diseases are likened to a great tree
with two tap-roots as causative agents: the
one is heredity; the other is alcoholism,
A careful study has been made by some
of our best men in the profession as to the
transmissibility of mental defects to the off-
spring, and no case has yet been found in
which a normal child has been born to idiotic
parents. .As a further proof of the statement
that our lot is largely determined by heredity,
I shall quote the findings of Dr. Goddard in
tracing the offspring of a common father, the
maternal parentage differing.
Martin Kalikak (the name is fictitious), a
young man descended from good English
parentage, in his younger days mated with a
feeble-minded girl, from which mating a nor-
mal son was born. This son married a nor-
mal woman, from which union five feeble-
minded children were born; and from these
five Dr. Goddard was able to trace 480 de-
scendants. Of the 480 only 46 were normal.
-Among these descendants all degrees of de-
generacy were found, from imbecility to hope-
less insanity; and criminality existed in every
Jog
setJtttfeftM iiEbtciNfe AWb stJfeGefeV
Uay, 1^39
degree frcm murdrr down. Not one of the
480 made his mark in the world.
This same ^Martin Kalikak married a nor-
mal Quaker girl and settled down to an even,
decent life, as lived by his English ancestors.
Frcm this union Dr. Goddard traced 496 de-
scendants; and in all this number there was
not a criminal or a feeble-minded person
found. Those found in the cities were law-
3 ers, doctors, and well-to-do merchants. The
descendants from the first mating, however,
were found in the slums. The descendants
from the second mating found in the country
were independent farmers, while those from
the first mating were hirelings — or at best
tenant farmers.
This is ample proof that heredity is the
great determining factor in the lot of the off-
spring; and that a feeble-minded woman of
the child bearing age is about three times as
dangerous to a community as is a feeble-
minded man. At the present rate of increase
of population of the United States and the
greater relative increase of degenerates, I
think a conservative estimate of the total
number unfit for propagation in 1939 — just
ten years from today — would be twenty mil-
lion.
Remedies
Three measures have been tried in different
states to control the production of defectives:
education, restrictive legislation, and segre-
gation. Education failed because the men-
tally defective lacked the ability to take ed-
ucat.on; restrictive legislation only added il-
legitimacy to degeneracy; segregation is
ideal in its aim, but impractical because of
the prohibitive cost.
Every effort having failed to prevent the
rapid increase of the physically, morally, and
mentally unfit, I see but one remedy left —
surgery of sterilization. Sterilization when
properly done is harmless, ine.xpensive, and
there is no question as to its effectiveness.
The medical profession must face this fact
with a calm determination which bides no
sentimentality or false modesty. Risking
any degree of criticism and from any source,
I make the assertion we should use more
care in breeding the human, and in the propa-
gation of the race, than is used in the breed-
ing of any other animal. Every child has
the right to be well born, and it is up to the
medical profession to see that he or she is not
robbed cf th!s birthright. What authority is
to decide the fitness or unfitness of a man to
propagate the race? The medical profession
had just as well come out in the open and
assume this burden; if they do not, the laity
will soon place it upon our shoulders — where
it belongs.
A bill providing sterilization has been be-
fore the Legislature of North Carolina a
number of times; but how many of us have
taken the trouble to advise our representative
just what should be embodied in such a
measure? Our last Legislature passed
House Bill Seventy-three, which provides
for the sterilization of all mentally defective
inmates of our charitable or penal institu-
tions. I want to commend our law-making
body for this step in the right direction; but
it did not go far enough.
In speaking of the unfit I want to make
myself perfectly clear, and I do not refer to
size or looks. .\ man nray be physically, mor-
ally, and mentally fit, though he did not come,
over on the Mayflower, nor possess a coat
of arms. I refer to those of low mentality,
the diseased, the criminally inclined, and the
confirmed criminal.
Let us close the doors of immigration a
little closer; and at the next meeting of the
General Assembly of North Carolina let the
Medical Society of our state sponsor a sterili-
zation bill, approved by the various organi-
zations of which it is composed, — down to the
county society — and it will be enacted into
law; the result will be a happier, stronger
and healthier race.
The science of improving the human race
through better heredity is a goal that the
medical profession dare not lose sight of. This
is not a Utopian idea; it is possible of attain-
ment; and such a state will be realized when
the prospective fathers and mothers of the
future are governed by horse-sense instead
of sentimentality and silly twaddle. Then
our courts will not have to spend so much
time listening to sordid recitals of domestic
infelicity and infidelity.
II. Cost of Medical Care
I am not going to burden you with figures
relative to the per capita cost of illness due
to natural causes, or resulting from accident;
sufficient to say, it is too high and getting
higher from year to year. Some of this in-
creased cost is to be expected and is defensi-
ble. It takes more time and money to pre-
Mav, 1929
SOtTttERN M£D1C1N£ ANt) SUftGEftV
m
pare for the practice of medicine and surgery,
and the outlay for equipment, instruments,
and drugs is much greater than it was a few
years ago. I do not want to bring an unjust
indictment against the profession, and if I
should do so, I hope that some of my friends
will take me to task about it.
{• j FEES
The first cause of the increased cost of
medical care that I wish to bring to your
attention is: there is too much specializing,
with a decrease in the number of general
practitioners. Some of the best friends I
have in the profession are specialists, and be
it far from me to say aught against them or
their si3ecialty; but there are two kinds of
specialists: one is specializing because he is
above the average in skill and ability, and
can do things better than the average prac-
titioner; the other turns to a specialty be-
cause he is below the average in skill and
ability, or has been more or less a failure in
general practice.
How many men in our district are doing
surgery of the major sort; how few could do
it all and more efficiently? If the few who
are able to do major surgery — with credit to
the profession and satisfaction to the laity —
were doing all the surgery of this kind, you
can readily see that they could work for less
money per operation, without any loss, and
perhaps with an increase, in their net earn-
ings.
1 dislike the term, practice of medicine, or
practice of surgery; but we are forced to
confess there is much practicing going on in
our profession. What 1 have said of surgery
is equally applicable to most of the other spe-
cialties. They are over-crowded; each one
must get a living, and the result is — the fee
must go up.
The laity has long ago caught the trend
toward specialism and those who can afford
it have a specialist for each and all of their
b(jdily ills. How about the great number
that cannot afford a specialist? As a direct
result of this tendency there has developed
a sort of inferiority complex, forcing some
men to say, "As long as I cannot afford the
best, just anybody will do; or, I will get the
cheapest"'; which in the end proves to be
the most expensive from the standjioint of
results.
Why is it that each meeting of the Legis-
lature we have to fight the licensing of some
one by legislative enactment? Such licen-
tiates are not qualified for the practice of
either medicine or surgery; but would such
men in the profession have a following?
They most surely would, because they offer
their services for less money. Some of them
would do some good in their communities;
but more often the^r work is harmful.
The people know just as well as you and I
know that such men are not the safest to
employ; but it costs less money, and they
get them. The offices of the quacks, faith-
healers, and all other irregular cults are filled
from the same cause — they promise much at
little cost.
The laity alone is not affected by this over-
specialization; it has its deleterious effects
up<in the general practitioner as well. For
as the general practitioner sees the most af-
fluent of his clientele flocking to the special-
ists, often without his advice or choosing,
and more often needlessly, he is forced to
raise his fee in order to live comfortably; or,
on the other hand, he becomes discouraged,
and falls into a routine which is not of the
highest standard, or best for himself or his
patients. This is a serious problem that
must be adjusted from within; and I predict
that when the proper adjustment is made it
will result in much good to both the laity
and profession.
Remedies
1. The field of the general practitioner
must be made so attractive that stronger men
will be drawn into it, for this field is so big
that it offers a challenge to the best in the
profession, as it requires more gray matter
to be an all-round, up-to-date, general man
than it does to follow any specialty.
2. There should be a more cordial relation-
ship existing between the general practiticjner
and the specialist.
3. The laity should be educated to the
[)oint that they will not risk their judgment
as to their need of special care.
4. The specialist when needed should be
selected by the family physician, as the phy-
sician is more competent to select than the
laity. Thus the work will naturally drift into
the hands of the specialists who are most
competent, and the unfit will gradually be
eliminated.
(b) OFFICK EQUIPMENT
Now let us consider the means of lessening
m
SftttttEfek kebtClNfe A^b StkGERV
May, l$i0
the cost of equipment. This is a much more
difficult problem, but I am sure it is not a
hopeless one.
At the last meeting of the Southern Medi-
cal Association I priced one little instrument
that contained about ten cents worth of steel,
and the price was ten dollars. I also listened
to a very instructive paper read by a learned
visitor, describing another instrument intend-
ed to do the same work as the one I had just
priced. This last instrument was a very elab-
orate affair — which led me to think that it
would require a civil engineer who was fa-
miliar with the sliding rule to read and inter-
pret its findings. I was afraid to price this
last instrument, as I did not have an extra
fifty dollars.
I mention these things in order to bring
out the fact that we need to standardize both
our instruments and our drugs. There is an
over-plus of instrument manufacturers, medi-
cal publishers, and drug manufacturers living
off the money paid by the sick of our coun-
try.
The Remedy
It is a well known fact in the business
world that massive production lessens the
cost of the article to the consumer. Suppose
the profession should standardize' on books,
drugs, and instruments; and instead of each
buying a heterogeneous mass of these, all
intended to serve the same purpxjse, we all
should buy the best from a few of the most
reliable firms; what would be the result?
The increased sales of the firms selected
would bring the articles to us at less cost,
and we in turn could divide the saving with
our patrons. This could be accomplished at
no loss to the efficiency of our armamenta-
rium.
LESSONS FROM ST.ATE TONSIL CLINIC
One of the chief causes for the encroach-
ment of state medicine upon the field of or-
ganized medicine is the increased cost of
medical care. What does the state tonsil
clinic demonstrate? These four things:
1. The need and efficiency of the opera-
tion— shown in the improved physical condi-
tion of the child after the operation.
2. Tonsils and adenoids can be removed
just as well for $12.50 as for 35 or 40 dol-
lars.
3. An operation performed for $12.50 yields
the state a profit of nearly fifty per cent.
4. With this profit the state can operate
upon an equal number free of charge.
How can the state perform these opera-
tions for such a small sum? Because one
surgeon performs 25 operations in a day, and
equipment is bought in bulk. Has this meth-
od been a success where tried? I can only
speak for North Carolina. This state has
operated on about 2,000 children for diseased
tonsils, without a single fatality.
State medicine is gradually fastening its
tentacles about the very vitals of organized
medicine. The care of the tuberculous, epi-
leptic, and mentally deranged is gradually
drifting into the hands of state institutions.
If organized medicine is to survive, serious
thought must be given to this problem before
it is too late.
H
H
,_^
Mav, 1029
SOUTHERN MEDIClNi: AND fUUGnUV
Serum Sickness*
R. M. roLLiTZER, M.D., Greenville, S. C.
Prior to the iiitrrduclion of d'phtheria an-
titoxin, serum sickness was almost unknown.
But shortly after its advent case reports be-
gan to appear. Latterly much has been writ-
ten as to the incidence and severity of this
malady. This is not surprising, for today
we administer antitoxin in a foreign serum
in the treatment and prevent'on of diphthe-
ria, tetanus, meningococcic, meningtis, erysip-
elas and sometimes pneumonia.
Considerable time elapsed before it was
proven lh:it this symptom-complex was due,
not to the antitoxin, but entirely to the horse
forum. Gradually through the years, as the
processes of manufacture improved and the
ferum became more concentrated the inci-
dence of serum sickness decreased. But to-
day where scrum is so often used, and since,
in some cases,' large amounts must be in-
jected, there has been a great increase in
frequency.
The chief factors that control its incidence
rre route of administration, previous injec-
t'on, amount of serum, individual peculiari-
t'es, and the type of horse.
The figures necessarily vary according to
author; but R. O. Clock puts it at approxi-
mately 60 per cent and Heckscher at 58 per
cent. Toomey recently found in a series of
28,? serum injections for scarlet fever that it
developed in about 38 per cent.
In general, it is believed that when less
than 10 c.c. of serum is injected only 10
per cent of the people are affected, but when
100 c.c. or more is administered only 10 per
cent escape. It is my impression that its
occurrence after the use of antitoxin for scar-
let fever is very frequent. A. Bougart states
that its incidence at the Boston City Hospital
in such cases amounts to 70 per cent. It is
by no means uncommon after the small pro-
phylactic dose against tetanus. The ques-
tion as to an accelerated and very frequent
attack where a series of toxin-antitoxin has
been previously given, is one worthy of fur-
ther investigation. The matter has been dis-
•Prescntcd to the Tri-State Medical Association of
the Carolinas and Virginia, Green.sboro, N. C, Meet-
ing February 19th, 20th and 2l5t, 1929.
cussed pro and con with much heat. To my
mind nothing has been proven, beyond th?
fact that some sensitization must be induced
inasmuch as these individuals exhib't a higher
percentage of positive intradermal reactions
(W. H. Park). From my experience, I am
inclined to the opinion that the anti-toxic
serum does sensitize. The subject is still
sub judice. In the meanwhile we should make
use of sera from different animals for pro-
phylaxis and for treatment.
SYMPTOMATOLOGY
Serum sickness has a very interesting
though by no means invariable symptoma-
tology. In some respects it bears a close re-
semblance to the exanthemata. The typical
case has an incubation period of usually eight
to twelve days, fever, mala'se, nausea, vom-
iting, and a skin eruption. In addition there
is often marked adenopathy, and sometimes
an arthritis or arthralgia. Some indiv'duals
become semi-stuporous. A leucopenia is said
to be the rule. The entire body is markedly
affected. While the eruption is most striking
it is but one feature of the disease. Gener-
ally there are successive crops of wheals with
oiis'derable erythema. Some cases resemble
measles, others scarlet, and still others both.
Rarely the eruption lasts only a few hours,
more often three to five days. Unfortunately
t may persist longer than a week. Some
ind'viduals escape with only a few wheals at
the site of injection. Rather infrequently
after a week of freedom from all rash, it re-
curs. This second eruption is nearly always
an erythema, often accompanied by high
temperature. It has been proven that the
r currcnce is due to an albumin, and not to
the globul'n. (Dale, H. H., and Hartley,
P.) Fever is almost a constant finding, hi
most cases the maximum is 102 or 103 de
grees, but not rarely for one or two days it
reaches lOS or 106 degrees. According U,
some authors an enlargement of the super-
ficial lymph nodes is one of the earliest phe-
nomena. This I have frequently noted in
my cases. As a rule the nodes are very ten-
der. It has hapjK'ned that the attending
SOUTHERN MEDICINE AND SURGERY
May, 102g
physician mistook the fever and adenopathy
rear the site of injection for signs of infec-
tion. Sometimes the nodes remain enlarged
after all other signs and symptoms have gone.
In my experience arthralgia has come on
very late, sometimes with the recurrent at-
tack. Most people escape. .According to
J.Iackenzie, however, when large amounts of
serum are injected over SO per cent of the
recipients are so affected. Nothing abnormal
is visible, but the patient complains greatly
of pain and stiffness. Last November (1928)
I was called in to see a boy of six who had
very properly been given a prophylactic in-
oculation of tetanus antitoxin. Prior to my
v'slt and seven days after the injection he
developed serum sickness. Four days later
when considered well again he developed fe-
v,T, a very slight but general and transient
' ythemi, along with arthralgia involving the
I'lees and the temporo-maxillary articulations.
He could not or would not open his mouth.
Very naturally his parents were quite sure
that he now had tetanus in spite of the anti-
toxin. Within two days he was perfectly
well. To have given more serum would have
been a grievous blunder.
Other findings, such as edema, particularly
of the face, conjunctivitis and albuminuria are
rather frequent. In general the symptoma-
tology while fairly uniform does vary as to
findings, duration and severity.
It is but natural that a foreign or heterol-
ogous serum parenterally administered should
induce some systemic disturbance. The ex-
act mechanism of its production has given
r'se to many hypotheses ever since the pub-
I'cation of "die Serumkrankheit" in 190S
(von Pirquet and Schick). But even today
nothing is definitely known. The condition
is one of sensitivity, not of hypersensitivity.
DIAGNOSIS
In general there is no difficulty in recogniz-
ing serum sickness. However early, before
the appearance of the rash or without a
proper history it may not be suspected. .An
incident will illustrate the point. A few years
ago a child of four developed a high tem-
perature (106 degrees) with vomiting and
general pain (lymph node enlargement), but
ro eruption, five days after a prophylactic
f'ose of antitoxin. Even with the history of
its administration, because of the short in-
cubation period and the absence of eruption
the attending physician excluded serum sick-
ness. A day later, a very severe generalized
urticaria appeared. In this stage the ques-
tion of diagnosis gives much concern to the
family as well as to the doctor. The patient
meanwhile may be quite well. .\ late erup-
tion may be mistaken for a recurrence of
scarlet fever or of erysipelas. Two such in-
stances have come to my attention.
PROGNOSIS
In general, regardless of the patient's feel-
ings, the degree of somnolence, of edema, or
of the extent of rash, we may be certain of
his recovery. Very rarely a fatality is re-
ported. However, such instances when
closely analyzed nearly always appear to
have been due to the pre-existing disease.
PROPHYLAXIS
No foreign serum should be injected
unless there is a clear indication. Aside from
the administration of antitoxin to prevent
tetanus, I question whether we are justified
in using routinely a serum to produce a very
temporary passive immunity, as in diphtheria
and in scarlet fever. At any rate such is
not my custom. Both these diseases should
be pre\'ented by a process of active immuni-
zation. Further, for diphtheria I employ
toxin guarded by antitoxin in goat serum.
(Sheep or some animal other than the
horse may be equally good. .-Anatoxin or
toxoid may later be proven to be better. As
yet I am not convinced as to the merits of
the ricinoleated product.) Certain F'ench
wr'ters believe that calcium chloride, and also
adrenal'ne have value as prophylactics. Th's
is questionable. Besredkas method of de-
sensitization is here ineffective. Sodium or
potassium citrate in fairly large doses every
four hours, for two days following the injec-
t'on, is said to lessen the severity and fre-
quency of serum sickness.
Local treatment for the intense itching is
demanded. One per cent phenol in calamine
lotion is of a little value. A strong solution
of magnesium sulphate is better. At times
atropine is helpful. .Adrenaline in small doses
repeated as necessary is of great service.
Children, however, fear the hypodermic nee-
dle ordinarily and much more so in their,
then, highly excited state. Ephedrine by
mouth should be efficacious, but often dis-
appoints. All treatment for fever, nausea,
arthralgia, etc., is according to general prin-
May, 1029
SOUTHERN MEDICINI' AND SURGERY
c'plcs. It seems best to limit food, especially
proteins. Some advocate reducing the fluid
intake. Treatment that would speedily and
ct mpletcly vanquish this symptom-complex is
[greatly to be desired.
SERUM ACCIDENTS
This outline of the untoward effects of a
foreign serum would not be complete without
a brief -description of serum accidents. The
term connotes the sudden shock-like, some-
t'mes fatal, reaction that ensues in hypersen-
s't!ve persons, immediately after an injection.
We no longer speak of it as anaphylaxis in
man. for many authorities are certain that
it is not such a phenomenon. It would take
us too far atield to outline the varied views
(if von Pirquet, Friedberger, JobKng, Vaughan,
Xovy, Coca and others.
It suiTices to say, that in general there
are seme individuals who are hypersensitive
to a foreign serum. They may be born so
or made so by a previous sensitizing dose
of serum. This explosive action or hypersen-
s'tiveness may be seen at any time from
within ten days following an injection up to
months or years. .As a rule it makes itself
l.nown within one or several minutes. The
larlier its occurrence the greater the gravity,
i he patient s in great discomfort, sometimes
terrified, and the physician m.ny well be the
same.
The symptoms are chiefly those of a sud-
den cevere asthma plus urticaria. There may
be cyanoss and some edema. As a rule an
attack is ushered in by sneezing or coughing
along with itching of nose or lips. There is
a spasm of the laryngeal and bronchial mus-
culature, producing dyspnea. iMost individ-
uals recover, but one can never tell at its
inception as to the outcome. W. H. Park
has stated tiiat death results in one out of
each 70,000 injections. It therefore is a very
remote poss bility and should never be a de-
terrent to the giving of antitoxin. On the
other hand it is unwise and surely bid prac-
fce to too lightly enter into its administra-
t'on.
.\ hi^if)ry as to the presence or absence of
;: thma or particularly horse asthma should
be obtained. Further the patient should bz
(jueslioned as to a previous injection of se-
rum. If the history is negative on both
counts we may proceed routinely. But even
£0 if the intravenous route has been chosen
the patient, whether tested or not, shiuild
always receive in advance several small sub-
cutaneous doses; then 1/10 that dose in-
travenously. Where the history is positive,
or the intradermal test (properly done) is
definitely positive it is imperative to give
ni'nute fractional injections for any method
of administration, whether it be intrathecal
or intramuscular. Errors in technique are
easily m?.de. The initial amount of serum
may be too large. One c.c. is a huge amount.
The successive amounts may be increased too
much or too rapidly. It is not safe to give
over 1/20 of a c.c. (0.05) at the first injec-
tion. The interval between doses should be
at least twenty to thirty minutes, and at times
two or more hours according to their reaction.
This is Besredka's method of desensitization.
It sounds logical. It should step up the
body's resistance; but certain writers claim
that it is not always successful where there
is a natural hypersusceptibility. Mackenzie
cites a fatality even where it was employed.
From the nature of things it is impossible to
prove its value. We do know of course that
it is useless as a prophylactic against serum
sickness.
In the event that a serum accident does
occur, the best and quickest procedure is to
!;ive hypodermxally a solution of adrenaline —
chloride. Should this not bring about relief,
't should be injected into the vein. If there
is still no improvement the situation is des-
perate. It is my opinion that no one should
be given any antitoxin (serum) without hav-
ing adrenaline immediately available. True
it is that in the vast majority of instances it
will not be required, but when needed it must
h? had at once. Some even advocate giving
routinely from three to five minims of ad.e-
nalne just prior to each injection of sevum.
May we not conclude this account of the by-
cf/.cts of serum with perfect fairness, by say-
'i\g that serum sickness and serum accidents
do at times occur; that they may be very
ir'vial or extremely serious; and while by no
means deterring us from that great benel'i-
ccnce, scro-thjrapy, yet that they do deserve
( ur must earnest consideration.
rp:ferences
1. Clock, R, O., "The conquest of communie.ihle
fl seaseb with scrums and vaccines," Am. Jour Di\
Child, (a'jit.) XXXVI-6, p. 1281 (Dec, 1028.)
2. C(,<A, .^RTurn F., "Scrum sickness," Arlic'e in
T:ce'.i Practice of Med., Vol. I, p. 162. VV :•" Prior
Co., 1028.
314
SOUTHERN MEDICINE AND SURGERY
May, 1929
i. Heckscher, Hans, "Serum sickness— in the
treatment of diphtheria" (abst.). Am. Jour. Dis.
Child.. XXXIII-4, p. 667 (April, 1027).
4. Lord. Frederick T.. "Serum disease and serum
accidents," Am. Jour. Opittk., 11-6, p. 451 (June,
162S).
5. Mackencie, Geo. M., "Serum sickness," Article
in Cecil's Text-Book of Med., p. 468. W. B. Saun-
ders Co., 1027.
6. Mackenzie, Geo. M., "Serum sickness," Article
in Blumer's Ed. of Forchheimer's Therapeusis, Vol.
VI, p. 23. D. Appleton & Co., 1025.
7. Stewart, Chester A., "Serum sensitization re-
sulting from diphtheria to.xin-antitoxin administra-
tion," Jour. A. M. A.. LXXXVIII-16, p. 1220 (April
16, 1027).
S. Spicer, Sophie, "The effect of previous admin-
istration of antitoxin and toxin-antitoxin on serum
reactions," Jour. A. M. A., XC, p. 1778 (June 2,
1Q2S).
0. Tuft, Louis, "Fatalities following the re-injec-
tion of foreign serum" (report of case), Am. Jour.
Med. Sc. CLXXV-3, p. .525 (March, 1028).
10. TooMEY. John A., and Golch, E. C, "Scarlet
Fever." VI— .4m. Jour. Dis. Child., XXXVI-6, p.
1173 (Dec, 102S).
DISCUSSION
Dr. James M. Northington, Charlotte:
Mr. President and Gentlemen: When Dr.
Pollitzer so kindly asked me to open the dis-
cussion on this paper and I consented, I did
not fully realize the wideness of the gulf be-
tween my knowledge of this subject and the
knowledge which is possessed and which has
been revealed here by our distinguished in-
vited guest, Dr. Kolmer. It would be a de-
privation to you and to me for me to take
up the all too little time that he can fill so
much more acceptably. I shall take only a
half minute to say and to say feelingly that
I, who have never believed that the clinician
should subordinate his judgment to that of
the laboratory man, or that there is any such
thing as a laboratory diagnosis, feel that Dr.
Kolnier's presentation of the subject, labora-
tory diagnosis, is the most wonderful presen-
tation to which I have ever listened. The
wideness of his knowledge, the cogency of his
reasoning, the preciseness of his expression —
all are marvelous. We are already indebted
to him, and I feel sure that our patients will
be indebted to him.
Dr. John A. Kolmer, Philadelphia:
I fear I have already talked far too much
this afternoon. I shall take advantage of the
opportunity, however, to compliment the es-
sayist on his paper, which is unusually com-
plete.
Serum sickness is a subject of great inter-
est to the profession on account of the mis-
information on the subject and on account
of the fear of serum accidents. The essayist
has distinguished between serum sickness and
serum accidents. I much prefer to regard
death as due essentially to the same mechan-
ism, a mechanism which I think is properly
designated as serum allergy. Probably the
majority of deaths that have occurred from
the administration of serum have occurred
after the first injection. The first death due
to serum on record occurred in 1896, that of
the little son of Professor Langerhans, in Ber-
lin, who received a prophylactic injection of
diphtheria antito.xin and died a few minutes
thereafter. This, of course, was a great blow
to the advancement of the use of diphtheria
antitoxin. The great majority of persons who
have died from the administration of diph-
theria antitoxin have died within the first few
minutes following its injection. Many of
these persons gave a history of being ren-
dered uncomfortable or asthmatic in the pres-
ence of the horse. In my opinion, serum
should never be given to an asthmatic indi-
vidual, particularly if the individual is a
stranger to the physician, because if the per-
son is subject to so-called horse asthma he is
likely to die. However, natural allergy to the
horse is extremely rare, as the doctor has
very p'operly pointed out. It has been stated
that in actual practice we do not meet with
these indivduals more frequently than once
in fifty to seventy thousind injections; but
the physician, in administering the serum,
should take the precaution of ascertaining if
his pat'ent has asthma.
The so-called acquired sensitization is not
nearly so dangerous as the congenital type.
Frequently we meet persons who have had
an injection of serum a month before or a
year before. I never hesitate to give serum
to a person of that type, subcutaneously or
intramuscularly; but if the serum has to be
given intravenously, then the physician does
well to hesitate and make sure his technic is
perfect, for if the serum is given intraven-
ously we have the stage all set for an explo-
sive typje of reaction. The individual rece'v-
ing serum in that way may develop tachycar-
d'a and may become even n- conscious. But I
have never seen a fatal case although one of
my assistants at the university, Dr. Tuft, has
recently described the death of two individ-
uals under such circumstances, so I think the
doctor has very wisely cautioned us in th!s
regard.
SOUTHERN MEDICINE AND SURGERY
31S
My own practice is to give the individual
an intracutaneous skin test. If that is posi-
tive, f^reat caution is required in the admin-
istration, but if the skin test is negative the
administration may proceed. I think it is
always well, even if the skin test is negative,
to. give the patient 1 c.c. subcutaneously and
then an heur later give the intravenous in-
jection. 1 th'nk in the interest of safety we
do well to take this precaution, the value of
which was established by the Rockefeller In-
stitute. Th?se patients are almost sure ulti-
mately to develop urticaria or other symp-
toms of serum sickness. That is not a dan-
gerous thing, although it may render one in-
tensely uncomfortable for days.
1 should 1 ke to lay emphasis upon the fact
that concentrated sera are not as dangerous
as raw sera. One should always use the con-
centrated sera from choice.
I hope that no one will hesitate to use
to.xin-antito.xin because of fear of serum sick-
ness. It might be well, as Dr. Pollitzer sug-
gested, to use the goat serum, so there is no
danger of sensitizing our little patient to the
l^rotein of the horse. In Philadelphia we are
trying the use of diphtheria toxoid as a sub-
stitute for T-A to avoid sensitizing the chil-
dren to horse serum.
Dr. Pollitzer, closing:
I merely want to thank Dr. Kolmer for
the discussion and to call attention again to
the fact that I omitted part of the paper for
the purpose of saving time. I believe in the
main Dr. Kolmer agrees with me.
Foreign Bodies in the Air and Food Passages*
E. G. Gill, M.D., Roanoke, Va.
Gill Memorial Eye, Ear and Throat Hospital
In a brief discussion of this subject only
a few of the salient points will be mentioned.
.Any one who is interested in bronchoscopy
should not nvss an opportunity to present to
a gathering of ge-ieral jjractitioners the value
of the bronchoscope as a diagnostic and ther-
an:'utic aid in the management of lesions of
the tracheo-bronchial tree. When we realize
I he vast amount of work that Chevalier Jack-
fon and his co-workers have done in this
specialty and the contribution thus made by
them to medical sc'ence, it seems incredible
that some well known surgeons will persist
in iierform'ng an external esophagotomy for
r; moval of a forei'jn body in the esophagus.
I I is not an uncommon thing for a patient to
Iring a ch'ld to the hospital giving a history
oi h'lv'ng aspirated a foreign body weeks or
months past, but was advised by the family
physician to wait, as the foreign body might
be cou';hed up. This advice, of course, was
htinestly given but the difficulty of removal
UL-uilly increases with the time the foreign
b jdy is allowed to remain in the air passages.
Only two to four per cent of bronchial for-
eign bodies are coughed up.
♦PrcHtitcd to till- Tri-State Mcdkal Association of
the Carulinas and \iri;inia, Greensboro, N. C-, Meet-
ing February 19lh, 20th and 21st, 1929.
PATHOLOGY PRODUCED BY FOREIGN BODIES
The pathology produced depends upon the
type and location. Non-obstructive metallic
foreign bodies may remain in the bronchi for
months or years without producing any
marked pathological changes, but eventually
they are fatal unless removed or expelled.
Organic foreign bodies, such as peanuts, beans
and grain of corn, produce violent reactions
in the bronchi of children and are rapidly
fatal unless removed.
DIAGNOSIS
.Ample time should be given to study every
case carefully. Very few foreign body cases
call for emergency procedures. Time is prac-
tically always given for thorough preparation
and study of each case before attempting
any endoscopic work. Patients are sometimes
told that the operation will only require a
few minutes and they can return home on
the next train.
We rarely attempt bronchoscopy unless we
have had at least twenty-four hours to study
the case. A patient should remain in the
hospital at least forty-eight hours following
bronchoscopy and longer if there is the
slightest evidence of complications.
Our routine procedure is the same as the
316
SOUTHERN MEDICINE AND SURGERY
May, 1929
one followed in the bronchoscopic clinic,
wh'ch is as follows:
1. History
2. Complete general medical examination
3. Roentgenologic study
4. Jlirror laryngoscopy
5. Endoscopy
PROGNOSIS
Jackson states that ninety-nine per cent of
foreign bodies in the lung can be broncho-
ccop'cally removed through the mouth. Gen-
erally speaking, foreign bodies in the bronchi
or esophagus, whether organic or inorganic,
obstructive or non-obstructive, ultimately
prove fatal. Mortality from e.xternal eso-
phagotomy is from twenty to forty per cent
and from esophagoscopy less than two per
cent.
DISCUSSION
Dr. C. X. Peeler, Charlotte:
I very much enjoyed Dr. Gill's presenta-
tion of these cases and his talk. I feel that
it is enough to say that it is not necessary
for our doctors to send their foreign-body
cases to some northern center to be handled.
Just a little b't of history of foreign body
work. The first removal of a foreign body
in the South was done at Charlotte in the
fall of 1896, so far as the literature or knowl-
edge goes. This foreign body was sent down
the throat of a child that lived in the coun-
try six miles from Davidson College. Dr.
Henry Louis Smith, who was pres'd?nt of
Davidson College, was working with an old
static machine and had a fluoroscope. He
put the fluoroscope on a wagon and hauled
it out to the child's home, looked through the
fluoroscope and saw a thimble in the child's
esophagus. The child was brou'^ht to Char-
lotte and the th'mble removed. A month
earlier, in Boston, a foreign body had been
removed from a child's throat. So Boston
and Charlotte, I think, have the honor of
being the first two cities in .-\merica in which
foreign bodies were removed.
In 1913 I attended a meeting where Dr.
Chevalier Jackson discussed the removal of
foreign bodies. His paper was d'scussed by
Dr. Kinyoun. Dr. Jackson emphasized that
foreign bodies should be removed without
."nesthesia, general or local: Dr. Kinyoun
took issue with him. But time has shown
that Dr. Jackson was right.
This work takes team work. You have to
have trained assistants who know how to hold
the child's head and shoulders and assist in
other ways. Dr. Jackson has the same nurse
with him now who was with him when I saw
h'm first do this work in Philadelphia.
.Another thing I wish to emphasize is the
d'agnosis. I think every general man should
familiarize himself to a certain extent with
d'agnosis of foreign bodies because we are
having more and more such cases. If you
will get the history (and nearly always you
can get a history of a foreign body), you can
rely to a great extent on what is told you.
I remember a case that came to us with a
peanut in the lung that had been there four
days. The doctor diagnosed this case as
pneumonia. On the third day of his attend-
ance the mother suggested to him that the
child had gotten choked on a peanut. Had
he gone into that he would have discovered
the real trouble immediately. When a pea-
nut goes into the larynx (a half one, usually)
the ch'ld has a severe fit of coughing and
often turns blue. Then the peanut goes down'
into the trachea and usually into the right
bronchus. The air is trapped in there.
Usually there is not complete blocking at
first, as you will find when you percuss, but
pretty soon the swelling around it closes it
completely. Then the lung will be hyper-
resonant. After a day or two the trapped
air will be absorbed, and then we have what
we call the drowned lung.
Dr. .a. L. Gray, Richmond:
1 am particularly interested and have been
for a long time in the diagnosis of non-opaque
foreign bodies, for the reasons that have been
brought out. A bean, a pea, a grain of corn,
a grain of coffee, etc., are the ones that cause
the chief trouble. The record length of time
that a metallic foreign body has been in the
air passages is forty years. But these non-
opaque foreign bodies are going to produce
trouble in a very short time; they are the
dangerous ones, the ones where immediate
procedure is necessary to determine whether
one is present. I want to emphasibe the
fact, as referred to by Dr. Peeler, that these
changes that take place following the inhala-
tion of a non-opaque foreign body take place
very rapidly and in order. The first thing
that happens is an emphysema it may
b;, all over the whole lung or the portion
of the lung that is supplied by the bronchus
in which that foreign body has lodged. Then
SOUTHERN MEDICINE AND SURGERY
the air is absorbed, and there is a time at
which there is practically no evidence of a
fo'-eVn body. Then a little later this air is
absorbed more completely, and this 'uns; be-
comes water-logged.
These cases should be e.xamined not just
once. If you fail to make a definite diagno-
sis at the first examination, the case should
be examined again the next day, and even
several days to a week afterwards if the
symptoms persist. .Actual blocking of the
entire main bronchus or blocking of the whole
trachea may take place, shutting off the
child's respiration immediately. We have had
that happen.
1 am thoroughly interested in this work
and congratulate Dr. Gill on the excellent
work he is doing in Roanoke.
Dr. De.^n B. Cole, Richmond:
I have seen a tooth in a lung abscess that
did not show up on x-ray immediately. I
also saw a bone that had been in the lung
for six years.
Dr. J. L. Miller, Thomas, W. V.
Dr. Peeler brou'jht out the history. I wish
lo call the attention of the gentlemen here to
a very remarkable case of removal of a for-
eign body lis years ago. A child had swal-
lowed a fish hook, a barbed fish hook. From
external indications, it was lodged somewhere
in the lower end of the esophagus. The prob-
lem was to get it out. Fortunately, there
was a section of line attached to the hook.
So Dr. Bright, of New Castle, Ky., who did
the work, took a large-sized rille bullet, made
a hole through it, threaded it on the line and
had the child swallow till the bullet rested
on the hook when it was withdrawn without
damage to the child.
Dr. Gill, closing:
What Dr. Peeler said in reference to Dr.
Jackson's not using an anesthetic I think
should be explained a little. He does not
use ether or any form of general anesthetic
but does anesthetize with morphine. I saw
a case not long ago in which he gave one-
sixth of a grain or morphine before the oper-
ation, and the child was apparently complete-
ly anesthetic. It is remarkable how much
morphine children will tolerate. We start
out several hours before the operation usually
with one-sixteenth. I think the secret of his
success, while not using any anesthetic, local
or general, is the use of morijhine.
ADRENALINE BY ALIMENTARY CANAL
.Adrenaline wn-i administered by stomach tube to 12 dogs. It caused a rise in the blood sugar
level. Adrenaline is absorbed, therefore, through the gastroenteric tract, other than the mouth
and throat. None of the other usually apparent effects of adrenaline were noted. The blood
pressure was not affected. Injections of adrenaline into the jugular and the vena cava gave
materially greater rises in blood pressure than did equivalent injections into the portal vein or into
the liver. .\pp. rcntly the liver removes most of the pressor effect of adrenaline. It appears that
the liver is able to remove the pressor effect of adrenaline as fast as the drug is absorbed, when
administered by stomach tube.
— GiRAGossiNTz and Mackjku in l'.nd(nrinok>f,y.
318
SOUTHERN MEDICINE AND SURGERY
Mav, 1<32<)
Uterine Fib'-oids — How the Pathology Affects Treatment*
Case Reports
Ivan Procter, ]M.D., Raleigh, N. C.
Mary Elizabeth Clinic
Fibroid tumors are of such common occur-
rence and abdominal surgery is so popular a
treatment, that many of us fail to give just
consideration to the type of tumor, its s'ze
and location, the time of appearance, the
syniDtoms and pathology produced, or to the
selection of treatment if any is indicated.
Fibro'ds are parasitic, smooth muscle and
connect-'ve t'ssue tumors, develop'ng within,
but not from, the uterine wall. The arrange-
ment of fibers are atypical and the size of
the growths vary from a minute node to that
of a huge mass. The evidence is that all
fibroids originate as interstitial tumors which,
as they rrow. follow lines of least resistance,
developing toward the surface to become sub-
fcous or toward the uterine cavity, becoming
submucous.
The etiology of the tumor has never been
d?finitely established but the function of re-
production seems to be the most innortant
factor, since the development takes place only
during the menstrual life.
Myomas are the commonest uterine tumors,
almost always multiple and, according to
Polak, present in 40 per cent of all women
fifty years of age.
The symptoms and signs of myoma consist
of pain, menstrual irregularities, sterility,
abort'on, pressure discomforts, d'gestive
disturbances and anemia. The physical
s'gns are those of a smooth, hard mass
connected with the uterus, usually producing
enlargement of that organ. The effects upon
menstruation are multiple, dysmenorrhea be-
irg the most common. Menorrhagia is usual-
ly present in the submucous and interstitial
tumors but absent in the subserous type.
The increased menstrual llov^ -s due to pres-
sure disturbances in the uterine circulation,
r'cducing hemorrhagic endometritis opposite
the atrophic endometrium over the tumor
mass.
In practice dysmenorrhea is frequently ex-
•Prcr-nted to the Tri-State Medical .Association of
(lie Caro.;nas and Virginia, Greensboro, N. C, Meet-
ing February 19th, 20th and 21st, 1929.
plained on a functional basis and the patient
goes on suffering for years only to show up
nt a later date with well developed niyomata.
Pain in the submucous and interstitial tumors
may be due to uterine contractions; in the
pedunculated intrauterine variety, it is due
to an attempt to expel the fore'gn body. Sub-
serous tumors do not cause di'smenorrhea but
produce pressure pain according to their lo-
cation. If only of moderate size and situated
on the fundus there may be no symptoms,
but often those on the anterior wall of the
uterus press against the bladder, causing fre-
quent, painful and difficult micturition. Like-
wise, pressure may be upon the ureters, re-
sulting in dilatation of th? kidney pelvis,
infection and pyelitis. A tumor on the pos-
terior uterine wall may cause obstinate con-
Et'pation or prevent engagement of the fetal
he^d in labor.
IMynmas play an important part in steril-
ity. Women married for a number of years
without conception or with repeated early
miscarriages, will often show myomatous
uteri. Nesting of the fertilized ovum is hin-
dered by atrophy of the endometrium, rigidity
and distortion of the uterine wall; also by
exaggerated congestion and excessive bleed-
ing. In other cases sterility is increased by
disturbance of tubal function, due to pres-
sure upon the interstitial portion. Kelly has
pointed out that reproduction is six times
bss frequent in the myomatous women than
the average. PhiU'ps found .SO per cent of
814 myomatous women sterile against 15 per
cent sterility among average women. Davis
reports 28 per cent fertility in such women
after myomectomy.
There is frequently an associated tulial and
ovarian disease in women with fibroids that
increases the percentage of sterility. Leucor-
rhea is a prominent symptom, due to chronic
passive congestion wh'ch results in over-activ-
ity of the cervical glands. Anemia is the rule
in submucous or intramural fibroids, the blood
pcture beng of the characteristic secondary
type, and sometimes becoming extreme.
May, 1929
sbtJtttERN MEWClKfe AND SURGERY
ii9
Necrosis and infection of fibroids often show
anemia out of proportion to the amount of
blood lost. There are at times cardio-vascu-
lar changes, and hypertension is a frequent
ci^mijl. cation.
The diagnosis of fibroids resolves itself into
a study of the individual patient. Any wo-
man in the child-bearing age who has painful
menstruation which is profuse and prolonged,
especially if there be a history of sterility or
repeated early miscarriages, should be con-
sidered as possibly presenting a case of
myoma. If the sound proves the uterine
canal to be elongated, that is additional evi-
dence, and the finding of multiple, irregular,
hard masses on the uterus is almost conclu-
sive.
Pregnancy and pelvic inflammatory disease
are to be ruled out. In the former, uterine
contractions may harden an area in the body
of the uterus and simulate a tumor; in the
latter, irregular, excessive bleeding that ac-
companies pelvic inflammation may suggest
myoma, and a large congested uterus tend to
confirm it. The examination of such cases
under an anesthetic is a wise procedure.
Although only about five per cent of fib-
roids show malignant changes, degeneration
is frequent and serious enough for us to
keep that possibility in mind as an associa-
tion or complication of the disease. At the
Long Island College Hospital 3 per cent of
fibroids show sarcomatous changes and 2 per
cent have associated carcinoma.
The most important factor in the treat-
ment of fibroids is the individualizing of the
cases in order to determine the need of ther-
apy and the selection of the type of treatment
best suited to the individual. The routine
treatment of all myomata by either myomec-
tomy or hystero-myomectomy, x-ray or ra-
dium, IS incompatible w.th good judgment.
For inc dence, the accidental finding of a 4
cm. fibvo.d in the course of a routine e.xam-
ination vvli.ch is producing no symptoms or
iwthology, does not call for treatment. But
m young women small tumors may at times
best be ojjerated while the growth is suitable
for myomectomy rather than wait until the
uterus iS extensively involved and requires
hysterectomy. (All fibroids should be kept
under close observation.) Myomectomy is
indicated in .small tumors where sterility or
frequent abortion is jiresent and cannot be
cxjjlained on any other grounds.
One of the patients reported in this paper
v.as thirty-five years of age, had been mar-
ried nine years without pregnancy and cams
to the clinic on account of irregular menstrua-
tion and sterility. .After some observation
we decided that a small fibroid situated in
the right horn of the uterus was the cause
ard advised operation, both as a curative
measure and to increase the chances of con-
ception. At operation a fibroid was found in
the fundus, near the interstitial portion of
the right tube. This was removed through
an incosion posterior to the broad ligament.
The patient became pregnant within eight
months after leaving the hospital and was
delivered at term.
Fibroids situated on the anterior wall of
the uterus are usually found as a result of
bladder disturbances. The tumor reduces the
size of the bladder, causing irritation and
even blockage to the urethra. (Such tumors
are best operated on early, any increase in size
causing more impaction, encroachment upon
the bladder and increasing difficulty in re-
moval.) On account of the position and
close proximity to the bladder these cases are
not suitable for radium.
.-Vnother patient treated in the clinic was
thirty-one years of age and complained of
retention of urine. She had a mass slightly
paipable S>2 centimeters above the symphi-
sis, Vvhich could be outlined anterior to the
u'lCrus on bimanual examination. The tumor
v/as causing considerable pressure upon the
bladder, obstructing the urethra and necessi-
tafn;^ catheterization. It was for this reason
liiat she sought relief and her physician re-
ferred her for cystoscopic study. The growth,
however, necessitated hystero-myomectomy.
Tumors developing on the posterior wall
of the uterus or in the lower uterine segment
r.rc prone to interfere with the normal mech-
anism of labor, even to the point of obstruc-
tion, and in such cases, not only is delivery
by the natural route prevented, but the re-
peated pounding and pressure upon the tumor
iub'ects it to necrosis and infection, which
complication greatly magnifies the danger to
the patient.
Removal prior to [iregnancy is the treat-
ment of choice, but, if not seen until labor,
every ei'fort should be made to force the tu-
mor up out of the pelvis by placing the pa-
tient in the knee-chest or Trerdelenburg posi-
tion. Cesarean section"', if necessary for the
m
SOtJtHERN MEDlCtMfi A^t) StJfeGEfeV
May, lOia
relief of obstruction, should often be followed
by hysterectomy rather than myomectomy.
Radium can be used to advantage in tu-
mors less than the size of a three months'
pregnancy in women forty years of age and
over, especially in patients with complicating
cardiac, renal or pulmonary disease. Younger
FIG. I
This shows the location of the submucous inter-
stitial and subserous tumors. Atrophy of the endo-
metrium can be seen — the result of pressure by the
tumor. Vessels run in the interstitial and submucous
part of the uterus, hence menstrual disturbances by
these tumors and not in the subserous variety.
women should be operated on in order to
preserve their menstrual and reproductive
functions. All intrauterine radiation should
be preceded by a diagnostic curettage as car-
cinoma may be present. A few weeks ago a
woman of forty-two with an enlarged, irreg-
ular uterus, and slight disturbance in men-
struation was seen. Operation was advised
and the patient prepared for intrauterine ra-
diation: e.xcept for the operator's invariable
rule of diagnostic curettage, a well developed
adeno-carcinoma would have been overlooked.
Radium may be used in some patients de-
siring offspring, but the dose must be consid-
erably smaller than usual, 1200 milligram-
hours being sufficient to induce permanent
menopause with fibrosis of the ovaries and
destruction of the graafian follicles. (Math-
ews. )
We recently did a cesarean section on a
woman who has been given 600 milligram-
hours of radium and the cervix amputated
FIG. II
A fibroid growing from the anterior wall of the
uterus pressing against the bladder. The first symp-
toms are often bladder disturbances. Radiation
usually contraindicated on account of the close
pro.ximity to the bladder.
at the same time. There was no menstrua^
tion after radiation for three years, and when
referred to us the patient was seven months
pregnant. Ai delivery the baby weighed six
and a half pounds, was in perfect physical
condition, contrary to the findings of many
observers reporting babies born after radia-
tion. Both mother and daughter are living
and well.
The treatment of fibroids in pregnancy de-
mands our most careful thought. .Although
the great majority of tumors take care of
themselves during pregnancy and labor, there
is a sufficient number that cause serious trou-
ble to make us apprehensive about all. Fib-
roids of moderate size or low-lying tumors,
should be operated on before conception in
women looking forward to pregnancy. If preg-
nancy has already taken place myomectomy
is probably not justifiable except in the face
of necrosis. If degeneration takes place, as
evidenced by fever and leucocytosis, the pa-
tient should be in a hospital at rest, and if
the symptoms fail to subside, operation should
not be delayed.
If necrosis comes in the puerperium it is
better to operate too early than late. Sub-
serous tumors do not usually cause trouble,
but the interstitial, especially the submucous
varieties, break down. It is in the latter that
infection and sepsis are so liable to produce
serious consequences.
We recently had the opportunity to exam-
Uiy, 1929
SOUTHERN MEDICINE AND SURGERV
iii
ire a puerperal patient with a large eroded
tumor filling the vagina. The evidence point-
ed to an inverted uterus and the patient was
prepared for a Spinelli operation. .After cut-
ting through the cervical ring a cavity was
located above and the mass turned out to b?
a large cervical fibroid. This was removed
and the patient recovered.
In a review of forty cases of uterine fib-
roids at the Mary Elizabeth clinic, the out-
standing points in the history were pain,
menorrhagia, dysmenorrhea, sterility, preg-
nancy with miscarriage, and prolongation of
menstruation over the five-day period. One-
half the patients were between thirty-five
and forty years of age and the other ages
ranged between thirty and sixty years. Many
patients had chronic endocervicitis and palpa-
ble enlargement of the uterus was the rule.
All but three patients were married. Four-
teen had never been pregnant; three pregnant
only once; seventeen twice or more. Si.x had
been pregnant and miscarried.
^Menstruation began between twelve and
fourteen years in 25 patients; the remainder
were older. Endocervicitis was present in
li: the uterus enlarged in 24. The adnexa
palpably diseased in 5. .Albumin and casts
were present in 10. Hemoglobin below 75
and above 60 in 12; below 60 and above 45
in 7; below 45 in 5; above 75 in 7; not taken
in 9.
There were 21 subserous tumors; 1 sub-
mucous: 16 intramural; 3 cervical; 2 poly-
pod; 1 degeneratint;.
Treatment consisted of x-ray in 1, diag-
nositic curettage and radium i, amputation
of polyp 2, myomectomy 7, subtotal hystero-
myomectomy 14, panhystero-myomectomy 2,
no treatment in 8, salpingo-oophorectomy due
to tragic ectopic in one.
There was one death following hystero-
myomectomy and appendectomy for a large
rubvesical fibroid, death resulting from par-
fal intestinal obstruction, due to a kink in
the lower ileum.
To summarize: — The treatment of uterine
fibroids is many sided and depends largely
up(jn the pathology produced by the tumor.
Each patient should be studied thoroughly
and the treatment chosen upon the merits of
the case. The question of desire for off-
spring is important in deciding upon strictly
conservative or radical treatment. Operation
is preferable to radiation for women in the
chld-bearing age in order to preserve their
greatest funct on in life. .And for the same
reason, myomectomy is preferable to more
destructive treatments.
When the fundus is destroyed by multiple
tumors, supravaginal hystero-myomectomy is
the treatment of choice, panhysterectomy be-
mg justifiable only when the cervix is dis-
eased or malignancy suspected.
In a review of 268 cases of cervical cancer
by the Pennsylvania State Cancer Commis-
sion, only 9 were found to follow supravaginal
hysterectomy, and this number could prob-
ably have been reduced by coning out the
cervix with the cautery.
Radium is best suited for women with
children, or patients forty years of age who
have uncomplicated fibroids producing hem-
orrhage. These cases should have a prelim-
inary diagnostic curettage in order to detect
carcinoma.
FIG. Ill
Fibroid prcwins from tlie posterior wall of the
uterus, frequently presses upon the rectum producing
constipation. This turner may or may not rise out
of the pelvis during labor. Trauma may set up
necrosis and infection, a crave complication in the
puerperium.
Pregnant women with fibroids should be
watched very carefully for signs of necrosis
or infection. If degeneration takes place
early in pregnancy myomectomy or hysterec-
tomy is usually indicated; if late, treat con-
servatively and, when necessary, follow i)y
cesarean section and extirpation.
In conclusion, the selection of treatment
for uterine fibroids should be based ujjon a
thorough study of the individual patient, the
type of growth, its size, location, the age of
the patient, her desire for offspring and the
322 SOUTHERN MEDICINE AND StJRGERY
pathology produced by the tumor itself.
REFERENCES
May, 1929
PoLAK — Manual of Gynecology, Third Edilion,
Lea & Febiger, Philadelphia, 253.
Graves — Text Gynecology, Second Edition, W . B.
Saunders, Philadelphia.
Kelly — Text Gvnecology, D. Appleton, New York
City.
Keene, F. E., Am. J. Obs. and Gvn., August, 1924,
Vol. VIII, No. 2, p. 201.
PoLAK — Jour. S., G. and 0., January, 1028.
KosMAK, G. W.—Am. J. Obs. and Gyn., Vol. VI,
No. 1, p. 63.
Mary Elizabeth Hospital Records.
Neill— ylm. J. Obs. and Gvn., 1924, Vol. VIII, p.
205.
Clark and Block — Am. J. Obs. and Gvn., \'ol. X,
p. 560.
Lyn'l'h and Maxwell — Pelvic Neoplasms, D. Ap-
pleton, New York City, p. US.
Cl.^rk and Norris — Radium in Gynecology, J. B.
Lippincott Co., Philadelphia, p. 260.
M.wo, W. J.— Jour. A. M. A., 1Q17, LXVIII, p.
SS7
G.ncc, 1016,
Alfieri, E. — .4m. di. ostet
XXXVIII, p. 300.
Ravmat, M. F.—Therapia Barcelona. 1Q17, IX, p.
129.
Case, J. T.—Surg. Clin. Chicago, 1Q17, Vol. I, p.
579.
Rural Hospitals as a Means of Properly Distributing Rural
Medical Service*
Wm. C. Tate, M.D., Banner Elk, N. C.
Grace Hospital
Rural medical service has been gradually
breaking down for the past twenty years,
and more especially for the past decade. The
American Medical Association Directory
over a seventy-five-year period showed only
a small variation in the number of physicians
in proportion to the population.. The United
States has more physicians in proportion to
the population than any other country. .Ac-
cording to latest figures of the Federal Bu-
reau of Education, there is one physician to
every 753 persons in the United States. Com-
parative figures are:
United States
Great Britain
Switzerland
Japan
Germany _
Austria
Sweden
1 to 753 population
" " 1087 "
" " 1200 "
" " 1359
" " 1040
" " 2120
" " 3500
By comparison with other countries, it
would seem that the United States would
have more than a sufficient number of phy-
sicians to take care of the health needs of
this country. But the distances to be cov-
ered are greater and the physician can see
fewer patients than in the thickly populated
European countries.
Individuals and organizations that have
made a careful study all agree that there is
♦Presented to the Tri-State Medical Association of
the Carolinas and Virginia, Greensboro, N. C, Meet-
ing February igth, 20th and 21st, 1929.
an abnormal distribution of th? phys'cians'
in this country, the general supply remaining
fairly constant, inlluenced by wars and eleva-
tion of medical standards.
In spite of all our progress in consolidated
schools, good roads, and mater.al expansion,
our three states here represented today are
near the bottom of the list in their propor-
tion of physicians to population. Of the 48
states, and the District of Columbia, Vir-
ginia ranks 38th, North Carolina 45lh, and
South Carolina is at the bottom of the Kst,
49th.
The urban distribution of physicians in
these slates is satisfactory, but in the remote
rural communities, with a center of popula-
tion not greater than 2,500, we find the break-
ing down of rural medical service. Instead
of showing increases, we find that Virginia
has dropped from 35th to 38th place. South
Carolina is 49th, while North Carolina has
advanced one place from 46th to 45th in the
three-year period from 1925 to 1928. But
this gain did not take place where most need-
ed, as North Carolina has 24 counties with
more than 2,000 population per physician,
while there were only 2i such in 1925, South
Carolina likewise showed 17 counties with
more than 2.000 population per physician,
while there were only 14 such in 1925. In
39 counties of Mrginia during the past twelve
years, the nimiber of physicians decreased
May, 1920
§OttHERN MEDICINE AND SURGERY
Hi
from 364 to 258, a loss of 29 per cent.
As a matter of interesting comparison
we will consider our sister state of Ten-
nessee, where we would expect similar
conditions. The area, population, and num-
ber of counties in Tennessee are just a little
less than those of North Carolina. Tennessee
has four large centers of population and three
class A medical colleges, two for white and
one for colored students.
To quote Dr. H. H. Shoulders of Nash-
ville, Tenn., on conditions in his state, "There
are 94 physicians under the age of 30 years;
77 of this group (81 per cent) are located in
four large counties, the other 17 are located
in the other 9 large counties." This leaves
82 out of Tennessee's 95 counties without
any younger practitioners. This information
further bears out the fact that the problem
is more or less the same in each state.
!More than one organization and various
individuals of the United States are making
an effort at the prseent time to assist in a
material way to solve this problem, but only
a bare scratch has been made when the whole
need is considered. Various persons have of-
fered a solution to this problem. The Medical
Times, in its issue for January, has an edi-
torial on "When Aesculapius Flies." The
article says that "even now, a ready means
of properly distributing medical service is by
the use of aeroplanes." The time may come
when every small village will have a landing
field and, with the proper organization, this
solution has many advantages to commend it-
self. Youth must be challenged with the
facts and presented with a call to the task.
This solution is placing the whole plan on a
very idealistic plane, but this does not meet
all the needs, for have we the right to ask
these young men to accept this challenge and
not provide facilities for the practice of their
profession? Some have suggested more medi-
cal colleges, that there may be turned out
such a large number of physicians that by
the law of supply and demand, economic
necessity will force doctors into local rural
communities. Too, the third plan would
bring the great evil of too many doctors
which, in a county or community, is harmful
to the profession and to the public. Fourth,
^ome believe that a man should have at least
a few years in general practice, and, as the
general practitioners are disappearing from
our cities, this solution of the problem might
come from these general practitioners locat-
ing in the rural fields for a period of time and
in preparation for entering specialties. Fifth,
that the citizens of small towns or rural com-
munities will exercise a greater spirit of loy-
alty to their local physician and if the city
specialist will be discreet in his remarks con-
cerning the diagnosis and treatment of the
pat>nt that is placed under his care, would
help to elevate the standard, so that more
men might be willing to enter rural practice.
Sixth, yet others have suggested that senti-
ment be created in favor of the establishment
of scholarships and revolving loan funds for
the medical students who have pledged them-
selves to serve as family doctors for a term
of years in the country and in villages of
less than 2,500. This plan is very practical
and, with additional facilities for real medi-
cal service, which include medical personnel,
nursing and technical personnel and hospital
facilities, this plan would prove ideal.
In the preparation of this paper, we sent
out a cjuestionnaire to associations and indi-
viduals that have made a study of this prob-
lem.
Questions and answers follow: (). Is the
shortage of rural physicians due in some
measure to the lack of hospital connection?
A, All but one answered in the affirmative.
Q. Will rural hospitals occupy a permanent
place in future rural programs? ,1. Every
one replied in the affirmative. Q. Are rural
hospitals practical? A. The answers varied
from, "The fact that there are a number of
rural hospitals being successfully operated,
justifies the opinion that they are practical,"
to, "They are in some communities and not
in others." {). Can the personnel for rural
hospitals be secured? A. The answers to this
cjuestion varied from, "yes," to, "Although
there is greater difficulty in securing properly
cjualified hosiMtal personnel for rural com-
munities, it is being done in many instances.''
Q. Will the county serve as a unit for rural
hospitals? ,1. The answers varied from "yes,"
to, "Given a hospital group large enough, the
county may serve as a hospital unit. Fhe
minimum population to justify a general hos-
pital, we believe, is 30,000." {). Is it
the county's duty to finance the building
and provide at least a part of the main-
tenance? .1. The answer was unanimously
"yes, " if the hospital is to furnish free
or part free service. (J. As the shortage
m
§btTHERN MEDICINE AND StJRGEkV
May, lOid
of rural physicians is becoming; more acute
each day, to what extent will rural hospitals
relieve this situation? .1. The answers were
from, "entirely," to. "If a county will not
support physicians, it will not support hos-
pitals." Q. At the present time, what solution
do you think is most practical? A. Answers
varied from economical improvement of rural
people to educating the physicians to demand
county hospitals just as lawyers demand court
houses. With these practical questions and
various opinions it is evident that a very
thorough study should be made by the medi-
cal profession of the whole problem.
We believe that this is a real problem and
one that will challenge the best efforts of the
medical profession of this country, one that
should be solved, not by legislation, but by
the constructive leadership of the profession.
For that reason when I was invited to read
a paper before this society, it was decided to
present the problem of rural medical service.
I trust you will pardon any personal refer-
ence to our work, for we can only illustrate
the point by the work with which we are fa-
miliar.
My own opinion, based upon twenty years
of rural service in a remote mountain district,
is that whatever solution is attempted it must
include an opportunity for hospital connec-
tion in the vast majority of instances. A
physician with hospital facilities can give
from two to five times the service and of a
far superior order. Of course it will not be
possible for each small village to have its
own hospital, but the great majority of coun-
ties can provide at least one institution each.
The very small counties can co-operate with
the surrounding counties in the erection and
maintenance of an institution. If a county
will provide hospital facilities, I am of the
opinion that it will have mi tnnible in keep-
ing its physicians.
The institution which I represent had its
beginning more than twenty years ago in
connection with the mountain school, which
was made necessary by the gathering together
of young people in this community of less
than 300 people, eight and one-half miles
from the nearest narrow-gauge railroad point
and thirty-five miles from the nearest broad-
gauge railroad, half-way between Lenoir, N.C.,
and Johnson City, Tenn. — Banner Elk, .Avery
county. The school and the local village peo-
ple furnished lumber and money and first
constructed a fourteen-room wooden building
to be used as a residence and an office for a
physician. iVIedical service was carried on in
this way for three years; then six rooms were
set aside for patients and the process begun
of educating the people to avail themselves
of the crude hospital facilit'es. .\fter twelve
years' experience with only one nurse as an
assistant, taking care of the office and hos-
pital patients in the absence of the physician,
we were able to influence outsid; philanthropy
to provide the necessary funds for building
a small fireproof general hospital, with oper-
ating room, sterilizing room, laboratory and
other equipment for the care and' comfort,
the diagnosis and treatment of patients. At
this juncture a second physician was added.
Comfortable homes for the two physicians
were provided on the grounds of the hosp'tal,
a nurses" training school and home was pro-
vided to care for the nursing personnel of the
institution. These four buildings at the pres-
ent time make up the hospital unit, together
with ten nurses and a total of 23 workers.
The professional services are divided into
two parts. One doctor taking the medical,
obstetrical, and x-ray end of th_^ work while
the other is responsible for the general sur-
gery and administration. Our work is divid-
ed into two main departments, the out-pa-
t ent department and the in-patient depart-
ment. In the out-patient department the
people are allowed to choose their own phy-
sician, returning for examination and treat-
ment as necessary from time to time. We
are able to care for about 6,000 office calls
each year. For the hospital, one of the de-
partments of the Edgar Tufts iMemorial As-
sociation and a board of trustees duly ap-
pointed for the purpose of d.recting the poli-
cies of the institution, th; following policy
was adopted by the board of trustees in 1924.
.\fter two years of experience with it we find
no reason for changing this general policy:
First — That it shall receive its proportional
part (jf the benefits of this organization as
well as a^ume its part of the obligation.
Second — That it shall administer the
physical and public health problems of the
Lces-McRae Institute and the Grandfather
Orphans' Home.
Third — That it shall follow the plan of the
giver of the new department in serving as
wide a section of the mountain territory as
possible, caring for the sick and ministering
May, 1«J^
SOtJtHERN MEDICINE AND StJRGEftY
Hi
to the wounded.
Fourth — That it shall be an institution for
the sick, without regard to race or creed.
Fifth — That the department have a pro-
gressive policy and allow the institution to
grow and expand to the limits of its oppor-
tunity.
Sixth — That we shall have a department
for the training of young ladies for the nurs-
ing profession, and in this way become an
educational institution.
Seventh — The financial policy is to secure
funds from any legitimate source for the pur-
pose of enlarging the sphere of usefulness of
the institution.
Eighth — To hold the cost per day per pa-
tient to the minimum consistent with ade-
quate service.
Ninth — Insist, and if necessary require, in-
dividuals and organizations receiving service
from the institution to pay a reasonable fee,
if within their power to do so.
Tenth — AH worthy charity shall receive
free treatment.
Eleventh — Physicians shall not receive any
compensation from the institution, and will
depend entirely upon their private work or
upon those who are able to pay more than
the hospital account.
Twelfth — All patients' obligations will first
be to the institution. Any compensation
above that point shall go to the physician or
physicians.
The in-patients come from the sifting out
of the office calls and patients that are re-
ferred by outside physicians, and people who
come on their own accord. On arrival of the
patient at the hospital, his history is taken
and every effort is made to arrive at the
diagnosis or at least a classification of his
case, and placing in the proper service. The
laboratory technician takes care of a large
amount of the routine, and of the usual lab-
oratory examinations. With this arrangement
we were in a position to discharge 702 bed
patients during the last year. Surgical, 272;
medical, 266; obstetrical, 57; other classifi-
cations, 107. These patients were drawn
from nine surrounding counties in two states
due to the fact that we are a border county.
.At the present time, we hear a great deal
of discussion as to the high cost of hospital
service in all parts of the United States. Hos-
pitals meet the needs of the very rich, and
of the very poor. Various methods are being
tried out to meet the average man's ability
to pay. During the last five years we have
found it possible to give the hospital service
at a cost of approximately $2.00 per day per
patient.
With our experience, observation, and in-
vestigation, we have come to the following
conclusions:
First — The shortage of rural physicians is
due to the lack of hospital connection.
Second — Not only can a small town hos-
pital be made a success, but a cross-road in-
stitution can be made of great service, pro-
vided it is strategically located and has a
sufficient territory to draw from.
Third — Although it is desirable in an in-
stitution to have several men to cover the
various specialties, it is possible for two men
to cover the field and give the people good
service.
Fourth — In an institution made possible by
philanthropic individuals and organizations,
although we may have many advantages, we
cannot expect to receive sufficient funds to
cover all needs. Therefore, we believe that
it is the privilege of the medical profession
to educate the people to demand at least a
county institution, which it is the duty of
the county to provide.
Fifth — We believe that eventually every
physician will have an opportunity for hos-
pital connection for the proper care of his
patients, and that the sooner this is made
possible the earlier we will have a proper bal-
ance between the rural and urban distribution
of physicians.
Sixth — We believe that it is the oppor-
tunity and the duty of the various organiza-
tions to more fully investigate conditions and
to recommend solutions of the various prob-
lems that concern medical service in all of
its phases.
^
ii6
§bttHfebN MEbtdi^fe kiJt stkofekV
May, 1029
Sterility*
Robert Thrift Ferguson, M.D., Charlotte, N. C.
Sterility ;is ordinarily defined means in-
ability to reproduce. I shall not burden you
with any classification, for this can be ob-
tained from any good text-book on the sub-
ject. In this paper the etiology, diagnosis
and treatment will be discussed from the
standpoint of trying to give the patient relief.
In another paper I reported a series of one
hundred cases diagnosed by means of an ap-
paratus devised by myself about six years
ago and I shall report a like series in this
paper and combine the two showing the re-
sults obtained in the two hundred cases.
Detailed description of the apparatus and
the technic|ue for its use were embodied in
an article publir.hed in Southern Medicine and
Surgery, April, 192S. Since the reprints of
this article were quickly exhausted I have
had many requests for the same data and
therefore I am repeating the technique with
a cut of the apparatus as formerly published.
The following paraphernalia will be neces-
sary: the F'erguson glass tube; ,a two-ounce
rubber ear syringe bulb; bivalve speculum;
tenaculum forceps; mercurial manometer;
cotton swabs for drying the cervix and paint-
ing the same with iodine. The rubber bulb
can be purchased at any drug store. Clip off
the tip so that it can be easily slipped over
the butt end of the glass tube. Sterilize the
glass tube with bulb attached along with the
other instruments necessary. I have used the
same tube for nearly six years and have not
had the misfortune to break one either from
handling or in the sterilization and I consider
the danger from this to be negative.
Presuming that you have previously exam-
ined your patient and know the position of
the uterus and the condition of all th? pelvic
organs, you are now ready to proceed. With
the patient on the table in the dorsal position,
feet in the stirrups, the bivalve speculum in-
serted, all mucous or other secretion is re-
moved and the cervix painted with iodine.
Grasp the anterior lip of the cervix crosswise
with the tenaculum, about one-quarter of an
*Presenlcd to the Tri -Slate Medical .■\ssociation of
the Carohnas and Virt;)nia, Greensboro, N. C, Meet-
ing February loth, 20th and 21st, 1929.
inch from the os, and insert the tip of the
glass tube into the cervix until the bulb plugs
the cervix, then attach rubber tube leading
to manometer to the side arm on the tube.
The curved tip will be inserted into the cer-
vix up or down according as to whether the
uterus is in normal position or retroverted,
just as you would the sound or dilator. With
the rubber bulb in your hand force the air
into the uterus very slowly, allowing from
fifteen to twenty seconds to complete the
operation, always pressing the tube firmly
into the cervix, using the forceps for counter-
pressure to prevent the escape of air around
the tube. You will be surprised to t'lnd how
little pressure this requires. If either tube
is patent the air will enter the peritoneal .
cavity at anywhere from twenty to two hun-
dred mm. of Hg. Normal tubes seem to be
open at a pressure of from twenty to forty
mm. I would strongly urge you not to run
the pressure above two hundred in any case,
no matter how strong the temptation may
be; in this way you will keep away from the
danger line. If the tubes are patent you will
feel the pressure give under your fingers and
the mercury will begin to tumble. This is
one of the nicest and most delicate points
about the test, as the instant the air enters
the peritoneal cavity the sensation is trans-
mitted to the fingers and you can release the
bulb allowing only the smallest quantity of
air to enter the peritoneal cavity, thereby
preventing the pain that might follow the
introduction of a quantity of air. Aiiy blood-
pressure apparatus that you happen to have
may be used. A trained assistant to use the
stethoscope over the fimbriated end of the
tube will tell you which tube is patent, in
case one should be closed.
I cannot urge it upon you too strongly that
dangers attend the haphazard use of this
test. I do not believe it should be attempt-
ed by anyone who has not at least seen its
use demonstrated. There are many little
points that will puzzle you if you have not
seen the test performed. Even in the hands
of one experienced in its use there are po-
tential dangers. In performing more than a,
May, 1929
SOUTHERN MEDICINE AND SURGERY
327
thousand tests I have had no serious conse-
quences in a single case and a very limited
amount of pain following the test except in
four cases, and in these it was insignificant.
I wish to point out the main contraindica-
tons to the test as I have seen them, the
chief of which are: acute pelvic conditions;
acute gonorrhea: menstruation: large masses
in the pelvis with or without temperature;
feverc forms of cardiac or pulmonary disease
a.:d where pregnancy might be suspected.
of these in my office, have been sterile on
account of blockage of the tubes, either by
malpositions, adhesions, pyosalpinx, hydrosal-
pinx or tumor formation. In only one of
the cases was I satisfied that the obstruction
was due to congenital atresia. While in only
a very small percentage of the cases could a
neisserian infection be absolutely demonstrat-
ed by cultures and smears, still at least forty
per cent of them were undoubtedly due to the
gonococcus, if the whole history b? tiiken into
Paraphernalia
In this paper I shall not attempt to give
you any classical text-book description of
sterility, but shall limit my remarks to a
personal experience gained by following this
subject over a number of years and give you
what I have gleaned as the cases have passed
through my hands. Forty-two ()er cent of
the cases that I have tested in the two series
that I have referred to above, practically all
consideration. I have never ix'eii able in a
single instance to deminstrate the gonococcu;
where the infection was as much as a year
old, but the evidence in practically all of
these cases is almost incmtrov.'rtible. .Many
cases develop sterility following abortion, and
clo;:cd tub?s are easily demonstrated. Tliere
is a small percentage of the cases (one to two
per cent) where there was never any history
328
SOUTHERN MEDICINE AND SURGERY
Mav, 1029
or other evidence of infection, or where the
patient had been sick, in her entire life, and
still the tubes were closed. Many women fail
to conceive from the fact that the sperms are
destroyed after being deposited in the va-
gina. This I have repeatedly demonstrated
by collecting specimens from the vagina with-
in an hour or less following coitus and finding
them all dead, and later obtaining condom
specimens from the husband and find ng
them alive and normally active. It is wise
in all cases where both sides of the house are
found to be normal in other respects to de-
termine the reaction of the cervical and va-
ginal secretions. In the normal female the
cervical secretion should be weakly alkaline
and the vaginal acid. In examining women
for sterility, and where they are found to be
normal in every respect, the next and most
important step is to examine the husband to
(1027 Series)
.AvcraRe age _ _. _ _ 27
Average menstrual age 13
.Average number years married 8
Previous operations 21
D. and C. 22
Headache 54
Bacl<aclic 72
Leucorrhca 43
Tonsils removed 33
Painful coitus
D\ amenorrhea !
Hemorrhoids
White count above 10,000,
Red count below 4,000,000_
Pessaries
Clots -
Cystic ovaries
Svphilis
Fistulae in ano
Gonorrhea ( proved)
Heart lesions
Tuberculosis
Fibroids
Constipation
One or more pregnancies .
Malpositions of uterus
Miscarriages
Ectopic
Cervicitis or endocervicitis 43
Patent tubes S3
Xon -patent tubes 45
Operations by me 17
Pregnancy iollowing test 3
.Average blood-pressure __ __ .100-72
see if he has azo-ospermia and if not are the
sperms active. Three per cent of my cases
have been traceable to the male s'de of the
house. Other physicians have found a much
larger percentage. It is not always easy to
get the husband to furnish a specimen, but
in all these cases a specimen can be collected
from the vagina and cervix following coitus,
and should the sperms prove to be dead and
so reported to the husband there will be no
further trouble in getting him to submit any
number of specimens. One of man's multi-
ple peculiarities, he does not like for the
cause of sterility to be laid at his door! The
fact that so large a percentage of the cases
of sterility are traceable to gonorrheal
infection, on one or both sides of the union,
is a terrible indictment of a civilized, cultured
nation.
The figures in the above tabulation speak
for themselves. I am particularly interested
in the etiology of sterility and find that in-
fection, malpositions of the uterus, tumors
and cystic ovaries are the major causes for
this condition. Miscarriages and abortions
are frequently the cause of sterility. Eight
per cent of my cases have conceived follow-
ing the patency test and th's alone makes the
test worth while. This only includes the
(102S Scries)
.Average age , 28
.Average menstrual age
Average number years married
Previous operations _
D. and C
Headache
Backache
Leucorrhea :
_ 5
SO
26
60
76
58
Tonsils removed 32
Painful coitus 10
Dysmenorrhea 66
Hemmorrhoids 6
White count above 10,000
Red count below 4,000,000
Pessaries _
Clots -
Cystic Ovaries
Syphilis
45
Fistulae in ano
Gonorrhea (proved)
Heart lesions
Tuberculosis
Fibroids
Constipation
One or more pregnancies —
Malposition of uterus _ 42
Miscarriages 24
Ectopic . 1
Cervicitis or endocervicitis 58
Patent tubes 62
Non-patent tubes .VS
Operations by me _ J 18
Pregnancy following test 4
.Average blood pressure 112-72
cases who have reported pregnancy to me.
There may be several others, as they are scat-
tered over a wide area and I have not sent
them a questionnaire. More than forty per
cent of the closed cases I have operated upon
and have demonstrated the correctness of the
diagnosis in every instance.
.A very interesting thing in connection with
the patency test is that a number of patients
who suffered from dysmenorrhea have been
SOUtHERN MEDICINE AND SURGERY
given temporary or permanent relief simply
by passing gas through the tubes. The ex-
planation of this I am unable to state defi-
nitely. The apparatus which I am using has
been a wonderful instrument in the diagnoses
of pelvic conditions which would otherwise
go unrecognized. It should be in the hands
of every gynecologist.
CONCLUSIONS
It is impossible to make a diagnosis of
non-patent tubes without the Rubin test or
some modification of the same.
In many patients who give no symptoms
cloiied tubes can be demonstrated with this
test.
.All cases who have been treated for neis-
f-r'an or other pelvic infection should have
(he patency test when you have pronounced
them cured.
REFERENCES
1. Southern Medic'ne and Surgerw April, 1Q27,
2. Surg.. Gyn. and Obsl.. 3Q:831, Dec, 1024.
3. "Fcrguron .Apparatus for Testing the Patency
cf the Fallopian Tubes," Mfgd. by Eimcr & .\mend,
.^rd .Ave., 18th to lOth streets, New York City.
Professional Building.
DISCUSSION
I'r. H. S. Lott, Winston-Salem, N. C:
In approaching an audience of professional
men, when offering a paper, reporting a case
cf interest, or taking a part in the discussion,
it has always been my hope to reach the
man in the field, the man who is doing the
work of the world in professional service, and
Jive him a thought that may be of help, or,
mayhap, that he may broaden, and vivify
into usefulness.
The paper of Dr. Ferguson is suggestive of
very many thoughts: one of these recalls to
me a case of interest recently in my office.
.\ young woman in her 'teens, brought to me
by her mother, the victim of "pelvic measles."
She had been bleeding from the uterus con-
stantly for about si.\ weeks, and all medica-
tion had failed to check the flow. The drain
was telling on her quite markedly, she was
pale, with very white conjunctivae. In going
over her history from childhood, I was told
that she had a very severe case of measles
when very young, this being the only thing
of note in the history, but quite enough to
account for the present nr.MKirrhagia. No
tender points were found in the abdomen,
from above. Per vaginam, the first thing of
note to the examining finger, waa a haid
fecal mass, filling the rectum and lower bowel
beyond the finger's length. The uterus was
normal in size and position, with marked
tenderness on each side indicating the exan-
thematous appendages, with welded fimbriae.
My first thought being to deplete the con-
gested pelvis, and restore normal circulatory
conditions, the mother was told to give the
girl no supper, and to give two ounces of cas-
tor oil at bedtime and a hot saline enema in
the morning. This, with a simple ant-acid
laxative mixture to be taken before meals,
constituted the treatment. The mother being
told that her daughter was suffering from
the effects of measles in her childhood and tha^
an operation would probably b? necessary,
the patient was dismissed, with the request
to return in two weeks if the bleeding con-
tinued.
Hearing nothing, and some time after the
requested report should have been made, the
physician was called, my request having been
that he be told of the visit to me. "W'hyl "
he replied, "the patient is all right, the bleed-
ing has stopped, and she is rapidly regaining
her normal tone.'"
Do we learn from this to deiilctc the jjel-
v's, and thus restore endometrial function in
these cases, rather than give the patient use-
less, arid constipating medication? .And, do
we forget that function is the soul of the
human economy, giving to each organic struc-
ture the power of procreation?
Now, let us look into the future of this
patiei.t, and see just what will happen. Under
marital relations, and short of infection,
which did not exist at this time; should a
possible pregnancy occur, the fimbriae may
be freed from their agglutination to the ova-
ries, and subsequent comfort established.
However, if this does not occur, and pain
with menorrhag'a still feature in her life;
then, ihiough a free median incision the ap-
pendages should be brought into view, the
fimbriae gently freed from the surface of the
ova.y, and, after carefully surrourid'Ug them
with gauze, a filiform bougie passed through
its lumen fr(!m llv.- cslium abdominalis to
its e trance to th: uterine cavity: fill the
abdi men with normal saline solution, to favor
"ficiting free," for a while, and close the
ab ii men. This is a surgical jjrocedure, only
jii t'fied and rendered safe by present-day
^ -rfcction of toilet and technique, and in hos-
SOUTHERN MEDICINE AND SURGERY
Mav, 1020
pital service.
The apparatus devised and described by
Dr. Ferguson, lil:e the one devised and used
by Rubin, is both unsurgical and unsafe.
Think of it! men who have not given serious
thought to the matter, in their earnest desire
to serve their patients, placing young women
on the table, in the office, perhaps, and forcing
a current of gas through the cavity of th?
uterus, through the fallopian tubes, and out
into the sacred precincts of the peritoneal
cavity! carrying with it, most surely a plug
of mucus; and more likely in most cases pus,
or other product of pelvic infection.
The contraindications to opening the lumen
of the tubes he wisely states, and he will ob-
serve them; but remember, this apparatus
may be purchased and used by the man in
the field, in his office work; and may I ask
you to picture its possibilities, as a menace,
to h"s patients?
Teach'ng, you know, real teach'n-?, which
means teaching the truth, is the greatest thing
in the world: not that it profits the teacher
at all, the teacher is forgotten, but the teach-
ing lives. An unfortunate feature of teaching
tcday is that men are making of their pupils,
not clinicians, but mechanics; and, in the
m'dst of our mechanics, are we forgetting the
woman?
Dr. Ferguson, closing:
I have nothing further to say except that,
in sp'te of what Dr. Lott says, from the e.x-
perience in thousands of cases it has been
proven by experience that the procedure is
thoroughly justified.
Gongylonema — With Case Report in a Woman*
Herbert W. Lewis, M.D., Dumbarton, Va.
Gongylonema — a filarial nematode, varying
in size from 7 to 140 mm. in length and from
.1 to .5 mm. in diameter, that infests the
mucous membrane of the alimentary tract of
cattle, sheep, rats, hogs, chickens at.d man.
Species: Gonyloncma sciitatiirii in cjtlb
and sheep is very widely distributed, having
been found in North and South .\merica,
Europe, Asia, Africa, and Austral'a. Gongy-
lonema pidchrum, in hogs, his been found in
North America, Europe and Africa. Gonn^y-
loncma neoplasticum infests rats and oth?r
rodents. This parasite sets up proliferation
of the epithelial elements, inflammation, ter-
minating in distinct carcinoma w th metasta-
ses. Gongylonema inghivkoh in chicke:i5
found in the Philippines and Florida. Gongv-
lonema hominis in man has been found in
Italy and U. S. of America (Ark., Fla., Ga.,
Va.)
Some authorities state that the different
species are so similar that it seems very prob-
able that there is only one species, varying
in size and other characteristics in different
♦Presented to the Tri-State Medical Association of
the Carolinas and Virginia, Greensboro, N. C , Meet-
ing February 19th, 20th and 21st, 1929.
hosts. Flbiger's researches have proven that
the parasite plays a definite part in the pro-
duction of cancer in rats. If, as has been
suggested, all these species are identical, the
lact has a very important bearing on human
pathology. Sanbon beleves it a cause of can-
c:r in man. One other authority states that
cancer can be lessened by prevention of
Gongylonema.
Intermediate hosts are dung beetles, cellar
beetles, cock-roaches, and meal beetles.
These insects swallow the eggs, which develop
to the laval stage in the insect and are taken
in the mouth of the final hosts and are th?n
taken up by the lymphatics.
These parasites are found in the mucous
membrane of the esophagus in aniinals, in
the mucous membrane of the mouth, esopha-
gus-and cardial end of stomach in rats, and
in the mucous membrane of the mouth in
man. They are four.d in sinuous galleries in
animals and rats, but in many they migrate
in the connective tissue of the mouth, a char-
acteristic peculiar to man.
Occurrence in Man: Dr. Leidy, of Phila-
delphia, in 1850, described a human parasite
as Filaria lioniinis oris, found in the mouth of
SOUTHERN MEDICINE AND SURGERY
331
a child. It possibly was gonjiylonema. Pro-
fessor Pane, of Rome, in 1864, found a gon-
gylonema in the upper lip of a medical stu-
dent. Professor Alessendrini, of Naples, in
1914, found 6 gongylonema in the mouth of
an eighteen-year-old girl; these worms were
extracted at different times covering a period
of six months.
Up to this case there have been three cases
reported in the United States. Hall (1916)
rcixjrted the first case. It occurred in the
practice of Dr. R. E. Covington, of Arkansas.
It was in a girl sixteen years old, and was
nervousness, irritability; may have digestive
disturbances and anemia; removal of the
worm brings cessation of symptoms.
CASE REPORT
On August 1, 1928, a single girl, aged 18
years, well developed, weight 160 pounds,
height 5 feet 7 inches, very cheerful disposi-
tion, came to my office and gave the history
of having trouble with her mouth for about
one month. Said she was not sick, but had
a worm wiggling in the flesh of her lower lip
and under her tongue.
iJrawiim of GunuyliiMcma (Lciaiicd Ijy Viniiiiia Mrdical Monthly)
extracted from the lower lip. Stiles (1917)
reports the second case. It occurred in the
practice of Dr. K. C. Clarke, of Florida, in
a girl thirteen years old, and was extracted
fnni the lower lip. Stiles (1919) reports
the third case. It occurred in the practice of
Dr. .Akridge, of Georgia, in a fifty-year-old
\v( man, and was extracted from the lower
lip.
Symptoms: Wiggling feeling in the mouth,
On examination 1 found hyperemic swol-
len patches on the mucous membrane of the
lower lip. She insisted that she could feel
and sometimes see the worm move in differ-
ent places in the lower lip, but I could see no
worm. I gave her an alkaline mouth wash
and told her to return to me if she was not
cured.
1 heard nothing from her until September
4th when she produced the worm about 1
332
SOUTHERN MEDICINE AND SURGERV
Mav, 1020
inch and a half lona;, the size of a 00 liga-
ture, which was removed by her brother (a
Methodist missionary) with a sterile needle.
He made an incision parallel with the worm
and removed it in toto from the mucous mem-
brane of the lower lip one-half inch to the
left of the mid-line. Patient was relieved of
the peculiar sensation in the mouth and has
remained well. The worm migrated about in
the lower lip as far back as the fauces and
in the floor of the mouth under the tongue.
This girl was born and reared in V'irginia,
and has never been out of the state. She
has lived on the farm that she is now living
on for the past five years. They have milk
cows on the farm, and some cock-roaches in
the house.
I am greatly indebted to Dr. C. R. Mc-
Ginnes, Department of Health, Richmond,
Virginia, for his untiring efforts to identify
this worm, and also to Professor C. W. Stiles,
Hygienic Laboratory, U. S. P. H. S., Wash-
ington, D. C, for his identification and diag-
nosis of the worm.
REFERENCES
Baylis, H. a., J. Trap. Med., 28:71-76.
Blair, K, G., /. Trap. Med., 28:76-81.
Baylis, H. A., J. Trap. Med., 28:316-317.
Baylis, Parr and Sanson, J. Trap. Med., 28:413-
410.
Sanbon, L. W., J. Trap. Med., 28:36-71.
Sanbon, L. W., J. Trap. Med., 28:313-316.
Ranson, B. H., and Hall, M. C, J. Parasitol, 1:
154.
Ranson, B. H., and Hall, M. C, J. Parasitol, 2:
80-86.
Ranson, B. H., and Hall, M. C, J. Parasitol, 3:
177.
Stiles, C. W., Public Health Report for 1921, p.
1177.
Ward, H. B., J. Parasitol, 2:119-125.
Wharton, L. W., J. Parasitol, 5:25-28.
DISCUSSION
President Hall:
Dr. Lewis, have any cases been reported
in the South before?
Dr. Lewis:
Three cases in the United States: one in
Arkansas, one in Florida, and one in Geor-
gia. This is the farthest north of any case
reported yet in the United States.
Dr. Hall:
I think this represents the practice of medi-
cine as it ought to be done. This girl had a
peculiar sensation in the lower lip, the worm
was extracted, and Dr. Lewis did not stop
until he had it identified.
"Bits Worth Bearing in Mind
(From Vrological and Cutaneous Review)
You will never know how little fun there is
in a cystoscopy until you have a cystoscope
passed through your own urethra. There
ought to be a law compelling intending urol-
ogists to submit themselves to the introduc-
tion of sounds and cystoscopes.
.\n intramuscular injection is bad enough-
don 't make it worse by using a dull needle.
One of the important duties of the general
practitioner is to seek out syphilis in pregnant
women.
Stop specific treatment the moment you
think your syphilitic patient begins to show
signs of impaired vigor.
Always make sure your ureteral catheters
are open before you insert them. And it is
best not to take the nurse's word for it.
The underlying cause of an eczema may
be an unrecognized scabies,
Mav, 10:9
SOUTHERN MEDICINE AND SURGERY
Hi
The Abdominal Symptoms of Extra-Abdominal Lesions*
DeWitt Kluttz, M.D., Greenville, S. C.
The cause of an upset gastro-intestinal sys-
tem is often difficult to definitely locate.
N'umerous d'sease conditions make their
principal manifestation in this tract. The
pathology may lie beneath the site of the
presenting s'gns and symptoms, it may be
nearby, or it may be hidden in another part
of the body. The spread of infections from
one abdom'nal viscus to another is a common
cau=e of failure to cure by removal of the
appendi.x, and ground upon which some are
led to doubt the existence of chronic appen-
dc'tis as an entity: the shifting of signs
and symptoms from one quadrant to another
by the nervous mechanism is of frequent oc-
currence. These variations from the usual
at t'mes justify exploratory laparotomy. But
it has happened to most of us that even the
opened abdomen failed to reveal anything;
or probably more often the roentgenologist
discovers no evidence where we had expected
corroboration of our definite opinions. Study-
ing further, we discover a lesion outside of
the abdomen, one that has made itself felt
on the same nerve ends that project irritative
impulses from within that cavity.
A brief description of a variety of such
cases is presented with observations from
them and deductions from these cases and
similar cases in the literature. The digestive
d'sturbances seen and the surgical conditions
sometimes simulated by protein sensitization
do not fall within the scope of this paper
because definite hyperemia and edema are
probably always present. However, this phe-
nomenon often appears with infections —
products of bacterial destruction introducing
a foreign protein into the circulation or caus-
ing a sensitization to certain ingested pro-
teins. This is probably a factor in some of
the cases mentioned in this paper, and one
that must he cimsidered when there is a rapid
recovery follnwing eradication of a distant
focus, .\bdominal infections — whether pri-
mary, or secondary to foci in tonsils, teeth,
mastoids, etc., are excluded. The following
•Prcscntf.1 to the Tri-Slatc Medical .Association of
the tarolinas and Virginia, Greensboro, N, C Meet-
ing February 19th, 20tb and 21st, 1929
case appears to be one of simple reflex from
the mastoid:
A middle aged woman, much overweight,
was taken with nausea, vomiting, pain and
tenderness over the gall-bladder region.
Cholecystectomy was considered for several
days. A quiescent sclerotic mastoid was dis-
covered and operation upon it was followed
by immediate cessation of abdominal symp-
toms, and they have not returned. There
was probable pressure involvement of the
eighth nerve in this case, with reflex nerve
paths similar to those described in Meniere's
disease. This latter is a distinct entity,
usually due to sudden hemorrhage and re-
sultant fibrosis in the semicircular canals.
.As you will recall Meniere's syndrome is as
follows: vertigo, tinnitus, nystagmus, nausea,
vomiting, diarrhea and partial deafness on
the affected side: these fade away as total
deafness approaches. Several of our patients
have received this diagnosis, but none has
shown all of these symptoms. The exciting
pathology may be ealsily overlooked, and
most attention centered on the abdomen. But
various lesions affecting the eighth nerve may
cause symptoms identical to Meniere's sya-
drome. Crane' mentions the following: brain
tumors and abscesses, skull fractures, syph-
ilis, infectious diseases and toxemias — those
conditions causing cerebral hyperemia or in-
creased intracranial tension. They may act
directly on the centers controlling vomiting
and processes related to it, or send impulses
there over some of the cranial nerves.
A case of encephalitis following influenza
had rested quietly for two weeks, when she
was taken with violent and rapid tic of the
diaphragm. After five days of continuous
hiccough, and pain and tenderness at Mc-
Burney's point, nausea and vomiting, she was
brought to the hospital with a diagnosis of
ajipendicitis. After observation for several
days, sectuin of the right phrenic nerve was
performed and this resulted in relief of the
spasm and immediate disappearance of the
abdominal symptoms. A next door neighbor
to this girl, several months before, had had
a similar but more prolonged diaphragmatic
in
SOUTHERN MEDICINE AND SURGERY
May, 1029
spasm, but in her case, the cause lay within
the abdomen, massive adhesions from peri-
tonitis being present. Bilateral phrenicotomy
was necessary to relieve her spasm.* The
presence of sensory fibers in the phrenic
nerves demonstrated at these operations,- and
the anatomical connection with the neighbor-
ini? Ranglinated cord suggest an explanation
of these abdominal symptoms — that is, a re-
flex through the solar plexus to which they
extend, and a continuation of fib:TS to th?
spinal cord cells of origin of the splanchnic
and lower intercostal nerves. The splanchnics
originate from the lower eight segments of
the thoracic cord and are probably connected
with all the thoracic gangl'a''. They pass
into th? abdomen, supplying parts just be-
reath surface areas innervated by the inter-
costal nerves from the same cord segments.
These outside areas make known the impulse",
rent around from b;neath. The vagi are oT
less importance in these connections.
The parietal and outer diaphragmatic
pleurae are connected in th's sam? abdomini'
arc by branches they send to the intercostals
as they pass along the ribs, and th^ir in-
volvement by pleurisy or pneumonia may be
felt below. A pneumonic lesion may be small,
deep and symptomless. The portable x-ray
was necessary to diagnose three such cases
in influenza patients who were slow to recover
frcm apparently mild attacks. In one, the
process was found deep in the right card o-
d'aphragmatic angle, and his chief complaint
was pain about the appendix. A similar in-
stance occurred in a man whose appendx
vas removed, and later an incis'on made into
the rght ischio-rectal fossa for pain in these
regions. Ten days later the pain disappear-
ed following the spontaneous rupture of a
lunT abscess into a bronchus.
Direct involvement of the posterior root
ganglia of a thoracic nerve is seen in the fol-
lowing case:
A middle aged man who appeared intoxi-
cated was brought in suffering severe pain in
the right abdomen, kidney and bladder re-
gion. Thorough genito-urinary, gastro-intes-
tinal and sp'nal flu'd study eliminated all
except possibly the appendix, which appear-
ed very tender as visualized under fluoro-
scopic examination. Badly diseased teeth
were present. An overnight elevation of
polymorphoneuclear leucocytes to 91 per cent,
precipitated an appendectomy with negative
results. Several days later a single herpetic
eruption appeared just to the right of the
eleventh dorsal vertebra. In time, following
extraction of the teeth and appropriate rest
and care, this case of toxic infectious psycho-
sis cleared up. A case is recalled in which a
gill-bladdcr was removed in such a pre-erup-
t've stage of herpes. The system'c symp-
toms of a masked focus, an etiological factor,
sometimes cloud the picture.
The vagus and splanchnic nerves are im-
portant parts of the digestive mechanism, reg-
ulating peristalsis, secretions and other func-
tions. In their course through the thorax
they are somet'mes interfered with by me-
d'astinal enlargements, adhesions or lung
pathology. Their terminal arborizations can
be squeezed in the sclerotic wall of a pulsat-
ing aorta or coronary vessel, and impulses to
the stomach are liable to be set up, particu-
larly when exertion or excitement burdens th?
heart. Fluoroscopic exam'nation of the chest
shows little or no cardiac and aortic enlarge-
ment in many of these. Barium study dem-
rrstrates in some an irritable gastric muscu-
lar funct'on with transient spasms of the
pylorus, and a small hypertonic fundus which
contracts on even a small amount of gas,
causirg a feeing of fullness or pain. Ths
may be felt only in the enigastrium, or it
may be referred back to the cardiac plexu:
for d stribution of sensations or conversion
into more serious motor eff:cts. Over-crowd
ing such a stomach is an explanation of at
least two card'ac deaths among my patients.
Dilatat'on of the aorta and hypertrophy of
the heart can exert pressure on the nerves,
and physical examination with or without th?
aid of the x-ray should suggest this in certain
dyspeptics. In congestive heart failure there
is added pathology from engorgement of th?
organs of the portal circulation.
Spondylitis deformans, secondary to ton-
sillar infection, was responsible for the left
abdominal pain in a woman of fifty-five who
had been passed along for years as a viscer-
oplotic with nervous indigestion. Some ver-
(cbral d seases and deformities furnish littl?
local evidence of their presence, and even
Pott's d sease has been seen to cause gastric
pain long before being located.
Of spinal cord diseases in this connection,
tabes dorsalis with its gastric crises, and sim-
c mmonly seen. Too often positive seriologi-
ple syphilis of the cord membranes, is most
May, 1929
SOtTHERN MEClCtNE AND StmCERY
Hi
cal tests and the response to therapy lead to
an x-ray diagnosis of intragistric lues be-
cause of retiex spasms and external pressure
defects seen on the films.
A rather rare affect on, simulating [jerito-
neal inflammation, is rheumatic myositis of
an abdominal muscle and is reviewed with
case repx)rts by Dr. Leas .of Cleveland^. He
points out as diagnostic points, the lack of
tenderness on pressure, the absence of super-
ficial tenderness, pain on stretch ng ihe mus-
cle, and prompt relief from large doses of
salicylates. It differs from the following
case:
A twelve-year-old boy who was kicked in
the left upper abdomen by a pony, developed
within several hours moderate signs of peri-
tonitis— vomiting, muscular rigidity, and ten-
derness, superficial sens.tiveness, m.ld shock,
101 degrees temi^erature, pulse 110, white
blood count 38,000. Laparotomy revealed no
internal injury, and within several days he
was entirely normal. Temporary leucocyto-
sis in abdominal injuries is not unusual.
There has been no attempt to state all
conditions capable of referring symptoms into
the abdomen from without. Cases showing
this reflex action from several different parts
of the body have been mentioned, and a brief
anatomical explanation of the nerve paths
involved has been attempted. The views of
others have been used freely.
REFERENCES
1. Dr. a. W. Cr.\ne, Radiology, D^c, 1Q2S, p. 447.
2. Uk. LIIA.S, K. UuWMA.V, Auumu, i,a.
3. Gray's Anatomy.
4. Dr. E. D, Leas, American Jonintil Med SV
Feb., 1927, p. 271.
♦These cases repcrled in lull hut nut vet pubiish-
ed (by Dr. Hugh Smith).
DISCUSSIOX
Dr. Frank A. Sharpe, Grcensb.iro:
I do not think there is anyone who has
conducted any branch of med.c.ne but would
be in sympathy with the situ ition Dr. Kluttz
has described, because all of us have spent
restless nights and anxious days about some
of our patients when we were not sure wheth-
er the explanation of their conditions by in-
side or outside the abdomen.
I think the most important thin'; we can
derive from a paper of this sort is to be re-
minded of the necessity for very carefully
going over our patients and to guard our-
selves against the error of hastily arriving at
a conclusion and hastily advising our patient
that he has a condition which should be dealt
with surgically. Before any patient is sub-
jected to a serious abdominal operation he
should be given the benefit of a mental re-
v.ew of the many conditions which might
cause the symptoms which he presents. We
shall avoid many errors which will cause us
chagrin if we go over our patients carefully,
avail ourselves of the laboratory and if neces-
sary of the roentgenologist, and review in
our own minds the causes which might cause
the condit.on from wh.ch the patient is suf-
fering. When we arc not quite sure whether
we have an abdominal or extra-abdominal
condition, in the majority of cases it is extra-
abdominal. 1 think that intuition and care-
lul phys-cal examination and patience on our
part are the greatest gu.des by which we may
be directed.
Dr. H. a. Royster, Raleigh:
As an abdominal surgeon, I wish to thank
Dr. Kluttz for bringing out a very, very vital
quest.on. We hear a great deal about the
"acute abdomen. ' The real question in the
diagnos.s of what may be called an acute
abdomen (which is a very poor term; we do
not say an acute leg or an acute head) is to
make sure the trouble is in the abdomen. In
baseball parlance, a hit is "putting it where
they ain't." Let us be very sure we do not
put our focus where it is not. Study of the
so-called abdominal reflexes is a very import-
ant thing. We know that sometimes so-called
chronic appendicitis exists in the head; some-
times also, I am sorry to say, in the head of
the surgeon. It requires a very nice d.scrim-
ination many times to know whether the pain
the pat.ent is suffering is due to abdominal
d.scase. It may be due to intercostal neural-
gia, a focus of infection in other regions, gas-
tric crises, etc. Pain is quite often not where
the d sease is; more often not, perhaps. Pres-
sure exerted where the disease is will elicit
tenderness. I am quite sure there is such a
thing as chronic appendicitis, and yet before
making such a diagnosis, I am always quite
careful to eliminate if possible, every other
probable cause of the symptoms. .As to chil-
dren, remember the truism of Trousseau, who
said: "When an infant com[)lains of pain in
the abdomen, examine the chest."
Dr. F. C. Rinker, Norfolk:
1 do not want to prolong this discussion,
m
SOrtHEftN MEDICINE AND SURGERY
i/liy, 1929
but I should like to say a few words. The
more we study abdominal pain the more we
are confronted with the masquerade that goes
on in the human body. The disease may be
situated where the pain e.xists; or, through
the integrating action of the spinal cord cen-
ters, the cause of the pain may be found at
some more remote point in the body. This
subject has been particularly well covered
from the standpoint of infections remote from
the abdomen and from the standpoint of the
gastric crises as found in tabes dorsalis and
from the standpoint of Pott's disease, which
gives us in the beginning pain in the abdo-
men, and from the standpoint of pneumonia
and pleurisy that exists in the chest; but
nothing has been said about coronary occlu-
sion and angina. This brings up the ques-
tion of so-called "acute indigestion, " which
we all admit is a very unfortunate term and
one that is not justified in medicine at all
but one that is too frequently used and one
in which the individual meets his death, which
is a cardiac death, without ever having a
proper diagnosis made. Lead poisoning,
again, is a thing that frequently sends the
patient to the operating room for operation
for either gall-stone colic or acute appendi-
citis. There are certain skin conditions which
are manifested first by abdominal pain: —
erythema multiforme and herpes zoster, which
has been mentioned. There is one condition
which has been mentioned as a possibility,
that is tic. I wonder if those cases might
have been encephalitis, which gives us myo-
clonus, which is tic of the abdominal muscles
themselves.
There is one other condition, which is on
the abdomen but not in the abdomen. We
have had two cases in the last eighteen
months. That is abscess formation of the
abdominal muscles, the recti, following either
acute influenza, grip, or pneumonia.
Dr. W. B. Porter, Richmond:
No one has mentioned a lesion which has
focused our attention rather frequently. I
have in mind a woman who has recently been
operated on for cord tumor and who has
had previously five abdominal operations.
The gall-bladder was removed, the appendix
removed, the left kidney suspended, and some
pelvic surger ydone. The real pathology in
this case was tumor of the cord. I think
you will recall that about two per cent of
patients with tumors of the cord, especially
those in the dorsal area, have had at least one
previous operation. It is a condition easy to
overlook.
Dr. J. BoLLiNG Jones, Petersburg:
This paper is one of the most important
ones on this program, as it deals with diag-
nosis.
I have seen three cases of insect bite, spi-
der bite, on the end of the penis. The fact
is that there is nothing in the medical liter-
ature about it. My friend Dr. Woodard told
me that some man in California has written
a very interesting article on it, but it has not
been my fortune to see it. I have seen three
cases. Two were white men and one
a colored man, all laboring men. They
used outside toilets. The bites were all in-
curred early in the morning. One man gave
me this history, a pricking sensation followed
in a few minutes by intense abdominal pain.
The man had all the appearance of an acute
abdominal lesion — vomiting, intense pain,
abdomen rigid. He had no fever and
no leucocytosis. This was followed by vio-
lent obstipation. He came out of it in forty-
eight hours. The next case I saw was so
much like it that 1 inquired of this man and
elicited the same thing. Within a year I saw
a third case. I was called by one of the best
medical men I know to a neighboring town
to operate for appendicitis. This was a col-
ored man who had walked from his work to a
doctor's office and collapsed on the floor. He
was suffering intense pain. This reminded
me so much of the others that I inquired into
it and found the same history.
Dr. C. C. Coleman, Richmond:
As Dr. Porter has just stated, a large num-
ber of cord tumor patients have had opera-
tions for some intraabdominal lesion in no
way responsible for the abdominal pain. Some
of our patients have had several operations,
including the removal of the appendix or
ovary, and sometimes the kidneys, gall-blad-
der or stomach have been operated upon,
naturally, without relief of pain which was
due entirely to a cord tumor. It should be
remembered that at the present time spinal
cord tumors may be localized with almost as
much precision as a fracture of a long bone.
By mechanical aids to diagnosis such as the
block test or injection of air or lipiodol into
May, 19i4
SOUtHERN MEDICtNE AND StJRGERY
HI
the cisterna magna, one can decide abso-
lutely whether an obscure abdominal pain is
due to a cord tumor, and thus the patient
may be spared an unnecessary abdominal
operation. It is quite natural for many cord
tumors, particularly of the dorsal region, to
give abdominal pain. Extramedullary tumors
of the cord have a close connection with the
posterior nerve roots and the pain is fre-
quently referred to the abdomen. Such pain
when due to cord tumor, is usually increased
by sneezing, coughing or straining at stool.
This is due to the fact that these acts may
produce intracranial pressure which is trans-
mitted to the tumor, causing irritation of the
posterior nerve roots and radiating pain. One
of the most important question to ask any
patient with chronic pain of the abdomen, is
whether sneezing or coughing intensifies the
pain.
Dr. Cyrus Thompson, Jacksonville, N. C:
There is just one thing about the character
of pain from spider bite which Dr. Jones
failed to mention, if he knew it. I asked him
hi)w long the pain lasted, and he said six or
eight hours. I asked if it was rhythmic, and
he said yes. There are two or three pains
which are rhythmic. One of them everybody
knows — the pain of labor. The pains of in-
tussusception in children, Wilson, of Roches-
ter, says, are rhythmic. The pains of spider
bite, which last from six or eight to twenty-
four hours, also are intense and are rhythmic.
That is a good diagnostic point. I have ob-
served it in a number of cases and thought
maybe the rest of you had not.
Dr. Kluttz, closing:
There was no attempt to cover everything,
and neither was an attempt made to cover
anything fully. Dr. Rinker's addition of co-
ronary occlusion I attempted to cover under
retfex pain.
Erythema multiforme, I should like to say,
which is quite often attended by abdominal
symptoms. I think comes under the general
class of erythemas closely related to allergy.
Acute abdominal conditions in allergy are not
uncommon. The abdomen has been opened
and sterile fluid found in the abdomen.
As to spider bite, I remember reading of
the sudden death of an infant from wasp
bite. I think that comes under the class of
allergy. I had another case of a man who
was bitten by a whole nest of yellow jackets.
He was very sick, nauseated, vomiting, with
acute jiain in the abdomen. I think that, too,
comes under the class of allergy.
m
SbtJtttfiftN WEbtCtMfi AMD StftGEfeY
May, I0i9
PRESIDENT'S PAGE
Tri-State Medical Association of the Carolinas and Virginia
—CYRUS THOMPSON
The late Romulus Z. Linney of Alexander
county was one of the most prominent and
one of the most noticeable men in the Re-
publican party in western North Carolina.
He was commonly called "the Bull of the
Brushes." He was of fine avoirdupois; he
had an aquiline nose, and his eyes, too, re-
minded of the eagle. His long black hair
flowed backward and he looked for all the
world like you might have imagined a Roman
Senator. His phraseology was as graphic as
his manner was at time picturesque.
Once upon a time he was asked what he
thought of a certain fellow-Republican. Lin-
ney replied with a tenor as tine as Caruso's,
"What do I think of him? I will tell you
what I think of him. I think he is a damned,
pestiferous Christian gentleman." These four
words described this man amazingly. They
made a frame about him which held him so
that you could see him as definitely as apples
of gold in pictures of silver.
Did you never see any one who would have
been defined by this phraseology? I am sure
that you have and that you will agree with
me that the type is not confined to either
male or female. It can be said of this type
of person in all truth, as of all other things
of God's creation, that male and female cre-
ated He them.
1 have never known of a single word with
which to describe this type of individual until
on the sixteenth of March I was reading the
Lexicographer's Easy Chair in the Literary
Digest and there I found the word kibitzer
which, like salvation, is said to be of the
Jews. The Digest defines this word as fol-
lows: "The kibitzer is a person who, un-
asked, interferes in the affairs of others; he
is one who breaks into conversation or vol-
unteers advice or tell how things should be
done without invitation to do so. Sometimes
he thrusts himself and his opinions conceit-
edly and undesirably into notice. He is
therefore as officious and inefficient as was
the great Pooh-Bah — obtrusive and intrusive
as well as meddlesome. He believes himself
to be appointed by Divine Right as the
Grand Panjandrum of the world's affairs, and
in this respect does not vary from Smollett's
Sir Launcelot Greaves, who was described by
the author as handsome, virtuous, enlightened
but crack-brained. . . He is one who minds
every one else's business but his own, or in
the slang of the day he is a buttinsky."
A word that contains a sentence is worth
adding to our vocabulary. I smiled when 1
read this definition. I thought of Linney and
his pestiferous friend and I thought how the
Bull of the Brushies would have been de-
lighted if he could have condensed his phrase-
ology sometimes into this one single word.
And I thought of other North Carolinians.
The President and the Secretary fo the
Tri-State desire to have the best possible
meeting, and to that end are asking the ad-
vice of its membership as to the character
and extent of the program that we shall put
on next year in Charleston. Some of you
will advise one thing and some will advise
another, and it will hardly be possible that
we shall be able to take all the advice that is
given us. But out of the multitude of your
counsel we hope to arrive at wisdom.
Therefore, advise us: you will not be but-
ting in; you will be doing what we ask you
to do, and therefore you will not be a kibit-
zer.
This good word, by the way, is pronounced
kecbitzer, accent on first syllable.
May, 1029
SOtJtHERN WEblCiNB ANb StftGERV
iid
PRESIDENT'S PAGE
Medical Socictv of the State oj Xortli Carolina
— /.. .1. CROW ELL.
At the beginniiii; i)f my administration I
desire, throu.i;h the offcial journal of the So-
c cly, to express my appreciation of the con-
fidence that the profession has reposed in me
by naming me its presiding officer for the
ensuing year. 1 am proud of the honor and
shall do all in my power to maintain the high
standard established by my predecessors.
At the same time I am keenly conscious of
the obligation and rcspons.bjlities carried by
a position held by so many distinguished men
serves to magnify my feeling of inefficiency.
What shall be the policies of my adminis-
tration?
As I view the matter at this early hour, it
appears that our attention should first be di-
rected toward stimulating interest in the
County medical societies. The success of the
State soc'ety depends to a large extent upon
the efficient functioning of the County units,
r.ome of the smaller County societies never
have meetings, not even for the election of
officers. Being a member of a small County
society myself, I can understand the difficul-
ties of keeping up interest. These men see
each other often, they are in frequent consul-
tations, they talk over their difficult prob-
lems frequently, which circumstances make it
wellnigh impossible for one member of the
proup to prepare a paper that would interest
the other members.
In these days of good roads, it should be
no trouble to get men of wide experience in
various branches of medicine from larger so-
cieties to present programs for these small
groups; clinical cases could be presented by
the local men. This method has been tried
out in some of the counties and has proved
to be very satisfactory. This plan if persist-
ed in should insure a good attendance. I am,
however, thoroughly convinced that there is a
certain class of physicians, the self-satisfied
type, that no program would interest.
The county society shou'd not only func-
tion locally; it should, through its delegates,
take an active interest in the aiTa.rs of the
state m_ctings. Active men should be elected
to represent the couiity in the house of dele-
gates— tiic law-making and business body of
the society. It is in this meeting that differ-
ences are fought out and adjusted; I use ths
woid "fought" advisedly, therefore, every
county should enter actively into its delibera-
tions.
Those present at the last meeting of the
house of delegates will remember when the
roll was called that less than half of the coun-
ties answered. This stale of affairs sh.nild
not be; if it were different there would be no
occasion for the remark that the State medical
society is being run by a few politicians.
We should be very proud of those who
have by hard work and constant unselfish ap-
plicat.on guded and directed the medical af-
fa rs of North Carolina. They have been
men with vision ever ready to do all in their
power to assist in placing medicine on the
high plane of efficiency that it now occupies.
Us med cal men rank with those of any state
in the Union.
The State meetings are not attended as
ihey should be.
We have in North Carolina 2,328 physi-
c'ans; 1,698 hold membership in the JNIedical
Society of the State of North Carolina, while
the average attendance for the past three
years has been only 646; only about 73 per
cent of the physicians of the state arc mem-
bcis fjf the State society, a;.d only i'i
per cent of those who hold membership take
:;ny ii Icrest in, or attend its meetings.
C\w efforts, Ihcr.'foro. should be along th;
Ki.e of ei.couraglng the profession of the state
in tak.ng more interest in organized medi-
540
SOUTHERN MEDICINE AND SURGERV
May, 1W9
Southern Medicine and Sur^er;g
^ „ ) T>i-S(iilo Slwlital Assofiation of (he Cai-olinas and Vii-niiiia
Official Organ of ,, ,. , ^, . „
I Mcilical h<)ii('(.v of llic Slate of North Carolina
James M. Northington, M.D., Editor
Department Editors
jAMts K. Hall, M.D
I'ka.vk Howard Richardson, M.jJ._
\V M ROBEY, D.D.S
J P. Mathf.son, M.D.
II L. Sloan, M.D
C. N. Peeler, M.D
F E. Motlev, M.D
V. K. H.\RT. M.D
F. C. Smith, M.D
The Barret Laboratories
O L. Miller, M.D.
Hamilton W. McKay, M.D
John D. MacRae, M.D
JusEPii .-X. Elliott, M.D
Pali, H Ringer, M.D
Geo. H Bunch, M.D. .
Federick R. Taylor. M.D
Henky J. Lanc.ston, M.D
CiiAS. R. Robins, M.D
Olin B Chamberlain, M.D.
' oris 1, Williams, M.D
Various .\uthors
-Richmond, Va
-Black Mountain, N. C.
-Charlotte. N. C.
.Human Behavior
- „ Pediatrics
Dentistry
E)
Charlotte, N. C.
^Charlotte, N. C.
Gastonia, N. C
_ Charlotte, N. C-
_.Asheville, N. C.-
Charlotte, N. C.._
_.\sheville, N. C„
_Columbia, S. C
_High Point, N. C
_ Danville, Va
_ Richmond, Va
.Charleston, S. C
.Richmond, Va
Diseases oj the
Eye, Ear, Nose and Throat
Laboratories
Orthopedic Surgery
Urology
Radiology
Dermatology
. Internal Medic. m
Surgery
Periodic Examinations
Obstetrics
Gynecology
-— Neuro'ogy
Public Health
Historic Medicine
Ex-President Kitchin; President
Crowell
At the close of an administration of rich
accomplishment the brilliant Dean of the
Wake Forest Med cal School turns over the
gavel of office to a doctor who spends all
his working time at bedside or operating ta-
ble. The iMedical Society of the State of
North Carolina does well to avail itself of
the talents of its professional teachers and
its practitioners. Almost certainly there has
b?en no conscious intent to follow any such
plan of alternation, the explanation lying in
a natural, orderly [uocess which is most fit-
ting.
As president, Dr. Kitchin made no sensa-
tional '"drive" for any catchy objective. As
we grasp the guiding purposes of his term,
they were: the preemption of the field of
medicine for regular doctors, and the stim-
ulation of these regular doctors to cultivate
that field so capably as to bring forth a rich
harvest of health and happiness for our peo-
ple, with its by-products of honor and pros-
perity lor the profession. This subject is one
of such vast importance and Dr. Kitchin is
so unusually well fitted for carrying on the
leadership of our society in this cause, that
this journal very earnestly hopes he will not
be allowed to relinquish its leadership. He
is alive to the reality of the menace, he has
accumulated much information on the sub-
ject, he is in a position peculiarly favorable
for accumulating and diffusing such informa-
tion, and he is zealous in the cause. We re-
peat what we said in iMarch, "It is our hope
and confident prediction that under
his fine leadership, the Medical Society of
the State of North Carolina will be the first
organization in the field to recapture lost
ground, to the end that we may maintain the
rights and dignities which belong to doctors
while we live, and transmit them unshorn to
doctors who come after us.''
Dr. L. A. Crowell was chosen president
over a large field, — according to some the
largest ever entered by their friends for the
office — and every entrant was a man of
marked ability and popularity. To carry off
first prize under such circumstances is honor
intleed.
i
May, 1929
SOUTHERN MEDICINE AND SURGERY
At a meeting of the doctors of our new
president's own district, held since his elec-
tion, it was very plain that he has his home
doctors solidly behind him.
Soon after his graduation in 1892, he be-
gan the practice of his profession at Lincoln-
ton. He early began doing surgery in the
homes of his patients and not many years
had passed before he began to plan a hos-
pital for their better accommodation. These
plans came to fruition in 1907, when the first
Lincoln Hospital opened its doors. Since
then, as invention has proceeded and funds
accumulated, improvement after improve-
ment has been made in personnel and mate-
rid. In 1922, after his graduation from the
]\Iedical School of the University of Penn-
sylvania, there was added to the staff Dr.
Gordon Crowell. son of the founder of the
hospital: and the father looked forward to
the time when the son would take his place.
But this was not to be. His orofess'onal
labors were limited to the space of four fruit-
ful years. As a monument to his memory,
the Gordon Crowell Annex was added to Lin-
coln Hospital and thus, vicariously, he con-
tinues to minister to the sick he would have
served in person.
We do not know a great deal about Presi-
dent Crowell's program, even whether he has
outlined one. We do know that he has the
interests of the family doctor much at heart:
that he realizes that the family doctor — the
foundation stone of our profession on which
the stability of every element in the super-
structure depends — does not rceeive the sun-
port ,encouragement and credit which are his
due: and we are confident that he will work
toward tuiding and applying remedies.
In this connection we venture to direct at-
tention to the excellent article by Dr. W. B.
Robertson carried in this issue, and the book,
"Physician and Patient," mention of which
will be found among this month's book re-
views?
President Crowell will • fill a "Presi-
dent's Page" each month. He will welcome
opinions, and, like the editor, he is just as
anxious to hear from those who disagree with
him as from those who agree. Every reader
is urged to make his ideas and views known
through the u.se of our pages.
The journal pledges its enthusiastic support
to President Crowell in all the plans he may
work out looking to the enlargement of !Medi
cine ar.d her votaries.
The Greensboro Meeting
The Scventy-s'xth .Annual Meeting of the
Medical Society of the State was rither de-
void of features. The mental pabulum was
substantial, but not highly seasoned. The
Committee on Arrangements, under th: direc-
tion of Dr. C. .A. Julian, funct'oned perfect-
ly, and made our ways smooth.
In some of the discussions a few jx)p-
crackers went off, but the final result was:
all feet in close formation on the brass rail —
figuratively sp:ak ng, of course.
\\'e believe everybody is happy in the hope
that the quest'on comhig up from the Wake
County Society has been disposed of finally,
and after the plan proposed by th's journal
in May, 1927, "in the hope of saving from
hurt the rights, the dignities and the sens"-
bilities of all concerned. "
It is noteworthy that of the many talked
with on the subject, every member expressed
himself as decidedly in favor of fewer sec-
tions: many are in favor of meeting in one
body, more want grouping in two sections,
a Medical and a Surgical. To repeat reasons
we have advanced heretofore: In a ge.ieral
society specialists should talk beforj family
doctors and fam ly djctors beforj spcjialists,
both for the supplying of need:d kaovvledge
on both sides and for gaining information as
to wise referring of patients: and enccs will
be assured: keeping the members to-;ether
will enhance interest and facilitate the trans-
action of all affairs of the society.
From this meeting was gained a great en-
thusiasm for the Woman's Auxiliary of the
society. iMeeting with the members of this
body, as a member of an advisory committee,
afforded an opportunity to learn of their zeal
in the cause of scientific medicine and im-
mediately it became evident that this :iuxil-
iary can accomplish great things in the war-
fare against all forms of quackery: in [jopu-
larizing vaccination, destruction of in.sect
pests and the cultivation of rational health
habits: in infiuenc^ng health legislat.on, a. id
in many other ways.
Through their ckibs aiuj oilu'r iirgani/.:i-
lions they can obtain more faxorable publicity
than can the doctors.
This is much more than a .social adjunct.
I'nder the enthusiastic leadership of Mrs. G.
SOUTHERN MEDICINE AND SURGERY
May, 1929
H. IMacon, of Warrenton, we look for great
accomplishment.
Dr. W. B. Robertson Thinks and Speaks
Out
Read carefully (pp. 307-10) the article,
"Medical Problems — Present and future." It
is full of meat.
We are always glad to have contributions
from the villages and small towns. The
quality is generally good, and the example
serves to induce other doctors outside the
cities to give our readers the benefit of their
experiences and their thought.
Particularly gratifying is Dr. Robertson's
willingness to suggest remedies. He is no
Jeremiah. He does not lament; he d a'];no5e3
the situations and recommends wise, bald
treatment.
We would be glad to have a letter express-
ing every reader's opinion on these vital prob-
lems, and to publish them for the considera-
tion of others.
We hope every County and District society
will take action on these suggestions as ste;:s
toward action by the Med cal Society of the
State of North Carolina at its next session.
In the menatime we can, individually, ap-
ply some of the remedies.
The Importance of "Minor" Medicine
AND Surgery
The E.\altation of the Commonplace
Frequently have we disserted on the im-
portant place in practice of what many re-
gard as lesser med'cine and surgery. INIore
than once have we expressed the opinion that
all these are worthy of far more attention
than they receive at the hands of practition-
ers, and of many times the pages accorded
them in our journals.
In d'scussing the excellent paper of Dr.
R. L. Raiford before the last meeting of the
Seaboard Medical Association, wc took occa-
s'on to say that, to the patient, there is no
minor medxine nor tn'.nor surgery. This pa-
per— publ'shed in this journal's issue for De-
cember, 1928 — showed clear recognition of
the importance of the "stub-nosed" condi-
tions, and of the importance of earnest atten-
tion to them. While making his plea mainly
on grounds of right, Dr. Raiford wisely
pointed it out that such attentions added very
materially to the incomes of doctors careful,
considerate and wise to despise not the day
of small things.
The American Journal oj Surgery for April
has been devoted to this idea. It contains
"forty-one articles on minor and common
surgical cond tions." If a journal which is
published for surgeons decides wisely — and
we have every confidence that wise was the
dccis o;i — to devote so much space to so-
called "minor" cond tions, it is imperative
that journals representing, and published for,
j^eucral doctors, should carry much on the
\e.y coi.ditions which are taken care of by
these general doctors.
Among the subjects of these papers are:
"Ingrowing Toe Nail"; "Warts, Moles and
Corns"; "Skin Cancer;" "Fissure of Anus
and Thrombotic Hemorrhoids"; "Adhesive
Plaster Strapping"'; "Exploratory Thoracen-
te^s"; "Strangulated Hernia"; "Infections
of the Face"; "Operative Treatment of Hal-
lux Rig.dus"; "Contusions and Abrasions"
"Injures of the Chest"; "Circumcision"
'Lame Back"; "Boils and Carbuncles"
"Everyday Ocular Injuries "; "Pruritus Ani"«
"Varices and Ulcers of the Lower Extremi-
t'es ; "Appl'cation and Removal of Plaster-
of-Paris Bandages '; "Gangrene of the Foot";
"Cartilage Injuries' ; "Perianal and Perirec-
tal Suppurations"; "Foreign Bodes in Ear
and Nose'; "Common Dislocations";
"Sjjrain and Injuries of Fingers and Toes";
"Rational Treatment of Burns"; "Pressure
D css.ng' ; "Catheterization in the Male";
"Infections of the Hand"; "Paronychia and
Felons' ; "Infections of the Breast"; "Non-
Operat.ve Procedures in Urology "; "Epithe-
Icma of the Extremities "; "Pdonidil Cyst"
and "mmicd-ate Treatment of industrial
Traum;i..'
Although the reading of th's list may have
grown tedious, it is well worth the readmg,
even the re-reading. Consider how large a
proportion of our daily work is there repre-
sented. Consider how many patients in the
families whose doctor you are suffer with one
or another, or several, of these conditions —
all of which you should be able to take care
of — and how many you refer or who refer
themselves to specialists!
We hope to get out an issue in this year
devoted to the lesser medical conditions, after
the order of this dealing with those surgical.
We ask our readers now to send in ideas and
offers to contribute articles.
Painless incision of a boil or cyst, — pain-
May, 1929
SOUTHERN MEDICINE AND SURGERY
343
less to the patient as well as the doctor — and
correct diagnosis and treatment of itch, dan-
druff or constipation, may add as much to our
standings and our earnings as would the
making of the blind to see or even the "giving
of ripe wits to a fool."
Let's pay more detailed attention to
"m'nor" things: and note the general im-
provement.
Third Post-Graduate Course at
Charleston
From May 27th to June 8th a post-grad-
uate course will be given by the Medical
College of the State of South Carolina. In
these twelve days instruction may be had
second to none in value for doctors of this
ject'on of the country — and at no cost.
Clinics will be given at the Roper Hospital
by the Faculty of the College. Attention will
be centered on internal medicine, pediatrics,
obstetrics, and surgical diagnosis. Individual
instruction in small groups will be given and
cl'nical ard laboratory findings correlated.
Cl'n'co-pathological conferences on four after-
noons of each week afford a means of final
instruction on patients who have come to
necropsy.
It is pmazing that such a course can be
conducted.
We hope many will gratefully avail them-
selves of this generous offer.
The War of the Lambs
ThouTh bearing it well in mind that all
the Prophets were Jews and that most proph-
ecies of which we have knowledge are la-
mentably lacking in accuracy of fulfilment,
we ventured to predict a good many months
back that hostilities would soon break out
between two of our goods friends, tobacco
and sugar.
Though newspapers, magazines, luncheon
club programs, and the orators in Congress
concern themselves much, we find ourselves
unable to work up a sweat about the issues.
We arc moved to wonder, though, that devo-
tees of the soothing weed and those of the
content-affording sweet should learn the ways
of war. Indeed, it would seem pfjssible that
S"me of the most energetic partizans neglect
to use the i)roducts which they so vigorously
champion.
The National Food Products Protective
Committee, New York City, is protesting
against a campaign "to transform 20,000,000
boys and girls into confirmed cigarette ad-
dicts." It demands that the licenses of 38
important stations of the National Broad-
casting Company be revoked because of the
objectionable cigarette advertising through
these stations. It is charged that "tainted
testimonials" are used.
We were quite disappointed when the cap-
tain of the Florida allowed his name to be
used in a cigarette testimonial. As to the
"professional athletes, football coaches, and
stars of stage and screen" whose willingness
to "sign for silver" gives such a hurt^—it
seems about what could be exjjected.
"Beyond the specific charges made by the
petitioners, they protest against the use of
paid testimonials on the air as contrary to
the public interest, dangerous to the public
health and public morals and inimical to the
honest business interests of the country.
'Such testimonials,' the petitioner holds, 'are
inherently misleading, when they are not de-
liberately false, because the radio public is
not told that alleged recommendations of
cigarettes and other products are bought and
paid for in the public market place."
Doctor, is not that reminiscent of some-
thing? How applicable it is to the advertis-
ing of fake "doctors" and fake "remedies"!
The difference in the cases of the two lies
in the fact that nobody has adduced evidence
worthy of the name that either tobacco or
sweets are dangerous to the public health,
while volumes of the most impeccable proof
have been made public projjerty as to the
needless suffering and deaths because of the
fake "doctor" and his or her "treatments"
and "remedies."
"The voice sent broadcast through the air
knows no barriers. It invades every home,
and it speaks alike to man, woman and child;
to the strong and to the weak, to the sophis-
ticated and to the innocent. The home lies
open and helpless to the intrusion of the spo-
ken word broadcast from a radio station."
We wish interest could be stirred to keep out
of the homes those who invade it on air and
printed page to slay innocent children by
inducing parents to refuse to vaccinate
against smallpox, typhoid and diphtheria,
and to bring men and women to death or
destitution by following the advice of cun-
ning mountebanks who know nothing of dis-
^44
SOUTHERN MEDICINE ANt) SURGERY
May, 1929
ease processes, but much of human gullibil-
ity. And they seem to find little dfficulty
in getting newspapers to go into partnership
with them for a share of the profits.
In the war now on our attitude is one of
benevolent neutrality. Believing firmly as
we do that our own cravings are far more
reliable guides than even disinterested scien-
tists, we trust no harm will come to either
the cigarette or the sweet, and that plenty
of both will survive the war, so they may be
had at will by those whose economies call
for them.
Sweets to the sweets,
Cigarettes to the sweeties!
A Way to Serve the Journal
In response to a letter soliciting advertising
for the pages of Southern Medicine & Sur-
gery, a manufacturer of medicinal agents
writes:
"All magazines in which our advertising is placed
are selected on the basis of a questionnaire which
we send out to several thousand doctors every two
years. In our letter we ask the doctors to let us
know which magazines they read and prefer and on
this basis we make our selection. We have found it
necessary to use this system since we are limited in
the amount of money we can spend for advertisin-^
and therefore cannot take all those we would like
to."
The friends of this journal are many and
staunch. Soon after it came under its pres-
ent management, a score or so of these wrote
companies from whom they were accustomed
to make purchases, or whose products they
frequently procured locally, saying they
would be pleased to see advertisements of
the wares of these companies in Southern
Medicine & Surgery.
At that time the journal had much less to
offer than it now has; despite this, the re-
sponse was gratifying. At this time much
more can be accomplished.
All friends of the journal — and we claim
all its readers as its friends — are reminded of
this great service which they can render at
very little cost to yourselves, and to the im-
mense benefit of the different elements work-
ing for betterment of the cause of Medicine.
Oldest .Alumnus of Univ. N. C. Dies
Dr. \Vm. Marshall Richardson, of Raeford,
Fla., died May 1st. Dr. Richardson was in his
98th year, and had the d'stinction of being
the oldest living alumnus of the University of
North Carolina. He took the B.A. degree at
Chapel Hill in 18S1 and the M.D. at Jeffer-
son in 1854.
Drs. \V. C. Bostic, sr. and jr., spoke be-
fore the Rutherford County Medical Society
May 9th on "Eclampsia."
May, 1929
SOUTHERN MEDICINE AND SURGERY
DEPARTMENTS
HUMAN BEHAVIOR
James K. Hall, M.D., Editor
Richmond, Va.
A Study of Human Behavior
The March issue of The Mental Hygiene
Bulletin carries the announcement of the es-
tablishment in Yale University of the Insti-
tute of Human Relations. The Institute will
be financed from a fund of seven and a half
million dollars provided by the Rockefeller
Foundation, the Commonwealth Fund, and
the Laura Spelman Rockefeller Memorial.
The purpose of the Institute is to bring to-
gether b'ologists, sociologists, psychologists
afid economists in such fields of applied
sc'ence as law, medicine and psychiatry, to
correlate knowledge of mind and body and
of ind'v'dual and group conduct and to study
the many interrelations of many factors in-
fluencing human action. President Angell of
Yale "conceved several years ago the object
of making the study of human behavior one
of the major aims of that University by pool-
ing the resources of all of its departments of
natural and social sciences in the hope of
achieving a coordination of knowledge and
technique such as has never before been at-
tempted in solving problems of human rela-
t'ons." And the Institute will approach its
problems on the theory that the body and
the mind of the human being are not separate
and inde[>endent entities, but unified and in-
terdependent entities, each dependent for its
wholesome functioning upon the sound health
of \h" other. .And an effort will be made to
elminate the sharp lines of separation of the
Afferent branches of sciences, so that all of
the sciences may be made use of in attempt-
ing to understand and to evaluate human
conduct. Dean Winternitz of the Yale
School of Medicine thinks of the Institute as
affording an opiwrtunity to introduced the
first fundamental change in medical educa-
t'on that has occurred in the last half cen-
tury. .And Dean Winternitz believes that
"medical men have become well aware of the
Treat imrwrtance of psychiatry, but they have
been more interested in outsiwken mental dis-
ease than in the development of mental effi-
ciency for the normal as well as for the ab-
normal. Now the Institute will make it {xis-
sible to realign studies dealing with the per-
sonality of the individual and his behavior,
but more than that, it will bring together
with physicians and psychiatrists, other
groups of scientists concerned with problems
of psychology and sociology, without which
individual behavior can not be projjerly inter-
preted. For individual behavior is in large
part a reaction of the individual to group
and environmental influences. Medicine, after
all, is a social science, and the evidence of
growing recognition of this fact is everywhere
forthcoming, both in America and in
Europe. To give prospective physicians a
clearer conception of the social aspects of dis-
ease and a fundamental training in individual
behavior from the biological and sociological
viewpoint, and to create a group of s[>ecialists
versed particularly in these relationships are
aims of the school now made possible through
the Institute and the cooperative activities of
great groups within the University." Those
directly interested in mental disease problems
will rejoice to know that for ten years the
sum of fifty thousand dollars will be expended
annually for educational work in the domain
of psychiatry, and fifty thousand annually
during a like period for the actual care of
mental patients.
It is high time that dignified and deliberate
and scientific consideration were given to the
matter of the behavior of mortals, whether
that behavior be looked upon as normal or as
abnormal. Those of us who have to do with
disorders of conduct kn'w too embarrassingly
well how prone the public are to believe that
mental abnormality clearly portrays itself in
some trick of conduct, just as pathognomoni-
cally, for instance, as smallpox declares itself
by a particular eruption on the body surface.
Out of the work of the great group of scien
tists of many kinds engaged in the study of
the behavior of human beings will come
eventually a more profound knowledge of
mental disorders, and then will come preven-
tive mental medicine of more defin't" and au-
thoritative stamp. .At present w.^ know prac-
tically nothing of epilepsy, the riunic-depres-
sive type of psychosis, deme'itia nr c.ox,
346
SOUTHERN MEDICINE AND SURGERY
IVIay, 1P20
drug and alcoholic addiction, and crime of the
graver kinds. And most of us are as unfa-
miliar with the more profound meaning of
normal behavior as we are unfamiliar with
the accurate meaning of most of the words in
our own language. We speak and we write
unmindful of what we are doing. Phenomena
of daily occurrence are observed but not in-
vestigated. The familiar does not excite k(.'en
interest.
SURGERY
Geo. H. Bu.n'ch, M.D., Editor
Columbia, S. C.
Blood Transfusion
Villari tells us, in his Life oj Savaiiarola,
that, in 1492, while Columbus was sailing
across the .Atlantic to discover .America, Pope
Innocent VIII lay unconscious in the Vatican
and that for some days the court thought
him dead. .\ Jewish physician tried to re-
store the aged pontiff to health by passing
the blood of a youth into the old man's veins.
The e.xperiment was tried three times and
cost the lives of three boys without helping
the Pope. However, in The Life and Times
oj Rodrigo Borgia, Mathew says that the
Pope died July 25, 1492, after a Jewish phy-
sician, in a vain attempt to save his life, had
administered a draught of the blood of three
young boys who immediately died. We thus
see that the report of the first attempt at
blood transfusion is clouded in the uncer-
tainty of antiquity. We know that the an-
c'ents thought there was virtue in drinking
human blood. It is a severe test of one's
credulity to believe that blood transfusion
should have been attempted before the cir-
culation of the blood was discovered by Har-
vey in 1628.
The h'story of blood transfusion really be-
gins in 1892 when von Z'emssen reported the
indirect transfer of blood from one individual
to another by needles and syringes. The
method was crude and made but little im-
pression until perfected by Lindeman 20
years later. Crile of Cleveland, by the use
of a metal tube around the vessel, succeeded
in turning the end of the ve'n back over the
end of the tube as an everted cuff, with the
intima exposed so that it could be brought
into proper apposit on with the intima of the
artery, similarly prepared, from which the
blood was to be obtained. This direct method
of transfusion was a real advance but had
the disadvantage of requiring great skill and
dexterity on the part of the surgeon. With
it success at best was uncertain and one could
never be sure how much blood was trans-
ferred.
Bernheim's book on blood transfusion
(1917) says, "Little real progress toward the
widespread use of anticoagulants was made,
until the work of Hustin, Weil, Lewisohn, and
.Agote, in 1915, rather unexpectedly placed
the method on a firm footing. All four of
these men, working independently, came to
the conclusion that sodium citrate, long
known to pharmacologists for its anticoagu-
lant properties, could be used in the human
with perfect safety, provid;d care was exer-
cised in securing the proper dilution. Elab-
orate experiments on animals proved the cor-
rectness of their contention and now the so-
d'um citrate method of indirect transfusion
of blood bids fair to supplant all previously
known methods."
Experience has proved Bernheim wrong,
for blood containing sod um citrate causes
unfavorable reaction in a larger percentage*
of cases than does whole blood and already
the method is b?ing abandoned. At this time
the best way is to give undiluted blood by
the indirect method. With a needle in the
vein of the donor and another in the vein
of the recipient, by multiple syringes the blood
is readily removed from one vessel and in-
jected into the other. However, we have
found the easiest and best way of doing trans-
fusion is by an apparatus which was per-
fected by Moore of the Henry Ford Hospital
in Detroit. The principle is that of the Da-
v'dson rectal syringe. The needle in the vein
of the donor is connected to a 20 c.c. Record
syringe, which is in turn connected to the
needle in the vein of the recipient so that,
as the piston works, by valves, the blood is
passed from one vessel into the other. By it
the operator with the assistance of a nurse
can give a pint of blood in 15 minutes. .All
transfusion apparatus must be kept scrupu-
lously clean, and aseptic technique must be
mii'rtained if results are to be satisfactory.
Whe 1 the transfusion is begun rapid and con-
t rucus v.ork is necessary to prevent clot-
ting.
i\Iofs of Johns Hopkins, in 1910. as a
rrrult of 1,600 tests, placed all human blood
in four groups, and showed that the blood of
May, 1929
SOttttftRM kEDlCtME AND SURGERY
Uf
the donor and the blood of the recipient must
be in the same grciup if at^gliitination is to
be prevented. The discoveries of Moss laid
th;" foundation for placing transfusion on a
rational basis. To make doubly sure most
modern technicians not only type the blood
according to the ^loss method, but also
match the blood of donor and recipient by
mixing a drop of each on a slide and watch-
ing the result under the microscope to be
sure there is neither agglutination nor hemo-
lysis.
Vigorous young men make the best donors
and can be obtained by insuring compensa-
tion for the blood given. A dimor with hy-
pertension should be rejected. We know of
one who, after giving a pint of blood, went
into coma which deepened into death.
With better understanding the indications
for blood transfusion have grown from year
to year. .\t the South Carolina Baptist Hos-
pital, an institution of 100 beds, in 1926
there were 18 transfusions; in 1927 there
were 28; in 1928 there were 62; and in Jan-
uary, February and March of 1929 there
have been 24, almost as many as in the whole
of 1927. For acute hemorrhage, after bleed-
ing has been controlled, transfusion is a spe-
cific. In secondary anemia it may restore
a patient in extremis to life and health.
Heretofore 30 per cent of hemoglobin was
considered a minimum for major surgical
work; now we require 60 per cent, any pa-
tient with less is given a transfusion. When
bleeding is anticipated at operation a donor
already typed should be in readiness for
transfusion. We think the mortality in pros-
tatectomy could be in this way lessened. The
resistance of the patient in many chronic
infections can be fortified by overcoming the
anemia by transfusions of blood. Patients
with blood dyscrasias ofte nrequire transfu-
sion. We know a hemophiliac who has to
have an injection of blood intramuscularly
or intravenously at least once a month to
prevent bleeding from the nose and from the
rectum. He is now 30 years old and it is
problematical even with this help if he can
be kept alive very long.
[In a very early — as recalled the very first
— number of the Boston Medical and Surgi-
cal Journal (est. 1828) there is an article on
blood transfusion, as being done at that time
in some of the European clinics. — Editor S.
M. & S.\
UROLOGY
For this issue, R.^vmonp Tikimpson, M.D., and
Lester C. Todd, M.D., Charlotte, N. C.
From the Crowcll Chnic of Urology and
Dermatology
Testicul.ar Tumor in Infancy
Case Report
New growths of the testicle vary from
tumors elsewhere in two outstanding charac-
teristics. The first is the complex pathology
that may present itself and the second is the
embryological and anatomical pjculiarities
that render the operative treatment both easy
and uncertain. Tumors of the testicles are
relatively rare, occurring about once in 1,500
admissions. Testicles retained in the inguinal
canal are more frequently the site of malig-
nancy than either the normally or abdomi-
nally placed organ. As a malignant tumor
of the male, the testicle is involved about
once in 200 cases of malignant disease.
Testicular tumors in infants and children
are diagnosed quite rarely. Following his ex-
haustive review of the literature and path-
ological study, Ewing came to the conclusion
that practically all tumors of the testis are
of teratomatous origin. The term "sarcoma
of the testis" is usually a misnomer as a true
sarcoma of the testis is an extremely rare thing.
Ziegler describes under the head of teratoid
tumors and cysts, those tumor-like formations
wh'ch are characterized by the fact that the
tissue comprising them either does not occur
normally at the site in question or at least
does not appear there normally at the time
at which they were found and classifies them
as (1) simple teratoid tumors, (2) simple
teratoid cysts, and (3) complex teratomata
which contain tissues derived from all the
germ layers.
The occurrence of tissue formation in re-
gions in which such tissues are not normally
present can be explained in part by the be-
lief that cells or groups of cells have not
undergone normal differentiation but retain
the capacity of forming different kinds of tis-
sue. The preferable explanation is that there
has been a germinal aberration or misplace-
ment of tissue in that in early embryonic life
embryonal cells of one organ find lodgement
in the anlage of another. Ewing's classi-
fication based on his belief that all testicular
tumors are teratomatous is as follows:
1. .\dult embryomas or teratomas — rare
cases in which the rudimentary organs of a
parasitic fetus may be found.
Hi
SOUTHERN MEfitCIfJfi AND SURGEftV
May, 1929
rious illness or operation; measles mild attack
age eight months. Present illness — swollen
left testicle which is painless — duration three
months.
2. Embryoid, teratoid or mixed tumors —
cases in which derivatives of all three germ
layers are found, but in such confusion as to
eliminate any resemblance to a fetus.
3. Embryonal malignant tumors, a mono-
dermal teratomatous derivative (seminome
of Chevassu, spermatocytoma of Schultz and
Eisendrath).
CASE REPORT
No. 22112— 5-16-28— J. R. H., age 16' '2
months — male. Chief complaint: swollen left
testicle. Family history negative. Past his-
tory— general health has been good; no se-
Examination: General appearance, well de-
veloped and healthy; heart and lungs nor-
mal; abdomen negative; external genitalia
negative except swollen left testicle, which is
typical of hydrocele — light is transmitted
through mass; both testicles in normal loca-
tion in scrotum. Urine: acid, albumin and
glucose negative. Sediment — no pus, no
blood, no casts, no bacteria. A diagnosis of
left hydrocele was made and operation was
advised.
5-19-28 — Operation: general anesthesia;
usual hydrocele operation; definite hydrocele
but left testicle and epididymis seen to be
involved in a mass of abnormal tissue. Speci-
men removed for pathological examination.
Pathological Report oj Tissue from
Epididymis:
The specimens obtained show the usual
structure of a benign cystic dermoid as nearly
all of the tissue is epithelial and shows many
hair follicles, sebaceous and sweat glands.
There is, however, cartilage and neuroglia
tissue present and it is therefore a teratoid
tumor (Wilms designates these tridermal
growths as embryoid or teratoid). These tu-
mors, especially the adult type as seen here
may be benign, there is a striking tendency
for one germ layer to outgrow the others and
become malignant.
On account of findings of 5-19-28, it was
decided that a more radical operation should
be done.
5-28-28 — Left testicle and adnexa remov-
ed.
Pathological Report oj Lcjt Testicle and
Adnexa:
This specimen consists of the main mass
of the teratoid and shows cystic open spaces
filled with blond hairs and sebaceous mate-
rial, a large amount of connective tissue,
blood vessels and one hollow bone. There is
also a large cystic island of neuroglia and a
mass of tubules lined by epithelial-like cells
and encapsulated in dense connective tissue
tunic. This latter probably represents the
atrophic testicle. No evidence of malignancy
found. Diagnosis: Teratoid of testis (It.)
Subsequent History: Patient left the hos-
pital on the eighth day and experienced an
uncomplicated convalescence. He has report-
ed at intervals during the past year and there
has been no evidence of recurrence or metas-
tasis.
Comment on Case: In view of the exp)eri-
ences of others that nearly all of these tera-
toids go on to malignant degeneration, it was
deemed best to do the more radical second
operation. Since it is the history of this
type of case to show prompt local recurrence
if all of the tissue has not been removed or
rapid growth of metastases if there has been
dissemination previous to operation; it would
appear now from the subsequent examination
of the patient that the expectancy of a cure
is well grounded.
HISTORIC MEDICINE
For this issue, John B. Fisher, M.D.
Midlothian. Va.
(With notes supplied by Frank Hancock., M.D.,
Norfolk, Va., and Herbert W. Lewis, M.D.,
Dumbarton, Va.)
Dr. Phillip Spencer Hancock
"In the center of the broad highway lead-
ing from Richmond west to Farmville and
Lynchburg, stands a beautiful little granite
shaft to the memory of a country physician
who gave his life that others might live.
He was Dr. Phillip Hancock, who spent
his life aiding the sick in and about the little
village of Midlothian, in Chesterfield county.
In his day physicians were few and his
patients were scattered over a vast area of
farm country. In his simple buggy behind a
plodding horse, the country doctor rode
thnnigh summer heat and choking dust; bit-
ter winter blasts, and hub deep mud; year
in, year out, regardless of the season.
From the home of the wealthy planter to
the cabin of the poorest negro, he called on
his errand of mercy. No plea for aid went
May, 1929
SOtJtHfeRK MEblCiNfe AND SURGERY
349
unheeded: no distance was too great; no
road too bad; no man too penurious. The
country doctor lived to serve. Xo man called
for aid in vain.
fast asleep in his old bugEjy after a circuit of
many cabins.
Nightfall might see him just started for a
len-mile drive through rainy darkness. Thus
rode the country doctor through two decades
of life.
The whole countryside knew of h!s wish
that when he died it might be while attend-
ing to the physical troubles of h's people.
"Just bury me where I die,' he often told
his friends. One morning the faithful old
horse was found plodding homeward, the
doctor fast asleep for all eternity, the reins
clasped in icy hands.
■Just bury me where I die,' he had said.
The granite monument which stands in the
very center of the broad highway marks the
sjTot where the faithful old horse was found
bringing his master home.
Many an astonished motorist has stopped
in wonder to gaze upon this altar to senti-
ment, at the base of which an occasional
lightless flivved has been sacrificed.
'Where else in all the world could such a
thing be true?' one often asks after hearing
the story.
We would also like to ask 'Where indeed?' "
Thus wrote a correspondent for the Times-
Dispatch (Richmond), last July, and he
wrote accurately except for one feature: Dr.
Hancock did not die in the road, but in a
hospital in Richmond.
The story of such a life is well worth the
retelling and record in the libraries and
hearts of doctors.
Born at Midlothian, in Chesterfield county,
\'irginia, November 16th, 1836, and died
January 11, 1893, Ur. Hancock received his
early efiucation from private teachers and
later entered the University of Virginia,
where he completed his academic studies. He
began his medical studies at Jefferson, left
with other Southerners in 1860, was gradu-
ated from the Medical College of V'irginia in
1861 at the age of 22, and returned to his
home village of Midlothian, where he prac-
ticed his profession until the outbreak of the
Civil War. When Virginia seceded and cast
her lot with the Southern Confederacy Dr.
Hancock was commissioned surgeon of the
Fourth Virginia Cavalry and as such served
the entire four years of the war. Dressing
wounded men during heavy tiring and con-
tinuing to do so until reinforcements arrived,
he was offered promotion for gallantry. This
he declined, saying he didn't deserve it.
When General Lee surrendered at Appomat-
tox he returned home and again took up the
practice of medicine in his native village. He
was a man of strong personality and a splen-
did physician and surgeon, doing many suc-
cessful operations in the homes of his patients,
using the kit of instruments he had brought
home from the war.
He was a poor business man; he kept no
books but served the rich and poor alike: he
was always ready and willing to go to the
sick and suffering, it mattered not how bad
the weather or how long the road or how
dark the night, and without a thought
of reward save the satisfaction of knowing
he had done his best to relieve his fellow-
men, ease their pains and cure their diseases.
His influence and his kindliness of heart
are alike attested by an incident which oc-
curred about 1870. An agitator had made a
rabid political speech which had so incensed
the populace that threats of violence were
made and were on the point of being put
into execution. Dr. Hancock advanced
through the crowd, took the object of the
crowd's wrath under his protection, marched
him off to his home, kept him through the
night and saw him safe on board a train the
next day.
A second political incident was less excit-
ing, but fruitful of a strange coincidence. A
\'ankee officer having settled in Chesterfield
county, made a speech at a colored political
rally near our village on one occasion. It
seems that he missed his train that afternoon.
.As nobody cared to entertain him he was
in some perplexity with night coming on.
Dr. Hancock, discovering this, went for him.
That night they were relating their respective
exjjeriences in the Civil War. The host's re-
cital of the incident was as follows: .\\. the
termination of the war he was transferring
wounded soldiers from Jackson Hospital,
Richmond, when a company of negro troop-
ers coming by proceeded to toss these wound-
ed men from their stretchers. Dr. Hancock's
ex[K)stulations were in vain. A Yankee ma-
jor rode up and ordered these negroes to
desist, and after upl)raiding th :i^i severely
m
SbttttfekM MeCtCtKt Akb StllGfeftV
May, 19i9
marched them off. Well, this was the same They were often as well dressed as the doc-
major that was being entertained that night tor, who had no more idea than they of crea-
in the good doctor's home at Midlothian. ture comforts. Dr. Frank Hancock says that
The Doctor and a partner in practice
He married Miss Helen Ball in 1870. She
died ten years later of arthritis deformans,
leaving two small children. His life after that
was lonely and devoid of the essentials that
go to make a comfortable e.xistence. .Acts of
unvarying benevolence characterized him. His
home was often the abode of people suffering
from chronic and acute diseases, and who
were for the most part unable to pay even for
their meals.
A number of times at night he called his
son to come and sleep with him, that some
wayfarer, who had come in late in the night,
might have a bed. Thus were tramps made
to feel at home in that house. They always
stayed to breakfast and sometimes longer.
his acquaintance with the hobo world became
extensive, and he was entertained with many
delightful stories.
He cared nothing about aristocracy. It
was the wayfarer that interested him. Peo-
ple born to the purple were not born at all
as far as he was concerned. He liked ordi-
nary folks, and indulged his fancy. Educat-
ed people who came to our village from time
to time often were startled at the play of
his mind, the vividness of his memory, the
versatility of his reading. He must have
been lonely in these solitudes, for few of his
neighbors had any means or time or desire
for such pursuits.
Having ridden, like John Wesley, a hun-
dred thousand miles on horseback, he was
induced by his friends to travel in a sullcy.
He had a strange perspicacity that often
enabled him to penetrate the obscurities of
disease, giving him a wide reputation among
doctors as well as the laity. It was quite as
true of him as it was of Hippocrates that
"he not only looked: he saw."
I do not know what bearings of genius he
had, but his eccentricities were many. A
queer abstractedness marked him at times.
He would sit for hours whittling sticks in
complete oblivion of the presence or absence
of any one; escaping thus from the world
about him, traveling apparently delightful
avenues. Perhaps he was preparing for the
many practical problems that confronted him
from day to day. Sometimes in the night,
he might be heard reciting, or declaiming
Shakespeare at great length. Then he would
relapse into profound slumber. Certainly his
reason at these times was outward bound.
.•\t the age of 56 he developed an acute
phlebitis and died after a life of fearful ex-
posure and privation.
He called his son to his bed two days be-
fore he died and said, "Do not weep for me;
I am terribly tired and glad to go." He has
gone to join, let us hope, the mystical influ-
ences that so exercised him during his life.
The acclaim that came to him after his
death was due to th^ selfessness, the artless-
ness that characterized him. There was no
design, no scheme, in his relations with oth-
ers; no eye for effect. He reached out to all
afflicted, man and animals, giving them
everything he had in complete selfabandon.
His foibles were many: A certain drollery
of dress and of manners marked him. He
had an aversion to changing his clothes and
developed an amusing elusiveness in avoiding
those who importuned him to do so. It is
very likely that he had read and often
thought, with many a chuckle, of Samuel
Johnson's comment when some one complain-
ed of the aversion of a mutual friend to clean
linen: "Well, I'm not overfond of it my-
self."
.Absent-mindedness was a cardinal feature
of his, often operating to produce amusing,
and sometimes serious, situations.
The promiscuous pronouncements of doom
upon the part of the churches did not meet
with his approbation. He couldn't see eternal
punishment. That deity would be wrathful
and send to hell, because of dissidence or
SOOtHEftN MEDlClKfi AND StRGEftY
3Si
frailty, was not a part of his philosophy.
It was his belief that every one is event-
ually acquitted whatever he may have lacked
of virtue or of good citizenship.
Thus he spent his entire life. He was re-
spected and loved by all who knew him. He
died in a Richmond hospital January 11th,
1893, was buried in Maury's cemetery in
South Richmond beside his wife, who pre-
ceded him to the grave some eight or ten
years. He left a son and a daughter. Dr.
Frank H. Hancock, of Norfolk, and Mrs.
Graham, of Richmond. .After his death his
grateful friends and patients of the village
of Midlothian erected a monument to his
memory and, by a decree of the county court
of Chesterfield county, they were allowed to
place it in the center of the public highway
that passes through their village. On this
granite shaft which stands some twenty feet
high is carved his name with the date of his
birth and death and the testimony that it
was erected as a token of love and esteem by
his grateful friends and patients.
(Inscriptions on thru sidf
Phillip Spencer Hancock
Born
Nov. 16—1836
Died
Jan. 11—1803
The Beloved Physician
Erected as an Expression of respect,
gratitude, and Devotion by the
Friends of the Deceased
Hi
SOUTHERN MEDICINE AND SURGERY
May, 1929
OBSTETRICS
Henry J. Langston, B.A., M.D., Editor
Danville, Va.
Long Labor — Its Dangers
II
The picture we have at the beginning of
a long test of labor is usually that of a young
woman, robust, heavily built, short from
pelvis to diaphragm, very muscular both as
to the trunk and extremities. The general
appearance is one of health, but the healthy
appearance does not withstand pain and the
v/ear and tear of labor. At the beginning
cf labor the patient's skin looks well, the
mucous surfaces appear to be functioning in
a first class manner, the eyes sparkle and the
patient's attitude is one of happiness and lit-
tle fear. As labor begins the muscles of the
body, including all the structures, are strong
and have stored up in them abundance of
energy. As the labor drags on, the skin that
was red and ruddy begins to appear pale and
glistening, the mucous surfaces lose their red
tint, the eyes of the patient become whitish
and weary, the facial expression is drawn
and tired, the patient is restless, impatient
and distressed. During these hours of wear
and tear the average patient is given very
little nutritive food, the patient becomes nau-
seated and there is intestinal pain along with
the uterine contractions; there may be
frequent urination with some pain or there
is dil'ficulty in emptying the bladder. Time
drags on with the burning of the stored-up
energy of the body and after so long a time
the pat-'ent gives up, bodily and mentally;
then it is that the physician takes really un-
der consideration the question as to whether
or not to interfere.
After debate and perhaps consultation, in-
terference is instituted, when the patient's
reserve forces have been burned and her vital
energy exhausted. The cells stand a poor
show to fight off infection of any form; the
patient is not in the best condition to accept
any form of anesthesia. The cervix, the uter-
ine muscles, the vagina and the levator ani
muscles have lost their reserve energy; they
are now easily torn; their condition is such
that they accept without much fight any
form of bacterial infection. Perhaps the
baby is already dead; if it is not it may be
dead before it has passed through the birth
canal. Repaired tears do not heal as they
should. In these cases of long labor where
so much injury is done to the birth canal
and repair is not followed by healing, we
take this as an argument against repairing
injuries. As a matter of fact it is not the
repair that has done the damage but the
long labor with trauma; all the tissues devi-
talized to the degree that they not only do
not heal well but they accept any form of
bacterial infection without putting up a fight.
If interference has brought either a live or
dead baby, with damage to the birth canal,
the mother now faces the puerperlum greatly
handicapped. What's the usual experience
of this? The patient has a stormy time,
is horribly sore, usually runs a temperature
with rapid pulse, not only with a local infec-
tion but with a general infection in a mild
or severe form. She drags through the puer-
perlum with all of her vital forces gone.
When she gets on her feet at the end of three,
four, five or six weeks, she feels uncomfort-
able; she is weak; she is unable to enjoy her
food; she is unable to take exercise; and she
is unable to enjoy her family and friends.
Weeks, months, and sometimes years b3fore
she has recovered from the horrible experi-
ence of the long-drawn-out labor.
With this experience she dreads to think
of having to go through pregnancy, delivery
and puerperium again; she sometimes has
brain storms brought on by anticipations of
repetitions of the horrible experience. This
group of cases is large and it extends over
every section of the face of the earth. In
this group we get our deaths and morbidities.
In this group appear patients with gynecol-
ogical conditions, some of which arc irrepara-
ble, others which can be partially repaired,
and others which can be put in 90 per cent
condition. These facts should really cause
every physician who is doing obstetrics to
study most carefully every principle which
has been taught and the principles that he
now practices in this field and if possible,
through safe measures, eliminate to the mini-
mum degree the so-called long labor test and
help these women to come through labor with
the minimum injury to themselves and baby,
and at the same time be comfortable, then
after the experience be in .1-1 condition in-
steadv of in a morbid state.
May, 1019
SOUTHERN MEDICINE AND SURGERY
JS3
PERIODIC EXAMINATIONS
Frederick R. Taylor, B.S., M.D., Editor
High Point, N. C.
What May We Learn From These
Examinations?
We collected and analyzed the data ob-
tained from 436 examinations of apparently
healthy persons, and presented our findings
in the Section on Practice of Medicine at the
recent meeting of our State Medical Society.
These findings will be published in this jour-
nal's issue for June, so brevity seems to be
the greatest desideratum for an editorial call-
ing attention to the data and whatever lessons
may be derived therefrom.
Our latest totals showed that in 436 persons
1,555 defects were found, an average of 3.57
defects per person. This is our text. The
sermon based thereon can be made very brief.
These persons come from 51 counties of the
state, geographically distributed over almost
the entire area of the state, from Tennessee
to the ocean, and from Virginia to South Car-
oKna. We believe they represent a fair cross-
section of the state. If the physicians of the
state all get busy and search for the defects
in the people of their respective communities,
think what an improvement could be made
in the health of our population!
North Carolina is approaching the 3,000,-
000 mark in her population. If only about
one-third of these persons had health exam-
inations, it would mean the discovery of over
35,000 defects, and if proper steps were ta-
ken to correct as many of these defects as
possible (and the vast majority of them are
correctible) the value of such work could be
hardly overestimated.
There are over 2,300 physicians in North
Carolina. If all of them should have health
examinations, and then correct the defects
found, probably over 7,500 defects would be
corrected among the members of our own pro-
fession.
He that hath ears to hear, let him hear!
INTERNAL MEDICINE
Paul H. Ringer, .\.B , M.D., Editor
.■\shfvillc, N. C.
Why is .Age More Prone to Cancer? .-
Cancer is usually considered a surgical con-
dition but it is a matter of such importance
that every internist should i)e interested in
it.
In the American Journal oj the Medical
Sciences for .April, 1929, Dr. James Ewing of
New York has a fascinating paper entitled,
'•The Relation of Cancer to Old Age." The
first part of this paper is primarily statistical.
.As a result of these investigations Ur. Ewing
remarks: "The foregoing studies seem quite
adequate to show these main facts: first, that
the greatest incidence of cancer occurs shortly
after middle life; second, that there is an in-
creasing liability to cancer practically up to
the end of life; and third, that the liability
to cancer has increased greatly in the last
two decades. However, the real medical sig-
nificance of these facts remains entirely un-
explained. One may accept the economic im-
portance of statistical facts presented without
admitting that they prove any essential con-
nection of cancer with senility. Automobile
accidents, multiplication of grandchildren,
and accumulation of wealth all belong espe-
cially to old persons, but they have nothing
to do with the process of senescence."
Dr. Ewing considers factors found in the
aged which may have some influence on the
development of cancer and lays stress on
three:
1. -Atrophy of the parenchyma of organs,
often attended with deposit of pigment.
2. Replacement fibrosis.
3. Arteriosclerosis.
He mentions that "all these changes tend
to produce lowered functional and metabolic
activity." He continues: "It is at once evi-
dent that none of these conditions, briefly
enumerated, give any direct clue to the origin
of cancers * * * however, one general factor
common to all the above states may be rec-
ognized as of importance. Thiersch conceiv-
ed that in the tissue atrophy of old age the
connective tissues offer less resistance to the
better surviving epithelial tissue, so that ab-
normal epithelial proliferation occurs more
rcad.ly. This theory assumes that there is
more atrophy of connective than of epithelial
tissue, and it fails to account for the atypical
character of the proliferation, but it has gen-
erally been accorded considerable import-
ance. "
Dr. Ewing cannot find any report of a
study of a large number of cases of cancer
in old people with the object of determining
to what degree that cancer was the result of
age. He feels that "during senile atrophy of
t.ssues and organs it seems to be a princi[)Ie
of importance that isolated cell groups, glancj
354
SOUtHEftN MEDICINE AND StRGERV
May, 1939
acini, lobules and probably tissue rests, escape
atrophy and find conditions of growth more
favorable."
He also feels that "the main factor which
accounts for the h'gh incidence of cancer in
the aged is the lapse of time, which permits
liie natural termination in cancer, of processes
which have their inception in adult life, or
in youth, in infancy, or even in utero."
A few more sentences will reveal Dr. Ew-
ing's position clearly.
"Arteriosclerosis probably plays an import-
ant role in the development of many cancers
in the aged, but it is by no means a constant
factor, and its exact significance has never
been determined."
"Probably the majority of cancers occurring
at advanced age periods show exactly the
same etiologic factors and clinical course as
those occurring in adult and middle life, and
their separation as a specific group is unwar-
ranted."
"For the same reasons, cancer in the aged
must hz regarded as always pathologic and
not as an essential phase of the process of
senescence. Senility merely acts in preparing
th? soil and rendering the tissue more sus-
ceptible to the action of the usual exciting
factors, the presence of which is almost as
essential as in earlier periods of life."
This article is masterly in its keen analysis
and philosophical conception. The editor
recommends it unreservedly to all who wish
forty minutes of thoughtful reading of the
opinions of one of our country's great path-
ologists.
"Cardi.ac Pain" Rather Than "Angina
Pectoris"
In the American Heart Journal for April,
1929, Dr. Robert L. Levy of New York has
a most interesting contribution on "Cardiac
Pain — A Consideration of Its Nosology and
Clinical Associations." Well conceived and
written in an easy style, it has about it a
historical flavor: William Heberden's
"Some .'Account of a Disorder of the Breast,"
written in 1768, is freely quoted, as is a let-
ter written by Edward Jenner in 1799; most
interesting is a long letter from Sir Clifford
Allbutt written to Dr. Levy in 1924 in an-
swer to a request for his opinion as to cardiac
pain.
Dr. Levy is in favor of discarding the term,
angina pectoris, and of substituting for it
cardiac pain. He says: "Those desirous of
retaining the term angina, stoutly maintain
that it denotes a sharply defined clinical pic-
ture, distinguishable from its imitators. So,
in contradistinction to true, primary, or major
angina, they have described false or pseudo-
angina, secondary angina, minor angina, the
mock anginas, hysterical angina, angina vas-
omotoria, tobacco angina, and finally, angina
sine dolore. Truly an imposing array of im-
postors I Differential diagnosis in many med-
ical conditions may be difficult; yet we do
not speak of false appendicitis ("Pseudo-Ap-
pendicitis" has appeared on the program of a
Section of the American college of Surgeons,
meeting in Charlotte; also on the program
of the Medical Society of the State of North
Carolina (1922), where it was discussed as
to etiology, symptoms, diagnosis and treat-
ment.— Editor S. M. & S.l\, because other
disturbances in the abdomen miy simulate
inflammation of the appendix. Our efforts
are directed toward describing and correlating
symptoms, signs, and anatomical states in
order to become familiar with a train of
events which we then call a disease. In this
concept of disease is implied disorder of both
function and structure."
Dr. Levy gives an excellent classification of
the conditions that will cause cardiac pain
and after citing one strikingly interesting
case, and making remarks on prognosis and
treatment, concludes with the following sum-
mary :
"The 'disorder of the breast' describ:d by
Heberden in the light of increasing experi-
ence, has proved to be the symptomatic mani-
festation of many pathological states. Per-
petuation of the name originally given to the
condition, and the concept of angina as a
clinical entity, has resulted in confusion and
disagreement as to its precise meaning. It
is, therefore, suggested that the term 'angina
pectoris' be abandoned. Correlation of clini-
cal and pathological data has demonstrated
that cardiac pain may be associated with a
variety of structural and functional changes.
Pain resulting from disturbances in the re-
gion of the heart is best described as cardiac
pain. In making a complete cardiac diagno-
sis, this should be qualified by a statement
as to the probable structural and functional
changes with which the pain is associated.
Further knowledge concerning the mechanism
of pain production may point the way to a
more precise terminology. The conception of
May, 1929
SOUTHERN MEDICINE AND SURGERY
3SS
pain as a symptom will make for better diag-
nosis, for rational therapy, and for more ac-
curate prognosis."
ORTHOPEDIC SURGERY
For litis
ue, ArsTiN T. Muore, M.D.,
Columbia, S. C.
The Use and Abuse of Prolonged
Immobilization
The orthopedic surgeon necessarily comes
in contact with a great many "bad result"
cases. By no means all bad results are due
to negligence or lack of skill on the part of
the attending physician. Particularly is this
true in regard to fractures. IMany patients
are not co-operative. Either through igno-
rance or failure to appreciate the dangers en-
tailed, they neglect to follow through the
after-care as instructed. Many do not return
for redress'ng, physiotherapy, etc., because
of the fact that they feel they are financially
unable to pay for the visits. Some have an
idea that all that is necessary, after the frac-
ture has been reduced, is to keep the splints
on from four to eight weeks or more, and
everything will be all right. It is just for
such reasons as this that each physician at-
tending a fracture case should be particularly
careful to warn the patient that if a cast or
splint is kept on continuously for a number
of weeks, everything will not be all right in
the majority of cases.
Because plaster-of-Paris bandages can be
easily made and kept, and practically any
type of simple fracture can be handled by a
plaster cast, this means of treatment is very
commonly used: but, because of the difi'iculty
of bivalving a plaster cast, frequently it is
left on until ample time has elapsed for bony
union to become perfectly solid and no fur-
ther support is felt necessary. This treatment
may frequently lead to unsatisfactory results
and normal function may be delayed for a
long time, or never return. Even if there is
perfect anatomical reposition of fragments
and x-rays can scarcely demonstrate the site
of fracture, if the patient cannot use the part
just as before the accident, he is, as a rule,
dissatisfied, and may institute legal proceed-
ings.
There are a few cardinal points in the
treatment of fractures that can be carried
out almost anywhere the observance of wh'ch
will lead to better end results. First among
these is the full understanding on the part
of both physician and patient that when the
fracture is reduced the treatment has just
begun. An axiom it would be well for all
physicians to remember is that a properly
reduced fracture becomes increasingly more
comfortable. If swelling increases, or pain
persists and grows worse after retentive ap-
paratus is applied, it is a sign that something
is wrong. That patient should never be given
anodynes or opiates and allowed to go along
until the acute period is over. .\n x-ray pic-
ture should be made, if this has not been
done already, to assure that the fragments
have been properly reduced, the part should
be elevated high enough to reduce the swell-
ing, or the dressing should be completely
removed to determine if there is any obstruc-
tion to the normal circulation. There are two
ways in which the circulation can be imped-
ed— one by internal, tht other by external,
pressure.
The bones having only a certain limited
space about them, if fractured and badly mis-
placed, encroach upon this space and cause
venous and lymphatic stasis which produces
the swelling; or perhaps blood infiltration
from hemorrhage will produce the internal
pressure.
External pressure is produced by a con-
stricting cast or bandages too tightly applied.
.\ splendid illustration of this is seen in fore-
arm fractures. Over the dorsal and ventral
surface of the forearm just above ih? wrist
there is a large plexus of veins that can read-
ily be seen when the arm is hanging by one's
side, or when a constriction is placed about
it. To shut off both of these venous plexuses
would necessarily produce a great deal of
swelling, and one of the best ways to do this
is by using splints with a pad over the upper
fragment on one side, and the lower fragment
on the other. Pads such as these are usually
superlluous, as there is no particular muscle
pull to displace a properly reduced fracture
in th's region. In treating ordinary Colles'
fractures probably more uniform good results
would be obtained if we would disregard the
fracture after it has been reduced and treat
the function of the hand and wrist. What
good are the arm and the forearm if the hand
is useless? The chief function of the arm
and forearm is to place the har.d where it
can be used.
Frequently the orthopedic surgeon is called
on to treat the hand with all its fingers com-
SOUTHERN MEDICINE AND SURGERY
May, 1929
pletely extended and only a few degrees of
motion possible in any of the joints, and this
very painful. Often the thumb and forefinger
will not meet, so he is unable to pick up even
very light objects. X-rays show diminution
of joint spaces with absorption of lime salts
about the joints. Inquiry into the patient's
history reveals that he has had a fracture, or
infection, or tendon laceration of some part
of the forearm. The injured limb had been
placed on a straight splint extending to the
finger tips and allowed to remain there six
or eight weeks. Sometimes such hands can
be completely restored, sometimes they are
irremediable. What causes this? Prolonged
immobilization and swelling throwing an ex-
udate into all of the soft tissues about the
joints and into the joints, producing an ag-
glutination and adhesion of joint surfaces, —
wh'ch might have been prevented by eleva-
tion, removal of constricting dressings or by
wet compresses.
.Another distressing condition, which may
develop in a few hours from tight bandages
and never be cured, is Volkmann's ischemic
paralysis.
Following fractures of the leg a frequent
d'sability is pain in the ankle joint and in-
ability to dorsiflex the foot. In a large num-
ber of cases the foot is put up in its usual
relaxed position, — plantar-flexion — the tendo
.^chillis contracts and the space between the
head of the astragalus and tibia is filled. Wry
often the astragalus is not perfectly reduced
in Pott's fractures and a chronic foot strain
results. Simply turning the foot into varus
will not replace the astragalus directly under
the center of the tibia: for this motion is in
the subastragalar joint. In Pott's fractures
the misplaced astragalus and early mobility
demand the most attention. Then the frac-
ture will take care of itself.
Frequently knees, hips, shoulders or elbows
are more or less permanently stiffened after
prolonged fixation dressings. Non-union of
bone sometimes results after prolonged im-
mobilization. There is a stagnation of the
circulation, and atrophy of all of the soft
parts. The bone suffers the same change.
One should, as a rule, reduce a fracture
as early as possible. The longer one waits,
the more difficult does swelling and muscle
spasm make the reduction. Swelling alone
does not militate against reduction. The idea
of waiting for swelling to subside has largely
been discarded. One of the best ways to re-
duce swellmg is to secure a perfect reduction
of bony fragments.
All fractures should be seen from four to
six hours after reduction and again the next
day. Burning pain over bony prominences
should suggest pressure sore. The pain may
subside in a few hours but on removal of
the splint a deep, well developed pressure
sore is found. Practically all fractured ex-
tremities should be elevated for forty-eight
houis or more to prevent swelling. In most
cases some form of physiotherapy can be be-
gun in a few days after reduction. If the
dressing is a plaster cast, this can be bi-
valved. Usually this is better accomplished
at the time the cast is applied when the plas-
ter has just begun to set and can be cut
easily. The upper portion of the plaster is
later removed, the parts baked and gently
massaged. If the splint is of metal or board,
the bandages can be removed and the baking
and massage carried on while the part rests
on the splint. It is surprising how quickly
the swollen, indurated, congested soft tissue
will subside under this treatment and how
comforting it is to the patient. This is con-
tinued every few days, and soon the parts
can be removed from the splint, the frag-
ments held supported by the hand while mo-
t'on in the joints is begun. The so-called
"relaxed motion" should be used at first, i. e.,
while all of the muscles are relaxed, the joints
are passively flexed and extended very gently
and only up to the point of pain.
As soon as the slightest union has begun
to occur, active motion should be started. The
active motion is internal massage. It not
only keeps up the tone and strength of the
muscles, but stimulates the circulation so that
swelling and stiffness subside and bony union
takes place more rapidly than if the part is
kept immobilized for a long time. In the
treatment of a great many fractures, by the
time the cast or splint is removed, the func-
tional use of the part should be back to nor-
mal except for diminished muscular strength.
To cut down the long period of disability
after splints have been removed is of tremen-
dous value. The patient can return to his
occupation sooner and a great deal of time
and money is saved. An elaborate array of
equipment is ideal, though not absolutely
necessary. If infrared heat lamps, diathermy,
etc., and the services of an expert masseur
May, 1929
SOUTHERN MEDICINE AND SURGERY
357
are not available, a basin of hot soapy water,
and cocoanut oil for massage will enormously
add to the likelihood of a satisfactory end
result. Heat, before the massage, can be had
from an\- common heat source.
If the attending physician is willing to give
a little more of his time and the patient is
an.xious to co-operate in every way, the per-
centage of good results in fractures, or other
cases that require splinting, can be definitely
increased.
DENTISTRY
W. M. RoBEV. D.D.S., Editor
Charlotte, N. C.
Vincent's Infection
A typical acute infection of this type in
the mouth can be compared with a conflagra-
tion in a crowded wooden cabin district of a
city. Its action is rapid, it is stubborn, and
the whole human being is endangered. Pe-
riodically a discussion of the diagnosis and
treatment appears in the journals, all prac-
tically agree that Vincent 's fusiform — a ba-
cillus parasitic and saphrophytic organism,
accompanied by the sp'rillum, and with the
local lesions and symptoms, make a diagno-
sis rather simple and certain.
The treatment has more variety; from
iodine, silver nitrate, etc., to 7 per cent chro-
mic acid and arsphenamine, accompanied by
alkaline and oxidizing mouth washes such as
peroxide of hydrogen and sodium perborate.
The appearance of the disease seems more
frequent each year, partially due, perhaps, to
the fact that it is more often recognized than
formerly. The dread of the laity has also
been aroused so that a sore mouth sends them
to the dentist, with a whispered question.
All cases of sore mouth are not Vincent's
infection, but a swollen congested gum pain-
ful to the touch, even without the characteris-
tic odor, in the mouths of young people, may
be suspected as an incipient case.
.\ laboratory report of the finding of
spirochetes and fusiform bacilli, without local
symptoms, does not indicate a case of Vin-
cent's infection, as these organisms are fre-
quently found in the adult mouth.
The severity of the lesion varies from a
slight gingivitis at a gum margin to the in-
volvement of the soft tissues of the throat,
and the bones of the jaws. Recently my at-
tention was called to a case in which the thy-
roid was infected.
The activity of the infection may be very
rapid or it may be very slow and become
chronic. No doubt many cases of pyorrhea
of long standing are chronic Vincent's.
These usually have little recession of the
gums, deep pockets, very extensive loss of
the alveolar bone and little or no visible pus,
with frequent flareups of acute pains in the
gums, little swelling and the characteristic
odor of spoiled meat.
The treatment of its incipiency is so sim-
ple that the home ministrations of the patient
relieve it. Vincent's spirilla and fusiform
bacilli are of the anerobic variety. There-
fore the logical treatment is to supply them
with oxygen by applying some oxidizing agent.
In incipient cases a mouth wash of peroxide
of hydrogen, several times a day will often
be sufficient. It is safe and cheap. Perborate
of soda in powder or solution is probably
better as an oxid'zing agent, and is safe in
the hands of the patient, but it is not kept in
every store. Hexylresorcinol solution, ST 37,
is being used with success by bath dentists
and throat men, but in my hands it has been
no more satisfactory than peroxide or perbo-
rate of soda.
In add tion to the home treatment by the
patient with mouth washes, as the lesions
become deeper and more inaccessible, it is
necessary to reach them directly with more
powerful agents as 3 to 7 per cent chromic
acid. Chromic is probably the most used,
by dentists and physicians, of these agents
for direct application to lesions in mouth and
throat. It is much better for both patient
and doctor that chromic acid be not swal-
lowed.
In severe cases with inaccessible lesions, in-
volving deep pockets, the throat or glands, in
addition to the local oxidizing treatment, a
shot of arsphenamine with the usual precau-
t'ons, will usually bring comfort and happi-
ness to both patient and doctor.
The treatment of X'incent's is complete
when the germ is no longer active. If your
house catches on fire, a little fire left in the
basement will jirobably cause it to burn down
after the main conflagration has been extin-
guished.
It is said Ihit Thomas Kdison said, that
we know only one millionth of (inc per cent
of anything. If we jiractice only what we
know our service will i)e small.
SOUTHERN MEDICINE AND SURGERY
May, 1929
EYE, EAR. NOSE AND THROAT
ITS GENERAL MEDICAL VALUE
For this issue, V. K. Hart, M.D.
Peroral Endoscopy
Much publicity has been given foreign
bodies in the air and food passages because
of their somewhat spectacular removal endo-
scopically. Endoscopy has a much bigger
field not fully appreciated or properly evalu-
ated by the profession as a whole. One has
only to visit the clinic of Chevalier Jackson
to appreciate that removal of foreign bodies
is a very small part of the field of usefulness
of th's measure.
Lung suppurations should always be inves-
tigated through the endoscope, at least ini-
tially. Is there a well defined localized ab-
scess? If so, in which lobe? If not, is there
a diffuse tracheo-bronchial suppuration? Is
there a bronchiectasis? The bronchoscope
answers these questions quickly, efficiently,
sometimes more accurately than the x-ray
and with no harm to the patient. In very
few instances is its use contraindicated. Fur-
thermore, specimens of bronchial secretions
are easily aspirated for bacteriologic study.
In the bronchial type of suppuration follow-
ing influenza, or abscesses of whatever cause
not too peripherally located, systematic,
repeated bronchoscopic aspiration with instil-
lation of proper medicaments brings about
many cures.
Careful co-operation between the broncho-
scopist and the surgeon is of the utmost im-
portance. Many lung suppurations ultimate-
ly go to operation. Conversely, many lung
abscesses are now cured without an open
operation.
Consider the infectious type of asthma,
not the allergic, which has defied ordinary
methods of treatment. Occasional broncho-
scopy with or without the instillation of oils,
is often a great boon to the sufferer. Auto-
genous vaccines made from spec'mens aspir-
ated directly from the bronchi into a sterile
specimen collector are more efficacious than
those made fnnii sputums collected in the
usual manner.
The astute clinician fmds an unexplained
bronchial obstruction. There is no hstory
of foreign body. Bronchoscopy often answers
the question. Primary carcinoma of the lung
is a clinical entity, as are other benign tu-
mors. Broncholiths occur. Removal of tis-
sue for pathologic examination endoscopically
is always possible. Even apparently success-
ful removal of new growths has been accom-
plished.
Likewise the esophagoscope has been a very
useful aid in diagnosis and treatment of eso-
phageal lesions. The diagnosis of carcinoma,
or other growths, and dilatation of strictures
by the esophagoscope are well known to med-
ical men. However, Jackson makes a strong
appeal for esophagoscopic aid in unexplained
hcmatcmesis. He emphasizes four esophageal
conditions which may give rise to bleeding
which are often overlooked: 1. Simple esopha-
g!tis. 2. Peptic ulcer. (Often this will not show
on x-ray.) 3. Gumma. 4. Esophageal vari-
cosity. Ruptured varicose vein may give very
free bleeding. The causes of these esopha-
geal varicosities is not pertinent here.
In the above conditions, the esophagoscope
will quickly explain the cause and possibly
save the patient an unnecessary operation.
The same obtains as with the bronchoscope:
in skilled hands the risk is nil and general
anesthesia unnecessary.
NEUROLOGY
Oi.iN B. Chamberlain, B.A., M.D., Editor
Charleston, S. C.
Neurology Set on Its Feet
Modern neurology owes its beginnings to
a rather bizarre figure. Duchenne of Bou-
logne came to Paris in 1842 an unknown,
unheralded country practitioner. He had no
letters of introduction; he had no stamp of
university approval. For several years he
had been tremendously interested in the ap-
plication of electrical currents to the body.
He wished for more material for his experi-
ments. And so, as Keith says, "he set out
for Paris carrying with him his beloved bat-
tery, the key of which was to unlock for him
the door of fame." Duchenne offers an ex-
ample of an unusual type of investigator. It
is quite apparent to anyone familiar with
medical privileges and prejudices that his
road was beset with various difficulties. Re-
garded by many as an impertinent interlofjer,
he haunted the large Parisian hospitals, delv-
ing into case histories, questioning patients
and begging permission to use his battery
box. His urge for discovery and investiga-
t on and his distaste for the commercial ex-
ploitation of medical science are shown by
his contemptuous refusal to explore the field
opened by his electrical reactions. The man-
May, 1929
SOUTHERN MEDICINE AND SURGERY
3S9
ner in which Duchenne overcame the preju-
dices of hospital staff physicians, surgeons,
residents and students indicates the tremen-
dous earnestness and perseverance of the
man. It was in direct opposition to their
experience of human behavior to think that
a country practitioner could come to Paris
with no ulterior or commercial purpose,
driven only by the spur of scientific curios-
ity. As Keith puts it, "patience, persever-
ance, tact and good humor ultimately car-
ried the day, and allayed the jealousies
aroused by his presence in hospital wards.
Awkward situations did arise: questions re-
lating to priority did crop up, and Duchenne
was never slow to defend his own. It was
under these circumstances that Duchenne
carried out his investigations in Paris from
1842 until his death in 1875 in his sixty-
ninth year.
What d'd Duchenne do for neurology?
Collins remarks that "he found neurology a
sprawling infant of unknown parentage which
he succoured to a lusty youth." Garrison,
after paying tribute to Duchenne's general
contributions to neurological diagnosis, says,
"But his great field was the spinal cord. In
1840 von Heine had described infantile pa-
ralysis as a spinal lesion, but it was usually
regarded as an atrophic myasthenia from in-
activity. Duchenne pointed out that such a
profound disorder of the locomotor system
cjuld only come from a definite lesion which
he located in the anterior horns of the spinal
cord. He also describes anterior poliomye-
I'tis of the adult as due to atrophic lesions
of the ganglion cells of the anterior horns,
and his name is permanently connected with
spinal progressive muscular atrophy of the
.Aran-Duchenne type." Duchenne described
bulbous paralysis, which is known by his
name, as is also the pseudo-hypertrophic
form of muscular paralysis. While he was
possibly not the first to describe locomotor
ataxia as a clinical entity, his accurate and
clear analysis of the disease illuminated the
subject.
"Here, then," to revert to Keith, ''in
Duchenne of Boulogne, we have one of the
most remarkable figures which have ever ap-
peared on the medical stage. His contempo-
rar cs were too clo.se to him to realize (hat
th's missionary for science who appeared be-
fore them in the garb of a rustic country
physician, and made his modest bow with a
battery of his own design under his arm, was
playing a greater part in the drama of medi-
cine than the star actors who kept themselves
in the center of the stage and in the full
limelight. It was given to him, as is given
to few men, to discover a key which would
open the door to a new field of knowledge.
He used that key, not for his personal ag-
grandisement but for the enrichment of medi-
cal knowledge. He had what the real inves-
tigator needs, patience and perseverance."
It would be pleasant to be able to report
that in the latter part of his life his authority
was recognized and men looked up to him
and called him "master." Truth demands the
depressing fact that "he died forgotten and
unhonored, except by a corixjraFs guard of
old friends at his grave." His death was
scarcely noted in the medical journals of the
dav.
PUBLIC HEALTH
For this issue. Ernest .\. Br.wcii. D.D.S.
RaleiRh, N. C.
Director Oral Hygiene, N. C. State Board of Health
Keeping the Gate
At first glance it might seem of local in-
terest only, when the father brought a two
and one-half-year-old child to the dentist to
have his teeth extracted because he "bit his
ma." This mother had not weaned the child
and of course the child's appetite was not
being satisfied from the breast and in its hunt
for satisfaction the child bith the mother.
This is just another opportunity for dental
health education. Realizing the great need
of information on this subject, the dental
profession is awakening to find the mothers
and children anxious for light on dental con-
ditions and the profession is taking advan-
tage of this desire by supplying through, their
iNIouth Hygiene Committees and the Dental
Department of the State Board of Health lec-
tures illustrated by lantern slides, plaster
models and chalk drawings. By th's means
of visual education, dental truths are finding
lodgment in fertile soil. Since the mouth is
the gateway of the body it is essential that
we keep it clean.
NOT THE KEEPER OF THE G.-\TE
".•\s I said, you've just regained consciousness after
the crash. My name is Peter — Dr. Henry Peter."
"What a fright you gave me ! I thought you were
the Saint."
J60
SOUTHERN MEDICINE AN6 SURGERY
May, I'll
PEDIATRICS
Frank Howard Richardson, M.D., Editor
Black Mountain, N. C.
The Tonsils and Heart Disease
Two very interesting and instructive papers
are abstracted in the hitcrnattonal Medical
Digest for February. They are: "Heart
Disease in Children," and "Tonsillectomy in
Its Relation to the Prevention of Rheumatic
Heart Disease," by Wilson, Lingg and Crox-
ford, appearing in the American Heart Jour-
nal of December, 1928.
The first concern the natural history of
rheumatic fever in its relation to heart dis-
ease. Observations on five hundred children
show that rheumatic infection is the common-
est cause. Rheumatic infection in children
is a general infection, esf)ecially common be-
tween the ages of si.x and nine: it shows pe-
riods of activity, most frequent during the
three years after onset, with diminishing
number of recurrences, what seems almost an
immunity developing after twelve. Especial-
ly predisposed are two age levels, — below
three, and 11 to 14 — as indicated by mortality
rate and activity of the disease. Growing
and joint pains, polyarthritis, chorea, nodules
and acute arthritis were the symptoms stress-
ed.
It seems to these observers that rheumatic
infection in children is a general infection,
with the heart the first and main seat of in-
fection, whether this is clinically demonstra-
ble at the time, or not. The degree of this
involvement seems closely related to the num-
ber of attacks. The commonest age of death
found was between 11 and 14 years.
Their main conclusion is that the preven-
tion of heart disease means the prevention of
rheumatic infection.
In the light of this quite definitely proved
conclusion, their second paper is especially
timely; for tonsillectomy is frequently urged,
and performed, with this prevention very
definitely in mind. These authors point out
that, while the frequent occurrence of tonsil-
litis and sore throat in children subject to
rheumatic infections has suggested an inti-
mate causal relationship, these complaints are
undoubtedly very common, and in the great
majority of instances are not followed by
rheumatic manifestations. A review of the
literature is still inconclusive as to just how
much tonsillectomy does in the way of pre-
vention of rheumatism,
It is a very suggestive fact, as they note,
that there is a diminished susceptibility that
commences around ten years, — and that in
children in whom the operation is performed
at this time (a very common age for tonsil-
lectomy) the age may be the cause of im-
provement, rather than the operation! A
study of cases showed that as the age of
operation increases, the likelihood of recur-
rence decreases, — exactly what happens w'th
the unoperated.
The conclusions are of such interest to
those who are constantly being called upon
to consider the advisability of operation in
individual instances, that they are quoted
here verbatim from Dr. Robert Strong's re-
sume of the paper:
1. As the age increases, the average num-
ber of attacks of infection a ch'ld may an-
ticipate decreases. At nine years, the average
child will have suffered as many attacks as
it will experience in subsequent years.
2. This is true whether a child has or has
not been operated upon. The curves for the
two groups are almost parallel. In both
groups the incidence of infection increases
with age.
3. Although the curves for the two groups
are approximately parallel, those representing
the untreated children are at almost every
point lower than those representing the treat-
ed group [italics ours|! That is to say, at
each age the untreated children experienced
fewer infections than did those that were
treated. One may assume from these figures
that the untreated children were less suscep-
tible to recurrent attacks of infection and
that perhaps for this reason they were not
subjected to tonsillectomy — a therapeutic
measure often applied, especially to cases of
severe and recurrent infection, in the absence
of knowledge of more certain therapy. On
the basis of this assumption the untreated
children in this series do not constitute a
perfect control group.
4. Excision of the tonsils seems to have
no effect on the recurrence of rheumatic fe-
ver.
The results, as judged by the occurrence
and recurrence of manifestations of infection
after operation, do not indicate that tonsil-
lectomy is to be advised as a routine thera-
peutic measure for the prevention of heart
disease in children. To expect tonsillectomy
to prevent the occurrence of rheumatic heart
May, 1929 SOUTHERN MEDICINE AND SURGERY
disease does not seem justified in the light
of present insuiTicient knowledge of this dis-
ease fend of quotation 1.
\\'h'le this does not affect us in advising
tonsillectomy for certain obvious effects, it
certainly does cut away the ground from one
of the big "selling points" that we have so
frequently employed in urging this operation.
When more of such unbiased studies and im-
partial reports are available, the status of the
operation may, it is hoped, emerge from its
present controversial state.
TREATING INGROWING NAILS
Prophylaxis consists in pood shoes and stockinRs from birth. Relief maN"! be obtained from
the milder varieties of inprovvins nail by purchasing longer shoes with a high soft cap, straight
last, broad toe and low heel. In addition to this the best treatment for many of these nails is a
thinning of the entire body of the nail by a small emery wheel such as is used in the offices of
many chiropodists. This makes the keystone of the nail arch soft and flexible and prevents exces-
sive pressure on the nail groove and also promotes outflaring of the sides of the nail.
The edge of the nail may be lifted by inserting cotton beneath it with the flat end of a probe.
Foote advises wetting the cotton with 1:50 silver nitrate solution. Crane advocates dentist's base
plate gutta pcrcha which he says possesses decided advantage over cotton. A small triangulan
piece is cut and heated in the flame and then inserted beneath the edge of the nail. It molds itself
to the shape of the nail and may be left until the nail grows in the correct direction.
For temporar,' relief, in an emergency, when much walking is necessary, a quarter-inch strip
may be split up the entire side of the nail with sharp pointed scissors and the lateral piece pulled,
out or the offending corner only cut away. This is usually poor treatment, as the pain and pres-
sure will quickly recur as the nail again advances.
Radical treatment consists of removal of the side of the nail and the corresponding matrix by
operation. This may, be done under nitrous oxide anesthesia or by novocaine block. An elastic
band is tightly drawn about the base of the toe to ensure perfect hemostasis. A vertical incision
is then made about -Ig inch from the laterafl edge of the nail and parallel to the nail groove. This
commences about '4 inch below the joint surface, at the root of the nail, and is carried down to
the bone by a single sweep of the knife, terminating at the tip of the toe and the free edge of the
nail. Next the blade of the knife is inserted into the incision down to the bone and a lateral
twisting motion carries the cutting edge laterally outward between the matrix and the bone, turn-
ing the matrix and the soft parts upward upon a hinge. Then the* tip of the matriic is grasped
V ith a mouse-tooth forceps and, with the point of the knife, is carefully dissected upward and
outward, cutting it away from the bone and soft parts, but taking a thin layer of the cutis with
the matrix, especially at the upper end near the root because at that point the nail grows from
(ells "above and below."
No sutures are used. The flap of skin is carefully held up in place against the cut edge of
the matrix and nail by a bandage, whfch is applied firmly but not too tightly, before the elastia
band is removed.
The dressing should be changed in a day or two after thorough soaking in an antiseptic solu-
tion and great care should be used not to tear the flap loose. Later a shoe with the cap cut away
is worn and, finally, when healing has taken place (from one to three weeks, depending upon the
amount of infection present) the patient is fitted with loose stockings and a long shoe with broad
toe, high cap, low heel and straight inner line.
Grah-^m in Amcncan Journal of Surgery.
[adv.]
por sale 200,000 volt kelley koett deef therapy
and rauiooraphic outfit complete, including
Acme air cooled cylinder, tube and adiustabe
COUCH. HAS SEEN VERY LITTLE USE. /nSTALIATION
and guarantee by factory distributor, cost FORTY-
FIVE HUNDRED. WILL SELL FOR TWENTY-FIVE HUN-
DRED.— Address "SK," care of Southern Med. & Surg.,
Charlotte, N. C.
SOUTHERN MEDICINE AND SURGERY
May, 1929
ON THE SUBJECT OF THE TOXICITY
OF IRRADIATED ERGOSTEROL
(From H. Simonnet & G. Tanret, in La Presse
Medicate, Paris, April 10th)
Translated and Abstracted By
E. K. McLean, M.D., Charlotte, N. C.
Ashe-Faison Children's Clinic & Hospital
A certain number of experiments and clini-
cal observations have recently called atten-
tion to the general disturbances and changes
in the metabolism of calcium by the use of
large doses of irradiated ergosterol.
Pfannenstiel and Kreitmair and Moll were
among the first to make experiments on ani-
mals with irradiated ergosterol; the first us-
ing rabbits and the others m'ce. They have
shown that daily doses of irradiated ergos-
terol have produced grave disturbances fol-
lowed by death in a few days. The lethal
dose for rabbits per day was 4 mgms., and
for mice 2 mgms. In the latter, toxic symp-
toms were produced by .5 mgms. Kreitmair
and Moll also obtained similar results with
rats, guinea pigs, dogs and cats. Death oc-
curred after a period of severe diarrhea. Au-
topsy showed heavy layers of calcium in most
of the tissues, particularly the blood vessels,
muscles, lungs, kidneys and suprarenals. The
spleen showed considerable atrophy. Calci-
fication was most marked in the cat and rat,
less so in the mouse, dog and rabbit. Guinea
pigs showed least changjs of all. Dixon and
Heyle, on the other hand, d!d not get these
results in young rats getting daily doses of
from 11 to 17 mgms. of irradiated ergosterol.
These animals developed normally. On au-
topsy they only found phosphate of I'me cal-
culi in the urinary system. They further
state that calculi are frequently found in nor-
mal rats. Harris and Moore have found that
the administration of irradiated ergosterol in
large doses arrests the growth and causes
death in young rats.
The administration of non-irradiated ergos-
terol did not produce any symotoms. Thev
state that the administration of an excess of
vitani'ne B prevents untoward syniDtoms oro-
duced by giving irrad'ated ergosterol. The
authors did not observe calcification. These
experimenters used ergosterol frcm d'fferent
sources and irradiated under varying condi-
tions.
Heilbrom and his associates have shown
that spectral absorption changes take place
when ergosterol is being irradiated, there be-
ing phases of activation and deactivation.
Prolonged irradiation produces an inactive
product. As the pwtency of ergosterol varies
with the quality of the oil used and the length
of time it has been irradiated Simonnet and
Tanret experimented with an oil of known
purity, irradiated for 30 minutes, which ex-
posure gave the greatest absorption of rays
with the minimum amount of attenuation.
The preparation was active on the rat at
1/1000 of a milligram. The irradiated er-
gosterol was dissolved in cocoa butter and
this was placed in tubes, each tube containing
sufficient ergosterol for a daily dose. The
mice used in the experiment were given the
cocoa butter apart from their food in order ,
to insure complete ingestion of the dose.
Twenty male mice were separated into four
groups of five each. The first group was
given a daily dose of four drops of melted
butter containing 5 of irradiated ergosterol;
the second 2.5; the third 1; and the fourth
.5 mgms. The fifth group of four mice were
given a daily dose of 5 mgms. of non-irra-
d'ated ergosterol in four drops of cocoa but-
ter. In addition a group of four mice was
given four drops of plain cocoa butter each.
At the end of four weeks 1 animal had d'ed
on the 2nd and 6th day from groups 1 and
2, receiving, respectively, 5 and 2.5 mgms.
They showed a loss of from 2 to ,S grams in
weight and the autopsies showed nothing of
interest. The remaining 26 animals showed
no notable changes in their weight or behav-
ior. Their average weight at the beginning
of the experiments was between 24 and 26
grams and at the end 28 to 30 grams.
The autopsies on those that were killed
showed no macroscopic changes. In the
roentgenograms of these receiving the large
and the small doses they were unable to dis-
cern any difference in calcification. A second
series of experiments of the same duration
and using the same methods as in the first,
with ergosterol irradiated for 6 hours, was
May, 1929
SOttHERN MEDICINE AND SURGERY
36J
carried out. In this case eight mice were
used, divided into two groups. The first
group of five mice were given 5 mgms. of
irradiated ergosterol. The second group of
three were given 5 mgms. of non-irradiated
ergosterol. Those in the second group all
survived. Of the five given the irradiated
ergosterol two died within 13 days and show-
ed a loss of weight of 6 and 9 grams. On
autopsy there was evident congestion of the
gastro-intestinal canal. The surviving three
were apparently normal.
As a result of these experiments the au-
thors conclude that so far as mice are con-
cerned, when given a product irradiated for
the minimal time that will produce a sterol
of maximum antirachitic potency no toxic
effects were observed in amounts of from 500
to 5,000 times the active dose.
But with a product irradiated for a long
time in which the spectral absorption is push-
ed to the limit without any marked increase
in its antirachitic activity we find gastro-in-
testinal disturbances developing which may
end in death.
COMMENT
The results of experiments carried out by
different investigators have been so variable
that it is obvious that a great deal has yet
to be done before the product can be safely
used in general clinical work.
So far there has been no standardization
of the dosage. Its pwtency apparently varies
with the solvent used in its extraction.
American manufacturers put irradiated er-
gosterol on the market some months ago but
several of them withdrew the product as a
result of the experimental work done by Ger-
man investigators.
Hess and Lewis in this country have used
irradiated ergosterol both prophylactically
and therapeutically rather extensively and re-
port excellent results. They state that irra-
diated ergosterol is equally valuable in tetany
as in rickets.
In view of the ease of administration and
its potency irradiated ergosterol should when
standardizefl become a valuable addition to
the therapeutics of rickets.
ADD APPLIED PSVCHOLOGV
("0. J." in Greensboro News)
hi a "Song for a Child Growing Up," F. P. A.
in the New York World's Conning Tower suggests:
The little I. Q.* is covered with dust,
.•\nd Victorian now it seems;
The little neurosis is red with rust.
And the phobia's fled from the dreams.
Time was when the little I. Q. was new,
.And the phobia was fresh and fair,
Kut that was before our Little Boy Blue
Socked them and put them there.
To which we beg leave to append:
"Now you stay there, said Little Boy Blue;
I'm fed up on psycho-analysis,
And I hope in Heaven, where I'm going to,
Psychologists have facial paralysis.
I've got the blues; I've got the blues!
Got 'em from too danged much I. Qs.
.■\11 that I know is, it's hell to have neurosis.
I got the blues! I got the blues!
I got them psychological blues."
'Intelligence Quotient.
COULDN'T WASTE THAT PLATE
.\n old Scottish doctor was a member of a golf
club, Tlie Skeich says. No one knew his age and
the old man made such a secret of it all the mem-
bers were very curious. At last the good old soul
died, and the club members deputed a fellow to at-
tend the funeral, and warned him to be sure and
read the plate on the coffin and note the age. The
next day they gathered around him to hear his re-
port.
"Did you see the plate?"
"Oh, yes."
"What was the age?"
"There wasn't any age. It just said 'Dr. Timothy
McFarlane, Office Hours o to 11 \. M. and 2 to
4 P. M.' " — Boston Transcript.
Dr. John Coaklcy Lettsom, born in West India in
1744 spent the latter part of his life as a highly
popular London doctor. .\ waggish friend wrote the
lines:
"I, John Lettsom,
Purges, bleeds and sweats 'em ;
If after that they still would die,
I, John, lets 'cm."
Real Estate Dealer — .\nd now that we have been
all over our little city that we think so much of what
is \our impression of it?
Prospect — Well, brother, this is the first cemetery
I ever saw with lights — Monroe Enquirer.
"Nurse," said a lovelorn patient, "I'm in love
with you. I don't want to get well."
"Cheer up, you won't," she assured him. "The
doctor's in love with me, too, and he saw you kiss
me this morning." — Colorado Medicine.
Physician reports that women are not so nervous
as they used to be. They're more unruffled, for one
thing. — Arkansas Gazette.
.\hc had shot a man, and was sentenced to be
electrocuted. On the morning of the execution the
w:irden told him how .sorry he was, and how it was
going to cost the state S.iOO to electrocute him.
"Bum bussiness," spoke up .Wn\ "(Jife me only
.5.=;0 and I'll shoot myself !"—r/jc Suit and Cloak
Trade.
^A4
SOtTHERN MEDtClNE AND SURGERY
May, 1929
NEWS
Upon Dr. Albert Compton Broders,
pathologist to the Mayo Clinic, the Medical
College of Virginia will confer the honorary
degree of doctor of science at commencement,
May 28th. Doctor Broders is an alumnus
of the Medical College of V'irginia, Rich-
mond.
Dr. Harry Bear has accepted the dean-
ship of the school of dentistry, Medical Col-
lege of Virginia, Richmond, as of July 1,
1929. Doctor Bear is at present professor
of exodontia and the principles of practice
of that institution. He is also one of the
vice-presidents of the American Dental As-
sociation. He will succeed Dean R. D.
Thornton, who has resigned to return to pri-
vate practice at Toronto, Canada.
The Johnston-Willis Hospital Train-
ing School for Nurses held its graduating
e.xercises May 7th, graduating twenty.
Dr. William Shipp, for many years a res-
ident of Newton, N. C, died suddenly of a
stroke of paralysis at his office at Valdese,
April 17th, while administering medical aid
to one of his patients.
The American Association for the
Study of Allergy will hold its next annual
meeting in Portland, Oregon, Monday and
Tuesday, July 8 and 9, 1929, at the time of
the meeting of the American Medical .-Asso-
ciation. Further information may be obtain-
ed from the Secretary, Dr. Warren T.
Vaughan, Medical Arts Building, Richmond,
Va.
Dr. Wilbur Scoville Awarded Medal
The greatest honor which the profession
of pharmacy can bestow — the Remington
Medal — has been awarded by the .American
Pharmaceutical .Association to Dr. Wilbur L.
Scoville, chief of the analytical department
of Parke, Davis & Co., for "distinguished
service to pharmacy" in acknowledgment of
his outstanding accomplishments as chairman
of the National Formulary Committee.
The Remington Medal, originated by the
New York branch of the Association, is
awarded annually by a committee of awards
consisting of all the past presidents of the
.American Pharmaceutical Association.
Besides being chairman of the present Na-
tional Formulary Committee, Dr. Scoville,
who has been a member of the scientific staff
of Parke, Davis & Co., since 1907, has been
a member of this committee for three pre-
vious revisions of the Formulary. He is also
vice-chairman of the U. S. Pharmacopoeia,
and has been a member of its revision com-
mittee for the 1900 and 1920 editions of the
Pharmacopoeia.
Dr. Scoville is a Fellow of the American
Association for the Advancement of Science,
a life member of the American Pharmaceuti-
cal Association, and a member of the Ameri-
can Chemical Society and of the British So-
ciety of Chemical Industry. He is the au-
thor of "The Art of Compounding," which
is widely used as a reference work at the
prescription counter and as a text book in
colleges of pharmacy. He was for several
years secretary of the American Conference
of Pharmaceutical Faculties, and has been a
chairman of the Scientific Section of the
American Pharmaceutical Association. In
1922, the A. Ph. A., awarded him the Ebert
Prize, a silver medal for the most outstand-
ing article presented at its annual convention.
He holds the following honorary degrees:
Master of Pharmacy (Ph.M.), conferred in
1924 by the Philadelphia College of Phar-
macy; Doctor of Pharmacy (Phar.D.), con-
ferred in 1927 by the Massachusetts College
of Pharmacy, where he received his graduate
pharmacist's degree in 1889; and Master of
Science (M.Scs.), conferred in 1928 by the
University of Michigan.
Eighth District Nurses' Association
The Eighth District of the North Carolina
Nurses' .Association met in Greenville, N. C,
Tuesday afternoon, .April 9th. After a short
business session the meeting was turned over
to Miss Edna McKee, of Greenville, who
presented Miss Lotta Veazey, director of pub-
lic school music, Greenville, who, with the
Boys' High School Glee Club, delighted those
present with two vocal selections.
It was a rare treat to have Dr. Ernest
Branch, Director of Oral Hygiene, State
Board of Health, Raleigh, N. C, give us a
May, 19i9
SOUTHERN MEDtClNE AND StRGERY
iss
very interesting and instructive lantern slide
illustrated lecture on "Development and
Care of the Teeth."
American Pharmaceutical Manufactur-
ers TO Meet at Old Point
The Chamberlin-Vanderbilt Hotel at Old
Point Comfort, \'a., has been selected for the
annual meeting of the American Pharmaceu-
tical Manufacturers" Association to be held
June 3-6.
The meeting this year will take on an in-
ternational aspect, as invitations have been
extended to more than twenty-five leading
Canadian manufacturers to attend and parti-
cipate. Representatives of the British Chem-
ical Manufacturers have also been invited.
The following committees will have charge
of the various sections of the program:
Attendance: Bern B. Grubb, Lafayette
Pharmacal Co.
Business Policy: J. H. Foy, Maltbie Chem-
ical Co.
Contact: C. E. Vanderkleed, Robert Mc-
Neil (including report of Research Board).
National Drug Trade Conference: Harry
Noonan, Drug Products Co.
Distribution Problems: F. A. Mallett,
Standard Chemical Co.
Legislative: C. D. Smith Pharmacal Co.
(including report of Councilor, U. S. Cham-
ber of Commerce).
Meeting: .\nnual — H. B. Johnson, Zem-
mer Co.
Membership: Dr. C. H. Searle, G. D.
Searle & Co.
Memorial: B. L. Maltbie, Altamonte
Springs, Fla.
Prior Rights Board: R. R. Patch, E. L.
Patch Co.
Publicity: F. A. Lawson, E. L. Patch Co.
Research Awards: Dr. A. S. Burdick, .Ab-
bott Laboratories.
Sales Problems: Dr. H. Sheridan Baketel,
Reed & Carnrick.
Standardization and Simplification: R. ^L
Cain, Swan-Myers Co.
Standardization of Glass Containers: C. C.
Doll, Zemmer Co.
Trade Names: R. R. Patch, E. L. Patch
Co.
Speakers of national reputation have been
secured for the annual banquet, which will
be one of the features of the meeting.
Und»r the able leadership of Mr. R. Lin-
coln McNeil, who has been president during
the past two years, the A. P. M. A. has been
very active in all departments of its work.
The annual meeting at Old Point Comfort
bids fair to be the most successful in the his-
torv of the association.
The Elizabeth City Hospital is soon to
become The Albemarle Hospital, because
it is intended to create about this hospital a
medical center for the counties about Albe-
marle Sound.
Col. Edward P. Odenhal, L'niversity of
Maryland, '95, medical officer in charge of
United States Veterans' Hospital No. 60, at
Oteen, dropped dead on the golf links of the
Biltmore Forest Country Club in the after-
noon of .\pril 27th.
Dr. Alan R. Anderson, a son of Dr.
Thomas E. Anderson of Statesville, has been
made Dean of the New York Post-Graduate
Medical School. Dr. Anderson recently com-
pleted a three years term of study under the
Mayo Foundation, Rochester, Minn., since
which he was offered a position under the
University of North Carolina Extension Ser-
vice, lecturing on tuberculosis.
Dr. W. W. Wilkinson, LaCrosse, Va., has
been appointed by Governor Byrd to till the
vacancy on the Board of Visitors of the Med-
ical College of Virginia made by the death
of Dr. Joseph ^L Burke.
Dr. G. Defoix Wilson, Kentucky School
of Medicine, '91, aged 64, was almost instant-
ly killed when his automobile and a heavy
truck sollided on .April ISth.
The Mecklenburg County Medical So-
cif.ty held a regular meeting May 7th. Case
reports were presented by Dr. Jno. R. Ashe
and Dr. Hamilton W. McKay. Dr. W. J.
Gardner, I'hiladelphia, the special speaker of
the occasion, gave an illustrated lecture on
"Encephalography."
Dr. L. a. Crovvell, Lincolnton, recently
elected president of the State Medical So-
ciety, addresses the May meeting of the Ruth-
erford County Club, at Lake Lure.
SOtTttERN MEOtCIKE ANt) StRGERV
May, i9i9
REVIEW OF RECENT BOOKS
PHYSICIAN AND PATIENT: Personal Care,
Edited by L. Eugene Emerson. Harvard University
Press, Cambridge, 1929. ?2.S0.
Such lectures as these are valuable for in-
formation and inspiration. "They emphasize
the whole patient, including his family and
home, his social and spiritual relations; and
they also emphasize the necessity of taking
them all into account in the study and treat-
ment, not only of functional but also of or-
ganic and even infectious diseases."
The book grew out of an idea to inaugurate
a series of lectures on the personal care of the
patient by the physician.
It is shown that the trouble is not in a doc-
tor being too scientific, but in his not being
scientific enough; for truly scientific consid-
eration takes into account, not only the body,
but the mind, and whatever else may go to
make up the personality.
Subjects and Lectures are: "Some of the
Human Relations of Doctor 'and Patient,"
David L. Edsall; "The Care of Patients: Its
Psychological Aspects," C. F. Martin; "The
Medical Education of Jones; by Smith," W.
S. Thayer; "The Significance of Illness,"
Austen Fox Riggs; "Some Psychological Ob-
servations by the Surgeon," Franklin G.
Balch; "Human Nature and Its Reaction to
Suffering," Lawrence K. Lunt; "The Care of
the Aged," Alfred Worcester; "The Care of
the Dying," .Alfred Worcester; "Attention to
Personality in Sex Hygiene," .Alfred Worces-
ter.
Some of the high points are:
"The doctor who is born not made, is not
merely a poor doctor: he is dangerous, and
if he is not a conscious charlatan he is little
better than the charlatan."
"We make errors and slip enough at best
and they teach us much, but as a method of
training, error is to be minimized."
"Even when no organic background can be
found for svmptoms, this shows only our ig-
norance and is not a charge against the pa-
tient's character."
— Dr. Edsall.
"The wisest psychology will never replace
quinine and mercury, nor can it obviate the
necessity of operative procedure for a perfor-
ated appendix That many benefits,
however, are conferred on the more fortunate
adherents of these cults is not to be ignored —
benefits, however, which should not be the
property alone of the untrained mental heal-
er, but are in the possession of every practic-
ing physician."
— Dr. Martin.
Dr. Thayer's method of handling does not
lend itself readily to quotation, but it is none-
the-less worthy of careful reading and pro-
found meditation.
"That all-embracing physiology called
psychology, which deals with the reactions of
the individual as a whole, is the parent science
to understanding, and I therefore recommend
it to you as being quite as important as your
indispensable anatomy and physiology."
"An understanding of what the patient's
illness is to him, and what to him are the
significances of the procedures he undergoes,
constitutes an important element in diagnosis,
an essential guide to treatment, and is abso-
lutely indispensable to prognosis."
— Dr. Riggs.
"I always feel disappointed with myself
when I have done a palliative operation with
the result that I have simply prolonged the
patient's suffering."
"A tendency of the present day is to lay
too much emphasis on laboratory findings as
distinct from the patient."
— Dr. Balch.
"There is no physical disturbance without
its mental concomitant; there is no mental
upset without some parallel physical disturb-
ance."
"The neuroses are no respecters of race,
religion, social position or bank account."
— Dr. Lunt.
"The acceptance of ageing as a perfectly
natural process is the only proper basis for
our study of the ideal care of the aged."
"Anatomical changes that are inevitable
May, I9i9
SOUTHERN MEDICINE AND SURGERY
36?
are not pathological."
"In spite of his confession of lifelong de-
pendence upon alcohol I had taken that away,
and also even the comfort of his pipe. I had
changed his diet from what he liked to what
he loathed. And, worst of all, when he want-
ed the encouragement of frequent visits,
which I knew he was well able to pay for, I
had refused him even that boon
My only atonement has been in never again
making such an egregious blunder."
"Except for drawing in the breath, sucking
is the first, as it is the last, instinctive action
for the body's sustenance Toward
the last after even a few drops would cause
choking, if a gauze wicking, one end of which
is held in a cup of ice water, is put into the
patient's mouth it will often be gratefully
sucked."
"God grant that in commg years your aged
parents shall have every possible comfort and
that you yourselves shall become more and
more worthy of our high calling."
"All competent observers agree that there
is no such thing as the 'death agony,' except
in the imagination."
"At the last we can stand by them."
— Dr. Worcester.
These many extracts from this most in-
structive and satisfying book, are but fail
samples. The careful reading and many
t'mes re-reading of all that the book contains
will make us more useful to our patients,
more companionable with our fellow doctors,
more satisfying to ourselves.
METHODS AND USES OF HYPNOSIS AND
SELF-HYPNOSIS, by Bernard Hollander, M.D.,
M.R.C.S.. L.R.C.P., Corresponding Member of the
Royal .Academy of Medicine of Madrid. The Mac-
Millan Co., New York, 102S. $2.50.
If hypnosis is of any great importance to
doctor or layman it is not receiving the at-
tention it deserves, nor being put to use as it
should be. Rightly or wrongly, a bad odor
clings to it: most likely because much of
fraudulence has attached to its exhibitions.
.•\11 agree that suggestion is operative in
every life, that no one escapes its influence;
but many refuse to capitalize the word or the
suggestion.
"To re-educate the patient, " which is stat-
ed to be necessary, is usually too large a
task.
The chapter on the subconscious mind is
nothing like so vague as are many treatments
of the same subject, but its illustrative cita-
tions are far from convincing.
If it be true that, as a constant thing, "m
hypnosis a person becomes capable of influ-
encing all his bodily functions, increasing or
delaying their activity," surely here is a ther-
apeutic measure of the first order.
Under "Methods of Hypnoss" are given,
in a clear way, the measures which have been
applied by practitioners of mermerism and
its successors through years. It is empha-
sized that other tried treatments for even
functional disorders should not be relegated
to the waste-pile.
It is said that the pulse can be quickened
or retarded, respiration slowed or accelerated,
perspiration can be producted, temperature af-
fected, a healthy appetite created, "and, what
is more remarkable, the menstrual period in
ordinary amenorrhea can be determined to
the day and hour"; that most forms of pain,
including migraine, can be relieved, etc., etc.
The reviewer would be glad to see all this
conclus'vely demonstrated; until that is done
he must regard the case as sub judice.
THE PRACTICAL MEDICINE SERIES, com-
prising eight volumes on the year's progress in Medi-
cine and Surgery.
General Therapeutics, by Bernard Fanlus, M.S.,
M.D., .Associate Clinical Professor of Medicine, Rush
Medical College of the University of Chicago ; Mem-
ber, Revision Committee, United States Pharmaco-
poeia and of National Formulary Revision Com-
mittee. Series 1028. The Year Book Publishers,
Chicago. $2.25.
"This collection of abstracts is launched
upon a book-deluged world" in the hope of
providing a common meeting ground for gen-
eral and special therapeutics.
Improvements and additions in technic are
noted, and dextrose, liver preparations,
ephedrin, anatoxin, peroral administration of
vaccines cited as worthy of special attention.
The editor is guided by the principle "in
order to care for a patient, you must care
for the patient."
Dehmatokic.v and Svphii.i*;, Edited by William
Allen Pusey, A.M., M.D., Emeritus Professor of
m
SOUTHERN MEDICINE AND SURGERY
May, 1929
Dermatology, College of Medicine, University of Il-
linois, and Francis Eugene Senear, B.S., M.D., Pro-
fessor and Head of Department of Dermatology and
Syphilology, College of Medicine, University of Illi-
nois; with collaboration of Max S. Wien, M.D., As-
sociate in Dermatology, College of Medicine, Uni-
versity of Illinois.
Urology, Edited by John H. Cunningham, M.D.,
Associate in Gcnito-Urinan,' Surgery, Harvard Uni-
versity Post-Graduate School of Medicine. Series
1928. The Year Book Publishers, Chicago. $2.25.
Note is made of the marked increase in
the incidence of tularemia. Ringvs'orm of
hands and feet is becoming more frequent and
in many cases produces much disability; cure
is not easily effected.
A report is made of the use of cholesterol
applied with a soft brush with favorable re-
sults on alopecia. An ether spray is also said
to promote hair growth.
One selection tends to show that malarial
infection is of no value as a preventive of
paresis. Bismuth arsphenamine sulphonate
is a valuable addition to our armamentarium.
Braasch is quoted as saying that stricture
of the ureter "occurs more frequently than
has been recognized, but not as much so as
some believe." iMcKay and Colston's article
(J. oj Urology, Veh., 1928) on a hew method
for priapism is quoted at length, with repro-
duction of cut.
lions, from arthritis to witer's cramp, is made
in the concluding chapters.
PHYSICAL THERAPEUTIC TECHNIC, by
Frank Butler Granger, M.D., Late Physician-in-
Chief, Department of Physical Therapeutics, Boston
City Hospital ; Director of Physiotherapy, United
States Army ; Medical Counselor. LTnited States Vet-
erans Bureau ; Member of Council on Physical Ther-
apy, American Medical Association; Instructor of
Physical Therapeutics, Harvard Medical School; As-
sistant Professor of Physical Therapy, Tufts Medical
School. With a Foreword by William D. McFee,
M.D., Boston, Mass. Octavo volume of 417 pages
with 135 illustrations. Philadelphia and London:
W. B. Saunders Company, 192Q. Cloth $6.50 Net.
The author writes here for the general phy-
sician with a limited equipment in apparatus.
A foundation is laid in chapters on electro-
physics and physiology, the different forms
of current, ionization, etc. Diathermy is given
30 pages; the electromagnetic spectrum 17.
Hydrotherapy and massage are given brief
consideration. The application of physical
therapy to a great number of disease condi-
CLINICAL ELECTROCARDIOGRAMS; Their
Interpretation and Significance, by Fredrick A. WU-
lius, M.D. Section on Cardiology, The Mayo CImic,
Rochester, Minn., and Associate Professor of Medi-
cine, The Mayo Foundation, University of Minne-
sota. Quarto of 219 pages with 368 illustrations.
Philadelphia and London: W. B. Saunders Company,
1929. Cloth, $8.00.
This book is prepared with a view to aid-
ing those with little experience in this field — ■
wiiich includes the great majority of doctors.
That this aid is needed is well evidenced by
the lack of interest so frequently shown when
electrocardiograms are bemg thrown on the
screen. From the normal electrocardiogram,
through the common and uncommon records,
all the way to those made by "the dying
heart," records and description are plain and
informative. Definite characteristics are defi-
nitely pointed out.
Helen Morgan has been acquitted of the charge
of being a nuisance. Properly so: pretty young
v.omen entertaining at night clubs may be, and per-
haps often are, pluperfect hellions, but nuisances,
never! — "O. J." in Greensboro News.
"There's a limit to all things," says Ichabod. "I
don't mind washing the dishes. I don't mind feed-
ing the cat. I don't mind mending my own clothes.
But I'll be durned if I'll wear pink ribbons on my
night shirts to fool the baby." — Stanley News-Herald.
The board of temperance, prohibition and public
morals of the Northern Methodist church has joined
up with an anti-cigarette crusade, and maybe the
Southern Methodists who have been affiliating po-
Utically with the board can laugh that off.
Colored Rookie — "I'd like to have a new pair of
shoes, suh."
Sergeant — "Are your shoes worn out?"
Rookie — "Worn out ! Man, the bottoms of mah
shoes are so thin ah can step on a dime and tell
whether it's heads or tails."
Sunday School Teacher: "Now children, you
must never do anything in private that you wouldn't
do in public."
Sammy: "Hurray! No more baths!" — Stevens
Stone Aim.
Customer: "When I put the coat on the first
time and buttoned it up, the seam burst down the
buck."
Tailor; "Yes? Veil dat just shows how well our
Tailor: "Yes? Veil dat just shows how good our
He had just returned from an unsuccessful duck
hunt with this advice to his son: "Always remem-
ber, my boy, that there is a lot of room around
a duck."
SOUTHERN MEDICINE and SURGERY
Vol. XCI
Charlotte, N. C, June, 1929
No. 6
Post-Operative Pneumonia and Its Relation to Atelectasis*
Walter E. Lee, M.D., Philadelphia
From the Pennsylvania Hospital and the Laboratory of Research Surgery,
University of Pennsylvania
Though the literature of the last few years
shows a startling increase in the incidence
of post-operative pulmonary complications,
undoubtedly a certain proportion of this in-
crease is due largely, if not entirely, to more
careful physical examinations and better rec-
ords of the post-operative course. However,
ths more nearly represents the real situation
than the impression obtained from our older
statistics. It now seems well established from
many sources that 1 in every SO patients
operated upon develops a pulmonary compli-
cation, and 1 in every 150 developing such
a complication dies — a morbidity of 2 per
cent and a mortality of 0.6 per cent. With
such figures the value of the generally ac-
cepted statistics of the risks of anesthesia:
ether— 1 in 16,000, chloroform— 1 in 3,000,
ethyl chloride — 1 in 12,000, nitrous oxide —
1 in 100,000, are entirely useless.
Xor can we continue to regard all post-
operative pulmonary complications as post-
anesthetic sequelae, or assume that the only
risk of post-operative pulmonary complica-
t'ons arises in the anesthetic. The present
day literature contains many references to
the effect that the incidence of these compli-
cations is as great, and many claim greater,
wth the use of local as with general anesthe-
sia, although the mortality following such
complications is apparently slightly greater
when f-eneral anesthesia is used. Instead of
the anesthetic being considered the most im-
portant factor in these complications (and
the only one by many), it should be consid-
ered as only one of the many contributors,
as pre- or post-operative infection, pre-exist-
•Presented by invitation to the Tri-State Medical
Ass.iciation of the Carolinas and Virginia, Grcei)5'
boro, N' C, February. 19, 1929,
ing lung disease, old age and debility, and the
chilling of the surface of the body, all of
wh'ch have been so carefully studied by
Whipple.
In addition to the necessity of abandoning
our complacent acceptance of anesthesia as
the sole cause of post-operative pulmonary
complications, the work of Cutler makes it
necessary for us to question the all-inclusive
diagnosis of pneumonia for these complica-
tions. Cutler and Hunt in a group of 63
cases demonstrated pulmonary embolism and
infarction in i2 of their 63 cases, embolism
being used in the sense of the transfer of
small particles, which may or may not be
sterile, from the operative field to the lungs
by either the lymphatics or blood channels.
It is our belief that pulmonary embolism and
infarction, alone or associated with other le-
[sions, Will be found to compose a much
larger proportion of the so-called post-opera-
tive pneumonias than has been reported by
Cutler, namely, 57.7 per cent.
Undoubtedly the most constant etiological
factors concerned in post-operative pulmon-
ary complications are the site of the opera-
tion and the character of the operative pro-
cedure. The relation of the operative field
to the diaphragm bears a direct relation to
the incidence of post-operative pulmonary
complications. Cutler and Hunt give perhaps
the highest figures. Thus in the group of
63 cases of post-operative pulmonary compli-
cations, 43, or 68 per cent, followed laparo-
tomy. Pasteur gives an incidence of 1.8 per
cent following operations ujxin the urinary
bladder, and 13.4 jjer cent following opera-
tions upon the stomach, while 11.0 per cent
following operations upon the liver and gall
bladder.
There is still another post-operative pu}-
SOUTHERN MEDICINE AND SURGERY
June, 1020
monary complication which we feel is prob-
ably constant, and which in varying degrees
may be associated with any one or all of the
other complications, such as infection,
embolism and infarction, namely, atelectasis.
Time will not permit an adequate review of
this subject, for the literature has been ac-
cumulating so rapidly since Scrimger reported
his cases in 1921 that any such attempt
would be impossible before this audience.
True it is that massive atelectasis has at-
tracted the most attention, and the report of
Pasteur in 1910 is probably responsible for
limiting our present conception of this lesion
of massive atelectasis, but more recent stud-
ies have demonstrated that we may have
varying degrees of atelectasis. The literature
now contains reports of some 260 cases of
post-operative massive atelectasis and we
have had the opportunity of studying the
records of 36 cases of this type.
It is of historical interest to recall that
this lesion was accurately described by
Shenck in 1811 while Toerg in 1834 just
applied the term atelectas's. Gairdner, of
Edinburgh, studied the lesion in 1850 and al-
most suggested our present conception of the
mechanism of its production. Forsyth Meigs,
of Philadelphia, described it in 1852, and
Foster, of New York, in 1850. Elwyn, in
1922, suggested atelectasis and subsequent
infection as the real pathology in post-opera-
tive pneumonia.
Our interest in the subject began in 1923,
when we suggested that the phenomena of
pulmonary collapse of varying degrees, to-
gether with pulmonary embolism and infarc-
tion and subsequent infection, are constant
etiological factors in post-operative pulmon-
ary complications. IMastics in a recent report
estimates that 70 per cent of the so-called
post-operative and post-anesthetic pneumo-
nias are varying degrees of atelectasis. As a
result of our continued interest in the subject
and unusual opportunities provided for ex-
perimental work in the Department of
Research Surgery of the University of Penn-
sylvania, we feel that we now can present
clinical and e.xperimental evidence in support
of this belief, and suggest that in the small
proportion of true pneumonias which develop
post-operatively, all start as varying degrees
of atelectasis, and upon these lesions are en-
grafted embolism, infarction and infection,
When we have massive atelectasis, involving
more than one lobe of the lung, it is usually
mistaken for pleural effusion, massive pneu-
monia, empyema or pneumothorax ( Fig. 1 ) .
In lobar atelectasis, in which only one lobe
is involved, we have the usual diagnosis of
lobar pneumonia (Figs. 9-11). In lobular
atelectasis, involving scattered areas in one
or more lobes, we have the diagnosis of
broncho-pneumonia or pulmonary infarction
(Figs. 13-14).
The fact that atelectasis has been recog-
nized as a congenital lesion, as seen in the
new-born; occurring spontaneously in pleu-
ritic and diaphragmatic pain; in bronchial
and pulmonary infections; in non-penetrat-
ing wounds of the thorax, when frequently
the injury is received upon the opposite side
of the chest, the so-called contralateral col-
lapse; in non-penetrating wounds of the ab-
domen; associated with intra-abdominal pres-
sure, caused by tumors, intestinal obstruction
and peritoneal effusions; in postures immobil-
izing the thorax and abdomen; in nasal an3
pharyngeal diphtheria; in foreign bodes in
the trachea or bronchi; during and following
operations upon the abdominal wall, intra-
abdominal organs, genitalia and lower ex-
tremities, would indicate that more than one
etiological factor may be involved. In the
group of 36 cases of post-operative massive
atelectasis whose records we have been able
to study, we are persuaded that three factors
at least have been constant. ( 1 ) Some in-
hibition or restriction of the respiratory
movements. (2) An inhibition or loss of the
cough reflex. (3) An accumulation in the
bronchi of thick, viscid, bronchial secretions.
Because of the thick, tenacious character of
this bronchial secretion, and the inability,
or disinclination, of the patient to clear it
from the bronchi, it accumulates in the de-
pendent portions of the bronchial tree until
at some point, or points, this stream of mu-
cus completely occludes the lumen. If this
occlusion takes place in a small bronchiole,
we have lobular atelectasis (broncho-pneumo-
nia) (Figs. 13-14). If it accumulates and
obstructs the bronchus leading to one lobe,
we have lobar atelectasis (lobar pneumonia)
(Figs. 9-11). .And if it occurs in the main
bronchus of either lung, we will have massive
atelectasis (massive pneumonia) (Fig. 1).
, An explanation of the mechanism, involved
June. 1020
■SOUTHERN MEDICINE AND SURGERY
MASSIVE ATELIX'TASIS
FIG. 1
G. M., male, white, 15 years. Pennsylvania IIos- rhaphy, massive atelectasis left lung. Service of
pital, 42 hours after radical right inguinal hernior- Dt . Milchel. Radiogr.im by Dr. Bishop.
G. M., male, white, li year?, Pennsylvania Hii>-
pital. Roentgenray taken 14 hours after brontho-
Scopic drainage by Dr. Clerf of the obstructing se-
cretion from the left main bronchus. Service of
Dr. Milchfil. Radiogram by Dr. Bowen.
SOUTHERN MEDICINE AND SURGERY
June, 1929
FIG. 3
Dog No. 456. Laboratory of Surcical Research, ploratory laparotomy and the e.xperimental produc-
Umversity of Pennsylvania, Philadelphia. Radiogram tion of post-operative massive pulmonarv atelectasis
taken by Dr. Pendergrass .'4 hours before the ex- of the right lung.— iff, Tucker. Ravdin, Pendergrass.
in such obstruction is suggested by the ex-
perimental work of Archibald, who found
that substances of the consistency of mineral
oil are drawn further into, and finally reach
the terminal alveoli of the lungs, after a
number of coughing spells stimulated by me-
chanical irritation of the pharynx, while sub-
stances of a greater consistency and viscosity,
such as mucus and sputum, are expelled
by the first expiratory efforts and cleared
from the bronchial tree and are rarely drawn
further into the bronchi. To us it is con-
ceivable that when the viscosity of the bron-
chial secretion is not sufficient to insure its
complete expulsion by the expiratory cough,
nor sufficiently fluid to be drawn into the
terminal bronchioles, it will move backward
and forward at expiration and inspiration
and definite waves will be created upon the
surface of this stream of viscid secretion.
There will be one point, of course, where the
expiratory and inspiratory waves meet, ancj
there a form of tidal bore may be created
which can be compared to the wave pro-
duced by the meeting of tides in a narrow
bay. There will be a piling up of the waves
of this viscid bronchial secretion until one
or more of them will reach the opposite wall
of the bronchus, and because of the viscosity,
adhere to it and thus completely occlude the
lumen of the tube. With recurring coughing
and marked inspiratory effort, this mass of
secretion is drawn further down into the ta-
pering bronchus until obstruction is produced
and maintained.
Chevalier Jackson has shown, in his work
with obstructing foreign bodies in the bron-
chi, that there are two types of bronchial
obstruction, (1) the ball valve type, and (2)
complete occlusion. In the ball valve type,
the foreign body is drawn into the tapering
bronchus with inspiration and the ingress of
air is prevented, but with expiration the ob-
struction is forced partially outward and a
June, 1020
SOUTHERN MEDICINE AND SURGERY
373
EXPERIMENTAL MASSIVE ATELECTASIS
FIG. 4
Dog. No. 456. Laboratory of Surgical Research,
University of Pennsylvania, Philadelphia. Radiogram
by Dr. Pendergrass 3 hours after exploratory laparo-
tomy and the bronchoscopic introduction by Dr.
Tucker of 7 c.c. of the obstructing secretion pre-
small amount of air is allowed to escape.
Thus after a short time the air will be
pumped out of the tissue distal to the ob-
struction and these tissues will become air-
less. In complete obstruction both inspira-
tion and expiration are blocked by the ob-
structing foreign body and the imprisoned
air is absorbed by the pulmonary circulation,
and though we have a slower developing
atelectasis, eventually we will have the same
degree as with the movable ball valve type
of obstruction. These airless tissues give the
physical signs of pneumonic consolidation
where they are in contact with the chest wall
(usually posterior), and hence the confijsion
viously removed bv Dr. Clerf from the left mam
bronchus of patient G. M. (Fk- D with massive
post-operative atelectasis. — Lee, Tucker, Ravdm,
I'endergrass.
in its diagnosis with the consolidation of
pneumonia. .-Xnteriorly, when the atelectatic
lung lies posteriorally, we usually find the
physical signs of a pneumothorax, except
when it occurs on the right side, when fre-
quently the displaced heart will obliterate the
signs of pneumothorax and again confuse one
with the physical signs of consolidation.
We have demonstrated, both clinically and
experimentally, that if such obstruction can
be overcome and an airway is established
past this point or |X)ints of obstruction, the
patient may, temporarily at least, free the
bronchial tree of large masses of secretion,
re-eftablisb the cough reflex, and thus rein-
374
SOUTHERN MEDICINE AND SURGERY
June, 1929
Dog No. 456, lateral view. Laboratory of Surgi-
cal Research, University of Pennsylvania, Philadel-
phia. Radiogram taken by Dr. Pendergrass 24 hours
before the exploratory laparotomy and the experi-
flate the pulmonary tissues. Various methods
have been suggested for re-establishing the
airway as making the patient cough
by the inhalation of irritating substances,
such as aromatic spirits of ammonia, by
changing the position, as suggested by San-
tee, by vigorous shaking, and in young chil-
dren, by actual spanking, by hyperventila-
tion of the lungs by means of inhalation of
carbon dioxide, immediately following the
completion of the operation, or subsequently
when the symptoms of atelectasis first de-
velop (as suggested by Scott) and if by any
means. In 19 cases Dr. Chevalier Jackson
and his associates have foimd it nec-
essary to deliberately aspirate through the
mental production of massive pulmonary atelectasis
of righ|- lung — normal. — Lee, Tucker, Ravd'.n, Pen-
der grass.
bronchoscope the obstructing portion of the
bronchial secretion, and in each case increas-
ed aeration and partial reinflation of the pul-
monary tissues distal to the point of obstruc-
tion has followed. In but one case has it
been necessary to repeat the bronchoscopic
drainage.
The fact that we have been able to
remove an obstructing mass of bronchial
secretion from the left main bronchus of a
human with the classical symptoms and ra-
diographic evidence of massive atelectasis,
and inject this substance into the right main
bronchus of a dog, and reproduce in that
dog all the clinical symptoms and physical
signs of massive atelectasis or massive pneu-
June, 1029
SOUTHERN MEDICINE AND SURGERY
US
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FIG. 7
Dor No. 555 Laboratory of Surgical Research,
University of Pennsylvania, Philadelphia. Radiogram
taken by Dr. Pendergrass 24 hours before laparotomy
and experimental production of ma.ssive post-opera-
tive atelectasis of the right lung. — Lee, Tucker, Ruv-
din, Pendergrass.
SOUTHERN MEDICINE AND SURGERY
June, 1920
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LOBAR ATELECTASIS
F;g. Q. — A. F., male, 43 years. Bryn Mawr Hos-
pital Radiogram taken by Dr. Pillmore 24 hours after
appendectomy and drainage of a gangrenous per-
forated appendix by Dr. Lee. Atelectasis lower right
lobe. Rigid mediastinal tissues have prevented the
usual movement of heart toward affected side re-
sulting in an unusual elevation of the right dia-
phragm.— Lre, Tucker, Pillmore.
monia which were present in the human, sug-
gests interesting possibilities for research.
Although Mendelsohn, in 1845, Traube in
1846, and Lictheim, in 1878, experimen-
tally produced massive atelectasis by ob-
structing the bronchi, many others have
failed in their attempts because of the
(Jiffculty in keeping the foreign bodies in
Fig. 10. — A. F., male, 43 years. Bryn Mawr Hos-
pital Radiogram taken by Dr. Pillmore b days after
appendectomy and drainage of a gangrenous perfor-
ated appendi.x by Dr. Lee and 5 days after broncho-
scopic drainage by Dr. Tucker of obstructing bron-
chial secretions from the main bronchus of the lower
right lobe. — Lee, Tucker, Pillmore.
the bronchi of dogs. The dog's cough
reflex is so sensitive and his expulsive efforts
so efficient that Jackson finds the greatest
diffculty in keeping the foreign bodies in the
bronchi of dogs long enough to give his stu-
dents the necessary experience in removing
them through the bronchoscope. Corryllos
in bis recent experimental production of pneu-
June, 1929
SOUTHERN MEDICINE AND SURGERY
377
LOBAR ATELECTASIS
Fig. H. — A. F., 43 year?. Bryn Mawr Hospital
Radiogram lai^en by Dr. Fillmore 24 hours alter
appendectomy and drainage of a gangrenous perfor-
ated appendix by Dr. Lee. Atelectasis of lower right
lobe. Rigid mediastinal tissues have prevented the
usual movement of the heart toward the affected
side resulting in an unusual elevation of the right
diaphragm. — Lee, Tucker, Plllmore.
fig 12. — .\. F., male, 43 years. Bryn Mawr Hos-
pital Radiogram taken by Dr. Fillmore 0 days after
appendectomy and drainage of a gangrenous perfor-
ated appendi.x by Dr. Lee and 5 days after broncho-
scopic drainage by Dr. Tucker of obstructing bron-
chial secretions from the main bronchus of the lower
right lobe. — Lee, Tucker, Pillmore.
LOBAR ATELECTASIS
Fig. l.i. — Mrs. F. W., il years. Jefferson Hospital
2-6-1920. Radiogram taken by Dr. Farrell ib hours
after laparotomy by Dr. Scheffey for a ruptured
ectopic pregnancy. Lobular atelecti sis of upper and
l( wer lobes of right lung. — Sclieffey, Clerj, Farrell,
Jones.
Fig. 14. — Mrs. F. W., 32 years. Jefferson Hospital
2-6-1Q29. Radiogram taken by Dr. Farrell 30 hours
itfler la|)arotomy by Dr. Scheffey, and immediately
after bronchoscopic drainage by Dr. Clerf of 4 c.c.
of bronchial secretion from the right main bronchus,
stem bronchus and lower lobe brnchus. — Scheffey,
Clerj, Farrell, Jones.
SOUTHERN MEDICINE AND SURGERY
June, 102Q
Fig. IS.— Mrs. F. W., i2 years. Jefferson Hospital
2-6-1020. Radiogram taken by Dr. Farrell 13 days
after laparotomy by Dr. Scheffey and 10 days after
bronchoscopic drainage by Dr. Clerf of 4 c.c. of
bronchial secretion from the right main bronchus,
stem bronchus and lower lobe bronchus. — Scheffey,
Clerf, Farrell, Jones.
monia in dogs used on the foreign bodies ex-
panding wire prongs whose pwints imbedded
themselves in the wall of the bronchi and
thus defeated the e.xpiratory efforts of the
animal. Not only have we been' able to pro-
duce atelectasis with the bronchial secretion
from a clinical case of post-operative massive
atelectasis (Figs. 3-4-5-6), but Dr. Ravdin,
of the Surgical Research Department of the
University of Pennsylvania, has made for us
a synthetic substance from acacia whose vis-
cosity is approximately that of the bronchial
secretion removed from the human, and it
has been possible to reproduce consistently
the same type of atelectasis as with the hu-
man bronchial secretion (Figs. 7-8).
In our first experiment, after placing with
the bronchoscope, the bronchial secretion
from the human in the right main bronchus
of a dog, paroxysms of coughing occurred,
which time and time again expelled the ob-
structing mucus, notwithstanding deep ether
and morphine narcosis. At this point Dr.
Ravdin introduced intraperitoneally 250 mgm.
of sodium amytol (sodium iso-amyl ethyl
barbiturate) with the object of producing a
deeper narcosis and abolishing the cough re-
flex, both of which objects were promptly ac-
complished. With the loss of the cough re-
jle.x, the respiratory efforts became deeper
and deeper and the entire mass of bronchial
secretion was drawn into the right bronchus.
A few minutes after the completion of the
introduction of the bronchial secretion and
following the removal of the bronchoscope,
definite respiratory distress developed. This
distress was so marked that it seemed for a
time that the dog was about to die. (Clinical
symptoms very similar to those seen in human
post-operative massive atelectasis). The res-
piratory movements finally became regular
and rhythmic and before the dog was placed
in the kennel the movements of the right side
were almost lost, while those of the left side
were very much exaggerated, and there was a
distinct bulging and a visible increase in thj
size of the left half of the thoracic cavity. In
our experiments with dogs, it has been prac-
tically impossible to produce massive atelecta-
sis with viscid substances unless the cough
reflex is abolished.
CONCLUSIONS
1. We suggest that atelectasis of varying
degrees, lobular, lobar or massive, are con-
stant factors in post-operative pulmonary
complications.
2. That subsequent to and associated with
atelectasis we may have embolism, infarction
and infection, with true pneumonia, lung ab-
scess and empyema as terminal processes.
3. That if embarrassment of respiratory
movements, inhibition or abolition of the
cough reflex, and accumulations of masses of
viscid bronchial secretion in the dependent
portions of the bronchial tree are causes of
post-operative atelectasis, we have definite
and clear-cut indications for its prevention
and treatment. Is is too much to claim that
this gives us a new conception of the path-
ology of post-operative pneumonia?
DISCUSSION
Dr. Rinker, Norfolk, Va.: I should like
to ask Dr. Lee two questions. In the first
place, did I understand you to say. Dr. Lee,
that atelectasis and pneumonia are the same,
pathologically?
Answer: No.
Dr. Rinker: I was wondering whether
you meant that, or not. Secondly, I want to
ask you whether or not, on account of the
fact that atelectasis is caused by the pres-
ence of a plug of mucus in a bronchus, arti-
ficial collapse of the lung might be advisable,
in the absence of the possibility of broncho-
June, 1029
SOUTHERN MEDICINE AND SURGERY
379
scopic treatment.
Answer: I do not mean to say that bron-
th'ectasis is pneumonia. The airless lung, as
it lies collapsed against the chest wall, will
g ve you the physical signs of a pneumonia,
but not anteriorly; anteriorly you will have
all the signs of a pneumothorax. Not only
ivill your percussion be that of consolidation,
but you will have very loud voice sounds
over the airless, unoccupied portion of the
chest. Where you have the collapsed, air-
less lung you get the physical signs of con-
sol'dation due to pneumonia. Atelectasis is
not pneumonia, but the work of Carlhoff, in
New York, shows more and more that atelec-
tasis always precedes pneumonia. There is
a type of bronchial obstruction in which you
have complete obstruction taking place, so
there is r.o outlet or inlet there; and in that
type you have complete stoppage of the cir-
culation of air; and the air is absorbed by
the pulmonary circulation in a short time.
In the other type no air can go in, but at
the outlet a little air can get out, so in that
type you have a loss of air past the obstruc-
tion; but I do not believe that that is the
most common cause, with this viscid mate-
rial. I do not think this viscid material will
move like a foreign body; I believe it sticks;
and we get an obstruction which is more or
less permanent and air-tight.
1 am not sure about the value of pneumo-
thorax. When we have a lung which is air-
less and the bronchi obstructed, it is true if
we put air under pressure in that pleural
cavity we shall push the heart back to its
normal position; but I think we shall also
increase the pressure on that collapsed lung,
and I do not see how that will help the cir-
culation. I do not think the symi)toms are
due so much to the displacing of the heart
as they are due to the loss of vital capacity
of the lung, whic his due particularly to this
thick bronchial secretion. This, if not evac-
uated, eventually becomes infected, when we
have purulent secretion as well.
Dr. Wright Clarkson, Petersburg, Va.:
I have at present a patient with paralysis of
the left diaphragm. This child has very bad
tonsils, and the physician is contemplating
removing them. The child's diaphragm be-
came paralyzed following an infection about
twelve months ago. When the child takes a
breath, under the fluoroscope, the left dia-
phragm is seen to go down and the right to
go up. Does Dr. Lee think the tonsils should
be removed? Does he think there is more
danger of pulmonary complications in a case
of that kind?
Dr. Lee: How old is the child?
Dr. Clarkson: Five years.
Dr. Lee: I would say the danger of pul-
monary complications is very great where you
have paralysis of one-half of the diaphragm,
because in a child of that age the movement
of the mediastinum is so free that there is
practically one thoracic cavity.
Question: What is the approximate per-
centage of complications of pneumothorax
that you have in these cases?
Answer: Of course, this type of collapse
is not the type of collapse in which you have
pneumothorax. It should not be called col-
lapse, and that is the reason why we have
abandoned the word collapse. We feel that
the term "collapse" should be confined to a
ptisitive air pressure, and this collapse is due
to airlessness.
Dr. Bolling Jones, Petersburg, Va.:
What shall we do in the absence of a man
who can do bronchoscopic work?
Answer: Some time ago I spoke of this
in New York City, and the impression was
gained that the only treatment for collapse
is bronchoscopic drainage. The first thing is
prevention. The prevention consists in not
giving too much morphine. Don't give your
patients too much morphine, because mor-
phine above all other drugs destroys the cough
reflex and allows this secretion to accumu-
late. The second thing is to keep the patients
moving. Many of these patients he on the
right side for twenty-four or forty-eight hours
after an appendectomy. Don't let them lie
on the chest, because lying on the chest in
one position will produce collapse. Don't
strap the lower thorax with adhesive. The
simplest and most practical suggestion is to
try to give inhalations of some positive pres-
sure. The smelling of aromatic spirits of
ammonia is one of the best and simplest —
to make the patient take a deep breath and
then cough. If the condition is recognized
within the first twenty-four or thirty-six
hours, not diagnosed as pneumonia — jxist-
operative pneumonia, bronchoscopic drainage
is not indicated. 1 think Lantey's suggestion
of placing them on the op{x)site side is one
of the recognized methods; in addition, smell-
ing aromatic spirits of ammonia.
SOUTHERN MEDICINE AND SURGERY
June, 1929
Dr. J. BoLLiNG Jones, Petersburg, Va.:
Of course, we are seeing a great many more
lung abscesses lately than we used to. Are
more of them secondary atelectasis, or are
they primary infections?
Answer: That is a question about which
there is a good deal of controversy at the
present time There is a mass of experimen-
lal work proving that it is something of this
kind and a mass of experimental work prov-
ing that it is some sort of blood-borne infec-
tion or infarction. It seems to me logical to
feel that a mechanical obstruction such as
you see here, with this bronchus filled with
secretion, is very often the cause of bron-
chial cavities and eventually of lung abscess.
Dr. Jackson, I know, feels very strongly him-
self that a large propxjrtion of post-tonsillec-
tomy abscesses are something of this type,
where mucus and blood have been aspirated
into the bronchi and have not been coughed
up and infection has been implanted into this
collapsed area.
Dr. Dean Cole, Richmond, \'a.: Did you
give any or all of the dogs atropine?
Answer: No, we did not give them atro-
pine. We tried everything, we thought, to
destroy the cough reflex. We gave them
almost fatal doses of morphine, and still they
coughed it up. Finally, with anitol given in-
traperitoneally, we destroyed it. Until the
cough reflex was absolutely destroyed we
could not reproduce this condition.
Dr. Cole: It has been thought if the sur-
geon would leave off the atropine before oper-
ating we might have less post-operative atelec-
tasis.
Suppose you stuck a needle in and pro-
duced a pneumothorax, so as to neutralize the
negative pressure which is pulling that plug
of mucus farther into the smaller bronchi?
Answer: That is one method which has
been suggested, but it does not seem to me
that the plug of mucus is being drawn into
the bronchus by the negative pressure but not
being pushed in by the positive atmospheric
pressure. The fifteen pounds of atmospheric
pressure, it has seemed to me, is more power-
ful than the negative pressure.
To him belongs the credit of having made the first Temperance Address ever
uttered South of ]\Iason and Dixon's line, taking then the position he has ever since
held, denouncing the habitual use of distilled liquors as beverages, while he approves
of, and favors the employment of the various products of mere fermentation. Hence
he warmly advocates ancl takes pleasure in the success of all efforts to grow the grape
in our country, and to manufacture its genial juice into wines of every character and
quality. — From fiioi^rap/iiral Sketch oj Dr. Samuel Henry Dickson, in Charleston
Medical Journal, January, 1857.
June, 1929
SOUTHERN MEDICINE AND SURGERY
Acute Cellulitis of the Orbit*
H. C. Neblett, M.D., Charlotte
This affection, while not of common occur-
rence, occupies a position of equal import-
ance with that of other acute conditions of
the orbit and its contents. By its location
and the nature of the infection it presages a
serious prognosis relevant to the functions
of the eye and often to life as well. Very
few cases, especially those which progress to
abscess formation, recover without complica-
tions and sequelae.
The etiology is an infection within the cel-
lular tissues of the orbit which may be either
focal, local, or systemic in origin. Usually
it is focal and arises as a complication in
acute diseases of the nasal accessory sinuses,
especially the ethmoids and frontals, less fre-
quently as result of injury to the tissues of
the orbit and its contents, and occasionally
from metastasis in acute infectious diseases.
The diagnosis is frequently difficult be-
cause several acute orbital and intraocular
conditions present signs and symptoms and
an etology similar to an acute cellulitis of
the orbit, therefore the importance of getting
a careful history and of making a thorough
physical examination in each case. It is im-
portant to supplement these measures with a
radiogram of the skull, including the teeth,
and of the chest, and a blood Wasscrmann
test, especially in those cases in which the
etiology is obscure and the diagnosis doubt-
ful. In addition to the above measures,
frequent ophthalmoscopic examination of the
fundus is helpful in establishing the diagnosis
and in determining the presence of complica-
tions.
The treatment of these patients comprises
four main factors, namely: removal of the
cause, especially when proximal to the orbit,
the use of local measures (hot moist fomen-
tations, leeches, etc.) designed to abort the
infection or to localize it, operative interven-
tion within the orbit, and .systemic treatment
of the patient who is frequently ill from the
♦Presented to the Tri-Statc Mediral Assorialion nf
the Carolinas and Viri;inia, Greensboro, N. C, Meet-
ing February 19th, 20th and 2l5t, 1929.
original disease of which this is a complica-
tion. In the event that local applications
have not retarded the progress of the affec-
tion and if local signs and constitutional dis-
turbances become severe, deep incision into
the orbit is productive of good results. This
procedure may not locate an abscess for the
reason that it may not have formed, may be
too small or too deeply placed, or we were
just not fortunate enough to find it. How-
ever, the free bleeding resulting from the in-
cision will temporarily relieve the local and
general symptoms, will lessen the probability
of complications and sequelae, and will form
an easier exit for purulent material which
may develop later.
In resorting to surgical intervention it is
important to know that the diagnosis is cor-
rect in so far that we are sure we are not
dealing with a cavernous sinus thrombosis, a
panophthalmitis, an acute inflammatory glau-
coma, an acute empyema of the nasal acces-
sory sinuses, or a pulsating exophthalmus.
Each one of these conditions frec|uently close-
ly simulates an acute cellulitis of the orbit
by presenting one or more of the following
symptoms: marked edema of the lids and
conjunctiva, episcleral and lachyrmal conges-
tion, exophthalmus, displacement of th?
/;lobe in either the vertical or horizont/tl
plane, retarded or suspended motility of the
eyeball, and fever and severe constitutional
d sturbances. The exceptions in the condi-
tions named are found in pulsating exophthal-
mus in which fever and constitutional symp-
toms are absent. The site for making the
incision into the orbit, whether in the early
^tages or when abscess formation has become
defin-tely established, is inferred from the
following considerations: The nidus of the
infection in the orbit is most likely to be
found near the causative agent, except in
cases in which the etiology is remote from
the orb't; a [wint of greatest induration and
tenderness usually can be found beneath th?
lid; there is usually more or less disi)lace-
ment of the globe.
SOUTHERN MEDICINE AND SURGERY
June. 1<330
Case 1. — White boy of five, was presented
for treatment with a severely inflamed right
orbit, Hds and conjunctiva greatly swollen,
the latter protruding beyond the margin of
the Kds. Exophthalmus was present with
downward and inward displacement of the
eyeball. Voluntary movement was suspend-
ed. Pain and tenderness were so pronounced
it was impossible to make a thorough exam-
ination. Associated with these findings were
high fever and marked constitutional disturb-
ances. A radiogram of the skull and a smear
from the conjunctiva were negative. The
tonsils and adenoids had been removed about
a year previously. The history was negative
except that the child, several days prior to
the orbital symptoms, had complained of a
sore right eye. Under general anesthesia an
ulcerated area was found at the outer canthus
of this eye. The interior of the eye was nor-
m-'l. An indurated area was found beneath
the supraorbital margin and toward the tem-
poral s'de. Deep incision at this point lo-
cated an abscess. Drainage was maintained
by gauze wick. Recovery was prompt with-
out complications or sequelae.
Case 2. — ^White man, 32, past history neg-
ative, Wassermann blood test negative, com-
plaint— slight pain and tenderness in the right
orbit of two days' duration. Temperature
100, moderate edema of the lids and conjunc-
tiva, tenderness to palpation beneath the su-
praorbital arch and toward the temporal side.
Radiogram of skull and teeth negative. Two
days prior to the orbital symptoms patient
had been bitten on the right upper lid by an
insect. At this point a wound was found
which was significant of an insect sting. For
four days local applications were used but
without success in controlling the progress
of the infection. At this time symptoms of
an acute cellulitis of the orbit were well ad-
vanced. The eyeball was displaced down-
ward and inward, and an area of induration
presented within the superior-external angle
of the orbit. Interior of the eye normal. An
incision through the most affected area into
the orbit was successful in locating an abscess.
Drainage was maintained by gauze wick. Re-
covery was prompt without sequelae.
Case 3. — White boy, 17, past history neg-
ative, had influenza which was complicated
with an acute empyema of the right frontal
and ethmoidal sinuses. Coincident with the
s'.nusit's, he developed pain and tenderness
within the right orbit associated with mod-
erate edema of the lids and conjunctiva.
These symptoms were principally confined to
the superior-internal angle of the orbit. Free
intranasal drainage from the sinuses was
promptly established. On the second day
following the sinus operation symptoms of
an acute orbital cellulitis were well marked.
An incision made through the upper lid at
the superior-internal angle, carried deeply
inward, and then brought outward along the
roof of the nasal side, resulted in failure to
locate an abscess. As result of this, there
was partial relief of symptoms for about
twenty-four hours. Three days later the
aspects of the case were greatly magnified
despite th? use of local applications. At this
time exophthalmus with downward and out-
ward displacement of the globe were marked,
especially the latter, with an annoying diplo-
pia. A second incision following the direc-
tion of the initial one resulted in locating a
very deeply placed abscess. Drainage was
mainta'r.cd as in the former cases. Prompt
recovc.y from the orbital affection resulted
from this procedure. Vision in this eye was
20/30 when the patient was discharged upon
recovery from the sinus infection. No other
sequelae were present. Repeated examina-
tions of the fundus of this patient during
the progress of the disease were negative.
SUMMARY
.-\n acute orbital cellulitis may develop
from a very insignificant injury or infection
of the lids. Complications and sequelae are
less apt to occur when the cellulitis is of
moderate depth in the orbit and temporally
placed. Local treatment externally appears
to be of little consequence in combatting the
progress of the infection. Deep incision
(through the lid) into the orbit is productive
of good results at any stage of the affection
in which the local signs and general symp-
toms are of great severity.
June, 1029
SOUTHERN MEDICINE AND SURGERY
Disturbances of the Peripheral Circulation*
With Report of Case
F. L. Knight, M.D., Sanford, N. C.
The blood flow through the peripheral ves-
sels is regulated by a group of nerve cells in
the medulla, the vasomotor center, afferent and
efferent nerve branches, the efferent forming
within the vessel walls two sets with oppos-
ing action, the vasodilators and the vasocon-
strictors. Changes in the peripheral circula-
tion can easily be seen in the blushing and
blanching of embarrassment, anger and other
emotions. It has been shown that the tem-
perature of the skin may vary greatly with
our environment while our general body tem-
perature remains fairly constant. The blood
volume in the cutaneous circulation may be
affected by temperature, drugs, trauma and
disease. .\ blood-vessel may be blocked by
obi terative endarteritis, thrombosis, embol-
ism and vasomotor nerve spasm. Some of
the more common circulatory disturbances
found in the extremities are:
1. Raynaud's disease, which is supposed to
be due to a spasm of the vasoconstrictor
rervcs in the very small arterioles. It occurs
more frequently in cold weather; is usually
but not always symmetrical; usually begins
at the d'stal ends of the toes, fingers, tip of
the nose or ear and progresses upward, but
may involve only isolated patches of skin on
the arm or leg. The onset is marked by a
numbness or tingling of the extremity which
may later develop local syncope and cyanosis
and progress to complete asphyxia and dry
gangrene. A line of demarcation forms and
the necrosed area is removed as a slough.
Widespread gangrene from pure Raynaud's
disease is rare.
2. D.'abetic gangrene, which may be moist
or dry, may be due to septic thrombosis, ar-
teriosclerosis, or obliterative endarteritis. The
diagnosis here is usually made in the labora-
tory.
3. Chronic ergot poisoning, which some-
t'mes results from eating bread made from
damaged wheat or rye. Epidemics have been
•Presented to Fifth ( N.C.) District Medical So-
ciety, Southern Pines, April 4, 1929,
known to occur after crop failures in Russia
and other countries. The ergot probably acts
directly on the smooth muscle of the vessel
wall and not on the vasomotor mechanism.
4. Dermatitis factitia, or self-inflicted inju-
ries which cause local death of areas of skin.
5. Dermatitis gangrenosa adultorum, which
may follow local or remote septic infection
and results in extensive ulceration.
Case Report. — Young white woman, 18,
negative family history, no birth injury, men-
struation normal, a negative Wassermann,
negative tuberculin test, and normal as to
blood picture and other routine laboratory
tests. About two years ago a trophic ulcer
appeared on the dorsum of the right foot.
This was of the same character as those you
now see on the patient's arm. She was
treated by her family physician for six
months when he referred her to the Central
Carolina Hospital for Alpine light and dia-
thermy treatment of the intractable lesion.
Other similar lesions appeared on the foot
and leg. During the winter of 192 7-28 we
succeeded in healing every lesion by keeping
her strictly in bed and applyin'^ artificial heat
in addition to diathermy, .Alpine lamp and
systemic medication. The right foot was al-
ways cold. There was no sense of localiza-
tion to touch or differentiation between heat
and cold below the knee. No pulsation could
be felt in any of the vessels about the ankle.
The gangrenous spots were absolutely pain-
less.
The characteristic lesion will apjiear sud-
denly in twenty-four hours' time as a black-
ening of a variably sha[ied area of skin.
There is absolutely no preliminary vesicula-
tion or change of any kind to indicate where
a new patch of gangrene will appear. In ,i
few days this patch sinks in by retraction
and after a few days or weeks will separ.ite
as a dry crust, leaving healthy granulations
beneath. There is no pus or drainage and
no inflammatory reaction about the borders.
They usually heal very slowly by epitheiiali-
zation from the borders. There is no pain
and frequently the patient herself is not
SOUTHERN MEDICINE AND SURGERY
June, 1929
aware of the presence of a new lesion until
she sees it, which may be upon arising in the
morning or when having the dressing
changed.
She returned home in the spring of 192'S
apparently well, but new patches soon ap-
peared and spread up the leg rapidly. The
cutaneous gangrene became so extensive that
we aminitated the right leg above the knee
on .\ugust 9, 1928. The stump healed per-
fectly and she soon returned home. In a few
weeks she returned with similar lesions on
the back of her right hand which have since
spread up the arm to the shoulder.
We have never made a positive diagnosis
on this case. It seems to me that the diagno-
s's narrows to two things: Raynaud's and
dermatitis factitia. Unfortunately we d'd not
have tissue sections of the amputated limb
mad? for microscopic study, but we d'd dis-
sect the limb and noted that the arteries were
of very small caliber. No obliterated vessels
were found. There is only one hint of a
possible previous cause. About seven years
ago she was thought to have had a meningitis
for two days. This may have been a mild
poliomyelitis which seems to have left no
defects.
Opposed to the diagnosis of Raynaud's dis-
ease is the fact that there is no preliminary
asphy.xia or vesiculation, no numbness or tin-
gling, and the spots heal fairly readily. The
lesions do not follow the course of any vessel
or nerve, but may be widely separated. A
second lesion has appeared on the scar of a
former one. This would seem to ban the
idea of a nerve spasm because we would
scarcely expect to find a well developed vaso-
motor supply in new scar tissue. The patches
do not enlarge and there is no progressive
change after the initial gangrene. The tissue
death is only skin deep.
Opposed to the diagnosis of dermatitis fac-
titia is the fact that she is a normal healthy
girl who certainly does not seem to have any
neurotic tendency and from our own personal
knowledge of her family and home life there
is nothing to be desired in devotion and at-
tention. She is of a cheerful, humorous dis-
position but rathor bashful. She has never
showed a desire to exhibit her sores. Living
out in the country, I do not see how she could
obtain or know about any chemical that
would produce such a death of skin.
VWLU.^BLE C.\NCER COMMENT
Generally, I think, mistakes arise from one of two
causes: The first is imperfect examination, which
may be the fault of the patient or the doctor. The
patient, for various reasons, may refuse to be thor-
oughly examined, or the doctor may continue to
prescribe for his patient without attempting any real
examination. He may, for instance, give treatment
tor "piles" without examining the rectum, or give
medicine for abdominal pain without inspecting the
abdomen. The other fruitful source or error is
want of thought — failure to attain, by a careful
summing-up of symptoms, the clear perspective
which would lead to an immediate diagnosis.
Unfortunately there is no royal road to a diagnosis
of cancer — no short cut, as there is in the case of
syphilis. But we have many valuable aids to diag-
nosis, both bedside and laboratory. In the former
category are such instruments as the proctoscope, the
sigmoidoscope, and the cystoscopc, which are used
far too rarely by practitioners, though in many cases
tkey are easy to use, easy to maintain, and most
invaluiihk in the iitjormalion they give.
In the latter category are tests for occult blood in
the Stools, or for free acid in the storaacb. But it j§
most important to remember that these are only
aids; they must never be considered apart from their
context — the patient. We must guard ourselves
against the danger of getting lost in a laboratory
maze; above all, we must not attach undue import-
ance to negative findings, especially to those of the
x-ray examination. One often finds that both patient
and doctor are lulled into a feeling of security by a
radiologist's report that there is nothing abnormal
to be seen, which is wrongly taken to mean that
nothing abnormal is present.
The subject of early diagnosis embraces a consid-
eration of the preventive treatment of cancer by the
early detection and prompt treatment of condition;,
that we know to be precanerous. I still often se?
patients with warts of the lip and tongue, papilloma:,
of the bladder, small rodent ulcers of the face or
small tumors of the breast, who have been told that
they need not bother about them unless they become
troublesome. By the time such things become trou-
blesome they are troublesome indeed.
— Cecil Ruwniree, in The Britisli Medical Journal,
May 4, 1929,
June, 1929
SOUTHERN MEDICINE AND SURGERY
38S
A Better Perspective in Urology*
C. O. DeLaney, IM.D., Winston-Salem
Lawrence Clinic
In the past decade or so the science of
medicine in all its departments has made un-
paralleled progress. The nine years which
have been added to the average span of life
in the past fifteen years is probably the best
proof of this statement. Preventive medicine
is responsible in part for this great achieve-
ment, but the curing of disease conditions
in which the majority of us are more inter-
ested must claim a part of this honor.
It is not my purpose to overstate the rcla-
t ve importance of my own specialty. How-
ever, it must be evident to all that urology
has passed from the experimental stage and
has firmly established its usefulness in the
diagnosis and treatment of many obstinate
and obscure lesions of the urinary tract.
The development of better instruments and
more skillful technique in their use has cre-
ated a new and better perspective in urology.
A few j'cars ago a cystoscopic examination
was regarded as a mild form of human torture.
In many instances this view was not without
justification. In some of our larger clinics I
have observed practices that stirred within
me a feeling of contempt. In making
cj'stoscopic examinations no anesthetic was
ever employed and any complaint or protest
on the part of the patient was severely con-
demned. Male patients with small urethral
meatus were subjected to meatotomy with
no thought of a local anesthetic. There is
no doubt that practices of this kind have
kept many patients from seeking relief.
The employment of local anesthesia may
well be described as the foundation upon
vh'ch the success of most cystoscopic proce-
dures depends. It is now universally agreed
that in the treatment of surgical cases, in-
cludmg all forms of preliminary exploration
and instrumentation, the infliction of unnec-
essary pain should be sedulously avoided.
The humblest hospital patient has the same
claim as the millionaire to the most anxious
consideration in this respect, an equal right
•Presented to the Tri-State Medical Association of
the Carolinas and Xirsinia, Greensboro, N. C., Meet-
ing February 19th, 20th and 21st, 1929.
to be spared needless suffering. By the use
of local anesthetics it is possible to make a
more thorough study of the urinary tract and
obtain more accurate and comprehensive in-
formation. A cystoscopic examination, prop-
erly conducted, is not a painful experience.
The improvement in the technique of the
use of instruments and the careful observance
of the contraindications has greatly reduced
the number of severe reactions following cys-
toscopic examinations and treatment. It is
hardly possible for even the most skillful
operator to introduce a cystoscope into the
bladder without producing some trauma. It
is of the utmost importance therefore that a
careful general examination and a careful
study of the personal history should precede
every urological instrumentation.
Sometimes a patient comes to us with his
own diagnosis which cannot be confirmed.
Backache to the average person means kidney
trouble. One is not justified in making a
cystoscopic examination in a patient suffering
from Pott's disease with no evidence of urin-
ary involvement. A careful urinarlysis can
usually be accepted as a guide in the study
of urological disorders, though sometimes mis-
leading because of disease conditions in the
kidney in which the urine may be entirely
negative. This is often the cause of delay in
the treatment of renal tumors and other se-
rious diseases.
Another advancement is a development of
a safe medium for urographic work. The
early work of this kind was attended by se-
vere reactions which were occasionally fatal.
Although an ideal solution has not yet been
discovered, there are today several which,
properly employed, are practically safe and
free from irritation. By the use of these in
conjunction with the x-ray, diagnosis has been
greatly simplified. There are many disease
conditions of the kidney in which pyelogra-
phy is essential and without which a diagnosis
cannot be made. The abundance of research
work which has been done in urography has
fairly well established the normal variations
in outline of the kidney pelvis and has per-
386
SOUTHERN MEDICINE AND SURGERY
June, 1929
mitted the classification of numerous abnor-
malities. The early diagnosis of renal tumors
which is so essential to successful treatment
is only accomplished in this manner. To wait
for the appearance of a tumor mass in the
side is to deny the patient any chance of a
cure.
Urologists recognize the necessity for early
and accurate diagnosis in urinary diseases but
our friends of the profession outside our spe-
cialty are not always so impressed. We have
all seen patients who have been suffering for
years under such diagnostic labels as "cys-
titis" and "pyelitis'' who have been relieved
from pain and restored to health by a thor-
ough examination, discovery and removal of a
stone or obstruction that should have been
removed ten or fifteen years before.
A few weeks ago it was my privilege to
examine a patient who had been under con-
tinual treatment for gonorrheal urethritis for
eighteen months. He had been given urethral
irrigations of potassium permanganate solu-
tion twice a week for more than a year and
still had a discharge and pyuria. The exam-
ination revealed granulations of the verumon-
tanum and two applications of silver nitrate
solution effected a cure.
Sometimes the family physician is reluctant
to refer his patient to the urologist because
he feels that it is not necessary for him to
be subjected to a prolonged and painful or-
deal of an examination.
There is one point I wish to emphasize here
for the sake of a better understanding be-
tween the general practitioner and the urolo-
gist. In connection with every disease con-
dition of the genito-urinary tract there are
certain diagnostic objectives that are of ut-
most value in leading straight to a definite
diagnosis. These objectives are clear-cut in
the minds of the urologist and are sought for
in every case that applies to him for treat-
ment. For example: if a floating kidney is
suspected, a pyelogram made in the standing
position will tell him the exact degree of
ptosis and the extent of hydronephrosis if
present. By withdrawing the catheter the
emptying time of the kidney pelvis can be
accurately estimated. While the catheter is
in place a separate kidney function test can
be made. All of this valuable information
can be obtained in less than an hour, and
without it one has no right to forrn an opin-
ion In regard to the management of the case.
Hematuria — which is a symptom and not
a disease — frequently requires an exhaustive
study to determine its cause, but without
knowing the cause what treatment could sug-
gest itself as a means of relief? The treat-
ment of hematuria without a definite diagno-
sis is now looked upon as malpractice.
Kidney colic which at one time suggested
only the passage of a renal stone through the
ureter is now known to be induced by various
forms of sudden ureteral obstruction the ex-
act nature of which must be revealed if a
successful treatment is to be instituted. Renal
calculi are respx)nsible for only a small per-
centage of ureteral obstruction. For this
reason one gains little information of value
from a plain radiogram of the urinary tract.
Full appreciation of the significance of this
fact by our friends in the profession and our
patients as well would mean a better under-
standing between the general practitioner and
urologist and clear up a frequent misappre-
hension on the part of the patient.
The last pwint I wish to make is that new
and better facilities have been provided for
more accurate work in the diagnosis and
treatment of urological conditions in children.
We all know that children are not immune to
genito-urinary diseases, and yet until very
recent years little thought has been given to
urinary diseases in children.
Why should not pyelitis in children receive
the same careful consideration that it does in
adults? Surely we do not all share the view
of a certain physician I know who still main-
tains that pyelitis in children is a self-limited
disease and will subside in a short while with-
out any form of treatment. In this connec-
tion I should like to relate a personal experi-
ence. A few months ago I was called in con-
sultation to see a child of five years who had
suffered a recurrence of influenzal pneumonia
complicated by otitis media and necessitating
paracentesis of both drums. The ears were
draining freely. The temperature was 104
degrees and the attending physician could not
find enough pathology in the chest to account
for the fever. The urine contained an abund-
ance of pus and the child was exquisitely ten-
der over both kidneys. Cystoscopy was per-
formed and both ureters catheterized, each
kidney specimen showed abundance of pus.
The kidney pelves were lavaged with 1 per
June, 102P
SOUTHERN MEDICINE AND SURGERY
387
cent mercurochrome solution. The tempera-
ture promptly returned to normal and re-
mained there. Such an experience makes one
wonder if there are not many similar cases
in which urological treatment is indicated.
Statistics point out that renal neoplasms are
very common in children, but when they are
brought to the attention of the urologist the
great majority are too far advanced to be
given any permanent relief. Urinary calculi
are also not infrequently met with in chil-
dren. In my limited practice I have had
four cases of vesical calculi in children under
four years in the past twelve months. In
each of these cases pyuria had been observed
for more than a year. Is it not reasonable
to presume that an earlier examination might
have obviated the necessity of a major opera-
tion in at least some of these children? It is
my bel'ef, and I am not alone in this conten-
tion, that pyuria in children that persists for
more than a few weeks is sufficient indication
for a thorough urological examination.
There are numerous other pathological con-
d'tions of the urinary tract which are common
in children, such as anomalies, atresias, steno-
s's, congenital strictures, abnormal valves of
(he urctlira and renal tuberculosis.
Instruments are now available which make
possible the same diagnostic methods that are
employed in adults and the more frequent ap-
plication of these measures will save the lives
of many of these little sufferers and thereby
greatly enlarge our field of service.
DISCUSSION
Dr. Hamilton W. McKay, Charlotte:
Mr. President and Gentlemen: The value
of such an essay as Dr. Delaney has just read
must be evident to all. The reaction I al-
ways get from such a paper is that I always
have a desire to take stock. In this way we
have an opportunity to review the accom-
plishments of the specialty in which we are
interested and also review and find out how
we arc attacking our own problems and if
we have any new problems to solve.
The history of the specialty of urology, in
brief, is as follows: We can date the birth
of urology from the birth of the .American
Urological .Association, when urology split off
as a specialty from surgery. For conveni-
ence we can divide this into two periods. In
the first ten years there were two outstanding
things, the development and perfection of
the cystoscope, which made possible the
study of the whole urinary tract. During
that period the urologist was trying to rid
himself of the stigma and classification which
naturally surrounded urology at that time —
of the venercalogist. The second ten years
found the urologist distinguished as a diag-
nostician, able to diagnose difficult disease
conditions of the urinary tract but still not
commander of his ship; in other words, he
would do the diagnostic work, and someone
else would do the surgery. During this pe-
riod the brilliant work of Dr. Young in pros-
tatic surgery was a distinct advance. He
demonstrated that any man of average skill
could enucleate a prostate but that it took a
man of special ability to say when it could
successfully be done. So in the third period
we see the urologist as a man in command
of his own ship, doing his own surgery. Dur-
ing the last period we have seen diseases of
the urinary tract classified, have seen the be-
ginning of work on the ureter, and have seen
the pediatrician turning to the urologist for
advice and examination in obstinate cases.
This, in brief, gentlemen, is a little history
of this specialty.
One of the points I wish to touch on is
anesthesia. One of my early instructors
taught me that three things are essential to
the successful practice of urology — patience,
gentleness, and the ability to select an anes-
thetic. Dr. Delaney did not mention any
anesthetic. If he will allow me to express a
personal opinion, routinely we use a two per
cent solution of cocaine in ma'e and female,
where the urinary apparatus has not been
traumatized. We feel this gives sufficient an-
esthesia; it is not, however, without pain.
Another point Dr. Delaney brought out is
thorough examination. I often picture my-
self standing with a cystoscope in one hand,
the x-ray at my elbow, often trying to find
out and do the spectacular; in other words,
looking for pathology that is difficult to find
when it is often in the urethra or could be
found out by a simple clinical study of the
patient. In other words, gentlemen, I feel
that we work with instruments of precision
so much that the urologist is inclined to be-
come mechanical and forget the clinical symp-
toms and the clinical aspect of his p:itient.
I feel that the modern urologist occui^ies an
enviable position.
SOUTHERN MEDICINE AND SURGERY
June, 1Q29
Dr. Delaney brought out the problem of
pediatric urology, and I think probably this
is the reason he asked me to discuss his pa-
per. I want to bring out two points, and I
believe I am correct and will be borne out by
any urologist — the fact that babies and chil-
dren as a rule stand instrumentation, espe-
cially cystoscopy and ureteral catheterization,
better than adults. I think, however, if a
man is going to do pediatric urology he should
have team work, just as in adults.
Dr. Lawrence T. Price, Richmond:
I enjoyed Dr. Delaney's paper. I rise only
to bring out one point that I think may be of
some benefit, especially to the general prac-
titioner. It is nothing more than the old
Thompson's glass test of urine. There may
be two, three, or more glasses; but
I prefer to use the three-glass test. While
it is not pathognomonic of the location of
the pathology, yet it is enough so to enable
you to say definitely, often, whether it is
urethral, bladder, or kidney. If the urine in
the first glass is cloudy or bloody, the path-
ology is in the urethra; if that in the second
glass is cloudy or bloody, the pathology is in
the posterior urethra. That is not correct in
every instance, but it is often enough to give
the general practitioner an idea of where the
pathology is and what disease he is dealing
with.
I do want to emphasize the matter of an-
esthesia. There is no reason why cystoscopic
procedures should be at all painful to the
patient. I use routinely morphine and hyos-
cine. I am very glad that Dr. Delaney men-
tioned cocaine because there has been so much
discussion of the use of cocaine in the urologi-
cal associations and the untoward results in
some instances. I know these results do oc-
cur in some cases, though I have had but
one bad experience with cocaine, and while
that was not fatal or particularly disagreeble
there was a history which caused me some
embarrassment after examination. Urologi-
cal diagnosis is now accurate in every partic-
ular, and there is no reason why any urologi-
cal problem can not be worked out, provided
the urologist is given sufficient time; but we
know so many Instances, as Dr. Gill men-
tioned in bronchoscopic work, when the pa-
tient is brought in or sent in and is supposed
to be returned home within an hour with the
proper diagnosis made and the pathology re-
lieved.
Dr. a. I. DoDSON, Richmond:
At the last three or four meetings I have
attended there have been a great many pa-
pers presented in which something was said
about the discomfort of an examination. This
is a very healthy attitude. I feel that the
average urological examination, particularly
the use of intraurethral and bladder instru-
ments, regardless of what you do, causes the
patient some discomfort and sometimes too
much discomfort; and efforts made to dimin-
ish this will certainly lead to great improve-
ment.
The urologist has to inform the physicians
he deals with and first has to educate himself;
and that is the fact that he himself is a doc-
tor as well as an instrument manipulator.
There seems to be an idea which has grown
up to some extent that you send a patient
there and he is going to have an instrumenta-
tion. The urologist ought to be capable of
examining and treating patients sometimes
without passing an instrument; he ought to
be able to develop some judgment that will
help him out and not feel that he has to pass
a cystoscope every time he meets a patient
that is sick.
So far as the actual instrumentation is con-
cerned, morphine before and cocaine will cer-
tainly reduce the pain. I find that sometimes
sacral anesthesia is very helpful. I have used
it for about two years and have not had a
reaction that has lasted over five minutes.
Another element is time; we must have
time in which to work out these things. Par-
ticularly in older people it is often unfortu-
nate and sometimes disastrous to try to do
something as soon as they come in. Recently
an old gentleman came in, and an effort was
made to pass the cystoscope the same day.
The cystoscope went partly in, and the urolo-
gist recognized that there was some obstruc-
tion and took it out. The old man went home
and died within a week. We should know
something about the patient before we at-
tempt to do an instrumentation.
It will not do for a procedure that is so
valuable to have doubters or people who are
afraid to use it because of pain. During the
last few months about half the people I have
seen with bleeding from the bladder have had
malignant tumors of the bladder. Bleeding
June, 1020
SOUTHERN MEDICINE AND SURGERY
m
from the bladder is too serious a symptom
for us to pass it over without thorough ex-
amination.
In the diagnosis of abnormalities of the
ureter and pelvis, I believe the urologist and
the roentgenologist, working together, can
give aimost absolute exactness.
Dk. Delaney, closing:
I thank these gentlemen for their discus-
sion. It was not my purpose to emphasize
the need of a thorough examination and to
seek to stimulate co-operation with the urolo-
gist.
The diagnosis sometimes requires several
days. There are some problems in the diag-
nosis that are extremely difficult and that
require that every means of diagnosis be re-
sorted to. Of course, the majority of them
can be worked out accurately if we take the
necessary time, but patients often come in
expecting to have a diagnosis in a few min-
utes and possibly treatment, when the pa-
tient on arrival is not in a safe condition for
any instrumentation but should be observed
for several days and perhaps given an op-
portunity to rest.
I use cocaine anesthesia in a stronger solu-
tion than Dr. McKay; I employ ten per cent
in the female on an applicator in the urethra,
so far without any untoward result.
CHRONIC ULCER OF THE LEG
Three hundred cases of chronic leg ulcer have been
treated by Joseph W. Sooy, Baltimore (Journal
A. Af. A., April 6, 1920), with a modified Unna's
paste. Complete healing has occurred in 85 per
cent and IS per cent show satisfactory progress.
The formula of the paste that Sooy is using is
glycerin, 1,000 Cm., (1,425 ex.); gelatin, 625 Gm.;
water, 1,^00 c.c; zinc oxide 250 Gm.; phenol, 1.50
per cent of total volume making a total of 4,075 Gm.
or 10 pounds, which is sufficient for seven dressings.
After its preparation it is placed in a double boiler
and heiUd to just above body temperature at which
point it becomes fluid and has a viscosity not unlike
that of ordinary paint. In this form it is applied with
a paint brush directly to the skin of the leg from the
bare of the toes upward to just below the knee.
It is allowed to come into intimate contact with the
ulcer, no preliminary dressing being necessary. A
simple spiral bandage without crosses or reverses is
i.|.p!ied over the paste, and then more paste is ap-
plied over the bandage. This is repeated until there
L a total of three layers of bandage and four layers
of paste. The final preparation, when cool, becomes
rubbery hard and makes a pressure bandage which,
ttcause of its slight porosity, will allow escape of the
discharge from the ulcer. A maximum of one hour
a week is required for the application of the band-
ace. The length of time that a single bandage
may be left in place depends on the amount of
Cficma and the amount of exudate from the granu-
lating surface. A light gauze bandage may be placed
around the more permanent paste bandage and the
pijtient instructed to change the former when neces-
5.'.ry. In this manner the exudate which escapes
through the pores of the paste will be satisfactorily
cared for and the dressing will always present a clean
and dry external surface. A paste bandag* which has
been cared for in this manner has been left in place
for as long as twelve weeks, and when at the end
of such a period the bandage has been finally remov-
ed, the ulcer has been found in excellent condition,
sometimes completely healed. The bandage is suit-
able for use in any climate. When the temperature
is very high it may be dehydrated and fixed with a
solution of 85 per cent alcohol, a diluted "solution
of formaldehyde U. S. P." (6 per cent), and 9 per
cent ether. This solution is applied by simply
spongins the bandage. This form of treatment has
also been used in cases of varicose veins with con-
siderable relief on the part of the patient and mark-
ed lessening of the edema of the ankles and lower
leg. Sooy has also used it in two cases of unhealed
secondary burns with very satisfactory results.
Regard that insup'rable mania called golf. It
ccnsists merely of knocking a ball into a hole with
a stick. But the devotees of this pastime have de-
veloped a unique and distinctive livery in which
to play it. They concentrate for twenty years on
the correct angulation of their feet and the proper
method of entwining their fingers about the stick.
Moreover, in order to discuss the pseudo-intr'cacies
of this idiotic .sport, they've invented an outlandish
vocabulary which is unintelligible even to an Eng-
lish scholar. — S. S. Van Dine's, Pliilo Vance.
There is much speculation as to why Marion
Talley has quit singing in opera to live on a farm.
We don't know why she did, but it's a fine example.
— Kay Features.
The inability to perform rhythmic movements
continuously by tapping seems to be associated with
disorders of the cerebellar system.
— F. I. Wertham, in The Journal oj Nervous and
Menial Diseases, May, 1929.
SOUTHERN MEDICINE AND SURGERY
June, 1Q29
Urine Tests for Some of the Products of Yeast Metabolism
J. Arthur Buchanan, M.D., M.S., Brooklyn
The final object of urinary examinations,
as well as of all others, is to determine evi-
dences which indicate causal agencies. Yeasts
produce in their activities in many instances
well known substances. Practically all of
them produce more or less alcohol. Appar-
ently there are some which do not.
The ever increasing number of patients
presenting themselves with so-called fungal
involvement of the skin and appendages stim-
ulates the investigation of similar invasion of
the internal organs. Fungi or molds are one
stage of the life cycle of yeasts. The most
direct means of making this investigation is
to test the urine for end-products of yeast
metabolism. The same tests are, however,
readily carried out on saliva, blood serum,
and watery solution of stool.
The simplest tests for determining the
presence of the products of yeast metabolism
are the bichromate, and the iodoform. These
tests indicate the presence of alcohols, acetal-
dehydcs, acetone and several. other products.
The quantitative methods in use in my labor-
atory require small equipment and a short
intervals of time for the work.
The Bichromate Test. — Pour two c.c. of
urine into a graduated centrifuge tube; add
one-half c.c. of ten per cent potassium bichro-
mate solution; then add concentrated sul-
phuric acid drop by drop until a final depth
of greenness is produced. The reading is ta-
ken as the end point. The fumes given off
during the test are significant.
The Iodoform Test. — Pour two c.c. of
urine into a graduated centrifuge tube; add
one-half c.c. of U. S. P. Lugol's solution; then
forty per cent sodium hydroxide solution drop
by drop until a final depth of yellowness is
produced. The reading is taken as the end
point. The characteristic odor of iodoform is
observed, and, if deemed necessary, the crys-
tals are examined under the microscope.
The quantities of substances present as rep-
resented by the end point are in reverse
amount to the reading. The end points are
used for comparative studies during treatment
and observation.
These tests are, of course, not original with
myself. They represent the clinical applica-
tion of tests well known to chemists.
In any patient in whom these tests are
positive proper cultural steps for yeasts will
show the causal yeast or yeasts. These tests
make it obvious that many hitherto poorly
understood diseases are the expression of pro-
longed poisoning by yeasts. The human body
by our present methods of feeding is being
constantly poisoned by the products of yeast
metabolism occurring at its roots — namely,
the bowels, the same as goes on in the roots
of trees on which seedless fruits are grown.
The intestines contain the poisonous sub-
stances that are left in the bottom of casks.
The wine- and liquor-maker gets rid of these
by decanting or by fractional distillation. In
the intestines many of these substances are
absorbed, so that not only local irritation re-
sults, but the organs of elimination, as well
as those of transportation, are gradually de-
stroyed by the products of yeasts. The
yeasts destroy certain substances that are in
the cells. These substances are necessary for
regularity of growth and intercellular co-oper-
ation. Remove these substances and the cells
harmed revert to independent action as pri-
mordial yeasts. The activity of the cells as
they revert to their primordial action is in
direct proportion to their physiologic activity
in the various organs of the body. This is
biologic.
The urine tests for products of yeast fer-
mentation are of extreme simplicity; yielding
information of paramount importance, while
opening a vast new field for clinical labora-
tory investigation.
SIO Ocean Avenue.
If, during the period of drainage preliminary to
a prostatectomy, the patient complains of constant
pain in the region of the prostate, bear in mind the
possibiUty that it is malignant.
It is held by some that carcinoma of the pros-
tate should be at least suspected in patients who
complain of pain in the end of the penis at the
beginning of micturition and which ceases as the
flow continues.
June, 1020
SOUTHERN MEDICINE AND SURGERY
m
Chronic Appendicitis as a Cause of Indigestion*
M. O. Burke, M.D., Richmond
There is a doubt in the minds of many in-
ternist as to the existence of chronic appen-
dicilis: Ihfy have some strong evidence in
their favor. This body of surgeons, internists
and specialists have had enough experience to
decide the question as to whether we have or
do not have chronic appendicitis.
Drs. Carnett and Boles\ of Philadelphia,
presented a paper at the A. M. A. meeting
in Minneaix)lis (1928) entitled: "Fallacies
Concerning Chronic Appendicitis." They
make this statement: "A clinical diagnosis
of chronic appendicitis implies that the pa-
tient has a localized disease confined to the
appendix, that appendectomy is indicated,
and that the operation will provide a cure.
We believe that chronic appendicitis is not
a disease limited to the appendix."
TakinjT these statements literally we can-
not confute them. Some claim that operation
for chronic appendicitis does not relieve the
digestive symptoms. We know that many
cases, both acute and chronic, have had ap-
pendectomies without benefit; some have been
made worse. We also know that many pa-
tients have died because they did not have
an operation soon enough or not at all. It
is evident that many appendices have been
accused, convicted and executed that were
entirely innocent. We are probably prone to
convict the appendix when we can't find some
other definite cause for the trouble. Discom-
fort and tenderness in the lower right quad-
rant does not always indicate appendicitis,
nor does tenderness and pain over the same
area necessarily mean intercostal neuralgia,
as described by Drs. Carnett and Boles.
Is it possible that all of the text books are
wrong in describing chronic appendicitis?
Are the experience of such internists as Aaron,
EInhorn, Friedenwald, Rehfus, Smithies and
the world famed Osier worth nothing? Shall
we discard the reports of our best roentgen-
ologists and count as fallacies the experiences
of our leading surgeons?
♦Presented to the Tri-State Medical Association of
(tie Carolinas and Virginia, Greensboro, N. C, Meet-
ing February 19th, 20th and 21st, 1929.
At the twenty-sixth annual meeting of the
American Radiological Society, Dr. A. L.
Gray- reported a series of cases of chronic
appendicitis as a cause of acidosis in children,
diagnosed as chronic appendicitis, operated
and cured. Deaver and Rodwin^ report 500
cases of chronic api)endicitis with operation:
83.1 per cent entirely relieved, 9.7 per cent
partially relieved, 7.07 per cent unrelieved.
Believing that chronic appendicitis is a
cause of indigestion has led me to write this
paper. Trouble manifested by the stomach
is more often extragastric than intragastric.
The following are replies from some of our
outstanding gastro-eiiterologists as to the per-
centage of cases of indigestion caused by
chronic api3endicitis: Aaron 10 per cent, Ein-
horn 2.5 per cent, Friedenwald 10 per cent,
Smithies 7 per cent.
In going over my own case histories I find
about 10 per cent of cases of indigestion diag-
nosed as due to chronic appendicitis: 50 per
cent of these were diagnosed, operated and
cured; 50 per cent diagnosed, not operated,
benelited by treatment, but not cured.
CLASSIFICATION
Royster's'' classification of chronic appen-
dicitis:
1. Catarrhal.
2. Interstitial.
3. Obliterating.
The types of chronic appendicitis that
cause indigestion may be classified as:
1. Recurrent mild api^endicitis.
2. Partial occlusion of any portion of the
appendiceal canal.
3. Appendices with adhesions.
In some instances of appendiceal adhesions
the appendix was not the offending party; it
was caught in bad company. The appendix
may be attached to any of the inhabitants
of the abdominal cavity. I have seen it at-
tached to the stomach, producing symptoms
of a gastric ulcer and have seen it imbedded
in a mass of omentum held fast in the femo-
ral ring. We can readily conceive of trouble
when the appendix, an organ two to five
inches long, has one end fastened to the ce-
SOUTHERN MEDICINE AND SURGERY
June, 1929
cum and the other end tied to something sev-
eral inches to several feet longer than itself.
Natural peristalsis of the intestines would
cause tension on the appendix and extensive
peristalsis would cause greater tension; thus
producing irritation in the appendix and in
the organ to which it is attached.
A narrowing of the lumen of the appendi-
ceal canal may permit the entrance of mate-
rial from the cecum but may retard or ob-
struct its exit; as a consequence, decomposi-
tion, fermentation and formation of toxins
take place, causing irritation, possibly ulcera-
tion and absorption of p)oisons.
Recurrent appendicitis may be of the ca-
tarrhal, interstitial or adhesive type, or it
may combine all three types. The attacks
may be frequent or far apart. The symptoms
may be irritative or mildly toxic. The gastro-
intestinal tract is supplied by the vagus nerve,
the nerves from the sacral portion of the
spinal cord, the sympathetics and the plexu-
ses of Auerbach and Meissner, also Keith's
nodes. The vagus extends to the descending
colon. The same portion of the gastro-intes-
tinal tract receives its sympathetic nerve sup-
ply from the superior mesenteric ganglion.
"The muscular and glandular structures are
activated by the parasympathetics and receive
inhibitory impulses from tlie sympathetics."
"An equilibrium of action is maintained
when the excitability of the parasympathetics
and sympathetics equal each other, or when
the excessive excitability in the one is still
short of overcoming the excitability of the
other."''
Chronic appendicitis may produce chemi-
cal, mechanical or toxic irritation. From the
symptoms produced by traction on an adher-
ent appendix we are led to believe that me-
chanical irritation stimulates the parasympa-
thetic nerve supply. The symptoms of a re-
current attack of api^endicitis bear out the
statement by I'ottenger" that "toxins stimu-
late the sympathetic nerves."
The symptoms produced by chronic appen-
dicitis are reflex symptoms, except the tender-
ness of the appendix or an inflamed viscus to
which it is attached; this accounts for the
difficulty in making a diagnosis— and enables
us to understand why chronic appendicitis
causes indigestion. Irritation in the appendix
is most frequently reflected to the stomach
and duodenum, if the impulse is transmitted
by the vagus it may cause cardiospasm or
pylorospasm, hypersecretion and increased
peristalsis; manifested by pain, a sense of
fullness and sour stomach. Next in frequency
the terminal ileum, cecum, ascending and
transverse colon are affected.
If the circular muscles receive the greater
impulse we may have contractions and in-
creased secretion with a dilated condition and
delayed contents above the constriction; pro-
ducing stasis, decomposition and fermenta-
tion; manifested by fullness, pain or discom-
fort and constipation; or if the longitudinal
muscles receive the greater impulse we may
have increased peristalsis and secretion; man-
ifested by diarrhea and mushy stools.
If the sympathetics are stimulated more
than the parasympathetics we may have sta-
sis of the main viscera with contraction of
the sphincters, decreased secretion and in-
creased absorption; manifested by slight rise
in temperature, headache, lassitude, irritabil-
ity, weakness, constipation, a dead heavj^
feeling in the abdomen with or without dis-
tention and a general miserable condition.
The symptoms may be constant companions,
frequent visitors, or occasional unwelcome
guests. They may be very mild in type or
of considerable vigor. Ordinary diet and ex-
ercise have but little effect in relieving or
causing tlie symptoms, while imprudence in
either may bring on an attack.
The symptoms can be briefly stated as col-
icy pains, acid stomach, gaseous distention,
constipation, headache, lassitude, irritability,
nervousness, general weakness, despondency,
and more or less rigidity of the muscles in
the lower right quadrant.
DIAGNOSIS
Remembering tiie fact that indigestion is
more often a symptom of trouble outside than
inside the digestive tract makes us more care-
ful in searching lor the cause. A full history
past and present is essential. A thorough ex-
amination of the patient is imperative. The
abdominal examination should be last and
exhaustive. Auscultation ascertains the rate
and rhythm of peristalsis. Percussion dem-
onstrates the presence or absence of solid or
liquid masses and the extent of tympany: by
the different notes we can usually outline the
stomach, intestines and colon. Palpation is
a most valuable ally in diagnosing abdominal
trouble; by it we recognize rigidity in the
June, 1929
SOUTHERN MEDICINE AND SURGERY
393
abdominal muscles, in thin abdomens we can
often feel the constricting spasms in the in-
testines and the distended portion above them.
We can feel the violent peristaltic waves pass-
ing under the hand; we can bring out the
tender points by pressure; we can feel and
often empty a stagnant cecum.
X-ray examination in chronic indigestion
is most valuable and for a correct diagnosis
often indispensable. Dr. Gray can give you
the x-ray diagnosis much better than I, so I
shall leave that to him.
The points upon which I rely most in mak-
ing a diagnosis of chronic appendicitis as a
cause of indigestion are these:
1. A history of an attack of colic or pain
in the lower right quadrant, diagnosed or un-
diagnosed as appendicitis.
2. Rellex types of indigestion.
3. A palpable tender cecum with some rig-
idity of oblique, transverse and psoas mus-
cles in lower right quadrant.
4. Recurrent attacks of so-called bilious-
ness in adults and acidosis in children, with
a tender palpable cecum.
5. The above symptoms, plus x-ray con-
firmation and diagnostic exclusion of every-
thing else that could reasonably cause the
trouble.
A positive diagnosis of chronic appendicitis
is the most difficult task undertaken by the
internist or surgeon.
TREATMENT
The only cure for appjendicitis is surgical
but surgery is not always advisable. We
must remember that the nerves involved in
indigestion caused by any chronic condition
are sensitive for a long time after the cause
has been removed. If we are reasonably cer-
tain that the appendix is the offender in a
child by all means remove it. There are
many brilliant examples of success in appen-
dectomies for chronic indigestion in children,
some in adults and even in old people. Com-
plications, the general condition of the pa-
tient and the type of patient often make us
hesitate to advise an operation.
Regulation of diet, exercise and general
advice as to living will often guide the
chronic appendiceal bark through the trou-
bled waters of a long journey to a safe haven
from which some other malady will finally
collect the ticket for eternity.
SUMMARY
1. We do have appendiceal indigestion.
2. Irritations in the appendix are trans-
mitted by the vagus and sympathetic nerves,
producing symptoms in the stomach, small
intestines and colon.
3. A diagnosis can be made by exclusion.
4. Appendectomy will effect a cure in prop-
erly selected cases.
BIBLIOGRAPHY
1. Jour. A. M. A., Dec. 1, 1928.
2. Amer. J. oj R. & R. Therapy, Nov. 1925.
3. 4. RovSTER — "Appendicitis."
5. 6. 'Symptoms of Visceral Disease," Potten-
CER.
DISCUSSION
Dr. R. C. Bryan, Richmond:
]\Ir. Chairman and Gentlemen:
Twenty or twenty-five years ago there was
hardly a meeting of any medical society but
that many papers on appendicitis were pre-
sented. So many were presented that I think
the committees had to call them down; and
very seldom now do we hear papers on ap-
pendicitis, except on the technic of the oper-
ation, diagnosis, and the x-ray diagnosis of
appendicitis. So I think possibly the technic
of operation and of diagnosis has been pretty
well covered.
I am indeed glad to have heard Dr.
Burke's paper. In my mind I am certain
there are cases of chronic appendicitis. The
appendix is an organ five inches long. It
presents its muscular and mucous wails, as
does the intestine. It is highly organized, a
blind pocket which hangs downward and is
therefore receptive of intestinal contents. Co-
litis and enteritis may advance by continuity
to this organ, and in doing so, the crypts of
Lieberkuhn are congested and produce more
mucus, and then follows a definite pathologic
invasion of changed epithelium, development
of rounds cells throughout the submucosa of
the entire organ; it becomes sclerotic, dense,
hard, and acts as an anchor, when attached
to some other viscus. This process may con-
tinue, with more round-cell invasion. The
organ becomes thicker and heavier. Here
and there is an over-production, shutting off
of the lumen of the organ, so that it is damm-
ed up. Retention occurs, inviting further re-
striction of the peristaltic waves of the in-
testine. If the round cell injection continues
the lumen becomes completely obliterated,
SOUTHERN MEDICINE AND SURGERY
June, 1920
and it is now a long fibrous cord most likely
attached to some other organ. I know all
of us here can report many cases of chronic
appendicitis.
I should like to recall one case that inter-
ested me, the case of a lawyer in Richmond
who had many attacks of severe indigestion,
violent attacks; often while in court he was
taken suddenly, while on his feet addressing
a jury, and had to stop. He went to Balti-
more and after prolonged study was said to
have colonic ulcer. The x-ray never could
pick it up. He came back and continued to
have pain. I put it up to him that possibly
he had appendicitis and that its obliterative
character did not permit of the barium meal's
being passed into the appendix. He was oper-
ated upon; and the appendix was found to
be of extraordinary length, running up in the
abdominal cavity and the end attached to the
pyloric orifice of the stomach. It was re-
moved; the patient recovered; and immedi-
ately he began to gain weight and to improve
in every way.
I am satisfied that there are many cases of
chronic appendicitis. To say that a tube five
inches long, lined with mucous membrane,
cannot undergo pathologic degeneration would
be about as unwise as to say that the intes-
tine, or any other mucous tract should forever
be free from actual pathology. To my mind
the appendix is subject to the same laws and
end results as any other part of the body,
and because of its frequent consideration and
advertisement enjoys no immunity from dis-
ease.
Dr. F. R. Taylor, High Point:
I am very glad to have this subject brought
up before this society, because the tendency
recently has been to think "there ain't no
such animal." Etiologically there may be no
such thing; it might be better to say "chronic
appendiceal disease."
I had a rther interesting experience with
a professional friend of mine a few years ago,
a graduate of one of the greatest medical
schools in the world but a school where it
seems to be the accepted teaching that chronic
appendicitis does not exist. He had been
suffering with indigestion for several years,
repeated attacks of indigestion, and was very
tender over the appendix. It took a long
time to persuade him to have an appendec-
tomy. I was present when the appendectomy
was done, and when an apparently normal
appendix was shown to me my heart sank
within me, because he had acted on my judg-
ment rather than on his own. When he de-
veloped pwst-operative pneumonia my heart
sank still further, but when he recovered
from both the pneumonia and the indigestion
I was encouraged, and he was converted to
the doctrine of chronic appendicitis.
Chronic appendicitis is one of the most
frequent clinical conditions we meet with in
apparently healthy persons, and I am cer-
tainly very glad to see this society going on
record in favor of chronic appendicitis.
What shall we do for it? One thing we
can do is surgery, and surgery is not always
indicated. There should be a consultation
of the surgeons with the internist and roent-
genologist before the case is decided upon.
Dr. James M. Northington, Charlotte:
I should like to have about a half minute
in which to say that I am in utter dissent
with what Dr. Taylor has just said and also
to protest against his saying that this society
has gone on record in favor of the idea that
chronic appendicitis is a condition frequently
met with.
Dr. a. L. Gray, Richmond:
Dr. Burke asked me to discuss briefly the
x-ray diagnosis of appendicitis. I may say
in the beginning, just as Dr. Bryan does, that
it is almost useless to say that you think
there are cases of indigestion produced by
chronic appendicitis. I have seen so many
whose clinical course was practically identi-
cal with the cases Dr. Bryan cited that I
think there is no question whatever about it.
He refers in this case to the fact that x-ray
examination did not show the appendix. Of
course, you all know we are dependent en-
tirely upon the filling of the appendix with
an opaque medium in order to see the appen-
dix at all or tell anything definite about it.
Sometimes we may presume, from tenderness
in the ileo-cecal region, that the appendix is
responsible for the tenderness; but we can
not say definitely.
I have set down the evidences of chronic
appendicitis. No roentgenologist who knows
what he is doing will attempt to prove wheth-
er or not a patient has acute appendicitis.
It is little short of criminal to try such a
thing. Doctors Carman and Miller, from
their work at the Mayo clinic, gave us a
June, 1929
SOUTHERN MEDICINE AND SURGERV
treatise which is recognized as an authority.
They have listed the diagnostic points as
brought out by the different authorities.
They placed them in this order: First, shad-
ows of concretions in the appendix; secondly,
kinking in the appendix; third, malposition;
fourth, adhesions about the appendix and
cecum; fifth, retention of barium in the ap-
pendix; sixth, ileal stasis; seventh, insuffi-
ciency of ileo-cecal valve; eighth, spasticity
of the colon; ninth, pressure on a tender point
related to the appendix. Some of these I
think are exceedingly valuable; others, in
my personal experience, I have attached very
little importance to. I would stress in the
following order the evidences of appendicitis
by the x-ray method: first, tenderness which
follows displacement of the appendix. Ten-
derness in the right iliac fossa does not al-
ways mean appendicitis, because in my ex-
perience there are just as many tender peo-
ple who have had the appendix removed and
that flinch when you press pretty hard over
this region, as there are who have not had
the operation done. So tenderness following
displacement must be confined very closely
to the appendix itself. Nearly always, in a
perfectly normal individual, the cecum re-
tains its contents longer than any other por-
tion of the large intestine. A certain amount
of fermentation goes on there, gas is formed,
and pressure over the gas causes a sharp pain
which causes the patient to flinch. The sec-
ond point I would emphasize is the presence
of concretions in the appendix; I mean by
concretions, fecolilhs. Third, adhesions, when
they are definitely adhesions. We can not
always say when the appendix is adherent,
because the position may be such and the
patient's abdominal muscles so rigid that it
is frequently difficult to distinguish between
imprisonment and adhesions. I have largely
refrained recently from saying that an ap-
pendix is adherent; I say it is fixed in its
position by adhesions or imprisonment.
Fourth, kinks. Fifth, dilatation of a portion
of the lumen, resulting in retention of the
barium contents from thirty-six to forty-
eight hours after the cecum has emptied its
contents. The appendix is supixised to empty
about the same time the cecum does, and
retention in the dilated portion of the appen-
dix, of the barium mixture longer than thirty-
six to forty-eight hours is significant. I have
seen it remain there for several months. Last
of all, but by no means least, I think pyloro-
spasm is one of our best indications of a dis-
eased appendix. When I see pylorospasm
and am unable to find an ulcer to account for
it, my first thought is the appendix and next
the gall-bladder.
Dr. T. Dewey Davis, Richmond:
Speaking from the standpoint of the in-
ternist, I should like to say that one of the
most difficult problems in our field is to de-
termine whether indigestion is caused by
chronic appendicitis or not. Several years
ago I analyzed the histories of four thousand
patients who had indigestion diagnosed as
due either to chronic appendicitis or gastric
neurosis, about half and half. Strikingly
enough, just about half the patients with gas-
tric neurosis had had the appendix removed.
This emphasized the difficulty of saying when
the appendix should come out and when it
should stay in. This adds to the difficulty
of the matter. So many of these patients
have other evidence of motor instability or
whatever you want to call it — that is, have
other evidence of being of the neurotic type.
In this type of case, particularly, the indi-
gestion may have no connection with the ap-
pendix. I am quite sure there is such a dis-
ease as chronic appendicitis, but I should like
to speak a word against the promiscuous tak-
ing out of appendices when the operation is
not justified.
BEAR THESE IN MIND
(From The Urologic and Cutaneous Review)
In acute iritis think of syphilis at once.
Rank and station mean nothing to the spirochete.
For sweating feet a weak solution of formahn is
well worth trying.
A little swank now and then does no harm even
to the best of men.
Work and fixedness of purpose put a doctor
f.irther along than brilliance.
For the purpose of making a micro.scopical dlag-
nniis of gonorrhea, learn a good method of using
tin Gram stain anil apply it with exactness each
time.
lie suspicious of vesical stone in the case of boys
who suffer from priapism and pull at the prepuce.
On more than one occasion an abdominal "tu-
mor" has been completely removed through a
catheter.
396
SOUTHERN MEDICINE AND SURGERY
June, 1929
Diabetes Mellitus*
H. C. Stillwell, M.D., Maiden, N. C.
Diabetes is a disease of metabolism in
which the carbohydrates are not properly
utilized which results in increase in the blood
sugar followed by glycosuria. The underly-
ing pathology is disease of the pancreas with
impairment of the function of the islands of
Langerhans.
Heredity plays an important part in the
etiology, it being often seen in more than one
member of a family. It seems that overeat-
ing helps to bring about the disease, probably
by overworking the islands of Langerhans,
just as with kidneys in chronic interstitial
nephritis. According to Dr. Thomas McCrae,
in the past two years diabetes has increased
in proportion with the consumption of sugar.
In 1900 there were 9.3 deaths per 100,000
population; in 1915, 17.5 per 100,000.
There occurs a so-called alimentary glyco-
suria sometimes from ingestion of large quan-
tities of food. It is not of very much im^
portance. The normal sugar content of the
blood is about .1 per cent; when the amount
of carbohydrates eaten goes beyond that
needed for immediate burning to produce en-
ergy and for storage in the liver and muscl^
as glycogen, even in the non-diabetic, the
amount in the biood is increased and goes
over the renal threshold which differs in indi-
viduals but is usually about .2 per cent and
the surplus is disposed of through the kid-
neys.
Brain injuries, tumors, meningitis and
hemorrhage sometimes cause transient glyco-
suria.
Symptoms. — Thirst, most pronounced an
hour or two after meals, is the most notice-
able, and this may be the symptom to bring
the patient to the doctor. There is an un-
usual craving for sweets. In spite of a raven-
ous appetite the patient usually loses flesh
and often the skin becomes dry and pruritic,
either generally or locally. The urine is in-
creased, often causing the patient to get up
5 or 6 times a night. The specilic gravity is
♦Presented to Tri-County — Catawba-Caldwell-Lin-
coln (N. C.)— Medical Society, Sept. 11, 1928,
high, usually about 1030 and sugar is pres-
ent.
Complications. — Coma is the complication
in diabetes, very often being the first indica-
tion leading to the diagnosis. The patient is
not cyanotic but is dyspneic and has the odor
of acetone on the breath. If the patient is
seen for the first time in coma, it is necessary
to differentiate between diabetic coma, ure-
mia and apoplexy. In diabetes the odor of
acetone on the breath is suggestive. The
blood-pressure is not necessarily high and
there is no evidence of paralysis in any part.
Examination of the urine shows the presence
of sugar; a demonstration of marked increase
of the blood sugar not dependent on the re-
cent taking of carbohydrate is conclusive. Art
important point and one that is not often
stressed is the tension of the eyeballs. In
diabetic coma they are soft. In cerebral
hemorrhage there is no distinctive odor to
the breath; the blood-pressure is high; there
is paralysis, which often includes the throat
muscles and tongue causing stertorous breatli-
ing and loss of speech or slurring; the urine
is sugar-free. In uremia the odor of the
breath is almost as conclusive as in diabetes;
the blood-pressure is usually high; there is
a silvery -white coating on the tongue;
there are profuse sweats which usually leave
a deposit on the skin, especially under the
arms; the urine usually shows albumin and
casts, and the non-protein nitrogen of the
blood is increased.
Boils and carbuncles often occur in dia-
betes. A frequent concomitant is arterio-
sclerosis, often followed by gangrene,
which usually begins in the great toe and
gradually spreads, often leading to amputa-
tion. Diabetic cataract is also frequent.
Diagnosis. — The history is suggestive. Ex-
cessive thirst and frequent urination should
lead to examination of the urine, and if nec-
essary examination of the blood for increase
in the blood sugar. The patient has a raven-
ous appetite but becomes emaciated.
Prognosis. — The outlook in diabetes has
been greatly changed since the discovery of
June, 1029
SOUTHERN MEDICINE AND SURGERY
insulin. The younger the patient the less
favorable the prognosis. In the days before
insulin, diabetes in children was almost in-
variably fatal; now the outlook is far more
favorable. Boyd and Nelson, of the Univer-
sity of Iowa, report that the average develop-
ment of the well controlled diabetic child in
a large group of cases was better than that
of a control group of non-diabetics. In older
persons, especially after the age of fifty, the
prognosis is more favorable than in the
young. Few if any diabetics get permanently
well, but, under the proper restrictions of diet
and with the aid of insulin, comfortable and
useful lives may be lived, with little reduc-
tion of expectancy.
Treatment. — The first thing to do is to
make an estimate of the severity of the case
by studying the symptoms, the urine and the
blood sugar. This should always be done in
taking charge of a case and the blood sugar
should be determined again to note the effect
of treatment. A rough estimate of the prog-
ress of the case may be made from the
amount of the precipitate with Fehling's so-
lution. The blood sugar, of course, is the
tiue index of the severity of the disease. The
amount of sugar excreted in the urine is only
a rough estimate because the renal threshold
is higher in some individuals than in others.
The presence of acetone and diacctic acid in
the urine are proof of acidosis from deficient
oxidation of the fats in the tissues.
\ good working plan is to get the urine
sugar-free and endeavor to keep it so. In
cases of moderate severity it is well to begin
by giving 15 units of insulin before the next
meal, then ten units before each meal. This
procedure is experimental until the proper
dosage can be determined. It should be re-
membered that the first ten units given do
most of the work, i. e., the effect produced
when large doses are given is not in propor-
tion to that of small doses. If after forty-
eight hours the urine remains loaded with
sugar and the symptoms are still present the
dose should be increased. If, on the other
hand, the urine becomes sugar-free in 2 or .3
days the dosage may be cut down and the
diet regulated so as to use as little insulin
as possible. The diet is of the greatest im-
portance. It should be rich in proteins and
poor in fats and carbohydrates. The more
food eaten the more insulin is required to
take care of it. There is a difference of opin-
ion among some of the authorities as to feed-
ing the patient well and giving him as much
insulin as required until he puts on weight,
or giving a more restricted amount and using
as little insulin as possible. Each patient pre-
sents a different problem. It is best in the
majority of cases to give as light diet as will
keep them fairly well nourished. The body
needs about sixteen calories per pound of
weight daily. Children need more for growth.
The diet must be worked out by a table giv-
ing the calories and the percentage of fats,
carbohydrates, and proteins in the various
foods. After the patient is started off, a
member of the family or the patient himself
can be taught to give the insulin and he soon
learns what to eat. He can tell fairly well
by his feelings when he needs insulin, but
this can not be relied on.
There is danger in giving insulin of pro-
ducing insulin shock from hypoglycemia.
This is easily remedied if found out in time.
The symptoms are thirst, dizziness, faintness,
syncope. Orange juice is the best practical
remedy. Cane sugar may be used. If the
[latient is too far gone to take anything by
mouth, glucose should be given intravenously.
All diabetics do not need insulin. The
mild cases can be controlled by restricting
the diet.
In March, 1928, I was called to see a girl,
aged eighteen, who was unable to sit up and
had been bedfast for a month. She had a
brother who died at the age of fifteen of dia-
betes. She was very fond of sweets and had
a ravenous appetite, but she had been losing
weight for the past two years. She was
always thirsty and had had to get up at
night to urinate for the past year — for some
lime, every two hours. Her normal weiglit
had been 130; present weight 75. The skin
was dry and scaly, the tongue and throat
diy, pulse 96, respiration 24, bedsore on right
buttock, edema of right ankle, urine loaded
with sugar.
Twenty units insulin were given before
supi)er, which consisted of a small piece of
lean ham, a slice of toast, and a glass of milk.
The patient went to sleep an hour after sup-
|)cr and slept six hours without having to
urinalo. Fifteen units were administered be-
fore each meal the following day and on the
third day the urine still gave the reaction of
SOUTHERN MEDICINE AND SURGERY
June, 1929
sugar, but decidedly less. This dosage was
continued and the fourth night about eleven
o'clock she had a slight insulin reaction which
was relieved by sucking an orange. The dos-
age was cut down to 12 units before meals.
The fifth morning edema of both ankles ap-
peared. It slowly increased for 5 days, al-
most reaching the knees and gradually dis-
appeared with salt-poor diet. It was entirely
gone in ten days. During this time she had
two more slight insulin reactions. Owing to
the fact that the reactions were in the after-
noon or evening, the noon and evening doses
were again cut down until she was getting
12, 10 and 8 units daily. There were no
more reactions, and the urine was now sugar-
free. This dosage was continued and in three
weeks she had gained considerable weight and
was able to walk about. At the end of six
months she had reached her normal weight.
The point I want to emphasize is develop-
ment of edema following administration of
insulin. At the time I first saw this patient
I had read an article in the Journal entitled
"Insulin Edema," in which the author cited
a case that gained 26 pounds in 10 days and
lost 12 pounds in a few days with the same
insulin dosage but restricted salt intake. The
author says the edema is not a result of im-
paired renal capacity. There is usually little
albumin in the urine and nitrogenous excre-
tion is not decreased. He advances the the-
ory that the insulin increases the hydration
power of the tissue colloids of the body and
hence the retention. The more severe the
case of diabetes the more apt is the edema
to occur.
The best procedure in the treatment of
coma is to inject intravenously 50 c.c. of a
25 per cent solution of glucose with 40 units
of insulin incorporated in it. The glucose is
more important than the insulin. Consider-
ing the fact that the blood is already over-
loaded with sugar it would seem an irrational
procedure to add to it; but coma is not the
result of increase in the blood sugar, but of
acidosis, or increase in the ketone bodies
which are formed from the fatty acids be-
cause of improper oxidation resulting from
the incomplete assimilation of carbohydrates.
Fats burn in the fire of the carbohydrates
and the greater the percentage of sugar in
the blood in diabetic coma, even though only"
part of it is oxidied, the better the oxidation
of the fats. It may be necessary to repeat
the injection. Of course, a case of this kind
is better treated where it is possible to check
up ori tlie blood sugar.
Rules for Bleeding in Pneumonia
(Abstract in Charleslcn Medical Journal, 1852)
If we are called to a case at a very early period before exudation is poured out,
and before dullness, as its physical sign, is characterized; but when, notwithstanding,
there have been rigors, embarrassment of respiration, more or less pain in the side,
and commencing crepitation; then bleeding will often cut the disease short. This
state of matters is rarely seen in public hospitals. When, on the other hand, there is
perfect dullness over the lung, increased vocal resonance, and rusty sputum; then
exudation blocks up the aircells, and can only be got rid of by that exudation being
transformed into pus, and excreted by the natural passages. In such a case, bleeding
checks the vital powers necessary for these transformations, and, as a general rule, if
the disease be not fatal, will delay the recovery. I believe this to be the cause of so
much mortality from pneumonia in hospitals where bleeding is largely practiced, for,
in general, individuals affected do not enter until the third or fourth day, when the
lung is already hepatized.
SYNTHALIN IN DIABETES
One cannot help but feel that synthalin is a step forward in the treatment of diabetes, as it
marks the inception of a drug which given by mouth has a definite effect on the blood-sugar level.
In its present form, and until its toxicity is definitely established, it should be used with care
and discrimination. We do not acree with Duncan that it should be used in every case of diabetes.
It cannot and should not replace insulin, especially in the younizcr diabetics. We have used it in
cases which we could not keep sugar free on diet alone and who were unwilling to t;ike insulin.
— E. P. Ralli, The Journal of Laboratory and Clinical Medicine, May, 1929.
June, 1929
SOUTHERN MEDICINE AND SURGERY
Carcinoma of the Large Intestine*
Jas. W. Gibbon, M.D., Charlotte
Distant metastases of carcinoma take place
through the lymphatics of the tissues involv-
ed. Thus the richness of the lymphatic sup-
ply very materially determines the rate with
which carcinoma metastasizes from any given
area. Accordingly, in regions with a sparse
lymphatic supply the development of metas-
tases is slow, and occurs late in the course
of the disease, the carcinoma remaining
purely a local lesion for comparatively long
periods. Conversely, in organs of rich lym-
phatic development, cancer metastasizes early
and rapidly. The foremost examples of the
first group are carcinomata of the large intes-
tine and the fundus uteri, both of which are
slow to metastasize and long remain local.
In the second group are the carcinomata of
the breast, the stomach, and the cervix uteri,
the ominous prognosis of these being a too
familiar subject to us all. In contrast to the
discouraging outlook of cancer of the rectum,
stomach, breast and cervix, carcinoma of the
colon offers a favorable prognosis for com-
plete cure after the eradication of the local
disease. Because of the peculiar scantiness
of the lymphatics of the colon, malignant
growths here remain local without distant and
even glandular metastases for prolonged pe-
riods. A prompt — or sometimes a late —
diagnosis with the institution of proper sur-
gical treatment should and does give a much
less dismal outlook than malignancy in other
portions of the body.
Carcinoma of the colon is relatively fre-
quent, and probably if given more attention
would be more commonly encountered. Too
often it is unsuspected, and the appendix is
reninvcd, and later it is found that a growth
in the colon is the real lesion. Jones, in his
series at the Massachusetts General Hospital,
reports several instances of this error. In
1918, there were 90,000 deaths in the United
States from cancer, and 10 per cent or 9,000
of these were due to cancer of the intestine.
While it is commonly a disease of the fourth
and fifth decades, the occurrence in early
♦Presented to Mecklenburg County Medical So-
ciety, May 21, 1929,
youth is by no means rare. In my own
experience, cancer of the colon was dis-
covered in a youth of 17 years. A number
of similar instances are reported in the liter-
ature. Every effort should be made to make
a diagnosis before the onset of an acute com-
plete obstruction. An acute obstruction with
its attendant hazards superimposed upon a
malignant disease of the colon converts a se-
rious enough condition into a critical one.
The earliest, and perhaps what might be
termed only "suggestive'' symptoms, of ma-
lignant disease of the colon are few and in-
definite. They consist chiefly of abdominal
discomfort, more gas than usaul, some dis-
tention, increasing constipation, at times mild
diarrhea, with small quantities of blood, pus
and mucous in the stools. Many years ago
Dr. Maurice Richardson of Boston called
attention to the fact that pain due to large
intestine obstruction is always located below
the umbilicus, while rarely the patient will
locate the pain at the site of the lesion. Pain
of small intestine obstruction is at or above
the unil)ilicus. Blood, pus and mucus are
usually absent when the carcinoma is scirrhus
in type, and is present more commonly in
such conditions as ulcerative colitis, dysentery
and tuberculous ulcerations. It is, therefore,
a variable symptom, but always should be
viewed with suspicion. In diverticulitis of
the colon blood, pus and mucus are never
present. When carcinoma is superiinposed
upon a diverticulitis they may be present in
the stools. Lower alodominal discomfort, gas,
and an increasing constipation constitute the
most constant early symptoms of malignancy
in the colon. Later, all the symptoms of par-
tial obstruction are present when the diag-
nosis is not difficult, with periodic attacks of
low abdominal colic, gas, distention, nausea,
vomiting, and great difficulty at stool. Loss
of weight is not striking until after a long
period of partial obstruction.
For further consideration, it is feasible to
divide the colon into a right and left half.
Developmentally, functionally, and pathologi-
cally, there is a difference between the two
sides which naturally leads to some variation
SOUTHERN MEDICINE AND SURGERY
June, 1929
of the symptomatology and surgical indica-
tions.
In the right half of the colon the fecal
content is largely liquid and absorption is
still taking place. Carcinomatous growths
here produce little or no obstruction and con-
siderable stenosis of the bowel lumen is well
tolerated by the patient, the patient conse-
quently seeks the physician later in the course
of the disease and the tumor may attain con-
siderable size before being discovered. With
obstruction usually wanting, a peculiar and
rather frequent finding in cancer of the right
segment is a striking degree of secondary
anemia, most marked when the lesion is in
the cecum. It is possible that in a patient
in whom malignancy of the right colon or
cecum is suspected, the presence of this
marked anemia may mislead the physician
or surj-^con into making a bad or hopeless
prognosis, as it may suggest emtastases, an
inoperable lesion, etc. Such a view is decid-
edly unwarranted by the facts. Alvarez ct
al. (Arc/lives of Surgery, 1927, xv, 402-417)
investigating the varying grades of anemia
produced by carcinoma in different parts of
the colon, found the tendency to anemia was
greater in the cecum than in the sigmoid, and
a definite gradation of the anemia-producing
property of cancers situated at Successive lev-
els along the ascending, transverse and de-
scending colon. They accounted for this fact
by reason of the difference in the "surface
areas" of the cancers of the right or cecal,
and those of the left or sigmoidal areas.
Right-sided cancers, as already shown, are
tolerated by the patient for a longer period
before the medical man is consulted; they are
therefore larger tumors, and when ulceration
is present there is a larger area of surface
ooze which ultimately produces the anemia.
On the left side, or in the sigmoid, a very
small annular growth produces early symp-
toms of obstruction, and the patient seeks the
physician and surgical relief earlier, when
actual surface area of the tumor is small. The
authors further showed that the anemia was
not due to toxins liberated by the cancer cells,
since "cancer cells have little or no effect on
the blood-forming organs," but from a con-
stant ooze from the surface area of the can-
cer. Nor was the anemia found by these
authors to be dependent upon distant metas-
tases. In a patient who came under our care
with a carcinoma of the cecum, the hemo-
globin was 30 per cent on the first examina-
tion. She is living todaj', more than five years
after resection, and certainly could have had
no metastases to have caused the anemia.
In addition, patients with malignant dis-
ease of the right segment of the colon are apt
to suffer low abdominal colic, gas and rum-
bling. Appendicitis is easily simulated, and
if the pain is higher gall stones or kidney colic
may be suggested. Acute obstruction is rare
but is more likely the nearer the lesion is
located to the left segment, or in other words,
with the increasing solidification of the bowel
contents.
The left colon from the middle of the trans-
verse to the rectum is sa'd to bs little more
than a reservoir. The contents are solid
and firm. Bacterial life teams. Here, as is
perfectly obvious, a small growth early in
the course of the disease produces obstruc-
tion. As anemia is the peculiar and rather
characteristic feature of carcinoma of the right
colon, so obstruction is the dominant and
ever-present quality of malignant disease in
the left colon. Marked anemia is practically
never present, and it is the symptoms of ob-
struction which bring the patient to the phy-
sician. It may be at first increasing consti-
pation is the only complaint, but very soon
symptoms of gas distention, lower abdominal
pain, nausea and vomiting will develop.
Chronic, partial obstruction is alwr" ~^csent,
with the constant danger of a sudden acute
obstruction developing. The chronic obstruc-
tion induces changes in the bowel wall proxi-
mal to the growth, as edema, infection, dila-
tation, hyperplasia, etc., which may be termed
secondary pathology. It is this obstructi^ .i
with its consequent secondary pathology that
makes the graded operation a thing of neces-
sity in growths of the left side.
In dealing with patients with malignancy
of the cecum or right colon, one stage resec-
tion and anastomosis of the bowel are applica-
ble. It is essential, however, that the general
condition of the patient be satisfactory. The
anemia is corrected by blood transfusions,
and the fluid intake greatly increased prior
to operation. If the patient is not in good
physical condition and cannot be improved,
multiple stage operations are indicated. But
a^ a gci.eral rule, the single stage operation
is the one of choice. The affected loop is
June, 1929
SOUTHERN MEDICINE AND SURGERY
delivered to the outside of the abdomen by
the division of the outer peritoneal reflection,
resected, and the continuity re-established by
an end-to-end, end-to-side, or lateral anasto-
mos's. The end-to-side anastomosis with the
Murphy button, as practiced by C. H. Mayo,
is our preference. The great danger after
the operation is from pas, which usually
develops the fourth of fifth day, and un-
less taken care of in some way will mean
complete disaster to the anastomosis. There
are two ways in which to forestall this occur-
rence. First, if the Mayo type of end-to-side
anastomosis is used, the closed end of the
colon is sutured and fi.xed in the incision. If
dangerous gas develops it is then a simple
matter to puncture the end of the colon with
a cautery and release the gas pressure. The
resulting fistula invariably closes with no
harm done to the anastomosis. The opening
of the bowel if gas develops then becomes a
life-saving maneuver. In three of our patients
in whom this operation was done the opening
of the colon on the third day saved the situa-
tion. Each had a fecal fistula for a variable
length of time. Each ultimately made a com-
plete recovery, and all three are living today.
We recently operated on the daughter of one
for carcinoma of the cervi.x. The second way
of handling the gas is by use of a prophylac-
tic enterostomy, done at the time of the oper-
ation and in the ileum 35 to 40 cm. from the
site of the anastomosis. This tube may be
kept closed with a forceps until gas distention
develops.
In dealing with carcinomata of the left
colon the problem is different, more difficult
and more tedious. Here the question of ob-
struction and its consequent changes, edema,
infection and thinning in the bowel wall be-
comes paramount. If the obstruction is acute
when the patient is admitted to the hospital,
little more than drainage of the intestinal
tract by the safest and simples tmcthod is
indicated. Cecostomy or enterostomy through
a right-s'ded McBurney incision is best. Even
e.xploration to determine the e.xact location
of the growth at this time should be omitted.
Si'strunk has shown how merely the explora-
tory handling and manipulation of the boggy
edematous, infectious bowel wall is liable to
give rise to a fatal peritonitis, since so slight
a trauma can increase permeability of the
bowel wall to the hordes of virulent bacteria
in its walls. The breaking up of adhesions
about the growth is still more prone to cause '
the liberation of these germs. Sistrunk has
shown a decidedly lower mortality rate in a'
series of cases of acute obstruction since he
has drained the intestine without exploration.'
Thus in the presence of acute obstruction due
to tumor of left colon, prompt and adequate
drainage proximal to the growth and nothing*
more is indicated.
After a period of drainage, the general con-'
dition of the patient having improved, the
infection, edema and sepsis in the bowel wall
having disappeared, the abdomen is again
opened, a complete exploration made, a re-
section and anastomosis of the affected loop
performed. The cecostomy being still open,
there is no risk of gas and leakage of the su-
ture line, and prompt healing invariably re-
sults. The type of anastomosis may be va-
ried, but our preference is the Parker-Kerr
method. Finally, the cecostomy is closed.
In the presence of chronic or partial ob-
struction, due to a growth of the left colon,
the multiple stage operation has its greatest
usefulness. Primary resection and anastomo-
sis of the left side of the colon "at one sitting"
for malignancy is predestined to utter and
almost universal failure. When we picture
the pathology, the reason is obvious. As a
result of the long obstruction, which as I have
already said is constant, the bowel wall is
edematous and friable, miriads of virulent
bacteria inhabit the intestinal lumen and
bowel wall, the escape of which to the perito-
neal cavity results in fatal peritt)nitis. Add to
these features the hard, solid masses of bowel
contents, and what chance has any suture line
to hold fast? They don't hold and the pa-
tient so treated about the fourth or fifth day
begins going down, and by the tenth or four-
teenth day, if not sooner, is dead from leak-
age at the suture line, peritonitis and sepsis.
To overcome these difficulties and unusual
hazards the multi[)le stage operation has
come into vogue. Sir Harold Stiles, was
among the early surgeons who preceded re-
sections of the left colon with a cecostomy
which drained the intestine, relieved the ob-
struction, and paved the way for a later suc-
cessful and safe resection, and anastomosis.
iSIikulicz in 190.? introduced his operation
in which the involved loop was first ex-
teriorized before resection was done. This
402 SOUTHERN MEDICINE AND SURGERY June, 1929
operation was introduced into this country by possible, when some other technique must be
C. H. Mayo, and popularized by such men employed. A more recent operation, and one
as Dowd. Today the Mikulicz operation is at once popular, devised by Kerr of Wash-
frequently the operation of choice for malig- ington, can often be used successfully in con-
nancies of the left colon. It has definite risks, junction with a cecostomy or a colostomy
however, and is not universally applicable, but above the growth. While the multiple stage
restricted by certain limitations and subjected operations do have certain drawbacks, any
to a certain amount of criticism by some sur- of these are completely overshadowed by the
geons. In very fat patients with a thick ab- remarkable reduction they have effected in
dominal wall making exteriorizing of the loop the mortality of surgery of the large intestine,
possible only under great tension, or impossi- The one-stage resections carried a mortality
ble, the Mikulicz is impracticable. Some- of 42 per cent, while the multiple-stage has
times the mesentery of the colon is short, reduced this to 12.5 per cent,
contracted, making delivery of the loop im- ^,3 p.^f,,,;^^^, Buiwing.
FOR FISTULAE
Perhaps the best medicamtnt ever employed in the treatment of chronic otorrhoea is a
mixture known as Calot's. It was first used for this condition by Fotiada, who was struck by
the success of this preparation in clearing up fistulae in the surgical wards of the Filantropia-
Spital in Bucharest.
The composition of this mixture is as follows:
Guaiacol 1.0
Creosote S.O
Sulphuric ether 30.0
Iodoform 10.0
Olive oil 70.0
Fussinger and Laurance attribute to the guaiacol and creosote a caustic action upon the
granulations in addition to their antiseptic properties. The iodoform, besides being an excellent
antiseptic, acts also as a very "good cicatrizant. The ether serves the purpose of a solvent for
the fatty components of the discharge, and thus allows the more active constituents a more inti-
mate contact with the diseased tissue.
— I. Harnick, in The Canadian Medical Association Journal, May, 1929.
We have treated about sixty cases of alopecia areata with a combination of thyroid and
adrenal gland extract with no external treatment. All of these cases responded to this line of
treatment except one case of a boy of sixteen, weighing about 190 pounds. Perhaps our doses
were too small in this case.
— F. A. Black, in Northwest Medicine, May, 1929.
IN THE INTEREST OF HAPPY MARRIAGES
(J. F. W. Meagher, in Long Island Medical Journal, June, 1929)
There are certain factors which if habitual will most certainly lead to an unhappy married
life, — e. g., fear, hatred, sh.ime, humiliation, excessive pride, bad manners; also a terrific struggle
for existence; boredom; yearnings neither fulfilled nor even sympathetically understood. One
cannot expect much energy left for love where it is all absorbed by work. Some women think
that a man is only for petty services around the house; and some men think that a wife is only a
cook. A master-slave atttude in marriage docs not tend to happiness. It is well known that
cynicism and irritability characterize unhappy marriages. The mere presence of cynicism is a
proof of marital dissatisfaction. Holdng a partner up to ridicule is pernicious. And undue joking
at the expense of the partner is bad, — for "many a truth is said in jest." Many insults, if they
have to be "swallowed" will eventually cause hatred. Fear or distrust of each other is always
bad. A person who is dominated b> a feeling of inferiority does an injustice to him or herself.
There are some women who instinctively aim to subject the man. Women who selfishly dominate
their husbands may do one of two things to him: (1) Make him weak jind ordinary, or (2)
Prive him to interests outside the home, if he is of the aggressive type.
June, 1929
*• - ■
SOUTHERN MEDICINE AND SURGERY
403
— •— *
PRESIDENT'S PAGE
Tri-State Medical Association of the Carolinas and Virginia
—CYRUS THOMPSON
I went to ?iIount Airy on the 12tli instant
to attend the nieetinc; of the Eiphlh District
Medical Society and to ni:!ke a few after-
dinner remarks.
The meeting was a very pleasant and suc-
cessful one with fair attendance. During the
afternoon a young man asked me if I thought
that Duke University could turn out good
doctors in the shortened time its curriculum
proposed. I replied that I thought that it
could and that the dean and the trustees had
carefully canvassed the requirements of the
course and were thoroughly satisfied of its
possibilities.
A generation or two ago there was much
less to put into a medical course than there is
tcd;iy and the course was much shorter; but
great doctors were e\en then made on much
less scientific education.
Of course a doctor should have all the med-
ical education he can get; but medical edu-
cation is not all the education that a doctor
needs. .\ doctor needs also a deal of educa-
tion that does not pertain directly to th?
practice of his profession.
Indeed, a marked difference between the
newer generation of doctors and the old con-
sists not so much in the fuller medical edu-
cation of the new and the lesser medical edu-
cation of the old as in the degree of culture
manifest in the old and lacking, I am afraid,
in the new. The medical curriculum is so
full IJicse days that a student ha,s no time to
spare for the acquisition of other knowledge.
The man who knows nothing but farming,
merchandise, or theology or law or medicine
lacks what the older men called culture and
is handicapped even in the practice of his
profession by very severe limitations. All
such a one's knowledge may be useful what
time he can use it, but it may be utterly use-
less when he comes to a time of life or a
physical condition which hinders him in the
use of it. "Man cannot live by bread alone."
Dr. Louis B. Wilson, of the Mayos, deliv-
ered in Rochester in 1921 an interesting ad-
dress on "The V'alue of Useless Knowledge."
He adverted to the fulness of the medical
curriculum which gave the student no time
for outside reading — for the acquisition of
information useless from the stand[)oint of his
medical education. Measureably he deplored
this crowded condition. Indeed he counseled
the wisdom of a student's cutting the curricu-
lum to read and gather in some "useless in-
formation"— useless indeed in the daily pur-
suit of his profession, but useful in the living
of the late afternoon and the twilight of life.
Since my early manhood I have had the
good habit of reading every year several
books in no way related to the study or prac-
tice of medicine. To this course I would ad-
vise all young medical men. The wisdom of
this course becomes evident in very mature
years. Dr. Wilson quotes Bacon as saying:
"Reading makes a man fit company for him-
self." .-,:
404
SOUTHERN MEDICINE AND SURGERY
PRESIDENT'S PAGE
Medical Society oj the State of North Carolina
—L. A. CROW ELL.
June, 1929 1
The Federation of Medical Examining
Boards of the U. S., meeting in Chicago a
few years ago, gave the medical profession of
North Carolina rank second to that of no
other state in the Union.
I am proud of the medical profession of
North Carolu/a. I am proud of her past. I
am proud of her present filled as it is with
high achievements. But I am more proud of
her future, bright with possibilities for devel-
opment and service, which will eclipse all ef-
forts of her past.
Some years ago a great economist and busi-
ness expert asked his guest, Mr. Charles P.
Steinmetz, the genius of the General Electric
Company, to outline for him something of
the development, which he looked for in the
next twenty-five years. He expected the
great scientist to forecast marvelous achieve-
ments in the field of business and commerce
with particular emphasis on the application
of electricity to industry. Imagine his aston-
ishment when the forecast was made that
the outstanding achievements of the next
quarter century would be in the realm of the
spiritual; that men will in the next few years
come to give more thought and attention to
man and his development than to the devel-
opment of the things that man uses — and
this is as it should be.
No nation has become great through the
accumulation of material resources, and no
country has maintained an enviable position
among the nations of the earth that neglected,
to develop and cultivate a substantial and.
healthy citizenry. It is just as true today as,^
when the poet wrote:
"111 fares the land to hastening ills a prey
Where wealth accumulates and men decay;
Princes and Lords may flourish or may fade —
.•\ breath can make them as a breath has made-
But a bold peasantry* its coimtry's pride.
When once deetroy'd can never be supplied." ,■■
I
Believing then as I finally do, that a na-
tion's most valuable asset is in its citizenry
rather than its material resources, my plea is
that we should give more attention to the
protection and preservation of the physical,
mental, and spiritual powers of our people.
In health matters I fear we are a wasteful^
and negligent people. Millions of dollars are.
spent annually in the treatment of prevent-
able diseases, to say nothing of the amount
lost in time by those who are sick and those,
who care for them. When will the state and
Nation realize that it is much cheaper to keep
well than it is to get well? When will we.
as a nation become willing to spend enough
of our immense wealth to provide for our peo-.
pie the protection that modern medical
science has made possible?
*Edilor's Note. — It seems well to call the reader's
attention to the fact that the term peasant, just as
pa^an. properly carries no opprobrium, meaning'
nothing more nor less than counlryman, or farmer.
June, 1029
SOUTHERN MEDICINE AND SURGERY
4D5
Southern Medicine and Sur§er;p
jTri-Slate Medical Assofialion of the Caroliiias and Virginia
OFFiciAt Organ OF jjledical Society of tlie Sta(e of Norlli Carolina
James M. Northington, M.D., Editor
Iamks K. Hall, M.D..
Department Editors
Richmond, Va ^Human Behavior
Frank Howard Richardson, M.l) Black Mountain, N. C Pediatrics
W. M. ROBEY, D.D.S Charlotte. N. C. Dentistry
J P Matheson, M.D. "\
H L. Sloan, M.D /
C N. Peeler, M.D .
F E. Motley, M.D.__
\'. K, Hart. M.D
F. C. Smith, M.D
The Barret Labosatories
0 L. Miller, M.D
Hamilton W. McKay, M.D.-
John D. MacRae, M.D
Joseph A. Elliott, M.D
Paul H. Ringer, M.D
Geo. H. Bunch, M.D .
Federick R. Taylor. M.D
Henry J. Lancston, M.D
Chas. R. Robins, M.D
Olin B. Chamberlain, M.D.__
Louis L. Williams, M.D
Various Authors
> Charlotte, N. C-
Diseases of the
Eye, Ear, Nose and Throat
_ Charlotte, N. C Laboratories
_Gastonia, N. C Orthopedic Surgery
_Charlotte, N. C Urology
_Asheville, N. C Radiology
_CharIotte, N. C Dermatology
_.\sheville, N. C Internal Medicine
ZColumbia, S. C Surgery
_High Point, N. C Periodic Examinations
_Danville, Va — Obstetrics
__ Richmond, Va Gynecology
..Charleston, S. C Neurology
..Richmond, Va Public Health
_ Historic Medicine
The Cleveland Horror Need Not Be
Repeated
The appalling Cleveland Clinic disaster
first sickened the heart and numbed the brain.
.After a momentary paralysis of the faculties
the medical world came to itself with a de-
termination to see that tliere shall be no repe-
tition.
One of the most fortunate of the endow-
ments of humankind is its enormous capacity
for forgetting. If our disappointments, griefs
and despairs, remained with us in all their
poignancy, the burden of life could not be
borne.
• Often in our eagerness to be rid of these
painful impressions, we fail to take sufficient
care to do what we reasonably can to profit
by our hard lessons.
Some twenty-five years ago hundreds were
burned to death in the Iroquois Theater fire
in Chicago. Investigation showed that most
if not all the deaths were caused by the main
doors having been hung to open /'wward. No
such horror should have been needed to teach
us that when excited persons rush against a
door it can not be opened against their weight
and strength. A stable door is hung to open
02//ward so as to prevent "hipping" the horse
as he comes out of his stall.
Profiting by the Iroquois lesson many states
passed laws requiring that all doors of public
buildings be hung to open outward. Our
recollection is very clear of the rehanging of
the massive doors of the old Egyptian Build-
ing of the Medical College of Virginia. But
all did not learn. The writer has occupied
an office in a medical college building erected
a number of years since the Iroquois Theater
was burned, and a good deal nearer to Chi-
cago than is Richmond, in which the outer
doors open mward.
Fortunately there is reason to believe that
there are means at hand for making it im-
possible that others shall die as did the 150
in Cleveland. We have it on reliable author-
ity that the acetate film will give as satisfac-
tory a picture as the dangerous nitro-cellulose
film, and that the acetate film is devoid of
danger. In many of the best hospitals of the
country the acetate film is even now used
exclusively.
SOUTHERN MEDICINE AND SURGERY
June, 1929
Some radiologists consulted express the
opinion that the acetate film is not a satisfac-
tory substitute for the nitro-cellulose; some
think information generally possessed pre-
viously, with that added by this incident, is
all sufficient for so handling the nitro-cellu-
lose films as to make their use perfectly safe.
We greatly desire information from those
having information, and expressions from all
interested.
Certainly there is a heavy obligation on us
all to see that everything practicable is done
to assure that none coming-to us seeking cure
shall be pwisoned with fumes from films.
The Pellagra Situation and Its
Management
A povre widwe somdel slope in age,
Was whylom dwelling in a narwe cotage,
Bisyde a grove, stondyng in a dale.
This widwe, of which I telle yow my tale,
Sin thiike day that she was last a wyf.
In pacience ladde a ful simple lyf,
For litel was hir catel and hir rente;
By housbondryc, of such as God hir sente,
She fond hir-self, and eek hir doghtren two.
Three large sowes haddc she, and namo,
Three kyn, and eek a sheep that highte Malle.
Ful sooty was hir hour, and eek hir halle,
In which she eet ful many a sclendre meel.
Of poynaunt sauce hir neded never a deel.
No deyntee morsel passed thrugh hir throte;
Hir dyete was accordant to hir cote.
Repleccioun ne made hir nevere syk;
Attempree dyete was al hir phisyk,
And exercyse, and hertes suffisaunce,
The goute lette hir no-thing for to daunce.
* * * *
A yerd she hadde, enclosed al aboute
With stikkes, and a drye dith with-oute,
* * * * she haddc a cok, hight Chauntecleer,
In all the land of crowing nae his peer.
This gentil cok hadde in his governaunce
Sevene henns, for to doon al his pleasaunce.
— The Canterbury Tales, Geoffrev Chaucer.
From 1910 to 1915 there was a tremendous
interest in pellagra in this state and section.
For five years or more after the time (1908-9)
that Dr. E. J. Wood and Dr. Harllee Bellamy
made their careful investigation into all
aspects of the disease and reported to the
North Carolina State Board of Health, the
profession of the state was thoroughly aroused
to the seriousness of the pellagra problem,
and close study was given to means of preven-
tion, diagnosis and treatment. Then — at least
it so appeared — there came a period of fewer
cases, these of much less severity.
The figures published by the N. C. State
Board of Health^ do not lend themselves very
readily to casual interpretation. Why the
deaths from pellagra in each of the years
1919-24, inclusive, were less than half the
number as in 1917 and '18, and then rapidly
moved to a new high level — 847 — in 1928 —
more than 23 per cent increase being made
from 1927 to 1928 — is not clear. Certainly
it seems most plausible to blame this on re-
laxation of that eternal vigilance which is
the price of nearly everything worth the hav-
ing.
As Dr. Cooper well and seriously says "the
eradication of this disease constitutes one of
the chief problems before the medical pro-
fession in North Carolina." Further on he
warns against newspaper menus, recipes and
newspaper advice in general — a warning to
which we would add all the force we can sup-
ply. Here be words of wisdom: "Much of
this stuff is rotten, some of it is misleading
and a considerable part of it would be act-
ually a menace to health if followed in detail.
A physician need not undertake to carry in
his head or pocket a detailed list of vitamin
this or that, how many calories in a bakery
cracker, or what the difference might be in
the fat content of milk from country-bred or
town-bred cows. But the physician does know
that the basic requirement of all life is food.
And he knows that success in maintaining
good health lies primarily in daily intelligent
food selection. Furthermore when the family
physician sperks on a matter in which people
trust him, his words mean something."
We know that pellagra usually, if not in-
variably develops in the persons of those who
either do not take proper food into their
stomachs, or who, through deficient powers
oj assimilation, after taking it into their
stomachs are vnahlc to so change it that it
can be lakcd into the blood stream. We can
not be sure that we can properly influence
the latter deficiency; but that is the minor
factor anyhow, so we can afford to ignore it
for the present. Then many still believe that
pellagra is due to a specific organism; but
even these agree that such an organism rc-
quires for its growth certain favorable condi-
1. This and much to follow from "Pellagra in
North Carolina," G. M. Cooper, M.D., read before
Wake County Med. Soc, Feb., 1929, published in
The Health Bulletin, April.
June, 1Q20
SOUTHERN MEDICINE AND SURGERY
467
lions which are brought about by insufjicient
nutrition. So, much as we would love to know
all about it, we can well afford to pool our
interests and combine our forces and work
energetically toward eradicating the disease -
for it can be eradicated; after that is accom-
plislicd, as Dr. Cooper so finely says, "we can
do nvire theorizing after our people stop dying
from it."
Our own idea of an ideal dietitian is a half-
and-half mixture of a smart graduate in
dietetics and a fat colored mammy with a
bandanna 'round her head; and, in case of
difference arising between the two halves of
our dual personage we would hope that the
mammy half would prevail.
The prevention and cure may be stated in
three words — cow, vegetable garden, poultry-
yard — those essentials for all satisfactory
feeding of man.
Note the lines at the head of this article.
Geoffrey Chaucer died in 1400. As he says
this was — put in modern English — a poor
widow who led a simple life, supported
("fond") herself and her two daughters, ate
many a slender meal and no dainty morsel
passed through her throat; that repletion
never made her sick and a temperate diet
was all her medicine, with exercise and heart's
sufficience.
And how did she do this? By the aid of
three large sows and their progeny, milk and
butter and an occasional veal and maybe a
two-year-old from the three cows (kyn), veg-
etable.; from her garden (the "yerd, enclosed
all aboute with stikkes"), and eggs and broil-
ers from the "sevene hennes, for to doon al,"
Chauntccleer's, "pleasaunce."
We may be well assured neither the "wid-
we" nor "hir doghtren" had pellagra. If
every householder in North Carolina, poor
and rich, had the same food sources and used
them as wisely in this, the 20th century, as
dd the "povre widwe" in the 14th, pellagra
would disappear from our land and tuberculo-
sis be greatly diminished.
Potassium Permanganate Treatment in
Pneumonia
With the exception of cancer, most likely
pneumonia is the most dreaded of all com-
mon diseases. Often do we hear doctors ex-
press such dread. The reason is plain: our
knowledge of bow limited is our ability to
inOuence the condition for good.
When results which appear favorable are
reported by reputable persons, in the treat-
ment by new methods of diseases which kill
many and for which our present methods are
far from satisfactory, we are glad to put them
before our readers.
In the May issue of the Annals of Internal
Medicine, official journal of the American
College of Physicians, Dr. John L. Chester,
of Detroit, reports on a series of cases of
lobar and broncho pneumonia, treated with
potassium permanganate. In the early part
of 1928, Dr. Chester treated an advanced and
seemingly hopeless case of influenza-pneumo-
nia with a standard solution of the drug,
giving 4 ounces, repeated every 3 hours for
10 days. Administration was by rectal injec-
tion, by means of a funnel and catheter. The
patient was then moribund. In 24 hours the
temperature had dropped from 102.2 to 100,
pulse rate from 115 to 88, with a slowing in
respiration from 40 to 26; in 48 hours, the
temperature was 99, respiration 32, and pulse
100; at the end of the fourth day the chart
was normal, and other symptoms progressively
relieved or abated. Convalescence was short-
er than would have been believed possible by
any other therapy.
Later, a iSeries of 23 cases were similarly
treated. The results continued satisfactory,
only two deaths being reported. Dr. Chester
was then permitted to select 20 very severe
cases at Eloise Hospital, an institution main-
. tained by the Poor Commission. These cases
were of the worst possible description, most
of them complicated with heart conditions of
long standing, syphilis and chronic alcohol-
ism. Ten of them were treated by other than
the potassium permanganate method, and all
died. The remaining ten received varying
doses of the solution, and SO per cent recov-
eries took place. Complicated as they were
with pneumonia superimposed on other dis-
eases, the recoveries were in the nature of a
surprise to the staff of the hospital.
Concise case histories and progress notes
are given in each instance, the chemical ac-
tion of the drug reviewed, the best method of
preparation of the solution and its modes of
administration explained. The method seems
to be an imiK)rlation from England, where
Drs. Nott and Roche have been using it since
1924. Their reports of the original experi-
SOUTHERN MEDICINE AND SURGERY
June, 1929
nients appear in the British Medical Journal
of March 7, 1925, and March 12, 1927, re-
spectively. It may be remarked that Dr.
Chester appears to have obtained success
comparable with the original English results.
No claim is made that potassium perman-
"ganate is a proved specific against the micro-
organisms of pneumonia, but the hope is en-
tertained tliat other clinicians will become
interested in the treatment to the extent that
further mvestigation be made, to the end that
a verdict may be arrived at as to its real ef-
ficiency.
.„, Subscribers Who Will Not Pay
i,(A verbatim copy of an Editorial in the Charleston
Medical Journal, May, 1S57)
.r,.,. In the February number of The Southern
Journal oj the Medical and Physical Sciences,
the Editor proposes that a Convention of the
Editors of the American Medical Press should
be held at Nashville, during the session of
the American Medical Association, "to delib-
erate upon all subjects pertaining to the sup-
port and progress of medical periodical liter-
ature." The Boston Medical and Surgical
Journal, commenting on this suggestion, re-
marks that "it is a well known fact that medi-
cal journals in this country do. not, as a rule,
receive that support from the profession to
which they are entitled. A large number of
subscribers take their journals regularly with-
out paying for them, or without paying
promptly; some from inadvertence, but many,
we fear, deliberately. One of the objects of
the proposed convention is to institute a re-
form in this respect, and to enable the con-
ductors of the periodical press, not only to
be indemnified from loss, but by a reasonable
pecuniary return for the expenditure of time
and talent to improve the quality of our
medical periodical literature, and thus indi-
rectly to elevate llie standard of the profes-
sion. The effect of good medical journals upon
the progress of medicine can hardly be over-
estimated. As the editor of the Southern
Journal justly remarks, without them the pro-
fession would be an 'army without banners,'
or a 'ship without sails.' It is only by means
of constant interchange of new ideas, the pub-
lication of new discoveries, the promotion of
friendly feelings throughout the scientific
world, that science can advance with those
..rapid strides which render the present age so
remarkable.
"It may seem a very easy thing to obtain
from subscribers to medical {periodicals tlie
small amount which is annually due from
them. Experience has shown that in many
instances this is not the case, and we suppose
that every journal has a certain number, some
a large number, of names on its lists, who
are not ashamed to receive the periodical
without ever paying for it, besides others
whose payment is withheld so long, or ob-
tained with such difficulty, as to make it no
adequate compensation for the expense in-
curred by the editor or proprietor. We are
therefore glad to see the suggestion of the
Southern Journal, and we hope it will be car-
ried into effect. If the majority of the edi-
torial corps will agree to adopt the cash sys-
tem, and refuse to supply subscribers who are
in arrears, until all accounts are settled, we
are confident that there will be no reason to
regret the reform. The only subscribers lost
will be those who do not pay, and hence the
result will be an actual gain to the proprietor;
while if all journals will unite in this plan,
the delinquents will not be able, as is some-
times the case, to supply themselves by run-
ning in debt for another periodical. We
think a convention of editors might also have
a favorable effect upon our medical periodical
literature, by deliberating upon the best
means of improving the character of our jour-
nals, by obtaining a larger amount of valuable
original matter, both on the science of medi-
cine and on the ethics of our profession."
The Editor of the Buffalo Medical Journal
thinks favorably of the proposed convention,
and says that "it would be a good idea to
publish these delinciuent gentlemen (previous-
ly referred to) by putting thein on short ra-
tions of jounialisra, to say to them, as they
forward their courteous notes enrolling their
names as subscribers, without money, that
they are unfortunately indebted to such a
journal, and inust pay up for that before get-
ting another on credit."
We had resolved to be present at the Con-
vention in Nashville, and had consented to
be a delegate from our State Association; but
circumstances have occurred to prevent our
attendance. Being favorable to the proposed
Convention of iMedical Editors, we will make
a few suggestions, which we trust the repre-
sentatives of the Editorial fraternity will take
June, 1929
SOUTHERN MEDICINE AND SURGERY
409
into consideration when they meet to deliber-
ate upon the subjects which concern the wel-
lare of all who are engaged in the publication
of medical periodicals:
1. We would advise that the cash system
be adopted;
2. That the name of no new subscriber be
enrolled until the amount of the annual sub-
scription is remitted;
3. That those who are in arrears be written
to, and that in the event of their refusal to
pay, or to reply, that they be drawn upon by
draft for the amount of their dues;
4. That on their refusal to honor the draft,
their names be stricken from the subscription
list;
5. That each medical publisher send, on the
first of each January, to every medical pub-
lisher in the United States, an alphabetical
list of those who refuse to pay, stating their
residences, and the amounts they owe.
Should these suggestions be adopted by all
medical journalists, we could all know which
subscribers should be indulged and which
proceeded against; and no one in arrears to
one journal could procure another, whether
the cash system of advance payments be
adopted or not, without paying in advance.
jority of patients requiring cystoscopy and
such can be adequately taken care of by their
family doctors.
A ^Ieans of Initiating Family Doctors
Into a Mystery
In The Urological and Cutaneous Review
(June) Langer has a description of an endo-
scope through which two can see at the same
time.
We quote:
"Although the acquiring of the necessary
technique, and the interpretation of the va-
rious pathological pictures offer no very great
difficulty, yet, anyone who undertakes to in-
struct others in the use of the endoscof)e will
find it unpleasant that the student cannot
observe an endoscopic picture at the same
time as himself Now we have an in-
strument which makes it possible for two
persons to see an endoscopic picture simul-
taneously In using it the observers
stand to the right and left of the patient,
who is lying upon the endoscopic table, and
they look through oculars 1 and 2."
We hope some of our urologists will pro-
cure or devise other special scopes to supple-
ment this one, organize classes and give the
necessary instruction so that the great ma-
W'HY Not Uo This in Your Town?
From the Chapel Hill Weekly we get a
valuable suggestion:
Dr. S. A. Nathan, the municipal health
officer, has launched a campaign against mos-
quitoes, and he asks that all householders
give aid by having their gutters thoroughly
cleaned.
''We have started oiling and ditching, and
are going to cover the entire village as quick-
ly as possible," he said yesterday, "but the
success of a fight on mosquitoes depends
largely upon the preventive measures taken
by citizens in their own homes. Stagnant
water in clogged gutters is responsible for
much of the trouble from mosquitoes."
Dr. Nathan knows of gutter-cleaning crews
whom he can send to any householder who
will call him. Two men with a ladder can
be employed at $1.50 an hour.
Bathing Customs and IManners of 500
Years Ago
The Italian author Poggio Bracciolini ac-
companied Pope John XXIII as secretary to
the famous Council of Constance in the year
1414, whence he visited Baden (Switzerland)
for a course of hydrotherapy. A letter to a
friends runs in part as follows:
"Quarter of an hour's journey from the
town, on the farther side of the Rhine, a
delightful village has been built for the en-
joyment of bathing.
"The lowest class of the people have access
to two buildings, open on all sides, where
men and women, youths and maidens, in
"short, the whole populace, may together in-
dulge in bathing. A partition stretching to
the ground — and it would restrain none but
those of good behavior — divides the two
sexes. It is truly laughable to watch the
spectacle of ancient granddams and sprightly
maids stepping down into the baths in view
of the whole company, exposing their naked-
ness unabashed to all eyes masculine and fem-
inine.
"This remarkable custom ofttimes amused
me, and I have felt astonishment at the sim-
plicity of the people whose eyes are as inno-
cent of guile as are their speech and thoughts
SOUTHERN MEDICINE AND SURGERY
June, 1929
with regard to the whole matter.
"The baths in the private houses are ex-
ceptionally fine, and in these also both sexes
bathe together. In some measure they are
separated by wooden partitions, but these are
pierced by many low windows, through which
the bathers can talk or drink together.
"There are no guards at the entrance, no
door is kept on the lock, nor is there any fear
of impropriety.
"The bathers recline together in the water,
and take their meals from a floating table.
Observing the customs and manners of the
people, their good food, and their free, un-
restrained behaviour, it was indeed remark-
able to note the confidence with which every-
thing was taken in good part, unworried and
unsuspicious. Such good folk would have
fitted well into Plato's Republic.
Clinical Excerpts.
WHY FRAUDS THRIVE
J. E. Card, an old resident of Elizabeth City has
seen his picture in the daily newspapers of Eliza-
beth City and Norfolk. Under his photograph ap-
pears a wonderful testimonial to the curative powers
of a medical nostrum called Samas. The public is
led to believe that this kindly old man who is over-
weight and who has been a sufferer from rheumatism
for years has been suddenly cured by 'Samas. There's
his picture and the testimonial.
But J. E. Card, who can't write his name, tells
those who ask him that he never took a dose of
Samas in his life and that he still has his rheuma-
tism. The none too clever representative of the
Samas company simply gave him a bottle of medi-
cine, paid for having his picture taken, gave him
one of the pictures and got him to make his mark
on a piece of paper that he didn't even take the
trouble to read.
The world is full of simple, credulous folk like
Mr. Card and because their number is legion they
provide great pickings for religious and medical
quacks. Thru their gullibility is the reputation of
most medical frauds built up.
Little headway is made against the patent medi-
cine evil in America because it is supported by re-
spectable druggists and respectable newspapers for
profit. The Standard Pharmacy in Elizabeth City
lends its name to the Samas fraud for profit. The
Daily Advance, the Virginian-Pilot and the Ledger-
Dispatch, three daily newspapers read in this city,
lend their columns to Samas and its fake testimonials
for the dirty profits they make out of it. And with
such respectable backing Samas and kindred frauds
will continue to thrive.
— Editorial The Independent, Elizabeth City, N. C.
IN TREATING CHRONIC NEPHRITIS
The indications in treatment of chronic nephritis
are, therefore, restriction of activities and a low
protein diet; but there is no need to reduce the
fluid intake, and it is wrong to attempt to reduce
the blood pressure by drugs, even if permanent re-
duction were possible. The high blood pressure
e.xists to keep an adequate circulation through the
diseased cerebral or renal vessels. It is suprising
how often the onset of uraemic symptoms may be
traced to a failure of the heart to keep up the high
pressure. As the pressure falls the renal function
becomes inadequate and the patient dies of uraemia
before he has time to die of heart failure. In all
such cases the indication is to treat the heart and
raise the blood pressure again ; I have recently used
piluitrin for this purpose, I think with some success.
* * * Lumbar puncture is useful in convulsions,
even in true uraemia. Intravenous injection of
glucose solution is probably more effective treat-
ment than the older method of injecting saline. Since
the respiratory type of uraemia (so-called "renal
asthma") is due to a true acidosis brought about
by failure of the kidney to maintain the acid-base
equilibrium, treatment by two-hourly administration
of alkaline sodium phosphate in 30-grain doses, as
suggested by Meakins and Davies, is a rational pro-
cedure.
— Robert Platt, M.D., in the British Medical
Journal, April 20, 1929.
VALUE OF AUSCULTATION OF JOINTS
Auscultation of joints may reveal a very early
stage of roughness or grating, which is not recog-
nisable by other means. As age advances the grat-
ing appears to increase steadily until it is manifest
to touch and the unaided ear; in the most ad-
vanced stages its cause is visible in skiagram as
the joint changes of osteo-arthritis. These joint
sounds are to be heard, by stethoscope, in a large
number of hospital cases, unselected save for sex
and age, and admitted for other than joint affections.
The sounds heard, judging from their wide dis-
tribution through many joints, are probably the re-
sult of changes produced by a blood-borne infection
or intoxication. This is confirmed by the fact that
the stethoscope will also often reveal, in the same
subject, many other joints in which disease is latent
and as yet unheralded by discomfort or pain. The
removal of a focus may render a manifest joint
again latent, but it will still be audible to the
stethoscope and sometimes to touch. In patients
with osteoarthritis in one joint, many other joints
will, by stethoscope, almost invariably be found to
b-' involved in a lesser or greater degree, of which
the patient is often quite unconscious.
C. F. Walters, in The Lancet, (London) May 4th
June, 1<529
SOUTHERN MEDICINE AND SURGERY
DEPARTMENTS
HUMAN BEHAVIOR
James K. Hall, M.D., Editor
Richmond, Va.
Our Lawlessness Will Be Explained
The National Commission of Law Observ-
ance and Enforcement has just been created
by Pnsident Hoover. Criticism of the na-
tional prohibition law during the recent presi-
dential campaign probably caused Candidate
Hoover to promise that he would organize
such a commission.
What are the ten men and the one woman
of the commission going to do and going to
say about the lawlessness of the American
people? The woman member has been en-
gaged in educational work of the higher sort
amongst young women. Has she had experi-
ence in lawlessness? The men members of
the commission are, I believe, all members of
the profession of law, and more than one of
them have occupied positions on the bench.
They know quite well, therefore, why many
laws are not enforced. The lawyers them-
selves are not infrequently the cause of non-
enforcement. Does the President expect to
obtain from the members of his commission
any confessions? Hardly. Is the commis-
sion going to confine its concern simply to an
effort to discover the reasons why so many
violators of our laws go unpunished? Or will
the membership of this great investigative
body direct some of its thought to an analysis
of some of our laws and their worthiness of
general respect?
It would seem that the President might
have felt moved to place on the commission
at least two or three individuals whose pri-
mary concern might be with human beings
them.selves. Crime arises out of the conflict
between legislative opinion and individual
opinion, or individual instinctive trend. The
lawyer talks frequently and iteratively about
the compelling motive, but he knows little
about the psychology of human behavior. He
goes to his heavy law books to find a plausi-
ble explanation of the criminal act. Behavior
has its genesis in the individual, and the in-
dividual rather than the isolated act, should
be studied. Those who should know most
about the origin and the meaning of behavior,
good or bad, are those who have closest con-
tact with mortals in large numbers during
their formative years, and this group includes
teachers, physicians, and welfare workers. A
doctor, preferably the superintendent of a
great state hospital, and the superintendent
of a large penal institution, would have made
valuable members of the commission. Dr.
William .\. White, the superintendent of Saint
Eli.v-abelh's Hospital in Washington, has a
profound understanding of the meaning of
conduct. What a magnificent chairman of
such an investigative body he would have
made! But the arid critics of the prohibi-
tion law are hushed. The President has
hearkened to them, a commission of eminent
lawyers has been organized, they have met
already with the President, and eventually
we shall ponderously be told why and to
what extent we are lawless.
Graduation Ruminations
Many a year ago, in class room and on the
campus of the University of North Carolina,
announcement was made that the student
body would assemble at the noon hour in the
ChaiJel. No one seemed to know for what
purpose, and for that reason, perhaps, all
were there, including medical students and
law students and pharmaceuticals. These
three latter groups embraced the academic
fringe, so to speak; under ordinary circum-
stances they were immune to the Presidential
call to convocation. Before the appointed
hour the hall was chocked full. No prayer
service in old Gerrard Hall had ever witness-
ed such a gathering. And on the rostrum
sat his excellency, Edwin .\nderson .\lderman,
Presideiit of the Lhiiversity of North Caro-
lina, and round about him sat solemnly mem-
bers of the Faculty, members of the Board
of Trustees, and members of the Board of
Health of the State of North Carolina. And
there was suspen.'ie, and expectancy, and on
the presidential rostrum, at least, anxiety and
api)rehension. I can see it now in those sol-
emn professorial faces, after the lapse of a
third of a century. Figuratively speaking, a
great interrogation point hung above the
heads of the multitude. The President of
SOUTHERN MEDICINE AND SURGERY
June, 1929
the University arose. He was a handsome,
graceful, appealing figure, usually just as
much at ease on the rostrum before a multi-
tude as in the quietness of his own study.
But the presidential face was troubled. In
careful and forceful and appealing tones he
told the students of their heritage. Were
not their fathers with the mountaineers at
King's Mountain and with the University's
own immortal Pettigrew in the frightful
charge at Gettysburg? Had not the sacri-
fices of their fathers reopened the old build-
ings after the silences of the reconstruction
era? He spoke to them not in vain. What
sacrifices was he calling upon them to make?
Surely they would prove worthy of their
fathers! Had the state been Invaded? The
suspense could scarcely be endured. The
President of the University presented to the
assemblage Dr. Richard H. Lewis, the Sec-
retary of the Board of Health of the State
of North Carolina. And Dr. Lewis e.xpressed
the firm conviction that the students would
measure up to the demands of any emer-
gency. The students were told that under
the unusual circumstances any of them could
return to their homes who felt impelled to
go. Their withdrawal from academic life
would not be held against them. And — •
finally, they were informed that a medical
student had develoijed small-pox. The ap-
plause was deafening! The roof was almost
lifted. From every corner of the room came
cries: Who is he? Where is he? There
was a wild rush for the infirmary. They
must see the small-pox victim. The assem-
blage was adjourned. The Presidential face
beamed. The result of the President's own
eloquence had astounded him. The variolous
victim recovered, and eventually he became
the possessor of a good practice in Piedmont
North Carolina.
The commencement season
drew near. .An invitation came to Dr. Alder-
man to deliver the address to the gradu-
ating class of Tulane University. He spoke
to them powerfully, as he had spoken to the
small-pox assemblage of his students, and
his speech went ringing through the nation.
Henry Horace Williams,
professor of psychology in the LTniversity of
North Carolina, pulled hard upon the string
suspended from the ceiling above his head,
as he tried to impress upon his students his
emphatic opinion that all mental states are
primarily teleological. Why teach psychology,
pray, if one can not also prophesy? And
Henry Horace Williams prophesied out loud,
before his class. He remarked that Dr. Al-
derman's speech had in it a teleological ele-
ment, and that in consequence of that con-
stituent the speech would take Dr. Alderman
away from the University
And the prophesy of the psychologist was ful-
filled. Dr. Alderman was called to the Presi-
dency of Tulane LTniversity in New Orleans.
And eventually, now an even quarter of a
century ago, he was called to the headship
of the University in .Albemarle County that
had its genesis within the calvarium of
Thomas Jefferson, the most previsioning
mortal that has ever breathed the air of our
own continent.
But seldom in all those twenty-five years
had I heard again the appealing eloquence
of Dr. Alderman's oratory. And within that
period there had been a war — not that of
nation against nation, but of group against
group — in Virginia. There were those who
thought that the medical teaching in Virginia
should all be done in Richmond. The large
city, you know, and the abundant clinical
material, and the hospital facilities? And
there were also those who thought and who
said out loud that the state's efforts in medi-
cal instruction should be made altogether at
the University of Virginia. The academic
atmosphere, you know, the ranges and the
serpentine walls, and the lengthening shadow
of the maker of the Declaration of Independ-
ence? There was much talk, some profanity,
many threats, but the two medical schools
continued to exist, and to do well, the one
in Charlottesville and the one in Richmond.
At 10:30 on the morning
of May 28th in the Mosque Theatre in Rich-
mond I attended the Ninety-first Commence-
ment of the Medical College of Virginia.
Edwin Anderson Alderman, President of the
University of Virginia, came down from the
foot of Monticello with a message to the mem-
bers of the graduating class. Less elastic?
Less jaunty? Some loss in the ringing qual-
ity of the voice? Perhaps and perhaps. But
the more matured eloquence, the more ap-
pealing diction, the great orator still — and
few of them are left. I know not his equal
in speaking to assemblages. He is naturally
June, 1929
SOUTHERN MEDICINE AND SURGERY
and unavoidably the orator. The mere charm
of his plirases must have repaid the students
for all their midnight burning of the oil. "I
bring quite simply and sincerely to the INIedi-
cal College of Virginia the congratulations
of the whole University of Virginia, not only
upon the abundant vigor and power, as mani-
fested here today, but upon the constancy
and courage, and the will to grow and to
serve, which has marked the life of this in-
stitution for three generations
What does bring to me, and should bring to
all thoughtful men immense satisfaction, is
not only the hope, but the belief, that these
two institutions, placing the welfare of the
commonwealth and humanity in the front of
their consciousness, have attained and are
attaining an ever increasing degree of under-
standing and of high purpose to cooperate
steadily and sympathetically to serve the
state and the country by uniting in all feasi-
ble efforts to promote the science of medi-
cine; by research and the discovery of new
truth, to wage common warfare against dis-
ease, and to alleviate human suffering."
Society gives little concern, apparently, in
the opinion of Dr. Alderman, to the training
of its ministers; not much more, perhaps, to
the qualifications of its lawyers: and too little
to the training of its teachers; but it has
come to insist that the physicians who min-
ister to it shall be adequately prepared for
their h"gh calling. This is the hour of the
scientific physician, but science is experience
tempered by reflection. Sydenham said that
the best book for the medical student was
Don Quixote, but Dr. Alderman would pre-
fer to suggest the life of Pasteur or of Wil-
liam Osier. The study of general literature
affords the best preparation for the under-
standing of psychology, and Osier's success
must have been due largely to his knowledge
of mankind as embalmed in the world's great
biographies. The great spotlight heroes of
modern life are the business man and the
doctor, and health is the chief human capital.
Medicine offers to the young man and the
young woman the largest opportunity for
disinterested service. Going to war is no
longer necessary for the display of high cour-
age.
Educator, orator, conciliator,
splendid gentleman — Edwin Anderson Alder-
man!
The Medical Department of the University
of Virginia and the JNIedical College of Vir-
ginia, venerable twin sisters, engaged in a
noble work!
*
Man's chief difficulty lies in his efforts to
express himself. Look upon his books and
tables and charts and maps and dictionaries!
Words and graphs and pictures and represen-
tations! And then, at commencement time,
there are caps and gowns and robes and col-
ors, indicating this sort of learning or that
kind of knowledge. But the symbol fails
always in its effort to represent the thing com-
pletely. A number of the graduates in medi- ■
cine were sworn in as lieutenants in the Unit-
ed States Army. The solemn oath was ad-
ministered to them by an officer of the Unit-
ed States Army, and he wore spurs. Why
the spurs? Do they constitute a part of the'
medical army's armamentarium?
Dr. Alderman apparently approves of the
lessened and lessening number of medical
colleges in the United States. In all the
states of the Union there are now only 80'
medical schools. In 1910 there were 120,
and in 1906 perhaps twenty-odd more medi-
cal institutions. In 1910 more than 19,000
young men matriculated in these medical
schools of our country, but six years prior'
to that time there were 8,000 more young'
men engaged in the study of medicine. There
are actually fewer young men and young
women in the medical schools of the United
States today than there were seventeen years
ago. In South Carolina there is one doctor
for every 1,400 of the [wpulation; in Vir-
ginia one doctor for every 900 people.
Perhaps fewer doctors are now needed.
Formerly the doctor, especially the country
practitioner, spent a large portion of his time
in traveling — in getting from one patient to
the other. Improvements in methods of
transportation lessen the time consumed on'
the road, and such time can now be devoted
to patients. But — there are too few doctors
or they are unevenly distributed. IMany'
communities are in need of a physician. All
the state hospitals that I know of are inade-
quately supplied with doctors. In Virginia
there should be more than three time.-; as
many doctors as there are ministering to the
mentally sick in the state hospitals. And the
SOUTHERN MEDICINE AND SURGERY
June, 1929
State actually invests a good deal of its money
in the education of doctors. It seems strange
that so few of them can be inveigled into the
state's service.
It would be interesting and perhaps start-
ling to know the kind and the extent of the
influence e.xercised by the great so-called
foundations in closing up medical schools.
Within the past twenty years forty of the
fifty-seven medical schools in the southern
states have been closed. You will observe
that the process was forced from the outside
and that it was not of internal origin. There
can be little doubt that the intluence which
put these schools permanently out of com-
mission had its origin in the north, and the
potency of such influence is as completely
due to money as the power of the internal
combustion engine is due to gasoline. But
the great foundations are philanthropies,
blessed of God, and they are beneficent in
their purposes, regardless of the character
and mode of life of their creators.
*
A division of labour has become necessary
in ministering to the sick. At the recent
graduation of students by the Medical Col-
lege of Virginia that opinion was confirmed.
The majority of the graduates, it is true, were
medical — 90 of them — but there were 23
graduates from the school of dentistry, 25 in
pharmacy, S dental assistants were given cer-
tificates, and 6 completed the course fitting
them for laboratory technicians. Nineteen
j'oung ladies were sent forth as graduate
nurses. With so many being fitted to grap-
ple with disease in the mortal tabernacle it
is little wonder that the lone family doctor
feels relatively helpless when called upon to
ward off single-handed the advances of the
Grim Reaper.
*
The commencement season releases a good
deal of vocalized optimism. Much of it is
liberated for inspirational purposes, and is
otherwise unjustified. But in spite of what
we hear at the graduating exercises of medi-
cal colleges there are reasons — a few of them
— for believing that some progress is being
made in medical science —if there be such a
science. Farther back than the variolous
episode at the University of North Carolina,
but easily within my memory, a number of
negroes in Statesville developed small-pox.
Wy recollection is that the citizenship was
rather profoundly moved, and that business
was practically suspended. The small-pox
victims — they were not called patients — were
transferred to a crude pest-house in the coun-
try and kept under the guard of a well-arsen-
alized officer. And eventually the houses of
the negroes were burned as it was thought
to be impossible to disinfect them. But the
discovery today of a case of small-pox in
Statesville or in the student body of the Uni-
versity would cause no more flurry than the
announcement by Collier Cobb that he had
found a strange sort of stone in Orange coun-
ty. A few years ago I had to deal with a
small epidemic of small-pox in my own hos-
pital. Cut no one felt any alarm, patients
continued to seek admission, and the vario-
lous individuals were not ostracized. Forty
years ago such an epidemic would have cre-
ated terror. The thing that is not under-
stood begets fear.
PEDIATRICS
Frank Howard Richardson, M.D., Editor
Black Mountain, N. C.
Ninth District Society Arranges Course
IN Pediatrics
Tiic Pcd'atric Department of Southern
Med' tine and Surgery has always been glad
to chronicle the creation of new agencies for
post-graduate medical education, especially
along iicdiatric lines. Pediatrics, the Cinder-
ella among the more flaunting, even if not
wicked, major sisters Surgery, Internal Med-
icine, and Pathology in the medical school,
has to be learned somehow by Uie practi-
tioriL-r after he leaves college; and the medi-
cal journal and the county medical society
program, potent teachers as they are, are not
adequate without some add'tional aid. Such
aid has been available for years in the South-
ern Pediatric Seminar, an interstate and sec-
tion-wide teaching agency situated in moun-
tainous western Carolina, which ministers to
a hundred or more general practitioner stu-
dents from all the southern states, through
the services of a faculty drawn from the fac-
ulties of all the medical colleges in the South-
land. But this is not enough; and local lead-
ers, have long cogitated as to what the next
step in post-graduate pediatric education
ci'.-^ht to be.
While some of the rest of us have been
June, 1029
SOUTHERN MEDICINE AISTD SURGERY
415
cogitating, the active and efficient secretary
of the Ninth District Medical Society, whose
programs of late years have been such as to
challenge the attention of medical men all
over the state, has hit upon a plan that prom-
ises to blaze the way for some years to come.
Dr. James W. Davis, of Statesville, conceived
the idea of bringing to the doors of the mem-
bers of his district society the knowledge of
the diseases of childhood that all of us ought
to have, but that some of us find it difficult
or well-nigh impossible to leave our homes
and our practices to obtain. Further than
this, it seemed wise to the group who were
planning this opportunity, to utilize the tal-
ent that they knew existed among their own
members and among doctors in adjoining dis-
tricts, rather than to roam far afield and
bring in distant celebrities who, good as they
m'ght be in their own locale, certainly were
not so well acquainted with the pediatric
problems of western North Carolina as were
the men who had been practicing there for
years. Still another conception was worthy
of noting well; and that was the recognition
that not all of the problems of the family
doctor who treats children are in the narrow
sense of the term pediatric at all, — but that
the child frequently presents a problem that
is dtimatologic, otologic, surgical, or (as the
vital statistics prove so conclusively) even
obstetric, for solution by the general practi-
tioner.
What then is the Ninth District Medical
Society offering to its members and to the
members of other units of organized medi-
cine who may care to share its good things
with it? Briefly, this: A program covering
two weeks, to be given in the latter part of
June and a few days in July, has been
mapped out, and will be available within a
few days for those interested. This program
includes lectures, clinics, and demonstrations
of proccduics that have been found useful
in the tre:)tnient of children. There will be
moving picture films, as well as "stills," illus-
trating such of the lectures as can be made
more valuable by such aids. Clinical mate-
rial is being located for the use of such lec-
tures as will avail themselves of this graphic
means of impressing their message upon their
hearers; and the wards and operating rooms
and e.xamining rooms of the Davis Hospital
will be available for the closer study of both
bed and ambulant cases, operative and other-
wise, that is possible only in the smaller inti-
mate group composed of teacher, patient, and
two or three students.
Juet how is the faculty made up; of what
does it consist, and what branches are repre-
sented? In the first place, pediatricians have
been invited from neighboring cities; and to
the credit of this branch of the profession it
should be recorded that the response has been
almost unanimously favorable. These men
have been asked to specify what type of cases
they feel best qualified, through interest and
expyerience, to demonstrate; and earnest effort
is being made to secure appropriate clinical
material to make their contributions vital
and compelling. Next, men from specialties
dealing largely with children have been asked
to contribute from their experience the sort
of knowledge that they find most valuable
for the general practitioner to know, — both
as to diagnosis, and as to the treatment of
conditions in their own fields that they feel
that the general practitioner can safely and
profitably handle without referring. Skin,
eye, ear, nose and throat, surgery, clinical
pathology, all are levied upon; orthopedics
and obstetrics (on its prenatal side) contrib-
ute heavily. The state department of health
contributes the services of two experts in
child health conservation. Dr. Laughinghouse
and Dr. George Collins, director of the Ma-
ternity and Infancy Bureau; and the very
best men in the various branches have been
glad to do their bit to make the course a
success.
It is believed that while this course is do-
signed primarily for the man in general medi-
cal practice, it will appeal to any physician
who is called upon to treat children. A more
comprehensive list of contributing teachers it
would be hard to conceive of; yet not one
of these men is coming with the idea of
reading a medical paper before a society.
The style of presentation will be distinctly
didactic and practical; rare cases are not to
be stressed, but rather the sort of thing that
is constantly being met with in actual prac-
tice. Nothing that is theoretical or unproved
is appropriate in this sort of work; what the
tCTcliPr has found to work in his own practice
is what he is asked to set forth for the use
of the most discriminating audience conceiv-
able, which is one composed of general prac-
SOUTHERN MEDICINE AND SURGERY
June, 1929
titinners right out on the firing line!
While this significant effort is being put
forth by one of our most aggressive aud ac-
tive district medical societies, it will be stud-
ied with much interest by the general medical
body, both locally and throughout the coun-
try. For the district society is the logical
unit of organized medicine to attempt this
task of offering educational facilities to the
members of the profession. Its larger field
makes it possible for it to furnish teachers
from its own membership, — something not so
readily possible with the county society. Sev-
eral of the districts have begun to deal ten-
tatively with the problem; and it is hard to
believe that this concrete example will fail
to stimulate many other efforts all over the
state and section, if not over the country in
general. Already other district societies in
North Carolina are contemplating an exten-
S'On of the Statesville idea; and it will be of
the greatest interest to watch the spread of
the movement that can easily be foreseen by
the thoughtful observer. The loyal North
Carolinian will rejoice that again the Tar
Heel State is in the van of progress; and will
want to put his shoulder to the wheel in his
own community, when the opportunity arises
for doing something similar or better for the
advancement of the health of his community
and the status of his profession. •' !i ■' >
.(i i.,;..
DENTISTRY V""*'
W. M. ROBEY, D.D.S., Editor .,ri !?'ff
Charlotte, N. C.
Debt
"He was a prince. But it was said that
he had lost some of his practice by attending
so many dental meetings in recent years,"
said a patient of a former dentist of a distant
city who has passed to the reward due one
who has served his patients and the profes-
sion to the point of criticism.
As we swell with pride and pat ourselves
on our backs at the great progress of our pro-
fession we may do well to take trial balance
and see what our individual contribution has
been.
First, we chose the profession as a life-
work^a contribution.
Second, we received an education at the
hands of a body of men who made a personal
sacrifice in attempting to instill sufficient
learning to provide the momentum to start
the profession moving.
Third, we applied for a license to practice
to a body provided by legislative enactment,
in an attempt to aid progress and prevent
retrogression, who were sacrificing time and
money.
Fourth, we opened an office and a bank
account in our attempt to retrieve our finan-
cial outlay.
Fifth, perhaps we joined the dental so-
ciety. We had paid our fees and so were not
conscious of debt, and probably we had some
cerebral congestion tliat, filling some of the
blank spaces in the cranium, gave a full mea-,
tal feeling that made the dental society seem
unnecessary — and didn't join.
But some of us did join and attended its
meetings — for the trip, golf, political reasons,
and even to hear some outstanding visitotj
discuss a popular subject of the day. It^
always seemed impressive to mention these
things back home, where neither poker nor
"bottled in bond' was mentioned; and some
of us read a paper or gave a clinic.
Some entered the field of research and re-
ported their findings.
Some had instructive cases and told the
others.
Sonic developed mechanical devices and
gave them to their fellows.
Church, charily and community advance-
ment appealed to all.
' Check each item. Do we give most or do
we receive most?
Am I a prince being criticised for attend-
ing meetings, or do I always receive and
never give?
EYE, EAR AND THROAT
For litis issue N. K. Hart, M.D.
Charlotte, N. C.
'"'"''• ''"RIenteee's Disease
!;i'.|iir.j . it! I . , ,,
Meniere's disease as usually described con-
sists of a very sudden onset of deafness, tin-
nitis, intense vertigo with its consequent haii-
sea and vomiting, and nystagmus. The at-
tack may be apoplectiform, the patient fall-
ing. Consciousness may or may not be lost.
Hemorrhage into the labyrinUi has always
been mentioned as the probable cause.
Drury has recently suggested (Laryngo-
scope, JMarch, 1929) that this phrase be
changed tq "symptom-complex Meniere." His
clinical premise for such suggestion is exce|-
June, 1929
SOUTHERN MEDICINE AND SURGERY
417
lent as he shows in his article.
Historically, only one of Meniere's several
reported patients at autopsy showed hemor-
rhaee into the labyrinth. Unfortunately this
has usually been interpreted ever since as the
cause of sudden deafness, and vertigo with
nausea and vomiting. (Meniere's disease.)
This s> inptom-complex is subject to wide
variations in its manifestations. The deaf-
ness or the vertigo may predominate. Some-
times both are marked. There may have
been just one attack or periodic attacks. These
may last from a few seconds to a week.
There is unquestionably a disturbance of
the inner ear. One ear or both may be af-
fected, though usually one ear is preponder-
antly affected.
The extent of involvement and a differen-
tial diagnosis can only be determined after a
careful ear examination. In the real case,
functional ear tests will show the nerve type
of deafness if the auditory branch is affected.
The vestibular tests during an attack or
shortly after may show a hyperirritable laby-
rinth. In an interim between attacks, espe-
cially after repeated attacks, definite hypo-
function of the vestibular apparatus can be
demonstrated. It is of a diffuse character.
The modus operandi is rarely hemorrhage,
the old belief notwithstanding. Autopsies by
reliable observers have failed to bear this out.
MacKenzie favors the focal infection the-
ory. He believes it to be due to toxins rather
than to direct metastasis of the organisms.
Minute emboli and vascular spasms or relax-
ations are tenets of some. Certainly when
one considers that the internal auditory ar-
tery is one of the longest in the body, and
that there is practically no collateral circu-
lation for the labyrinth, these latter opinions
bear weight. Certainly in most of these pa-
tients bad teeth and tonsils are found. In
oiher cases a gastro-intestinal toxenva is oper-
ative. Drury believes a hypothyroidism is
occasionally a factor and claims relief from
the judicious use of thyroid extract.
These patients merit more attention than
heretofore given. Especially must a cerebel-
lar or ande lesion be ruled out. Other fre-
quent causes of vertigo are eye strain; cardio-
vascular disease: more rarely neurasthenia or
other functional nervous disturbances. If
these are not factors, attention should be
given to eradication of obvious foci. Such
removal often gives marked improvement,
sometimes a cure. Certainly it occasionally
will prevent progression to a complete deaf-
ness.
During the acute attack the Vienna school
advocates pantopon. However, it is best to
control the patient if possible with sedatives
such as luminal, bromides and chloral. The
latter two may be given by bowel if gastric
distress is present. Typically the patient de-
sires to be on the sound side and dreads sud-
den movements.
Pasteur said "The characteristic of errone-
ous theories is the impossibility of ever fore-
seeing new results." Hence, probably no one
cause always operates. Some are due to a
toxemia (which could explain cases of bilat-
eral involvement); some to minute emboli
(which would explain unilateral involvement
exclusively); and some are without doubt due
to vascular changes inherent in the vessels or
secondary to nervous phenomena (which
could affect one or both sides). Drury
stresses the endocrine etiology. In hyperten-
sion cases, hemorrhage may be a factor.
First, however, one must be sure that the
patient has a true "symptom-complex Me-
niere." A careful ear examination will alone
settle the question.
LABORATORIES
For this issue, Nannie M. Smith, M.A.
Charlotte
EosiNOPHiLiA IN Diabetics Treated With
Insulin
In the course of routine laboratory exam-
ination of the blood eosinophilia is often
observed in patients who do not give a his-
tory of having had any of the diseases in
which eosinophilia is ordinarily found.
Eosinophilia occurs in various conditions.
Infection by any of the worms may cause an
increase in the number of eosinopliilcs in the
blood. The highest figure is reached in
trichinosis. The eosinophiles usually range
between 10 per cent and .SO per cent in this
disease but they may go much higher.
True bronchial asthma ordinarily shows a
marked eosinophilia during and following the
paroxysms.
In myelogenous leucemia there is usually
an absolute increase in the number of eosino-
philes but since there is also a great increase
in other leucocytes the percentage is not
SOUTHERN MEDICINE AND SURGERY
June, 1929
raised.
The number of eosinophiles is also increas-
ed in many skin conditions; such as pem-
phigus, prurigo, psoriasis and urticaria; in
anaphylactic conditions, notably in hay fe-
ver; and in scarlet fever.
R. D. Lawrence and O. B. Buckley have
recently reported an eosinophilia in insulin
therapy. They observed a marked eosino-
philia in a diabetic patient treated with large
doses of insulin. A thorough investigation
failed to show any of the usual causes of
eosinophilia, hence it seemed possible that
insulin might cause the increase of eosino-
philes. Other diabetics were investigated.
Blood counts were done on twelve diabet-
ics who were not being given insulin. In
these cases the eosinophile count did not go
above 4 per cent.
Twenty cases of diabetics of all ages and
degrees of severity, which were being treated
with insulin were then studied. Ten per cent
of these cases showed an eosinophilia of over
4 per cent. In five cases out of the ten
which showed an eosinophilia, the eosino-
philes were 9 per cent or over. The highest
count observed was 20 per cent. No factors
were noted which would account for the pro-
duction of eosinophilia in half of these cases
and its absence in the other half. There was
no relation between the degree of eosinophi-
lia and the amount of insulin given. In cases
where the blood count was repeated several
times considerable variation in the degree of
eosinophilia was observed, normal counts
being obtained at times. It is thought possi-
ble by the investigators that eosinophilia
may have been present in the other ten of
the series but was not discovered by a single
blood count.
Lawrence and Buckley offer no definite
explanation of insulin eosinophilia but since
insulin is an acid solution which irritates the
skin and subcutaneous tissue causing stinging
and edema at the site of the injection they
suggest that the eosinophilia may be asso-
ciated with the skin irritation in the same
way that it is frequently associated with skin
diseases.
After scarlet fever a marked pallor, and puffiness
under the eye-lids should make one at once think
of kidney damage.
ORTHOPEDIC SURGERY
For this issue, Edward King, M.D., Asheville, N. C.
Infantile Paralysis: Early Diagnosis
AND Treatment
Statistics show a steady increase in the
number of cases of infantile paralysis from
year to year. Although in the South there
has been no severe epidemic such as New
England has witnessed, each summer brings
its c|uota of new cases of this dread disease,
[n the past poliomyelitis has been handled
in two well defined and separate stages and
each stage treated by different specialists
without coordination of their activities; the
fust stage dealing with the acute illness and
lasting until the general health of the patient
is regained, and the second, dealing with the
residual paralyses and accompanying deform-
ities.
As a rule, the general practitioner or child's
specialist is called in to see cases of infantile
paralysis in their incipiency, and on his
shoulders rest the responsibility of diagnosis
and treatment. Having carried the patient
through an acute febrile illness, his attention
is focused on the improvement in the general
condition. The rapid progress of deformities,
due to overstretching of temporarily if not
permanently paralyzed muscles, is not prop-
erly appreciated at this time. The patient
having recovered in general health is now
urged to get up, to exercise without protec-
tection of the weakened muscles, and in-
stead of increased improvement the reverse
takes place. Partially paralyzed muscles rap-
idly play out and limp and deformities rap-
idly increase. At this stage of the disease or
later the orthopedist is consulted. The time
of prevention has passed and only reconstruc-
tive methods of treatment are available. If
from the outset there is a combination of
treatment focused, not only on the promotion
of the general condition of the patient, but
also on the protection of the damaged neuro-
muscular system, the ultimate results will be
far superior to those usually seen.
In the summer season especially the phy-
sician should be on the watch for possible
cases of infantile paralysis. Any case of fe-
ver, particularly if its origin be undetermin-
ed, should put him on his guard, and he
sliould not be satisfied to await the arrival of
paralysis to confirm his diagnosis.
June, 192P
SOUTHERN MEDICINE AND SURGERY
"It is," says Aycock, "the physical signs
to which one must look, for diagnosis, and
these make the early picture of infantile pa-
ralysis a fairly characteristic one. On obser-
vation the child seems prostrated to a greater
degree than the temperature — usually under
102 degrees F — would indicate. The face is
flushed, the e.xpression is an.xious and fre-
quently there is pallor about the nose and
mouth. The throat is mildly infected but not
enough in itself to account for the child's con-
dition. The pulse is usually rapid, out of pro-
portion to the temperature. There is frequent
portion to the temperature. There is frequently
a rather coarse tremor when the child moves
which may be very striking. There is a dis-
tinct rigidity of the neck, but not to the
marked degree seen in meningitis. The pa-
tient tilts the head on the neck but does not
bend the neck on the shoulders; as a result
the head can be brought about half way for-
ward when resistance is encountered and the
child complains of pain. More constant than
the stiffness of the neck is the stiffness of the
spine. This is best brought out by having
the patient sit up in bed and try to bend the
head down onto the knees. The average child
ill with other affections is very flexible and
has no difficulty in doing this. If these pa-
tients bend forward at all it is from the hip
with the spine held rigidly. Kernig's sign is
not usually marked at this stage, but the
deep rcllexes are frequently hyperactive
rather than diminished as they are later. A
cerebral tache is almost always present. It
is the presence of these signs and symptoms
which justifies a probable diagnosis of ante-
rior poliomj'elitis and calls for the final step
in the diagnosis.
This step is the examination of the spinal
flu'd. The fluid is usually under moderately
increased pressure. When viewed with trans-
mitted light, it presents a faint liaziness.
There is an increase in cells, usually between
SO and 250, occasionally as high as seven to
e-pht hundred, or as low as 20. The cells
may be largely polymorphonuclear early;
later lymphocytes preponderate. There is an
increase in globulin."
// is a proved fact that with a dia<:,nosis
made and proper treatment instituted more
can he done jor cases oj poliomyelitis in the
first jciv hours and days oj their disease than
in as many weeks or months following the on-
ict of paralytic symptoms.
What, then, have we to offer these patients
in the way of early and efficient treatment?
In every suspected case lumbar puncture
should be performed for diagnosis and when
the pressure of the spinal fluid is found in-
creased, this procedure should be frequently
repeated as a therapeutic measure to reduce
the pressure. By doing this, not only are the
acute symptoms lessened, but in many cases
they disappear entirely in a most phenomenal
way. The cord involvement in these cases is
diminished and residual paralysis is less se-
vere. The acute stage is shortened and their
recovery is more rapid.
Numerous experiments have shown that
human convalescent serum and the anti-
streptococcic scrum of Rosenow will neutralize
the virus of poliomyelitis. Better results are
reported with the former, but it is more dif-
ficult to obtain. The earlier the serum is
given the more marked is its effect, and cases
so treated show a surprisingly low percentage
of the severer grades of paralysis. The se-
rum is usually given intramuscularly or intra-
venously at the time of the lumbar puncture,
repeated the next day if fever persists.
Complete rest is essential during the first
few weeks of the disease, and can be accom-
plished by plaster casts or splints. Deformi-
ties should be prevented by holding the ex-
tremities in a neutral position to avoid
stretching of muscles of one group, with re-
sulting failure to regain their power. It is
important that rest be maintained until the
disappearance of tenderness in the muscles,
which usually occurs in from four to six
weeks. Light massage, baking and exercises
can now be instituted. Exercises should not
be done in a haphazard fashion, but given by
a trained physiotherapist thoroughly ac-
quainted with muscle function. Muscles are
never to be permitted to do work too heavy
for them, and fatigue is at all times to be
avoided. Occasionally, a case of infantile
paralysis of long standing is seen, in which
there is constant overloading of weak muscles
from daily activity. An acute unrelated ill-
ness places the individual in bed for several
weeks. Much to his amazement, on his re-
turn to work it is found that the enforced
rest has done wonders for the impaired mus-
cles and, until overfatigued again, the patient
is much better. Tub baths, baking, diather'
SOUTHERN MEDICINE AND SURGERY
June, 1929
my and quartz-light all have their advocates
and accomplish their good probably by in-
creasing circulation in the paralyzed part.
When fair recovery has taken place, — after
two or three months — graduated weight bear-
ing may be permitted with the use of braces.
In conclusion then: an early diagnosis is
to be sought before paralysis appears. Treat-
ment should consist of isolation, antipyretic
measures and complete rest. Lumbar punc-
ture should be performed early and repeat-
edly to reduce spinal pressure and human
convalescent or antistreptococcic serum of
Rosenow administered. More attention should
be paid from the outset to protection of weak-
ened muscles and deformities prevented. If
these procedures are carried out the severer
grades of paralysis will less often result and
the death rate from this disease will be mark-
edly lowered.
UROLOGY
For this issue, John P. Kennedy, M.D., F.A.C.S.
Charlotte, N. C.
Reporting a Case of Ureteral Stone
A farmer of 51 was admitted to the hos-
pital April 15, 1929, complaining of pain in
the abdomen, nausea and vomiting. He was
taken suddenly ill at noon tefore admission
that evening with cjuite severe pain in the
epigastrium with some radiation to left back.
He took a dose of salts which he promptly
vomited. IMorphine gr. ;3,s did not relieve
the pain and he was removed to the hospital
six hours after onset. He stated that he has
never suffered anything like this before. He
had never had any urinary symptoms and does
not have any now. He considered that he
had been quite healthy, never having had any
severe illness and only one operation, we hav-
ing removed an acute suppurative appendix
for him in 1924. Has had no digestive symp-
toms.
On admission pulse was 74, temperature
98.8 and respiration 18. He was suffering
with pain in the epigastrium and left back,
was nauseated and vomited soon after ad-
mission. There was marked rigidity in the
upper left abdomen extending into left back.
There was less marked rigidity in upper right
abdomen. White count was 11.600 and urine
showed an occasional red blood cell. The
abdomen and seemed to localize for the time
(^bout his gall-bladder region. During this
time he was much distended and nauseated.
This condition persisted for four days with
pain, rigidity, distention and nausea; pulse
rate went to 94, temperature to 100.4 and
leucocytes to 12,700; on third day urine
showed an occasional pus cell, an occasional
red cell and a faint trace of albumin. Dur-
ing this time the diagnosis could not be made
and operation was withheld although it was
thought the patient had an acute abdominal
condition. It was not until the fourth day
that his bowels could be moved. This gave
partial relief of his pain but considerable rig-
idity of the upper abdomen and some disten-
tion remained. Now his pain and tenderness
seemed to center over the left kidney so an
x-ray examination of the kidney, bladder and
ureter was made. This failed to show any
stone shadow but did show the left kidney
at a lower level than the right and the left
kidney shadow much larger than normal. Fol-
lowing this x-ray report I made a cystoscopic
examination and found the left ureteral ori-
fice contracted with noticeable swelling about
it, and apparently no urine coming from it.
A number five catheter met and, after some
manipulation, passed an obstruction in the
lower left ureter 4 cm. from the bladder.
Pus was seen to come from the orifice about
the catheter and then urine. Thirty c.c. urine
and pus drained from the kidney pelvis and
the catheter was left in place 48 hours with
rapid clearing up of all symptoms. Another
x-ray centered over the pelvis showed the
shadow of a stone lying next the catheter in
the pelvic ureter. Two days later the cysto-
scope was again introduced and, with the aid
of caudal anesthesia and a spiral stone ex-
tractor, a stone removed from the lower end
of the left ureter.
This patient is still under observation two
months after removal of the stone and during
this time he has been symptom-free and the
pus has almost entirely cleared up. Such pa-
tients should not be discharged until the kid-
ney infection has cleared up, foci of infection
have been eradicated and good drainage as-
sured from the ureter. His case is thought
worthy of reporting because such marked ab-
dominal symptoms might so easily have oc-
casioned a needless abdominal operation. The
radiation of pain in cases of kidney and ure-
teral stones has been frequently referred to,
but in the mind of many physicians that ra-
June, 19J9
SOUTHERN MEDICINE AND SURGERY
Ail
diation is always downward towards the groin
and testicle or inner side of the thigh. Here
was a stone in the lower end of the ureter
without bladder symptoms and without any
pain in the lower abdomen, groin or testicle,
but with marked upper abdominal symptoms.
Appaiently in this case the kidney pelvis was
more sensitive to the back pressure than was
the uieler.
505 Professional Building.
RADIOLOGY
John D. MacRae, M.D., Editor
.'\sheville, N. C.
Cancer of the Uterine Cervix
Cancer of the uterus occurs far more fre-
quently in the cervix than in the body. Cerv-
ical carcinoma in its earliest stage is operable
but the symptoms are so insignificant when
,the disease is in this stage that a very small
percentage of cases are diagnosed in time for
operation.
The broad ligaments become infiltrated
and the lymphatics are involved so early that
surgical treatment can not be done with as-
surance that a clean sweep of malignant cells
has been accomplished.
Even in the most favorable type of cancer
of the cervix, radium and short wave length
x-rays have accomplished as much as surgery;
and in advanced cases radiation treatment
rarely fails to relieve pain and prolong life.
Even in women who seem hopelessly sick
with cancer of the cervix, a fair number of
five-year cures are obtained.
Because these facts are becoming well es-
tablished many eminent surgeons have dis-
carded operative for radiation treatment in
cervical cancer.
In the practice of medicine nothing is more
important than early diagnosis. This is espe-
cially true in cancer therapy. Educational
propaganda may occasionally create an ab-
normal fear of cancer. Such a fear is quickly
allayed when the patient consults her physi-
cian. On the other hand if there is cause for
anxiety, early diagnosis is accomplished. It
is every physician's duty to support such
propaganda as is being promoted by the
American Society for Control of Cancer.
Child-bearing almost inevitably results in
erosions and lacerations of the cervix, which
are the beginning of degenerations that ter-
minate in cancer. Every mother should be
examined shortly after her lying-in period
with the purpose of recognizing and removing
scars and lesions which might create chronic
irritation. All functional disturbances occur-
ring as the menopause approaches should be
investigated. Also there should be routine
examination of the pelvic organs at the time
of the change of life. Endocervicitis, at this
time, is a precanerous lesion and should be
relieved by constitutional or local treatment,
or, if necessary, by amputation of the cervix.
Carcinoma of the cervix in the first stage
is operable. The growth will be small, with-
out infiltration of contiguous tissues and the
uterus freely movable. Radium applied in
such cases yields a high per cent of complete
or five-year cures.
In the next stage there is congestion of the
cervix and it is hard to tell whether or not
malignant infiltration exists. Also the mov-
ability of the uterus is questionable.
Treatment of this group will yield a good
percentage of five-year cures, but in addition
to radium, deep x-ray treatment is applied.
When the broad ligaments and adjacent
structures become involved, and this is rec-
ognized by definite uterine fixation, infiltra-
tion and palpable lymph glands, we have
come to another group. The greatest number
of carninomatous uteri are seen in this group.
Prognosis now becomes very much worse.
Inflammatory infiltration complicates the
disease and marks the extent of malignancy,
or makes it appear more extensive than is
actual. Considerable attention should be paid
to clearing up infections and acute inflamma-
tion before starting treatment with x-rays or
radium.
It is desirable to make microscopic exam-
ination of tissues in all cases but often this
is omitted when a diagnosis can be made by
sight and touch. When metastasis to distant
parts and extension to contiguous tissues is
established x-ray and radium treatments are
purely palliative. It is sometimes difficult
to decide whether to advise such management
of the case. However, it must always be re-
membered that radium and x-rays will relieve
pain, stop offensive discharges and prolong
life. Sometimes when not exi^ected, a patient
may be returned to useful life for many
months.
Methods of applying radium and x-rays in
cervical cancer have varied greatly in the
SOUTHERN MEDICINE AND SURGERY
June, 1929
hands of different radiologists. There is a
decided tendency toward much needed stand-
ardization and results are better.
Radium and short wave length x-rays are
very new therapeutic agents and it takes
years to evolve the very best technic in their
application. Confusion still prevails as to
which is the most useful. Many physicians
fail to grasp the truth. The gamma rays of
radium and short wave length x-rays, as used
in deep therapy, are each competent to de-
stroy cancer cells and convenience of appli-
cation determines which should be used in
any given case. In fact the two agents are
used to support each other in treating cancer
of the cervix; x-rays being applied to the
malignant tissues through multiple ports of
entry on the skin, and radium being applied
within the uterine cavity, cervical canal and
in the vault of the vagina. By this proce-
dure a massive dose of x-rays and radium
rays (acting in identically the same way) are
delivered into the diseased area in the quan-
tity desired.
Rapidly growing cancer cells are more sen-
sitive to the rays than the normal tissues sur-
rounding them. This is expressed by saying
that the rays have a selective influence on
malignant tissues. Because of this fact, and
our method of applying the dose through
many ports of entry the healthy tissues are
prevented from receiving an overdose.
During the life cycle of the cancer cell
there is a short period when its vulnerability
is greatest. This fact guides us in selecting
what appears to be the best method of apply-
ing radium in these cases.
First a biopsy is done, the measures to re-
lieve the pelvic tissues of infecting and in-
flammatory conditions are carried out as long
as necessary, generally a few days to one
week. Then the total dose to be given is
decided upon and instead of an enormous
dose delivered in a short period, a dose is
selected which is as much as the patient can
safely be given. Treatment is applied inside
the uterine cavity by using a small quantity
of radium, properly screened, for a long time;
thus attacking as many cells as possible while
they are in a vulnerable condition.
Radium m:iy be placed in the fundus, cerv-
ical canal and vaginal vault at the same time,
or these regions may be treated one after the
other until the full dose is given. When the
radium dose is finally completed, deep x-rays
are applied externally in the dose decided
upon. The whole dose of x-rays and radium
should be finished inside of two weeks and
repeated doses are to be used after careful
consideration.
There is no doubt that x-ray and radium
treatment is giving increasingly good results
in cervical cancer and that prognosis in this
condition will improve as more perfect tech-
nic is developed.
DERMATOLOGY
Joseph A. Elliott, M.D., Editor
Charlotte
Dermatitis Venenata
Dermatitis venenata is an acute inflamma-
tion of the skin caused by an external irri-
tant, of either vegetable, animal or chemical
origin. It is characterized by redness and
swelling, frequently by vesicles and bullae
and is accompanied by sensations of burn-
ing and itching of varying degrees.
There is a large group of occupational
dermatoses that may be included in this
group. Some forty or more occupations have
been responsible for the production of a der-
matitis in susceptible individuals. Cases of
dermatitis are frequently produced by hair
dyes, cosmetics, laquers, dyes in furs, animal
proteins and numerous chemicals. The larg-
est group producing dermatitis venenata is
the plant group. White has found that more
than one hundred plants produce a derma-
titis in susceptible individuals. While we see
cases of dermatitis venenata produced by
many of the various substances enumerated,
that produced by Rhus toxicodendron (poison
ivy) is the most common in our southern
states. We will therefore confine our fur-
ther discussion to the latter type.
This type appears within a few hours to
several days after contact with the plant and
is accompanied by erythema, swelling, vesi-
cles, bullae and a serous discharge after the
lesions rupture. The swelling is most pro-
nounced where the tissue is lax, such as about
the eyes and genital region. The vesicles
vary a great deal in size depending on the
location and severity of the attack. The
areas commonly involved are the hands, arms,
face, neck and genital region. Any portion
of the skin may be affected. The average
June, 1020
SOUTHERN MEDICINE AND SURGERY
case runs an acute course, lasting from one
to three weeks. Constitutional symptoms
are usually absent in uncomplicated cases.
Individual susceptibility plays an import-
ant part. Brown, however, has shown that
very few, if any, persons, are insusceptible.
He concludes from his experiments that there
is not only a variability in susceptibility in
different individuals, but there is a variability
of susceptibility in a given person.
Treatment: If the patient is seen shortly
after exposure it is advisable to wash the
parts with soap and water followed by alco-
hol as a precautionary measure. After the
dermatitis has developed boric packs and
soothing lotions are indicated. Krouse and
Wiedman were unable to confirm either the
prevention or curative value of Rhus toxi-
codendron antigen in a large series of care-
fully controlled cases. This form of treat-
ment is therefore of doubtful value.
INTERNAL MEDICINE
Paul H. RrNCER, A.B., M.D., Ediler
Asheville, N. C.
The Aging of the Heart Muscle
Dr. Alfred E. Cohn in the May number
of the American Journal of the Medical
Sciences takes up this matter from a gen-
eral biologic point of view.
Growth in the sense in which Dr. Cohn
uses the term means "successive changes in
an organism both from the point of view
of its bulk or mass which increases, as also
from that of the progressive differentiation
of all the tissues and organs of the body.
Nor is the term confined to that stage in
which bulk or mass continuously increases;
growth continues also during the period of
involution, of decline, of old age. Growth
is now negative where before it was posi-
tive."
There are in the main two theories of
senescence. These are known as
1. Mechanistic
2. Teleological.
The first, to cite Herbert Spencer's the-
ory, is that matter during growth (and evo-
lution in general) passed from simple and
homogeneous to complex and heterogeneous
states. The second may be exemplified by
examining an organism or a system with
the view to learning whether its mechanism
tends to satisfy a purpose, of course not
explicit.
Investigations have been carried on in
order to ascertain what changes in jorvi or
matter, that is to say in anatomy, and what
changes in junction, that is to say in physi-
ology, may be detected.
'"Chemical differentiation may be regarded
as an ultimate form of anatomic structure.
Research in the direction of defining constitu-
tion in this way has also been attempted.
Desiccation, or decrease in the concentration
of water, is, for example, one of the common-
est observations in the aged, having as a con-
seciuence increase in the concentration of ni-
trogen * * *. There can be no doubt that
the body undergoes both structural and
chemical changes."
Among the factors which modify the proc-
ess of growth, Cohn mentions: 1. Infectious
diseases, and 2. Heredity. Some lines about
heredity are well worth quoting verbatim.
''The influence of heredity is a different
matter; the evidence here so far is in no sense
anatomic — at least so far as the heart muscle
is concerned, but rather statistical. There is,
of course, the popular natural history which
refers to the arteries, but about this there
seems now to be doubt; Pearl thinks that
even beyond the state of these, the degree of
longevity of one's ancestors plays a determin-
ing part, though on this point there is also
dissent. The matter of the arteries — about
the heart muscle itself there are no criteria —
brings up for discussion the difference be-
tween age expressed in numbers of years
lived or chronologic age, and age manifested
by physical states or physiologic age. The
meaning of the difference is simply that a
man may be older, or younger, so far as his
physiologic state, which implies the number
of years he is likely still to live is concerned
than the number of his years, his chronologic
age, would have led one to suppose. Inter-
esting as is this distinction, and important
when it is better understood, now it is practi-
cally impossible to appreciate in terms of
structure and of course of correlated function
how either acceleration or retardation in the
life process may have taken place.
Cohn notes the fact that with improvement
in hygiene and in preventive medicine, more
and more people are living out their allotted
span of years. lAir this reason the structures
which appear to bear the brunt of the stress
SOUTHERN MEDICINE AND SURGERY
June, 192Q
of life are the heart and blood vessels. By
this it must not be imagined that other or-
gans and structures are exempt from wear
and tear but simply that the wear and tear
on the circulatory system is the most obvious.
Blood vessels undergo change with increas-
ing years. Bramwell has studied this ques-
tion in an ingenious manner. "It is well
known that a fluid of a certain consistency
flows at a rate through a vessel, depending
on the elasticity of its walls. Bramwell found
that at the age of five years, blood flows at
the rate of 5.2 meters per second; as the ves-
sels stiffen with years, the rate rises conspic-
uously so that at eighty it has mounted to
8.55 meters."
Growth in the heart is encountered in form
and structure. The muscular apparatus
shows marked growth. About the tenth year
pigment begins to be deposited in bipolar
fashion about the nuclei of the heart muscle.
"This increases progressively until in the
si.xth or seventh decade it lends to the appear-
ance of the muscle a brown color. It is
known as brown atrophy to pathologic ana-
tomists, but there seems little doubt that its
occurrence is a natural, normal phenomenon."
With the lack of concentration of water in
the aged, as previously mentioned, the heart
muscle unquestionably partakes in the gen-
eral desiccation, its chemical structure
changes and "the muscle of the aged is a
different muscle from any that preceded it."
Clinical Manifestation oj the Senile Heart:
From the biological and philosophical con-
sideration of his theme, Dr. Cohn goes on
to its more practical aspects. He traces two
anatomical changes:
1. The Desiccation
Pigmentation \ muscle.
Nuclear changes j in the heart
2. Changes connected with what is al-
ready known of new elements as evidence of
inflammatory processes and connective tissue
growth.
When considering the senile heart it must
be approached also from the junctional side.
Two orders of disability require examina-
tion:
1. Weakness
2. Pain
Dr. Cohn differentiates weakness from fa-
tigue and says: "By fatigue I mean a phe-
nomenon which is asymmetric to, out of time
with, the performance of other still vigorous
structures and organs. * * By weakness I
mean that phenomenon of symmetrical dis-
ability which, as the result of age, involves
the whole organism in uniform progressing
decrepitude * *. Weakness, on its anatomic
side, I have just been predicating, so far as
contemporary knowledge permits, as the des-
iccation and pigmentation and perhaps other
changes still unknown of the heart muscle.
It may perhaps be regarded as the most nat-
ural of the manifestations of involution. The
pump, without putting too fine a point ujx)n
it, is, after all, the life-distributing organ of
the body. Its estate is still high, even if the
estimates of a later physiology have displac-
ed it from being in Harvey's phrase, the sun
of the microcosm."
Pain:
Heart affections give rise to all varieties of
pain. Only two structural abnormalities have
been projX)sed for correlation with cardiac
pain and both are lesions of the coronary
vessels.
1. Coronary thrombosis:
a. Nature of pain \ Give this a
b. Fever I place as a
c. Leucocytosis I clinical entity
d. Pericordial friction / though not
rub I necessarily as
e. Coronary thrombosis 1 a disease.
With regard to the nature of the lesion
"on two points there is knowledge. First,
there occurs involution of the capillary ves-
sels throughout the body, and presumably
also in the heart. Second, there is invo-
lution, as Gross has shown, in the number
of vessels of the heart. A third point may
be added: Wintermitz and his pupils * *
have insisted that in many arterial lesions the
essential alteration is to be found in the vasa
vasorum and that it is the alteration in them
which is essentially connected with the oc-
currence of thrombosis. I am not aware that
specific study has been made of this process
in the coronary artery. If thrombosis of the
coronary artery depended upon capillary in-
volution, and if it were this essential process
which underlay the occurrence of thrombosis
of these particular vessels, there would be a
somewhat clearer understanding of the whole
June, 1929
SOUTHERN MEDICINE AND SURGERY
niatler." If this hypothesis be correct, then
It IS equally correct to say that the condition
IS the result of the process of growth and of
continuing differentiation.
2. Angina Pectoris.
Though many are no longer in accord
with the description given of this condition
by Heberden, yet it is generally assumed to
be dependent upon "abnormality or malfunc-
tion of some sort of the coronary arteries."
Keefer and Resnik claim that anoxemia of
the heart muscle due to affection or disease
of the curunary arteries or of the aorta brings
on the characteristic pain.
The following paragraph is of particular
interest: "Although not usually described
in text books, there is a form of pain which
occurs in the middle aged, of great interest
and, so far as is known now, not associated
with a demonstrable cardiac lesion. It oc-
curs, as did that in Heberden's description
of angina pectoris, in association with exer-
tion and with exertion only. Prolonged rest
of two, three, four or even more months re-
lieves such cases; and certain ones, though
which they are it is difficult to predict, it
relieves permanently."
With regard to treatment. Dr. Cohn
touches on but two things: First, the giving
of digitalis, and second, operating on the
cardiac nerves.
He states, as is well known, that the opin-
ion is now abroad that digitalis does not
act as well on the hearts of the aged. He
himself does not hold that to be proven by
any means. While citing certain diagnostic
distinctions necessary in order to evaluate the
action of digitalis, such as determining
whetlier the case is a purely cardiac one or
one in which there is also renal involvement
with edema; the type of cardiac affection
present; whether the auricles fibrillate or
flutter; he feels that there is no reason to
withhold digitalis when it appears to be in-
dicated.
With regard to operating on cardiac nerves
he has this to say: "Section or excision of
a nerve may have or may interfere with one
of several possible functions. It may cut
the retlex arc which is instrumental in caus-
ing pain. If it does that and nothing more,
no haim, but benefit only may be expected
to result. But whether it interferes with.
alters or stops the process which gives rise
to the pain is not yet known. There are
those who have hesitated to advise the use
of the method lest patients be led to believe
in a false security, when, in point of fact,
the absence of a warning pain may induce
them to undertake exertions and to become
exposed to dangers which it would be better
to avoid. Other things being equal, the ques-
tion may be raised as to whether the ex-
change of comfort for danger may not de-
pend on a decision in which the wishes of
patients may perhaps be consulted."
This paper is full of deep thought, wide
erudition and penetrating philosophy. It is
the type of paper that stimulates thought
and whets the curiosity and the interest of
the medical man causing him to exclaim with
the psalmist, "we are fearfully and won-
derfully made" and with Shakespeare,
"there are more things in heaven and earth,
Horatio, than are dreamt of in your philoso-
phy."
Write Dr. Alfred E .Cohn, The Rockefel-
ler Institute for Medical Research, New
York, N. C, for a reprint of this paper.
In all probability a testicular tumor that makes
no response to the iodides is a new growth.
Suspect tuberculosis in the case of the irritable
bladder that becomes worse under nitrate of silver
irrigations.
SURGERY
Geo. H. Bunch, M.V., EJilur
Columbia, S. C.
Wounds and Infections of the Hand
Made for mobility rather than for strength
the hand is so much used both in work and
in play that it is peculiarly liable to injury
and to infection. Wounds of the hand are
apt to result in disability out of all propor-
tion to their extent. Both artist and artisan
are dependent upon the hand for a livelihood.
It is unfortunate that the care of this im-
portant member is considered a part of minor
surgery and is often delegated to any avail-
able physician irrespective of his qualification
or experience in this work. A stiff finger is
a handicap to any one, but to a musician
or to a mechanic it may cause such disability
that he may be forced to change his work.
It behooves every physician to know some-
thing of the anatomy of the hand and of the
I
SOUTHERN MEDICINE AND SURGERY
June, 1029
principles of its surgical care.
Active bleeding from an injured hand
should be temporarily controlled by a tour-
niquet put on above the elbow. Because
there are two bones from the elbow to the
wrist a tourniquet applied below the elbow
cannot stop the bleeding, for it does not com-
press vessels lying between these bones.
Thorough debridement should be done in
lacerated or crushing wounds and devitalized
tissue removed. A preliminary application
of half strength tincture of iodine is satisfac-
tory in making the operative field fairly ster-
ile. Gauze dipped in alcohol or in some
mild antiseptic solution should be used for
dressings. The continuous application of ir-
ritating chemical solutions to wounds causes
necrosis of injured tissue and predisposes to
infection and to sloughing.
The retracted ends of severed tendons
should be carefully brought together and
sutured with fine chromic catgut. If possible
sheaths should be replaced over tendons with
interrupted sutures of catgut. The hand
should be immobilized for several weeks in
extreme llexion or extension, as indicated, to
put it at rest and to insure minimum tension
on the sutured tendons. Tendons have a
small blood supply with but little resistance
to infection. When infected the entire ten-
don is apt to slough. If trauma or infection
destroys the sheath a tendon becomes fixed
and practically without function.
Nerves in the hand and wrist are so small
that unless injury to them is suspected and
carefully looked for at operation it goes un-
recognized. Severed nerve ends should be
brought together and sutured. Even if there
be infection and function does not return re-
traction is prevented and identification made
easier at secondary operation when the wound
has healed and aseptic suture can be done.
Digital nerves are only sensory and need not
be sutured.
When a finger is amputated the nerve
should be severed high so that the end will
retract. When possible the flap should be
taken from the palmar surface and the suture
line should be on the extensor surface so the
scar will be posterior. In this way the stump
will not be tender and tactile sensation will
not be impaired. Excepting that of the
thumb, heads of metacarpal bones should not
be removed, otherwise when flexed the fin-
gers will overlie. Tendons should not be
sutured to finger stumps. In the thumb, par-
ticularly, every phalanx is of such functional
value that bone with a blood supply even
though uncovered with skin had better not
be sacrificed. Resection can be done later
if, after skin grafting, results are not satisfac-
tory.
Most infections of the hand come from
neglect of a primary injury or focus. Lym-
phangitis is recognized by red lines up the
arm from the congested hand. On the radial
side they may reach the axilla. Swelling is
from edema rather than from induration.
Treatment consists of elevation and rest. Hot
compresses are helpful. Incision should be
only of the primary focus.
Pus under tension about the bone will soon
destroy it and a felon should be opened
early. This is best done by the alligator in-
cision which begins near the base of the nail
and extends to the bone around the end of the
finger ending at a place near the base of the
nail on the other side. The pulp of the finger
is freed from its attachment to the bone. A
rubber strip placed in the wound insures
drainage. A median incision does not give
proper drainage and leaves a scar that impairs
tactile sense.
When infection occurs in the palm of the
hand the pus collects beneath the palmar fas-
cia or along the sheaths of the flexor tendons.
The spread of pus under the fascia is limited
in some directions. From under the thick
middle triangular portion pus follows along
the lines of least resistance to point near the
hypothenar eminence on the inner side or in
the web of the thumb on the outer side. It
may extend upward beneath the annular liga-
ment to point in the wrist or it may go down
through the openings for the digital arteries
into the webs between the fingers. It may go
between the distal ends of the metacarpal
bones and point on the back of the hand.
When pus forms in a tendon-shealh its spread
is limited only by the extent of the sheath.
Infection in the sheath of the thumb or in
that of the little finger is more serious than
that of the other three fingers because the
sheaths of the middle three fingers extend
only to the heads of the metacarpal bones just
above the webs of the fingers. The tendon-
sheaths of the little finger and of the thumb
pass under the annular ligament and into the
June, 1929
SOUTHERN MEDICINE AND SURGERY
wrist so that pointing may occur there from
infection beginning in them.
Before opening a deep abscess in the hand
its location and extent should if possible be
determined so that proper incision may be
made lor drainage. Incisions should be made
distal to the level of the web of the thumb so
that the superficial palmar arch will not be
cut. Longitudinal incisions should not be
made in the palm, healing may be followed
by disabling scar contraction with one or
more fingers bound in flexion. Through su-
perficial transverse incisions through the skin
blunt lorceps should be forced down into the
deeper tissues and brought out with the
blades open (Hilton's method). In this way
the flexor tendons which run longitudinally
are not in danger of being cut. The tendon
sheaths unless distended with pus are not en-
tered by the forceps and are left undisturbed.
Incisions should be sufficient in number and
adequate in size. Hot compresses of boric
acid solution are helpful or the hand after
incision can be kept in a basin of weak creo-
lin solution for a few days until healing has
begun. Any tendency to contracture should
be overcome by splinting before permanent
deformity has developed.
OBSTETRICS
Henry J. Langstom, B.A., M.D., Editor
Danville, Va.
Long Labor — Its Dangers, HI
In the April and May issues of our Journal
we have discussed long labor from a conserv-
ative attitude and have made some sugges-
tions as to how to eliminate long labor. In
the previous editorials we have discussed the
dangers of long labor from the standpoint of
infections to mother, damage to the birth
canal and damage to baby. In this issue we
wish to continue our discussion of the dan-
fiers, first to the mother. In addition to the
complications that these mothers have from
long labor tests, as infections and lacerations,
— many of which are unrepaired and others
repaired without getting good results — also
the morbidities caused by relaxed vagina with
retro-dis[)lacement of the uterus and the ad-
nexa with cystocele and rectocele. The gyne-
cologists are kept busy day in and day out,
tiying to correct pelvic conditions which have
been cau:;ed by mismanaged deliveries. Prac-
tically all of the cases of long labor present
themselves to the gynecologists with physical
ailments that cost the patient discomfort, dis-
couragement and abundance of money; so it
is not only a problem of taking care of the
physical human ailments, but to this is added
an economic problem of far-reaching import-
ance. So, the physician is faced with these
problems in this modern period for a solution
which cannot be met by our ordinary prac-
tices in this important field. Therefore, we
must study more carefully the principles
which we have practiced through the years
and try to devise methods which are scien-
tific, mechanically safe and physiologically
sound to be applied to our present obstetrical
practice with the hope of eliminating, as far
as humanly possible, the so-called long labor
test.
Besides the dangers of infection and the
destruction to birth canal and baby, one of
the most common complications in these cases
is profuse hemorrhage. A patient may not
lose enough blood to cause her to lose her
life, and still lose so much that it will take
her months to recover from the ordeal of long
labor.
The question may be asked — How can we
then truly eliminate the dangers of long labor
and at the same time have a test that is safe,
scientific and successful? We believe we can
answer this question by providing: (1) That
Ihc physician know thoroughly the physical
shortcomings of his patient, understand the
cervix from the standpoint of thickness and
dilatability, and know that there is no dis-
proportion between the baby and the birth
canal such as to cause obstruction after the
cervix has been fully dilated. (2) That he
know exactly the relationship of the baby to
the mother.
If the attending physician has this knowl-
edge at his finger tips and has surrounded
himself with assistants he will be able to
bring his patients through the test of labor
successfully. During the first stage of labor
he may with reasonable safety give morphine
sulphate hypodermically; then, after the cer-
vix has dilated so that it will admit two or
three fingers, he may administer rectal anes-
thesia and eliminate practically altogether the
l)ains of the first stage. While patient is still
under the influence of rectal anesthesia and
morphine, the attending physician may save
much time and protect against lacerations by
SOUTHERN MEDICINE AND SURGERY
June, 1929
ironing out the pelvic floor, under strict anti-
septic precautions, as the head begins to pass
down through the birth canal. By the time
the head has reached the pelvic floor the
birth canal will be thoroughly relaxed. As
the head passes under the symphysis pubis it
can be suppored by the hand and allowed to
come through slowly and gently, rotating the
head as it begins to pass over the pelvic floor
either to the right or left so as to prevent lac-
erations. As soon as the baby has been de-
livered an ampoule of 1 c.c. of obstetrical
pituitrin is administered hypodermically to
cause the uterus to contract more rapidly.
Usually the placenta is e.xpelled in eight or
ten minutes. There will be less bleeding fol-
lowing this technique than if we allow patient
to go on and deliver herself without this as-
sisance.
In case the rectal anesthesia does not give
enough relaxation during the second stage the
patient may be given by inhalation sufficient
ether to produce complete relaxation, thereby
saving the patient suffering and at the same
time giving her all the protection pwssible.
If, after the physician has studied most
carefully the pelvis, the condition of the cer-
vix and the condition of the birth canal, he
finds there is evidence of disproportion be-
tween the baby and the birth canal, he should
not expose his patient to the long test of labor.
Consultation should be had and, as soon as
the cervix is dilated so that it will admit two
fingers — the bag of waters yet unruptured —
while patient is in first class physical condi-
tion, and an intact bag of waters assures a
minimum of risk of infection, cesarean sec-
tion should be done.
The physician should have thorough train-
ing to do this operation safely. If it is done
before the mother has burned up too much
of her vital energy and before the bag of
waters has ruptured there is little opportu-
nity to get infection and she has pretty near-
ly 100 per cent opportunity to recover. This
operation may be done under local, sacral or
spinal anesthesia. Some use ether, some gas
and oxygen, and others chloroform. Local
anesthesia properly managed offers less com-
plications and the delivery can be done as
easily as with general anesthesia. This
method offers opportunity to have as many
babies as the mother can rear, and she will
come through with her various pregnancies
and deliveries and still have a healthy body
with practically no injury to the organs of
reproduction.
We feel we are justified in suggesting to
the profession at large a decidedly open mind
toward the study of this group of cases and
we believe that until we have equipped our-
selves so that we can manage this group of
cases as safely as we can the ordinary easy
cases of labor we have not met the need.
Neither have we equipped ourselves to the
point where we can really call this branch of
our practice adequate. The study of the
present physical ailments of women who are
bearing children is sufficient to cause every
physician who practices obstetrics to exert
himself to become more thorough in this im-
portant field. He should study each case that
comes in his experience more carefully than
the one before to correct any mistakes he
may have made; he should call to his aid
frequently the assistance of his fellow-practi-
tioners; he should exchange ideas often with
other doctors; all should work to create more
and more a co-operative spirit among physi-
cians as to the importance of proper man-
agement of long labor cases and the cases
which should not be exposed to long labor.
It is also necessary to acquaint the public
with the situation, and if possible get the co-
operation of the public in helping us to bring
these cases through in good health without
injury, infection, hemorrhage or morbidity.
HISTORIC MEDICINE
NOTE. — Following is the first contribution of a
Colonial practitioner medical literature
and is taken Irom an article by Dr. Frank
H. Rodin, of San Francisco, in California &
Western Medicine, Mav, 1929.
BRIEF RULE
To guide the Common People of
NEW ENGLAND
How to order themselves and theirs in the
Small Pocks, or Measles.
The Small Pox (whose nature and cure the
M easels follow) is a disease in the blood, en-
deavouring to recover a new form and state.
2. This nature attempts 1. By Separa-
tion of the impure from the pure, thrusting
it out from the V'eins to the Flesh 2. By
driving out the impure from the Flesh to the
Skin.
3. The first Separation is done in the
first four dayes by a feaverish boyling
June, 1029
SOUTHERN MEDICINE AND SURGERY
(Ebullition) of the Blood, laying down the
impurities in the Fleshy parts which kindly
effected the Feverish tumult is calmed.
4. The second Separation from the Flesh
to the Skin, or Superficies is done through the
rest of the time of the disease.
5. There are several errors in ordering
these sick ones in both these Operations of
Nature which prove very dangerous and com-
monly deadly either by overmuch hastening
Nature beyond its own pace, or in hindering
of it from its own vigorous operation.
6. The Separation by Ebullition in the fe-
verish heat is over heightened by too much
Clothes, too hot a room, hot Cordials, as
Diascordium, Gascons powder and such like,
for hence comes Phrenzies, dangerous exces-
sive sweats, or the flowing of the Pocks into
one overspreading sore, vulgarly called the
Flox.
7. The same Separation is overmuch hin-
dered by preposterous cooling that Feverish
boyling heat, by blood letting, Glysers, Vom-
its, purges or cooling medicines. For though
these many times hasten the coming forth of
the Pox, yet they take away that supply which
should keep them out till they are ripe, where-
fore they sink in again to the deadly danger
of the sick.
8. If a Phrensie happen, or through a
Plethoric (that is fulness of blood) the Cir-
culation of the blood be hindered, and there-
upon the whole mass of blood choaked up,
then eilher let blood, Or See that their diet,
or medicines be not altogether cooling, but let
them in no wise be heating, therefore let him
lye no otherwise covered in his bed then he
was wont in health: His Chamber not made
hot with fire if the weather be temperate, let
him drink small Beer only warm'd with a
Tost, let him sup up thin wafcr-gruel, or
water-pottage made only of Indian Flour and
water, instead or Oat-meal: Let him eat
boiled Apples: But I would not advise at this
time any medicine besides. By this means
that excessive Ebullition (or boyling of his
blood) will by degrees abate, and the Symp-
toms cease; If not, but the blood be so in-
raged that it will admit no delay; then either
let blood (if .-Xge will bear it) or else give
some notably cooling medicine, or refresh him
with more free Air.
9. But if the boiling of the blood be weak
and dull that there is cause to fear it is not
able to work a Separation, as it's wont to be
in such as have been let blood, or are fat or
Flegmatick, or brought low by some other
sickness or labour of the (Gonorrhea) run-
ning of the Reins, or some other Evacuation:
In such Cases, Cordials must drive them out,
or they must dye.
10. In time of driving out the Pocks from
the Flesh, here care must be had that the
Pustules keep out in a right measure till they
have attain'd their end without going in again,
for they are deadly.
11. In this time take heed when the Pus-
tules appear whilst not yet ripe, least by too
much heat they suffer new Ebullition (or Fe-
verish boyling) for this troubles the driving
out, or drives back the separated parts into
the blood, or the Fleshy parts overheated are
disabled from a right suppuration or lastly
the temper of the blood and tone of the Flesh
is so perverted that it cannot overcome and
digest the matter driven out.
12. Yet on the other hand the breaking
out must not be hindered, by exposing the
sick unto the cold. The degree of heat must
be such as is natural agrees with the temper-
ature of the fleshy parts: That which ex-
ceeds or falls short is dangerous: Therefore
the season of the year. Age of the sick, and
their manner of life here require a discrete
and different Cons'dcration, requiring the
Counsel of an expert Physician.
1.3. But if by any error a new Ebullition
ariseth, the same art must be used to allay
it as before exprest.
14. If the Pustules go in and a flux of the
belly follows (for else there is no such dan-
ger) then Cordials are to be used, yet moder-
ate and not too often for fear of new Ebulli-
tion.
15. If much spitting (Ptyalismus) follow,
you may hope all will go well, therefore by
no means hinder it: Only with warm small
Beer let their mouths be washed.
16. When the Pustules are drycd and fall
purge well, especially if it be in Autumn.
17. As soon as this disease therefore ap-
pears by its signs, let the sick abstain from
Flesh and Wine, and open Air, let him use
small beer warmed with a Tost for his ordi-
nary drink, and moderately when he desires
it. For food the water-gruel, water-poltnge
and other things having no manifest hot
quality, easy of digestion, boiled Apples, and
SOUTHERN MEDICINE AND SURGERY
June, 1929
milk sometimes for change, but the coldness
taken off. Let the use of his bed be accord-
ing to the season of the year, and the multi-
tude of the Pocks, or as found are
wont: In summer let him rise according to
custome, yet so as to be defended both from
heat and cold in Excess, the disease will be
the sooner over and less troublesome, for be-
ing kept in bed nourisheth the Feverish heat
and makes the Pocks break out with painful
inflammation.
19. In a colder season, and breaking forth
of a multitude of Pustules, forcing the sick to
keep his bed, let him be covered according to
his custome in health, a moderate fire in the
winter being kindled in his Chamber, morn-
ing and Evening, neither need he keep his
Arms always in bed, or ly still in the same
place, for fear least he should sweat which is
very dangerous especially to youth.
20. Before the fourth day use no medicines
to drive out, nor be too strict with the sick;
for by how much more gently the Pustules do
grow, by so much the fuller and perfecter
will the Separation be.
21. On the fourth day a gentle cordial may
help once given.
22. From that time a small draught of
warm milk (not hot) a little dy'd with Saf-
fron may be given morning and evening till
the Pustules are come to their due greatness
and ripeness.
23. When the Pustules begin to dry and
crust, least the rotten vapours strike inward
which sometimes causeth sudden death; Take
morning and evening some temperate Cordial
as four or five spoonfuls of Malaga Wine
tinged with a little Saffron.
24. When the Pustules are dryed and fal-
len off, purge once and again, especially in
the Autumn Pocks.
25. Beware of anointing with Oils, Fatts,
Ointments, and such defensives, for keeping
the corrupted matter in the Pustules from
drying up, by the moisture
into the Flesh, and so make the more deep
Scarrs.
26. The young and lively men that are
brought to a plentiful sweat in this sickness,
about the eighth day the sweat stops of it-
self, by no means afterwards to be drawn
out again; the sick thereupon feels most
troublesome distress and anguish, and then
makes abundance of water and so dyes,
Few young men and strong thus handled
escape, except they fall into abundance of
spitting or plentiful bleeding at the nose.
27. Signs discovering the Assault at first
are beating pain in the head. Forehead and
temples, pain in the back, great sleepiness,
glistening of the eyes, shining glimmerings
seen before them, itching of them also, with
tears flowing of themselves, itching of the
Nose, short breath, dry Cough or sneezing,
hoarseness, heat, redness, and sense of prick-
ling over the whole body, terrors in the sleep,
sorrow and restlessness, beating of the heart,
Cirinc sometimes as in health, sometime filthy
from great Ebullition, and all this or many
of these with a Feverish distemper.
28. Signs warning of the probable Event.
If they break forth easily, quickly and soon
come to ripening, if the Symptoms be gentle,
the Feaver mild, and after the breaking forth
it abate; If the voice be free, and breathing
easy, especially if the Pox be red, white, dis-
tinct, soft, few. round sharp top'd only with-
out and not in the inward parts; if there be
large bleeding at the nose. These signs are
hopeful.
29. But such signs are doubtful, when they
with difficulty appear, when they sink in
aga!;>, when they are black, blewish green,
hard, all in one, if the Feaver abate not with
the'r hrf^aking forth, if there be Swooning,
d'ff'r'ilty of breathing, great thirst, quinsey,
g'C.Tt unquietness and it is very dangerous,
if tlicre be bejoyn'd with it some other ma-
I'gnant Feaver, called by some the pestilen-
■ tinl Pox: the Spotted Feaver is oft joyned
with it.
.iO. Deadly Signs if the Flu.x of the Belly
happen, when thej' are broke forth, if the
Urine be blood}', or black, or the Ordure of
that Colour: Or if pure blood be cast out by
the Belly or Gumms: These Signs are for the
most part deadly.
These things have I written Candid Read-
er, not to inform the Learned Physician that
hnfh much more cause to understand and
what pertains to this disease than I, but to
give some light to those that have not such
advantages, leaving the difficulty of th's d's-
ease to the Physicians .Art, wisdom and Faith-
fulness: for the right managing of them is the
whole Course of his .Administration: For in
vain is the Physicians .4rt imployed, if they
arc utider a Regular Regimen. I am, though
June, 1P29
SOUTHERN MEDICINE AND SURGERY
no Physician, yet a well wisher to the siek:
And Iheiejore intreatlng the Lord to turn our
hearts, and stay his hand I am
A friend reader to thy Welfare,
THOMAS THACHER.
BOSTON, Printed and sold by John Foster,
1677
NEWS ITEMS
Moore County INIedical Society Medal —
1928 Session
Your committee on the award of the Moore
County Medical Society Medal, be^s to re-
port that we have given careful consideration
to the papers recommended by the committee
from each section, that is the committee of
three from each section recommends to us the
paper in each section that they consider the
best paper for that year as per the rules pub-
lished last year.
The committee then grades the papers rec-
ommi'ndcd by the above mentioned commit-
tee from each section and decides the best
paper in this group, taking into consideration
original work, as mentioned in rules formu-
lated by this committee and adopted by the
House of Delegates at the 1928 session.
The committee having performed its duties
and hiving carefully considered the papers
presented, have decided to award the m"dal
for the 1928 session to Dr. P. P. jMcCain,
F.A.C.P.. superintendent of the State Sana-
torium. Sanatorium, N. C. for his paper on
"The Diagnosis and Significance of Juvenile
Tuberculosis."
Respectfully submitted,
W. C. Mudgett, M.D., Chairman.
J. M. Parrott, M.D.
John Q. Myers, M.D.
Officers South Carolina INIedical
Association
At its recent session the South Carolina
Medical .Association elected Dr. C. R. May,
of Bennettsville, president, and Florence was
chosen as the ne.xt convention city. Other
officers elected were: Dr. E. B. Neel, of
Greenwood, first vice-president; Dr. J. B.
.Johnson, of St. George, second vice-president;
Dr. J. F. Davis, of Clinton, third vice-presi-
dent; Dr. E. A. Hines, of Seneca, re-elected
secretary and treasurer. Dr. M. R. Mobley,
of Florence, was elected to the board of coun-
cilors to succeed Dr, May,
The Robeson County Medical Society,
on May 9th, celebrated its 25th anniversary,
with the same president in the chair as of its
organization meeting in 1904, Dr. H. T. Pope,
Lumberton. Dr. B. F. McMillan, Red
Springs, was the only other charter member
present. The meeting was purely social and
reminiscent. Mrs. A. Byron Holmes, Fair-
mont, contributed in wit and eloquence; the
President and Drs. R. D. McMillan, Red
Springs, J. O. INIcClclland, Maxton, and R.
S. Beam, Lumberton. held forth for the doc-
tors; Rev. Mr. A. J. Hobbs, Red Springs, and
Rev. Dr. C. S. Matthews, Lumberton, sup-
plied spiritual refreshment, and Mr. J. A.
Sharp, of The Rohesoniau, paid the tribute
and pledged the influence of the press.
The Tar Heel Sanitarium, Inc., has been
recently organized to be located about five
miles out of Greensboro on Route 10 toward
High Point. Mr. J. R. Thomas is president
of the corporation and Dr. W. J. Meadows,
of Greensboro, is to be in charge. The board
of directors was authorized to proceed with
the erection of the building, which will prob-
ably cost between .^50,000 and $100,000. It
will specialize on the rest cure and in the
treatment of nervous diseases.
The Biltmore HosnxAL, at Biltmore, N.
C, is building an additional wing to cost
.^nS.OOO, to be known ns the Battle wing,
in honor of the late Dr. S. Westray Battle,
first medical director of the institution, which
position he held for many years. It is stated
that Duke Foundation will contrihtiic $50.-
000 toward the erection of this building and
$75,000 will be raised by the directors and
patrons.
Dr. W. deB. INTacNtder, Kenan professor
of pharmacology in the University of North
Cirnlma and noted authority on diseases of
the kdneys, recently delivered two lectures
before the School of IMedicine of V^anderbilt
University and a short time before this he
delivered one of the annual series of Harvey
I,ectures before the Harvey Society of the
New York .Academv of Medicine.
Dr. TI. C. Dodge, chief of the regiond of-
fices of the United Stales Veterans Bureau.
Washington, D, C, has been apjx)inted by
SOUTHERN MEDICINE AND SURGERY
June, 1929
the bureau as medical officer in charge of
United States Veterans Hospital No. 60, at
Oteen, near Asheville, N. C, and is driving
through in his car to assume his duties.
It is reported that the Duke Foxjndation
and the Rosenwald Foundation will build
a dozen district hospitals for negroes in North
Carolina.
Dr. K. p. B. Bonner has recently been
elected Mayor of his home town of Morehead
City.
Dr. L. B. McBraver has been recently
elected president of the Chamber of Com-
merce, Southern Pines.
Dr. J. G. Reynolds, formerly of Madison
county, who has been practicing medicine in
Marion, in McDowell county, since I91S, died
JNIay ISth. He had been in failing health
for some time but his death was hastened by
an attack of heart trouble.
Dr. E. p. Snipes, of Jonesboro, Lee coun-
ty, died May 1st. He was an Honorary Fel-
low in the Medical Society of the State of
North Carolina. Death was caused by cere-
bral hemorrhage.
Dr. W. T. H. Brantley, of Bethel, Pitt
county, died May 15th of acute nephritis.
Dr. Alan R. Anderson and Miss Lide
Frances Anderson were married in the home
of the bride in Saranac Lake, New York, on
April 13th. They are now at their home at
Freeport, Long Island. Dr. Anderson is the
son of Dr. and Mrs. Thomas E. Anderson, of
Statesville. He is a graduate of the Univer-
sity of North Carolina and of the Medical
Department of the University of Pennsylvania
in the class of 1923.
Dr. H. M. Baker, Lumberton, has been
rechosen for membership on the Board of
School Trustees, under circumstances which
reflect great credit on himself and his town.
Quoting The Robesonian:
"It so happened that Dr. Baker some time
ago knew of a flagrant violation of the rules
by two members of one of the school teams.
He reported the matter and the boys were
disciplined, as was right and proper. That
entirely proper attitude of Dr. Baker aroused
the ire of some enthusiastic lovers of all sorts
of athletic contests and they determined to
put Dr. Baker off of the board. The sober,
cool judgment of the voters stood between,
and the decision was more important than
the personal victory of any person."
Dr. James W. Keever, recently res'dent
physician at Pine Camp Hospital, Richmond,
Va., has located at Hickory, N. C. He will
pay special attention to diseases of the lungs.
Dr. Keever is a member of the class of '27,
Medical College of Virginia, and was former-
ly assistant resident in medicine at the Medi-
cal College of V'irginia Hospitals.
Drs. Grantham (W. L.) and Montgom-
ery (K. E.), Asheville, announce the removal
of their offices from the Castanea Building
to Suite 807, Public Service Building.
Dr. Wm. F. Drewry, formerly Superin-
tendent of the Va. Central State Hospital for
the Insane, Petersburg, and recently city
manap;er of Petersburg, has been made Direc-
tor of the Bureau of Mental Hygiene of the
Va. State Board of Public Welfare. His new
address is 1605 Hanover Avenue, Richmond,
Va.
Fkesident Hoover, on May 23rd, at the
Executive Offices of the White House, award-
ed the Charles R. Walgreen Prize of $500
for the best essay on "The Life and Achieve-
ments of William Crawford Gorgas and Their
Relation to Our Health" to Gertrude Carter
Stockard, Mountainburg, Crawford County,
Arkansas.
Adolph Lewisohn, New York philan-
thropist, celebrated his 80th birthday May
2 7th with the announcement of acceptance by
the Johns Hopkins University of a $30,000
gift from him to help in the training of e."-
ceptionally talented students in diseases of
the eve.
Dr. O. L. Miller, Charlotte and Gastonia,
delivered the commencement address for the
graduates of the training school of the North
Caiolina Sanatorium, on May 16th, sketching
the life of Sidney Lanier,
June. 1020
SOUTHERN MEDICINE AND SURGERY
Positive n \
Chemotactic
^ Action!
rs^
T
N infections of the
hand and in those
accidental wounds
associated wth bacterial in-
vasion of the body, the
application of Antiphlogis-
tine means fortified re-
sistance to infection plus rapid re-
generation of damaged tissue.
The immediate effect of an Anti-
phlogistine dressing is to induce an
active hyperemia and relaxation of
the smaller arteries, bringing into
the involved tissues a greater
number of leukocytes in proportion
as the volume of arterial blood is
increased. The advent of
leukocytes and the con-
comitant leucocytosis stim-
ulates the blood-forming
"17ppmf mechanism to greater ac-
luo^l tivity and hastens the new
formation of fixed tissue
elements upon which the entire
healing process depends.
The application of Antiphlogistine,
through the induction of active
hyperemia, constitutes a kataphy-
lactic procedure which is both
leukocytagogic and seragogic in its
physiological effects. In short, Anti-
phlogistine is Nature's synergist.
i» a icientific antiphlogistic, supporting and augmenting the defensive mecha-
nism of the body at every stage of the inflammatory or infectious process.
. Co., 10 j Varick St., New York City
y Bcrid me a copy of your booklet "Infected
py" (Sample of AntiphlogiBtine included).
454
SOUTHERN MEDICINE AND SURGERY
June, 19«
Dr. J. RuFus Braxton, Confederate Sur-
geon, and for long afterward a distinguished
doctor of York, S. C, was celebrated by the
York County Historical Association May
22nd. Miss Margaret Gist, of York, read
a paper on Dr. Bratton 's Civil War experi-
ences and his observations and reflections in
war and peace.
Dr. p. H. Fleming, Burlington, has been
re-elected superintendent of public welfare
of Alamance county.
Dr. W. H. Wadsworth, Jefferson '11.
died at his home in Concord June 5th.
Dr. and Mrs. John Croom Rodman cele-
brated at their home in Washington, North
Carolina, on June 7th, the twenty-fifth anni-
versary of their marriage. Dr. Rodman is
a graduate of the Bellevue Hospital Medical
College in the class of 1892.
Dr. C. M. Lentz, city and county health
officer (Albemarle-Stanly) and popular phy-
sician, is in the Yadkin Hospital, Albemarle,
suffering with injuries received in an auto-
mobile smsh-up June 9th.
Dr. and Mrs. Dunbar Roy, of Atlanta,
recently spent a few days in Richmond.
Dr. Clyde R. Hedrick, of Lenoir, and
Miss Stella Mae Lambkin, of Selma, Ala-
bama, were married June 1st.
Dr. Hubert Work, Pennsylvania '85, has
resigned the chairmanship of the Republican
National Committee.
Dr. W. P. Beall's SO years in Medicine
Celebrated.
Dr. Joseph Dorsey Collins, Portsmouth,
Virginia, has been appointed surgeon-in-chief
of the Seaboard .'^ir Line Railway System in
succession to the late Dr. Joseph M. Burke.
Dr. Collins is a graduate of the University
College of Medicine, Richmond, in the class
of 1905.
Dr. Reginald C. Alverson, Spartanburg,
S. C, received his degree at the College of
physicians and Surgeons, Colwn^bja Univer^
sity. New York, June 4th. He will remain
in New York until the macting of the Na-
tional Medical Board to take the examination
on the last two years of his course, after
which will serve an internship at Grady Hos-
pital, Atlanta.
Dr. Floyd Johnson, Whiteville, N. C,
county health officer for Columbus county,
was re-employed and highly commended at a
meeting of the Board of Commissioners, held
on June 3rd.
Reidsville, N. C, is soon to have modern
hospital of 50 beds. It is to be called The
Annie Penn Memorial Hospital, in honor
of the mother of members of the Penn family
through whose generosity the hospital be-
comes a pfjssibility at this time. The hospital
will be operated with a complete staf^ of
nurses under the supervision of Dr. T. W.
Edmonds, of Danville, and a training school
for nurses will be maintained.
Eighth (N. C.) District Society at Mt.
Airy, June 11th
Two of the most popular doctors in the
state. Dr. "Dave" Tayloe, of Washington,
and Dr. "Cy" Thompson, of Jacksonville, ad-
dressed the meeting. Dr. L. A. Crowell, Lin-
colnton, recently elected president of the State
Medical Society, made a stirring call to arms
against disease. Dr. J. T. Burrus, High
Point, respxinded appropriately to the wel-
come.
Other speakers were Dr. C. W. Banner,
Greensboro: Dr. C. S. Lawrence, Winston-
Salem; Dr. J. L. Spruill, Jamestown; Dr.
Fred Hubbard, North Wilkesboro; Dr. Carl
Tyner, Leaksville; Dr. Harry L. Brockman,
High Point; Dr. LeRoy Butler, Winston-Sa-
lem. Dr. A. deT. Valk, Winston-Salem, and
Dr. Roy C. Mitchell, Mount Airy, president
of the District Society. Dr. E. C. Ashby, of
this city, is secretary of the society and Dr.
R. B. Davis, of Greensboro, is councilor.
Drs. E. M. Holingsworth, C. A. Baird, J.
L. Woltz, W. M. Stone and S. T. Flippin
composed the reception committee and Drs,
Robert Smith, R. J. Lovill, Holman Bernard,
Harry Smith and I. S. Gambill the ^nt^rtajt}'
pient coniinittee.
June, 1929
SOUTHERN MEDICINE AND SURGERY
43S
No "^^Whispering Campaign" . . .
can withstand the light of this truth: Lucky Strikes are made from the finest of
fine tobaccos — the cream of the crop. Lucky Strikes alone are toasted because
toasting is a secret process. 20,679* physicians definitely state that toasting
removes impurities. Then, too, it adds to the flavor and prevents throat irri-
tation. Therefore, without fear of contradiction, we can say truthfully:
"No cigarette, regardless of price, is as good as Luckies whether manu-
factured by the American Tobacco Company or by any other company."
•The figures quoted have
been checked and cerlitied
lo by LYBRAND, ROSS
BROS. AND MONTGOM-
ERY, Accoanlaoln and
Auditors.
It's toasted
SOUTHERN MEDICINE ANV SURGERY
June, 1920
Dr. Charles Bernard Herman, Jefferson
'23, Statesville, and Miss Mary Ruth JNIil-
LER, Cherry Hill, were married June Sth.
Degree Conferred on Dr. Joseph A.
White
Dr. Joseph A. White, of Richmond, was
awarded the honorary degree of Doctor of
Laws at the 120th commencement of Mount
Saint Mary's College, Emmitsburg, Mary-
land, of which he is an alumnus.
Dr. White is one of the distinguished oph-
thalmologists of the world, founder and chief
surgeon of the Richmond Eye, Ear, Nose and
Throat Infirmary in 1880, professor of oph-
thalmology at the University College of Med-
icine and the Medical College of Virginia
for years, ophthalmic surgeon of the Memo-
rial Hospital, past president of the Richmond
Medical and Surgical Society and contributor
to various medical publications, as well as
inventor of several instruments in his spe-
cialty.
His education was received at Rock Hill
College, Loyola College and St. Clary's Col-
lege, from which he holds A.B. and A.M.
degrees. He graduated from the L^niversity
of Maryland School of Medicjne in 1869.
Dr. Marion Keith and Miss Caroleen
Lambeth, both of Greensboro, N. C, were
married in New York City, June 1st.
Dr. E. E. Robinson, Concord, N. C, has
been made physician to the Cannon Mills
Company, Kannapolis, N. C.
Dr. T. W. M. Long, Chief Executive Of-
ficer, Roanoke Rapids Hospital, Roanoke
Rapids, N. C, member Board of Directors
of North Carolina Sanatorium for the treat-
ment of tuberculosis, member State Board
of Medical Examiners of the State of North
Carolina, was recently elected mayor of his
home town of Roanoke Rapids, N. C.
Dr. p. p. McCain, superintendent of the
North Carolina State Sanatorium, Sanato-
rium, N. C, has recently been awarded the
Moore County Medical Society !Medal which
is given for the best paper presented at the
annual meeting of the State Medical Society,
taking into consideration original work and
priginal Studies.
Dr. John T. Burrus, High Point, presi-
dent of the Medical Society of the State of
North Carolina, 192 7-1928, has been appoint-
ed on the Governing Board of the State Hos-
pital for the Insane at Morganton, N. C.
Dr. C. H. Cocke, Asheville, has been ap-
pointed on the Board of Governors of the
-American College of Physicians for North
Carolina.
Dr. P. P. McCain, superintendent of the
North Carolina Sanatorium, Sanatorium, N.
C, was elected a member of the Board of
Directors of the National Tuberculosis Asso-
ciation at its recent meeting in Atlantic City.
Dr. R. L. Carlton, Winston-Salem, was
elected a member of the Executive Commit-
tee of the Board of Directors of the National
Tuberculosis .Association at its recent meet-
ing in Atlantic Citv.
.\t the recent commencement exercises at
the University of North Carolina at Chapel
Hill, the degree of Doctor of Laws was con-
ferred upon Dr. C. A. Shore, Director of the
North Carolina Laboratory of Hygiene, Ral-
eigh. Dr. Shore graduated with B.S. at the
L^niversity of North Carolina in 1901; M.S.
in 1902; M.D. from Johns Hopkins Univer-
sity in 1908. He has been director of the
State Laboratory of Hygiene since its begin-
ning.
The officers of the Medical Society of
THE State of North Carolina elected at its
recent meeting in Greensboro are as follows:
President, Dr. L. A. Crowell, Lincolnton; first
vice-pcesident. Dr. W. B. Murphy, Snow
Hill; second vice-president. Dr. Wm. E.
Warren, Williamston; third vice-president.
Dr. N. B. Adams, Murphy; secretary-treas-
urer. Dr. L. B. McBrayer, Southern Pines.
Dr. H. Q. -Alexander, of Charlotte, died
June 11th at the age of 66 years. Dr. Alex-
ander had been in more or less failing health
for several months.
Dr. Kenneth Baxter Geddie, of Roches-
ter, Minnesota, and Miss Irma Russell
Nisbet, of Ra;i:id, N. C, were married June
J2th.
June, \0i^
SOtlTrtEftN MEbtClNfe ANrt) SURGERY
43r
SOUTHERN MEDiaNE AND SURGERY
June, 1929
REVIEW OF RECENT BOOKS
THE PRACTICAL MEDICINE SERIES, com-
prising eight volumes on the year's progress in
Medicine and Surgery.
Nervous and Mental Diseases, edited by Peler
Bassoe, M.D., Clinical Professor of Neurology, Rush
Medical College of the University of Chicago. Series
1928. The Year Book Publishers, Chicago. $2.25.
A discriminating synopsis of important in-
dications and advances in this field in the
past year, with pertinent editorial comments.
Under General Considerations as to Mental
Diseases, there is quoted from the presiden-
tial address before the Philadelphia Psychia-
tric Society, a paragraph which seems to be
of special interest:
"One school insists on the all-prevailing
importance of sex as a common denominator
in the determination of the direction of the
stream of consciousness in normal and abnor-
mal mental life; another emphasizes the pri-
mary importance of the herd instinct and be-
lieves that insanity is in effect a rebellion
against the codes and conventions of society;
another traces almost all the manifestations
of mental activity, sane or insane, to a sense
of inferiority; and so on. It seems advisable
to admit that we do not know."
A MANUAL OF DISEASES OF THE NOSE,
THROAT AND EAR, by £. B. Gleason, M.D.,
LL.D., Professor of Otology, Graduate School of the
University of Pennsylvania. Si.xth Edition, thor-
oughly revised. 12mo of 617 pages with 262 illustra-
tions. Philadelphia and London, W. B. Saunders
Company, 1Q29. Cloth $4.50 net.
Note is taken of the necessity for conden-
sation in order that there may be given in a
book of reasonable size the essentials of the
present knowledge of oto-laryngology. In a
few instances only is more than one method
described, and then only for very definite rea-
sons. Directions for examination are partic-
ularly painstaking; the probability of local
symptoms indicating general disease is kept to
the fore; constitutional treatment is not neg-
lected. A list of valuable formulas is given,
with discussion, in an appendix of some
length.
SURGICAL PATHOLOGY, by William Boyd,
M.D., Professor of Pathology, University of Mani-
toba, Winnipeg, Canada. Second Edition, revised
and reset. Octavo of 933 pages, with 474 illustra-
tions and 15 colored plates. Philadelphia and Lon-
don, W. B. Saunders Company, March, 1929. Cloth
$11.00 net.
This edition following in three years on the
first evidences its value and popularity. Our
own review of the first edition enthusiasti-
cally proclaimed these virtues and predicted
this success.
The highly commendatory foreword by Wil-
liam J. Mai^o is well borne out in the body
of the work.
For this edition much has been entirely
rewritten, additions have been made to nearly
every chapter and some 150 illustrations add-
ed. The thoughtfulness of the author is well
shown in the change of the title of a chapter
from "Surgical Pathology" to "The Surgeon
and the Laboratory."
The book, as Dr. Mayo says, "is a sincere
attempt to place pathology before the student
and practitioner from a practical standpoint."
EPIGRAMS IN HAI-KAI and THE NEW
RUBAIYAT, by Bob Lafferty. The Culture Press,
40 Exchange Place, New York City. $3.00 each.
Two beautifully bound volumes of homilies
in an odd script quaintly illustrated.
The New Rubaiyat is often the meter of
the old, and a Fitzgerald translation of Omar
Khayyam's gems is appended in small, but
readable and attractive type.
Illustrative of both books is the final ex-
planatory note in the New Rubaiyat: "Writ-
ten by an humble believer in an immanent
and benevolent Deity, and who likens himself
to a mite on a mote and marvels at blessings
even he, with so little knowledge, has been
privileged to enjoy and to now offer unto oth-
ers."
1928 PROCEEDINGS OF THE INTERNA-
TIONAL ASSEMBLY OF THE INTER-ST.\TE
POST-GRADU.\TE MEDICAL ASSOCL\TION OF
NORTH AMERICA (held at Atlanta, Oct. 15-19),
June, 1929
SOUTHERN MEDICINE AND SURGERY
in amebic dysentery
STOVARSOL
REG. IN U. S. PATENT OFRCE
ACETYLAMINO-OXYPHENYLARSONIC ACID
Accepted by the Council on Pharmacy and Chemistry
of the American Medical Association
Manufactured by
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SUCCESSORS TO
POWER3-WEIQHTMAN-ROSENGARTEN CO.
Literature on request to Philadelphia Office 916 Parrish St.
Pneumonia
need not be regarded so despondently by physicians, now
that Disulphamin is at their disposal to combat this dread
disease.
DiSULPHZIMiM
quickly reduces tem-
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of sepsis in such conditions as Pneumonia, Puerperal Fever,
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Oral Administration
American Bio-Chemical Laboratories, Inc.
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Dr. - -_
440
SOUTHERN MEDICINE AND SURGERY
June, 1020
edited and published for the Association by Edwin
Henes, jr., A.B., M.D., F.A.C.P., Executive Secre-
tary, Milwaukee, Wis.
These proceedings are a record of a re-
markable achievement. Those who attended
the Atlanta meeting will immediately desire
a permanent record of that program; others
will desire it as they learn of the scope of
the volume, the eminent medical men whose
contributions make it up and the "Subject
Matter Digest" which has been arranged for
facility of reference.
Eighteen of our own states are represented,
and five foreign countries contributed of their
best. Addresses and diagnostic medical and
surgical clinics follow each other in great pro-
fusion and cover a great part of the field of
Medicine.
Subjects attracting especial attention are:
"Headaches," "Tumors of the Abdomen,"
"Pneumonia," "Care of the Heart in Acute
Infections," "Modern Diagnosis of Nervous
Disease," "Fish, Cut Bait or Go Ashore,"
"The Emergency Function of the Spleen,"
"Diverticulitis," "The Functioning Human
Breast," "When a Fellow Needs a Friend,"
"From the 14th Century to the Present,"
"Contributions of Georgia Doctors to Medical
Science," "Deviations from the Standard,"
"Differential Diagnosis of Referred from True
Abdominal Pain," "Pellagra of Today,"
"Mind — Man's Most Distinctive Organ."
ness. It is of unusual value because it does
not assume the reader's knowledge to be very
great, but goes on the assumption that those
who do not know will learn and those who
know can skip. The profusion of illustrations
make possible great cutting down of the text
at the same time giving added clearness.
DISEASES OF THE THYROID GLAND, by
Arthur E. Hertzler, M.D., Surgeon to the Halstead
Hospital; with a chapter on Hospital Management
of Goiter Patients, by Victor E. Cbesky, M.D., As-
sociate Surgeon to Halstead Hospital. Second edi-
tion, entirely rewritten. C. V. Mosby Co., St.
Louis, 1020. $7.50.
The second edition follows the general plan
of the first in being largely an individual
work. It records what has been seen in pa-
tients rather than what has been seen in
books or journals; and, because these patients
were drawn from a limited territory around
a hospital in a small center, these patients'
cases could be followed with remarkable ac-
curacy. The style is frank and the flavor
spicy. There is no tendency to represent, as
known, things which are not known.
Here is no common run-of-the-press book.
It is well worth reading for its piquant forth-
rightness; it is worth careful study for guid-
ance at the bedside and as a model after
which to fashion medical essays.
DIAGNOSTIC METHODS AND INTERPRETA-
TIONS IN INTERNAL MEDICINE, by Samuel A.
Loewenberg, M.D., F..-I.C.P., Assistant Professor of
Clinical Medicine, Jefferson Medical College; As-
sistant Physician to the Jefferson Hospital. 547 il-
lustrations, some in colors. F. A. Davis Company,
Philadelphia, 1020. $10.00.
The author has conceived and executed the
idea of putting out a book from the stand-
point of the man doing general practice. It
sets off pathological findings against normal
findings, and, whenever possible, gives rea-
sons. The signs and interpretations are dis-
cussed from the viewjMint of the medical stu-
dent, the general practitioner and the special-
ist. The chapter on laboratory interpreta-
tion gives the interpretation of analyses re-
ported by pathologist, serologist, and chemist,
with descriptions of only the simplest techni-
cal methods.
The book is remarkably free from vague-
EAT PORK ONLY WHEN THOROUGHLY
COOKED
To cat raw pork is dangerous. There is risk of
contracting trichinosis. Trichinosis causes serious
illness and sometimes death. It comes from very
small worms, known as trichinae, that live in a
small proportion of hogs and remain in the pork.
Thorough cooking will kill these parasites and make
them harmless. If meat containing them is eaten
without being well cooked, they multiply rapidly in
the intestines, get into the blood supply and scatter
into the muscles where they grow in little lemon-
shaped nests which they form within the muscles.
No dependable treatment is known for the disease.
Although only between 1 and 2 per cent of pigs
have these trichinae, almost any pork may contain
them, and it is useless to take even one chance in a
hundred on a serious disease. The worms are too
small to be seen with the naked eye and pork con-
taining them may look perfectly sound. Some peo-
ple like the flavor of raw pork in sausages, hams,
and other meats. But it is dangerous to eat it.
Leaflet No. ,54-L may be obtained by writing to
the Department of Agriculture, Washington, D. C,
and asking for a copy.
June, 10:0 SOUTHERN MEDICINE AND SURGERY
FIVE REASONS FOR THE
USE OF BIPEPSONATE
1. It contains a combination of remedial agents best suited for the
purpose for which it is used ,i. e., Zinc, Sodium and Calcium Phenolsul-
phonates, Sadol and Bismuth subsalicylate, all INTESTINAL ANTISEP-
TICS and maild astringents; also Pepsin in sufficient quantity to allay
nausea.
2. These agents are dissolved and suspended in a soothing, mucilaginous,
demulcent mixture, aqueous, not alcoholic. It is soothing to inflamed
mucus membrane and at the same time antiseptic and astringent. Prepara-
tions which contain alcohol in considerable quantities are not desirable as
intestinal antiseptcs for infants and children. Bipepsonate is free from
these objectionable features.
3. Containing no Opium or narcotics, Bipepsonate can be administered
freely with perfect safety and it does not readily constipate. It removes
the cause of diarrhoe, cholera infantum, etc., and the stools soon become
normal and healthy, the injurious effects of a sudden checking of the bowels
and of other body .secretions, as with Opium, being avoided.
4. Bipepsonate tastes like peppermint candy. There is no taste of
"medicine' 'about it and it is easily retained. This is a partcularly desirable
feature since it is largely given to children.
5. The u.se of Bipep.sonate is not limited to children. It is equally
eff"ective with adults when taken in doses of two or three teaspoonfuls, fre-
quently repeated. Without constipating it quickly gives relief in cholera
morbus and diarrhoea.
BURWELL & DUNN COMPANY
Afanujiicluring Pharmacists
CHARLOTTE, N. C.
Sample sent to any physician's address in the
United States on request
SOUTHERN MEDICINE AND SURGERY
June, 1929
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June, 1929
SOUTHERN MEDICINE AND SURGERY
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SOUTHERN MEDICINE AND SURGERY
June, 10^0
OTOSCOPE SET
No. 975 Combination Set Contains Otoscope
with three Speculae and Ophthalmoscope. A
popular model with the Welch Allyn principle
of direct illumination.
Complete in Case _ - $37.50
This Otoscope has the largest lens disc and
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and provides magnification and easy observa-
tion for diagnosis, operative work or testing
the mobility of the ear drum.
The Mirrorless Ophthalmnscope is easy to use
For Direct or Indirect Methods
POWERS & ANDERSON
503 Cranby St.
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603 Main St.
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Smsical hislriimcnts. Hospital Supplies, Etc.
During 1928 it was my privilege to
make Supporters jor doctors in every
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1701 DIAMOND ST.
ir and Maker
PHILADELPHIA
CHUCKLES
SOME FIND IT SWEET TO SEE LOOK OF
PAINED ASTONISHMENT
I'oung Doctor (a bit sobby) Addressing Mothers'
Meeting: "In all this world there's nothing so
sweet as the smile on the face of an up-turned
child." — Boston Transcript.
A WILLEBRANDT DEMOCRAT
"May I see the gentleman of the house?" she
asked a large woman who opened the door at one
residence.
"No, you can't," answered the woman decisively.
"But I want to know the party he belongs to,"
1 leaded the political worker.
"Well, take a good look at me," she said sternly.
"I'm the party."
A S.\D TALE, MATES!
The charge was drunkenness. The magistrate ad-
dressed the officer. "What further evidence of in-
toxication was there except that you found this
man lying quietly in the horse trough?"
"Only this your honor," said the bobby, and pro-
duced a whiskey bottle. "This was floating in the
trough with a note in it: "Wrecked off Bull's Head.
One survivor." — London Calling.
TAKING A SPORTING CHANCE
After a generous sprinkling of minor mistakes he
played a king on an opponent's ace. This brought
down the wrath of his partner.
"Good heavens," she stormed, "a king doesn't
usually beat an ace, you know."
"Well I just thought I'd give it a try." — London
Calling.
THE UIP MODEST
"It must be three years since I saw you last.
hardly knew you — you have aged so!"
"Really ! Well, I wouldn't have known you ex
cipt for that dress!" — Exchange.
Lucky old boys ! They did their kissing when a
girl didn't taste of anything but girl. — Kingston
Vi'hig.
"Was Maude in a bright red frock at the dance?"
"Some of her, darling, some of her." — Montreal
Star.
Dinna spend money on drink, but aye keep a
corkscrew.
[adv.]
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June, 1020
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SOUTHERN MEDICINE AND SURGERY
June, 1929
Dr. Samuel H. Connor, a native of Ox-
ford, Miss., Medical Department, University
of Virginia 1926, member of the Faculty of
his alma mater 1926-27, died at Blue Ridge
Sanatorium June 10th.
Dr. Charles OH. Laughinghouse,
Health Officer of North Carolina, delivered
the address before the graduating nurses of
Lincoln Hospital, Durham, June 10th.
One Hundred and Second Session South-
side Virginia Medical Association
More than fifty doctors attended the one
hundred and second quarterly session of the
Southside Virginia Medical Association, held
at La Crosse, June 11th.
On the reception committee were Dr. W.
W. Wilkinson, La Crosse, and Dr. C. V.
Montgomery and Dr. \V. L. Varn, South Hill.
Following the dinner the doctors adjourned
to the high school auditorium for the scien-
tific session. Dr. R. H. Mason, of McKen-
ney, president of the association, presided.
Members of the association were welcomed
to La Crosse by Mr. L. M. Raney. Dr.
Wright Clarkson responded on behalf of his
colleagues.
Papers were read by Dr. Geo. H. Reese,
of Petersburg; Dr. W. L. Peple, of Rich-
mond: Dr. Herbert C. Jones, of Petersburg;
Dr. W. W. Gill, of Richmond, and Dr. Philip
Jacobson, of Petersburg. Dr. Carrington
Williams, of Richmond, gave a lantern slide
demonstration of stomach cases, and Dr. W.
W. Wilkinson led in discussing cases of spider
bites. Dr. Wilkinson also had three patients
present whom he is treating for pellagra.
Counties and cities comprising the South-
side Virginia Medical Association are the
counties of Surry, Sussex, Brunswick, Prince
George, Greensville, Dinwiddle, Isle of
Wight, Lunenburg, Prince Edward, Amelia,
Nottoway, Southampton, Mecklenburg, Nan-
semond, Norfolk, and the cities of Norfolk,
Suffolk, Petersburg, and Hopewell.
The practical nature of the program is
shown by the fact that Dr. Varn, on return-
ing from the meeting where one of the topic*
of discussion had been "Poisoning from Spi-
der Bites," was called to see a child who had
just been bitten by a spider.
(Contributions to these columns are made regularly by Dr. L. B. McBrayer, Southern Pines,
N. C, and Dr. James K. Hall, Richmond, Va.)
(J. A. Philpott, in Colorado Medicine, June, 1929)
About Catheterization
Infection in the urinary tract plays quite an important part in the convalescence of the sick.
The seriousness of catheterization is not fully appreciated. Catheterization should always be done
by the attending surgeon, or his alternate, the house physician. Each landing should have emer-
gency outfit for catheterization, consisting of a good grade of rubber catheters, sterile lubricator,
towels, forceps, and a freshly prepared solution of some of the silver salts, with a rubber bulb
syringe, also a sterile bottle to collect the urine. A careful microscopic examination of the urine
is essential. In those cases in which the retention persists, search should be made for some local
cause. Careful instrumentation, which means little trauma, is paramount.
June, 1929 SOUTHERN MEDICINE AND SURGERY 447
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SOUTHERN MEDICINE AND SURGERY
June, 1929
The Baby Hospital is situated just across the sound from Wrightsville Beach.
It is a modern lire-proof hospital for infants and sick children, with accommodations for the
mothers who desire to stay with their babies.
There is a milk station in the hospital where infants outside of the hospital may obtain milk
formulas.
Pcdiatrtcians-in-Chargc
j J. BUREN SiDBURY, M.D.
I Tom M. Watson, M.D.
SAINT ALBANS SANATORIUM
RADFORD, VA.
S.MNT Albans is a modern, ethical institution fully equipped for the diagnosis, care
and treatment of medical, neurological, mild mental and selected addict cases. Ideally
located, 2,000 feet above sea level in the heart of the "Blue-grass" region. Completely
equipped laboratory. Nurses especially trained for the work. The sexes housed in
separate buildings. Two physicians live in the institution and devote their entire time
to the patients. Rates reasonable. Railway facilities excellent. For further informa-
tion, address: St. Albans Sanatorium, Radjord, Virginia.
STAFF: J. C. King, M.D. Ira C. Long, M.D.
SOUTHERN MEDICINE and SURGERY
Vol. XCI
Charlotte, N. C, July, 1929
No. 7
Primary Tuberculous Infection in the Infant*
Edwards A. Park, !M.D., Baltimore
Johns Hopkins Hospital
Tuberculosis as it is seen in infants is one
might almost say that it is a different disease
from tuberculosis in the adult.
It is a common saying that if tuberculosis
is among the workers in a laboratory, the
laboratory monkey will get tuberculosis. It
may also be said that, if tuberculosis exists
in the environment of a baby, the baby is
exceedingly liable to acquire tuberculosis;
and he can be infected on the day on which
he is born. A short time ago a baby was re-
ferred to me because the father had pleurisy
with effusion and was in the state sanato-
rium. I telephoned to Dr. Cullen, the head
of the state sanatorium, who told me he
thought the father was not infectious, al-
though he had tuberculosis. We examined
the children of the family and found that
they were all infected. There is more than
one way of telling whether an adult has an
open tuberculous lesion or not; one can find
the tubercle bacilli in the sputum of the
adult, or one can find the infection in his
baby.
In England, and in Scotland particularly,
bovine tuberculosis used to be very common.
In this country, where milk is pasteurized,
bovine tuberculosis is rare; and when an in-
fant has tuberculosis, one can almost be cer-
tain that a human being infected with tuber-
cle bacilli exists in the environment of the
baby. Most commonly the infected individual
is one of the parents; but not infrequently it
IS a relative, a boarder, or a neighbor to whom
the baby is taken to visit. The baby is more
»Presented by invitation to the Tri-State Medical
hfm'' m'"/^ "I /''^ Carolinas and VirginU, Greens-
Doro, N. C., February 19, 1929.
apt to develop tuberculosis early, if the in-
fecting person is the mother, because the con-
tact between the baby and the mother at the
beginning of infancy is far closer than be-
tween the baby and anyone else. I am anx-
ious to emphasize the danger to the baby of
contact with human beings infected with tu-
berculosis because it is not fully appreciated
even by physicians much less the laity. I
had a cousin who had a baby born in Berlin
during the war. The baby was t?ken care
of by a nurse for one month when nine
months old. At the end of the month the
nurse was removed to the Charite hospital
suffering from "galloping" consumption and
died several months later. The baby return-
ed to this country with his parents and was
found to have complete tuberculous consoli-
dation of the upper third of the left lung.
The parents had no thought at any time that
the baby was in any danger from tuberculo-
sis.
Sometimes tuberculosis is transmitted by
objects, but not very often; almost always it
is transmitted directly from person to person.
Once a physician with newly born twins came
to Baltimore. One of them became sick and
was brought to the hospital. The baby had
fever. We found a slightly inflamed ear drum
which did not account for the fever. The
father would not permit a tuberculin test.
Presently the child developed tuberculous
meningitis. We believe that the child was
infected from a rug. The house had been
occupied by a man who died of tuberculosis,
and it had been thoroughly renovated with
the exception of this rug. The baby had crept
on the rug and had contracted tuhorculosis.
I think, however, it is rare for tuberculosis to
4S0
SOUTHERN MEDICINE AND SURGERY
July, 1929
be acquired from inanimate objects.
There has been great debate, as you know,
whether tuberculosis is air-borne or whether
it finds its entrance through the alimentary
tract. It seems to me that the question is
chiefly of academic interest. If it is air-
borne, the bacilli are carried directly to the
lungs; if the infection enters the alimentary
tract, it reaches the lungs by a more devious
route; but the end result is exactly the same.
What happens if tubercle bacilli are
brought by either route into the lungs of an
uninfected infant? (Drawing on board.)
We shall suppose that tubercle bacilli are
brought to this spwt in the lung. What oc-
curs? They are carried from the spot to a
lymph node, say, one of the nodes near the
bifurcation of the trachea. What may hap-
pen in this node, which becomes filled with
tubercle bacilli? One possibility is that the
node becomes encased in fibrous tissue, the
process does not spread, and later the node
may calcify. Another possibility is that the
infection does spread, and it is not uncom-
mon for it to spread out into the lung. If
we take x-ray pictures of babies with bron-
chial lymph-node tuberculosis, not infre-
quently we can watch the process spread from
the hilus out into the lung as a broncho-pneu-
monia until finally it reaches the periphery.
Another possibility is that it may rupture
into a bronchus, in which case the part of
the lung supplied by the bronchus distal to
the point of rupture becomes infected; an-
other possibility is that the node may rupture
into a blood vessel. If it ruptures into a
blood vessel in considerable quantity, then
it produces what we call acute general miliary
tuberculosis. Something which I have learn-
ed recently is that the tuberculous mass does
not rupture always suddenly into a blood
vessel but may rupture into it very gradually.
Instead of tubercle bacilli being discharged
on a single occasion in great quantity, tuber-
cle bacilli are continually or every little while
discharged from the focus into the blood
stream. This constantly recurring type of
dissemination happens very frequently in in-
fants. This method of gradual dissemina-
tion accounts for the cases showing dessemi-
nated foci of tuberculosis without a general-
ized miliary tuberculosis.
Dr. Katharine Merritt recently examined
the autopsy records of one hundred babies
dying of tuberculosis under one year of age
at the Harriet Lane Home, Johns Hopkins
Hospital. What are the interesting things
that she found? She discovered that death
occurred in fifty f>er cent of the babies as a
result of tuberculous meningitis. May I say
a word in explanation of what I have learned
from conversations with Dr. Arnold Rich. If
one injects tuberculous material into the blood
stream of an animal, one can not by so doing
infect the meninges. If one injects tubercle
bacilli into the spinal fluid one can succeed
in infecting the meninges immediately. Dr.
Rich finds that if tuberculous meningtis is
present there is an old tuberculous lesion
near the meninges or in the brain substance,
which has infected the cerebrospinal fluid. I
had always supposed, before I was shown
Dr. Rich's evidence, that the infection came
from the blood stream. In order that the
meninges become infected it is now neces-
sary to suppose that the tubercle bacilli must
lodge in a portion of the brain or meninges
bordering on the cerebrospinal fluid, a focus
must develop and give off tubercle bacilli.
Fifty per cent of the babies studied by Dr.
Merritt died from tuberculosis elsewhere than
in the meninges. Tuberculous meningitis may
supervene when the infection elsewhere is
very slight. On the other hand, if tubercu-
lous meningitis has not supervened, the de-
velopment of tuberculosis in the infant may
become so extreme as to make one wonder
how the infant ever lived as long as it did.
You can think of tuberculous meningitis in
the infant as a sort of sword of Damocles
which may at any moment, early or late, fall
and kill the infant.
Tuberculous enteritis is extremely common
in infants. It gives rise to no symptoms;
blood and pus and mucus do not occur in
the stools. I have seen jx)ssibly two or
three cases in which tuberculous ulcers may
have been responsible for blood in the stools,
but generally the intestines may be riddled
with tuberculous ulcers without giving evi-
dence of the condition.
It has been thought that cavities in the
lungs are unusual in infants affected with
tuberculosis. On the contrary, they are not
at all uncommon, and we have seen them
reach extraordinary dimensions, so large for
example that only a shell of a lobe remained.
Dr, Merritt found cavities, small or large,
July, 1929
SOUTHERN MEDICINE AND SURGERY
451
in almost one-half of the babies studied at
autopsy.
In the great majority of infants dying
from tuberculosis, particularly those dying
from tuberculosis without tuberculous menin-
gitis, one finds extensive manifestations of
the disease. How do these widespread lesions
develop? They come about in the ways I
have indicated. The tuberculosis becomes
established somewhere in the body, caseation
takes place, tubercle bacilli enter the blood
stream and are carried all over the child's
body, independent foci are established, these
foci break down and become centers of dis-
semination; the tuberculous infection grows
and grows and finally the child dies. If the
tuberculosis is extensive in other organs, one
can think of the lungs as acting like a filter
which keeps taking the bacilli out of the
general circulation. This is the reason why
the lungs become so heavily involved.
So much for the pathology. I now turn
to the clinical study of these children. What
happens when the tubercle bacilli enter the
body of the child? Nothing. Nothing occurs
for a period of from one to twelve or thirteen
weeks. There is no fever, no loss of appetite,
nothing. The tuberculin test is negative. Sud-
denly the temperature rises. If the tuberculin
test is now done it is found to be positive.
The fever may go on for days or for
several weeks or for several months or as
long as the child lives. If one takes an x-ray
picture after skin sensitiveness develops, one
may find abnormal shadows which in many
instances at least lie near the hilus of the
lung. What is the meaning of these shadows?
When a child develops a skin sensitiveness,
he probably develops a sensitiveness of the
entire body. Around the foci of tuberculosis
in the lung, pneumonia-like shadows develop
which correspond to the developments around
the skin test. These shadows are often cir-
cular in outline. The recent work with
B.C.G. has shown that the development of
skin sensitiveness may occur without fever
or rather constitutional manifestations. The
length of the latent period after infection and
the violence of the symptoms which mark
the development of skin sensitiveness prob-
ably depend on the dosage and virulence of
the tubercle bacilli.
What physical signs do these infected ba-
bies show? On inspection they exhitiif
usually nothing. On percussion they may
show slight dulness, in one or the other inter-
scapular space, or slight dulness to the right
or to the left of the sternum in the first or
second spaces. But dulness in these situa-
tions is very difficult to be sure about. In
some cases a large area of the chest is dull
corresponding to the upper half or upper third
of one of the lungs. But the dulness is al-
most always slight and often is detected only
after seeing where the consolidation lies in
the x-ray picture. On auscultation there are
usually only slight modifications of the breath
sounds or no modifications. Over the dull
area the breathing is most often merely
slightly diminished with prolonged and high
pitched expiration. It is exceedingly rare in
the tuberculosis of infants to obtain the out-
spoken dulness and the intense tubular
breathing so frequently encountered in pneu-
monia. Usually, too, no rales are heard. Of
course, one does hear rales when the tubercu-
losis is widespread and ulceration has taken
place with or without the formation of defi-
nite cavities. But in contrast to the apical
tuberculosis of adults the development of
rales is a late symptom and denotes a most
extensive lesion and one of long standing.
There is rarely any restriction of movement
of the chest wall on respiration unless the
tuberculous process is extremely advanced.
It is a most common experience to examine a
chest of a tuberculous infant and to find noth-
ing and then to be overwhelmed with surprise
at the sight of the x-ray picture of the lungs
which reveals extensive consolidation or most
widespread broncho-pneumonic involvement.
In contrast to pneumonia the physical signs
in the tuberculosis of infancy are notoriously
slight and deceitful.
The spleen is enlarged in about SO per cent
of the cases of tuberculosis in infants. If
under three months of age the spleen is found
to be enlarged we think esjjecially of con-
genital syphilis, though we ought, also, to
think of tuberculosis, because not very infre-
quently tuberculosis becomes well developed
at that early age. If the spleen is found to
be enlarged in an infant from three to six
months of age, we think of syphilis but more
particularly of tuberculosis. After six months
of age tuberculosis is many times a more
common rau.se of enlargement of the spleei)
452
SOUTHERN MEDICINE AND SURGERY
July, 192Q
than congenital syphilis. An enlarged spleen
in an infant ought always to suggest tuber-
culosis and regularly constitutes an indica-
tion for a tuberculin test. Of course there
are other causes than tuberculosis or syphilis
for the enlargement of the spleen in the in-
fant, but the causes for splenic enlargement
are far less numerous than in the older child
or the adult and, consequently, the enlarge-
ment of the spleen has far more significance
as pointing to the possibility of one of the
two diseases mentioned in the infant than in
the child or adult.
Some infants having extensive infection
with the tubercle bacillus exhibit enlargement
of the liver. But enlargement of the liver
is not a symptom of tuberculosis in infants
and the liver is rarely found to be the seat
of such extensive tuberculosis as one sees so
commonly in the spleen. Recently a baby a
little more than two months of age died of
tuberculosis in our wards. The baby showed
enlargement of the spleen and of the liver
and an intense jaundice and was thought to
have congenital syphilis with involvement of
the liver. The diagnosis of tuberculosis
should have been made, because the baby
was covered with small papulo-necrotic tu-
berculides. At autopsy the liver was seen
to be the seat of most extensive tuberculosis
and the tubercles surrounded and filled the
finer bile ducts and apparently caused an ob-
structive jaundice. Indeed, the degree of in-
volvement of the liver with fine tubercles was
so great that the cut sections of the liver
resembled shad roe. But so extensive an in-
volvement of the liver is most unusual.
T'^^ually at the autopsy of an infant dying
of tuberculosis the liver is found to be yellow
and spotted here and there with miliary tu-
bercles. Occasionally, of course, large con-
"lomerate tubercles develop in the liver as in
other organs.
Among the physical signs of tuberculosis
in infants should be mentioned papulo-
necrotic tuberculides which occur in a large
percentage of cases. The papulo-necrotic
tuberculides shown by infants differ from
those described in text books on the skin and
from those seen in older children and adults.
It is common for the consultant dermatolo-
gist to decline to admit that the lesions shown
by these infants are tuberculous in origin
because they differ so much from the corre-
sponding lesions in the adult. When the le-
sions are excised and studied microscopically,
however, they are seen to be tuberculous in
nature. In the infant in contrast to the adult
the usual papulo-necrotic tuberculides are not
much larger than large pinheads though they
may be several millimeters in diameter. In
the center is a little scab. When this is
scratchtd off a depression is left. Surround-
ing the central scab the skin has a glossy
shiny appearance like cigarette paper. The
lesions show no sign of acute inflammation.
They last for a few days to one or two weeks
and disappear, leaving no scars. The large
papulo-necrotic tuberculides which extend
well down into the true skin do of course oc-
cur in infants as well as in adults and do
leave scars. There may be only a few tuber-
culides present, or the body may be covered
with them. I have seen cases in which there
were a hundred or more on the scalp alone.
Sometimes one is aided in their recognition
by find'ng them in unusual places not often
the seat of pyogenic lesions, such as the mar-
gin of the concha. As everyone knows,
it is exceedingly difficult to be certain of tu-
berculides and the diagnosis of papulo-
necrotic tuberculides is more often made after
the discovery that the infant is infected with
tuberculosis than before. The tuberculides
may, however, be so typical as to make the
diagnosis certain at a single glance. Another
common skin manifestation of tuberculosis
in the infant is lichen scrofulosorum. When
this occurs in an infant, the infection is usual-
ly extensive.
Rarely one is aided in the diagnosis of
tuberculosis in the infant by the discovery
of a choroidal tubercle which is nothing more
than a tuberculide of the eyeball. Choroidal
tubercles are not infrequently seen in chil-
dren dying of tuberculous meningitis and, in
one instance, at least, a choroidal tubercle
led to an immediate diagnosis of tuberculo-
sis. An infant was brought to the New Ha-
ven Hospital by his physician who suspected
some obscure trouble of the eyes and asked
the examining physician. Dr. T. Cook Smith,
now at Louisville, to examine the eyes first.
Seeing the pupils widely dilated. Dr. Smith
looked at the fundus with an ophthalmoscope
and was surprised by the sight of a typical
choroidal tubercle. Such experiences are ex-
ceedingly rare and almost always the choroi-
July, 1029
SOUTHERN MEDIcmE AND SURGERY
ASi
dal tubercles are found only after the diagno-
sis of an acute general miliary tuberculosis
or more often tuberculous meningitis has been
made.
Before leaving the discussion of tne mani-
festations of tuberculosis which can be seen,
heard or felt in the infant, I must make a
brief reference to the involvement of bones
by the tuberculous infection. In the infant
tuberculosis curiously enough frequently af-
fects the shafts of the long bones producing
a tuberculous osteomyelitis. The shaft be-
comes the site of a spindle-shaped enlarge-
ment and finally sinus formation establishes
itself. The x-ray picture in these cases is
often characteristic, showing a thickening of
the cortex or better an encasement of a new
cortex around the old. This encasement is
symmetrical as seen in the x-ray and there
are evidences of central destruction with,
perhaps, the outline of the bone as it existed
before the advent of the tuberculosis still visi-
ble. If one bone is affected by a tuberculous
osteomyelitis, it is common to find other
bones affected, also. Tuberculous dactylitis,
sometimes, occurs in infants. There is a baby
now under observation in our tuberculosis
clinic, aged about 13 months, who shows the
condition. Usually, however, tuberculous
dactylitis manifests itself after the second
year.
Now we come to symptoms. Most babies
infected with tuberculosis, even quite severely
infected, show no symptoms, or at least no
symptoms which are conspicuous. Often-
times, they look the very picture of health
and give no indication in their behavior that
there is anything at all the matter with them.
For example, a baby 5 months old was
brought into the dispensary already infected
with tuberculosis. She has been under ob-
servation for six months. .'\t present at the
age of 10 months she weighs 20 pounds and
11 ounces and has the general appearance of
perfect health and behaves like healthy baby.
Yet the x-ray picture reveals the consolida-
tion of the upper half of the right lung. To
be sure the involvement of the lung is in the
nature of the so-called epituberculosis in
which the extent of the involvement of the
lung appears to be out of proportion to the
dangerousness of the disease. I do wish to
emphasize the fact, however, that many in-
fants severely infected with tuberculosis gain
and gain steadily, though the majority of
severely infected infants gain at a decreased
rate, have stationary weight or actually lose
weight. I have seen a baby with bilateral
tuberculous broncho-pneumonia having fever
almost all the time steadily gain in weight
until two weeks before death when the weight
curve began to plunge downwards. Week by
week in the x-ray pictures one could trace the
steady progressive march of the tuberculous
process toward the periphery of the lungs.
In saying what I have said in regard to the
capacity of infants severely infected with tu-
berculosis to continue to gain weight, I do
not mean that the weight curve is of no value
as a symptom of tuberculosis. If the baby
does not gain satisfactorily or actually loses
without cause tuberculosis ought of course to
be considered.
Perhaps the most common symptom is fe-
ver but for several weeks at a time the baby
may show no rise in temperature. Usually,
if the baby is under constant observation in
the hospital, the temperature is found to be
occasionally elevated. In some cases, of
course, there is continuous fever. The point
I am trying to make is that fever is quite
an inconstant symptom of infection of the
infant and may be absent for considerable
periods. The next most common symptom is
probably cough. But most of these infected
babies do not cough or at least cough so
infrequently that the symptom is not obvious.
Usually the cough is said to be dry, because
the baby swallows the sputum. It is not
uncommon to find tubercle bacilli in the fast-
ing stomach contents, even when the cough
is slight and does not seem to be
productive. This indicates that secretion
containing tubercle bacilli is actually be-
ing discharged from the lungs and swal-
lowed. Under certain circumstances the
cough may be a very prominent feature and
point directly to the tuberculous infection.
This happens when the involvement of the
tracheo-bronchial nodes is marked. Then the
cough is apt to become paroxysmal and have
a brassy quality. Sometimes, the cough
strongly suggests that of pertussis in that it
occurs in paroxysms which produce flushing
of the face and oftentimes vomiting. The
characteristic whoop of whooping cough is
absent. The distinguished French pediatri-
cian, Marfan, describes the "bitonal cough"
as characteristic of tuberculosis with affec-
4S4
SOUTHERN MEDICINE AND SURGERY
July, 1929
tion of the tracheo-bronchial nodes. As the
word indicates, the cough gives the sound of
two notes instead of one. Marian's "bitonal"
cough is merely what we know as the brassy
cough.
As already indicated babies rarely expecto-
rate. They expectorate in whooping cough
because the sputum is discharged with such
force and so suddenly that expectoration oc-
curs in spite of the child. Marfan told me
last summer that when a baby expectorates
sputum it means either whooping cough or
that the child has a cavity.
Very rarely do babies have hemoptysis. I
once had under my care a four-months-old
baby who quite frequently brought up blood
streaked sputum. At postmortem examina-
tion he was found to have most extensive
tuberculosis with cavity formation. Exten-
sive hemorrhage must be very rare from tu-
berculous lesions of the lung in infants, a
fact which seems all the more remarkable
because cavity formation is so common. I
have never known a case of tuberculosis in
an infant in which a large pulmonary hem-
orrhage took place, to declare itself either by
the hemoptysis or by the passage of a tarry
stool.
Pallor is a common symptom, when the
tuberculous infection has become extensive.
The reduction in the hemoglobin is not ex-
treme in tuberculosis of infancy. The hemo-
globin reading is not often lower than 50
per cent. Tuberculosis by itself is not one
of the causes of extreme anemia in infants.
As already indicated anemia is a late symp-
tom of tuberculosis in infancy or rather oc-
curs when the tuberculosis has become ad-
vanced.
Often one notes that babies with extensive
tuberculosis are flabby. Their nutrition may
be good but their muscles feel soft and the
child as a whole seems to be lacking in vigor.
Like the pallor this loss in muscular tone,
this lassitude, occurs only when the tubercu-
losis is advanced.
On what does the diagnosis of tu-
berculosis depend? I first mention the
history. The infant who is known to
have been associated with a tubercu-
lous individual ought to be suspected of
having tuberculosis. So far as my experience
extends, tuberculous adults are far more com-
monly sources of infection than tuberculous
children, probably because tuberculous adults
so commonly have open pulmonary lesions
whereas tuberculous children have lesions
which are quiescent or limited to the tracheo-
bronchial nodes. If there is an adult with
tubercle bacilli in the sputum in the environ-
ment of the infant, it usually happens that
he is infected. One does encounter, however,
exceptions to this rule, even when it is the
mother who is the bacillus carrier. It is not
difficult to protect an infant from tuberculo-
sis if sufficient care and intelligence are ex-
ercised but the requisite care and intelligence
are rare. I have already alluded to the en-
largement of the spleen as suggesting the ex-
istence of tuberculosis. Probably in about
one-half the cases symptoms such as unex-
plained fever, cough, loss of flesh and strength
or an anemia otherwise unexplained lead the
way to the diagnosis. Rarely physical signs
on examination of the chest lead to the diag-
nosis of tuberculosis. Of course the first
indication that the child has tuberculosis
may be the development of a tuberculous
meningitis. In a great many instances the
diagnosis of tuberculosis is made through the
accidental discovery of a positive reaction to
tuberculin The test, preferably the intra-
cutaneous, ought to be used with great fre-
quency. It should always be done when for
any reason tuberculosis is suspected.
It is most difficult to say what the prog-
nosis is in the tuberculosis of infants and
any figures given are guesses on my part.
As our experience with tuberculosis in infants
increases, the more aware we are that recov-
ery very frequently takes place. But the
danger to the infant of tuberculous infection
is exceedingly great. Probably SO per cent
of those infected under six months of age
die and probably 30 per cent of those in-
fected under the age of one year. Probably
tuberculosis is not particularly dangerous,
statistically speaking, if the infection takes
place after the age of three years. The
younger the baby, the worse the prognosis.
We get no help in the prognosis from the
tuberculin test. In general infants give
marked reactions to intradermal tuberculin.
The reaction is particularly intense in the
case of infants who are recently infected and
in infants with the so-called symptom com-
plex of scrofula and is apt to be intense if
tuberculous involvement of the bones or
joints is present. The tuberculin test may
July, 1929
SOUTHERN MEDICINE AND SURGERY
4SJ
be negative in very extensive tuberculosis
when the infant is in a moribund condition.
If the tuberculin test is negative, usually it
can be made to become positive, provided
the baby has tuberculosis, by increasing the
dosage, for example, from 0.1 mg. of tuber-
culin to 1.0 mg. We have frequently given
in doubtful cases intracutaneous tests as large
as 3.0 mgms. and occasionally S.O mgms. If
the child is negative to 1.0 mgm. of tuber-
culin given intracutaneously and the tuber-
culin is a potent preparation, one can feel
fairly certain that the infant does not have
tuberculosis. We have had one or two cases
at the Harriet Lane Home in which the baby
failed to react to 3 mg. of tuberculin but was
found to have tuberculosis at autopsy. Such
cases are, however, rare. In very sick in-
fants the reaction to tuberculin may be atypi-
cal and seem to be negative when in reality
it is positive. There may be no reddening
of the skin and yet palpation at the point
where the tuberculin is injected will show
swelling and induration.
We frequently get aid in prognosis from
the examination of x-ray pictures taken at
two weekly or monthly intervals. If the x-
ray picture shows that the tuberculous proc-
ess is in the form of a broncho-pneumonia
and repeated x-ray pictures show the lesion
extending steadily outwards to the periphery
of the lung, then one knows that the prog-
nosis is bad. The complete consolidation of
large areas of a lung as shown by the x-ray,
the so-called epituberculous shadows, do not
mean a bad prognosis. It is not uncommon
to see children having complete consolidation
of two-thirds of the lung, as shown in the
x-ray picture, completely recover. If, of
course, the involvement of the lung, as deter-
mined by physical examination or far better
by x-ray examination, is marked, then the
prognosis is bad, for the degree of involve-
ment of the lungs is in a general way a meas-
ure of the involvement elsewhere. If the
involvement of the lung is extensive — I am
not referring to the so-called epituberculous
involvement — one knows that there are scat-
tered foci of tuberculosis all through the
body. If the spleen is greatly enlarged in a
baby with tuberculosis, this means that the
tuberculosis is extensive and that lesions are
present in the viscera as well as in the tho-
rax. For all practical purposes tuberculous
meningitis is fatal, though cases have been
repwrted in which recovery has taken place.
I have never seen such a case. Acute general
miliary tuberculosis without tuberculous men-
ingitis is nearly always fatal. Dr. Schick
told me that he had seen several cases of
acute general miliary tuberculosis in which
recovery took place, but they were all in
children three or more years of age. It
is not uncommon to see recovery take place
in infants who have had tuberculides or lichen
scrofulosorum. Of course, the progressive
decline in weight, the continuation of fever
and other symptoms indicate that the prog-
nosis is bad. But the weight curve may be
deceiving, as had already been pointed out.
I shall not say much in regard to treat-
ment. I do wish to point out, however, that
a great good to the infant can be accomplish-
ed, if a separation from the source of infec-
tion can be brought to pass. The babies most
apt to die from tuberculosis are those kept
in constant contact with a human source of
infection.
In conclusion I wish to urge uf)on your
attention the chief points which I have at-
tempted to bring out in this discussion of tu-
berculosis as it manifests itself in infants.
Tuberculosis is a disease to which the infant
is extraordinarily susceptible. The mortality
among infected infants is great. The symp-
toms and the physical signs are misleading.
The diagnosis can be made by means of the
intracutaneous tuberculin test with a great
deal of certainty and the intracutaneous tu-
berculin test should be used with great free-
dom if any symptom or if any circumstance
suggests that the infant may be infected.
Though the infant is so susceptible, he has
a great capacity to recover and he can be
greatly aided in his recovery, if he can be
separated from his source of infection.
Finally, it is the duty of the physician to
^make sure, when a baby comes under his
care, that the environment is free from tuber-
culosis or that the baby is protected from the
infection, if it exists in the environment.
The danger to which the infant is subjected
from contact with human beings infected
with tuberculosis is not appreciated by the
laity or by the profession.
456
SOUTHERN MEDICINE AND SURGERY
July, 1929
Coronary Occlusion, With Report of Two Cases That Came
to Autopsy*
Dewey Davis, M.D., and Douglas VanderHoof, M.D.
Richmond
Sudden occlusion of a coronary vessel often
gives rise to one of the most striking clinical
pictures seen in medical practice. The char-
acteristic pain, sudden in onset, intense and
lasting; marked dyspnea; pulmonary edema;
a peculiar ashen hue of the skin which is a
blend of the colors of cyanosis and shock;
the clammy perspiration and subsequent fever
with leucocytosis are so characteristic and fa-
miliar to you all. Variations from this pic-
ture, however, are legion and each case is pe-
culiar unto itself. The size of the vessel oc-
cluded, the location of the resultant infarct,
and the condition of the remaining myocar-
dium will largely determine this, but one or
more of the above features will almost assur-
edly be recognized unless death is so sudden
that they are not apparent.
Current medical hterature contains many
articles on coronary disease, but for a mas-
terly discussion of the subject, we would refer
you to an article by Hammari* published in
1926. He sets forth the etiology, pathology
and symptoms clearly and concisely.
The etiology of the condition is almost in-
variably arteriosclerosis. A few cases have
been reported where an embolus has blocked
a vessel, and disease of the root of the aorta,
particularly syphilis, may occlude the coron-
ary openings. An important fact to bear in
mind is that extensive sclerosis of the coron-
ary vessels may occur without obvious change
in other vessels.
The relation between the symptom com-
plex, angina pectoris, and coronary occlusion
is close, the former frequently terminating in
the latter, but it should be remembered that
sudden blockage of a coronary artery may,
and does occur without any warning.
The two cases we are presenting today il-
lustrate certain features which are of consid-
erable interest
Case 1. — Mrs. T., age 35, was seen in con-
sultation April 5, 1927. Her complaint was
attacks of substernal pain radiating to the
left shoulder and arm. Of some importance
in her history was the fact that she had been
married twice, and the morals of her first
husband were not of the best. In October,
1926, as a result of an automobile accident,
she sustained an injury to the right knee
which required an operation under a general
anesthetic. None of her past illnesses seemed
pertinent, and there was no history of vene-
real disease.
In December, 1926, she began having at-
tacks of pain in the left sholder and arm
which were definitely influenced by exertion,
but were treated as neuritis by her physician.
These attacks became more frequent and
severe and were associated with precordial
distress so that their more serious import was
recognized. Not only did she have them on
exertion but even while lying quietly in bed
at night. She became dyspneic in the at-
tacks so that the sitting p)osition was more
comfortable. Partial relief was obtained
from nitroglycerine. During this time her
blood pressure was very variable, the systolic
extremes being 130 mm. and 180 mm.
The pertinent features of her physical ex-
amination were pulse 80, blood pressure sys-
tolic 140, diastolic 90, and a soft systolic
murmur at the aortic area. The heart was
not demonstrably enlarged and there was no
palpable thickening of the peripheral vessels.
All routine laboratory examinations were nor-
mal, including the blood Wassermann reac-
tion. The electrocardiogram showed an in-
version of the T wave in lead one and evi-
dence of left ventricular preponderance. A
second tracing taken one week later showed
diphasic T in leads one and two and left ven-
tricular preponderance. Slight increase in
the transverse diameter of the heart and
moderate tortuosity of the aorta were observ-
ed fluoroscopically.
The opinion was expressed that this pa-
tient had aortitis and sclerosis of the coron-
ary vessels. At her age the possibility of the
♦Presented to the Tri-State Medical Association of the Carolinas and Virginia meeting at
Greensboro, N. C, February 19-21, 1929.
July, 1929
SOUTHERN MEDICINE AND SURGERY
4S7
aortitis being luetic in origin was considered
and, in spite of the negative Wasserman re-
action, antisyphilitic treatment was advised.
With this treatment and rest in bed she
showed gradual improvement until the night
of June 19, 192 7, when she was suddenly seiz-
ed with an agonizing pain in the precordial re-
gion radiating to the left shoulder and asso-
ciated with marked dyspnea and shock. A
grain of morphine during the next few hours
did not relieve her, and when seen by one of
us the next day at rioon she was evidently in
extremis, showing marked dyspnea, cyanosis
and pulmonary edema with the expectoration
of large amounts of frothy blood-tinged
sputum; pulse 130, regular and of poor vol-
ume, blood pressure could not be obtained,
the heart-sounds were completely obscured
by respiratory noise. She was given mor-
phine and digifoline but died a short time
afterward.
An autopsy limited to the chest showed the
following important features: A patchy type
of aortitis most localized about the origin of
the left common carotid artery and distinctly
of the luetic type, the right coronary was con-
siderably sclerosed but patent, the left exhib-
ited similar changes but the anterior descend-
ing branch was completely occluded by an
organized thrombus.
The interesting features of this patient are
her comparative youthfulness, a probability
of syphilis as a cause of the lesions and the
degree of coronary sclerosis without palpable
evidence of arteriosclerosis in the peripheral
arteries.
Case 2. — Mrs. S., age 46, seen November
21, 192S. Chief complaint pain in the chest
and arms. There was no history of acute ill-
ness in the past but for three years her sys-
tolic blood pressure had ranged between 180
mm. and 210 mm., and she was partially in-
capacitated. For several months she had
noticed some dyspnea and slight substernal
constriction on exertion, but her present ill-
ness began six weeks before when attacks of
pain came on in both arms, especially local-
ized in the wrists and associated with precor-
dial distress. These attacks gradually became
more frequent and substernal pain became
severe. They were not relieved by nitrites
and frequent hypodermics of morphine were
necessary for any degree of comfort. Early
in her illness she had considerable cough
which was followed by hoarseness and diffi-
culty in swallowing. The latter two symp-
toms persisted throughout her illness and
were never satisfactorily explained. She was
unable to exert herself at all, and suffered a
good deal while in bed. Dyspnea was never
pronounced until a few days before death.
Physical examination showed slight cyano-
sis and an anxious expression on her face,
her voice was distinctly husky. Pulse was
irregular as a result of frequent premature
contractions with rate 112, blood pressure
systolic 174, diastolic 100, left border of the
heart on percussion was just outside the
mammillary line. On auscultation frequent
premature contractions were noted and a soft
systolic murmur was audible along the left
border of the sternum. No pericardial fric-
tion rub was heard at any time in her illness.
There was moderate edema of the lung bases.
Temperature 100 degrees, leucocyte count 12,-
800 with 80 per cent polymorphonuclear cells,
blood Wassermann reaction negative, electro-
cardiogram showed diphasic T in lead one as
did a second two days subsequent. Fluoro-
scopic examination of the heart with ortho-
diagram revealed an increase in the transverse
diameter of the heart of 1.6 cm., but the
aorta appeared normal. Films of the chest
disclosed increased density in the mediastinal
region suggesting mediastinal inflammation
or possibly malignancy.
She was given moderate doses of digitalis
and iodide with sufficient morphine, some-
times amounting to one grain in twenty-four
hours, for relief. The attacks of pain, the
fever and leucocytosis gradually subsided,
but she became more dyspneic and her fam-
ily were told that she would probably die
suddenly at any time. This occurred as pre-
dicted on the morning of December 11, 1928,
shortly after she had eaten a light breakfast.
Permission for an autopsy was obtained
limited to the chest. The mediastinal region
contained considerable scar tissue but no
evidence of active inflammation. There were
no pericardial adhesions and no excess of
pericardial fluid. Moderate hypertrophy of
the left ventricle was present and on its pos-
terior wall near the apex were two small
fibrous areas evidently representing old heal-
ed infarcts. On the anterior surface of the
right ventricle near the interventricular sul-
cus was a fresh infarct measuring two by
458 SOUTHERN MEDICINE AND SURGERY
four centimeters. The heart was then opened
and the valves were normal except for mod-
erate sclerotic changes, especially the aortic.
A small organized thrombus was found in the
left auricular appendage. The aorta showed
only mild arteriosclerosis. On the inner wall
of the left ventricle and involving the inter-
ventricular septum there was a fairly recent
infarct about two by three centimeters, gray-
ish in color and soft when cut. The left
coronary artery showed considerable sclerosis
but no occlusion was found as far as it could
be traced. The right coronary appeared like
a yellowish fibrous cord, the aortic opening
was narrowed, and a probe could not be
passed beyond about four centimeters. In
places beyond this point a slight lumen could
be demonstrated filled with yellow material
of fatty appearance. It was perfectly evident
that it had been occluded for some time.
The most interesting feature in this case
is that although the right coronary artery had
evidently been occluded for a considerable
period of time there was no evidence of in-
farction in its normal distribution. We would
conclude from this that the closure had been
so gradual that collateral circulation had been
established to nourish this portion of the
myocardium. On the other hand, several
branches of the left coronary artery were oc-
cluded over a sufficient period to allow com-
plete healing of two infarcts, and a third
July, 1920
comparatively large one was not sufficient to
cause death. The recent one involving the
right ventricle appears to have been the last
straw and caused sudden exitus. It is re-
markable how a heart can stand such insults
and still function.
The immediate and ultimate prognosis of
coronary occlusion is grave. If individuals
survive the first attack they almost invaria-
bly have a reduction in cardiac reserve and
eventually develop gross evidence of myocar-
dial failure. A few cases of clinical recovery
have been reported, but the very nature of
the cause, usually arteriosclerosis, is against
a complete cure.
Treatment of coronary occlusion may be
summed up in a few words, complete rest for
a long period of time with morphine frequent-
ly and in sufficient amount to relieve the pain
and insure complete rest. Digitalis is indi-
cated in myocardial failure from this cause
just as in any other.
In conclusion, we would like to say that
occlusion of the coronary arteries frequently
occurs, possibly more often in recent years
than formerly, but certainly it is more widely
recognized today. Cases still go undiagnosed,
but if the clinical picture is always in our
minds, their number will gradually become
fewer. The prognosis is grave but not hope-
less, and careful treatment may lead to sur-
prising improvement.
1. Hajiman,
38:273-319,1926.
The Symptoms of Coronary Occlusion. Bull. Johns Hopkins Hospital,
OBSERVATIONS ON VOMITING OF PREGNANCY
Vomiting of pregnancy severe enough to warrant admission to a hospital occurs about once
in one hundred and fifty pregnancies, and severe cases occur once in four hundred.
The age and parity are not predisposing factors.
Severe vomiting usually starts before the eighth and occasionally before the fourth week of
pregnancy.
Neither the time of onset, duration of vomiting, nor loss of weight indicates the severity of
the disease nor affords a safe guide for prognosis.
A high pulse rate usually indicates severe vomiting but does not necessarily imply a serious
prognosis. On the other hand a low pulse may persist in a severely ill patient.
Fever due to dehydration is frequent.
The presence of urinary albumin is frequent but is of slight prognostic importance.
Acetone bodies are frequently absent from the urine in severe cases.
A high ammonia coefficient is usually seen, but a low one docs not necessarily indicate a mild
case.
In mild vomiting of pregnancy the blood chemistry is not essentially changed, although the
uric acid tends to rise and the chlorides to fall.
In severe cases a definite increase in NPN, uric acid and sugar is usually noted in the blood.
The chlorides are often considerably lowered.
In most patients isolation in a hospital and suggestive treatment will effect a cure, but ex-
ceptionally all therapy fails and the induction of labor is indicated.
A considerable percentage of patients abort spontaneously some time after cessation of symp-
toms, a phenomenon which requires explanation and study.
— C. H. Ve.cx.bau, a. Jour. Obs. and Gyne., Tune, 1929.
July, 1929
SOUTHERN MEDICINE AND SURGERY
4S9
The Importance of Frozen Section in Surgery*
Byrd Charles Willis, M.D., F.A.C.S., Rocky Mount
Park View Hospital
It is as important today as it was in the
yesterdays to arrive at a clinical diagnosis
lest we become too def)endent upon the lab-
oratory. On the other hand the surgeon of
a small hospital should know his gross and
microscopical pathology. The clinical and
gross diagnosis should always be checked by
immediate frozen section and this in turn
should be checked by permanent sections or
there will be many errors of omission and
commission in surgery, some of which will
either cost the lives of patients by inade-
quate surgery or they will suffer unnecessary
mutilation. Some few years ago a famous
surgeon, under a clinical diagnosis of cancer,
removed the lower rectum of a patient, and
a microscopical diagnosis of the specimen was
syphilis. The location was a very common
one for cancer but all tumors that grossly
look and feel like cancers are not cancers
until proven so microscopically.
If the tumor is so small that a microscopi-
cal section will include one-half of it, the
pathological diagnosis of one section will
probably be sufficient. Where the tumor is
of any size, many sections of various portiens
should be studied before an opinion is ren-
dered unless a positive diagnosis of cancer
can be made on the first.
At Park View Hospital we make it a rule,
in all tumors of the breast, to do an imme-
diate frozen section so as to do as Httle or
as much surgery as the actual disease war-
rants. We believe we have saved several
breasts and some lives.
In removing small tumors of the breast,
it is well to allow a healthy margin of free
tissue and await the immediate pathological
report before closing the wound. One should
bear in mind that all cancers have a minute
beginning and that very small nodules may
be very malignant and require extensive sur-
gery. If the patient is to be put to sleep for
the removal of a small noduJe, it is a very
good rule, prior thereto, to obtain permission
to remove the breast and glands if necessary.
Most of these, however, can be removed un-
der a local anesthesia; but in these cases it
is well to have the patient prepared for gen-
eral anesthesia so as to be ready to carry out
any necessary surgery. In the past eighteen
months the permanent section check upon the
breasts of two women, made while they were
still in the hospital, have necessitated a radi-
cal resection of the breast and glands. The
frozen, fresh sections were not positive, but
the permanent sections made from many dif-
ferent portions of the chronic, cystic breast
tumors showed early cancer in both.
We make it a rule to take biopsy speci-
mens of all tumors of the cervix, even of
those that are grossly advanced, before treat-
ing them with radium, as we find that Bro-
der's grading is of material aid in prognosis.
A chronic, cystic, infected cervix many times
feels and looks malignant, but a microscopi-
cal section will reveal the true diagnosis.
Only recently in the case of a young wo-
man in the thirties who was having irregular
uterine bleeding without offensive odor, cur-
ettage brought away a moderate amount of
what appeared to be hypertrophic endome-
trium; but frozen section showed that we
were dealing with adeno-carcinoma of the
body of the uterus. This patient was given
the benefit of an early pan-hysterectomy and
left the hospital in good condition, but it is
too early to say that we have a cure. Last
spring we had a woman of thirty-six with
an early, incomplete abortion whose cervix
was friable on the posterior lip. Immediate
frozen section showed cancer, grade four.
Radium was given and poor prognosis made
to husband. This patient, in spite of mas-
sive doses of radium, is in the last degree of
cancer.
I would like to sound a note of warning
regarding the type of cancer that occurs on
the face and hands, which simulates, and is
often mistaken for, a small abscess or car-
♦Presented to the quarterly meeting of the Fourth District Medical Society, Goldsboro, N. C,
February 12th, 1929.
460
SOUTHERN MEDICINE AND SURGERY
July, 1929
buncle. When seen it is about l.S cm. in
size, raised, slightly reddened, tender, and of
about six weeks' duration. The patient states
that he thinks he has injured himself at this
point and wants the place opened.
We had such a case, a man of 76, with a
growth at the base of the left index finger
which had been incised for drainage some
time previously without any pus being found.
The tumor continued to grow. Microscopical
section showed epithelioma of third degree
malignancy. Patient was advised amputation
should be done but refused. Extensive ex-
cision with cautery was resorted to but recur-
rence was finally fatal. We have seen several
of the face prior to being opened.
SUMMARY
First, microscopical sections and study
should be made of all tumors removed from
the body.
Second, permission obtained and prepara-
tion should be made for any necessary sur-
gery that might have to be done before doing
biopsy.
Third, slides, properly labeled, should be
filed away for reference.
BOSTON DOCTORS F.^CE ARREST IN RHODE ISLAND
Under this caption the daily papers announce that a bitter fight is being waged in Rhode
Island by physicians and medical societies against the Providence Branch of the National Health
Bureau.
The charge is that the Massachusetts physicians connected with this Bureau have been prac-
ticing illegally in Rhode Island because of not having secured registration in that State and the
article sets forth that warrants have been issued against Dr. William R. P. Emerson, Dr. Harold
Bowditch and Dr. Josiah E. Quincy. Dr. John A. Ragone of Buffalo is also named in the
statements. The warrants have been sworn out by Dr. B. U. Richards, Secretary of the Rhode
Island State Board of Health.
Dr. Emerson is quoted as being surprised. He claims to have been in conference with Dr.
Richards and supposed that the Bureau was being operated in conformity with Rhode Island Laws.
— The New Eng. Jour, of Med., June 20, 1929.
ASTHMA FROM UNUSUAL SOURCE
Among two hundred patients who have been tested to dusts collected and prepared in this
manner, nineteen have been found who gave large reaction to extracts of the dust collected from
their own mattresses, but who did not react to cotton or kapok, of which the mattresses were
made. In each instance complete relief was produced almost like magic by discarding the offending
mattress and the substitution of a new one. However, in three cases attacks recurred after free
intervals of from four to six months, whereupon positive skin tests were again obtained to extracts
of the new mattresses. It was found however, that recurrences could be prevented if the mat-
tresses were covered with some impervious material, either rubber sheeting or Dupont's satin
fabricoid. Studies are being made to determine the nature of the sensitizing material in theses
cases. It is probable that mattresses become infected with molds to which patients become sensi-
tized. This is probably what has occurred in these cases, since mattresses, the dust extracts of
which give no reactions and which produce no symptoms in patients when new, do cause trouble
after several months' use. — M. B. Cohen in The Jonr. of Lab. and Clinical Med., June, 1929.
1 ^
[^m
July, 1929
SOUTHERN MEDICINE AND SURGERY
Gastric Ulcer*
Samuel Ork Black, M.D., Spartanburg
Gastric ulcer produces a train of symptoms,
frequently referred to as dyspepsia. There
is no other group of symptoms so difficult to
interpret at times.
Dyspepsia may be organic or functional in
origin. \\"hen organic, it may be due to a
lesion within or without the stomach. The
iiiiragastnc lesion may be ulceration, malig-
nancy, polyposis, tuberculosis, syphilis, or
what not. The extraga.stnc lesion may be
situated in the duodenum, liver, gall-bladder,
pancreas, appendix or bowel. Chronic con-
stipation is one of the most frequent causes.
When functional in origin, there are usual-
ly other evidences of an unstable nervous
equilibrium.
As this paper deals with gastric ulcer, the
other above enumerated causes of dyspepsia
will be disregarded.
There is now a rather clear-cut clinical
picture, more or less characteristic of ulcer,
v/hich, when taken into consideration with
certain roentgen-ray and laboratory findings,
lends to clarify the symptomatology and to
establish the diagnosis.
Every medical man, however, has a certain
proportion of cases in which positive diagno-
sis is extremely difficult. The idea then is
to determine whether the case is organic or
functional.
Functional dyspeptics are among the most
trying patients the physician has to deal
with. As a rule their symptoms are varied.
They lack the constancy or periodicity
found in the true ulcer. The patient is in-
definite in his or her story. Frequently,
symptoms are included referable to some dis-
tant part of the body, e. g., headache, blind
spells, numbness, needle pricks, pain in the
legs, backache, insomnia, etc.
The handling of these individuals requires
tact, sympathy, kindness, and the treatment
in the main Djnsists of psycho- and physio-
therapy, hot and cold showers, electric and
mechanical massage, simple diet, occasionally
placeboes, and certainly for a time, if indi-
cated, sedatives sufficient to induce restful
sleep.
A recent published statistics covering two
thousand consecutive necropsies showed gas-
tric ulcer, active or in the process of healing,
in 141 instances, i. e., in about 7 per cent of
the cases.
Gastric ulcer is from eight to ten times less
frequent than duodenal ulcer. The two to-
gether are comparatively common and con-
stitute by far the most frequent cause for
surgical attack on these two organs. It is a
matter of record, however, that the two com-
bined constitute only 1.7 per cent of all the
intra-abdominal operations. It is four times
more frequent in the male than in the female.
The average age at which operation is per-
formed is 47 for gastric ulcer and 43 for
duodenal ulcer (Balfour).
Clinically, in many instances, the gastric
ulcer will be confused with the duodenal
one. It is said that the clinical picture is
more blurred when the lesion is in the stom-
ach than when it is in the duodenum. In
our experience they are nearly identical. The
surest way of locating the lesion anatomically
is by the x-ray.
The exact etiology is not known, but the
persistence of symptoms certainly is connect-
ed with the acidity of the gastric contents
and frequently with the presence of a focus
of infection.
Rosenow has repeatedly grown from the
excised human gastric or duodenal ulcer a
green streptococcus, which, when intraven-
ously injected into animals, has produced ul-
ceration in the same area of the animal's
anatomy as that from which the original ul-
cer was taken. In like manner, he has iso-
lated this same organism from the tonsils,
teeth or prostates in patients with ulcers.
These tonsil, tooth or prostatic organisms he
has injected into the veins of animals, and
later at autopsy, these animals' stomachs and
*Presented by title to Tri-State Medical Association of the Carolinas
Oreensboro, February 19th-21st, 1929.
and Virginia, mcctinf,' at
462
SOUTHERN MEDICINE AND SURGERY
July, 1929
duodenums were found ulcerated. Recently,
his work has been substantiated at the Uni-
versity of Edinburgh. This same streptococ-
cus has been removed from teeth, which
roentgenologicalh' were sound, but bacterio-
logically were devitalized sufficient to pro-
duce metastatic lesions.
It is, therefore, apparent that the causa-
tive bacterium can be found in the tooth, ton-
sil and prostate as well as in the ulcer itself,
and that it can be readily identified as the
same organism. Any treatment, therefore,
not designed to remove the bacterial cause
from the system is incomplete, and leaves
ample ground for re-activation or even recur-
rence of the ulcer.
Three years ago we f)erformed a posterior
gastro-enterostomy for a calloused ulcer on
the lesser curvature near the cardiac end.
The patient remained well till a short time
ago when his old svTnptoms recurred. He
had failed to have his pyorrhea treated as he
had been advised to do upon leaving the hos-
pital. Intensive medical treatment for ten
days after return to the clinic failed to dimin-
ish the pain and he was again operated on.
The diseased area was larger than formerly
and there was evidence of e.Ntensi%-e acute in-
flammation. The old ulcer had become re-
activated.
The same thing is occasionally seen in a
duodenal ulcer after gastro-enterostomy. It
is characterized by pain, burning, belching
and nausea coming on, usually, some months
after the operation. It is predisposed to by
overwork, fatigue, worry, improfjer diet and
perhaps an overlooked focus of infection.
Rest, alkali, plain diet, cessation from physi-
cal and mental strain and eradication of foci
of infection when found usually suffice to
overcome the distress. Should, however, the
symptoms [persist in spite of treatment, gas-
tro-jejunal ulcer should be suspected and the
stomach examined roentgenologically. Ulcer
is determined by deformity and surgery will
be necessary before definite improvement can
be brought about.
The great majority of gastric ulcers occur
on the posterior aspect of the middle one-
third of the lesser curvature of the stomach.
In 81 cases recently reported by Louria, 77
were in that location.
A gastric ulcer may be complicated by
bleeding, perforation, obstruction or perhaps
superimposed malignancy. Bleeding may be
acute, severe and prostrating. Bad as it
sometimes is, the initial hemorrhage is rarely
if ever fatal. Bleeding from a gastro-jejunal
ulcer is rarely ever copious, but is more apt
to be characterized by an oozing, which is
constant and which in time produces extreme
anemia and weakness.
Perforation may be acute or chronic. In
deaUng with the acute type the primarj^ ob-
ject, of course, is directed towards saving the
patient's life. The procedure to follow de-
pends upon the patient's condition and the
time elapsing since the perforation. Within
the first six hours, gastro-enterostomy might
with safety be performed in addition to clos-
ing the f>erforation, as the exudate remains
sterile that length of time. After six hours,
infection sets in and every additional proce-
dure is hazardous.
When dealing with a chronic perforating
ulcer, we always trj- to remove the ulcer-
bearing area by cautery or knife excision be-
fore doing gastro-enterostomy. In two re-
cent cases the stomach wall adjacent to the
ulcer measured three-fourths inch in thick-
ness. Obviously such pathologj- could never
be absorbed by any means other than a direct
attack.
Obstruction occurs in about 15 per cent
of the cases. It may be partial or complete.
Its extent is in no wise indicative of the loca-
tion of the ulcer. In 8 per cent of the cases,
it produces hour-glass deformity. When of
long standing, it often produces toxemia,
characterized by a decrease in blood chlo-
rides, an increase in the urea and an increase
in the carbon dioxide combining power of the
plasma. Gastric lavage twice daily, sodium
chloride 1 per cent and glucose 5 per cent
daily per rectum should be given freely be-
fore resorting to operation. The patient's
general condition should be improved to the
maximum, under the circumstances before
operation.
Clinically, in the main, it is impossible to
say that a given chronic gastric ulcer is be-
nign. Microscopic evidences of malignancy
are occasionally found when all the other
findings suggest a benign lesion. The possi-
biUty of malignancy, therefore, affords ample
justification for its radical removal.
We have now had 93 cases of peptic ulcer.
Twenty-eight were gastric and sixty-five were
July, 1929
SOUTHERN MEDICINE AND SURGERY
duodenal. Of the gastric ones, five occurred
in the female and twenty-three in the male.
The average age of our gastric cases was 43.6
years. Ten of them were perforated ulcers
when first seen.
The treatment of gastric ulcer is medical,
or surgical with the removal of foci of infec-
tion. Surgery, of course, offers the quickest
and surest way of securing permanent relief.
If medical treatment is to be used, it should
be orderly, systematic and intensive. It gives
better results when used in younger patients,
or in patients with a symptomatology of less
than 18 months duration.
The underlying principles in the medical
treatment are: first, rest of the diseased part,
second, reduction of the acidity, and third,
eradication of sources of infection. Rest is
to be secured by recumbency, and the sim-
plest of diet at short intervals, of which milk
is perhaps the simplest. Small doses of alkali,
three to four to five grains at one to two-
hour intervals surpass in efficacy, the large
doses heretofore used to reduce the acidity.
Daily aspiration of the stomach is a splendid
adjunct for the first seven to ten days. As
the acidity and pain lessen, the diet is in-
creased and the aspirated fluid and the stools
are examined at three-day intervals for blood.
If the symptoms persist for several weeks
after the institution of the medical regime,
notwithstanding reduction in the acidity, sur-
gery had better be resorted to, as the ulcer
has probably perforated or caused obstruction
or else the lesion is extragastric.
Experience with simple excision for gastric
ulcer has been that about one-third of them
get along nicely and remain symptom-free.
The other two-thirds had sufficient trouble to
warrant further surgery or treatment at a
subsequent date. It is, therefore, our policy
to combine the Bilroth No. 2, or some modi-
fication of it, with the excision whenever the
patient's general condition warrants.
Rarely, if ever, do we simply j>erform gas-
tro-enterostomy for gastric ulcer. If the
ulcer-bearing area can be directly attacked,
we go after it either by cautery or knife ex-
cision. When the ulcer is on the upper or
anterior wall of the pylorus or duodenum, we
excise it, and leave the posterior wall intact.
The closure is made by beginning the anasto-
mosis at the top and carrying it down to
about the middle of the anterior aspect and
tying it there. Then begin at the bottom and
run up to and meet the suture line already
made. This technique simplifies closure, and
insures perfect coaptation at the upper and
lower angles, respectively.
If the ulcer is very large and on the pos-
terior wall down near the pylorus and caus-
ing obstruction, one is occasionally compelled
to do simple posterior gastro-enterostomy,
though there are now an increasing number
of surgeons advocating pylorectomy with di-
rect anastomosis, the so-called Bilroth No. 1
operation. An alternative is to close the
stomach and the duodenal end and to connect
the stomach to the bowel by means of a new
opening, the so-called Bilroth No. 2. Still
another alternative is to close and invert the
duodenal end and to anastomose the stomach
end direct to the jejunem, either anterior or
posteriorly to the transverse colon.
REFERENCES
1. LouRiA, Surg., Gynec. and Obst., Oct., 1928,
Vol. XLVII.
2. RrvES, The Journal-Lancet, Jan. IS, 1928.
3. Morton, Am. Surg., 1927, LXXXV, 207.
4. McVicAR, Canadian Med. Assn. Jour., 1927,
XVII, 14S1.
5. Alvanz, /. Amer. Med. Assn., 1927, LXXXIX,
440-S.
6. Balfour, Mayo Clinic Papers, 1927, LIX.
SOUTHERN MEDICINE AND SURGERY
July, 1929
An Analytic Research Based Upon Four Hundred and Thirty-
six Health Examinations in Fifty-one Counties*
Geographic Range: Hyde to Cherokee and Ashe to Brunswick
Time Range: February, 1928 — March, 1929
Frederick R. Taylor, B.S., M.D., High Point
For a little over a year, the Health Main-
tenance Bureau of the State Board of Health
has been engaged in a state-wide campaign
to arouse interest in periodic health examina-
tions by means of personal interviews with
physicians, talks to medical societies, and to
a variety of lay organizations, and by demon-
stration clinics. In these clinics, as most of
you already know, we have made no attempt
to examine any considerable number of per-
sons in any one locality — they have been
demonstrations, pure and simple, to show the
value of such work to both the medical pro-
fession and the public, to get the doctors of
the state to take an increasing interest in the
careful examination of apparently healthy
persons, and to get as many of the people of
the state as possible to go to their own phy-
sicians at least once a year for a health ex-
amination. So far, we have qovered seventy-
five counties of the state, but our clinical
data come from only fifty-one counties. As
a general rule, to which there have been a
few exceptions for special reasons, clinics
have not been held in counties having large
and strongly organized medical societies —
there we have felt it wise to get the societies
to conduct their own campaigns as far as
possible. In a few counties the influenza
epidemic prevented clinics during the time at
our disposal for those counties. In not more
than three counties does lack of interest on
the part of the medical profession explain the
failure to hold clinics in them.
All the data reported here are based on our
own personal examinations, made with the
assistance of a laboratory technician, who also
helped take a number of the histories. These
e.xaminations have been unhurried, and as
careful as we know how to make them. They
have been conducted over a practically state-
wide area, as shown by the title of this paper.
It seems, therefore, timely to try to learn
what lessons this work may teach us.
A few factors involved in the type of per-
sons examined are of importance in interpret-
ing these data.
1. They were persons supjwsed to be
healthy, or practically so. One person was
being treated for an antral sinusitis, but she
also had an inoperable carcinoma of the rec-
tum which no one knew anything about. Two
others had some so-called indigestion — one
was diagnosed a carcinoma of the liver, prob-
ably secondary to the stomach, and the other
chronic gall-bladder disease. With a few
such exceptions, all answered the question,
"Do you consider yourself in good health?"
by "Yes,"' or "Practically so."
2. Most of our patients were middle-aged.
This explains such things as the low inci-
dence of hyjiertrophied tonsils and adenoids.
3. Comparatively few women were exam-
ined, hence the low incidence of gynecologic
conditions. It is regrettable that we kept no
record of the sex incidence of our patients—
the complete records of our examinations
were left with the patient's own physician,
and v.'e merely made a copy of the diagnosis
made on each patient. It is from these diag-
noses that our data are obltained.
4. Most of our patients have been of a
high grade of intelligence, who read a good
deal, and take care of their teeth, hence the
predominance of refractive errors over oral
sepsis.
5. Our work last summer was done in the
mountains, and we worked in the warmer
parts of the state in the spring, fall and win-
ter, hence our low figures on eczematoid
ringworm of the toes, one of the most fre-
quent defects in the state in warm weather.
6. We made no attempt to compile data on
venereal disease, as we had no time to wait
for Wassermann reports. Bloods were fre-
quently sent to the State Laboratory, and
repeated prostatic massage advised to detect
gonococci, but the results of such work were
♦Presented to the Medical Society of the State of North Carolina, Greensboro,.\pri] 16, 1929.
July, 1929
SOUTHERN MEDICINE AND SURGERY
46S
learned only by the family doctor, as we had Dejects Involving Over 5% of Persons Examined
moved elsewhere by the time they were ob- ,, , J^" "^
. ■^ - No. of Persons
tamed. Defect Cases Involved
7. We must have missed manv psychoneu- Refractive errors-uncorrccted or in-
... , , . f J completely corrected 165 37.84
rotic conditions, tor such matters may require Dental infection (oral sepsis) of all
weeks of contact to gain a patient's confi- ^'"'^^ - - 123 28.21
J A, j.^. 1 -c J J Obesity (more than 10% over stand-
dence. Many conditions classified under ^rd weight) 67 IS 37
"Harmful Habits" are no doubt on a psycho- Tonsils, chronic infection of S7 13.07
neurotic basis. ' m T°7 v'*^' ; .,;-- .7^-— .- ^^ ^^'^^
Malnutrition (more than 10% under
I have here a rather formidable array of standard weight) 52 11.93
statistics, which I will attempt neither to E\cef've tobacco 41 9.40
J . ,.■ 11 • 11 ., , Painful corns and calluses of feet 39 8.94
read, nor to express graphically in all its de- Appendicitis, chronic 3S 8.03
tail, for either would be impossible in the Prostate, hypertrophy of _ 32 7.34
time and space available.! ^""''itZ.^lT ■ °^ T''' ^'"^''^ ,.
^ among physicians) 31 7.11
The first lesson, we learn at a glance, and Deafness, all grades , 30 6.88
that is, the overwhelming need of health ex- ^"""^ shoulders, marked 28 6.42
• ,. T A-,^ ., , w. Anemia, secondary 25 5.73
amtnatwns. In 436 apparently healthy, or Hypertension, essential 23 5.28
almost healthy persons examined, we found
1,555 defects— an average of 3.57 defects ^^^^^ ^S"'^' emphasize the great import-
per person. A very few defects of no a"" of two procedures all too often neglected
clinical importance were included because '" '"''"""^ examinations— simple visual tests
thev were pathologic curiosities, such, e. g., ^"J,rectal examinations,
as a vaccination scar on the abdomen, but in , ^^^ """'^ ^^"o"^ unsuspected defects
the main, defects recorded are real defects ^""""^ '^"^- ^ ^^'^ "^ t°^3"° amblyopia, 11
Deflected nasal septa, e. g., are recorded only '^^^^^ °^ ^'^^'"^ pulmonary tuberculosis, 1 case
where they are obstructive. °^ pernicious anemia, 1 of subclavian aneu-
rism, several of marked hypertension (some
Total Number of Kinds of Defects Found 259 of our cases were known to exist to some
^'tha^n o'2^%":f'ttfe%'xamir;dVL^""" ^'"^ 143 ^'^'''^ ' ' ^^^^ °^ -^--dial weakness, a
No. of kinds of defects involving $0.25% to considerable number of cases of chronic gall-
Nn^ofk/nd'^^nVH^r'?'''- r ■■■■---« ^^^^^^^^^ ^° '''^^^" d's«^3se, three cases of carcinoma
I\o. ot kinds of defects mvolvine 0.51% to n- » 1 ■ .,
1.0% of those examined .._ 26 ("ver, rectum and a probable one involving
No of kinds of defects involving 1.1% to 2.0% the prostate), a number of cases of nephritis
of those examined ._ ??-> r^t-i ... , '
No. of kinds of defects involving" 2.7% to"s;o% ^^^ °* tuberculous peritonitis, and one of
of those examined _ 22 probable tuberculosis of the kidney (intract-
^of1htie'lx°am1ned" '"'""!'"' ^•'^" '" '°°^" 9 ^^^^ P-^""^ ^'^^^ hematuria at times in a per-
No. of kinds of defects involving 10.1% to ^°" *''^ pulmonary tuberculosis). The last
20.0% of these examined 4 named patient considered himself in fair
No. of kinds of defects invo ving 20.1% to v,„oUi, j •. .u r . .l . 1 •
40.0% of those examined . ___. 2 ^^''" despite the fact that his urine contain-
ed pus whenever he had it examined!
Here you will note that 259 different kinds A number of serious defects already known
of defects were found, and of these 143 af- to the patient were also discovered,' such as
fected only one person each— that is, more alcoholism, morphinism, general bad habits of
than one-half of the varieties of defects found a serious nature, chronic gonorrhea of over
were comparatively rare in our experience, a year's duration, congenital syphilis etc
Again, of the 259 kinds of defects, 244 each The two cases diagnosed as'congenital ab-
affected less than 5 per cent of those e.xam- sence of the knee jerks had been intensively
ined. W hile it is, of course, common sense studied by neurologists manv years ago (one
to think of the commonest diseases first, these of them 20 years ago), and no obvious ex-
hgures indicate the importance of considering planation found, and the lapse of time has
also a large number of relatively uncommon produced no further evidence of trouble
conditions in making health examinations. Excessive hours of work and insufficient
Dublilhe^d" in'^'f'^MI "i ',h'"'*,'n,'n'^' '''"'''"^ ^'3'*^'*" d" ""t ^PP^" here. They will presumably be
466
SOUTHERN MEDICINE AND SURGERY
July, 1920
sleep are, of course, occupational hazards of
the practice of medicine, as well as of some
other vocations, and as our records include
examinations of 77 physicians themselves,
these figures are unusually high in our statis-
tics.
The rather low ratio of constipation, once
called "the great American disease," may be
due to the increasing knowledge of dietetic
principles, which the home economics depart-
ments of our high schools, colleges, woman's
clubs, county demonstrations, etc., are doing
so much to disseminate to the great benefit
of public health.
We found a surprisingly small number of
functional heart murmurs, for which we have
no e.xplanation, other than that they are
more frequent in younger persons than
those we examined. Even so, we should
have expected to find more, for included in
our list were the boys of the Eastern Carolina
Training School at Rocky Mount. Uncom-
plicated mitral regurgitation has recently been
shown to be so rare that we look with sus-
picion on our two diagnoses of that condi-
tion. (There were three diagnoses of mitral
regurgitation, but the other one was asso-
ciated with stenosis). Possibly these two
cases should be added to the functional mur-
mur group. A low rate of valvular heart dis-
ease is to be expected where there is a low-
incidence of rheumatic fever, as in our state.
We very much regret that we failed to
record the number of persons who were un-
protected against smallpox and typhoid fever.
Such a lack of protection was noted in the
record left with the patient's physician.
These cases were few, as our patients were
of a high average of intelligence. However,
the data would be interesting.
We record only one case of excessive child-
bearing, again because we worked with an
exceptionally intelligent group. A much
higher rate would doubtless be found among
the poor and ignorant.
We found no case of chronic nephritis with
edema, probably because it is relatively un-
common, and such patients practically always
know they are sick and do not come into the
health examination group.
W'here flat feet caused no symptoms they
were disregarded, and not listed as defects.
The age and sex incidence of our patients
explain why only two c^ses of colloid goitef
were found.
Our cases of chronic arthritis are too few
to show any data of value regarding the asso-
ciation of focal infection discoverable by or-
dinary methods of physical examination. So
were our cases of angina pectoris, though all
three had associated conditions supposed to
be of importance — one had focal infection,
one had the excessive use of tobacco, and
one an undue stress and strain of life.
The majority of our glycosurics were obese,
though hardly in the overwhelming majority
noted by Joslin, for S of the 16 were not
overweight. Ten of our 16 nephritics were
noted as having some form of focal infection,
whereas only 7 of 23 patients having what
we considered essential hypertension are so
noted. This latter incidence is lower than
our general incidence of focal infection, for
some form of such infection, including dental
caries, was found in 206 of the 436 patients,
or 47.2 per cent. .'Xmong our 5 patients with
exclusively diastolic hypertension, however, 4
showed focal infection. This, of course, may
be mere coincidence.
Our hypotensive patients were too few to
base any conclusions on, but the incidence of
focal infection in them did not differ signifi-
cantly from the general incidence.
These facts would seem to show that, while
focal infection is exceedingly frequent, in-
volving almost one-half of middle aged
adults, the vast majority of those harboring
it do not show evidences of serious visceral
or constitutional disease. Further, no defi-
nite relation is shown between focal infection
and essential hypertension. Chronic nephri-
tis, on the other hand, does seem to have an
unusually high incidence of such infection,
and as this is a growing factor of importance
in our mortality rate, the importance of focal
infection should not be underestimated.
Moreover, whatever the general rule may be,
we have probably all of us seen at least a few
cases of essential hypertension and other
chronic conditions clear up after cleaning out
infected areas, so we have no warrant what-
ever to regard focal infection as a harmless
process.
One boy was examined in whom we found
no physical defects, but he had habit defects
bad enough to cause his commitment to the
Eastern Carolina Training School, and such
(iefects are just as important from a medical
July. 19^9 SOUTHERN MEDICINE AND SURGERY
467
Standpoint as ones that have a demonstrable diagnosis— comparatively few of those exam-
material basis. ined had only one defect noted, and two per-
sons had 12 defects each!
SUMMARY AND CONCLUSIONS a t\ i. , i . .
, , . , 4. Ihe one hundred per cent American
1. An appalling number of defects exist in from a medical standpoint is probably a
our apparently healthy adult population, an mythical creature.
average of between three and four per per- c a j c •. i ,• ■
5- A verv definite ob igation confronts us
son, in our experience. , . , , ^ v.ui"njiiis us
"^ as a profession, and that is, to regard the
2. A very considerable number of these periodic examination of apparently healthy
defects are of the utmost significance to life persons as one of the most important things
and health. jj^ ^^^ practice of medicine, and to develop as
3. Multiple diagnoses are the rule in keen an interest and competent a technic in
health examinations, rather than a single this field as in any other branch of our art.
BOGY OF HEART-BLOCK IN DIGITALIS
THERAPY
William D. Reid, Boston (.Journal A. M. A., June
22, 1929), asserts that the fear of the production of
heart-block by digitalis medication seems to indi-
cate a misconception of the therapeutic use of this
drug. Heart-block is not a prominent feature of
the toxic action of digitalis. In fact, some degree
of impairment in auriculoventricular conduction us-
ually appears at the dosage associated with the thera-
peutic effects. There are no records of adequately
studied patients who have died solely as a result
of digitalis-induced heart-block. Complete heart-
block may sometimes be present for years in patients
who experience little if any reduction in their ability
to perform heavy muscular work. The ventricle
possesses tissue that is capable of initiating contrac-
tions, and the circulation adjusts to the slowed rate
drug-induced, is usually associated with some serious
without untoward symptoms. Heart-block, not
form of heart disease whose lesions are not limited
to the junctional tissues. It is the wide-spread and
often progressive lesions of these diseases which
doubtless have caused heart-block to be considered
serious. The production of therapeutic heart-block
of a degree sufficient to slow the ventricular rate to
normal, in such conditions as auricular fibrillation
with an accelerated heart (ventricular) rate, is an
established principle in the use of digitalis medica-
tion. It is occasionally beneficial to convert partial
into complete heart-block. Digitalis is often of
benelit in complete heart-block with insufficiency of
the heart. Reid concludes that the inordinate fear
of the production of heart-block by digitalis may be
disastrous in those cases in which the patient's only
chance is dependent on the full therapeutic effects
of the drug. Digitalis should be administered until
beneficial results are obtained or there is evidence
pf toxic effects.
SOUTHERN MEDICINE AND SURGERY
July, 1029
Early Pericardotomy in Purulent Pericarditis*
Addison G. Brenizer, M.D., Charlotte
There is no therapeutic measure capable
of preventing the occurrence of pericarditis
in the course of an infectious disease.
For therapeutic purposes the diseases of
the pericardium may be considered as (1)
those cases in which a simple fibrinous peri-
carditis is present, (2) those in which a peri-
cardial effusion occurs, (3) those in which
effusion becomes purulent and (4) those
cases in which adhesions form between the
parietal and visceral layers of the pericar-
dium.
In pericardial effusions tapping may be-
come necessary, not only for diagnostic pur-
poses, but for urgent need of relief to a
hampered heart. The largest amount of fluid
Williamson was able to inject into the peri-
cardium of a cadaver was 650 c.c. but in a
living body with elastic pericardial walls
more can accumulate. Gibson is said to have
removed a gallon of fluid from a pericardium
obtaining an ultimate recovery. In the case
presently to be reported, 480 c.c. of turbid
fluid was removed by aspiration and 14 days
later 620 c.c. of thick purulent fluid by peri-
cardotomy.
There are two definite surgical procedures,
puncture and incision or piericardotomy. Both
can be carried through under local anesthesia
alone, with nitrous oxide and oxygen alone
or a combination of the two. In the child,
it may be necessary to resort to ether.
In the eighteenth century Riolan and Se-
nac declared that puncture of the pericar-
dium was fxjssible though they did not have
the opportunity or boldness to perform it.
It is an error to attribute the first attempt
to Desault. In 1793, indeed, this author per-
formed a puncture in a patient suffering from
p)ericarditis but he had the frankness to ac-
knowledge that the fluid was not situated in
the pericardium. Its true originator was
Omero, of Barcelona, who obtained two cures
in three cases of pericarditis. In 1827, Jow-
ett, of Nottingham, employed the trocar for
the first time. In 1829, Schuh, of Vienna, at
the instigation of Skoda, by puncture of the
pericardium removed a few grams of bloody
serum but without other result. In 1841,
Heger performed puncture in the fifth left
space two inches from the sternum and was
able to withdraw at first 50 ounces (1500
grams) and in a second intervention 17
ounces (500 grams) of fluid. The patient, a
sufferer from tuberculous pericarditis, suc-
cumbed a short time afterward. This opera-
tion was performed also by Aaran in 1854,
using a papillary trocar, evacuating 12 ounces
(350 grams).
In 1870, Fremy used for the first time the
method of aspiration that had just been de-
vised by Dieulafoy. He entered the pericar-
dium to the left of the sternum one centi-
meter above the lower border of the dullness
and withdrew 27 ounces (800 grams) of pu-
rulent serum resembling that of a cold ab-
scess. In 1875, Henri Roger presented to
the .Academy a complete statement of the in-
dications and contra-indications for puncture
of the pericardium and since that time the
operation has been performed frequently.
\'arious methods have been recommended, all
designed to avoid perforating the pleural
sinuses, the heart and especially the mam-
mary vessels.
The left extramammary method was used
almost exclusively by the early authors and
was recommended especially by Dieulafoy.
The puncture is made preferably in the fifth
space 2'! '4 inches (6 centimeters) to the left
of the sternum. The needle is inserted slowly
and obliquely upward and inward and, as
the fluid escapes, the needle is inclined so as
to be parallel to the surface of the heart and
thus avoid wounding it.
The left parasternal method, suggested by
Baizeau in 1868, was adopted several years
later by Delorme and Mignon. The punc-
ture is made close to the left sternal border
in the fifth or sixth space.
♦Presented to the Tri-State Medical Association of the Carolinas and Virginia meeting at
(Jreensboro, N. C, February 19-21, 1929,
July, 1929
SOUTHERN MEDICINE AND SURGERY
469
The right parasternal method was proposed
by Rotch. It is designed to reach the fluid
at the right of the sternum in the cardio-
hepat!c angle, where it accumulates as soon
as it is present in any quantity. The punc-
ture is made at the inner end of the fifth
right intercostal space.
The epigastric method, devised more than
a century ago by Larrey, was followed by
Jaboulay in 1899: then by Cyril Ogle and
his colleagues in the London hospitals. It
has been perfected recently by Marfan. The
technique is given by Blechmann as follows:
Th3 patient being seated half-upright in
bed, a local anesthetic is applied to the epi-
gastric region. Then the tip of the ensiform
cartilage, which is the guiding mark, is lo-
cated with the end of the left index finger.
The small trocar of Potain's apparatus or a
lumbar puncture needle is inserted immedi-
ately below the ensiform cartilage in the me-
dian line. The needle is directed obliquely
upward and in the first steps of the operation
it grazes the posterior surface of the ensiform
cartilage for a distance of about '4 inch (2
centimeters). In this way one is sure to
keep half-a-finger breadth from the perito-
neum which is soon reflected to the arch of
diaphragm. After a variable course and after
having traversed the subperitoneal cellular
tissue, we pass through the muscular hiatus
left between the sternal insertions of the dia-
phragm. Since the base of the pericardium
is attached to the conve.xity of the diaphragm
over an area that varies from 3yS to 4J-^
inches (9 to 11 centimeters) in the trans-
verse direction and from 2 to 2 '4 inches (5
to 6 centimeters) in the anteroposterior di-
rection after passing through the muscular
hiatus, the needle necessarily penetrates the
cavity of the pericardium and, since this
area corresponds to the lowest part of the
sac, it will almost surely meet any fluid that
is present there. Exceptionally, in posterior
pericarditis, puncture may have to be per-
formed in the seventh space at the back.
What are the advantages and disadvan-
tages of these different methods?
The left parasternal method is not to be
recommended, for it is very complicated and
gives no guaranty against wounding the pleu-
ral sinuses.
The right parasternal method of Rotch is
defensible at least theoretically for, according
tg the studies of this author, it seems indeed
that the fluid accumulates at first in the car-
diohepatic angle; but in practice one is never
sure that the dullness found at this pwint is
not due to dilation of the right heart, and, in
this uncertaintly, it is better to refrain.
There are the left extramammary and the
epigastric methods. The first has been the
object of unreasonable criticism by Blech-
mann, who objects to it as offering the maxi-
mum of danger and the minimum of advan-
tage. He says, "If, by lucky chance, one
avoids puncturing the heart, he will almost
certainly perforate the pleura, which one
wishes to avoid." Now this is not so certain.
The accumulation of fluid by pushing the
pleural sacs outward protects them from the
needle and, since the heart floats on the sur-
face of the fluid, a puncture made about half-
an-inch ( 1 centimeter) above the lower bor-
der of the dullness scarcely risks wounding
it. It is, therefore, to be recommended as an
exploratory operation to ascertain that there
is fluid in the pericardium.
Epigastric puncture is the surest way to
reach the effusion and to avoid wounding the
mammary arteries and the pleura but if, con-
trary to expectation, there should be no fluid,
we should hesitate to puncture in the neigh-
borhood of the right cavities of the heart and
to risk wounding them in a particularly dan-
gerous spot. Therefore, by preliminary punc-
ture in the left intercostal space, we should
assure ourselves of the presence of fluid in
the pericardium. If the result is positive,
there need be no more hesitation; the fluid
should be evacuated by the epigastric route.
This method has been employed successfully
several times by Marfan, A. Robin, Noel
Fiessinger and Chauffard.
Pericardotomy is preferred by the sur-
geons, who raise the objections to puncture
that it does not prevent the reproduction of
the fluid and that it is ineffectual in circum-
scr bed effusion. In our opinion, puncture
remains nevertheless the method of choice for
rheumatic or serofibrinous pericarditis for, if
the effusion is circumscribed, pericardotomy
will do no more and, if it is not, puncture will
be sufficient. This is not true of acute pu-
rulent pericarditis and tuberculous cold ab-
scesses of the pericardium. Here incision is
imperative. An adequate exposure of the
pericardium is desirable in all ojierative pro-
cedures.
Many lines of attack have been suggested;
SOUTHERN MEDICINE AND SURGERY
July, 1929
some may be mentioned only to condemn
them. Trephining of the sternum is unnec-
essary, does not furnish an adequate exposure
and its margins are too inflexible. An inci-
sion over the xiphoid angle may involve the
diaphragm, may open the peritoneal cavity,
and should the pus be loculated, of which
there are cases on record, may result in not
bringing the accumulation into a position to
be tapped and drained. Resection of one or
more of the costal cartilages then seems the
only reasonable method of attack. It has all
the good points and fewer of the bad ones
than either of the others. True, there is dan-
ger of opening the pleura, but by careful
dissection this can be successfully guarded
against. Having decided, then, upon this
method of approach, the operative procedure
resolves itself into a few elementary steps.
1. Incise over the fifth or sixth costal
cartilage about two and one-half or three
inches long, curved or straight at the discre-
tion of the operator.
2. Strip back the periosteum from the car-
tilage.
3. Reset the cartilage for adequate expos-
ure and, if necessary
4. Ligate the internal mammary artery
above and below.
5. Retract the pleural overhang.
6. Incise and drain the exposed pericar-
dium through the smallest possible niche,
thus allowing a long time to elapse during
the process of evacuation.
7. Investigate by palpation for any locula-
tions or adhesions.
8. Drain.
The last of these steps is open to discus-
sion. Whether or not the pericardium should
be sutured to the wound edge or the skin for
permanency in drainage will depend upon the
circumstances governing each case. As a rule
this procedure is not practical. Tube drain-
age is objectionable and is not advised. A
rubber dam (rolled) changed daily, may be
used, the result aimed at, of course, being
adequacy of opening, maintenance of the
opening and self-draining facilities of the
wound.
Brooks reports 36 cases of pyo-pericarditis
secondary to osteomyelitis of bone in which
drainage of the pericardium was performed
and in which recovery occurred in only two
instances. The e.\planation of this high mor-
tality probably lies in the delay in operative
interference. For example, in 20 of the 36
cases pericardotomy was performed three to
four or even ten days after fluid in the peri-
cardium had been definitely diagnosed,
whereas in the two cases which recovered,
pericardotomy was performed early and be-
fore the effusion had become purulent.
DANGER OF DELAYED OPERATION
"In the first place, pericardial effusions oc-
curring during the course of osteomyelitis, if
not purulent in the early stages, almost in-
variably become so later on, for, being pyemic
in origin, there are usually coexisting ab-
scesses in the heart muscle. Besides, the dan-
ger of the operation is much less if done
early, for the general resistance of the patient
is then altogether higher. Further, the me-
chanical interference with the heart's action
caused by the fluid will be removed, and
hence the heart and circulation will be in
better condition to deal with the foci of in-
fection. If, on the other hand, the fluid is
allowed to remain until it becomes purulent,
the outer layers of the heart muscle, bathed
in pus, will lose their vitality, with great func-
tional impairment of the whole organ."
"Blind needling of the pericardium in more
than one case has led to puncture of the heart
itself, a dangerous accident; what is more,
it is almost impossible to drain a pericardium
efficiently by needling, because the bulk of
the fluid lies behind the heart in oblique sinus
and is difficult to get at. The heart is thus
pushed forward and is directly in the way
of the exploring needle. Finally, if the peri-
cardium is drained before pus forms, adher-
ent pericardium is a less likely sequel."
The embryological aspect of the pericar-
dium is rather interesting and makes the con-
ception of its pathology comparatively sim-
ple. The pleural and peritoneal cavities are
developed by a budding process from th;
body cavity. Later another budding process
takes place from the pleural membrane or
cavity, which develops into the pericardium.
A bar arises and gradually inserts itself be-
tween the pleural and pericardial sacs, event-
ually separating the two cavities. Hence, we
may safely say that within certain limits the
pathology of the pericardium will be that of
pleura and in all likelihood their diseases with
some modifications will be the same. There
is a divergency in this analogy in one respect.
July, 1920
SOUTHERN MEWCIN6 AND SURGERY
471
The subserous layers of the visceral pleura
have only a few fibrous bands continuing
and becoming a part of the interlobular struc-
tures of the lung, while the visceral pericar-
dium is closely and intimately related to the
intramuscular septi. This proves of great
pathological importance in pericarditis, par-
ticularly of the purulent variety.
As has been previously stated, a delayed
diagnosis makes for a high death rate in the
surgery of purulent pericarditis and to a less
degree in the serous variety. The visceral
pericardium being so thin, so intimately con-
nected with the cardiac muscle, and the sub-
serous coat sending so many fibres into the
intramuscular septa, favors the advance of
any septic process from the pericardial sac,
by direct continuity of tissue, into the intra-
muscular septa and from here leading to an
involvement of the musculature itself. Local
abscesses are then the possibility and, if de-
layed, the probability, in all purulent peri-
carditis. Hence, you have to deal with a
weakened heart muscle in every instance.
This, in itself, forms no mean obstacle to suc-
cessful surgery.
In pericarditis the myocardium is often at-
tacked. Indeed one of the earliest results of
pericarditis is dilatation of the heart. As the
visceral layer of the pericardium sends a
fibrinous meshwork carrying blood and lymph
vessels into the myocardium, the inflamma-
tion is carried into the vascular walls with
every pericarditis: therefore there must be
more or less myocarditis and consequent car-
diac weakness. These inflammatory effects
gain in importance in the presence of an ac-
cumulating effusion which mechanically in-
terferes with cardiac efficiency.
Rfsiimc oj Case:
.\ married woman of 20 years already sick
for two weeks, still has broncho-pneumonia
of ape.x and left lower lobe; developed mark-
ed e.xtension dullness over heart area, heart
sounds feeble and distant and tend to become
more so on inspiration, pulse 106; sent to
Charlotte Sanatorium by Drs. Lienbach and
McLesky, October 9, 1928, when x-ray
showed large water-bottle pericardial shadow.
Shadow in upper two-thirds of left lower
lobe; patient definitely embarrassed in
breathing and quite sick. W. B. C. 20,800,
polys. 87.
October 10, 1928, left pericardial puncture
in fourth interspace, 480 c.c. of turbid fluid
aspirated, rise of temperature following and
left breast became tender.
October 24, 1928, a pericardotomy was
done along the lines indicated in the body of
this paper. At this time 620 c.c. of thick
purulent fluid was evacuated and aspirated.
On dissecting back the left breast an abscess
was found beneath the fascia, result of punc-
ture 14 days previously and likely giving rise
to temperature elevation at that time. On-
November 28, 1928, the .x-ray findings were
as follows:
There is still very marked congestion
throughout the left lung, but this is improv-
ed over previous examination. There is still
marked expansion of this entire lung. The
mediastinal structures are drawn over to the
left side. The pericardium is not distended
with fluid at this time. On December 6th
the patient made her exodus with final diag-
nosis:
(1) Pneumonia, (2) suppurative pericardi-
tis, (3) chronic passive congestion of liver,
etc.
Recall that this patient bore pneumonia, a
pericarditis, becoming purulent, a heart weak-
ened from accumulated fluid and most likely
a myocarditis from extension of infection into
the heart muscle with chronic passive con-
gestion as a result. While the pericardium
drained to a small amount of almost serous
discharge, the pneumonia never quite resolv-
ed. Now and finally the question? What
would have been the result of earlier peri-
cardotomy not only for the more complete
relief of intrapericardial pressure against the
heart, but chances of extension of infection
into the myocardium? With a more efficient
heart her fight against the pneumonia would
have undoubtedly been more effective and the
passive congestion of intraal)doniinal organs
avoided. The answer to these questions is
l.kely given by the cases cited by Brooks
and other advocates of early pericardotomy.
— 210 Professional Building.
472
SOUTHERN MEDICINE AND SURGERY
July, 1929
On the Technique of Thyroidectomy*
Hubert A. Royster, A.B., M.D., F.A.C.S., Raleigh
Since my part on this program is limited
to a discussion of the operative methods in
the management of goitre, I shall omit all
consideration of other forms of treatment.
ANESTHESIA
The question of anesthesia naturally comes
up first. Each surgeon has his preferences in
the choice of an anesthetic. Some still use
ether; many continue to employ nitrous o.xide
or are beginning to substitute ethylene; a
few seem pleased with oil-ether in the colon.
The large majority, I find, are operating on
goitres under local anesthesia, and depending
on it more and more. In only one instance
in the past five years has it been necessary
in our own work to supplement local with
general anesthesia — a small amount of nitrous
oxide gas toward the close of the operation.
The advantages of local anesthesia are: It
reduces the risk of bronchitis, pneumonia and
other respiratory affections; it prevents pro-
longed vomiting; it permits control of the
recurrent laryngeal nerve and trachea during
operation; it allows early ingestion of food;
it does away with danger to the heart's ac-
tion. As in other fields of surgery, local an-
esthesia— here for a stronger reason — presup-
poses a proper temperament in the surgeon
and a favorable reaction in the patient. These
attributes usually overcome whatever disad-
vantages there may be. A preliminary injec-
tion of morphine with atropine or hyoscine
should be given.
In general there are four methods of in-
troducing the local anesthetic:
1. The subcutaneous and subfascial; infil-
tration of the anesthetic solution in and un-
der the skin along the line of incision and
below the deep fascia and muscles in the
area of operation. 2. Nerve-trunk injection;
first at the middle of the sternomastoid mus-
cle and then through the same needle in a
radiative direction from that point. 3. The
paravertebral; a deep injection of the spinal
nerve roots as practiced in so-called regional
anesthesia. 4. Infiltration of the perithyroid
space in ring fashion, all around, superficial
and deep. There are many modifications of
these methods and every experienced operator
has a way of his own, which he may — and
will, if he is wise — vary to suit his patient
and himself.
INCISION
By common consent the "collar" incision —
the incision en cravatte — ^is universally em-
ployed. True, now and then other incisions
may be indicated, but since ligations have
been largely given up and unilateral lobecto-
mies are rarely done, seldom do we see criss-
cross or longitudinal incisions. The placing
of the incision across the neck is important.
If too high, it will be difficult to expose the
lower portion of the gland: if too low, the
flap will be too long and ugly adhesive tug-
ging will result. There is no particular line
which can be pointed out; much depends
upon the shape and size of the gland. I
always insist upon dissecting downward the
lower flap to the base of the neck just as we
carry the upper flap up to the cricoid car-
tilage. Also I still believe in the slightly
curved incision with convexity downward, in
spite of the fact that many of the best sur-
geons advocate the straight line. In Fig. 1
is shown a suggestion of Lahey's which great-
ly facilitates lifting the flaps.
Let me say here that in my judgment trans-
verse section of the ribbon muscles of the
neck should not be done as a routine proce-
dure. In many instances it is not necessary,
and the operation may even be done more
easily without it. I was almost on the verge
of saying that cutting across the recti abdom-
inis for aid in the removal of a pelvic tumor
would be analogous. There is some reason
for comparing a thyroidectomy with a hyster-
ectomy— incision, delivery of the tumor, se-
curing the main vessels, stripping off the mem-
•Presented to the Section on Surgery Medical Society of the State of North Carolina, Greensboro,
April 16, 1929.
i
July, 1929
SOUTHERN MEDICINE AND SURGERV
473
Fig. I
Showing incision made through skin but not to sub-
cutaneous fat. Platysma raised by blunt scissors
without damage to the large veins on anterior mus-
cles of neck. !n most of the cases incision penetrates
only half way through skin and does not show sub-
cutaneous fat as shown in illustration.
(After Lahey)
brane (peritoneum, posterior capsule), leav-
ing the ovaries (compare the parathyroids)
and avoiding the ureters (suggesting the re-
current nerves). Some surgeons immediately
apply forceps and sever the muscles on each
side of the neck without any attempt to de-
termine the size, mobility or shape of the
thyroid lobes. Curiously enough, in many
instances the larger the goitre the less the
need for cutting the muscles, for that they
are flattened and thinned-out by pressure and
so are easily stretched over the protruding
gland. The difficulties of thyroid surgery are
by no means confined to the very large
goitres; sometimes quite the reverse is true.
TYPES OF REMOVAL
Within the past five or six years consider-
able change has taken place in our specific
methods of dealing with the goitrous gland
at operation. .Modes of approach, handling
of the structure, the amount to be removed,
the details of technique — all have changed
[ more or less, and it may be said in the direc-
I tion of improvement. \\ the hands of various
• surgeons in many [jlaces there is an increas-
' ing intelligence and a more direct form of
j action in thyroid surgery. Far more experi-
ence, however, is needed on the part of many
before a conscientious attack can be consist-
ently made upon a goitre with the same com-
fort and ease as upon a tumor in certain
other regions of the human body. Until that
time arrives, as a result of training and cul-
tivated judgment, the hand should be stayed.
Three types of removal of the thyroid are
in vogue:
1. Hemithyroidectomy — or lobectomy, the
removal of one lobe. This is less popular
than it was formerly — and for reasons; it
leaves an asymmetrical neck, results in many
secondary operations for taking out the op-
posite lobe. Occasionally this method is indi-
cated, when one lobe is very large and the
other atrophied. But even here the remain-
ing lobe may take on active growth when the
pressure is released.
2. Enucleation — the shelling out of a sin-
gle nodule or of a cyst. This may be de-
manded on one side or both — a well recog-
nized procedure. One must be sure that the
enucleated mass contains all the pathological
material, or else a different type of removal
is indicated.
3. Resection-enucletion — the method of
choice in the large majority of thyroidecto-
mies and the principle of which is employed
in one form or another by most surgeons to-
day. It implies the excision of a wedge-
shaped portion of both lobes, well away from
the trachea on one side and the posterior
capsule on the other, avoiding the very ap-
pearance of the recurrent laryngeal nerves
and the parathyroid nodes. The approach
can be made from above, from below, or from
either side of the lobe. No set program
should be followed because in the individual
case it might be expedient to begin at one
point or another, according to the ease of
manipulation. Usually it will be found com-
forting to clamp or tie the superior thyroid
vessels first, for in that region the posterior
capsule can be more readily identil'ied and
separated from the gland from above down-
ward, both on its inner and outer aspects.
Notable authorities, however, insist that it is
better to secure the inferior thyroid vessels
first, working upward and inward. Whatever
procedure is followed should suggest itself
when the gland is ex|X)sed to view, making
certain at the outset to occlude the main blood
supply before proceeding to place additional
474
SOUTHERN MEDICINE AND SURGERY
July, 1920
clamps on the lateral surface of the posterior
capsule as far down as may be indicated.
The use of as few clamps as f)ossible is to
be encouraged; a heavy load of hardware on
the neck is not conducive to the patient's
comfort, nor does it leave much room for the
surgeon's manipulations. The same proce-
dure is carried out on each side. The portion
of each lobe to be left nestles deeply along-
side the trachea in the trench occupied by
the recurrent nerve beyond which there should
be no trespassing. The thyroid isthmus is
not to be stripped off the trachea or removed
at all, unless it is involved in the pathologi-
cal process, in other words a part of the
goitre. If it is large enough to constitute a
deformity afterward, it must be resected. But
never should it be necessary to peel the
trachea clean or even e.xpose it barely. Too
clean a removal is likely to result in collapse
of the trachea, disturbance of circulation in
its mucous membrane or the leaving of an
unsightly depression. The typical resection-
enucleation operation, according to de Quer-
vain, is depicted in Figs. 2, 3 and 4.
Fig. Ill
Right lobe briUKht outside the wound and resected
by "melon-slice" method.
(From de Quervain)
I
Fig. II
Lobe delivered. True capsule incised, posterior sur-
lace being prc-ierved (dangerous zone).
i.ifler de Quervain)
DRAINAGE
In some cases the wound may properly be
closed without drainage. Most always,
though, there is a considerable oozing of blood
or serum which should be allowed to escape.
A perfectly dry wound is difficult to obtain.
Fig. IV
Typical resection — enucleation.
(From de Quervain)
Remnants of gland tissue left behind will ex-
ude and very small blood vessels may con-
tinue to discharge even after careful hemos-
tasis. No suturing of the thyroid stumps
need be done e.xcept to stop the bleeding
which cannot be controlled in any other way,
but, after ligating the areas holding clamps,
the capsule may be brought together or sewed
over to the thyroid tissue; often the inner
July, 1929
SOUTHERN MEDICINE AND SURGERY
47S
flat muscles can be sutured down upon it.
When all this is done a thin strip of rubber
dam is passed from each cavity formerly
occupied by a lobe out through the middle of
the skin wound. I have tried many other
forms of material for drains, and have had
most satisfaction from the rubber strips.
These must not be removed too soon. After
forty-eight hours they should be pulled out
one inch and then every other day thereafter
until none remains. The guarding safety pin
ought to be placed before cutting off the
drain beyond it, or the rubber tissue may be
lost in the neck. Once I had this to hapfjen
— and it was troublesome fishing to get it
out. If it is considered proper to remove the
drainage strips entirely on the second day,
or if, indeed, they slip out of themselves, one
may wait for the bulging of serum under the
skin and provide for its exit by introducing a
grooved director through the opening. In
fact this may be done as a routine practice
instead of the gradual removal of the drain;
but the patient generally enjoys it less. Ab-
sorption of wound products also is rapid and
abrupt, producing a more pronounced reac-
tionary rise of temperature, when drainage is
checked early. This drain detail is a question
of judgment founded on experience. It has
been said that a really good surgeon is one
who knows when to put in a drain and — of
equal imp(jrtance — when to take it out.
CLOSURE OF THE INCISION
I have never receded from my pristine prac-
tice of using a subcuticular suture of tine cat-
gut for closing the skin incision. It is simple
to put in, it is less likely to produce infection,
it leaves nothing to be removed, it makes the
neatest scar, present and remote. Other
kinds of suture are used by various surgeons
and, no doubt, with utmost satisfaction to
themselves. I have seen many different
methods and materials employed, but none
of them has caused me to alter my adherence
to the absorbable subcuticular stitch. Mini-
mum scarring should be the tinal goal. An
unsightly neck, even in spite of beads, is a
drawback to thyroid surgery, because it may
prevent some patients from submitting to a
necessary operation. The worst-looking scars
I have seen were from the use of metal clips,
said by their proponents to result from leav-
ing them on too long; and yet I observed
two incisions to split apart when the clips
were removed according to rule on the second
day. Perhaps, as with many events, the fault,
if any, may be with the man and not the
method.
AMOUNT OF THYROID TISSUE TO BE REMOVED
The question of how much of the thyroid
gland may safely be removed and how much
retained at operation has been discussed over
and over again. No mathematical reply can
be made. The nearest approach has been the
general estimate that three-fourths of the
gland may be taken away without producing
hypothyroidism. Modifications must be made
to tally with the extent of disease manifested
in the gland and the symptoms presented by
the patient. It is held that the more path-
ologic the gland the more sparing we should
be with it; while the more toxemia the more
of the gland should be removed. Nothing in
surgery is more dependent upon the individ-
ual operator's judgment than the decision of
this matter. Certainly in the earlier days
much too little of the gland was removed,
and even at this time the tendency to err is
on the side of leaving more than is needful.
There is much less danger of a hypo-state
from taking away the major portion of the
thyroid than there is of leaving behind a
part of a lobe which may regenerate and
give recurring symptoms or constitute an
obvious deformity. In rare instances the re-
maining tissue may undergo regeneration,
even when a maximum removal had been
done {Fif;. -').
PITFALLS AND ACCIDENTS
There are three preliminary measures
which, if carried out in detail and as a regu-
lar rule, may prevent or reduce the number
of accidents that may befall the most experi-
enced operator. These are: intelligent palpa-
tion, expert laryngoscopy, and careful radiog-
raphy. Palpation of the goitre is best per-
formed by standing behind the patient and
pressing, not with the lingers on both sides
at once, but first to one side rather forcibly
and then to the other. The relative size and
direction of the lobes can be grossly deter-
mined. From my records, when there was a
difference in size, the right lobe was larger
in 80 per cent of the patients. Internal ex-
amination of the larynx enables the surgeon
to know the condition of the vocal cords be-
SOUTHERN MEDICINE AND SURGERY
July, 1920
Fig. V
Excision of lobe with ligation of isthmus, showing
average amount of gland that may be left.
(From de Quervam)
fore operation — a very important matter when
post-operative laryngeal complications arise..
X-ray films give generally a good idea of the
position of the gland chiefly in its relation
to the trachea. Trouble may, be averted by
knowing beforehand whether the windpipe is
displaced laterally or angulated in the antero-
posterior direction; whether the goitrous
gland surrounds the trachea or is growing
downward into the thora.x. Knowledge of
these matters beforehand has forestalled many
mistakes, while the lack of it has led the un-
wary into pitfalls.
The common accidents which may happen
to any operator are injuries to the trachea,
the recurrent laryngeal nerve, and the para-
thyroid glands. The trachea may be sub-
jected to unusual trauma in manipulation, it
may be opened by mistake, or it may suffer
collapse. The latter is by far the most se-
rious accident of the three, requiring an im-
mediate tracheotomy for saving life. In any
case efforts should be directed toward the pre-
vention of aspiration of blood into the open-
ing and the edges of the tracheal rings su-
tured, if cut or torn. Some mode of vapor
inhalation is to be installed in the after treat-
ment. The best way to avoid injury to the
recurrent nerve is not to look for it, on the
ground that "what you don't know won't hurt
you." All forceps should be applied during
operation in a direction parallel to the trachea
— not at a right angle to it. Keeping out of
the tracheal trench is safe, but one must also
be careful not to injure the nerve high up
near the thyroid cartilage. Staying inside
the posterior capsule is the sure way not to
injure the parathyroid bodies.
Fig. 6 represents the only case of my series
Fig. VI
Huge colloid goiter, removal of which in
followed by tetany.
{Author's case)
Fig. VII
Large adenomatous thyroid, complicatea by ptosis
of left, upper eyelid.
(Author's case, June, 1911)
July. 1020
SOUTHERN MEDICINE AND SURGERY
in which tetany fdllowed thyroidectomy. It
was a very large goitre, operated on twenty-
two years ago, before attention had been
drawn to the importance of preserving the
posterior capsule. The patient was treated
with calcium lactate and recovered.
A curious freak case is illustrated in F/',?. 7.
Th? patient had a large non-to.\ic adenoma-
tous thyroid and a ptosis of the left upper
eye-lid, accompanied by intense pain. No
possible connection between this phenomenon
and the thyroid enlargement could be estab-
lished, but one week after the thyroidectomy
the ptosis had entirely disappeared and the
pain was all but gone.
Case Reports
Pneumococcic Meningitis Treated With
Optochin (Xeumoquin Base) With
Complete Recovery
M. .X. Lackey, M.D., Mooresville
Lowrance Hospital
On February 29, 1929, I was called out
about five m'les in the country to see a 21-
\ear-old white man, who was complaining of
severe frontal headaches.
The family history was negative and per-
fonal history negative except for influenza in
1925. H's health had been generally good.
Present illness began on February 28th,
with severe frontal headaches and occasional
vomiting.
Upon examination considerable tenderness
was elicited over the frontal region. The
pulse was 80, respiration 20 and tempera-
ture 102.2. Lungs, heart, kidneys and abdo-
men were negative.
The next day (March 1st) I brought him
to the hospital and washed out the frontal
S'nuses which were negative for pus. Ears
were negative. He had a slight diplopia;
otherwise the eyes were negative. Blood
count showed a leucocytosis of 17,000, 80
per cent polys. He was very nervous and
required morphine every four hours for the
relief of pain. Even the morphine did not
put him entirely at rest. Was irrational at
t'mes. Temperature at this time was rang-
ing from 97.3 to 104.2. On the third day
he developed paralysis of the external rectus
muscle of the left eye. Pulse was down to
48.
On the fourth day we decided to take him
to Baltimore. While on the way considerable
rigidity of the back and in the neck devel-
oped showing very pronounced meningeal in-
volvement. In Baltimore a spinal puncture
showed the fluid cloudy, under pressure and
a cell count of 4,000 and numerous intra-
cellular cocci present. The organism was
typed by Dr. Amos, of Johns Hopkins Hos-
pital, and proved to be pneumococcus, typ>e
2, after which a very unfavorable prognosis
was given.
Due to the fact that practically no hope
was held out for his recovery his father de-
cided to bring him home. He arrived home
in miserable condition, very rigid, running a
very septic temperature and pulse ranging
from 50 to 60, eyes red, swollen and bulg-
ing, and practically blind. The optic discs
were slightly swollen.
I started him on optochin (numoquin base)
at eleven o'clock that night, giving him two
tablets every five hours orally with five
ounces of milk. I was out to see him the
next morning after the third dose and he
showed some improvement. The second day
his rigidity had so lessened that he could
raise himself in bed, and turn his head to
expectorate. After taking fifteen doses he
was able to sit up and take all the nourish-
ment he was allowed and still complained
of being hungry. I stopped the treatment
at this time. Blood count was 14,000, tem-
perature normal.
On the tenth day after beginning the treat-
ment he was able to come to the hospital for
treatment. He was feeling fine althou jh the
leucocytes had gone up to 32,000; however,
he had no treatment for nearly seven days.
I gave him eight more doses optochin after
which the leucocytes were down to 10,000.
He has had no further treatment and has
steadily improved, gaining five pounds in one
week.
.After starting the optochin no further mor-
phine was required for the relief of pain,
SOUTHERN MEDICINE AND SURGERY
July, 1P:9
On the third day after starting the treat-
ment his pulse was up to 72, sixth day 80,
eighth day 90, after which it began to slow
down until in a short time it was normal.
About the middle of April he went back to
his job in a cotton mill. Since that time
he has had no further symptoms. The pa-
ralysis of the external rectus muscle of the
left eye remains; however, it has improved.
Vision is good and no diplopia.
The results were so remarkable and so
rapid that I can ascribe it to no other cause
than the treatment administered. The red-
ness, swelling and bulging of the eyes disap-
peared so rapidly after starting the treat-
ment that there can be no doubt that the
organism was destroyed.
Acute Intestinal Obstruction Due to
Meckel's Diverticulum
James W. Davis, M.D., F.A.C.S., Statesville, N. C.
Davis Hospital
A man of fifty-six, more than six feet in
height and weighing 280 pounds, was ad-
mitted to Davis Hospital on February 20,
1929, complaining of pain in the abdomen.
He stated that since he was a small boy
he had suffered attacks of pain in the abdo-
men but that these had never been severe
until fifteen or sixteen years ago when he had
a series of attacks of acute intestinal obstruc-
tion lasting from one hour to one day. These
attacks were ushered in by an acute attack
of pain in the abdomen which was colic-like
and very severe. During some of the attacks
the pain was excruciating. The treatment
that was usually given was a hypodermic of
morphine and enemas. This usually relieved
the trouble although sometimes the enemas
would have to be repeated several times be-
fore relief was obtained.
Fifteen years ago patient entered a Balti-
more hospital for treatment and there had
the appendix removed through a IMcBurney
incision. Following this he made a good re-
covery, returned home and was all right until
thirty days later when he had another attack
of acute intestinal obstruction just like the
ones he had before the appendix was re-
moved. This attack was relieved by a hypo-
dermic of morphine and enemas. Following
this there was no further trouble to amount
to anything except slight attacks of abdom-
inal pain which were not sufficient to give
him any concern until the day of his admis-
sion to the hospital.
On admission the patient's temperature
and pulse were normal, W. B. C. 12,000, 59
per cent polymorphonuclears, blood urea nor-
mal. He was given enemas which produced
free bowel movements and this apparently
relieved the pain and the patient left the hos-
pital next morning. That night, however, he
returned complaining of pain in the abdo-
men more severe than the attack the day be-
fore. .An enema was given which gave good
results and much relief. The next morning
the patient felt well but remained in the hos-
pital. About noon the pain returned with
greater intensity than ever before. Patient
was nauseated and vomited. The pain be-
came excruciating. There was no distention
of the abdomen. The bowels did not move
following enemas. W. B. C. 7,300, polymor-
phonuclears 50 per cent, blood urea 15.
A diagnosis of intestinal obstruction was
made and immediate operation was advised.
intestine by the diverticulum.
Drawing showing obstruction of a loop of small
On opening the abdomen a Meckel's diver-
ticulum was found adherent to the mesen-
tery of the small intestine and forming a
small opening through which a coil of small
intestine had passed producing an intestinal
obstruction. This was immediately relieved,
July, 1020
SOUTHERN MEDICINE AND SURGERY
the diverticulum removed and the abdomen
closed. The patient made a rapid and un-
eventful recovery.
Discussion: This case is very interesting.
The past history of trouble indicated more
than appendicitis. The fact that a recurrence
of the attacks followed the removal of the
appendix confirmed this.
That the obstruction was not due to ad-
hesions was likely because similar attacks
had occurred before the operation. It is not
uncommon for a Meckel's diverticulum to
cause adhes'ons in anv one of a number of
ways. The temperature, pulse and blood
count being a little low indicated that the
trouble was probably not due to an acute in-
flammatory condition. It was evident that
there was an intestinal obstruction due to
some cause or other and treatment in any
event was the same — immediate operation.
The fact that the blood urea was not abnor-
mally high indicated that the obstruction was
either not complete or had existed only a
very short while. A complete intestinal ob-
struction usually produces a high urea in a
verv short while.
I
SOUTHERN MEDICINE AND SURGERY
July, 1929
The Mutual Dependency of Dentistry and Medicine With an
Argument for Amalgamation*, **
James M. Northington, M.D., Charlotte
Mr. President and Gentlemen of the Society:
I don't know why your Secretary did me
the honor to invite me to appear before you.
You well know, though, that he is a highly
efficient officer, so I shall not dare question
his judgment.
Certainly there is little I could say on the
mutual dependence of the professions of den-
tistry and medicine, and the duty of both to
their mutual dependents — ailing human be-
ings— not already known to most of you; I
shall venture only to hope to remind you of
some of the things which, although known
to you, are perhaps not actively in your mind,
being, so to speak, laid on shelves of your
mental storehouses.
What I shall have to say on matters pe-
culiarly in the province of your specialty
must be prefaced by the statement that no
claim is made that these are original observa-
tions, that the facts have been established
and the theories advanced by men eminent
in yonr profession and mine, and that they
represent, so far as I can gather, the best
thought of today. The scope is so broad
that, to attempt to give credit to each would
be tedious, if not, indeed, futile.
Most likely the most available common
meeting-ground is afforded by the subjects
of dental decay and pyorrhea, and these sub-
jects seem to afford the best illustrations for
our problem; so these will be considered in
a sketchy manner as a basis for the sugges-
tions which are to follow, because they both
seriously concern every practitioner of the
healing art and every man, woman and child
on whom we practice.
For our purposes we will assume it to be
accepted that dental decay is the disintegra-
tion of the hard substance of the teeth by
acids produced largely by fermentation of
carbohydrates, these acids acting under fa-
vorable conditions brought about by many
factors, important among which are local bac-
terial infection and metabolic deficiencies.
This seems sufficiently far to go to show that
the idea commonly held by patients and med-
ical doctors that a clean tooth will not de-
cay is erroneous. It is also well to empha-
size that carbohydrate foods are the only
ones which can produce acid in sufficient con-
centration to cause tooth decay, that wheat
derivaties — perhaps from their excess of
gluten — are the worst offenders, that action
of bacteria which thrive in an already acid
medium decompose these residues of these
carbohydrate foods to produce more acid,
and that the process of decay is much fa-
vored by a deficiency of available calcium.
From the foregoing it would appear that
the prevention of dental decay must come
largely through the provision of a proper diet,
local measures playing a minor role. All
these things we physicians need to have you
dentists teach us that we may teach our pa-
tients.
In recent years pyorrhea has attracted
much attention through the propaganda of
the manufacturers of tooth-brushes and
pastes, much of it being misinformation, some
leading to disaster. Most of the members
of your profession and some of the members
of mine have done much to spread education
in the truth on this subject, but we have
been able to do comparatively little to com-
bat the influence of nation-wide commercial
advertising campaigns. We know that a per-
son may take the greatest care of his teeth
and still have pyorrhea and that many who
rarely give a thought to their teeth escape it.
The need is for oral prophylaxis including
the care of teeth, gums, jaws, adjacent or-
gans— and of the general state of the patient
as a whole. Even then it is often a long and
tedious, but by no means a hopeless, task.
An individual may have dental decay with-
out pyorrhea; he may have pyorrhea with-
out dental decay; the two frequently co-
exist. In the course of either or both, remote
complications may arise which demand at-
*Presented bv Invitation to the North Carolina Dental Society, meeting at Wrightsville Beach,
June 10th-12th, 1929.
♦♦Published jointly in Pentai Cosmos and Southern Medicine & Surgery.
July, 1929
SOUTHERN MEDICINE AND SURGERY
481
tention from the general medical man or
specialists in other fields. One need hardly
mention serious lesions of joints, eye, nerve,
heart, or so widespread an affection as per-
nicious anemia, as having been shown to have
had their origin in, or been aggravated by,
infection in the tooth sockets. This brings
us to a consideration of the necessity, if the
patient's best interests are to be served, of
the closest collaboration between the family
doctor and all the medical and surgical spe-
cialists. We are all agreed on this. I shall
offer a means for accomplishing this end.
As a distinct vocation dentistry is first
alluded to by Herodotus (500 B. C.) There
are evidences that earlier Egyptians and
Babylonians replaced lost teeth with wood
and ivory substitutes. Early gold "fillings"
were ornaments. In the 10th century A. D.
crowns were attached to adjacent sound
teeth. John Hunter devoted much attention
to transplanting sound teeth.
All are familiar with the monumental work
of Fanchard (1728) and his noteworthy state-
ment that, "most celebrated surgeons aban-
doned this branch. It was only since 1700
that the intelligent in Paris opened their eyes
to these abuses, when it was provided that
those who intended to practice dental sur-
gery should submit to an examination by
men learned in all the branches of medical
science." In the winter of 1781-2 Joseph
Lemaire, a French dentist who came over
with the army of the Count de Rochambeau,
found time to instruct Joseph Flagge, prob-
ably the first American dentist. In Novem-
ber, 1840, the Baltimore College of Dental
Surgery, the first in the world, was established
after those desiring to provide dental educa-
tion had been snubbed by local medical col-
lege authorities. In England and on the Con-
tinent Dentistry is now a Department of
Medicine in the universities.
It can scarcely be doubted that if our
early teachers of general medicine and sur-
gery had had the same broad conception of
the relation of oral pathology to general
pathology as had their contemporaries in oral
surgery, what we now know as the separate
profession of dentistry would be a specialty
of general medicine and surgery exactly as
orthopedics or ophthalmology. Who can
say how much all of us, as doctors and as
patients, have lost because of this short-
sighted policy of our ancestors in medicine?
The passage of nearly 100 years has made
what was plain to your professional ances-
tors in 1840, fairly plain to us medical men
of today. Each addition to our stock of
knowledge of etiology, pathology and therapy
makes it plainer and plainer that gross and
serious errors arise every day from assuming
that the disease process is where the patient
feels his pain, that local pain and disability
frequently mean systemic infection from
some obscure process in a remote area, and
that the broadest possible training in general
medicine provides none too broad a founda-
tion for any healing specialty.
This is primarily in the interest of the pa-
tient, that he suffers no unnecessary pain,
disability, risk or expense. There is much
to be said for it, too, from the viewpoint of
self-preservation; and here, as elsewhere, the
two professions may well make joint cause.
The dentist and the physician viewing the
encroachment of governmental authority on
their fields of practice — their means of liveli-
hood— and knowing how strong is the ten-
dency to demand "more, more," will be wise
to consider seriously and take steps to put
proper limitations on all forms of health
service provided by taxation. Then, all will
agree that no one should suffer for lack of
dental or medical attention because he can
not pay for attention. All will agree, too,
that no one should suffer for lack of food or
fuel because he can not pay; but no one ex-
pects the grocer to feed, or the coal mer-
chant to warm, the poor without pay — in
their cases the community, through taxation
largely, is expected to provide the funds.
Doctors of all varieties support associated
charities and like organizations through taxa-
tion and voluntary subscription; why should
doctors be expected to contribute services?
Why should their services to the needy not
be paid for from such funds just as are the
wares of a merchant or the services of a
plumber? The united strength of the dent-
ists and medical doctors of North Carolina,
if we exerted it, would be sufficient to obtain
relief from these inequitable demands.
Many of us see the amalgamation of den-
tal and medical societies as a certain happen-
ing of the not distant future, and see in it
nothing but good for patients and profes-
sional men. All those practicing the healing
SOUTHERN MEDICINE AND SURGERY
July, 1929
art should be members of County, District,
State and National medical organizationis,
attend the meetinfiss and there continually
learn and relearn of the variousness of the
local manifestations of general diseases, and
of the general and remote symptoms and
complications of what we commonly regard
as local conditions. Of course there would
be organized special societies to meet less fre-
quently to discuss matters especially concern-
ing dentists and their work, just as there are
societies of neurologists, gynecologists and
urologists, all, however, recognizing the gen-
eral medical society as the parent organiza-
tion.
Only a step from professional society amal-
gamation— and an absolutely necessary one
for getting the most out of the plan — is the
use of publications in common. Addresses,
formal essays, clinics, case reports, news
items, new discoveries — all those things pre-
sented at the meetings, with added features
from current world literature coming through
a central editorial office are indispensable.
Added to these — rounding out, systematizing
and applying emphasis where needed — would
be editorial matter dealing with the live ques-
tions of the day having to do with the eco-
nomic and social as well as the professional
aspects of practice, e. g., aro\ising sentiment
and organizing action against threatened
encroachments of quacks of all kinds, and
toward seeing that all doctors are treated
with as much consideration and rewarded as
well for their services by courts and other
agencies of government, as are lawyers.
Change does not at all necessarily mean
progress. Frequently we retrogress; but the
idea is so distasteful that we usually refuse
to admit the fact, so the word which repre-
sents the idea has a strange sound. What a
pity the stand taken 200 years ago, when
■'the intelligent in Paris opened their eyes
and it was provided that those
who intended to practice dental surgery
should submit to an examination in all
branches of medical science, was not main-
tained!"
Gentlemen of the Society, I hope to leave
the ideas with you:
(1) That in view of present-day knowl-
edge and of the e.xtensions of this knowledge
which may be expected, the time has arrived
when in order to do our best for patients
and to satisfy these patients, all those who
treat patients must get a common broad
viewpoint and work together in the closest
harmony and sympathy;
(2) That the extension on all hands of
the work of Boards under various branches
of government — City, County, State, Na-
tional and even International, and of various
philanthropies, constitutes a real menace to
us, and that, insofar as they compete un-
fairly, they should be curbed before they
grow so powerful and we become so weak
that our efforts to maintain our rights will be
vain;
(3) That the members of the reputable
branches of the healing art, united and prop-
erly led, can prevent further licensing of
impostors and stop unlicensed ones from prey-
ing on the public;
and that the way to do these things is:
(1) To put on foot a movement looking
to regarding dentistry as a sp)ecialty of the
practice of medicine of equal rank with any
other surgical specialty, and providing as a
means to this for the same general medical
education for those who would specialize in
oral surgery as for those who are to practice
eye surgery or orthopedic surgery, and
(2) Unite the societies and journals of
dentistry and medicine, participate actively
in the society meetings and read the journals
attentively, with a full consciousness of the
fact that in every case you are dealing not
alone with teeth, gums or jaws, but with a
complete human being; and of the further
fact that you are determined that if your
son wants to follow in your footsteps he shall
have an opportunity to make a living and a
name for himself out of his profession,
without working on salary from any branch
of the Government or at the dictation of any
Board supported by meddlesome and often
misguided charity. The united strength and
vigilance of Doctors of Dentistry and Doc-
tors of Medicine is needed against this threat
of State Medicine which seems world-wide.
In the not distant future Dentistry will be
a Specialty of Medicine, just as is now Ob-
stetrics, Pediatrics or Neurology. Your sons
who wish to become members of the profes-
sion of their fathers will study Medicine and
specialize in Dentistry. It is desirable; it is
essential; it is inevitable — that this should be
so,
July, 1929
SOUTHERN MEDICINE AND SURGERY
The Dental Profession of North Carolina
is as capable a body as any in the Nation for
taking the leadership in this movement and
carrying it to successful completion. You
suffer from no inferiority-complex, and I do
not believe that you will wait for Massachu-
setts, Indiana, North Dakota, or Rhode Is-
land to blaze the way.
I believe the members of your society will
study this problem between this meeting and
the next and that in 1930 the North Carolina
Dental Society will launch a movement which
will hasten the bringing about of these great
objects, a movement which will greatly im-
prove Health Service everywhere by increas-
ing the usefulness of all doctors to their pa-
tients, and carry the name of North Carolina
Dentistry 'round the world.
CORRESPONDENCE
Winston-Salem, July 6th.
My Dear Dr. Northington:
In the current issue of the Journal you
have an abstract of an article on the potas-
sium permanganate treatment of pneumonia,
in which it is stated that the standard solu-
tion of the drug is used. Please tell me what
a standard solution of potassium permangan-
ate is.
I was interested in the article and would
like to try it.
Yours very sincerely,
T. C. REDFERN, M.D.
Standard Permanganate Solution foe
Pneumonia
The "standard solution" of potassium per-
manganate, referred to in an editorial in our
issue for June, is 2 grains of the drug to lyi
pints of sterile water and it is to be admin-
istered warm.
Thanks are expressed to Dr. Thomas C.
Redfern, Winston-Salem, for the inquiry and
for his expression of intention to try out the
treatment.
484
SOUTHERN MEDICINE AND SURGERY
July, 1929
PRESIDENT'S PAGE
Tri-State Medical Association oj the Carolinas and Virginia
—CYRUS THOMPSON
In one of his essays Montaigne relates that
having a dear friend suffering with a pro-
found melancholy, he being of a very viva-
cious temperament, was advised to go and
spend some time with him for his betterment.
This he did with great benefit to his friend,
but after a few weeks of this association
Montaigne noticed that while his friend im-
proved, he himself was approaching his
friend's melancholy condition, and so for his
own sake he was minded to end his visit and
return home. We are all chameleons in a
way and are fashioned by the things that
play upon us. We influence others and others
influence us. I would not like to be an un-
dertaker, though the business seems so profit-
able that it really pays no man to die; and
I would not like to be the superintendent of
an asylum for the care of the insane. I prefer
a normal atmosphere.
To visit an asylum for the insane for a day
now and then would be interesting enough;
but to have daily attendance upon that class
of folks and control of them for years would
not appeal to me though the position were
hedged about by very lucrative considera-
tions.
I have known several such superintendents
in North Carolina: Grissom, Kirby, Murphey
and Faison, 1 recall. Do you remember any
of these good sad-faced men? They were un-
avoidably moulded by their surroundings and
the mental condition of their unfortunate cli-
entele. I was always sorry for these men.
They seemed to like their work and seemed
fitted for it, and I never saw how they could
do any unkindness to their patients or any
wrong to the state in such an atmosphere.
But Dr. Albert .Anderson, superintendent
of the Slate Ht)spital on Di.\ Hill, another of
these serious sad-faced men, my acquaint-
ance and friend for twenty-five years or more,
some months ago was grievously accused and
haled into the courts and has just recently
been let loose froni them. No man was more
shocked and grieved than I by his prosecu-
tion and no man was more pleased than I
that the courts have let him go scot-free of
all his pursuers.
If Anderson had been guilty of any crime
he should have been punished for it. The
prosecution even with acquittal has done both
him and the institution and the state great
injury, and this injury is to be credited to the
account of his prosecutors. The patients have
not been benefited and the prosecution has
made the control of the institution harder for
Dr. Anderson and harder for any other man
after him to go on with. It calls the author-
ity of the head of the institution into question
before inmates that need to be controlled by
an absolutely authoritative head. The mat-
ter of discipline in every institution is a thing
to be maintained; but the courts have acted
justly, wisely and well, and as a citizen of the
state I am right proud of our courts.
This whole matter should have been pre-
sented first to the Board of Directors. The
Board was entitled to the courtesy. If they
had found cause they are honest enough to
have displaced Dr. Anderson and to have
gone to the courts with any serious charges
against him. This would have been doing
things decently and in order. This would
have been the horse-sense mode of procedure,
wise from every point of consideration, though
not very spectacular. Some people there are
who love only the spectacular and care little
for wisdom and welfare. Horse-sense, I said.
"What is horse-sense?" A student at the
University of North Carolina once asked Dr.
Geo. T. Winston when the Doctor had used
the expression several times in his talk. Dr.
Winston immediately replied: "It is that
sort of sense, sir, that an ass does not have."
It is what you and I know as that most un-
common thing, plain common-sense, which is
never displaced by mere smartness nor ever
displayed by a kibitzer,
July, 1920
SdtJTHERN MEDICINE AND SURGERY
48S
PRESIDENT'S PAGE
Medical Society oj the State of North Carolina
—L. A. CROW ELL.
Someone has said that most doctors are
good, some are decidedly bad, while all too
many are indifferent.
Doctors are careless about attending medi-
cal meetings. Some of them who have prac-
ticed medicine for twenty years have never
attended a clinic.
The late Dr. Jacobi of New York once
said that doctors make the same mistake for
twenty years and call it experience.
Most of the trouble with the medical pro-
fession is internal; trouble within the profes-
sion itself. If we have State medicine in
North Carolina, it will come as a result of
the carelessness and indifference of the medi-
cal profession.
Our profession is our greatest asset. We
should lose no opportunity to invest in it.
This investment should consist of both time
and money.
Time is the most precious thing that we
have, and yet many of us are extravagant
and uneconomical in the use of it. No pro-
fessional man has time to engage in street-
corner loafing or association with the crowds
in the market-place. If he does this to the
neglect of his professional reading and study,
he will awake sooner or later to find that he
has suffered irreparably from it. I believe it
was Ruskin who deplored the fact that people
spend their time talking with kitchen maids
and stable boys, when they might, through
the medium of literature, associate and con-
verse with the kings and queens of the earth.
What a change would take place in the medi-
cal profession if every doctor would give un-
stintedly and unsparingly of his time and
energy to professional study and research.
There are times when the best financial in-
vestment you can make is to spend a few
hundred dollars in attending clinics; and
siirh an investment will pay the largest divi-
dends in dollars and cents, to say nothing of
the increase in your capacity for service
wliich should be your greatest reward.
1.J
4S6
SOUTHERN MEDICINE AND SURGERY
July, 1929
Southern Medicine and Sur^er:g
Official Organ of
/Tri-State Medical Association of the Carolinas and Virginia
I Medical Society of tlie State of North Carolina
James M. Northington, M.D., Editor
Jamis K. Hall, M.D
Frani Howard Ricbakdson, M.IJ.
W. M. RoBEY, D.D.S
J. P. Matheson, M.D.
H. L. Sloan, M.D
C. N. Peeler, M.D
F. E. Motley, M.D
V. K. Hart. M.D
F. C. Smith, M.D
The Barret Laboratories
O. L. Miller, M.D
Department Editors
Richmond, Va..
-Black Mountain, N. C.
-Charlotte. N. C.
-Human Behavior
Pediatrics
Dentistry
Charlotte, N. C._
Diseases of the
Eye, Ear, Nose and Throat
Hamilton W. McKay, M.D..
John D. MacRae, M.D
Joseph A. Elliott, M.D
Paul H. Ringer, M.D
Geo. H. Bunch, M.D
Federick R. Taylor. M.D.-
Henry J. Langston, M.D
Chas. R. Robins, M.D
Olin B. Chamberlain, M.D..
Various Authors
.Charlotte, N. C._
_Gastonia, N. C
_Charlotte, N. C._
_Asheville, N. C._
.Charlotte, N. C
_.\sheville, N. C
-Columbia, S. C
-High Point, N. C-
-Danville, Va
-Richmond, Va
-Charleston, S. C._
-Orthopedic Surgery
Urology
Radiology
-Dermatology
Internal Medicine
Surgery
-Periodic Examinations
Obstetrics
Gynecology
-Neurology
Historic Medicine
Dr. Anderson Exonerated
We rejoice that the evidence against Dr.
Albert Anderson, superintendent of the State
Hospital for the Insane at Raleigh, has been
held by a Superior Court judge to be in-
sufficient to put before a jury.
We are confident that ninety-nine out of
every hundred who know anything about the
man or the case are glad that it fell of its own
weakness.
The charges against Dr. Anderson have
been blotted from the books, but not alto-
gether from memory. He has suffered some-
what in reputation and, presumably, much
in pocket.
What lessons of value may be learned from
this case?
The private practice of medicine is more
and more beset with pitfalls which even the
wisest and wariest can hardly avoid. Few
there be that dare practice surgery now with-
out carrying liability insurance. It is no
great rarity for a demand for payment for
medical services or of a hospital bill to be met
with a threat of a suit for malpractice or
neglect; so, it becomes doctors to walk warily
as well as worthily.
Patients afflicted mentally and obliged to
remain under treatment and much restricted
in their movements over long periods are
prone to bring groundless charges against
those under whose control they must be; and
all will agree that patients are more apt to
be displeased with doctors provided by the
state, however good, than with those of their
own selection, however poor.
We hold with the News & Observer that
"when there are charges against any public
official, the proper course to pursue is to bring
them to the attention of the board of directors
of the institution. If, after investigation the
board is satisfied of his innocence, as in this
case, the State should defend the official if a
grand jury should present him."
On the other hand, by the very fact of
having been found to have mental disease,
such patients have been pretty effectually
prevented from effectively testifying for
themselves, even if they are subjected to
grave abuses. We have no doubt certain
patients need exercise and are made healthier
July, 1929
SOUTHERN MEDICINE AND SURGERY
4S»
and happier by doing regular work. We be-
lieve that no serious opposition would be
offered by patients, or any concerned for
their welfare to the employment of suit-
able patients in raising food supplies for
the hospital or other state uses, caring
for the hospital grounds, or other work for
the state, on state property. Evidence that
mental patients in private institutions do
work in the fields of the private institution
is beside the point, for patients do not have
to stay in these private institutions unless
conditions there are satisfactory to them, or to
the relatives or guardians who placed them
there. It is very questionable, too, whether
one employed for his whole time can have
any other time for the prosecution of any pri-
vate business.
The doctors in the employ of the state are
much underpaid. We would like to see the
salaries raised materially, and we stand ready
to join any movement looking to this end
which is launched with any prospect of suc-
cess. Whatever the salary, though, unless
the terms of engagement be on a part-time
basis, it would be wisest and best not to at-
tempt to supplement it by engaging in outside
pursuits.
As a preventive of losses and heart burn-
ings, all doctors, especially all state doctors,
and most especially all state doctors having
in charge patients with mental disease, are
pointed to that certain admonition of the
Sapient Saint:
"Abstain from all appearance of evil."
Some strange significance may attach to
the fact that, of the four Gospels, the only
one to make the observation "for the chil-
dren of this world are in their generation
wiser than the children of light," is the Gos-
pel accredited to Luke, the beloved physician.
Dr. Crane Dissents
Dr. Thurman D. Kitchin's Presidential
Address to the Medical Society of the State
of North Carolina was carried in this jour-
nal's issue for May. We believe that, by
resolution of the Society at its meeting at
Greensboro in April, it was given to the press
and promptly published. Somehow it at-
tracted the attention of Dr. Harry W. Crane
— Ph.D., we believe — professor of abnormal
psychology in the University of North Caro-
lina. Our then President's Address concerned
itself with many subjects, one of which is
the problem of sterilization of the unfit, and
his handling of this subject grieves and hurts
Dr. Crane.
Now Dr. Crane is not a man to be grieved
lightly; nor one whose spirit says "peace!
be still!", when there is to the fore anything
about the sick-in-mind, in esse or in posse.
(Ask Dr. Albert Anderson.) So he writes
a piece for the papers expressing his "regret"
that "such a highly respected citizen" should
have in part used his recent address "to at-
tack the principle of sterilization"; says there
are fallacies in Dr. Kitchin's statements, that
some of his contentions fall flat, some are
beside the issue, and some, as we gather it,
would reflect no credit on "the veriest lay-
man."
Dr. Kitchin doesn't mind being disagreed
with: as a college professor and a doctor
he's used to it. It's the manner of its doing
he doesn't relish. When we read Dr. Crane's
statement that he had been sure of his ground
only two weeks, and Dr. Kitchin's address
was then more than a month old, it does
appear that he would be tolerant of igno-
rance of knowledge which has so recently
become available; for we assume that Dr.
Crane's information has been kept up-to-
the-minute. Certainly in his advocacy of
his two-weeks-old conviction is shown all the
zeal of a recent convert.
We have no quarrel with Doctors of Phil-
osophy. Our respect for the degree is real
and profound. But many incidents have
come under our observation which served to
bring into mind the idea that all those who
are to direct the care of health, physical or
mental, should have the training regularly re-
cjuired for the degree of Doctor of Medicine.
The instance in this discussion which so
clearly brought up this thought is Dr. Crane's
statement: "But Dr. Kitchin is quite in
error in assuming that it is impossible uix)n
the knowledge we have to identify some, or
even most, of these cases. Doctor Kitchin's
general position would be just as tenable as
applied to the ^natter of identifying syphilit-
ies. (Italics ours. — S. M. & S.] Diagnostic
tests for syphilis are by no means infallible;
SOUTHERN MEDICINE AND SORGERV
July, im
but I am sure Doctor Kitchin, or the veriest
laymen, would not on that ground, or on the
ground that we do not already know who
are or who are not syphilitic, say that it is
impossible to determine with our present
knowledge who most of the syphilitics in a
given community are."
Now, syphilis is one of a very small group
of diseases which can be identified positively;
in the vast majority of cases with ihe same
certainty that we know a certain fish to be
a bass, a certain tree a white oak, a certain
insect a house fly — all matters of fact on
which there can be no difference in informed
opinion. We believe Dr. Crane will cheer-
fully admit that, as to a large proportion of
cases of supposed or alleged feeble-minded-
ness, there is room for much difference of
informed opinion.
Returning to the specific question of ster-
ilization: it was not our understanding from
Dr. Kitchin's address that he was opposed
to it; indeed, he said it was a step in the
right direction, but warned against expecting
too much from it. Later he appears to have
lost what little faith he had in it. Both Dr.
Crane and Dr. Kitchin quote eminent men
of broad experience and great, intellectual
ability. It seems to us that Dr. Kitchin has
the greater weight of authority on his side,
at least so far as is quoted. Certainly the
seasoned opinions of Dr. Wm. A. White are
not to be lightly disregarded.
This journal is in general firmly opposed
to drastic measures for any conditions except
those regarded by practically all as very se-
rious indeed, and then only when the remedy
selected is agreed on with a well-nigh unani-
mous voice.
Who can say how many of us are "unfit"
or "asocial" in the opinion of any certain
Board? We wish they would use some
other terms. These are too disquieting.
Private Practice Must Prevail
Many of our best educated and most
thoughtful doctors, seeing the many imperfec-
tions in our present system of seeing after the
health needs of the people, are inclined to
roll an inquiring eye toward State Medicine
— in the sense of the State providing medical
care through taxation after the fashion that
provision is now made for education.
In the event of so entirely unanticipated a
condition as would result from a falling off
of, say, 25 per cent, from our present degree
of satisfactoriness to our patients, we would
admit of the bare possibility of a trial of
state medicine; but we would wager our all
on its breakdown within the year. The rea-
son: Man will choose his doctor, and when
he can not do so conditions promptly become
more unsatisfactory for all parties concerned.
The relation of pupil to teacher is nothing
like so intimate and personal as that of pa-
tient to doctor.
The pupil is under the teacher a few hours
in the day, five days in the week, for seven
to nine months in the year (much time out
for holidays), for from 8 to 12 years. The
patient is under his doctor 24 hours out of
each day from nine months prior to his birth
to the drawing of his last breath.
Moreover, hard fact though it be, we are
most requiring in making personal selection
of those who are to see after "those we love
best, our noble selves."
Then, man wants his doctor when he wants
him — night or day, meal-time or fast-time,
Sunday or Monday — and as frequently as his
discomfort, his fear, his humor, his caprice,
or even his malice prompts him to apply for
attention. In private practice doctors regu-
late this fairly satisfactorily by charging ac-
cording to amount of attention paid the pa-
tient and of inconvenience caused the doctor;
and always recourse can be had by either to
giving the other up. Picture conditions after
a few months of state medicine: every doctor
(or practically every doctor) appointed by
political methods, on salary from the State,
and fearful of having complaint made to the
authorities because he cannot respond imme-
diately and simultaneously to two cells com-
ing in, one at three and the other at three-
three a. m., each caller announcing angrily
and loudly that he pays taxes and he'll have
attention or know why.
In one of our departments, in this issue,
Dr. F. R. Taylor pwints out some grave de-
fects in our present system of caring for the
sick, and makes some suggestions as to means
of remedying. With much of what he recom-
mends we are in complete and enthusiastic
accord; but our conviction is firm that any-
thing gained by the weakening of the indi-
vidualistic practice of medicine will be bought
at too great a cost.
July, 1929
Heresy has no terrors for us; we are con-
strained by considerations of workability.
When human hearts and human minds
have come to be of the quality which would
make state medicine endurable for the house-
to-house doctor, ownership in common will be
working perfectly, and few will be the dis-
eases to slay or other ills to vex.
SOUTHERN MEDICINE AND SURGERY
489
The Ninth District Clinics
An account of the teaching clinics held in
lieu of the usual District Medical Society
meeting, with comments and suggestions, will
be found under the Department of Pediatrics;
but we wish to add our own testimonial of
praise of so unique an endeavor, into which
so much labor was put and whose success
was far beyond the brightest hopes of those
responsible for the experiment.
This journal's confident prediction was
that these clinics would prove a highly suc-
cessful exi>eriment. Dr. James W. Davis
has a way of pushing his undertakings to
successful completion; and he chose his as-
sistants with care.
The Diplomate, for June, carries as its
leading article, a discussion of "Some Needed
Developments in Graduate Medical Educa-
tion," by Dr. Edward H. Hume, Director of
the New York Post-Graduate Medical School.
The Diplomate is published by the National
Board of Medical Examiners. The article's
opening sentence is, "The emphasis of the
future will be on the continuous education
of the practitioner," and that term he means
to embrace all medical doctors.
The plan worked out by Dr. Davis and
his associates is in accordance with this idea.
He and the other officers of their District
Society are in intimate continuous contact
with the whole membership of the society,
and so in position to follow through. Con-
tinuous education can come only from accu-
rate observation, careful investigation, prompt
and accurate recording and logical correla-
tion. In working up case histories of pa-
tients to be presented to this clinic, these are
the steps carried out. We trust the habit
will prove a pleasing one to all who tried it.
If this process were carried out in the case
of each patient, each doctor would be con-
stantly giving himself the best kind of post-
graduate course, the "continuous education"
on which Dr. Hume says will be the empha-
sis of the future,
The Ninth (N. C.) District Medical So-
ciety has taken a long step toward bringing
about this very habit, and has placed itself
in favorable position for advancing further
toward this goal.
This journal appreciates, applauds and
votes its confidence.
South Carolina Vegetables Superior
Somehow the 1928 South Carolina legisla-
ture was induced to provide funds for inves-
tigating the mineral content of the important
vegetable foods grown in the state.
The investigation was made by Dr. Wil'
liam Weston, Columbia, and Dr. R. E. Rem-
ington, Charleston.
The iodine content of vegetables grown in
South Carolina is shown to be enormously
greater than that of the same vegetables im-
ported from northern and western states.
The iodine content of Irish potatoes increas-
ed from the seashore to the Blue Ridge,
which is contrary to the usual assumption
that it is greatest near salt water.
It is significant that vegetables produced
in the section showing the highest incidence
of goiter contained least iodine.
We congratulate the forces which brought
about this investigation, and the State of
South Carolina on the excellent showing made
by her food-stuffs.
Dr. Louis L. Williams
Because of assignment to duty in the
Orient, Dr. Louis L. Williams, who has for
more than a year so capably conducted the
Department of Public Health of this journal,
has been obliged to resign the editorship of
this department.
For the past six years Dr. Williams has
been detailed to Virginia in charge of ma-
laria control work. He has been ordered to
India for a six-months survey of those sec-
tions of the lower country where mosquitoes
are most prevalent, and will also make an
investigation of other insect pests there.
Dr. Williams was born at Fort Monroe,
Va., and is a graduate of the University of
Virginia.
The journal is sorry to be deprived of his
services, which deprivation it trusts is only
for a time; and it wishes for him the great-
est measure of success in his new station at
the front of battle against disease.
49d
SOUTHERN MEDICINE AKD SURGERY
July, 1924
DEPARTMENTS
HUMAN BEHAVIOR
James K. Hall, M.D., Editor
Richmond, Va.
The Conclusion of an Outrageous
Attack
Last fall Dr. Albert Anderson, superin-
tendent of the State Hospital at Raleigh, was
tried in a special term of Wake County Su-
perior Court, for various crimes in connection
with his administration of that institution.
The jury found him guilty of one or two
charges, and the court imposed upon him a
fine. The result of an appeal to the state's
Supreme Court was the pronouncement that
the charges did not constitute crimes. Again,
a few days ago, in another special term of
the Superior Court of Wake County, he was
tried — chietly for transferring to his own use
property of the state. Judge Henry A. Grady,
the trial judge, after having heard the state's
principal testimony, dismissed the charges
and ordered a non-suit entered. So the state's
agencies have at last made an end of their
efforts to convict a seventy-year-old man, the
last seventeen years of whose life 'have been
given over to the service of the state. From
start to fmish the whole business has been
an outrage, discreditable to the state, and
beneath the dignity of those upon whom the
prosecution has devolved. The two trials
have cost Dr. Anderson twelve or fifteen
thousand dollars. No good purpose has been
accomplished.
The management of the State Hospital is
placed in the hands of a Board of Directors,
appointed by the governor of the state, and
the superintendent of the institution, selected
by that board, is given the control and direc-
tion of the hospital. All the catalogue of
charges against Dr. Anderson were not only
kept away from the Board of Directors, but
the charges were carried instead to the grand
jury. Why were such charges not taken first
to the Board? One of the chief functions of
such a board is to hear charges leveled against
its agents, and to investigate them. The
State Hospitals in North Carolina operate
under the auspices of the Department of Pub-
lic Welfare. The Commissioner of Public
Welfare lives in Raleigh. Did the Commis-
sioner know that such charges were floating
around in Raleigh, that they were being taken
to the grand jury, and that a trial in the
Superior Court would probably result? Dur-
ing the trial of Dr. Anderson last November
the prosecuting attorney had as his elbow
companions at the prosecutor's table the As-
sistant Attorney General of North Carolina,
the Commissioner of Public Welfare of North
Carolina, and Dr. Harry W. Crane, a mem-
ber of the Department of Public Welfare and
also a member of the faculty of the Univer-
sity of North Carolina. No one of these
three occupants of chairs at the table of the
prosecution throughout the first trial was in
the court room at the last trial. What caused
their absences?
Dr. Anderson is the highly efficient head
of a great hospital. The Board of Directors
of that Hospital should have insisted that
the charges preferred against him be brought
to them for analysis and investigation. Since
that was not done the Board of Directors
should have engaged counsel to defend him.
Dr. Anderson has been shamefully and out-
rageously dealt with, and the state owes him
an apology — and it owes him, too, reimburse-
ment for the cost of the defense of his ad-
ministration against an outrageous and an
unjust assault.
An Honest Diagnostic Effort
More progress would be made in the un-
derstanding of mental diseases if most of the
diagnostic terms were entirely abandoned.
Such terms, for instance, as depression, or
excitement, are suggestive only of an emo-
tional state and of the particular type of
behavior manifested by that particular emo-
tion. The individual suffering from an ab-
normal mental condition should be studied
as an individual and not as the member of
a psychotic group. Attachment of a label
to a medical condition tends to limit subse-
cjuent thought to the conception represented
by the nosological tag, with more or less com-
I)lete forgetfulness of the individual who is
disordered in thinking. I find myself, I am
glad to say, less and less inclined to make
the diagnosis of dementia praecox. My dis-
inclination to attach such a diagnostic label
to any mental condition is justified by several
July, 1929
SOUTHERN MEDICINE AND SlJRGEkY
m
reasons. The only definite, clear-cut sugges-
tion that dementia praecox conveys to my
mind is that of prognostic gloom and I do
not like to generate within my own mind a
gloomy feeling about the condition of a pa-
tient under my care. The study of every
patient should constitute an adventure — a
personal medical expedition into the region
of the unknown. Too often our examinations
are undertaken not for the purpose of making
a diagnosis — the very word carries with it
the suggestion of a thorough understanding — •
but rather for the purpose of confirming our
preconceived notions about the patient's con-
dition. Such an attitude makes completely
impossible the scientific practice of medicine.
Such a method saps professional life of all
joy. Such a mode of life soon dperives the
practitioner of all intellectual honesty. My
own feeling is that in the examination of an
abnormal mental condition the physician
should never be condemnatory. His concern
should be limited to the effort to understand
the individual's conduct and to find out the
reasons for the particular behavior. In diag-
nostic work right and wrong, moral and im-
moral, legal and illegal have no proper place.
The examiner is not concerned about the
attitude of the law, or the church, or any
other group of society towards the patient's
conduct. The quality of the individual's be-
havior, from the point of view of diagnosis,
is of no moment. The consequential factor
in conduct is the meaning of it. What is
the mental state represented by the partic-
ular conduct? What factors have changed
the individual conduct from normal to abnor-
mal? There is always a valid and a power-
ful reason for such a transformation. Not
infrequently, however, the reason is hidden
from the patient, buried in the domain of
the subconscious, perhaps, just as the cause
of fever, for instance, is often buried deep
in the tissues.
We easily lose sight of the probable fact
that the main business of the mind is to pro-
tect itself, and to protect the individual whose
choicest possession it is. Efficiency is prob-
ably not the mind's principal concern. Its
highest function is self-protection; its chief-
est desire is self-comfort. It must give little
attention primarily to matters of ethics; it
cares fundamentally perhaps not at all for
neighborhood opinion. But if comfort must
be got through conforming to the attitude
of the herd, then personal opinion must be
sacrificed.
Many of the current conceptions of so-
called insanity are altogether erroneous. The
behavior of the insane is not irrational — for
them. Their conduct is as truly representa-
tive of their mental states as your behavior
and mine are manifestations of our own way
of thinking. And not infrequently the so-
called insane person is entirely rational in
conduct in the sense that his physical move-
ments manifest without restraint or modifica-
tion his state of mind. The maniac, for ex-
ample, often says and does exactly what he
feels like saying and doing. Maniacs, in be-
havior, have become children again. They
have abandoned those restraints imposed
upon them by the assumption of adulthood.
I was not at all surprised that the young man
refused to eat after I found out that he
thought his food had in it large amounts of
veronal. He knew the veronal would induce
sleep, and that during that sleep the attend-
ants would castrate him. He had actually
heard them speaking to each other about the
technique of the operative procedure. His
behavior was entirely reasonable — for his
state of mind. I regarded his auditory hal-
lucinations as symptoms of dementia praecox,
but I must not rest until I find out from his
past life why he hears imaginary voices say-
ing those particular things, and not some
other things, about him.
Meaningless diagnostic reference terms,
such as dementia praecox, manic-depressive
oscillations, and involutional changes, obtrude
themselves as barriers against the proper diag-
nostic study of mental conditions. Behav-
ioristic manifestations are reflections of
causative factors buried in the individual's
past, and if the physician is to be a discoverer
he must be an explorer of that past. The
individual patient must be studied as a think-
ing unit, his ancestry must be thought of as
a large biological part of him, and his envir-
onment must be conceived of as related to
him both individually and ancestrally. There
are two objects only — the individual, and the
rest of the universe. The response to that
universe is either — sanity or insanity.
49i
SOUTHERN MEDICINE AND SURGERY
July, 1920
The Psychologist Enters Politics
Two political organizations in the ancient
commonwealth of Virginia have reached their
alluring hands into a college campus and
have touched with their nominating magic the
occupant of the chair of psychology. Dr.
William Moseley Brown, who occupies the
chair of mental philosophy in Washington
and University at Lexington, has been made
the nominee for governor of the state. And
he has resigned his professorship and has
made himself ready for the campaign, which
will be a warm one undoubtedly, both sea-
sonally and politically.
The rather popular notion that the teacher
is unl'itted for the practical affairs of hard
political life is hardly borne out by history.
The teacher often possesses an uncanny
knowledge of the hopes and the yearnings of
the multitude, and leadership on the campus
has not infrequently expanded into larger
leadership. It will be interesting to observe
how successful the candidate psychologist is
in making useful his understanding of the
operations of the voting mind.
The First International Congress on
Mental Hygiene .
The first International Congress on Mental
Hygiene will be held in Washington City
May 5-10, 1930, under the honorary presi-
dency of Herbert Hoover. No other citizen
of the world has probably had so much and
such intimate experience in observing human
behavior under tragic and difficult circum-
stances. And no other citizen of the world
is probably so well known to so many people
of the world. He will make an admirable
president of such a magnificent assemblage.
In conjunction with the International Con-
gress the American Psychiatric Association
and the American Association for the Study
of the Feebleminded will hold their annual
meetings, and the program of each of these
bodies will be arranged to interdigitate into
the general program of the Congress. Most
of the organizations which have to do even
remotely with problems relating to mental
health will cooperate actively in making the
first meeting of the Congress the largest med-
ical gathering the world has ever known.
PEDIATRICS
Frank Howard Richardson, M.D., Editor
Black Mountain, N. C.
Post-Graduate Education and Organized
Medicine
An Experiment in Medical Teaching
In the not very distant past a young man
desiring to study medicine apprenticed him-
self to an older man, usually one whom he
admired, perhaps loved. He rode the circuit
with him; observed him as he fought disease
in his neighbors, and gradually grew into a
knowledge of disease and of folks who suf-
fered from disease that formed the basis —
usually supplemented by a year of formal
lectures — for a life of service as a family
doctor.
The medical college has superseded this
system of personal medical education. While
it has gained vastly over the old, it has ob-
viously lost in the change much of the per-
sonal relationship that made of the doctor
of former generations a craftsman as well as
a scientist. An attempt at retaining this
human relationship was made by the medical
colleges of our early days, which demanded
of the entering student that he be vouched
for by some older practitioner, styled his
preceptor.
Some of us have felt that the standardiza-
tion of medical education has not been alto-
gether for good; and that many practical
things which the medical student might be
taught during his novitiate are neglected, to
be learned at the expense of his patients.
Undergraduate medical education is in the
hands of foundations and boards and various
other agencies, medical and non-medical,
dictating what it shall include and how it
shall be shaped; and with it the rank and
file of the medical profession has little or
nothing to say. With graduate, or better
postgraduate medical education, however, an
entirely different situation exists. Here we
have the doctor already out in practice, real-
izing keenly his limitations and the things
that he did not learn in medical school and
hospital. If he can devise a means of getting
the teaching that he feels that he needs, he
will be indeed an authority on medical edu-
cation; for he has learned by hard knocks
and by bitter experience wherein he is lack-
ing.
It is just this that makes the two weeks
July, 1929
SOUTHERN MEDICINE AND SURGERY
of clinics put on for their own members by
the Ninth District IMedical Society of the
State of North Carolina at Statesville such
a significant step forward in medical educa-
tion in this country. The idea of a unit of
organized medicine deciding for itself what
its members need to help them practice medi-
cine more efficiently, and then organizing its
own resources so as to furnish this lack from
its own membership and the membership of
adjoining district branches, is so eminently
sensible and so universally applicable that
it cannot fail to be adopted and adapted by
other societies as the outstanding method of
carrying on postgraduate medical education
for the mass of the profession the country
over.
The providing of all instruction by utiliz-
ing the teaching ability inherent in the local
profession, while by no means the only ad-
mirable thing about this demonstration, is
the outstanding feature of what may well be
called "the North Carolina idea." At first,
it does not seem feasible; for how is a group
to lift itself higher than its own level, if it
employs no leverage better than that provid-
ed by its own boot-straps? As a matter of
fact, the first plan suggested, when Dr. Da-
vis conceived the idea of the clinics, was to
invite one or more pediatricians of note
from some one of the big medical centers. It
is one of the glories of our profession, how-
ever, that some of the most noteworthy con-
tributions to medicine, as well as to the un-
derlying sciences upon which it is based, have
been made by men working in the smallest
and most isolated communities. It was rec-
ognized, further, that the peculiar problems
of the men of a locality are not best known
by outsiders. And so it was planned that
the clinics should be given by members of
the society, aided by a few men from adja-
cent branch societies invited in to help. This
course was given for the purpose of helping
family doctors to treat children in their own
practices, so clinics were needed in many
more subjects than mere medical pediatrics;
for many of the problems presented to the
family physician by the sick babies and
children he treats are not strictly pediatric.
Orthopedics, dermatology, x-ray, eye, ear,
nose and throat, dentistry, preventive medi-
cine, prenatal care, surgery — each had a con-
tribution to make; and who could give it bet-
ter than men in the locality engaged in
these branches of the practice of medicine?
The men chosen to present these subjects
had it impressed upon them strongly that
two things were wanted of them. First, they
were to bring before the men attending the
clinics the means of diagnosing and treating
some of the simpler and commoner of the
ailments that children present. Second, they
were to present methods of determining when
given conditions were beyond the scope of
the family doctor, and should be referred to
the specialist for treatment.
The course opened with a consideration of
the recent medical specialty, prenatal care,
given by an obstetrician of note from a neigh-
boring city, who has made an outstanding
contribution to this subject. The first clinic
was given by a pediatrician from a neighbor-
ing town, who demonstrated the possibilities
of breast feeding when intelligently super-
vised in general practice. Later this same
man gave another clinic, devoting the time
partly to a consideration of complementary
and, when necessary, artificial feedings; and
partly to a practical consideration of the han-
dling of diarrheas in infants, avoidinij the
cumbersome and unsatisfactory attempts at
classification that have been made from time
to time without clarifying the subject.
Next came a professor from the State Uni-
versity, whose subject was to be habit forma-
tion in the pre-school child. (This will be
presented instead at the next regular annual
meeting of the district society.) The needs
of the older child who begins to fall below
the average established for children of his
age and height (a vast number, sometimes
estimated as two-fifths of our whole school
population, and so deserving of the c:treful
attention of every practitioner, were prf^sent-
ed by a pediatrician who has made a special
study of this problem.) The general run of
diseases seen commonly in the ordinary run
of practice, fell to the lot of four other pe-
diatricians from neighlx)ring societies.
For all of these clinics, the patients were
sent or brought in by the resident physicians
themselves; or else they notified the chief
of the clinic, who studied the cases as far as
opportunity presented itself, and aided each
man in presenting the case to the best possible
advantage. He was wonderfully aided in
getting this material to the place of meeting,
SOUTHERN MEDICINE AND SURGERY
July, 1929
by the untiring efforts of the city social
worker, whose tactful handling of the pa-
rents of the children was no small factor in
making things run off as smoothly as they
did. While the men were asked to bring in
average rather than startling or stunt cases,
they were encouraged to use the facilities
presented for the solving of any problems
that they happened to be meeting in their
work; and for this purpose the clinic proved
a vastly valuable consultation, as the patients
were quick to appreciate.
The orthopedic problem was covered by
the presentation by the clinician of patients
of his own living in the neighboring terri-
tory. The surgeon, the ej)>ear-nose-and-
throat man, and some of the others resident
in town, were able to present their own illus-
trative clinical material. The roentgenologist
spent his hour showing plates illustrative of
the points he wished to emphasize. The sec-
retary of the state board of health presented
the subject of the high infant death rate that
the clinics were designed primarily to com-
bat; and discussed the value of inoculation
against preventable diseases in childhood,
explaining some of the methods he had used
during his own thirty-five years of private
practice in converting his patients to the
idea.
How thoroughly was the course appreci-
ated? The attendance upon the clinics for
the whole two weeks varied from fifteen to
thirty-five. Many of these men came day
after day, some from as great a distance as
seventy-five miles. Perhaps twenty would be
a fair estimate of the average attendance;
and when it is remembered that for its first
year's session the best known postgraduate
p>ediatric teaching organization in the South
today boasted but three registrants, whereas
last year it registered one hundred, it can
readily be seen that the Statesville effort was
successful far beyond the hopes of the most
sanguine of its promoters. The secretary of
the society estimated that about one hundred
men had been touched by the course; and if
the experience of the one who said that his
whole viewpoint as to the treatment of the
children in his practice had been improved
by his attendance was at all typical of the
feelings of the rest of the attendants, it is
almost impossible to even guess at the good
that the course must have done.
What of the future? Can other district
societies fail to follow suit, without admitting
that they are failing in their duty to their
members? No power on earth can force any
doctor, once he is licensed to practice medi-
cine, take further work to better fit himself
for his duties — save two: and these two are
the force of the opinion of his confreres, and
the force of his own self-respect. Graduate
medicine for the practitioner at the hands of
his own unit of organized medicine would
seem to be the best solution of one of the
biggest problems that confronts the profes-
sion today.
Dr. G. W. Kutscher supplements Dr. Rich-
ardson's account of the Ninth District clinic
by paying a high compliment to Dr. J. W.
Davis, Secretary, and emphasizing the follow-
ing points:
The clinical director should be present at
least a few days ahead of the opening day
of the clinic.
All patients should come to the clinic
through the attending physician, the director
of the clinic having found the case to be a
proper one for presentation.
Clinicians should be requested to state the
particular phase of the subject in which they
are most interested and the type of case they
feel best prepared to discuss. The clinician
should also be present at least an hour prior
to the time of his clinic in order to go over
the case history and make an examination of
the child.
Considerable help from the physician can
be obtained if he is asked for a few remarks
relative to the patient before the clinician
begins his discussion, and in this way many
interesting points along the lines of past and
present history, and treatment prescribed,
are brought out.
One hour is sufficient time for each clini-
cian. Two or three cases can be well pre-
sented in that time.
Practically every clinician has some pet
disease he would like to discuss, especially his
own methods of diagnosis and treatment.
Much can be learned by this method and it
should be encouraged, even if no case of that
particular disease is available.
Whatever barrier exists to prevent a free
discussion should be sought out and removed.
Probably the clinicians would do well to leave
July, 1929
SOUTHERN MEDICINE AND SURGERY
49S
loop-holes for the purpose of eliciting discus-
sion.
Promptness in beginning the meetings is
appreciated by those who attend. The privi-
lege of leaving the meetings at any time
should be extended, as many men will be
able to drop in for only a few minutes at a
time. If the clinician understands this he
will not take it as a personal reflection when
someone gets up and leaves.
The family doctor, for whom these clinics
were held, encounters rare and unusual cases,
and any help offered him in these cases, is
appreciated; but he is decidedly more inter-
ested in the type of case which he encounters
daily in his practice.
The attendance of the public at such meet-
ings, except where the parent accompanies
the child to be presented, must be carefully
avoided. It hampers the clinician in a free
discussion of the condition, and the laity
gains a wrong conception of many things that
are said. When one case has been presented,
it is excused, and another case is called from
the adjoining room. Any remarks by the
clinician relative to the patient just excused,
and not intended for the patient's ears, can
be made while the second patient is being
ushered into the clinic room.
The idea, as carried out at Statesville, of
inviting the public to attend especially pre-
pared meetings was most helpful in stimulat-
ing public interest in the subject of children's
diseases. Naturally the programs at these
meetings were of such a nature that they were
of public interest.
The assistance of the social worker and
welfare worker of the locality is of inestim-
able value.
Announcements of the work and progress
of the clinic were made from the various pul-
pits. This was done at Statesville; and it
was felt that interest in the clinic was mate-
rially improved as a result.
EYE, EAR AND THROAT
For this issue, F. C. Smith, M.D., Charlotte
CharloUe, N. C.
— Eye Strain at Different Ages
The symptoms of eye strain are met from
the time a child begins to notice small objects
until past seventy years. Its importance is
being obser\'ed more and more by physicians.
"Eye strain is generally nerve strain from
the use of eyes. Its unusual and rare effects
may be found as widely distributed as the
important nerve connections and nerve func-
tions of the body. The form in which the
strain is likely to be manifest is connected to
some extent with the age of the patient. Eye
strain may cause either sensory or motor dis-
turbances. The former are more commonly
recognized, but the latter are also important."
Convergent strabismus associated with hy-
peropia usually develops when the child is
approaching three years of age; the time
when small objects are more closely observed
thus calling for a greater use of accommoda-
tion. This is the most important effect of
strain accommodation in childhood and can
usually be permanently cured when the re-
fractive error is properly corrected by glasses.
"Twitching of the lids and face, choreic
movements, and even epileptiform seizures,
arise from eye strain in a few cases. Usually
they are associated with exceptionally high
ametropia; but a moderate error of refrac-
tion, influencing a defective nervous system
or the sequels of acute disease, may help to
establish or perpetuate such disorders."
During school life eye strain is the most
common cause of headache. This is the pe-
riod when the recurring or habitual head-
aches of adult life are established. Also the
time of development of myopia which is fre-
cjuently evidenced by an aching of the eye-
ball rather than headache. Muscular asthe-
nopia at this time often causes headache and
vertigo.
In early adult life indoor occupations re-
quiring close use of the eyes predispose to
e\e strain. Headache is the most common
manifestation but many other symptoms may
be traced to eye strain as a sole or contribut-
ing cause. Anorexia, dyspepsia, nausea, poor
nutrition, anemia and other departures from
health should suggest inquiry into this as
one of the possible causes of impaired health.
In middle age, diminished power of accom-
modation may cause eye strain in one whose
eyes have previously given perfectly satisfac-
tory service. Headache, nausea and vertigo
may develop and there is a susceptibility to
conjunctival irritation. At this a^e mental
disturbances from this cause have been re-
ported by well known and qualified observers.
The diagnosis may be made only by relief
from the eye strain.
SOUTHERN MEDICINE AND SURGERY
July, 1929
After fifty years of age it is often assumed
that accommodation has become unimportant
in causing eye strain. It may be important
until after seventy.
Even when not expected eye strain must
be kept in mind and considered as a possible
cause for undetermined symptoms.
Abstract from Editorial "Eye Strain at Different
Ages," by Edward Jackson. American Journal of
Ophthalmology, June, 1929.
ORTHOPEDIC SURGERY
For this issue, Bernard H. Kyle, M.D.
Lynchburg, Va.
Abnormalities of Ossification in Both
scaphoids
April 13, 1919, five-year-old boy comes in
limping on right foot. Mother says he limp-
ed all winter; after going bare-foot two weeks
ago he has grown worse. Examination shows
both arches high, marked swelling over sca-
phoid of right foot with tenderness on pres-
sure, temperature normal. Left foot except
for high arch, symptoms and findings are
negative. Associated with this the x-ray
shows a marked abnormality in the appear-
ance of the scaphoids of both feet, irregular
in outline and with increase density. After
examining the x-ray negative the mother was
questioned as to the left foot. , She says he
limped about a year ago but she is not sure
which foot it was, perhaps the left. In look-
ing up the literature one finds the scaphoid,
radiographically, the most interesting of all
the bones of the foot. Ossification usually
from one center may appear radiographically
as early as three and a half years of age and
is rarely later than the fifth year.
The scaphoid is sometimes affected by that
curious condition known as Kohler's disease,
usually between the fifth and tenth years.
This condition was brought to the attention
of the profession by means of the radiogram
and is usually manifested by pain and ten-
derness on pressure over the affected bone
and a limp, is usually unilateral and termi-
nates favorably.
In this case a cast was applied from toes
to the knee for three weeks. On removal of
the cast patient had no pain or tenderness on
pressure.
"Veil, Abie, how's business?"
"Terrible ! Even de people vot don't pay ain't
buying nothing."
— Jour. Kansas Med. Soc, June, 1929.
An Abstract on Poliomyelitis and a
Suggestion
The frequency with which anterior polio-
myelitis goes unrecognized is the reason for
this extract being made of Amos' excellent
article in Tice's Practice of Medicine:
This dreaded disease is infectious, contag-
ious, communicable. It results from the
growth of a filter-passing virus in the central
nervous tissues. The symptoms are first
those of a systemic infection and then, in
some cases, those referable to lesions of the
cord and brain.
With few exceptions this disease begins
more or less suddenly with general symp-
toms. A previously healthy child seemi out
of sorts and listless, with loss of appetite.
This is the period of invasion of the virus
which is followed in three to ten days by the
second phase, the lesion of the cord. This
is also called the febrile period. In most
cases there is drowsiness and fever from 100
to 102 for from a few hours to three or four
days with rapid return to normal. The sec-
ond phase comes on a few days later with
flushing and a picture of the onset ot the
acute diseases of childhood; yet there is a
difference often obvious to the experienced
mother, for the sclera are slightly dulled and
the face seems glazed over. It is as though
the patient is seen through smoked glasses.
The pulse rate is greater than can be ac-
counted for by the fever. Pain is present
in the head and neck, often in the back and
legs. One of the distressing symptoms is the
exquisite hyperesthesia of the skin, prolonged
by pressure of bed clothing or massage.
Retention of urine and stools is common.
Presented with a patient as described inval-
uable information is to be gained by micro-
scopic and chemical examination of the spinal
fluid, since from the beginning of the acute
attack abnormal findings are the rule. The
fluid is usually clear and under increased
pressure, the average count in this disease is
from 400 to 1,000 per cm. The globulin in-
creases as the cell count comes down. The
reflexes are usually increased early in the dis-
ease; later they disappear entirely. Paralysis
usually comes on three to five days from the
onset of the second phase. A motor paralysis
without disturbance of sensation.
During the summer months a child with a
gastro-intestinal upset, headache, and fever,
July, 1020
SOUTHERN MEDICINE AND SURGERY
497
less alert and bright than with ordinary fe-
vers, somewhat cranky and unapproachable
should be examined more carefully with this
disease in mind. Such a child is difficult to
examine. It is even more difficult for a con-
sultant, as the patient has learned from the
previous examination that stretching the neck
and back are painful. To test the intercos-
tals, the diaphragm is immobilized by pres-
sure with the hands on the abdomen and
likewise the intercostals are immobilized by
pressure on the chest to test the function of
the diaphragm. If there is no involvement of
the respiratory center and there are no other
contraindications the patient is allowed to
sit on the side of the bed. The patient as-
sumes a characteristic attitude: the back is
held straight and both arms rest on the bed
slightly behind the buttocks with arms
straight and stiff in an attempt to take the
strain from the painful back. When the pa-
tient is asked to bend over and place the
head between the knees, the back is held
straight and the patient bends only from the
hips. This is the most constant of all signs.
The attempt to bring the chin to the chest
causes pain.
.Anterior poliomyelitis may be confused
with epidemic meningitis, tuberculous menin-
gitis and epidemic encephalitis. If human
convalescent serum is given prior to the on-
set of paralysis, accompanied by spinal drain-
age, the patient usually recovers in seven
days. It is of no value after the onset of
paralysis. Serum from recently recovered
cases is recommended, although serum from
cases three to five years recovered contain
antibody content.
Obviously the donor should be free from
infectious disease and the blood Wassermann
negative. As much blood as can be safely
withdrawn (200 to 500 c.c. according to the
weight of donor) is collected in sterile cen-
trifuge tubes, allowed to clot and stand at
room temperature over-night. The serum is
drawn off, centrifuged and inactivated at 56
degrees C. for one-half hour. After testing
for sterility, it is sealed in bottles and kept
in the icebox.
After withdrawal of the spinal fluid the
needle is left inserted, sample of the fluid
examined niicrosco[)ically and chemically
within a few minutes. If the fluid findings
and clinical picture warrant the diagnosis of
acute poliomyelitis, 15 to 30 c.c. of serum
are given slowly intrasiiinally and the needle
is then withdrawn. This method saves time
and a second lumbar puncture in positive
cases. The patient is placed in a comfortable
position and from 50 to 100 c.c. of serum
are injected intravenously. If the patient is
no better in 24 hours it is wise to do a spinal
drainage. The progress of the disease is
arrested in cases treated within forty-eight
hours after the onset and with more than 50
c.c. of serum.
It seems pertinent to ask:
Should not the State Health Departments
throughout the United States collect human
convalescent blood from prospective convales-
cent cases and be prepared to furnish same
on short notice when and wherever a case is
diagnosed within the state?
UROLOGY
For this issue. John W. Vi.sirEK, M.D.
Evansville, Indiana
Unusual Nucleus for Vesical Calculus*
The following case is reported as an exam-
ple of the queer objects sometimes found in
the urinary bladder. Such are found more
frequently in females than in males.
The patient is a young man thirty years
old, whose family and past history are in-
consequential except for an attack of acute
gonorrhea four months prior to coming to
the hospital. This was an unusually severe
attack and was associated with symptoms of
posterior urethral involvement. He had sev-
eral attacks of acute retention which neces-
sitated catheterization by a physician. On
one occasion he was on a fishing trip far
from a doctor, and had just eaten a large
amount of watermelon. At this most inop-
portune time he was unable to void. He was
unwilling to spoil the trip for his friends,
more especially since the fish were biting
nicely, so he tried to make a catheter from
chewing gum. He wound it around a piece
of wire, removed the wire, and inserted this
improvised catheter into the bladder. He
says that this was not difficult to do but he
was surprised that no urine came through it.
.After removing the gum he urinated freely.
From that time on he had frequent, painful,
urination and some low backache, and occa-
*From the Department of Urology of the Wel-
born Hospital Clinic.
498
SOUTHERN MEDICINE AND SURGERY
July, 1Q20
sional stopping of the urinary stream.
Examination disclosed tenderness over the
blader, the urine was strongly alkaline and
was full of pus. Cystoscopic examination
showed a severe generalized cystitis and a
large, oval, white stone. Radiographs of the
bladder showed that the calcification sur-
rounded a clear center. In view of the his-
tory and radiographic findings we thought
that part of the gum had been left in the
bladder and had formed a nucleus for a stone.
It was decided th.it a crushing operation
would not be feasible because of the sticky
nature of the nucleus, so a suprapubic cys-
totomy was performed and the stone was re-
moved intact. The patient made an unevent-
ful recovery, and was entirely relieved of
h's symptoms.
Examination of the stone confirmed the
pre-operative diagnosis as section of it showed
the gum still in a cylindrical form surrounded
by phospatic material. The accompanying
photograph shows the stone before and after
sectioning, and a part of the gum, and the
radiograph shows it in the bladder.
RADIOLOGY
JoH.N D. MacRae, M.D., Editor
.■\shcvillc, N. C.
X-R.AY Films '
On May ISth of this year the whole coun-
try was schocked by the disaster in the Cleve-
land Clinic.
X-ray films stowed in the basement of this
institution accidentally exposed to great heat,
exploded. The deadly gases resulting rapidly
filled the building and caused the deaths of
a large number of patients, attendants and
doctors.
Radiologists have not been unmindful of
the problems inc'dent to handling and storage
of x-ray films. Fireproof vaults and other
safety devices are the rule in establishments
where large numbers of films are used and
filed. Other users of films purchase supplies
as needed and only file such films as are of
peculiar interest; consequently their accum-
ulation of new and used stock is small and
not dangerous if due precaution is observed.
There is no question of the hazard sur-
rounding the handling of x-ray films, but it
is possible to overestimate the danger in lab-
oratories where sinall numbers of filrns are
handled.
Cellulose nitrate in transparent sheets and
coated with silver emulsion is what is used
for photographic and x-ray films. It is in-
flammable and explosive. When it burns it
produces poison gases.
Cellulose acetate films are now availab'e.
They burn like so much paper but are non-
explosive and lack the danger which goes
with the old-time nitrate film. They are spo-
ken of as "safety films" and add about twenty
per cent to the cost.
It is said that the safety films have not
been popular because they curl and roll up,
making them harder to handle and also they
are more costly.
A little over one year ago a fire in a hos-
pital in .Albany, N. Y., was accompanied
with burning x-ray films. It attracted atten-
tion to the problem of handling and storing
them but does not seem to have made very
much impression. Now the Cleveland disas-
ter has focused the attention of hospital au-
thorities and radiologists on the need for re-
moving the dangers incident to the handling
of x-ray films.
Cities all over the country will pass ordi-
nances controlling these matters. It is to be
hoped that such ordinances will not be too
costly or difficult to observe. The National
Board of Fire Underwriters will no doubt be
responsible for the form which these ordi-
nances take.
Protection against fire which might ignite
x-ray films will be accomplished by careful
observation of standard rules in regard to
installation of heating and electric light fix-
tures. Excessive heat from steam pipes
should be easy to guard against and if all
electric wires and fixtures are installed ac-
cording to standard regulations, danger in
this direction will be eliminated.
No waste material which is inflammable
must accumulate where films are stored and
smoking in these places must be prohibited.
Cellulose acetate or "safety" films present
no greater fire risk than so many paper rec-
ords and may be filed and stored in any con-
venient manner (E. K. Co.) There can be
no such accident as the Cleveland disaster
where only cellulose acetate x-raj- films are
used.
Hospitals and x-ray laboratories can elimi-
nate danger and save themselves trouble by
adopting the use of safety x-ray films. With
July, 1Q:9
SOUTHERN MEDICINE AND SURGERY
most of them the additional twenty per cent
cost of this film will be less than the cost of
providing fireproof storage facilities.
Many x-ray laboratories have accumulated
large quantities of the generally used cellu-
lose nitrate or inflammable x-ray films which
constitute valuable pathological records which
should not be destroyed.
It has been recommended that when more
than two hundred and fifty pounds of such
films are stored they shall be kept in a spe-
cially constructed film vault; preferably lo-
cated on a roof. Such vaults must have vents
opening outside and safe doors so that in the
event of fire the poison gases generated may
not escape into buildings where there are
people.
In many instances large quantities of films
will be prevented from accumulating by cull-
ing and disposing of useless ones and by re-
ducing valuable radiographs to small photo-
graphic negatives which may be safely filed
for reference.
X-ray laboratories will do well to cull and
dispose of all useless films and adopt the use
of cellulose acetate or safety x-ray films and
at the same time ree that all their heating
and electric fixtures conform to approved fire
regulations.
INTERNAL MEDICINE
Paul H. Ringer, A.B., M.D., Editor
.■\shevillc, X. C.
Fungi in jMedicine
.*.n unusual and interesting paper from the
pen of Dr. Fred D. Weidman appears in the
June number of the American Journal of the
Medical Sciences entitled, "The Place of
Fungi in Modern Medicine."
Dr. Weidman stresses the fact that more
and more the average medical man is realiz-
ing that occasionally at least, fungi play a
part in human disease.
The subject of mycology has been much
neglected and as the diagnosis of mycotic dis-
ease rests more up<in laboratory findings than
upon clinical evidence, laboratories contain-
ing an expert in this field should be situated
at various points throughout the nation, so
that physicians could avail themselves of his
services. This is particularly necessary, as
many of the fungus infections bear a strong
similarity to tuberculosis and accurate labora-
tory diagnosis becomes essential. Fungi are
far less important than are bacteria. More-
over, their detection is rather more difficult
than that of bacteria. An important point
arises with respect to treatment, for it is well
known that potassium iodide and iodine are
specific for many fungi, while as a rule they
are more or less contraindicated in tubercu-
lous disease.
Fungi as a class have a predilection for the
same tissues as the tubercle bacillus, namely,
the skin, lungs and bone.
Fungi may cause a localized or a general-
ized lesion. Actinomycosis, blastomycosis,
sporotrichosis and coccidioidal granuloma are
those that frequently are generalized, and no
organ is exempt from secondary involvement.
Practically all fungi may and do invade the
respiratory system. The most important are
the streptothrices and blastomycetes. Moni-
lias are responsible for many cases of bron-
chitis and asthma. In most cases fungus in-
fections of the lung are clinically indistin-
quishable from tuberculosis, and the only
hope of identifying the fungus is through
laboratory methods.
In the digestive tract the best illustration
of a mycosis is thrush. Many feel that moni-
lia psilosis is the cause of tropical sprue, and
yeast cells are commonly met with in the
intestinal tract in chronic diarrheal condi-
tions.
The gcnito-urinary tract and the nervous
system are strikingly free from mycotic in-
fections.
The skin is literally ridden with fungus in-
fections. Dr. Weidman merely mentions
sycosis, tinea circinata, ringworm of the
scalp and passes at once to dermatojihytosis.
He says: "The general practitioner ought to
diagnose dermatophytosis for himself from
the eczema with which it is likely to be con-
founded— he will be served best in this way
by its localization; that is, usually intertrig-
ous position. Once he suspects dermato[)hy-
tosis, he can check up in the following way:
first, determine whether the margin is sharply
outlined; if so, this very strongly fortifies the
diagnosis. Second, is there a delicate collar-
ette of epiderm extending around the margin?
Again, this is helpful toward the diagnosis.
Finally, the direct examination of scrapings
under the microsco[)e is often a final and un-
equivocal answer to the question. This is a
very simple laboratory procedure; really, it
SOUTHERN MEDICINE AND SURGERY
July, 1Q20
is an office rather than a laboratory examina-
tion and one which should be applied by all
those who wish to keep abreast with modern
practice." ( Dr. Weidman has described the
procedure under the heading: "Laboratory
Aspects of Dermatophytosis" in the Archives
oj Dermatology and Syphilis, 1927, No. 15,
p. 415.— Editor).
Iodine is the best drug to use in fungus
infections and does good when applied locally
and when taken internally. Potassium iodide
is also of value. It is important to bear in
mind that to produce results the dosage both
of this drug and of iodine must be large.
Considerable space is devoted to treatment
which is so clearly and tersely given that its
abstraction is impossible.
This paper should be of value to every man
doing general medicine. It stresses a condi-
tion which has hitherto not received the at-
tention it merits.
SURGERY
Geo. H. Bunch, M.D., Editor
Columbia, S. C.
Hemorrhoids
Hemorrhoids are varicose veins of the rec-
tum and are caused primarily by man's up-
right position. Gravity, mechanical obstruc-
tion to venous return and constipation are
common causes of this e.xtremely common
condition. The hemorrhoidal plexus has but
little mechanical support from the loose con-
nective tissue of the lower rectal wall in
which it lies. From it arise the superior hem-
orrhoidal vein whose contents pass into the
portal system through the inferior mesenteric
vein, the middle hemorrhoidal vein and the
inferior hemorroidal vein, both of which pass
into the vena cava by the internal iliac. The
hemorrhoidal plexus is thus an anastomosis
of the portal and the systemic venous sys-
tems, and obstruction to either will cause dis-
tention of the plexus veins which become
hemorrhoids. The portal system has no
valves; so when one stands there is a column
of blood, extending to the liver, which is sup-
ported by the thin-walled veins of the plexus.
Patients with cirrhosis and portal obstruc-
tion bleed profusely from hemorrhoids.
iJ.Iany women suffer from them in the later
months of pregnancy and are relieved when
the child is born and the uterus returns to
normal size. Constipation causes passive
congestion, and straining at stool miy force
the dilated veins through the sphincter with
cversion of the parts forming the hemor-
rhoidal rosette. Trauma and stas's miy
cause the blood to clot and the hemorrhoids
to become thrombotic. Strangulation may
occur and the protruded tissue become gan-
grenous. V'aricosities covered with rectal mu-
cosa are known as internal hemorrhoids and
those about the muco-cutaneous junction as
external hemorrhoids.
Symptoms vary with the location of hem-
orrhoids and with their condition. iMost
adults have some degree of involvement.
They only have symptoms when there is pro-
trusion, thrombosis or bleeding. Quiescent
piles may exist for years without symptoms.
Bleeding may be more or less constant or
may occur only after stool. Secondary ane-
mia may reach an extreme degree. Hemo-
globin may be reduced to 12 or 15 per cent.
Pain occurs when there is ulceration or throm-
bosis. Piles that are kept reduced give but
little pain. \ thrombotic pile is exquisitely
tender. Defecation is painful and there is
pain when the patient sits down or walks.
This condition lasts about a week, until the
clot becomes organized. Organization de-
stroys the vein, converting it into a fibrous
cord. Piles may thus be cured by nature and
be self-limited.
Itching about the anus is often attributed
to hemorrhoids by laymen. Really the ex-
pression itching piles is a misnomer. There
is but little relationship between pruritis ani
and piles.
The correct diagnosis of hemorrhoids is
most important and the physician must be
sure that bleeding does not come from some
more serious rectal lesion. In the alimentary
tract, second only to the stomach, the rectum
is the most frequent location for cancer.
Bleeding after stool is a common symptom of
cancer after ulceration has taken place, so
that it is necessary when there is rectal bleed-
ing to investigate the cause before making a
diagnosis or beginning treatment. .After the
age of 40 cancer should always be suspected
as a cause of bleeding and the patient have
the benefit of proctoscopic and x-ray study
before hemorrhoidectomy is done. Rectal ex-
amination with a well lubricated gloved fin-
ger only takes a moment and is usually suf-
ficient to make the diagnosis. Many patients
July, 1020
SOUTHERN MEDICINE AND SURGERY
with carcinoma of the rectum have been
operated upon for hemorrhoids one or more
times before the correct diagnosis has been
made. The mistake is the result of careless
or imperfect examination and occurs even in
the largest clinics. In doubtful cases the
general surgeon should call upon the proc-
tologist for help. Recently in commenting
upon the surgeon's ignorance of rectal path-
ology a proctologist of Columbia facetiously
said that the surgeon knows only two rectal
diseases, hemorrhoids and piles.
In making the diagnosis of hemorrhoids we
should remember that they may be secondary
to pathology far removed from the rectum.
Some time ago an elderly man had hemor-
rhoids removed by an e.xcellent general sur-
geon twice and by a competent proctologist
twice. In a short while after each operation
there was return of hemorrhoids with bleed-
ing. Neither the surgeon nor the proctologist
could see anything but recurring hemorrhoids.
.•\n internist made the correct diagnosis of
splenic anemia with cirrhosis of the liver and
explained why the operations had not cured
the patient. We must learn to study the
body as a whole if we are to properly under-
stand many local conditions.
The treatment of hemorrhoids is simple.
They may be removed by clamp and cautery
or by ligature. General, local, spinal or cau-
dal anesthesia may be used. One must be
careful not to remove so much rectal mucosa
that stricture follows from scar contraction.
We have never attempted the Whitehead
operation, — removal of the entire lower rec-
tal mucosa with the hemorrhoidal plexus —
for we believe it unnecessary. In suitable
cases the varicosities may be obliterated by
local injections of quinine and urea. Hospi-
talization is not necessary and the patient
loses no time from work. But before any
treatment is begun we should think of David
Crockett's motto, "Be sure you are right and
then 20 ahead."
_ PERIODIC EXAMINATIONS
^ Frederick R. Taylor, B S., M.D., Rdtior
Hi^h Point, N. C.
Some Serious Drawbacks to the Present
System of the Private Practice of
Medicine
Our work brings us into contact with a
large majority of the physicians of North
^ Carolina, chiefly in their own offices. We
have, therefore, the unique opportunity and
privilege to get a state-wide view of the prac-
tice of medicine. Most of the state's doctors
are men one may well be proud of. Almost
all of the best of them feel, though, that they
are striving after an ideal but are handi-
capped by the system of present-day practice.
It is one thing to point out the defects in a
system, and quite another to offer help in
changing things. In this editorial we are
merely thinking in print, as it were, in the
hope that others may be stimulated to think
about the same subjects in a more construc-
tive way.
The June number of The Forum contains
an article on "Our Guess-and-Prescribe Doc-
tors" by a Mr. Harding. The July number
contains a reply by an M.D. We think the
layman has so much the best of the argu-
ment that the doctor's article, attempting to
be convincing from the other side, really
strengthens his opponent's position.
Mr. Harding classifies doctors as follows:
1. The intensive man. — He does thorough
work. He takes as much time to each indi-
vidual patient as the exigencies of his case
demand. He constantly studies, attends
medical meetings regularly, and keeps up
with what is going on in medicine. He is
forced, however, to practice at prices that
about three-fourths of the people feel unable
to pay, and very many of them are unable
to pay those necessary costs. He works hard.
2. The extensive man. — He handles a huge
volume of practice at a price anyone except
the very poor can pay. He has no consid-
erable lime to devote to any one patient be-
cause there are always a large number wait-
ing and he has to get around to them all, or
thinks he does. He has no time to study or
go to medical meetings. His life is a steady
treadmill of routine, and his chief effort is
to get through with the individual patient as
quickly as possible in order that he may
see the next one. He makes many honest
mistakes, and f^radually deteriorates from
lack of keeping up ivith the advances in his
fit Id. He works even harder than No. 1, as
he very often has insufficient time to eat or
sleep, but he is a slave to the system.
.1. The lazy man. — He just doesn't want
to work, and is as much out of place in medi-
cine as anywhere else.
-Mr. Harding does not use the words "ex-
tensive," "intensive," and "lazy" — we use
502
SOUTHERN MEDICINE AND SURGERY
July, 1929
them for conciseness's sake — they express
Mr. Harding's meaning.
Of course most medical men have a cer-
tain admixture of elements in them, but one
of the three types usually preponderates in a
given man.
Our own observations have caused us to
think a great deal about present-day medi-
cine, as a system. We have noted a number
of things that have made us pause. Here
are some of them:
1. A doctor may, and sometimes does,
practice medicine on less than he learned 40
years ago. There is nothing to make him
keep on studying after he graduates if he
does not wish to. Consequently, he learns
little new, and forgets much. Experience
does not teach this type, for he is an illus
tration of the statement of Osier's, that the
man who carefully studies eight cases of
pneumonia will know more about pneumonia
than the man who carelessly treats five hun-
dred cases. We compel our teachers, in our
public schools, at least, to attend summer
school. Not so our doctors!
2. A deaf man may listen to heart beat?
and base his diagnosis on what he does not
hear. He may percuss the chest as a ritual,
though he cannot hear the notes, and thus
arrive at a "diagnosis." There is nothing to
protect the public against him.
3. A man may have eyes so weak that he
cannot look closely at anything for IS min-
utes at a time without having badly blurred
vision, yet he may do major operative sur-
gery. He could not, however competent
otherwise, by the wildest stretch of the im-
agination, be permitted to drive a locomo-
tive, but he is allowed to operate! These are
not jancijul ideas — they are based on actual
observation of certain conditions that do
exist.
4. Three or four men in a town may have
about $5,000 each tied up in x-ray equip-
ment. They may all be excellent physicians,
yet exceedingly mediocre roentgenologists.
They probably keep that equipment working
less than one-fifth of the time it could work
to advantage from an economic standpoint.
How much better would it be for them to
save the $5,000 each, and have one really
competent roentgenologist in the town, with-
out duplication of equipment, doing all the
x-ray work of the town, and doing it very
well, rather than in a mediocre manner!
Modern business would not tolerate such in-
efficiency— it would go to the wall of it did.
Is medicine, therefore, a business? No, but
it can be practiced efficiently or inefficiently.
5. Under our present system of "ethics,"
what chance has an intelligent newcomer, a
layman, to select a physician if suddenly ta-
ken sick? Advertising personal prowess,
promising or suggesting the promise of cures,
etc., are, of course, a stench in the nostrils,
but why should a physician not state in a
card large enough to attract notice without
being in bad taste, carried in a local paper,
the date and place where he received his col-
lege degree, his medical degree, his hospital
internship, his post-graduate study, his hos-
pital and teaching affiliations, etc.? We of-
ten note that the hail-fellow-well-met who
has great poverty of medical knowledge has
the largest practice in town, whereas the real
student of medicine has barely enough to do.
Does not our system of "ethics" favor this
condition? There was a time when the high
grade merchants believed that a good wine
needed no bush, but that time is past. Ad-
vertising began largely as a crooked game,
played by the quacks in merchandising as
well as in medicine, but the merchants of
the better type soon found that good clean
advertising with definite high standards of
truth were not only worth while, but neces-
sary. Should not medicine of the best typ)e
consider the development of advertising on a
really high plane?
Because of these and other evils, there
seems to be an increasing demand for state
medicine. Is this such a horrible idea, oj
necessity^ With our present system, do we
not often pretend we are dodging state medi-
cine when we are really on a half and half
basis, depriving the private practitioner of
much of his living, yet not paying him any
salary, but taxing him for doing his work?
So-called state medicine, where it has been
practiced, seems to have been pretty much
of a failure. Certainly, the panel system as
practiced abroad has not come up to expec-
tations. However, this is not strange, when
one analyzes the situation. It is a change
in form, without a change in reality. The
state school system here in this country had
many grave faults that kept it far behind
the private schools in value until good roacis
July. 1929
SOUTHERN MEDICINE AND SURGERY
S03
and busses made the consolidated school pos-
sible. Then, with adequate equipment, came
tl•em^ndous progress. Might not the devel-
opment of a system of consolidated hospitals
with doctors" offices in them, each man re-
quired to take post-graduate education, fur-
nished adequate equipment, and encouraged
to work in the line of medicine for which he
was best qualified, be worth while? It would
not, and should not, completely destroy pri-
vate practice, any more than our public school
system has completely destroyed private
schools, but it would raise the minimum
standards of practice. There would still be
the disadvantage of rather too great a num-
,ber of patients per doctor, but special cases
could go to the private practitioner who could
devote more time to them. Under some such
system, the surgeon would no longer treat
psychopathic patients, the half blind man
would no longer op)erate, the man with in-
adequate surgical training would no longer
be permitted to operate single handed, and,
moreover, there would be a more equitable
distribution of rewards for the thinker and
student who would painstakingly work out
diagnoses, the careful competent laboratory
worker, and others who get little considera-
tion today from the financial standpt^int, com-
pared to the surgeon who makes a dramatic
appeal to those emotions which control the
purse-strings. Moreover, an adequate sys-
tem of hospitals comparable to our schools
would make it entirely unnecessary for the
private hospital owner to ever assume the
burden of caring for indigent patients at his
own expense — a great evil — for the care of
indigent persons should be the duty of the
whole people, as a conservation activity di-
rected towards keeping up the efficiency of
the man power of the state, rather than a
matter dependent upon the good will and
the economic status of the individual doctor.
Many of our very best men admit freely
that they cannot practice medicine as they
would wish because the present system forces
th^m to do otherwise, so they simply make
'he best compromise they can. Sheer eco-
nomic necessity forces many men into the
"extensive" class of practice — first class men,
who abhor such a necessity.
If the doctors largely had their offices in
well equipped public hospitals, the day of
the one-room shanty office with an equip-
ment of empty bottles of gallon capacity
covered with cobwebs, one broken chair, an
old croquet set, and a broken bicycle — no
table, no desk, no office equipment of any
kind, would be over; yet such things can
still be found within the confines of our fair
state.
As stated before, we are simply thinking
out loud, as it were. We do not feel that
we have solved the problem. We just rec-
ognize beyond peradventure that there is a
problem, and that so-called organized medi-
cine is really pretty badly disorganized in
some ways — it seems to be doing little as yet
to remedy the defects of a system. The doc-
tor is sometimes spoken of as a soldier in
the army fighting disease. He is usually, we
believe, nothing of the kind. A soldier is a
disciplined individual, a member of an or-
ganized army that can function as a unit
where it is needed most. The majority of
doctors are splendid, conscientious, self-sac-
rificing, inefficient individualists, often forced
to be individualists and inefficient along some
lines by the system under which they live
and move and have their being.
A lot of this is rank heresy, medically
speaking — we are fully aware of that. But,
after all, has not most of the great progress
in medicine been made by heretics, as well
as in religion? Were not Vesalius, Harvey,
Lister, and others rank heretics in their day?
There seems to be a ray of hope on the
horizon. The leaders in medicine appear to
be increasingly cognizant of the fact that a
real problem exists in our present-day system
of practice that must be faced somehow. The
Committee on the Cost of Medical Care is
doing a lot of investigating that should bear
real fruit in due time. Meanwhile, let us all
be thinking in a broad way about the prob-
lems that daily confront us, eager to do what
we can to help in any way we can, ready to
make what readjustments may be necessary,
yet not throwing to the winds a reasonable
degree of prudence. We must blaze new
trails, yet hold fast to that which is good.
OBSTETRICS
Henry J. Lancston, B.A., M.D., Editor
Danville, Va.
Placknta 1'rf.via
Placenta previa is a condition which has
been encountered since the early days of the
human race. There is no condition met with
in the practice of obstetrics more dangerous,
SOUTHERN MEDICINE AND SURGERY
July, 1929
The fetal and maternal mortality are high;
the complications are many and far-reaching.
It has been poorly treated and the results
are not so good. Any physician practicing
obstetrics will meet placenta previa a good
many times in the course of a few years. He
is frequently forced to think quickly and to
act quickly when he encounters this condi-
tion.
For the most part it is easily diagnosed,
sometimes in the first three months of preg-
nancy, when there may occur considerable
hemorrhage without any pain. After the
third month usually the hemorrhage is not
encountered until the sixth month has passed;
then we may have spells of hemorrhage, very
slight or very marked. In such cases the
patient should be thoroughly informed as to
the seriousness of the condition and the ne-
cessity of complete co-operation with the at-
tending physician. If possible, when these
hemorrhage spells occur the patient should
be taken to the hospital. If the hemorrhage
is not very marked patient can be carried to
the hour of labor and when labor sets in or
even before labor begins, she may have pro-
fuse hemorrhage. Therefore, one should be
ready for immediate action in order to check
hemorrhage and bring the patient safely
through either active or inactive labor with
a live baby, which means this: Immediate
delivery and transfusion if necessary. Make
all provisions for transfusion in every case.
Unquestionably, many of these patients have
died because forethought was not used and
when the hour came for emergency treatment,
no emergency treatment was ready.
There are two methods of managing pla-
centa previa. Both are dangerous, not be-
cause of the method of treatment, but be-
cause of the actual condition prevailing.
First, packing the cervix and vagina, wait-
ing until the cervix is completely dilated, and
then delivering. These men who have had
limited experience have been fortunate in
coming out with live babies and mothers, en-
countering no complications. Others have
had most unfortunate results in that several
hours after delivery the mother bled to death
almost instantly.
The second method is that of the use of a
rubber bag inserted into the cervix and in-
flated with water or air to control hemor-
rhage until the cervix is dilated. Of the two
methods this is preferable. If the placenta
previa is marginalis or lateralis, probably the
bag is one of the best things to be used for
the first stage of labor. If the placenta pre-
via is centralis neither of these methods
should be used.
Another method is that of manual dilata-
tion and rapid delivery. In our opinion this
method is criminal. We assume that all pa-
tients with placenta previa should be in the
hospital. Sometime we may have to have
them in the home. Whether in the hospital
or home manual dilatation and rapid delivery
should be condemned. The first reason is
that in manual dilatation of the cervix we
are destroying what protection we have in
the way of preventing hemorrhage; second,
that we usually tear the cervix and damage
the structures in this territory so that it is
impossible to repair them in a way so as to
have as good a cervix as we had before this
procedure. Too, in these cases of dilatation
with rapid delivery, the baby loses much
blood and in many instances is delivered
dead, or, in such shock that it dies soon after
delivery.
The hour seems to be coming when we
shall be able to establish more or less a
standard method of treating placenta previa.
Literature of recent years gives abundance
of evidence to prove that cesarean section is
the most scientific method of handling these
cases. The average case can be diagnosed
usually before we have profuse hemorrhage.
Such a patient should be put in the hospital,
and the hospital force informed of the con-
dition and instructed minutely to have every-
thing ready so that cesarean section can be
done at a moment's notice. Probably ether
or spinal anesthesia is the best form of anes-
thetic to use in these operations. The prob-
abilities are that the high cesarean section is
better, doing as little destruction to the lower
uterine segment as possible, allowing only a
short time in labor and operating rapidly.
Pituitrin should be given as soon as the uter-
us is emptied and ten drops of ergot may be
given every six hours thereafter. Cesarean
section offers safety for both mother and
baby. If these cases are diagnosed promptly
and treated at once we have reason to believe
that we can cut down the maternal and fetal
mortality to the minimum.
Doctors who are practicing obstetrics in
July, 1929
SOUTHERN MEDICINE AND SURGERY
SOS
the outlying districts and in villages without
hospital facilities should make the diagnosis
and have such a patient in a hospital the last
few days of pregnancy and be ready for any
emergency that may arise.
There are a good many men practicing
obstetrics with a conservative attitude who
feel that, because they have been successful
in delivering a few babies satisfactorily by
the birth canal in placenta previa, they are
justified in following this practice. Men who
have had bigger experience and who have
delivered a good many thousand babies by
the birth canal and by cesarean section now
feel that the choice of treatment in this con-
dition is by section.
We have in many instances saved babies
and mothers by delivering by the birth canal
in placenta previa, but the danger that, in
cases of lateralis placenta previa and cen-
tralis placenta previa where much of the
placenta is found in the territory of the in-
ternal OS and the lower uterine segment, after
delivery the sinuses in this section do not
close up properly and many of these mothers
who have been delivered successfully and ap-
parently are safe suddenly bleed to death be-
cause of this mechanical and physiological
condition. This is the biggest reason why
cesarean section is the safest method. The
structures in the lower uterine segment are
not stretched: the muscles in this territory
do not burn up their vital energy in trying to
force the passage of the baby; they are left
with abundance of food and their contractile
ability; and when cesarean section is perform-
ed properly we do not encounter profuse post-
partum hemorrhage.
We hope the profession in our territory
will view with more seriousness this condition
which is killing a great many mothers and
babies annually.
We arc rill agreed in Mobile on this point — when-
ever the pulse begins to flag we begin to stimulate,
and nothing seems to hit a Mobile stomach like a
mint julap. — Dr. J. C. .Nutt, "Sketch of Epidemic
of Yellow Fever of 1847," Charleston Medical Jour-
nal, 1848.
HISTORIC MEDICINE
J. RuFus Braxton — Planter, Doctor,
Patriot, Gentleman of the Old
School
.Autobiographical sketch of the First Fifty Years of
His Life, superscribed. "For my Children in
Future Life," supplemented by a Note on His
Later Years, by Miss Margaret Gist, of York.
For ingrowing toe-nails an absorbent cotton
pack under the center of the nail — not under its
narrow edge will cjuickly bring relief, and subse-
quent square trimming of the nail will prevent re-
currence.
I was born at the old original homestead
in York District, S. Ca., settled by (irand
Father' some time in the year seventeen hun-
dred, in the year 1821, Novr. 12th; was first
sent to school to old Mr. George Dale, who
lived then at what is called the Dale place
and in the same house to learn my letters —
next to H. F. Addickes who taught in a log
house on the spot where Uncle Sam Rainey's
house now stands.
In 1830, Rev. Mr. Cyrus Johnson came
into the neighborhood and established a large
& excellent English and Classical School for
boys and girls. To him I continued to go
to School, preparing for the S. Carolina Col-
lege untill the year 1839, when with my
Brother John I was sent to VVinnsboro to
Mr. I. M. Hudson in Charge of the Mt. Zion
School to finish our preparation for admis-
sion into the Sophomore Class at Columbia,
which we did in the year 1840 & graduated
at that College in the winter of 1842, not
with the first honours of the class, but with
an honorable & creditable standing for mor-
ality & intellect in the Same. In January
1843, myself and my Brother John com-
menced the study of -Anatomy with Drs. Fair
& Wells in Columbia in their dissecting
Rooms in their garden to the rear of their
office. Having completed the course of dis-
section in April 1843, we returned home to
continue the study of the other branches un-
der the instruction of our Father. -
Upon his untimely & lamented death in
1843, April 2 7th, we were for a time impeded
in the course of our Studies, John having be-
come .Admr. of the Estate of my Father in
connection with George Steele gave up the
Study of Medicine, whilst I continued the
study and attended my first course of Lec-
tures in Medicine & Surgery at the Charles-
ton Medical in 1844 & graduated at the
School in the vear 1845. March 15th. Was
1. Colonel William Bratton, of Revolutionary
fame.
2. Dr. John S. Bratton.
506
SOUTHERN MEDICINE AND SURGERY
July, 1920
married Feby. 12th, 1850. On the 1st of
April same year I went to Philadelphia to
attend the hospitals there & at same time
became engaged in the pauper practice of the
City with the view to familiarize myself with
the nature of diseases & their remedies and
their process of operation. In this expedition
I took with me my Sisters Martha'' & Mary^
who went to visit the Cities & Country North
as well as to learn Music. I attended the
hospitals daily. With the City Hospital
Almshouse across the Schuylkill & the Eye
Hospital & got a large pauper practice under
the Supervision of Professor Homer, Drs.
Smith, Benedict, Ludlow, Neil & others.
During the Summer of 1845 with my Sisters
& with our friends from Camden, S. Ca., Dr.
Jas. D. Starke & his widowed Sister, Mrs.
Abbot, I visited New York, Albany, Troy,
thence partly by Erie R. Road & Canal the
principal Cities of Western New York, Ni-
agara Falls, Lake Erie, Montreal by the
River, thence by Lake George to Saratoga
Springs, where we remained for a few days,
then again back to New York & Philadel-
phia— about the last of August. Here I re-
sumed my duties another month and returned
home by Wilmington & Charleston in Octr.,
1845. I bought my first supply of medicines,
&c., from Dr. Carpenter in Pha. & com-
menced practice of medicine in copartnership
with Dr. Wm. Moore in Yorkville Nov. 1845.
My income for the first year in Said Co-
partnership was only 600 hundred Dollars.
I am Satisfyed I could have done better alone
and would advise all young men commencing
practice of Medicine to lean on themselves
alone unless their Copartner is a JMan of
much influence & Medical Skill. In 1847 I
continued the practice alone with much more
profit & instruction & realized over 1000 dol-
lars profit. For every year afterwards by
attention to my profession my practice in-
creased beyond my expectations. In 1850,
Feby. 12th, I was married to Mary Massey,
of Lancaster. I continued to practice alone
untill the year 1855 when I formed a copart-
nership with Dr. A. I. Barron. This copart-
nership continued with much satisfaction and
profit to both of us untill April 13th, 1861,
when the war between the North & South
began. I volunteered my Service as Asst.
Surgeon to Col. Jenkins of the 5th Regiment,
S. Ca. Volunteers & was willingly and Cheer-
fully accepted. This Regiment had three
companies from York. Captain Seabrook's,
Capt. Jackson's & Capt. Glenn's. It left
Yorkville"' on Saturday, 13th April, 1861, went
to Columbia, quartered in the Columbia Fair
Grounds for two days & then went to the
Race Course in Charleston, where we stayed
three days more & then were ordered to Sul-
livan's Island. Here quartered in the homes
of Citizens & and the Moultrie house we
stayed & performed Military duty in drilling,
&c., until the 27th of May. During this time
much sickness, as Diarrhea & Dysentery, ex-
isted among the troops & but one death only
occurred during our stay there. This was
Claibn. Mason who was left in my Charge on
the Island when the Regiment was ordered
to Virginia with a week's furlough at home.
I remained with him a few days, when, grow-
ing better, he insisted that he should be taken
home but the fatigue on the Cars proved to
heavy fcr him & I was forced to stop at
Hunt's Hotel with him when in two days he
died. I then went on home, stayed a week
with your Mother & the three boys & started
for Columbia again to be mustered into Ser-
vice by Col. Bee, afterward Genl. Bee &
killed at the first Manassas battle. Being
taken sick with Dysentery I returned home
and stayed until I recovered which was about
a week after the Regiment had left home for
Richmond (about the 7th of June). In com-
pany with Wm. Barron, now Dr. B., I re-
joined the Regiment at Richmond encamped
near the Reservoir, where this Camp Winder
Hospital is now situated & from which I
now write this short history of myself & my
works for your future, pleasure, gratification
and instruction. The Regiment left Rich-
mond about the 16th of June & went by R.
Road to Manassas Junction, thence IJ2 miles
above to a large field on the R. Road, where
we encamped in tents & established a hos-
pital in tents for the sick, of which there were
many soon with measles & Typhoid fever. Dr.
A. W. Thomson as Surgeon & myself as .\sst.
Surgeon to the Regiment worked well to-
gether doing all that we could for the com-
fort and relief of the patients. .\t this place
we fared well in plenty to eat, tho" anxiety
of mind and Separation from Your iMother
& you were the only causes of my trouble.
3. Mrs. J. Thomas Lowry,
4. Mrs. W. H, ;-owry.
S. The county scat of York County. Name
changed to that of the County within the past 20
years.— -JSrfj,
July, 1929
SOUTHERN MEDICINE AND SURGERY
S07
This however I soon learned to bear with
patience & fortitude. This Camp was in
Prince William County & was called Camp
Walker in honour of Genl. Walker then of
the Confederate Army. Here we remained
until the 17th July, when we were ordered
to prepare three days rations & march to a
point just a short distance this side of Cen-
treville and take position in a cluster of woods
near the Road so as to cover the retreat of
Genl. Bonham, who would leave Fairfax that
night. All thou<^h the night the heavy lum-
bering of the -Artillery waggons could be
heard passing along the road to Mitchell's
Ford as I & Dr. Thomson lay in the ambu-
lance not far from the Regiment. At day
break Genl. Beauregard's aide came to us in
a hurry and told us to get back to McClane's
ford as soon as possible as the enemy were
in our rear but a short distance. The Regi-
ment & we with the ambulance made good
time back to McClane's ford which we
reached about 8 o'clock in the morning &
began throwing up temporary breast works
against the expected attack of the Enemy.
Had we remained 20 minutes longer in the
woods we would have been surrounded &
cut to pieces as the Yankee prisoners said
who were taken in the tight of that day, July
18th. The Enemy did not attack us at Mc-
Clane's ford, but at Blackburn's ford, when
they mere met by the Georgia, La. & Va.
troops under Genl. Longstreet & driven back
with heavy loss. Our loss about sixty killed,
wounded & missing. Our Regiment was not
immediately engaged though under fire of the
Shells during the fight which began at 11
o'clock & lasted until 5 P. M. The wounded
were carried to McClane's barn a Stone
building at which the Yankees frequently
shot though the hospital Yellow Flag was
flying from its top. I assisted in dressing
the wounds of men from other Regiments that
Evening, some of whom died as soon as they
were brought in.
.After dressing the wounded & whilst going
from the Hospital across the field with Ur.
T. to our Regiment, several shots from the
Rifled Cannon called "Long Tom" were fired
at us, one of which struck in four feet of my
head after 1 had thrown myself on the ground
to avoid the shell. Fortunately it did not
burst. To escape the Shells & the sight of
the Enemy we were compelled to roll our
bodies into a branch with high banks which
ran through the field. This movement shield-
ed us from their view & their shells, here we
remained for a few minutes when we made
our escape afterwards across the field in
double quick time to our Regiment still at
its post at the ford. Here we remained until
the first on Sunday, July 21st, when we had
another battle, in which our Regiment had
hot work. Late in the afternoon about S
o'clock in Charging over a large broken field
upon the Yankee batteries which the Enemy
ran off with & thereby saved their batteries.
Our Regiment lost — killed & about
thirty wounded. Ur. T & myself were all
that night (Sunday) to near day break busy
in amputating limbs and dressing wounds.
It was a gloomy weary day. My anxiety for
myself, though in the rear of the Regiment
exposed the whole time to flying & bursting
Shells & for Napoleon" who was on the field
made me deeply sad & how thankful I was
when the battle was over, that we should
meet again both unhurt. I shall never forget
the scene nor my feelings on that night, when
I went to the Camp & found Napoleon un-
hurt. Next morning by daylight I was or-
dered to take a squad of men with me, pro-
ceed to the battle ground & collect the bal-
ance of the wounded under a white flag, but
the Enemy had gone, leaving much of their
Camp Equipage & provisions. The few of
our wounded left on the field during the
night were dressed & sent back to the Hos-
pital, the dead were collected on the center
of the field & wrapped in their blankets with
their hats over their faces were buried there.
This was a solemn scene long to be remem-
bered. This was on Monday, a very wet
day (24th) when we were ordered forward
nearer the Enemy; to our next Camp called
"Camp Pettus" — here we remained drilling
every day until 12th .August, when the whole
Brigade moved to Germantown beyond Cen-
treville & left me in Charge of the Sick of
the whole Brigade near about 400 men, with
none to assist me but Barron & Meek, then
assistants. For the first week I had the hard-
est work of the Campaign. Here I remained
for three weeks, when the sick sent back to
the different hospitals of their respective Reg-
6. A brother.
{To be Continued)
SOUTHERN MEDICINE AND SURGERY
July, 1929
NEWS
Virginia's Traveling Mental Clinic
The Department of Public Welfare of Vir-
ginia has established a mobile mental hygiene
clinic. Dr. W. F. Drewry will have general
charge of the mental work in the Department,
but eventually a psychiatrist will give whole
time to the mobile clinic. The work of the
clin'c got under way at Roanoke on June
17-18-19. There Dr. Virginia T. Graham
and Miss Elizabeth Rice, both of the Depart-
ment of Public Welfare, and Dr. O. B. Dar-
den, of Richmond, held a clinic, at which a
number of children were examined, some of
whom had exhibited troublesome conduct
disorders and others had experienced difficulty
in school work.
giene make possible proper emphasis on the
teaching of preventive medicine.
Southern Parenthood Institute at
Black Mountain
Dr. Frank Howard Richardson announces
the first session of the Southern Parenthood
Institute to be held at Black Mountain, N.
C, in connection with the Children's Clinic.
The Institute will run from August 12th to
August 16th inclusive. The mornings will
be given over to lectures by authorities on
various phases of parenthood and child study.
The afternoons will be occupied by actual
observation of children in playground, nutri-
tion class, posture class, handwork room, etc.
Children may be left in the playground under
observation while parents attend morning
sessions. Oppf)rtunity will be given for con-
ference over particular problems. A nominal
registration fee of two dollars, to cover the
actual expenses of the course, will be made.
Chair Public Health in U. Va.
Dr. Kenneth F. Maxey, assistant surgeon
of the United States Public Health Service,
has been elected professor of public health
and hygiene in the University of Virginia.
The establishment of a chair of public
health and hygiene in the University has
been made possible by a gift from the gen-
eral education board to the department of
medicine.
New quarters in the recently completed
medical building, with special laboratories
for the teaching of public health and hy-
Roaring Gap Children's Hospital Opened
Roaring Gap Children's Hospital, located
at an elevation of 3,400 feet, in the Blue
Ridge Mountains in Alleghany county, open-
ed on June 2 7th. This hospital is under the
direction of Dr. L. J. Butler, of Winston-
Salem, and was made possible through a gift
of Mr. and Mrs. James A. Gray, of Winston-
Salem.
The staff on duty at the hospital includes
the resident physician. Dr. B. E. PuUiam,
graduate of Jefferson Medical College, Phil-
adelphia, and recently connected with
Memorial Hospital, Winston-Salem, and the
superintendent. Miss Lillian Anderson, R.N.,
formerly superintendent of nurses at the Bap-
tist Hospital, Winston-Salem.
The hospital, which will be open during
the summer season, is equipped to take care
of 22 patients. One of the unique features
of the hospital, and one which is thought to
have a strong appeal, is the fact that a num-
ber of rooms are so arranged that the mothers
can have beds in the same rooms with their
sick children, when the parents so desire.
Grace Hospital, Richmond, erected in
1911 by Drs. Rijbert Bryan and Stuart Mc-
Lean, has changed hands. The new owner is
the Henry Franklin Hospital Corporation,
which is headed by Dr. A. L. Herring, presi-
dent; Dr. John A. Rollings, vice-president;
Dr. T. B. Pearman, secretary, and Dr. E. T.
Trice, treasurer. They, with an added group
of more than a dozen physicians, are owners
of the new company. The hospital is at pres-
ent operated on a fifty-two bed capacity ba-
sis. It is planned to enlarge this to a ca-
pacity of from eighty-five to ninety beds, and
to have all the facilities of a general hospital
and making a specialty of surgery. The in-
stitution will retain its present name.
At the recent commencement of the Uni-
versity of North Carolina the honorary degree
of Doctor of Laws was conferred on Dr.
George Hughes Kirby, of New York City.
July, 1929
SOUTHERN MEDICINE AND SURGERY
The Babies Hospital is situated just across the suund from Wrishtsvillc Beach.
It is a modern fire-proof hospital lor infants and sick children, with accommodations for the
mothers who desire to stay with their babies. There is a milk station in the hospital where infants
outside of the hospital may obtain milk formulas.
/( four-months post-graduate course given to graduate nurses interested in pediatries
Pediatricians-in-Charge — J. Buren Sioburv, M.D., and Tom M. Watson, M.D.
NEW YORK POST-GRADU.\TE MEDICAL SCHOOL AND HOSPITAL
Announces new courses
in
PEDIATRICS
Physical Diagnosis, Practical Pediatrics, Infant Feeding, Communicable Diseases, Gastro-Intestinal
Disorders of Childhood, Malnutrition, Bedside Rounds and Allied Subjects.
Courses are of one, three and six months' duration and are continuous throughout the year.
For descriptive booklet and further information, address
THE DEAN. 300 East Twenty-first Street, New York City
University of Maryland School of Medicine and
College of Physicians and Surgeons
Requirements for Admission — Two years of college work, including English, Chcmistrv,
Biology and Physics, in addition to an approved four year high school course.
Faeilities for Teaching — .Abundant laboratory space and equipment. Two large general
hospitals absolutely controlled by the faculty and several hospitals devoted to specialties, in which
clinical teaching is done.
For catalog apply to J. M. H. ROWLAND, M.D., Dear
N. E. Cor. Lombard and Greene Sts., Baltimore, Md.
"Are you here for mmslaughter?" the warden
asked the prisoner.
"No, sir."
".Aren't you? This card says you arc here for
manslaughter."
"Yeah, that's what thit fool judge said. But I
told him twice it was a woman I croaked."
— Jour. Ind. State Med. Assn., June, 1929.
THE BIG-HEARTED HUSBAND
"Your wife is talking of going to Palm Beach for
the winter. Have \ou any objections?"
"None at all. L 't her talk. — .Irmc International
Bulletin.
.\ gentleman asked a poor old Scot:
"Sandy, how's the world treating you ?"
"Very seldom, sir, very seldom."
SOUTHERN MEDICINE AND SURGERY
July, 1929
Dr. Kirby is a graduate of the University in
the class of 1896 and a graduate in medicine
from the Long Island College Hospital Medi-
cal School in the class of 1899. Dr. Kirby
occupies the chair of psychiatry in the medi-
cal school of Columbia University.
.At the same time the same degree was con-
ferred on Dr. Clarence Albert Shore, of
Raleigh. Dr. Shore is a graduate of the Uni-
versity in the class of 1901 and of the medi-
cal schools of Johns Hopkins University in
the class of 1908. Dr. Shore is the director
of the laboratory of the North Carolina State
Board of Health.
The last legislature passed a law provid-
ing a Workmen's Compensation Act which
applies to all employers who employ five or
more people. Hon. Mat .Allen, Chairman of
the Industrial Commission, who will handle
th's matter, has appeared before a number
of the County and District !Medicil Socie-
ties to discuss the matter. .At the request
of Governor Max Gardner a conference was
held by the Industrial Commission and the
E.xecutive Committee of the Medical Society
of the State of North Carolina to discuss
plans and measures. The conference seemed
to be entirely satisfactory to all parties con-
cerned and a liaison committee was appoint-
ed by President Crowcll to advise with the
Industrial Commission. The personnel of the
committee is as follows: Dr. L. A. Crowell,
President of the Medical Society of North
Carolina, Chairman: Dr. R. B. Davis, Coun-
cilor of the Eighth District, Greensboro; Dr.
T. C. Bost, Councilor Seventh District,
Charlotte; Dr. J. B. Cranmer, Councilor
Third District, Wilmington.
Dr. Frank Howard Richardson an-
nounces the opening of the Children's
Clinic at Black Mountain, N. C, for the
coming season. The group confines its at-
tention exclusively to children. It is pre-
pared to give the child, whether sick, under-
nourished, or well, a comprehensive physical
examination, supplemented by every diagnos-
tic aid, for the discovery and removal of
any handicap to his highest efficiency. .A
complete transcript of findings, with recom-
mendations for the future management of
the ch'ld, is sent to the home physician, for
his guidance.
The Black Mountain Diagnostic Labora-
tory is in operation during the summer sea-
son and is prepared to render to physicians
every aid in their clinical problems.
The Ninth Session of the Southern Pedia-
tric Seminar will be held July 29th to Au-
gust 10th, 1929, at Saluda, N. C. Dr. D.
Lesesne Smith, of Spartanburg, S. C, and
Saluda, N. C, is registrar. Dr. Wm. A.
Mulherin, of Augusta, Ga., is Dean and Dr.
Frank Howard Richardson, of Black Moun-
tain, N. C, and Brooklyn, N. Y., is Vice-
Dean. Thirty-three men of great ability
compose the staff. There are a few scholar-
ships for doctors who live in small towns in
North Carolina.
The Third District ^Medical Society,
at its recent meeting in Wilmington, elected
the following officers for the ensuing year:
President, Dr. John D. Robinson, Wallace;
Vice-President, Dr. W. I. Taylor, Burgaw;
Secretary and Treasurer, Dr. Thurston For-
myduval, Boiton.
At a recent meeting of the Tenth Dis-
trict Medical Society at the Battery Park
Hotel, Asheville, Dr. W. B. Robertson, of
Bur:i?ville, was elected President; Dr. D. M.
Mcintosh, of Old Fort, was elected Secre-
tarv.
At a recent meeting of the Sixth District
INIedical Society, held at Burlington, the
following officers were elected: Dr. H. A.
Newell, Henderson, President; Dr. R. E.
Brooks, Burlington, \'ice-President; Dr.
Burton W. Fassett, Durham, Secretary-
Treasurer. Dr. L. A. Crowell, President of
the Medical Society of the State of North
Carolina, was present and delivered an ad-
dress on the Relation of the Physician to
the Workmen's Compensation Act.
It is reported that the Duke Foundation
Hospital section and the Rosenwald F'oun-
dation plan to establish twelve regional hos-
pitals for negroes in North Carolina.
Dr. Robert McKay, of Charlotte, was
one of the principal speakers at a meeting of
the staff of the Baptist Hospital, Columbia,
July 2nd.
July, 1929
SOUTHERN MEDICINE AND SURGERY
SOUTHERN MEDICINE AND SURGERY
July, 1929
A number of visitors were present at the
gathering for a discussion of the value of a
urological department for the hospital. Talks
on the subject, in addition to that of Dr.
McKay, were made by Dr. Milton Wein-
berg, Sumter, and Dr. Robert Wilson, jr.,
Charleston. Dr. George H. Bunch, chairman
of the staff, presided.
Dr. T. N. DuLiN, member of the S. C.
Legislature from York county, had the mis-
fortune to seriously injure a negro woman
by striking her with his automobile while
driving through Clover, S. C, July 3rd. The
accident is said to have been unavoidable.
Dr. G. M. Gold, of Shelby, N. C, died
July 2nd, at the Rutherford Hospital while
undergoing a physical e.xamination, which he
decided upon in recent days due to declining
health.
The veteran physician practiced medicine
in Shelby and Cleveland county for 48
years prior to retiring a few months back.
During his medical career he ushered 4,000
babies into the world in Cleveland and Ruth-
erford counties. .At the time of his death
he was county commissioner, and prior to
moving to his country residence at Polkville
18 months ago he was a mem'ber fo the city
council of Shelby.
Dr. E. L. McQuade, Henrico County
(V'a.) health officer, has resigned to accept a
position as instructor of epidemiology at
Johns Hopkins University. His resignation
becomes effective July 1st, and he will be
succeeded by Dr. A. L. McLean. Dr. Mc-
Quade has been in office for two years.
Dr. McLean was for three years health
officer of Southampton County, but for the
past year has been doing graduate work at
Johns Hopkins University. He completed
this work just before returning to Virginia,
being awarded the degree of doctor of public
health.
The past month Dr. McLean has spent
with the Virginia State Board of Health,
studying the typhus fever problem.
Dr. L. a. Crowell, Lincolnton, head of
the State Medical Society, addressed the Ki-
wanis Club of Shelby, July 4th.
An outbreak of typhoid (7 cases) in
McDowell County, Va., calls attention to the
urgent need for vaccination for safety from
this disease. Doctor, are you, your family
and your patients protected?
Lieutenant-Colonel Gerald .\. Eze-
KiEL, Major William R. Weisiger, Major
Franklin A. Taylor and First Lieuten-
ant Yale Passamaneck, all Richmond med-
ical officers, have been ordered to the Medi-
cal Field Service School at Carlisle Barracks,
Pa., for active training with the 305th Medi-
cal Regiment from July 7th to July 20th.
Governor Gardner has re appointed Dr.
A. J. Crowell, of Charlotte, and Dr. C. C.
Orr, of Asheville, as members of the State
Board of Health. Their new terms are six
years.
Dr. Crowell is president of the board.
There are nine board members, five being
appointed by the Governor and four elected
by the State Medical Society.
Dr. Harold Porter, of Red Springs, N.
C, and Miss Gertrude May Gates, of Pat-
rick County, Va., were married June 24th.
Dr. George B. Barrow, Clarksville, Vir-
ginia, has become a member of the medical
staff of the Western State Hospital at Staun-
ton, X'irginia. Dr. Barrow is a graduate of
the Medical College of Virginia in the class
of 1910.
Dr. N. Thomas Ennett, ^Medical Direc-
tor of Richmond Public Schools, sailed from
New York on the Majestic on the 10th for
Europe. He will attend a number of School
Clinics abroad, visiting Scotland, England,
Belgium, Germany, France, Switzerland and
Italy, returning September 1st. Mrs. Ennett
accompanies.
Dr. Eugene Robinson, M. C. Va.. '2 7,
Kannapolis, N. C, and Miss Mildred
Eaves, of Cabarrus, were married June 22nd.
Dr. Charles Lewis Baird, of the staff of
Walter Reed Hospital, Washington, and
Miss Mary Virginia Smith, of Richmond,
were married June 2Sth.
July, 1929
SOUTHERN MEDICINE AND SURGERY
LukiLre /i/IonxxC
/s nx)Co ntaae d
ae
Tfiii caxtral adyninisfraiwn build in q of
it\e mco ^ocke'JahomToriesaT^Xut&yJleojJerjcy
DOSAGE:
For Nervousness
1 to 2 tabids a dav
For Pain
For Sleep
for pain and sCeebdessywss
ALLOMAL
ik,
Kcn-nan
■coiJi
c
is the remedy almost universally prescribed in place
of opiates. Allonal is routine in practicaliy every
hospital in the country. To be certain that they
■ are employing the safest a.'id the best sedati%'e,
hypnotic, and analgesic for allaying n^-rvousness,
insomnia and pain physicians order A'lonal 'Roche'
Hoffman n-La Roche, Inc.
SMaicn of SMedicinet of %are Siual'.ty
NUTLEY, NEW JERSEY
SOUTHERN MEDICINE AND SURGERY
July, 1Q29
Dr. James Lewis Poston, Statesville, and Dr. Chipman Hunter Binford, formerly
Miss Mildred Sedberry, Fayetteville, were of Pamplin, V'a., now of Norfolk, M. C. Va.
married June 2Sth. Among the attendants '28, and Miss Thelma Lynette Beau-
were Dr. V. K. Hart and Dr. R. A. Moore, champ, of Rxhmond, \'a., were married June
Charlotte, and Dr. S. R. Ryler, Durham. 29th.
Dr. Emerson iM. Babb, of Ivor, Va., and
Miss Virginia Smith, of Franklin, were
married June 24th.
Dr. Guy L. Wicker, Kannapolis, N. C,
and Miss Clarice Tuttle, of Wallburg,
were married June 24th.
Dr. R. K. Adams, for several years a mem-
ber of the medical staff of the State Hospital,
Raleigh, North Carolina, has resigned to ac-
cept a position with the State Epileptic Vil-
lage, Skillman, New Jersey. Dr. Adams is a
graduate of the Jefferson Medical College in
1912.
Dr. William A. Murphy has resigned his
medical commission in the United States
Army and returned to his home near Staun-
ton, Virginia. Dr. Murphy is the son of the
late Dr. P. L. Murphy, for many years the
superintendent of the State Hospital, Mor-
ganton, N. C. ,
Dr. p. p. McCain, superintendent of the
North Carolina Sanatorium, although ill and
unable to attend the meeting of the National
Tuberculosis Association, held during the
week of May 28th in Atlantic City, was hon-
ored by election as director-at-large of the as-
sociation.
Dr. Stuart McGuire, Richmond, was
elected chairman of the e.xecutive committee
of the board of visitors of the Medical College
of Virginia, at a recent meeting, according to
an announcement made by Dr. W. T. Sanger,
college ]3resident.
Other members of the committee are: Ju-
lien H. Hill, vice-chairman; H. W. EUerson,
Eppa Hunton, Jr., W. R. Miller, W. T. Reed,
Dr. Douglas \'anderHoof and Dr. W. T. San-
ger, ex-officio.
Dr. C. a. Julian and Dr. Fred M. Pat-
terson, both of Greensboro, have returned
from a six-weeks European tour.
Dr. Louis ^L Fowler, 27, son of Capt.
C. W. Fowler, of Greensboro, was drowned
in the Mississippi river, near Rochester,
Minn., Sunday, July 1st.
Dr. J. L. McElroy, following several
months given to visiting medical centers of
Europe, has become superintendent of the
hospitals of the Medical College of Virginia,
Richmond. These are the Memorial, the
Dooley, and the St. Philip Hospitals. The
Crippled Children's Hospital is affiliated as
the orthopedic department for white children.
REVIEW OF RECENT BOOKS
OSTEOMYELITIS .^ND COMPOUND FR.\C-
TURES .'VND OTHER INFECTED WOUNDS,
TREATMENT BY THE METHOD OF DRAIN-
AGE AND REST, by H. Winnett Orr. M.D..
F.A.C.S., Chief Sureeon Nebraska Orthopedic Hos-
pital, etc. Illustrated. C. V. Moshy Co.. St. Louis,
192Q. .$5.00.
The author is very much in earnest about
the value of methods aiming at helping oiU
Nature in her efforts to drain and rest, ar.d
he regards antiseptic treatment as of very
much less importance. A refreshing and ap-
proving introduction is made by Dr. John
Kidion.
The methods of management recommend-
ed for infected wounds are certainly very dif-
ferent from those in general use and they
appeal greatly to the reason. They deserve
careful consideration and the most extended
checking against methods now being used by
most doctors.
CLINICAL LABOR.^TORY METHODS, by
RusicU Landram Hadeit, M.A., M.D., Professor of
July, 1029
SOUTHERN MEDICINE AND SURGERY
RELIEF! Nothing Else Matters!
TJ/^ confronted with abdominal pain — in the host of in-
flammatory conditions pecuHar to pregnancy — in cases
of acute gastroenteritis, gastralgia, enterocolitis and chronic
mucous colitis, physicians find that relief of local discomfort
comes more rapidly when
is used as an acljiinct to the general treatment. Applied in hot, thick
layers to the alidomen and liver area, this simple procedure has an active
influence over not only tlie amount and character of the bile that is se-
creted, but upon the production of the digestive juices generally. Leading
practitioners everywhere confirm the beneficial results obtainable with
this standard poultice and dressing in many types of inflammatory
conditions, both superficial and deep-seated.
AJ4C< \
\S-
The Denver Chemical Mfc. Co.,
163 Varick St., New York City. ^
Dear Sirs: '^ ou may send me a complimentary copy of your booklet "Pregnancy
— It8 Signs and Complications" (sample of Antiplilogistine included).
■■■■■■■■■■■■■■1
:si6
SOUTHERN MEDICINE ANt) SURGERY
July, 1039
Experimental Medicine, University of Kansas School
of Medicine. 60 illustrations and 4 color plates.
Third edition. C. [-'. Mosby Co., St. Louis, 1920.
$5.00.
f
Simplicity, completeness and brevity are
aimed at, ard to a sreat decree, attained. Tis
concseness is indicated by the whole of qual-
itative uranalysis being given in 17 pages.
only 10 of reading matter. It is a book which
will serve well as a guide to laboratory aids
in diagnosis and to convince men in general
pract ce that there is nothing mysterious or
particularly dii'iici'l'i about routine laboratory
work.
INTERN.\TION.'\L CLINICS, A Quarterly of
Illustrated Clinical Lectures and Especially Prepared
Oriftlnal -Articles, edited by Henry W. Cattell. A.B..
M.D. Vol. II. Thirty-ninth Scries, 1920. /. B.
LippUnott Co., Philadelphia.
Subjects and Authors as follows:
"Congenital and Developmental Aneurysms
and Their Importance in Regard to the Oc-
currence of Sudden Intracranial (Especially
Subarachnoid) hemorrhage," by Drs. F.
Parkes Weber and O. B. Bode, of London;
"Treatment of Pneumonia," by Dr. A. H.
Gordon, of Montreal; "Diagnostic Value of
Some Refle.xes," by Dr. Alfred Gordon, of
Philadelphia; "The Syndromes of Chronic
Nephritis and Their Corresponding Morpho-
logical Changes," by Dr. Francis D. Murphy,
of J.lilwaukee; "The Renal Factor in Eval-
uating the Patient With Chronic Gastro-In-
testinal Symptoms," by Dr. Jonathan For-
man, of Columbus, Ohio; "Prostatic Involve-
ment in the V'ery Aged," by Drs. G. S. Foster
and John Deitch, of Manchester, N. H.;
"Clinical Sp rograms and Their Significance,"
by Dr. Max Trumper, of Philadelphia; "De-
generative and Diffuse Inflammatory Diseases
of the Liver," by Drs. George Baehr and Paul
Klemperer, of New York; "Roentgenographic
Visualization of the Coronary /\rteries in
Normal and Pathological Hearts," by Dr.
Wendell E. Boyer, of Germanton, Pa.; "The
Present Status of Pyelitis in Children," by
Dr. Louis Barash, of New York; "Varicosity
of the Inferior Vein," "Carcinoma of the Rec-
tum," "Empyema of the Gall-Bladder," by
Dr. Moses Behrend, of Philadelphia; "Spinal
Anesthesia," by Dr. Frank N. Dealy, of New
York; "The Significance of Injuries at the
Ilio-Ischio-Pub'c Junction of the Acetabulum
in Children," by Dr. Henry Keller, of New
York; "The Maternal Side of Femininity," by
Dr. Edward Lodholz, of Philadelphia; "What
Can the Medical Profession Do for Phar-
macy?", by Dr. Horatio C. Wood, jr., of Phil-
adelphia; "What Professional Pharmacy Can
Do for ^ledicine and What It May E.xpect
in Return," by Dr. Charles H. LaWall, of
Philadelphia; "Manners and Morals," by Dr.
Lewellys F. Barker, of Baltimore.
THE CONQUEST OF C.'\NCER BY RADIUM
AND OTHER METHODS, by Daniel Thomas
Quigley, M.D., F.A.C.S., Instructor in Surgery in
the University of Nebraska College of Medicine;
Member A. Asso. Advancement of Science, Nebraska
Academy of Sciences; N. A. Soc, Amer. Radium
Soc; F.A.C.R., etc.; Director Radium Hospital,
Omaha. Illustrated with 334 engravings. F. A.
Davis Company, Philadelphia, 1929. <;6.00.
It is difficult to see how an author can
speak of the conquest of a disease of which
he says, "the rate of increase each year seems
to be greater, so that the very life of the race
is threatened." However, if the choice of a
title was guided by optimistic enthusiasm, as
we presume it was, certainly few will object.
Causation, prophyla.xis and treatment are
given e.xtended consideration. The section of
greatest interest is that, the title of which is,
"A Summary of W'hat We Know Concerning
Cancer;" and what we know, so far as ap-
plies to its prevention or cure, seems patheti-
cally little. According to the author, "the
basic fact in connection with new growth of
tumors is irritation of living cells by m'cro-
organisms and their toxins," and to prevent
cancer one must "keep the resistance of the
body so that the individual will not be easily
made the victim of infectious processes, and
to keep free from foci of infection," eschew
food which has been refined or canned, "at
times exercise mentally and physically to the
utmost capabilities of his organism" and not
"shut himself away from sunshine and fresh
air."
It's a large order.
NOT MOUNT.AIN DEW
"What's the matter with that physical wreck over
there? Has he had the flu?"
"No but he did everything people told him would
keep it off." — Liverpool Post.
July, 1929
SOUTHERN MEDICINE AND SURGERY
Sir
The
I
§ugar Institute
Appeals to the
American Public
^» Marshaling scientific and
medical opinion for the
improvement of diet and of
health
M()dp;rn business intilligcnce realizes
that the interests of an industry can-
not be permanently advanced unless
the public is benefited by sucli an
advance. The Sugar Institute — rep-
resenting an association of the cane
sugar refiners of tlie United States —
is proceeding on the belief that the
position of the sugar industry cannot
be permanently enhanced unless sucli
enhancement results concurrently in
improved diet and liealth for all ages
and classes.
The Sugar Institute, under tlie
guidance of eminent scientific author-
ities, is seeking to show the public in
simple, understandable language, in
more than 500 newspapers, how sugar
as a flavor may be used to encourage
the ingestion of many healtliful foods
so likely to be neglected in tlie inade-
(juate diet.
Kvciy effort is being made to dis-
courage the ])nblic from gorging or
overeating sugars or other sugar-
containing foods.
Tlie public is being advised not to
eliminate sugar or any otlier food
from the diet unless upon the advice
of a physician.
The dangers of extreme dieting for
unnatural wciglit reduction as pointed
out by numerous physicians arc being
eiii])liasi/ed.
A constant drive for a varied, bal-
anced diet is being carried on with
special emphasis upon milk, fruits,
\egetables ami cereals.
Recipes, prepared by cooking ex-
perts of national standing, are being
])ublislie(l to show how small amounts
of sugar as nature's supreme flavorer
relieve the natural blandncss of many
foods and make these healthful foods
more acceptable and delightful
to the taste of growing children
and adults.
The Sugar Institute asks the co-
operation of all physicians and health
authorities who are sympathetic with
its platform to hclji make it effective.
Good for)d jiromotes good health. The
Sugar Institute, 129 Front Street,
New York, N. Y.
Examine our pages! Does your supply house advertise with us? Ij not, please let us know.
SOUTHERN MEDICINE AND SURGERY July, 1029
FIVE REASONS FOR THE
USE OF BIPEFSONATE
1. It contains a combination of remedial agents best suited for the
purpose for which it is used ,i. e., Zinc, Sodium and Calcium Phenolsul-
phonates, Sadol and Bismuth subsalicylate, all INTESTINAL ANTISEP-
TICS and maild astringents; also Pepsin in sufficient quantity to allay
nausea.
2. These agents are dissolved and suspended in a soothing, mucilaginous,
demulcent mixture, aqueous, not alcoholic. It is soothing to inflamed
mucus membrane and at the same time antiseptic and astringent. Prepara-
tions which contain alcohol in considerable quantities are not desirable as
intestinal antiseptcs for infants and children. Bipepsonate is free from
these objectionable features.
3. Containing no Opium or narcotics, Bipepsonate can be administered
fi'eely with perfect safety and it does not readily constipate. It removes
the cause of diarrhoe, cholera infantum, etc., and the stools soon become
normal and healthy, the injurious effects of a sudden checking of the bowels
and of other body secretions, as with Opium, being avoided.
4. Bipepsonate tastes like peppermint candy. There is no taste of
"medicine' 'about it and it is easily retained. This is a partcularly desirable
feature since it is largely given to children.
5. The use of Bipepsonate is not limited to children. It is equally
effective with adults when taken in doses of two or three teaspoonf uls, fre-
quently repeated. Without constipating it quickly gives relief in cholera
morbus and diarrhoea.
BURWELL & DUNN COMPANY
Manufacturing Pharmacists
CHARLOTTE, N. C.
Sample sent to any physician's address in the
United States on request
July, 1920
SOUTHERN MEDICINE AND SURGERY
S19
The Distinctive Properties of Gonosan
G0N05AN
RIEDEL
Inhibits gonococcal development and
minimizes its virulence.
Aids in reducing the purulent secre-
tion .
Encourages normal renal activity.
Relieves the pain and strangury and
allays the irritation and inflamma-
tion.
Does not irritate the renal structure
or the digestive organs.
Prescribe GONOSAN for acute and
chronic cases.
Samples are at your disposal
RIEDEL & CO. I
BERRY AND SO. 5TH STS. BROOKLYN, N. Y. S
Manp Black Clinic & PriVateHospital
Spartanburg
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H. R. Black, M D., F ACS., Consultant
S. 0. Black, M.D., F.A.C.S., Goiter and General Surgery
H. S. Black, A.B., M.D., Disea^^es oj Women ani Abdominal Surgery
H. E. Mason, M.D., General Medicine
Russell F. Wii^on, M.D., Genii o-Urinary Diseases and X-ray
Paul Black, Hydro- and Electro-Therapeutist
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Rates per week (payable v/eekly in advance): Wards— $17.50; Two and Three Beds in Room—
$24.50; Private Room— $21.00 to $28.00; Private Room with Lavatory and Toilet— $35.00 to $40.00;
Private Room with Bath— $45.00 to $SO.0O.
Address communications to: MISS HELEN LANCASTER, Business Manager
Counsel — "Xow, sir, tell mo how lonii you have
known the prisoner?"
"About twenty years."
"Have you ever known him to be a disreputable
character?"
"No, sir."
"Have you ever known him to be a disturber of
the peace?"
"Well, if I can remember correctly he used to
beloni; to a band I"
POSITIVE PROOF
/-(ici'vcr: "You honor, I claim the release of my
client on the grounds of insanity; he is a .stupid
fool, an idiot, and he is not responsible for any
act he may have committed."
Judge: "He doesn't appear stupid to me."
I'riscnrr: "Your honor, just lake a look at the
lawver I've hired !"--r/ic Doctor.
Support pift Jfurnall Buy jr«m Us adverlistrs.
SOUTHERN MEDICINE AND SURGERY July, 192Q
IT COSTS LESS TO TRAVEL BY TRAIN
The Safest, Most Economical, Most Reliable Way
TWO-DAY LIMIT round trip tickets on sale daily at ONE and ONE-THIRD
(11-3) FARES for the round trip between all points within a radius of 150
miles.
SIX-DAY LIMIT round trip tickets on sale daily at ONE and ONE-HALF
(1 1-2) FARES for the round trip between all points within a radius of
150 miles.
FARES FROM ;
CHARLOTTE
NORTH CAROLINA
To
BARBER. N. C
BLACKSBl Rti. S. C.
CHESTER. S. C
COLIMBIA. S. C
DANMLLE, VA
GVSTO\I\ N C
One
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$1.56
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78
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(iREEWILLE, S. C.
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3.84
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SALISBI RY, N. C
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1.91
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To all oilier slaiions williiii 150 miles from Charlotte, on the same
hasis.
Also 10-trip, 20-trip and 30-trip low fare tickets,
miles apart, good for 6 months.
between stations 200
ASK AGIINTS FOR PARTICTILARS
CITY TICKET OFFICE
237 West Trade St., Charlotte Hotel
Phone Hemlock 20
SOUTHERN
RAILWAY SYSTEM
July, 1929
SOUTHERN MEDICINE AND SURGERY
S21
OTOSCOPE SET
No. 975 Combination Set Contains Otoscope
with three Speculae and Ophthalmoscope. A
popular model with the Welch AUyn principle
of direct illumination.
Complete in Case $37.50
This Otoscope has the largest lens disc and
best lamps used in instruments of its type,
and provides magnification and easy observa-
tion for diagnosis, operative work or testing
the mobility of the ear drum.
The MirrorUss Ophthalmoscope is easy to use
For Direct or Indirect Methods
POWERS & ANDERSON
503 Granby St. 603 Main St.
Norfolk, Va. Richmond, Va.
Surgical Instruments, Hospital Supplies, Etc.
CHUCKLES
During 1928 it was my privilege to
make Supporters for doctors in every
State and in many distant countries. —
Katherine L. Storm, M. D.
"TYPE N'
"STORM"
SUPPORTERS
for all condi-
tions. Three
distinct
"Types" with
many varia-
tions. Prices
$5.00 up.
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to Hospitals and
to all Social Ser-
vice Departments
Every Belt made to order
Ask for literature
KATHERINE L. STORM, M.D.
Originator, Sole Ov
1701 DIAMOND ST.
•■r and Maker
PHILADELPHIA
TIME NOT RIPE
Hall Boy: "De man in room seben done hung
h;s;e!i !"
Hotel Clerk: "Hung himself? Did you cut him
dcwn?''
Hall Boy: "No, sah ! He want quite dead!" —
Stanley SeM-s-Herald.
PLAIN TO HER
Dizzy 17-year-old blond shows restlessness a*
reading passes third minute.
Grand Dame in next Seat: "Shh! That's Brown-
ing."
D. B.: "My Gawd! No wonder Peaches left
him."
COMPARATIVELY PERMANENT
A human being has thirty-two permanent teeth,
unless he or she decides to cure the neuritis on ex-
pert medical advice. — Ohio State Journal.
CURED
"Where is that ham you said you would bring
me?"
"Well, doctor, I intended, just like I told you, but
that hog up and got well."
DESPERATE CASE
Sympathizer: "How's your insomnia?"
Incurable: "Worse and worse. I can't even sleep
when it's time to get up." — Answers.
HUMAN HARDWARE
"I hear Mrs. Murphy is still taking in washings
since her husband left."
"Yes, the washer often stays on long after the nut
is gone." — Orange Peel.
NOR "ARF-and-'ARF "
The witness was nervous on the stand and tried
to pass it off with some racy testimony. At one
time he mentioned "a coupla quartsa Scotch."
"What is Scotch?" asked the magistrate.
"Not wot it used to be, yer honor, not arf." —
Humorist.
OPEN THE WINDOWS
They blindfolded old Nero,
King Tut and Richelieu;
Then each one puffed a cigaret,
The way all heroes do.
"I know this brand," said Nero;
"There's brains inside my dome.
It smells the way the camels did
When I burned 'cm in old Rome."
Springfield Union.
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SOUTHERN MEDICINE AND SURGERY
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SOUTHERN MEDICINE and SURGERY
Charlotte, N. C, July) 1929
Vol. XCI
No 8
Clinics in Nervous and Mental Diseases*
I. Michael P. Lonergan, M.A., M.D., New York City
Clinical Director, Manhattan State Hospital
INTRODUCTION OF DR. LONERGAN
Dr. .Albert Anderson, Raleigh:
Our President requested that we furnish
patients today for a clinic in mental and
nervous diseases which will be conducted by
Dr. Lonergan, of Manhattan State Hospital.
Dr. Lonergan has been associated with Dr.
George H. Kirby, in whom all of you will
be interested because he is a North Carolin-
ian. Dr. Lonergan has been for some time
with Dr. Kirby and is well qualified to make
this clinic interesting to the general practi-
tioner. I know very well that it is hard to
hold a clinic where there is so much noise
and when you are not familiar with the sub-
ject of mental diseases as they will be pre-
sented by Dr. Lonergan, and I shall therefore
ask you to be as quiet as possible. We should
like to show you enough of these cases to
interest you somewhat in psychiatry. There
is a great gap between the general practitioner
and the special work of psychiatry which
ought to be narrowed — filled up. I have in-
sisted for years that our North Carolina doc-
tors come to the state hospitals and have
given them a cordial and urgent invitation to
come to Raleigh for clinical material and to
attend our staff meetings, which we hold three
times a week. We shall be glad to have you
come to our staff meetings and to serve you
in any other way, if you come in groups.
We shall now have the clinic conducted by
Dr. Michael P. Lonergan, Clinical Director,
Manhattan State Hospital, Ward's Island,
New York.
Mr. President and Members of the Tri-State
Medical Association:
It is with trepidation that I come here to
hold a clinic on nervous and mental diseases.
There are many others who could do this
much better than I, among them a native son
of this state, and one who is ranked among
the foremost psychiatrists of the country. I
refer to Dr. Geo. Kirby, Director of the
New York Psychiatric Institute, which func-
tions as a research organization for the study
of the causes and treatment of mental disor-
ders. He regrets that he could not be here
to meet you. A few days before I left New
York, I visited him and asked him if he had
a message for you, something which he would
tell you if he were here. He then asked me
to call attention to the fact that at the pres-
ent time there is too much aloofness and de-
tachment between the hospital psychiatrist
and the medical practitioner of the commu-
nity. The great desideratum was to bridge
over this gap and bring into closer contact
and co-operation the psychiatrists and the
general practitioners. He mentioned the fact
that there are numbers of patients at the
present time going the rounds of the doctors'
offices who will next year be residents of the
state hospitals. These patients, complaining
of vague somatic ills for which no physical
basis can be found after a thorough medical
survey, offer a problem which often is over-
looked by the general practitioner. This
condition of affairs would be improved by
encouraging extra-mural contacts by the hos-
pital psychiatrists and the establishment of
mental clinics to which patients may be re-
ferred by the medical practitioner and which
would be visited regularly by the psychiatrist.
He feels that there should be an interchange
of viewpoints. The medical man of the coni^
•Presented to the Tri-State Medical Association of the CaroUnas and Virginia meetini? at
Greeaaboro, N. C, February 19-21, 1929.
SOUTHERN MEDICINE AND SURGERY
Augtist, 1929
munity should be better acquainted with the
state hospital personnel as well as the run-
ning of such a hospital. In most communi-
ties there is very little contact between the
peneral practitioner and the hospital psychia-
trist. This is inimical to the welfare of those
concerned, especially the patients. The co-
mingling of the psychiatrists and the medical
practitioners will result in mutual benefit and
satisfaction, as well as add to the social and
economic efficiency of the community.
Another eminent psychiatrist, as well as
hospital administrator, Dr. C. Floyd Havi-
land, formerly chairman of the New York
State Hospital Commission and for the past
few years superintendent of Manhattan State
Hospital, also sends you a message by me.
He was selected by your president to be here
today, but, owing to the pressure of numer-
ous duties, he could not make it possible. He
is very active in extra-muralizing psychiatry
and passing it to the community in terms of
preventive mental hygiene. I am well aware
that I cannot take his place, but he was
gracious enough to select me and I hope that
our clinical demonstration will be satisfactory
to you.
He stresses the great need for the psychia-
tric approach in dealing with apparently or-
dinary medical as well as surgical problems.
At the Manhattan State Hospital, he has de-
veloped the policy of having many of his
medical personnel establish extra-mural con-
tacts with mental hygiene clinics in the com-
munity, provided this does not interfere with
their hospital duties. In fact, we have found
that the hospital psychiatrist becomes better
equipped and more efficient for his work
after he has had experience in these com-
munity clinics. The type of patients seen
and treated at these clinics, such as the
psychiatric department of the Cornell Clinic
which I have had the privilege of attending
now for about two years, is not easy to size
up or diagnose, or to treat. I had had sev-
eral years experience in state hospital work
and thought that I could easily handle these
borderline, incipient cases. However, I felt
quite inadequate to the situation when I first
took up this clinic work. There we find very
few, perhap* only occasional, psychotic cases.
The majority of these patients come with
vague mental and somatic complaints which
aie very difficult to evaluate, so that we ar?
disfwsed to look upon their troubles as due
to an overactive imagination or a neurotic
disposition. They are really suffering and are
not only looking for an understanding of
their complaints, but a sympathetic attitude.
They go with confidence to the physician
whom they look upon mainly as a healer and
when they find, after spending a good deal
of time and money, that the physician does
not understand their condition and that they
have not been benefited by their contacts
with him, they often become bitter and an-
tagonistic. Many of these persons event-
ually patronize irregular practitioners such as
the christian scientists and other mental heal-
ers.
The message which Dr. Haviland asked
me to deliver to you, consists of three clinical
cases.
Case 1. A woman had suffered from gas-
tric indigestion for over three years during
which period she had visited numerous spe-
cialists, sometimes getting relief and some-
times none. She had had numerous exam-
inations of the stomach contents but in no
instance did the examination reveal an or-
ganic lesion, despite symptoms being more
pronounced than ever when she came, by ac-
cident, to the attention of Dr. C. Macfie
Campbell, then with the Phipps Clinic, Bal-
timore. Owing to the history of long con-
tinued, unsuccessful effort to treat the pa-
tient on a physical basis, a mental examina-
tion was made, as the result of which it was
found that the entire symptom-complex was
of psychogenic origin.
The patient was happily married but had
no children and, her range of interest being
limited, she lacked adequate conscious means
for securing emotional satisfactions. About
a year prior to the development of the gas-
tric symptoms the husband had arranged for
his older maiden sister to live with his wife
and himself and, as the sister was of an
aggressive, domineering type, she began to
assume the direction of the household. The
wife never consciously objected and was on
relatively good terms with the sister-in-law,
but subsequent events proved that the indi-
gestion represented an automatic attempt, on
the unconscious level, to secure desired atten-
tion and a more important place in the
household. When the mental mechanism in-
volved was explained to the patient and
August, 1929
SOUTHERN MEDICINE AND SURGERY
I brought into consciousness and when the hus-
I band made arrangements for the sister to
live elsewhere, the physical symptoms
■ promptly disappeared and failed to return.
This case illustrates very nicely the need
of looking elsewhere when your patient's
symptoms continue and there is no evident
physical basis for them. The difficulties here
were apparently due to the emotional con-
flict caused by her losing her position in the
household to the aggressive sister-in-law. We
see the conflict solved by having the sister-
in-law leave the house, when the patient
again resumes her position, not only in the
household, but in the regard of the husband
in terms of recognition and security.
Case 2. Dr. Thomas Salmon, lately de-
ceased, used to relate the case of a woman who
was under treatment by a gynecologist for
symptoms referable to the uterus and who
failed to improve, so that the gynecologist
eventually resorted to curettage. However,
the symptoms afterwards continued unabat-
ed, when a psychiatrist found them to rest
upon a psychogenic basis which Dr. Salmon
used to say ought to have been discovered
by the physician first treating the patient.
Dr. Salmon used to express his attitude re-
garding the case by stating that it was his
opinion the gynecologist could have well been
charged with "assault with a blunt instru-
ment."
Case 3. Dr. Pratt, of the National Com-
mittee for Mental Hygiene, recently spoke
of a woman with gall-bladder symptoms as a
result of which a surgeon removed the or-
gan. Following operation, the symptoms per-
sisted and, again, when she accidentally came
under the observation of a psychiatrist, it
was found that the physical symptoms rested
wholly on a psychogenic basis. When her
environmental situation was modified and the
mental mechanism involved brought to the
conscious level, the symptoms disappeared.
About a year and a half ago, I met a wo-
man 35 years old who had for 3 or 4 years
been complaining of vague pains in her arms
and back, in the precordial region and in the
area of the right sciatic nerve. She had been
to various physicians and finally visited the
clinic where a medical survey did not dis-
cover any physical basis for her complaints.
She was then referred to the psychiatric de-
partment and when I was taking the history,
I found that she was sexually frigid. This
was apparently due to a conflict on a relig-
ious basis which had given rise to a feeling
of guilt. She had been married about ten
years, and being a Catholic and her husband
a Protestant, she felt that she was living in
a state of sin as long as she had not been
married by a Catholic priest. The husband
was very much opposed to Catholicism and,
although he had promised to go through the
religious ceremony at the time, still he kept
putting it off and the ceremony had never
been performed. In his opposition to his
wife's religion he was backed by his mother
and other members of his family. About
three years before I saw the patient, she
had moved from New York City to a subur-
ban community and during this period she
found that her physical complaints had be-
come more exaggerated. She noted they gave
her more trouble in the spring than during
any other season of the year. When I asked
her about the cause of her sexual frigidity,
she said that she felt that she was living in
sin because she had not been married in the
church. She therefore refused to continue
to cohabit with her husband. After a few
visits we had her husband come to the clinic
where he was informed of the probable
cause of his wife's invalidism. The relig-
ious contract was executed and in a few
months our patient had ceased to come to
the clinic because her physical condition had
greatly changed. I haven't seen her now for
a year and a half and the last time I saw
her, she was comparatively free from any
complaints. The exacerbation of symptoms
after the patient moved to the country and
the symptoms becoming worse during the
spring season are significant. We know that
there are less distractions in the country and
the routine house activities were not suffi-
cient to distract the patient from her emo-
tionalism. In the spring season comes Lent,
a time of penance. During this period, there
are very frequent contacts with the church,
penitential sermons are heard and undoubt-
edly the patient's sense of guilt was increas-
ed during this time.
From these cases it is readily seen that
emotional conflicts can create problems which
appear to be medical or surgical. So it is
very important for the physician to recognize
SOUTHERN MEDICINE AND SURGERY
August, 1929
temper tantrums, anxieties, fears, as well as
the ordinary emotional reactions in the every-
day individual. It isn't far-fetched to state
that through the emotional conflicts set up
we have functional disturbances, interference
with fundamental vegetative activities which
sap energy and cause many and various com-
plaints. I would like to mention the auto-
nomic visceral cravings and tensions induced
by unpleasant emotional stimuli which sy-
phon off the energy of the individual. When
an otherwise healthy, robust individual tells
you he has no strength, that he does not feel
able to do his work and examination reveals
no basis for his tiredness and fatiguability,
one should look for the emotional factor in
the case.
Another young woman whose case is of
unusual interest is the only girl in a family
of four. She lost her father when she was
six years old and finally became quite at-
tached to her oldest brother who had as-
sumed the place of head of the family. She
was the home type of person, did not mix
much with the group, was quite dependent
upon the mother. She had been referred to
the clinic by her employer who stated that
she had become quite inefficient at her cleri-
cal work. It was found that she had the
secondary sex characteristics of the opposite
sex. For instance, there was a fairly mod-
erate production of hair on her extremities;
the pubic hair showed masculine distribution
and there were a few hairs around each nip-
ple. She appeared rather asthenic, lacking
in "pep" or drive. The mother gave the his-
tory that for about six months previously,
she had been behaving rather peculiarly. She
began to spend more time in the bathroom.
She was washing her hands and bathing more
frequently than usual. She was a Catholic
and she was going to confession oftener and
all around was quite scrupulous. In fact,
this was what interfered with her work. She
gradually lost confidence in herself and had
to do things over and over again to be sure
that they were done right. Even after sev-
eral repetitions of a simple task, she was not
sure whether it had been properly done.
After several visits to the clinic her condi-
tion was worse. She did not follow the ad-
vice given and she was finally so bad that
the mother couldn't do anything with her.
She would take three or four hours to get
up in the morning, could not make up her
mind to get dressed, spent long periods in
the bathroom, after locking the door and
window and pulled down the shades. She
could not be prevailed upon to change her
behavior, and it was useless to continue
advising her, I recommended that she
promptly be voluntarily admitted to a state
hospital. She was not a very suitable case
for voluntary admission because she did not
realize there was anything wrong with her
mind.
Going back into her history, we find that
shortly before her symptoms began, her old-
est brother married and she had, herself, be-
come engaged to her sweetheart with whom
she had been going for a couple of years.
On questioning her closely, I found that she
was very scrupulous about letting this young
man perform even the customary attentions
such as kissing or embracing her when visit-
ing. She said that she didn't mind traveling
outside with him where people were present,
such as, riding in the bus, in the park, or
other public places. She couldn't, however,
tolerate being alone in the house with him.
I felt there was a good deal of conflict asso-
ciated with this engagement and that the guilt
feeling which was at the bottom of her scru-
pulosity was in some way tied up with this
matter. I then suggested that the engage-
ment be suspended, but, as the family was
unwilling to have this done, I did not insist
upon it. It was quite significant that she
felt "quite relieved" if her lover didn't come
as often as he had planned. I also found
that the oldest brother was very much inter-
ested in her welfare, in fact unduly so and
this gave me another slant on the case be-
cause I felt that such attention and devotion
of her family (her mother as well as the
brother), was inimical to her adjustment.
After three months hospitalization, she was
discharged. She had improved a good deal,
but this was more due to disciplinary meas-
ures than any actual insight that she had
gained into her difficulties. There was not
only a psychological reason for her difficul-
ties, but a biological one. Some time after
leaving the hospital, her engagement was sus-
pended after which she went back to her
work.
This case is somewhat different from the
previous ones because the patient evidently
August, 1020
SOUTHERN MEDICINE ANB SURGERY
S29
was not equipp)ed biologically for the hetero-
sexual role. We have found that patients
who show the secondary sex characteristics
of the opfwsite sex do have difficulty in ad-
justing to hetero-sexual situations. Dr.
Charles Gibbs, formerly associated with the
New York Psychiatric Clinic and now Direc-
tor of Clinical Psychiatry at Kings Park
State Hospital, has done a great deal of
work in this line of investigation and this
case corroborates his findings.
I will now discuss the clinic material we
have here today. As you recall, in psychia-
try we have two major groups of reactions,
the organic and the functional or biogene-
tic. The organic is characterized by struct-
ural changes in the central nervous system,
especially in the brain. At times we do
find emotional changes accompanying intel-
lectual disturbances, but these are secondary
and usually not so imp>ortant. As you are
aware we may have, also, clouding of the
sensorium, delirious and confused reactions,
as a result of infectious disorders such as
typhoid, pneumonia or influenza; from ex-
haustive states brought about by severe and
prolonged illness; and from toxins, endogen-
ous or exogenous. In these latter reactions
we don't get any structural changes, still we
classify them with the organic groups on ac-
count of the clouding of the sensorium which
is shown by impaired memory, orientation
and retention, and reduced mental capacity.
There may be hallucinatory phenomena
present, in either the auditory, visual or ol-
factory fields.
Now in the second large group, the func-
tional or biogenetic, we do not find any
structural organic changes, either macro- or
microscopically. It is this latter group which
we can understand and prescribe for after
we have studied the antecedents, the consti-
tutional make-up, early training, life experi-
ence, environment, habits and the special
situation which caused the breakdown. This
group is sometimes called the psychogenetic
because we feel that it is due more to psych-
ological factors than it is to any physical
or organic condition.
We will begin with the organic group and
the first case which I will show you is one
of general paralysis. This is an important
group because of the number and the fact
that many of these cases are not spotted by
the practitioner because they complain of
symptoms which do not suggest the real se-
riousness of their condition. It is not infre-
cjuent that we find these cases being treated
for neurasthenia or other vague somatic ill-
ness, which is just a symptom of the under-
lying cause. In the early stage of this dis-
order, we find the patient showing gradual
changes in dispwsition. The finer, cultural
equipment is affected first. For instance, he
is less considerate of others; he neglects the
little amenities of life; his finer sensibilities
are blunted. This is especially evident in
those who have achieved some cultural de-
velopment and is manifested by coarse lan-
guage, irritability, jxjor judgment and finally
some overt act or series of acts such as re-
fusal to pay restaurant or taxi bills, or going
to the other extreme of great extravagance,
spending money foolishly. It is well to bear
in mind that syphilis is protean in its somatic
manifestations and much more so in the men-
tal phenomena which it may induce. It may
simulate any of our definite groupings. This
makes it very important to have resort to
serological, as well as neurological and clini-
cal examinations in order to arrive at a cor-
rect diagnosis.
Now about the therapy:
These are cases which can be benefited by
treatment. You are familiar with the va-
rious arsenical preparations as well as mer-
cury, bismuth, bismogenol, and so forth, so
I will not go into the specific treatment.
For the past five or six years at the Man-
hattan State Hospital, we have been using
non-specific thera[)y in the form of typhoid
vaccine and infection with malaria. Nearly
all our paretics are now given malaria, pro-
viding llicy do not show any contraindica-
tion in terms of physical disease such as tu-
berculosis, nephritis, cardiac disease. The
age period is also a consideration. Wc find
tliat individuals who have reached the age
of sixty are poor risks. However, there are
suMie exceptional cases which have been bene-
fited by malaria therapy in the late sixties.
I'here are also a number of patients within
the age period whose physical state is such
as to make it a risky procedure. Many of
these cases can be raisid to a higher physical
level by administration of the arsenicals and
then can be given malaria treatment.
Dr. Kirby, whom I mentioned in my of)en-
S30
SOtJTHfeRN MEt)IClK6 AND SUkGERY
August, i9iO
ing talk to you and who is classed as one of
the greatest psychiatrists in the country, has
been using the malaria treatment for cases of
general paralysis for the past six or seven
years, and has found good remissions in 30
per cent.
As regards the technique of administering
malaria: we take blood from one of the arm
veins of a patient who is running tertian ma-
laria, S c.c. for each patient with paresis to
be treated; place this immediately in a test
tube containing half as much sodium citrate
solution, and gently rotate the tube between
the palms of the hands. About 2 c.c. are
then injected into an arm vein of each paretic
prepared for treatment. At the Manhattan
State Hospital, we usually inoculate three or
four patients at one time. The temperature
is then taken twice a day; after it has reach-
ed 100 we put the patient to bed and it is
taken every hour. Of course, before we in-
oculate the patient, we must be sure that we
are dealing with a case of general paralysis
and for this we depend principally upwn our
serological and physical findings. We find
the incubation period from three to ten days.
It is very important that the patient have
good nursing care; otherwise accidents may
occur especially if the patient is allowed to
get out of bed during the height of the fever.
The number of paroxysms we allow the pa-
tient to run depends upon the patient and
his ability to tolerate the malaria, and this
means physically and mentally. The maxi-
mum number of paroxysms we have run in
New York has been thirty. One cannot be
too watchful of these patients when they are
running malaria because they may develop
jaundice or become septic, and then we have
to stop it.
Dr. F. R. Taylor questions: "Are you
using other fevers in place of malaria now?"
Yes, when malaria is contraindicated or the
patient is immune to it, we give typhoid vac-
cine. It is our experience with the colored
patients who develop paresis that they are
usually immune to malarial inoculation. The
exceptions that we find are those colored folks
who have been born or lived for years in the
north.
This case of general paralysis comes from
Dix Hill at Raleigh, where he has been re-
ceiving specific treatment for his syphilis.
We haven't much history of the family and
not much history of the patient himself, as
he has not been visited during residence. The
little history that we have is that he worked
on a farm and that he had been arrested sev-
eral times. We do not know the actual cir-
cumstances of the arrests, but one would de-
duce from this that he is an unstable indi-
vidual who has been psychopathic in his be-
havior. He finally developed the idea that
somebody was persecuting him and "throw-
ing electricity at him."
When he came to the hospital examination
did not disclose very much. Neurologically,
we find that he has Argyll Robertson pupils,
that is, pupils that do not react to light, but
do to accommodation. His knee jerks are
also absent. He does not show any coarse
tremors and there is very little speech defect
when we use test phrases. In examining his
spinal fluid and blood, we find that he has
some globulin as well as cells and a four plus
Wassermann in spinal fluid and blood. We
probably would give this patient malaria. As
I have said previously, we have good results
with this therapy.
The second case belongs to one of the or-
ganic groups also, that is, encephalitis leth-
argica. Observe closely the gait and expres-
sion as he comes into the room. The rigidity,
the mask-like expression with the staring
eyes is quite characteristic of the Parkinso-
nian syndrome we usually find in this disease.
The history of this case is that four or five
years pricr to his admission to the hospital
he had influenza, also malaria. A few months
subsequent to his infection, he manifested
disturbed behavior, then he was hospitalized.
He remained a few months in the hospital
and went home, but, as is usual in these
cases, he could not make good in an environ-
ment outside of the hospital and was re-
turned in a short time to the institution. As
you undoubtedly observe, he has marked tre-
mor of the hands and his knee jerks are spas-
tic. Of course, the Parkinsonian picture of
the disease is of rather late development and
is one that you could not very well miss
when such a patient is referred to you. How-
ever, in the early stage of the disease there
are very few physical signs and what brings
the patient to a state hospital is some be-
havior disorders in school, at home or in the
community. In the school we find that, with
the onset of this disorder a change in dis-
position and habits will be shown. Such in-
dividuals become problems very difficult to
August, loiO
§6t7f HEkN ilEbtCiN^ ANi) SiTRGfiRV
HI
handle, and quite a number show sex delin-
quencies. They steal, play truant and are
emotionally unstable. If, before the onset of
the difficulty, they have had some jjerson-
aiity traits which interfered with their ad-
justment, we find these traits exaggerated in
the mental disorder. What is characteristic
also of this organic group is that we do not
find any memory or other intellectual defect.
Their trouble usually lies in the emotional
sphere. We have not been able to do much
in the way of treatment. Sodium iodide and
bismuth salts have been used intravenously.
The group consists mostly of young people
in their adolescent period, a time of rapid
physiological change. It is a period of stress
and instability when we have these dynamic,
primitive urges asserting themselves and les-
sening the inhibitions of youth. So when
we consider the added stress of a brain insult
in terms of organic nervous disease, then we
naturally expect behavior disorders. We find
the biological rhythms, such as breathing,
sleeping and drinking, interfered with in
many cases. It is not unusual for these pa-
tients to sleep in the daytime and be up at
night disturbing others. Also they may drink
large quantities of fluid or have certain res-
piratory phenomena which to the uninitiated
would impress one as due to malingering or
a drive for sympathy. However, when we
study these cases and the situations that we
find them in, we can account for their ab-
normal reactions by consideration of the
vegetative nervous system which prob-
ably receives the brunt of the disturbance
after the disease is established. As a whole,
these patients, being of the younger age
group, do pretty well under supervision where
they are subject to a certain amount of dis-
ciphne and are living in a sheltered atmos-
phere. We can account for their apparent
activity at night time because we have ob-
served that when the exteroceptive stimuli
are numerous the patient is more or less im-
mobilized and rigid from the continual bom-
bardment of his central nervous system. Now
at night there is a great lessening of these
stimuli; there is less light, less noise, etc.; the
patient relaxes in this much changed atmos-
phere. It is not unusual to see a patient who
during the day was lying rigid in bed, unable
to use his limbs or help himself, at night, in
the subdued light and the quietness of the
room or dormitory, walking around disturb-
ing other patients.
Now the next case is a patient who exhib-
its what we call involution melancholia. It
is a mental disease which often accompanies
the climacteric period or the change of life,
usually between the 40th and 50th years.
Now these patients usually have a guilty feel-
ing which they attribute to what is to us a
rather trivial matter not at all adequate to
explain the tremendous emotional reaction
they experience. The characteristic picture
is one of an agitated, anxious depression with
self -accusatory ideas. The real motif lies in
the unconscious; something has happened in
the patient's life which has inflated the un-
conscious asocial yearning. Of course, we
know that during the change of life the sys-
tem is adjusting to a physiological change.
This is a period of stress for the individual
and may be the occasion of lighting up a
psychosis. We do not find any organic de-
structive changes in the nervous system or
any intellectual impairment in these jjatients.
The outstanding tendency is to commit sui-
cide and we should take every precaution to
prevent this. The majority of such patients
get well, but it is a long-drawn-out disorder
and usually requires hospitalization. It is
dangerous to temporize with a patient in this
condition as only constant supervision will
prevent suicide.
This patient's family history does not show
anything of special importance. It appears
that he had a mental attack about 20 years
ago and at that time was seen by your presi-
dent, Dr. Hall, who remembers him very
well. He had another attack about ten years
ago. He got over each of these in a few
months. The present attack began about
four years ago. He became very depressed,
agitated, anxious and spoke of suicide. We
know one means of handling these cases is
to distract them sufficiently from their very
depressive thoughts, but this is not easy to
do especially during the acute stage of their
trouble. The question is asked, do we use
scopolamine in these cases? We don't in
our hospitals, but we du frequently use either
the triple bromide or sodium bromide. If the
patient is nihilistic or expresses ideas of un-
reality, the outlook is not favorable. Schi-
zoid elements in the personality are unfavor-
able; at least the course is prolonged. We
SOUTHERN MEDICINE AND SURGERY
August, 1929
very often find sex coloring to their ideas,
and even indulgence in sex perversions. This
man talks a good deal about sex indiscre-
tions of which he says he has been guilty.
With the disappearance of the sex drive the
individual may over-compensate by sex in-
discretions which may be determined psych-
ologically from a knowledge of what the
change of life usually connotes to the indi-
vidual.
The next patient is a man of 38, married.
He complains of feeling nervous and of inabil-
ity to sleep or to concentrate, says that he
has lost his manhood. He also speaks of
fainting attacks. He blames his difficulties
on sex indiscretions and undoubtedly there
are conflicts in this sphere which he is un-
able to solve.
He belongs to the psychoneurotic group.
These are the cases that go from one phy-
sician's office to another looking for relief
for their vague somatic complaints for which
the physician can find no physical basis. We
know that there is some unresolved conflict
at the basis of their trouble which engenders
a great deal of emotionalism and this in turn
disenergizes the patient. We find these con-
flicts expressed in somatic or physical symp-
toms. It requires a good deal of sympathy
and patience to evaluate their difficulties.
Even when we cannot solve the problem we
may relieve the pressure by distraction or
some form of interest which we can arouse.
Many of these patients get relief just by
"talking out" their troubles with the physi-
cian.
The next case is one of schilzophrenia. This
is the most important group we have in the
state hospitals and constitutes about two-
thirds of our resident patients. These are
the ones to whom we are devoting a great
deiil of research. There are various ap-
proaches depending on the individual reac-
tion. Adolph Meyer, founder of the New
York Psychiatric Institute and its first direc-
tor and who is at the present time Professor
of Psychiatry in Johns Hopkins and Direc-
tor of Phipp's Institute, has made the most
valuable contribution to our understanding of
this group. He introduced the psycho-bio-
logical approach which takes in not only the
antecedents of the patient but the native
equipment as well as the training, education,
life experience, habits and the study of the
situation which caused the breakdown. In
all these cases we find evidence of constitu-
tional inadequacy which renders them un-
able to cope with life's problems in a normal
way. Through this approach we study the
individual's reaction to his problems and if
we can get them early enough we probably
can help them to adjust to a modi-
fied environment. A number of them
establish compensation through various pro-
jective mechanisms and can carry on for a
number of years in a sheltered environment
at a fairly good level. When the individual
is slipping in his efficiency in the commu-
nity, he may project his difficulties and blame
others for his inefficiency. These people
keep at a fairly high level biologically but
not sociologically. The case on hand is on«
of dementia praecox, paranoid type. He is
now middle aged and for 24 years, he has
had his delusional trend, believing that he
is God, king and ruler of another planet. In
1905, he had his "second birth," at which
he "was born God." Observe he is well
nourished and robust. Considering that he
has been very delusional for 24 or 2S years,
you would not expect him to be in such good
physical state. We feel that his trend, that
is, his delusional system, has helped to keep
him at a fairly good level not only physi-
cally, but mentally.
(Dr. Albert Anderson, Superintendent of
Dix Hill State Hospital, where patient is a
resident: "I may say that this patient is
well established in his disease. I want to
say that he is one of the finest patients we
have ever had at Dix Hill. He has a con-
sciousness of power and a drive that mean
a good deal to us.")
This is a most interesting case because he
represents a very large group of hospital
patients, but I might add that they do not
all remain at his level. We like to go into
the family history and personality make-up,
life history of the patient, and so forth, in
order to understand the reason for his ideas
and arrive at what we can do for him. This
man was married, and soon developed suspi-
cions of infidelity, saying that the Masons
had relations with his wife. He considers
the Masons as a body, his enemies. Looking
back into his early early life, we find that he
was not a good mixer and that he had diffi-
culty in getting along with f)eople and that
August, 1929
SOUTHERN MEDICINE AND SURGERY
S33
he kept to himself a good deal. This was a
period of maladjustment to which he reacted
by developing a compensatory reaction which
we observe now in his psychosis. The usual
history of these cases is that they cannot get
along in the ordinary run of life. They can-
not achieve recognition and security in the
group in a socially acceptable manner
through some basic conflict which they can-
not solve.
It is well to remember that we are all
working for security and recognition and if
we cannot get it in a socially acceptable way,
then we will get it asocially.
I have been highly edified and pleased
with my trip to the South and have great
admiration for the psychiatrists I have met
such as Dr. Hall, Dr. Anderson and Dr. De-
Jarnett. These men know their patients by
name and from what I have been hearing
about Dr. Dejarnett, he establishes very in-
timate and personal contacts with all his pa-
tients and enjoys his vocation to the fullest.
I may speak from personal experience of Dr.
Anderson at whose hospital I remained for
two days. I can tell you, as you already
know, that he is a very fine host and carries
on his work in an exemplary fashion. I was
very much impressed by his opening his staff
meeting with a passage from the Bible and
a prayer. This is the first time I observed
such a ceremony at a staff meeting and I
was very much edified. In fact, I was so
much taken with it that when he asked me
the other morning to open the meeting with
a passage from the Bible and a prayer, I was
only too glad to do so.
I wish to say in closing that I am glad to
have had the opportunity and privilege to
come here and address you in behalf or
psychiatry.
II. Joseph Spencer DeJarnette, M.D., Staunton, Va.
Superintendent, Western State Hospital
The first thing we want to consider is, what
is insanity? As hardly any man has been
able to tell what sanity is, we shall have to
make a few rough guesses. The best I can
say is that insanity is perverted mentality
due to disease of the brain. That does not
carry you very far, because a man with dis-
ease of the brain can have good mentality,
and a man with good mentality can get drunk
and have all the manifestations of insanity.
Is the mind a result of the molecular action
of the brain, just as much as the bile is of the
liver; or do you agree with Thompson that
the mind is a spirit, entity; or that, as St.
George Mivart said, it is an immaterial sub-
stance, or spiritual substance, which mani-
fests its phenomena through the brain? We
know that nervous cells are material things
and can be trained.
Jim Hall asked me who is God? I told
him that in my opinion God is everything
and everything is God; whatever He wills so,
it was and is.
Insanity is perverted mental action — delu-
sion. What is a delusion? Delusion is a
false belief. Everyone of you who comes in
contact with your fellow-man has a false idea
of him; you do not know what he is. You
do not know, even, what the cloth on this
table, the floor under you, are. So Miss
Gladys Hancock here has some ideas that you
call delusions. But how do you know? Here
is a most remarkable human being, a woman
in man's form. She will tell you she has
borne a thousand children. She has a mem-
ory going back thousands and thousands of
years in former existences. She was empress
of India, empress of China, but in some
mysterious way she can not assert her power.
That lady there is a cannibal; she has eaten
human flesh, and it was good. If a man's
appetite calls for the best to nourish his body,
what better food can he get to nourish the
inner man? So cannibalism is really a nat-
ural reaction, as it gives ingredients of his
own body. This woman can tell you all
about everything in olden times. The way
of children being born now is a new thing;
every child long ago was created; there was
none of this woman-birth business, which has
come into fashion in the last eight or ten
hundred thousand years — none of that. She
remembers it all. She remembers her former
existence. That woman has been skinned
alive twice; she has been burned alive. This
is a Christian community, but I know you
tH
SOtJtHEkN MEbiCmfe AM) SWlGEkV
August, 1924
will be interested to know that ke crucified
our Saviour; he drove the spikes in His
hands. He was at that time the king of
Rome. He has all that kind of ideas. He is
a man who has been to Heaven and sat on
the throne of God; he has been down to the
depths of Hell and talked with the devil. He
has had all kinds of experiences. This man
talks in different words from us; he makes
new words. He has the perverted ego.
The continuous ego is a remarkable thing.
You are not the same person you were when
you were a boy; your hair is gone, your teeth
are gone, your shape is changed; all your
emotions are changed; your feelings, your de-
sire; how do you know you are the same per-
son?
This is a case of what I consider dementia
praecox, paranoid. The fact of the business
is he had in his youth a usual condition, shut-
in personality. You know dementia praecox
is hardly the proper name. Dementia prae-
cox means the dementia of adolescence, but
it occurs at almost any age. It is like some
other definitions. The dictionary defines the
crab as a small sea fish that moves backward.
In the first place, it does not live in the sea;
in the second place, it is not a fish; thirdly,
it does not move backward. So dementia
praecox covers the case about as well as the
definition of a crab.
Patients with dementia praecox are stere-
otyped; they repeat their actions. They are
stereotyped as to location; that is, they stand
in the same place; they are stereotypyed as
to attitude. They have p)ersecutory ideas;
they feel that people are persecuting them.
Just as physical forces move in the line of
least resistance, so the mind moves between
two emotions, one of pleasure and the other
of pain, one is of fear and the other of love,
one of desire and the other of dread. So all
our actions are motivated between those two,
between God and the devil. These dementia
praecox cases do the same thing. Finally
they get in such a condition that they want
to kill. This man had his hand or a pistol
pulled down on the heart of one of the most
prominent citizens of Lynchburg, and but for
the grace of God he would have been killed.
He said he was afraid the jwlice would not
understand, and that saved him. This man
has hallucinations of hearing and hallucina-
tions of sight. Every night the devil comes
and sits on his bed and snaps his fingers at
him.
This is the most valuable citizen in our
institution. He has been with us for twenty-
one years. A peculiar thing about dementia
praecox is that it may arrest at any time.
He wears women's clothes because he is a
a woman in man's form and he wants to be
according to his belief.
Now I am going to digress; I am going to
give you a little something that I think may
interest you. About one hundred years ago
(July 24, 1828) the Western State Hospital
of Virginia came into being. I was writ-
ing a history of it, and I looked in a
book printed in 1828, and there I found this
poem. In those days, gentlemen, the insane
were tied down. Four were tied in one jail;
they had been chained to the walls of the
jail for years, with nowhere to go. Here is
a little poem written by one who knew the
situation well and probably had experienced
it. It is entitled "The Forgotten Prisoner."
Found in an old book at Western State Hospital,
Staunton, Va., dated 1828:
THE FORGOTTEN PRISONER
My hands are bound with cuffs and chain,
My withered limbs move but in pain;
The chains that bind my limbs that shake
Are worn so thin that they would break.
If I could put on them the strain
I did when first I wore the chain.
'Tis years since this dark prison cell
Became my home — I call it hell;
I raved and screamed from year to year.
My echo was all that I could hear.
The jailor came and gave the lash
And cursed me for my language rash.
I cursed him back at every trip
And laughed the more he used the whip;
But now I sit with head bowed low —
The years and months they come and go.
I do not care since hope is dead.
My tangled beard and tangled head,
Proclaim to all, I do not care,
These rags are all the clothes I wear.
Though conquered, still the irons cold
Bind my limbs and bind my soul;
This prison cell, my end must be, ,,
August, 1920
SOtTttERN MEblClNfi AND SCRGEkY
sii
No loved one comes or cares for me;
All who reach my lonely lot,
Pass out of sight and are forgot.
I sit and sit and wait the end
For death, yes, Death, my only friend.
The bolt is drawn, the prison door
Opens wide as ne'er before,
I do not even turn my face
To see who comes in this dread place.
A gentle hand has come at last
And loosed the bonds that held me fast,
I follow through the open door.
Where once I had been led before,
And when I reach the sunshine bright,
I can not see, 'tis too much light.
They lead me to a stage-coach there —
I do not ask, I do not care:
On the road, the flowers in bloom
Fill the air with sweet perfume;
The birds, the trees, the mountain range,
Recall old scenes that now seem strange.
The guard spoke of a wondrous place.
An asylum new, to treat my case;
In Staunton near Mt. Betsy Belle
The mount of which the legends tell.
'Twas eighteen hundred and twenty-eight-
I never shall forget the date;
For that's the year, and that's the time
I found myself and found my mind.
SPONTANEOUS CURE OF CANCER
Since a medical press existed there have appeared from time to time reports of
cases in which carcinoma has disappeared, temporarily if not permanently, following
some inflammatory attack or some constitutional disturbance. The value of the
older records is small because they do not provide that evidence, histological as well
as clinical, without which no case can be accepted for statistical purpose. Neverthe-
less, the possibility of an occasional spontaneous disappearance of a carcinoma must
be borne in mind.
In 1927, Avramovici reported the case of a man, aged 45, whose father died of
a malignant tumour fo the frontal bone and a brother of carcinoma of the stomach.
He was the subject of a flat-cell carcinoma of the lower lip, the diagnosis being fully
established both clinically and microscopically. He had had no treatment when he
took a severe attack of quartan ague which continued during seven weeks. By that
time all signs of carcinoma had disappeared and he remained well three and a half
years later.
After reference to this case Mathez reports that of a man, aged 63, whose cheek
was perforated by a buccal carcinoma. Radium treatment failed to bring about im-
provement. The tumour was then excised and the wound developed erysipelas.
During four weeks he had hyperpyrexia, the temperature ranging about 106 F., after
which the wound appeared well and healthy.
The beneficial effect of such constitutional disturbances is ascribed to — (1) A
local defensive cell-reaction; (2) the increased production of antibodies; or (3) the
action of the hyperpyrexia.
Reding insists on alkalinity of the blood and hypocalcemia being essential fac-
tors, and he and Sloss seem to have found benefit following the administration of
parathyroid extract.
— A. Mathez in Lyon Chirurg, via Edinburgh Medical Journal, July.
NEW EUSTACHIAN CATHETER
A new eustachian catheter has been devised by Dr. Geo. B. McAuliffe, of New York', the
features of which are a pyramidal handle and a flexible shaft, the latter allowing accommodation
to various angles. Emphasis is placed on the fact that saving patients from suffering gives any
doctor the best hold on their confidence.
1. The Lryngoscope — June.
SOUTHERN MEDICINE AND SURGERY
August, 1929
Differential Diagnosis of Brain Tumor From Vascular Disease*
C. C. Coleman, M.D., and J. G. Lyerly, M.D., Richmond
Dept. Neurological Surgery, Medical College of Virginia
The appearance of symptoms of brain tu-
mor may be as abrupt as those of simple
blockage or rupture of a blood vessel of the
brain. It is this suddenness of onset of
brain tumor symptoms which may be the
cause of failure to recognize the fact that the
patient's condition is due to a brain tumor
with complications and not to a simple block
or rupture of a diseased vessel.
The blood vessels of young people who do
not have high blood pressure are not likely
to rupture unless the patient has either a
tumor or a congenital aneurysm. Sudden-
ness of onset of brain tumor symptoms may
be due to one of several things. First, there
may be a rupture of a blood vessel in the
tumor itself; second, the tumor acting as a
foreign body may bring about a sudden ede-
ma of the brain, thus causing a rapid in-
crease of intracranial pressure, with the usual
signs of compression of the brain. Third,
the tumor may be so situated as to be shifted
suddenly and block the escape of cerebro-
spinal fluid. Such a tumor must be in con-
tact with the ventricles or their connections
and, if sudden blockage of the cerebrospinal
fluid occurs, the symptoms may be as abrupt
as those of an apoplectic stroke.
In reference to the first complication,
hemorrhage into the tumor, it is well known
that blood vessels of a tumor are less capable
of resisting rises of vascular tension than
those in other parts of the brain. A bleeding
tumor rapidly enlarges and the resulting
compression is announced by sudden cerebral
disturbance. The profession has been accus-
tomed until very recently, to regard any
sudden cerebral disturbance causing paraly-
sis or focal impairment, as a manifestation
of rupture, thrombosis or spasm of a blood
vessel. The typical apoplexies are quite
easily recognized in most cases. The blood
pressure is usually high, the patient is often
beyond middle age, and the rupture is gen-
erally accompanied by unmistakable signs
and symptoms.
There is little accurate information as to
why cerebral blood vessels rapture spon-
taneously in the cases of so-called simple
apoplexy. The old theory of Charcot* that
these ruptures take place through small mil-
iary aneurysms, usually located in the pene-
trating arteries of the base, has been attacked
since recent investigation. Globus- and
Westphal^ believe that vessels of the brain
do not rupture, even under high tension, un-
less there has been an area of softening
around the vessel, which deprives the vessel
of its support. The cause of this pre-hem-
orrhagic softening of the brain about a vessel
is not entirely clear, but it is believed by
some to be due to a toxin elaborated in
chronic nephritis. Spasm of the vessels of
the brain has been suggested as a cause of
localized softening about a vessel, and while
there is no accepted proof that the blood ves-
sels of the brain have vasomotor nerves, yet
the transient focal impairments could hardly
be explained on any other basis than that of
spasm of the blood vessels. Aphasia or a
paralysis of the arm existing for a few mo-
ments, is not likely to be due to actual or-
ganic changes in the brain tissues. Globus
seems to think and apparently with good rea-
son, that rupture of a blood vessel is a ter-
minal event in the condition of so-called
apoplexy, and that the miliary aneurysm
itself resulting from lack of vascular support,
is due to pjerivascular softening of the brain
tissues. We have seen a considerable num-
ber of patients whose symptoms of brain
tumor developed with as great suddenness
as those of an apoplectic crisis. These pa-
tients are usually young people who may
retire feeling perfectly well, and become pa-
ralyzed during the night.
Case I. — A white man, 33, was admitted
to Memorial Hospital on October 10, 1928.
He complained of headache, nausea and vom-
iting starting four days previously. On the
*Presented to the Tri-State Medical Association ol the Carolinas and Virginia meeting at
Greensboro, N. C, February 19-21, 1929.
August, 1929
SOUTHERN MEDICINE AND SURGERV
morning of his admission to the hospital, he
had severe headache and vomiting. Upon
lying down after breakfast he became para-
lyzed on the left side. At the time he en-
tered the hospital the patient was in a semi-
conscious condition, and had a partial left
hemiplegia and a right third nerve palsy.
His blood pressure was 120/80. A hemor-
rhage into a brain tumor (probably a glioma)
was suspected. The patient improved re-
markably during the next two weeks, and he
was allowed to leave the hospital after com-
plete disappearance of the left-side weakness.
About two months later he was admitted to
Sheltering Arms Hospital in a similar con-
dition as when first seen with the exception
that he had developed a well-advanced chok-
ed disc. A tumor of the right temporoparie-
tal region was diagnosed and operation was
advised. At operation a deeply seated cystic
glioma was found in the above-mentioned
area. The cyst was evacuated and a decom-
pression done. This patient is still living,
with a very large herniation over the decom-
pression, showing a very rapidly growing tu-
mor. The explanation of the suddenness of
cerebral disturbance accompanied by hemi-
plegia and impairment of consciousness is
not clear. Inasmuch as the patient was not
operated upon until two and a half months
later it may be that he had a hemorrhage
into the tumor at the time of the first attack.
At any rate the case well illustrates the ab-
rupt appearance of brain tumor symptoms.
We have been accustomed to regard brain
tumor symptoms as of gradual development.
It is widely believed that such patients must
have headache, choked disc, vomiting, vertigo
and other signs of marked cerebral impair-
ment in order to justify a suspicion of brain
tumor. Such conceptions must be materially
modified.
The second cause of sudden onset of brain
tumor symptoms may be edema of the brain,
brought about in some way not entirely clear.
A brain tumor may provoke a sudden edema
of the brain tissues with a sharp rise of intra-
cranial tension, causing unconsciousness. It
is true that in some cases we have found an
enormous enlargement of the hemisphere with
a very small tumor. This enlargement was
not due to blockage of ventricular fluid.
These cases may give symptoms of a vascular
crisis.
The third class of brain tumors which an-
nounce their presence by sudden onset of
symptoms, are those in which the tumor has
a pedicle, allowing incarceration or shifting
of the tumor in such a way as to interfere
with the circulation of the cerebrospinal fluid
or with the medulla. The onset of symptoms
in this type of tumor is extremely abrupt and
may be followed by early respiratory failure.
Such a shift in the tumor may be brought
about by injudicious employment of spinal
puncture, and we must bear in mind the risk
of spinal puncture when removing fluid in
cases of brain tumor. A choked disc is nearly
always a contraindication to the use of spinal
puncture.
Congenital aneurysm and varicosities of
the cerebral vessels are much more common
than was formerly believed. The clinical
picture of the rupture of one of these vessels,
which is usually situated about the base, is
a striking one. The patient, often a young
person with normal blood pressure, is seized
with violent pain in the suboccipital region
and may become unconscious with the sud-
denness of an ordinary apoplectic stroke. If
the case proves to be one of ordinary apo-
plexy, the patient will generally die in a
short time because of the fact that tho hem-
orrhage breaks into the lateral ventricle. In
the case of aneurysm about the base, how-
ever, the onset is sudden, but the patient may
recover entirely from this attack and pass
on to future similar attacks. In both cases
the spinal fluid is very bloody. The import-
ant clinical difference is that the patient with
an aneurysm may recover from the .ittack,
while the patient with hemorrhage into the
ventricle from ordinary apoplexy nearly al-
ways dies within a short time.
Case II. — A white woman, 36, was ad-
mitted to Memorial Hospital on November
8, 1928. Her history dated from thirteen
years previously when she had attacks of
unconsciousness preceded by headache, nau-
sea and vomiting. These attacks would be
initiated by a sense of blood gushing through
her head. Three years later she had a simi-
lar attack followed by a complete left hemi-
plegia, from which she later partially recov-
ered. Four years ago she had another attack
of headache starting off with a "bang," a^;
the described it, followed by a drawing and
cramp-like sensation of the entire left tide
538
SOUTHERN MEDICINE AND SURGERY
August, 1929
of the body. Since then there have been rep-
etitions of these attacks with progressive
weakness of the left side of the body. Exam-
ination showed a spastic left hemiparesis,
blurred discs and a blood pressure of 100/60.
Suspecting a tumor, or an intracranial aneu-
rysm, operation was advised. At operation
there were found numerous varicosities of the
cortical vessels in the region of the fissure
of Rolando. The largest one measured 11
mm. in diameter. Anterior to these varicos-
ities was a blackish, discolored, excavated
area, apparently the result of a previous
hemorrhage. Nothing beyond decompression
was done toward alleviating the condition,
and the patient was discharged from the hos-
pital after making an excellent recovery from
the operation.
While a patient with a brain tumor and
sudden appearance of symptoms is often
thought to have a simple thrombus or rup-
ture of a cerebral vessel, the patient with
a slow bleeding of one of the vessels of the
cortex from trauma is frequently thought to
have a brain tumor. Slow bleeding of the
cortical vessels may become encysted, and a
large cystic clot may form, which covers the
entire hemisphere. Such bleeding may fol-
low slight trauma, and it may be months be-
fore the cystic clot is large enough to cause
compression symptoms. Choked disc, head-
ache and vomiting, with marked personality
changes may be found in these cases, and
a diagnosis of frontal lobe tumor is often
made. Removal of the clot is generally fol-
lowed by rapid recovery.
Thrombosis of the cortical vessels of the
brain is very rare, and we have encountered
this condition only once. This patient had
Jacksonian attacks of the opposite side of the
body followed by paralysis and signs of pres-
sure. At operation there was found a throm-
bosis of the Rolandic vein on the right side.
The vessel was completely occluded by a yel-
lowish-red thrombus.
Case III. — A white man, 51, referred by
Dr. F. W. Upshur, was admitted to Memo-
rial Hospital on February 23, 1926. The
patient was brought to the hospital on ac-
count of two generalized convulsions and he
was unconscious on admission. During the
next few days in the hospital, he had several
Jacksonian attacks starting in the right hand
and spreading to the entire right side. There
were no signs of increased intracranial pres-
sure, and his blood pressure was 122/75.
There was a pronounced weakness of the
right arm, leg and face. A diagnosis of
brain tumor was made. At operation a
thrombosis of the left Rolandic vein, with
degeneration and softening of the neighbor-
ing cortex was found. The patient died four
days after operation, apparently from ad-
vancing thrombosis of the cerebral vessels.
It is unusual for a patient with brain tu-
mor to have an elevated blood pressure un-
less the tension is suddenly raised either by
hemorrhage into the tumor or a massive ede-
ma of the brain. We are prejudiced against
the diagnosis of brain tumor if the blood
pressure is raised. The usual range of sys-
tolic blood pressure in brain tumor cases, re-
gardless of the age of the patient, is between
90 and 120. About one in ten brain tumor
patients will have an elevation of blood pres-
sure. The following case is illustrative:
man, 54, for two years had had jerking and
weakness of the right arm and leg. In a
number of these Jacksonian attacks, uncon-
sciousness followed the spasms of the leg,
which in turn was followed by weakness of
the extremities. His blood pressure ranged
from 190 to 200. He had never complained
of headache. There was a mild papilledema
on the right, but no measureable swelling of
the disc. After carefully considering the pos-
sibility of a localized vascular disease of the
right hemisphere, Drs. Beverley R. Tucker
and R. Finley Gayle came to the conclusion
that this patient had a tumor of the left
motor area. In view, however, of the arte-
rial hypertension, and the possibility of cor-
tical thrombosis and scar tissue formation,
a ventriculography was done. The ventri-
culogram was typical of a left-side tumor,
which was found at operation to be a large
endothelioma arising from the falx and longi-
tudinal sinus on the left side, and impairing
the function of the leg and arm areas. The
patient made an excellent recovery from
ofjeration and is now strenuously engaged in
his official duties. This case is quite illus-
trative of Jacksonian attacks which we are
accustomed to ascribe to tumor rather than
to vascular disease. Confusion of brain tu-
mor with cerebral arteriosclerosis before a
blockage or rupture of the vessel occurs is
not so common. The advanced age of the
August, 1929
SOUTHERN MEDICINE AND SURGERY
539
patient and evidence of body-wide degenera-
tion taken together with signs of disease of
the retinal vessels and absence of choked
disc, are usually sufficient to lead one to the
diagnosis of cerebral arteriosclerosis. The
difficulties are greater in the young, who
may have an elevation of blood pressure —
the so-called hypertension cases. These pa-
tients may suffer from constant headache
with choked disc and vomiting and may have
very obvious impairment of the cardio-vascu-
lar-renal system. In several such patients it
seemed wise to do a subtemporal decompres-
sion for the protection of vision and relief of
headache. Relief, however, by operation
rarely lasts longer than a few months.
The ophthalmoscopic examination is of
the greatest value in differentiating between
vascular disease and brain tumor. Choked
disc is not found in simple apoplexy, but is
often present in brain tumor in which there
has been a hemorrhage. It may be impossi-
ble to distinguish between simple rupture of
a blood vessel and a vascular accident of a
tumor, in spite of certain clinical differences
which generally appear. In such cases x-ray
may be of the greatest help, provided it
shows the pineal body. If the pineal body
is shown to be located in the midline, the
condition is likely to be due to simple rup-
ture of a blood vessel. If the calcified pineal
has been pushed to one side, it is good evi-
dence of a tumor on the opposite side. When
all other means of differentiation have been
exhausted, injection of air into the ventricles
will often clear up the diagnosis.
The few illustrative cases presented in this
paper might be indefinitely multiplied from
the series of tumors observed by us during
the past several years. The main purpose
of the papier is to call attention to the fact
that sudden cerebral disturbance may fre-
quently be due to a brain tumor with com-
plications. Careful neurological studies some-
times supplemented by mechanical diagnostic
aids may be necessary to differentiate between
such tumors and simple vascular disease of
the brain.
REFERENCES
1. Charcot, J. M., in collaboration with Bouch,
ard, M. C.: Hcmorrhapie Cerebral, in Oeuvres Com-
plets, 9: 3, 1890.
2. Globus, Joseph H , and Strauss, Israel: Arch.
Neuro. and Psych. Aug., 1927— No. 2— p. 215.
3. Westphal, Karl, and Baer, Richards: Ueber
die Entstehung des Schloganfalles, Deutsches Arch.
i. KJin. Med. 151:1, 1926.
DISCUSSION
Dr. R. Finlky Gayle, Richmond:
I remember distinctly when I went to the
Neurological Institute in New York at my
first conference the case of a young woman
was discussed who had complained of head-
ache for some weeks prior to that time but
had no other symptoms. Dr. Joseph Collins
said in his opinion the woman had a hemor-
rhage in a brain tumor. I was very much
impressed, for I had never heard of such a
thing. A day or two later she was operated
on, and this condition was found.
One cause of blood vessel rupture in young
people is central nervous system syphilis.
It seems to be a common belief that we
must wait until localizing symptoms are
found, but if we wait until that time for
operation it i£ too late.
Dr. R. F. Leinbach, Charlotte:
I want to say one word in commendation
of Dr. Coleman's paper. It is very helpful,
and I think everyone should carry home one
idea that is brought out; namely, that the
sudden onset of brain symptoms does not al-
ways mean vascular lesions. It is very diffi-
cult sometimes in working up the symptoms
in a neurological case to determine whether
the onset is sudden or not. I saw a case re-
cently in which the symptoms presumably
were not present at II o'clock at night, and
when the patient awoke at 6:30 in the morn-
ing they were present. It was very difficult
to tell whether those symptoms came on in
the course of a half hour or seven or eight
hours. Of course, seven or eight hours is
abrupt. There are many cases, of course, in
which mild symptoms have existed for some
time, but it is difficult to read from the his-
tory exactly what is going on. The general
rule, I think, still holds that an abrupt onset
in a patient wjth no previous history of cere-
bral disease means a vascular accident, but
not always. Well recognized syndromes have
been described with reference to the major
arteries. Those things should be borne in
mind by everyone doing neurological work.
However, the syndromes relating to those ar-
teries are not always produced by occlusion
of the arteries but sometimes are produced by
brain tumors, notably of the posterior cere-
bellar regain. Everybody who exam-
ines neurological cases carefully recognizes
the great responsibility of differentiating be-
SOUTHERN MEDICINE AND SURGERY
August, 1929
tween vascular accidents in the brain and
brain tumors, and one should give every care
to the study of those cases. It is exactly for
that reason, that there are a great many brain
tumors that are not recognized until late, in
the first place, and, in the second place, that
there is so much cardio-renal-vascular disease
in persons who otherwise are well and other-
wise have no symptoms that I think Dr.
Coleman's paper is very fine.
Dr. Coleman, closing:
Someone asked me whether that last pa-
tient lived. The long time those patients live
is one of the pathetic things in brain surgery.
He is still living, for these is no pressure to
kill him. I very greatly appreciate the kind
expressions of Dr. Leinbach.
The Medical Center in Richmond
Plans for the development of the medical
center in Richmond at the Medical College
of Virginia have been announced by Dr. W.
T. Sanger, president of the institution. The
work will cover a number of years.
The first unit of the new center, a building
for the college school of nursing costing ap-
proximately $300,000 for construction, equip)-
ment and site, has been completed. The
other units will go up as fast as funds, which
are being sought in different directions, are
available. Most of the ground to be used
has already been acquired.
The buildings projected are:
1. A library to be constructed in associa-
tion with the library of the Richmond Acad-
emy of Medicine, cost approximately $125,-
coo.
2. A teaching unit to house the outpatient
department and laboratories for the teaching
of chemistry, bacteriology and pathology,
co5t approximately $750,000.
3. A nurses' dormitory for the St. Philip
Hospital School of Nursing, an institution
maintained by the college for negro girls, cost
approximately $150,000.
4. A building for clinical dentistry, cost ap-
proximately $400,000.
5. A general hospital for white patients to
be built in association with the outpatient de-
partment and teaching laboratories, cost $1,-
000,000 or more.
6. A gymnasium, auditorium and recrea-
tional center, cost undetermined.
When this plan is carried through then it
is hoped to provide dormitories for students
in the schools of medicine, dentistry and
pharmacy.
FACULTY additions
Additional faculty appointments for the
Medical College of Virginia for the schools
of medicine, dentistry and pharmacy are:
Major James B. Anderson, professor of mili-
tary science and tactics; Miss Mary Brock-
enbrough, associate in art; Cliveden L. Cox,
associate in pharmacy; Dr. Garrett Dalton,
instructor in obstetrics; Dr. J. B. Dalton, in-
structor in orthopedic surgery; Dr. J. R.
Ellison, assistant in surgery; Dr. J. Arthur
Gallant, assistant in medicine; Dr. Oscar L.
Hite, assistant in nervous and mental dis-
eases; Dr. Paul W. Howie, associate in sur-
gery; Everett H. Ingersoll, associate in an-
atomy; Miss Myrtle Krouse, assistant in
d'spensing pharmacy; Dr. W. A. Peabody,
associate in chemistry; Dr. John H. Reed,
Jr., assistant in surgery; Dr. Earl L. Sham-
blen, assistant in surgery! Dr. Merrill G.
Swenson, associate professor of prosthetic
dentistry.
The States shown in the birth area
have for 1928 a death rate of 12.3 as com-
pared with 11.4 for 1927 and increases were
reported in 36 of the 38 States. The highest
1928 death rate (14.5 each per 1,000 popu-
lation) is shown for California and Missis-
sippi and the lowest rate (7.4) is for Idaho.
The infant mortality rate for 1928 repre-
sents an increase as compared with 1927, the
rates being 68.0 for 1928 and 64.6 for 1927.
The highest infant mortality rate (142.2) is
for Arizona and the lowest (46.9) for Ore-
gon.
Write for Farmers' Bulletin 1166-F.
It contains valuable information on poison
ivy and poison sumac, and may be obtained
free by applying to the United States Depart-
ment of Agriculture, Washington.
i
August, 1929
SOUTHERN MEDICINE AND SURGERY
541
Gas Gangrene*
R. B. Davis, M.D., Greensboro
Wesley Long Hospital
By gas gangrene we mean a death of tissue
en masse as the result of gas formation pro-
duced by anerobic bacteria,' which are found
almost universally in the intestinal contents
of mm and animal.- Until the recent world
war. this infection was thought to be pro-
duced only by the bacillus aerogenes capsu-
latus. However, it was then discovered that
it could follow infection from the bacillus
of malignant edema, the bacillus tetani, the
bic'llus bellonensis, as well as other spore-
forming anerobic organisms. ."Mthough the
infection is usually a mixed one'', the bacillus
aerogenes capsulatus was found in 77 per
cent of a group of cases studied by Segu and
Weinburg.
Gas gangrene destroys the muscles by
pressure produced from gas. The gas sepa-
rates the sheaths from the muscle fibres and
this pressure cuts off the nourishment. Im-
mediately they become bright red in color
and resemble rare cooked beef. Following
this, they disintegrate and finally the sar-
colemma itself disappears and the whole mus-
cle becomes a gelatinous mass.* The infec-
tion does not spread from one muscle to an-
other except by pressure.
It is of diagnostic value to observe that
with the single exception of the malarial
Plasmodium, the gas bacilli are the only
microbes which produce methemoglobinemia.''
There are two toxins formed, one which en-
ters the blood stream and destroys red blood
cells, the other remaining in the muscle tis-
sue producing edema and sloughing." As to
which destroys the most tissue, this toxin,
or the pressure from the gas, there is still a
question, but most authorities lean toward
pressure.
The early symptoms are mental alertness,
severe pain and swelling around the wound,
increased pulse rate out of proportion to the
temperature, gas bubbles in the x-ray pic-
ture. The late symptoms are listlessness,
followed by delirium, edema over large areas,
blistering of skin with foul-smer::'.^ discharge,
gangrene, rapid pulse, high temperature,
crepitation u[X)n palpation, tympany upon
percussion" and hemoglobinuria.
The diagnosis is based upon the clinical
history, signs and bacteriological examina-
tion. A history of severe, deep laceration is
usually obtained. Gunshot and dirty wounds
are most likely to be followed by gas infec-
tion. The most dependable diagnostic symp-
toms are pain, swelling, rise of temperature,
increased pulse rate and a characteristic,
foul-smelling discharge. The laboratory will
confirm the diagnosis by isolating the germ.
The x-ray will show early formation of gas
bubbles and these are conclusive proof.
Treatment, during war, or under unfavor-
able conditions, should be prophylactic and
curative. Generally speaking, in civil prac-
tice, with the exception of the tetanus infec-
tion, it is confined to curative. The prophy-
lactic treatment consists of giving a polyval-
ent anti-gas serum and doing a debridement
upon all cases that seem unduly predisposed,
from the nature of the injury.
The curative treatment is surgical, sero-
logical and medical. The surgical treatment
consists of cutting away from the wound all
dead or dying tissue and establishing free
drainage. One should not hesitate to ampu-
tate a limb in advanced cases. Remember
that this infection is beneath the muscle
sheath and to establish free drainage it should
be incised widely.
The serological treatment consists of giv-
ing, either intravenously, intramuscularly, or
both, 50 to 100 c.c. of a polyvalent anti-gas
serum, which has been prepared by immun-
izing a horse with the three most common
gas germs — bacillus aerogenes capsulatus,
bacillus of malignant edema and bacillus
bellonensis. If given intravenously, the se-
rum should be well diluted with saline and
given slowly. The above dose sh Mid be re-
peated every six or eight hours, until four
•Presented to the Tri-State Medical Assocjat'on Of the Carolinas and Virginia meeting a^
Greensboro, N. C, February 19-21, 1929.
SOUTHERN MEDICINE AND SURGERY
August, 1929
doses are given. All writers upon the sub-
ject recommend the use of the serum but em-
phasize the fact that the serum should in no
way replace the surgical treatment.
The medical treatment consists of hydro-
ren peroxide, mercurochrome, iodine and
Dakin solution locally. Infusions of saline,
glucose and sodium bicarbonate are indicated,
as well as transfusions of blood. Hypnotics
and stimulants are often required.
The prognosis is always grave. The ear-
l"cr the treatment is begun the lower the
mortality rate: the further the infected area
from the trunk of the body, the more effect-
ive the treatment. In one large group of
cases treated surgically and medically, the
mortality rate was 25 per cent; when the
serum treatment was also given, the mortal-
ity was reduced to 19 per cent."
In conclusion, then, let us bear in mind
that gas gangrene is most likely to develop
in persons who live under poor hygienic con-
d'tions, in wounds made with dirty instru-
ments, in wounds of the intestinal canal and
in localities where the soil has been heavily
manured. It is essentially a muscular dis-
ease and destroys tissue by toxins and pres-
sure produced by gas. Prompt surgical and
serological treatment will reduce the mortal-
ity greatly.
C.\SE 1. — Colored woman, 30, entered hos-
pital November 26, 1928, with a bullet
wound from pistol in left shoulder, left side
of abdomen and left thigh. Past medical
history was negative except for syphilis and
poor hygienic conditions. There was a
pinched expression of face, skin clammy,
pulse could not be palpated at the wrist,
heart sounds rapid and weak, blood pressure
would not register. Patient was stimulated
and immediate laparotomy performed. Left
side of the abdomen contained much blood
and fecal contents. This was mopped out
and six holes in the large and small intes-
tines closed. Many drainage tubes were put
in and abdomen closed. One thousand and
five hundred units of anti-tetanus serum were
administered.
For the next 72 hours pulse remained weak
and ranged from 100 to 140, with tempera-
lure from 97 to 99 and respiration 20 to 30.
Patient had no great pain and no nausea.
Several infusions of saline and glucose were
given. At the end of 72 hours pati?nt Jj^d
a chill, temperature went down to 96J/2 but
rose next day to 104, with pulse 160 and
respiration 40. Post-operative atelectasis
was suspected but not found. The abdomen
wound drained a little brownish discharge.
Eighty hours after the injury, while the
nurse was bathing the patient, she noticed
the right foot was cold. Upon examination,
the foot and leg were found to be swollen,
discolored and cold. Crepitation could be
felt upon palpation and tympany upon per-
cussion. Patient's pulse and general condi-
tion were so bad that it seemed hopeless to
attempt an amputat'on. Serum treatment
was considered but we were unable to obtain
any serum in town. Blisters formed on the
leg and foot. These broke and discharged,
giving off a very foul odor. X-ray showed
gas formation in the abdominal muscles and
it was felt that infection was too extens.ve
for any operation to do good. Swelling con-
tinued until December 5th, when the abdom-
inal muscles ruptured and the wound broke
down. Patient died on the 9th day after
injury and 5 days after onset of the gan-
grene.
Case 2.— (Dr. J. W. Tankersley.) Col-
ored man, 2i, came into hospital October 20,
1928, immediately after receiving gun-shot
wound in left forearm, badly shocked, pulse
not perceptible at wrist, flexor muscles and
the vessels of the forearm severed and wound
bleeding profusely.
History of poor hygienic conditions.
Hemorrhage was stopped, wound closed
and patient put to bed. Next morning 1.500
units of anti-tetanus serum were given. Tem-
perature dropped to 97 at 4 a. m. but during
the next 24 hours it rose to 103, while the
pulse rose from 80 to 120.
On October 22, 1928, two days after ad-
mission, arm continued to be painful and
there was much oozing. Swelling grew worse
and crepitation was noted. The next day, J
the third after the injury, the arm was am- I
putated at the upper third and the flaps left
open. Peroxide, mercurochrome and Dakin
solution were used freely. Pain and foul
smelling discharge were prominent symptoms,
but the sloughing tissue gradually came away.
On November 7th, IS days after onset of
gangrene, 14 days after guillotine amputa-
tion, the temperature having been normal for
seven days, the second amputation was done,
August, 1029
SOUTHERN MEDICINE ANB SURGERY
543
this time up to the shoulder joint. Flaps
were closed loosely and drains put in.
Patient from now on made an uneventful
recovery and was discharged November 18,
1928. after 28 days in the hospital. Patient
spat blood several times but no evidence of
pneumonia could be found. The gas forma-
tion extended around the shoulders, up into
the sides of the chest.
Case 3.— (Dr. H. H. Ogburn.) Colored
man, 20. brought to the hospital in ambu-
lance, after having been wounded in right
leg, by shotgun. Many shot could be felt
under the skin but no large amount of tissue
was destroyed.
History of poor hygienic conditions.
Patient's temperature rose from 98 to 103
and pulse from 80 to 110. A dressing was
applied, 1,500 units of anti-tetanus serum
were administered and patient was giveji
anodynes for pain. Next day the leg was
cold and crepitation could be felt about the
knee. There was much oozing from the
wounds. No pulsation could be felt in the
flint. Patient suffered continually.
Multiple incisions were made to let out gas
and discharge, but patient grew rapidly worse
and became delirious. Temperature and
pulse continued to rise until temperature was
103^j and pulse 130. The infection extend-
ed to the hip, with crepitation and swelling.
On January 9th, patient died, 72 hours after
he was shot.
BIBLIOGRAPHY
1. Arch. Fur Klin Chir, Veh. 21. 1Q2S. Zeissler,
J., and Ni.EER, K.
2. Koi.MER — Text Book on Infection, Immunity,
Biologic Thenipy.
i. N. Y. Jour, of Med, Oct. IS, 1928— Dickin-
son-, .\. M., and Traves, C. A.
4. Annals of Surg., Veh., 1927, Baldwin, Jas. H.,
.ind Gii.MdRE, Wm. R.
.V Munch. Med. Woch., July 2, 1926.— Eichler,
P.
b. Jour. Exp. Med., July, 1917— Bull and Prit-
CIIEIT.
7. .V. Y. Stale Med. Jour., Oct. IS, 1928— Dick-
inson, .\. M,, and Traves, C. A.
DISCUSSION
Dr. D. .\. Garrison, Gastonia:
I agree with the doctor in his statements
in his paper and indorse all except his treat-
ment of the stump. I do not think anything
has any effect on that tissue that I have ever
used — that deadened tissue. When the stump
is kept absolutely dry and warm, that is the
best treatment. As to the peroxide, I would
not want it.
If your olfactory and optic nerves are in
good condition, you can make a diagnosis
without the laboratory. One of my teachers
in medical school was a man who had been
through the Civil War. He said: "There is
only one thing to do; amputate as far away
as possible from the seat of the disease, and
when he wakes up give him a teaspoonful of
calomel."
My first case was that of a boy five miles
in the county. I operated just as high as
I could and left forty grains of calomel to
give him as soon as he waked up. Gentle-
men, he recovered and was out walking in ,
ten days, in fine condition. (Question: Did
he take the calomel?) Yes, he took the cal-
omel.
The next was a man who was working ,
around his barn and stuck his sprout hoe
practically through his foot. The third day
I amputated his leg just below the- knee,
without any result. The next day I ampu-
tated just above the knee, and the next day
I gave him to the undertaker. He got no
calomel. (I am not an advocate of calomel
and hardly give it at all, but I am just giving
you my experience.)
The third was a man injured in a motor-
cycle wreck on the last day of the year. He
was brought to the hospital, and we did
what we could for him, but we could see this
gas coming into the wound. It was decided
to amputate. We fixed the field below the
knee but saw this gelatinous tissue and d's-
coloration, so amputated above the knee. We
decided to get some serum if we could. The
nearest place was Atlanta, and we got it in
twenty-four hours. While waiting for that
serum we gave him twenty grains of calomel.
This serum came and we gave it to him, a
dose each day. He got only 100 units; we
gave him 50 the first day and 25 the next
day and the third day. Put it in the stom-
ach. He got along finely until the ninth day,
when he had the most terrible liemorrhage I
ever saw; the blood just poured mit of him.
I hap[)ened to be in the hospital when it
happened. Seven days later he had another
hemorrhage, a profuse one, and we gave him
four blood transfusions. On the twenty-third
day he had his third hemorrhage, but that
was stopped. He is in fine condition, wori^-
544
SOUTHERN MEDICINE AND SURGERY
August, 1929
ing daily as a bookkeeper.
Dr. C. S. Lawrence, Winston-Salem:
I know of some old Civil War surgeons
who will walk a mile to talk about their ex-
perience with gas gangrene. In the World
War it was brought out to the light. We
heard very little of it in civil practice and
knew little about it except that it is due to
the B. welchii. During the war we found
there is a large family of these anerobes. We
found that practically from eighty to one
hundred per cent of the wounds carried an
infection of gas bacilli. In the sector where
I operated, eighty per cent of the wounds
were infected with gas-forming bacilli. It
calls upon the surgeon to decide what to do
at once in order to save the patient's life.
There is no time for waiting, no time for
serum, no time for laxative, no time for cal-
omel. If you wait the patient is gone — that
is, if he has the real gangrene. A great
many of these wounds, however, harbor
anerobes and do not develop gas. That was
shown during the war, when plastic opera-
tions were done several months later, when
the wounds were reopened under strict asep-
tic technic and gas gangrene developed.
In the sector where I worked in France,
wounds were cultured immediately'. When
the men were unloaded from the train they
were given attention, given a bath and their
Ti'ounds cultured. Thorough debridement
was done, and the wounds were watched very
closely for gas. If the gas appeared in the
tissues, amputation was done. In that way
our mortality was not high, and I have tried
to follow that practice in civil life. I make
cultures from compound fractures, lacera-
tions, wounds received in automobile acci-
dents, railroad accidents, etc., do thorough
debridement, and leave the skin open. The
skin is an impervious sac; if you close it, it
closes in the infection. Do a thorough de-
hridetnent, leave the skin open, and watch
for gas. If gas appears, amputate. Doing
that will leave the patient a good stump and
often save his life.
I shall report one case. A man coming
down out of his barn loft fell and sustained
a compound fracture of the tibia and fibula.
.':• '--.Ts advised to come to a hospital but
wds somewhat stubborn and would not. Un-
fortunately, they sewed up the wound. Sev-
eral days later he was brought to the hos-
pital. He had the pallor peculiar to gas gan-
grene, abdomen distended, pulse about 130,
black vomit. He was advised to have the
leg amputated. Gas had appeared between
the stitches. I told him it was either that
or die and he said he would rather die. I
did, under light gas anesthesia, slit the leg
from the knee to the ankle: and when I did,
the periosteum slipped off the bone. The
next day, however, he decided to have an
amputation, and I amputated at the knee
joint. I never saw a man recover so prompt-
ly. The vomiting stopped, the fever went
down, the pulse went down, and he made a
good recovery.
Dr. H. R. Black, Spartanburg:
A young football player, while on the field,
received an injury in his left chest, ante-
rior. In a few hours he developed gas gan-
grene. Dr. Sam Black was requested to see
this patient. After his examination he ad-
vised immediate operation, and an operating
room was improvised in the home. He made
a multiplicity of incisions and inserted a simi-
lar number of drainage tubes. This patient
was brought to the Mary Black Hospital
right away, a distance of twenty-nine miles.
For two weeks or three he remained in the
balance, during which time a very, very ex-
tensive sloughing was going on. Finally the
slough separated, leaving a large raw surface.
.After the raw surface had granulated, as we
thought, sufficiently, we decided the proper
thing to do would be a skin graft. As young
as I am, gentlemen, I claim the distinction
of having done the first skin-grafting opera-
tion in the State of South Carolina. We skin-
grafted this surface after the Thiersch meth-
od. The surface was carefully prepared. This
case was then about four weeks old. We lost
every graft; every single graft perished. Two
weeks later he was grafted again, and we
lost every graft with the exception of a few
islands here and yonder. This is the only
case that I ever had or knew of in skin
grafting that failed after the Thiersch method
when auto grafts were used. I do not know
why, unless there were still living in that
wound the bacilli or the poison of the gas
gangrene. The young man eventually made
a good recovery and is as well today as be-
fore and is still an athlete. Of course, he
has considerable scar tissue,
August, 1030
SOUTHERN MEDICINE AND SURGERY
s*s
Periodontia
Wallace D. Gibbs, D.D.S., Charlotte
There are several general conditions that
concern the dentist. For purpose of this ar-
ticle the two conditions of decay only will
be dscussed. The other conditions that deal
with malformation and malposition of the
teeth are dealt with by the orthodontist and
the exodontist, respectively, and excellent
results are being obtained in each field.
First, a condition of decay or disintegra-
tion of the tooth itself; the other a decay or
disintegration of the bone socket that sup-
ports the tooth. The first is called dental
caries and is fairly well understood by the
laity. It is treated by the dentist by the
simple process of removing the decayed part
of the tooth, sterilizing the remaining walls
and inserting a substitute or filling for the
lost tooth structure. The dentist does not
know the basic cause of tooth decay and is
therefore unable to combat the primary at-
tack or to prevent a recurrence of the decay.
He understands the phenomena of attack, en-
vironment, and predisposition, as well as the
habit of the patient and he is aware that
these things tend to produce the condition
known as dental caries. He instructs his
patient in certain fundamental laws of mouth
hygiene that will tend to lessen the chances
of decay, and he repairs the various revages
to the teeth; many of his repairs and restora-
tions are both artistic and ingenious. They
serve for awhile to replace the teeth and
parts of teeth that have been lost. But these
restorations are replaced from time to time
as other decay sets in or as new areas mani-
fest themselves. Hence the desire of the den-
tist for the patient to visit him every six
months for purpose of inspection and repair
of areas of decay — both old and new. If
the dentist had a cure for dental caries there
would be no necessity for the patient to re-
turn. However, the dentist has a multitude
of duties that he performs each day and
thereby renders an indispensable service to
humanity. It has always been the dream
of the dentist that he may one day discover
a prevention for dental caries or, failing this,
at least a permanent cure for the condition.
To this end much literature has been devoted
and many years of ardent research work.
But, the fact remains that no dentist knows
the cause of, or the cure for dental caries.
The other condition, generally known as
pyorrhea alveolaris, is a decay of the bone
socket. Like the first condition known as
dental caries a definite cause has never been
satisfactorily proven nor has a specific cure
ever been accepted. P'or some reason den-
tists in the past have devoted very little of
their time to this condition and consequently
have very little knowledge of it. Just why
the dental profession in the past devoted
their time almost exclusively to the study
and treatment of dental caries to the exclu-
sion of bone decay is not clear. It may have
been due in a general sense to the fact that
dental caries is always more rapid and there
is inevitable pain associated with it. What-
ever the cause, the fact remains that dentists
have devoted very little of their time to the
condition known as pyorrhea — a decay and
disintegration of the alveolar bone. However,
in recent years, some dentists, and their num-
ber is constantly increasing, have given up
the study and repair of the teeth and have
devoted their time exclusively to the study
of the other form of decay in the oral cavity.
These men, by devoting their time exclusively
to this part of dentistry are standardizing it
and excellent results are being obtained.
The status of this field is today on a par
with the other, which deals with decayed
teeth and there is no logical reason why re-
sults equally as good cannot be obtained in
pyorrhea, so called, as in the other field.
The dentists devoting their time exclusively
to the field that deals with diseased alveolar
bone and associated structures are known as
periodonists — more often referred to by the
laity as pyorrhea specialists.
The length of th's article would not be
sufficient for me to go into the many theories
as to the cause or the cure for so-called py-
orrhea. Many volumes have been devoted
to this subject. .Although no definite cause
has been established, or specific cure discov-
SOUTHERN MEDICINE AND SURGERY
August, 192Q
ered for pyorrhea, I shall give, in a general
way, some of the factors that contribute to
its cause and shall touch in a general way
upon its treatment. Until recent years the
condition was considered a gum disease and
was supposed to be a primary or direct in-
fection. Therefore, most if not all of those
doing research in this field were endeavoring
to isolate some specific micro-organism or at
least some definite strain. In the light of
present knowledge it is easy to understand
why they never found a specific germ, or
even a strain, with any constantcy, and why
various drugs and serums failed. Not even
their autogenous vaccines were of any value.
The primary lesion is in the alveolar bone.
The gums naturally reflect this trouble being
in such proximity to the bone. Such symp-
toms as hemorrhage of the gums were from
the deeper structure of bone, as was also the
recession of the gums which was due entirely
to the collapse of the supporting understruc-
ture, while a flow of pus is easily traced to
its seat — the bone. The pus comes from be-
neath the gums, it is true, but never through
them. Naturally after a vicious cycle has
been established, the gums, peridental mem-
brane, and other soft tissues become involv-
ed. Pyorrhea is not primarily an infection
and naturally no specific germ has been
found. While there is a hereditary tendency
noticeable in some families, pyorrhea has
never been transmitted from one person to
another and it is therefore only logical to
conclude that it is simply a low grade con-
dition of atrophy or decay and that infection
is secondary. JMalformation of teeth, mal-
position of teeth, irritating margins of fillings
that do not fit and other poor dentistry, and
individual habits all play their part in the
initial lesion. Treatment consists in general
of proper diagnosis, proper classification and
a restoration to as near normal as possible.
Differential diagnosis must be made by the
careful consideration of the history and elim-
ination of those conditions which present
symptoms in common with pyorrhea, Vin-
cent's, thrush, stomatitis — the making of a
complete and accurate set of x-rays for diag-
nosis and future reference in treatment, re-
ferring to the general dental practitioner for
correction of all mechanical defects and for
the removal of any teeth that are hopelessly
involved.
Treatment includes correction of occlusion
for abnormal stress, thorough prophyla.xis,
which includes not only the removal of ac-
cumulations on the root surface, but resur-
facing of the tooth root and curettage of the
epithelium of the pocket, thorough instruc-
tion and demonstration in the correct use of
the proper brush, — so little understood by
the average patient — and use of such ot^ier
local measures as may stimulate nutrition.
The diet should be considered and general
elimination seen to.
Although Vincent's, thrush, or stomatitis
should not confuse the competent dentist,
any one of these diseases is treated as pyor-
rhea, so it is best to eliminate them system-
atically. Likewise local manifestations of
diabetes, tuberculosis and syphilis are often
mistaken for pyorrhea and so treated. These
conditions will show little or no response to
local treatment and should be referred to
the physician if they are not already under
his care.
CONCLUSION
Pyorrhea, if systematically studied and the
same sound principles applied as in other
dental conditions, will respond as readily.
Under proper treatment all adverse symp-
toms, including pus, can be eliminated; and
where the co-operation of the patient is ob-
tained by periodical visits, as advocated by
general practitioners of dentistry, the teeth
can be preserved for many years of usefulness
without any detriment to the health of the
patient. A proper realization of the truth
of this statement will eliminate the necessity
of having to tell our patients that nine out
of ten of the teeth lost are from pyorrhea.
This word criticism is of Greek derivation
and signifies judgment. Hence I presume
some persons who have not understood the
original, and have seen the English transla-
tion of the primitive, have concluded that it
meant judgment in the legal sense, in which
it is frequently usde as equivalent to condem-
nation. — Fielding.
For Sale- Tice's Practice of Medicine, complete,-
with Index and all new revisions placed properly.
This set has not been used or injured in any way.
Price ^75.00 Address "MRD," care of Southern
Medicine & Surgery.
August, 1029
SOUTHERN MEI5ICINE ANt) SURGERY
S4?
The Thymus Gland as the Cause of Convulsions
Charles P. Mangum, M.D., Kinston
The Kinston Clinic
The thymus gland is situated behind the
manubrium and in front of the trachea, great
vessels and other structures which fill the
superior entrance of the thorax. The antero-
posterior diameter of this space is 2 cm. This
gland at birth is between 4 and 5 cm. long;
1.5 to 2.S cm. wide; and .8 to 1.4 cm. thick.
The average weight at birth is 6 grams.
Anything over 10 grams is considered path-
ologic. There is not much change in the size
of this gland during the first two years, .'\fter
this it gradually diminishes in size until at
puberty only a vestige remains.
The thymus consists of two lobes, attached
above and separated below, the shape being
more or less that of a half opened pea-pod.
V'ery little is known of the function of this
gland. It is assumed that it produces some
internal secretion which supplies the defi-
ciency of those of the reproductive organs
up to the time when they are fully developed.
Whether it bears any relation to other inter-
nal secretory glands or not is unknown.
The thymus may enlarge as the result of
neoplasms, lues, tuberculosis, cystic forma-
tions, or abscess. It may also enlarge during
the course of an acute disease. The most
common cause of enlargement is simple hy-
perplasia. Nothing is as yet known as to
the cause of this hyperplasia. It may be
accompanied by congestion, either acute or
chronic.
This enlargement may produce varied
symptoms; caused chiefly by pressure on the
trachea, the large vessels and nerves having
a tendency to slip aside. Such symptoms as
repeated attacks of cyanosis dyspnea, a
crowing sort of cry, a high pitched metallic
cough, stridulous inspiration and e.xpiration
which may be confused with congenital stri-
dor, "convulsions of unknown origin," tre-
mors and contractions resembling spasmophi-
lia or symptoms resembling those produced
by bronchial adenitis or retropharyngeal ab-
scess. The convulsion associated with en-
largement of the thymus is what I wish
chiefly to call attention to in this paper.
The mechanism by which an enlarged thy-
mus produces convulsions is unknown. Ex-
perience, however, has most convincingly
shown us that it does. It is thought by some
to be an imbalance of internal secretions.
Another theory is that pressure on the re-
current laryngeal nerve — a fixed nerve, which
supplies all the muscles of the larynx except
the cricothyroid with motor impulses and
controls approximation of the vocal cords —
causes a deficiency in oxygenation which in
turn may produce a change in blood chem-
istry resulting in convulsions.
Following are a few illustrative cases:
Case 1. — A full term baby, 2 months old,
weight 2 lbs. 14 ozs., normal delivery, third
child. Nothing unusual was noticed about
this baby until she was six weeks old. She
then began to have attacks of cyanosis asso-
ciated with restlessness and a peculiar high-
pitched cry. These attacks occurred at ir-
regular intervals, each attack more pronounc-
ed than the preceding one. Between attacks
baby would seem perfectly normal. On the
day before admission she had two hard con-
vulsions with marked cyanosis. X-ray show-
ed an enlarged thymus measuring 3.5 cm.
wide and 5 cm. long, practically all the
enlargement showing in the right lobe.
Case 2. — A full term baby, 5 weeks old,
weight 9 lbs. 10 ozs., normal delivery, first
child. Baby nursed well during the first
week of life. Showed no symptoms of intra-
cranial birth injury. Three days before baby
was brought into hospital the mother noticed
a slight tremor of all extremities. He had a
h'Story of difficult breathing since birth and
a peculiar crowing sort of cry. X-ray shows
an enlarged thymus measuring 4 cm. in
width and 6.5 cm. in length. Deep therapy
relieved all symptoms.
Case 3. — A full term baby, 2 months old,
weight 11 lbs., 11.5 ozs., normal di'livery,
third child. This baby seemed a perfectly
ncjrmal, healthy, happy baby up to the morn-
ing of the day of admission when he had a
severe convulsion. He has a negative per*
SOUTHERN MEDICINE AND SURGERY
August, 192Q
sonal history. However, the family history
reveals that one brother who seemed perfect-
ly healthy died suddenly in infancy following
a convulsion from no discoverable cause. X-
ray shows an enlarged thymus measuring 5
cm. wide and 6 cm. long.
Diagnosis. — A history of repeated attacks
of cyanosis, the metallic cough, the crowing
cry, difficult breathing especially when lying
on the back with the head e.xtended, repeat-
ed convulsions ranging from slight tremors
to hard spasmodic seizures of unexplainable
origin, of sudden death claiming an infant
brother or sister who was apparently in the
best of health — all these should make one
suspicious of an enlarged thymus. The
symptoms present may be e.xaggerated by re-
traction of the head which produces a nar-
rowing of the antero-posterior diameter of
the superior mediastinum. Crying or excite-
ment will also cause an exacerbation of symp-
toms by producing an acute congestion of the
enlarged gland. In the case showing stridu-
lus breathing it will be noted that the larynx
does not move up and down as in congenital
stridor, but is held stationary by the enlarged
gland. There may or may not be dullness
on percussion on either or both sides of the
sternum as the enlargement may be all an-
tero-posterior, all lateral, or both. The x-ray
picture makes the diagnosis positive.
There is only one treatment — deep therapy
with the x-ray; which as a rule gives excel-
lent and almost immediate results.
In conclusion, the point that I wish to em-
phasize is that the child with such a history
as I have outlined, especially of repeated con-
vulsions, should have a thorough study in-
cluding x-ray, instead of simply a purgative.
The intestinal tract and birth injuries should
not be made to bear all the blame.
Catarrh of the Head*
A. J. Ellington, M.D., Burlington, N. C.
In this brief paper only the high spots will
be touched. Symptomatology and many
other important phases will be left open for
discussion. One reason for this presentation
is to discourage the use of the term, catarrh.
The latest medical books have almost dis-
carded the word. Catarrh is derived from
the Greek "kato," meaning "down" and
"rheo," "I flow," which being interpreted
means, "a cold in the head causing a running
at the nose." Catarrh covers a multitude of
conditions and means very little. It is simi-
lar to the terms, bad cold, neuralgia, indi-
gestion, rheumatism or acidosis, all of which
are expressive of symptoms, rather than a
definite disease.
To follow my own suggestion and to prac-
tice what I preach, I shall from this point
discuss "Chronic Symptoms in the Nose,
Throat and Ears," briefly mentioning the
pathology, the most common causes and the
best recognized methods of treatment.
In long continued head symptoms, hyper-
trophic or atrophic, changes occur in the
structures of the ears, nose and throat. The
hypertrophic changes lead to turgescence and
polypi with overproduction of secretion; the
atrophic type, often called "dry catarrh,"
leads to necrosis and ozena with foul odor.
There is sometimes a combination of hyper-
trophy and atrophy. No specific germ has
been found to account for these changes in
the tissues.
The etiological factors in producing this
pathology are many and varied. Heredity
and environment undoubtedly play a part.
The general health and personal hygiene are
factors. Foreign bodies, new growths and
syphilis are comparatively rare. The most
common local conditions are chronic sinusitis,
deformities of the nasal septum, polypi and
polypoid turbinate bones, diseased tonsils and
adenoids, naso-pharyngeal adhesions, and
dental disease. I would say the three S's
are the causes of catarrh of the head — sinuses,
septum and so-forth.
♦Presented to Slitb (N. C.) District Medical Society meeting at Burlington, June 20tb, 19J9.
August, 1029
SOUTHERN MEDICINE AND SURGERV
S49
Among the thousands of people complain-
ing of so-called catarrh of the head, one or
more of the causes listed above can invariably
be found. The remedy or relief lies first in
a correct diagnosis and then in persistent
well-directed treatment — medical, hygienic
and surgical. Great diffculty in getting de-
sired results is caused by the natural dread
of an operation and the discouragement given
by would-be friends and advisors. These
patients are willing subjects for patent medi-
cines, cubebs and quacks. After years of
suffering and expense, some will submit to
proper treatment, which then has become
more complicated, more difficult and neces-
sarily less effective.
As already indicated, the treatment of
chronic changes in the ears, nose and throat
consists: first, in the proper general manage-
ment: secondly, in adequate (not temporiz-
ing) attention to local pathology. A chronic
sinus is a surgical problem. The failure of
some sinus operations to entirely cure is not
a just cause for the condemnation of all sinus
surgery. It is a challenge for more thorough
work and a call for closer co-operation be-
tween patient, family doctor and specialist.
There are eight separate sinuses or groups
of sinuses, which frequently require more than
one operation for relief. This is very differ-
ent from an uncomplicated appendicitis — one
operation and a complete cure.
Deformities of the nasal septum producing
mechanical pressure or obstruction are easily
relieved by operation and by no other meth-
od. JNIechanical obstruction requires me-
chanical relief. A submucous resection of the
nasal septum gives definite and satisfactory
results.
Enlarged turbinate bones or nasal polypi
causing obstruction to respiration, blockage
of sinus drainage, interference with ventila-
tion or production of abnormal secretion
should be partly or wholly removed or re-
peatedly cauterized to produce shrinkage.
The sinus infection behind these conditions
should not be neglected.
Diseased tonsils and adenoids should be
removed and pharyngeal adhesions broken
up. These often play a part in the catarrhal
picture. Lastly, dental caries and pyorrhea
should receive thorough treatment, not only
for the relief of local irritation but for the
effect on the general health.
SUMMARY
1. The diagnosis, "catarrh of the head," is
indefinite and misleading.
2. Causes can be found if carefully sought.
3. Early relief of nasal obstructions is es-
sential in preventing secondary affections of
the ear, nose and throat — call it catarrh or
what not.
FIFTY AUTOPSIES, PRBIARY CAUSE OF DEATH PULMONARY
TUBERCULOSIS
In these autopsies unexpected conditions were often found. This was strikingly
true in connection with the intestinal tract. Of nine cases in which extensive intes-
tinal lesions were observed of both small and large bowels, note was made in the
clinical records of no bowel symptom except moderate constipation in three cases,
abdominal distress alone in one case, and abdominal distress together with diarrhea
in five cases. Of the ten cases in which tuberculous lesions were found only in the
small bowel, no notation was made in the clinical record of any abdominal symptoms
in four cases, moderate constipation was recorded in two, and abdominal distress
with diarrhea was reported in four cases. Of the two cases in which intestinal lesions
were found only in the cecum and colon, no mention was made of abdominal symp-
toms in one, but diarrhea was noted in the other. Of the fifty cases, the clinical
records reported thirteen with notable diarrhea. In these thirteen, tuberculous intes-
tinal lesions were found in ten at autopsy.
— \. O. Sandersin, The A. Rev. Tuhercidosis, July, 1929.
SOUTHERN MEDICINE AND SURGERY
August, 1Q29
Some Notes on the Examination of Roentgen-Ray Plates
Groesbeck F. Walsh, M.D., Fairfield, Ala.
Chief of Medical Clinic, Employees' Hospital
This custom is su£!£;ested in the examina-
tion of all x-ray plates. Look for no one
particular th'ng. Regard the plate as a
whole, as a puzzle. Do not put it down until
every part of it has been systematically exam-
ined, and you are sure that in it lie no hidden
abnormal findings or variations from what
we consider the normal. Consider the plate
with an open mind. Regard it as a source
from which may come all manner of unex-
pected information, this information frequent-
ly bearing little, if any, relation to the pur-
pose for which the plate was originally taken.
We will find, as our education in the read-
ing of x-ray plates proceeds, that many gross
mistakes are made by ourselves and by others,
due more to disregard of this general rule
than to any other circumstance.
This is easy to understand. If a plate is
taken for a specific purpose or a particular
lesion, let us say a fracture, and that frac-
ture which we expected to find is found, then
for some reason or other our interest in the
plate automatically ceases. We can see into
then our examination ceases. It is best to pre-
be permissible when a plate is made to look
first for the lesion which we suspect, but I
believe even this is bad practice, and that the
plate should be examined systematically, be-
fore even the definite purpose for which the
plate is taken is fulfilled.
If we examine an x-ray plate with the ex-
pectation of finding almost anything, our
interest in the plate survives to the end of the
examination. If we take it for one purpose,
and that purpose is fulfilled or unfulfilled,
our examination ceases. It is best to pre-
serve some orderly method of examining x-
ray plates.
I think it is a very good rule, no matter
for what purpose the plate is taken, to begin
with the examinaton of the skeletal struc-
tures which show.
Let us consider the chest for a moment.
We will save ourselves a good deal of em-
barrassment, if we begin the examination of
^U chest plates, not by the examination of
the shadows shown in the soft parts, but by
the examination of the bones themselves.
Since the vertebral column is a single struc-
ture and can not be compared with anything
else in the same plate, and can indeed be
compared only with our recollection of num-
erous other vertebral columns seen in pictures
taken at similar distances and with sim'lar
penetration, it is not a bad plan to examine
first the shape, size and position of all the
parts of this structure. The eye can be slow-
ly run down the vertebral column from the
uppermost parts which show down to where
the shadows of the lower thoracic vertebrae
are lost at the level of the diaphragm. The
vertebral column is narrow, and at a s'ngle
examination we can measure with our eye the
relative sizes of the vertebral bodies. We can
note the varying densities. We can quickly
look for abnormalties such as spina bifida.
With one glance we can determ'ne whether^
the ribs lie in their articular facets in the
manner in which they should. We can note
any variations which occur in the intervals
between the vertebral bodies where the carti-
lages lie, and note the presence or progress
of lesions in the articulations themselves.
Finished with this detail, we can again rase
our eyes to the top of the plate, and by mov-
ing them from one side to the other we can
note the shape, size and number of the ribs, the
presence or absence of cervical ribs, Ih?
equality or lack of equality of the various arc,
through which the ribs fall. In a few mo-
ments examination we can satisfy ourselves
whether the ribs match evenly by comparing
one side against the other: whether or not
there is rib splinting; the appearance of sus-
picious opacities or lack of opacities; the
presence or absence of old fractures; the pres-
ence or absence of premature calcification in
the costal cartilages. It might be well then
to take up the clavicles and such of the
shoulder girdle bony structures as are visble
in the plate, comparing one side against the
other: whether or not they match eveilv:
whether each shoulder girdle is niaintaine(i
August, 1929
SOUTHERN MEDICINE AND SURGERY
SSI
in its proper position; whether or not the
clavicle, scapula, and such of the humerus
as is visible, show the same quality of den-
sity as do the ones on the opposite side. We
can determine whether or not in this exam-
ination our suspicion may be excited as to
the presence of calcareous deposits in the
deltoid bursae. I think it is wise then, and
only then, to turn our attention to the shad-
ows which are cast by the soft parts, the
mediastinal contents, and the various parts
of the bronchial trees.
.A point of importance is the determination
of the position of the trachea in the upper
chest, and the relation which the bifurcation
of the trachea bears to its immediate sur-
roundings. Variations in the position of the
trachea at this point should be carefully
noted, as they materially assist many times
in our conclusions as to the age of various
lesions which may be elsewhere apparent in
the upper chest. The quality of shadows
in the lungs themselves will not be discussed,
but one point is worthy of mention, and that
is the frequency with which moderate devel-
opments of pneumothorax are overlooked.
This, I think, is due to the fact that very
often after looking at many chest plates, the
eye falling down the side of the chest identi-
fies at once the margin of the pectoral mus-
cle and the lower margin of the breast shad-
ow in women; and undoubtedly we overlook
moderate deposits of air in these localities,
believing as in past instances that they are
due to the two means of shadow casting
above mentioned.
It is of interest and importance to note the
two shadows which the phrenic leaves cast.
It has not been accentuated frequently
enough that our breathing apparatus consists
in fact of an engine with two separate cylin-
ders, and that impairment on one side is very
quickly met by an increased function on the
other. In acute right-sided abdominal lesions,
which have had time enough to create an im-
pression on the human body, a picture of the
chest will very often show the right dia-
phragm fixed and elevated and the left dia-
phragm pushed down, as the compensating
left lung forces itself, like an ameba, into the
left pleural sinus.
This is one of the factors which has so made-
it often difficult to differentiate between an
early right-sided lower lobe pneumonia and
an acute right-sided intra-abdominal lesion,
both the x-ray and physical findings, as we
know, closely resembling each other.
Before we are through examining our
plates of the chest we should have gained
much of value from conditions in the chest
itself, and from the level of the shadows
cast by the phrenic leaves; and from their
relation to each other, we should have some
suspicion at least in many instances of any
gross abnormalties in the abdomen itself.
In examining pictures of the abdomen let
us make the same rule to follow. Let us con-
fine ourselves first of all to examination of
the bony structures. Let us do this, regard-
less of the purpose for which the picture was
originally taken. Let me describe a case in
illustration of this.
Some years ago a patient was being treated
in a hospital in this city for some form of
kidney lesion. She had been seen by several
men of skill and experience. She was ex-
amined cystoscopically with very little, if any,
benefit. A number of pictures of the abdo-
men were made, as one of her consultants
was confident that she had a kidney stone.
This was before the pyelogram became wide-
ly used. When the plates were developed and
the kidney shadows examined, a controversy
arose as to whether one kidney showed undue
enlargement. When attention, however, was
diverted from the study of the soft parts to
the study of the bones, it was determined that
this patient had a fairly well-marked tuber-
culosis of the lumber vertebrae, which was
proven by subsequent plates. This mistake
would not have been made, had it not been
for the fact that the attention was concen-
trated on a single definite jxjint, and not
enough interest or curiosity had been excited
to consider other features which might have
produced the picture which we saw.
In this instance, had the rule which we
spoke of at the beginning of the discussion
been adhered to, a correct conclusion would
have been arrived at much earlier.
.Another case in point: several years ago a
I)atient was seen suffering from some thoracic
lesion. He was x-rayed several times,
and the plates were examined by individuals
of considerable experience in plate reading.
A i)roa<l shadi)w in liic mediastinum was
ratiier indefinite. One said it was an aneu-
rysm, and one demurred. Two inches out
SS2
SOUTHERN MEDICINE AND SURGERY
August, 1929
from the vertebral column on the left side
was a rib which had been eroded, and which
had dropped to the level of the rib below.
This rather unusual development had not
been seen by the original observers, until it
was called to their attention at a later date.
Their interest had been found entirely upon
the solution of the problem: whether or not
an aneurysm was present. The case turned
out to be a malignancy of the mediastinum,
which had already begun to erode the ribs.
Not long ago in our own clinic here an in-
dividual was given a barium meal, and a nega-
tive report was turned in as a result of the
examination. The barium, of course, was
spread throughout the abdomen in large
and irregular masses, as a result of the e.xami-
nation. Twenty-four hours later, on making
a second plate, a kidney stone of considerable
size was plainly evident in the right kidney.
On re-examining the first plates the same
shadow was detected mingled with the shad-
ows cast by the barium; but by a process of
self-hypnosis we had viewed the plate as a
gastro-intestinal study only, and had com-
pletely overlooked the large shadow which we
subsequently discovered. Had we followed our
general rule of making a scout plate of the
abdomen before the meal was • given, this
would have been seen the first time. But this
is little, if any, excuse for the mistake we
made.
Instances of this sort, after a few years
of plate reading, could be multiplied almost
indefinitely; and while it is true we all learn
from mistakes of this sort, we might learn
just as readily, and be of greater benefit to
our patients, if we applied the simple rule
which was stated at the beginning of this dis-
cussion.
Here at this institution such a large pro-
portion of our x-ray readmg is made for the
determination of the presence of fractures,
that our interest is always first directed to-
ward the bones, and I think most advantage-
ously so, as we have preserved this attitude
in the reading of other plates as well. It has
been a great help to us.
Many x-ray men, and I think very wisely,
ray the injured arm or leg and the uninjured
arm or leg also for the purpose of compari-
son. It would probably be best to do this
in all instances, but it should be an invariable
fi^le in raying tlie bocjies of adolescents, where
the various epiphyses give rise to much con-
fusion. In raying a hand or foot, let us
regard each picture in its entirety. Regard-
less of where the lesion is, it is not a bad
rule to first go over each tarsus and carpus,
looking for fractures and abnormalties, even
if the point of injury is at a considerable dis-
tance from this p)osition. In this institution
we start our examinations invariably with
this measure. We know from past experience
that fractures of both tarsal and carpal
scaphoids are among the fractures most fre-
quently overlooked in x-ray work.
Another point in the examination of x-ray
pictures of the extremities which is of value,
to observe closely the silhouette of the soft
parts. The position and degree of the swell-
ing, taken in connection with the history of
the injury (if the case is traumatic) and the
age of the patient, not infrequently makes us
strongly suspicious of the fact that a frac-
ture is present, even if this fracture can not
be demonstrated. The study of the soft parts
has helped us in many instances, particularly
in cases of fracture of the lower outer end of
the tibia, where the fragment is concealed be-
hind the fibula and is at times very difficult
to make out. Soft part swelling of consider-
able degree and persistence at this point
should make one very suspicious of a broken
bone, and suggest replating, if necessary, at
different angles.
A point which should never be forgotten is
t/ie value oj examination oj all the plate, pay-
ing as much attention to the periphery as
we do to that part of the plate which is in
the immediate focus of the tube.
This autumn a plate was seen which had
been examined months ago for a fracture of
the lower third of the ulna. The fracture was
found and the plate so described. Far out of
the immediate focus and at the extreme peri-
phery of the picture was dimly visible a dis-
location of the radius. This picture was taken
by a competent radiologist and, so far as we
have been able to find out, the latter lesion
had never been discovered. The woman ap-
peared at this institution for treatment weeks
after the fracture with a disabled elbow joint.
We have lately seen another instance in-
dicating the value of examining the periphery
of x-ray plates: .An individual was rayed at
this hospital, pictures being made for some
purpose of the lumbar spine. Tbese pictures
August, 1929 SOUTHERN MEDICINE AND SURGERY S53
were negative, so far as the immediate pur- cinating study, and its chief benefit lies not
pose of taking them was concerned. At the in the discovery of any particular lesions
margin of the plate some indefinite shadows which we may or may not be looking for,
were seen, which excited our interest and but in the development of orderliness in ob-
curiosity. The patient was brought back to servation and the training of the mind and
the x-ray department, and rayed with this eye to detect any visible variations from the
area of his body in the immediate focus of noimal.
the tube. These indefinite shadows were then If we bear in mind the simple rule of
easily identified as residues of some intra- viewing each plate without undue prejudice,
muscular injections of salicylate of mercury, and refrain from bringing our observation
On being confronted with these facts, our ^^^ quickly to any definite conclusion; and
patient readily gave us information concern- ■ .u ■ u t .u i .
^ ,,,.,,,, . . .• if we examine the penpherv of the plate
ing himself, which he had up to that time i < .
withheld, and which assisted us materially "^'th at least as much attention as we bestow
in the solution of his problem. upon the central parts of it, we will save
The examination of x-ray plates is a fas- ourselves many necdltss blunders.
STABILITY OF DIGIT.'VLIS AND ITS PREPAR.ATIONS
Six specimens of powdered digitalis have been exatnined by Harvey B. Haac. and Robert A.
Hatcher, New Yorlc (Journal A. M. A.. July 6, 1Q20), in the laboratory after intervals varying
from one to si.xtcen years, and in no case has deterioration been detected, and no one in the
laboratory has ever observed anything indicative of deterioration in one of the many specimen?
of powdered digitalis used. Powdered digitalis, in tablets or in capsules, is admirably suited for
securing uniformity of dosage where individual patients, clinics or groups of clinics are provided
with sufficient to last one year or more. A sterile infuson of digtalis undergoes little change
within several months, and deterioration then results solely in diminished activity, not in increased
toxicity. The official tincture of digitalis retains its activity with comparatively little change during
several years, and any change that does occur merely calls for a corresponding increase in
dosage. The secret of deterioration of liquid preparations of digitalis has not been explained fully,
and there is no evidence that any of these preparations are as stable as powdered digitalis kept
with ordinary care in a corked glass bottle. Aqueous solutions of strophanthin, ouabain or other
digitalis principles, kept in ampules of soft glass, deteriorate rapidly. Ouabain solution in ampules
of hard glass aecomposes slowly. Their investigation lends no support to the contention ihit
any of the digitalis specialties are more stable than the official digitalis tincture. All liquid
preparations of digitalis should bear the date of manufacture.
COLLOIDAL ALUMINUM HYDROXIDE AS A GASTRIC ANTACID
In cases of functional hyperacidity and moderate subacidity with subjective complaints of
pain and heartburn the relief afforded by l.'i to .(0 grains of colloidal aluminum hydroxide is
almost immediate. The relief so afforded may last for thirty to sixty minutes only occasionally
being followed by recurrence of heartburn, or the subsidence of symptoms may be complete and
enduring. An undesirable constipating effect such as is seen with the bismuth salts has not been
observed, nor have nausea, vomiting or diarrhea or any other toxic by-effects been noted on any
occasion.
Colloidal aluminum hydroxide seems to be the more desirable of the neutral nonabsorbable
antacid salts in so far as it is an efficient agent in reducing ga.stric acidity to a point where
symptoms are relieved but gastric digestion allowed to continue. It hastens gastric emptying; it
is nontoxic and devoid of de'eterious by-effects. It is clinically applicable in cases of gastric
secretory disturbances characterized by hyperacidity and can be used in ulcer cases in moderate
dosage over prolonged periods without the anxiety of producing or the production of alkalosis or
the toxic symptoms such as may be due to the absorption of soluble alkaline salts — B. H. Crohn,
in Jour. Lab. & CUn. Med., April.
SOUTHERN MEDICINE AND SURGERY
August, 1Q20-"-
Harelip and Cleft Palate
James W. Davis, M.D., F.A.C.S., Statesville
Davis Hospital
There are few greater disfigurements than
untreated harehp or cleft palate. Every child
born with a deformity of this kind is entitled
to and should receive treatment. Fortunate-
ly few cases are now left untreated.
There are many different forms of harelip
and cleft palate. These may occur singly or
together. Harelip or cleft lip may appear
only as a slight notch or may be a complete
cleft extending up into the nasal passage. A
double harelip sometimes occurs.
Cleft palate may vary from a slight notch
in the uvula to a complete cleft separating
th: ma.xillary bnnes entirely. The various
types and combinations of these congenital
deformities require different treatment. Also
the condition of the child governs to some
extent the age at which surgical correction
cm be accomplished successfully.
Where only a harelip is present this, as a
lule, should be operated on within the first
nnnth of 1 fe if the child is in good physical
cond t'on. Where there is a cleft palate as-
cocated with a cleft lip, an operation to se-
cure union of the maxillary bones may be
u; dertaken from the third week to the fourth
mmth. Six weeks to three months later the
hi elip can usually be closed. The closure
of the soft palate should be accomplished, if
possible, before the eighteenth month, cer-
t.:'inly before the chid begins to try to speak.
Where a child has already learned to speak
before any surgical treatment is begun, the
lesult is never so good as where the correc-
ton is completed before the eighteenth
month.
Brophy has called attention to the fact
that unless treatment is attended to early
there will not be a full complement of tissue
which forms the perfect palate because the
tissue will not develop in proportion to the
other parts, due to the presence of the de-
form ty. The importance of closing these
clefts in early infancy cannot be ovcrcniplta-
sized.
The most noticeable deformity is naturally
the harelip, and in closing this every elYort
should be made to preserve the line of the
vei'nT'lion border of the lip so that the repair'
will be as inconsp'cuous as possible. Another*
important point to attend to in the repair of
the cleft or harelip is to replace the nose so
that the nostril will not be left broad and
flat. This is not easy to do, especially when
a late repair is done.
The full co-operation of the parents of the
ch'ld and the fanvly doctor is necessary in
getting a good result in these cases, especially
where the operation must be done in stages.
Sometimes the most carefully executed oper-
at'on for the closure of the soft palate will
not hold and will require a second operation,
or occasionally a third before there is a suc-
cessful closure. Fortunately, however,, if ta-
ken at the right age the first operation is
usually successful.
.Another thing that must be taken into eon-
s'deration and which the family should be
made acquainted with is the fact that there
is di:iTcr in these cases. The mortality is
comparatively small cons'dering the age at
whch the children are usually operated upon.
The deformity itself, especially where there
is a cleft palate, makes the child more sus-
cept b'.c to respiratory complications and for
th's reason the danger should be carefully ex-
plained to the parents.
On the other hand parents should hi in-
formed of the fact that the death rate among
ch'ldrcn with untreated cleft palate is from
25 to 50 per cent due to various infect'ous
diseases to which they are more susceptible
because of this deformity. The safest pro-
cedure then is operation, the mortality from
whch is far less than the natural or e.xpected
mortality in the untreated cases.
The parents should be warned in plain
terms of the results that follow if the con-
d tion is untreated. The child will grow up
almost an outcast. Individuals who are so
unfortunate as to have deformities of this
kind are usually shunned, and it is difficult
for one who has this deformity to make a
success in life, to say nothing of the mental
suffering because of the condition.
August, 1029
SOUTHERN MEDICINE AND SURGERY
S5S
^^^^^^r //iy
^~Jm.
Ir
fl
i^^^H
CONCLUSIONS
1. Every child who has a harehp or a cleft
palate should be taken to a surfjeon by the
third week. Treatment should be begun at
the earliest possible time.
2. The mortality from operations for hare-
11]) and cleft palate is less than the natural
or expected mortality in untreated cases.
Fig. 1
Girl, age 10. Untreated harelip and deft palate
showing typical deformity. Operation at this age is
never so satisfactory or so successful as when done
earlier. Much, however, can be done for these pa-
tients.
3. Unless the surj^ical repair of harelip and
cleft palate is completed before the child
learns to talk the results are never so satis-
factory.
4. Every child who has a deformity which
can be remed'ed by surgical treatment is en-
titled to and should receive the proper treat-
ment at the earliest possible time.
^^^^^^^4t^^^H
■
1
^v>^
^^
■ ■ *
•
i
'"■ * *
(
■f
Fig. 2
Typical case of harelip immediately before opera-
tion.
Same patient
after operation,
Fix. ■'■
as in Fig. J one and a half years
SOUTHERN MEDICINE AND SURGER\
August, 1929
Harelip.
Fig. 4
Fig. 5
Same patient shown in Fig. 4 two years after
operation.
REFERENCES
1. Brophy, T. W.: Cleft Lip and Palate. Phila-
delphia, P. Blakiston Son & Co.. 1925.
2. Bfophy, T. W.: The Late Results of Cleft
Palate Operations. Surg.. Gvn. & Obst.. 20, 9S.
3. Brophy, T. W.: The Best Age for Cleft Palate
Operations. 1921 Records, 41, 4S1 (Abstract).
4. Blair, V. P.: Surgery and Diseases of the
Mouth and Jaws. St. Louis, C. V. Mosby Company,
1O20.
5. Blair, V. P.: Ideal Age for Cleft Palate Oper-
ations. Interstate Med. J.. St. Louis, 1010, 118.
6. Blakeway, H.: Treatment of Harelip and
Cleft Palate. Practitioner, Lond., 1014, 92, 219.
7. Hoesley, J. S.: Operations on Harelip and
Cleft Palate. Virginia M. Monthly, 1920, 47, 97.
International J. Orthodontia, 1921, b, 497.
August, 1929
SOUTHERN MEDICINE AND SURGERY
Broken Back*
J. S. Gaul, M.D., Charlotte
The last straw to break the patient's back
often is our faihire to recognize the true path-
ology present where the traumatizing factor
has been either slight or severe.
In this discussion it is not my intention to
allude to the unfortunate group with irrepara-
able damage to the cord for whom little of
value can be done except to prolong life, pre-
vent renal complications and add in some
measure to their comfort. It is rather the
desire to focus attention on those cases in
which there is a fracture of spinous processes,
trasverse processes, laminae, articular facets
or compression fractures of the body.
It is in the last named group that the real
"breaking of the back" occurs in our failure
to recognize the condition. We are prone to
lightly dismiss these cases to find later that
they develop a severe disability.
There is a history of trauma, the severity
of which and the application of which varies.
It may be one of sudden flexion of the spine
in any one of the four primary directions of
movement. Given a history of acute flexion
of the spine, or of force applied perpendicular
to the transverse axis, we should be suspicious
of compression fracture of the vertebral
bodies; with acute lateral flexion we should
suspect fracture of the articular facets, and in
acute hyperextension, fracture of the spinous
processes. The history, including the man-
ner in which the force is applied in the direct
trauma cases, suggests the possibility of the
transverse processes, the spinous processes or
the laminae being fractured.
Practically the only subjective symptom
complained of is pain. This is more or less
localized to the injured area, but occasionally
there is referred pain in the distribution of
the nerves having origin near to or emerging
from the injured site. Objectively we find
marked muscle spasm and a form of postural
attitude is assumed by the patient which gives
him the most relief from pain.
X-ray negatives give us the greatest aid in
arriving at the correct diagnosis. Stereoscopic
films should be made using an excellent tech-
nique. These will give the best detail. Pic-
tures should be made in more than one plane
and then studied carefully. This is esfjecially
true in the compression fractures. Osgood
has conclusively shown the spongy bone may
be collapsed and, because of its resiliency,
the body nearly resume its normal shape.
Careful search will reveal a hair-like line of
fracture or some disturbance in the mass of
the body.
Untreated cases pass into that unfortunate
group of chronically painful backs to be total-
ly or partially disabled over long periods of
time. They complain of pain, inability to lift
objects or to stoop over, find themselves un-
able to follow their usual vocations, and at an
inopportune time must make some readjust-
ment in their scheme of living. This intro-
duces the economic factor, a vital and serious
one for the patient be he a laboring man.
Many develop traumatic arthritides or
radicular pains for the relief of which the in-
genuity of any one will be severely tried.
To treat these spines requires absolute rest
in the supine position for a period from six
to twelve weeks. When the parts to which
the psoas muscle is attached are involved the
thigh should be immobilized. The back
should then be suported with some form of
brace for a period of from three to twelve
months, the determining factors being the re-
lief from symptoms and the x-ray findings.
CONCLUSIONS
1. Many broken backs are not recognized.
2. The history gives a clue to the correct
diagnosis.
3. Stereoscopic films in more than one
plane should be made.
4. Failure to recognize these fractures re-
sults in severe disability, economic loss and
inconvenience to the patient.
5. Treatment when instituted should be
continued until the patient is free fronf
symptoms and the x-ray findings indicate
complete healing.
*Prese»ted to the Tri-State Medical Association of the Carolinas and Virginia meeting at
Orecniboro, N. C, February 19-21, 19i9,
8M
SOUTHERN MEDICINE ANB SURGERY
August, 1929
Case Report
Interstitial Pregnancy
Douglas Jennings, M.D., Bennettsville, S. C
Marlboro Hospital
A white woman, aged 38, was admitted to
the Marlboro Hospital on July 18, 1929, com-
plaining of amenorrhea of six months dura-
tion and a f)elvic mass which had slowly de-
veloped over the same period of time.
The family history was not significant.
The patient has always been in good
health, never sick and, as far as she knows,
she has no organic trouble. Is the mother
of eight children, who are living and well.
All pregnancies normal and deliveries easy
and spontaneous.
Present Illness. — Was nursing an 18-
months-old child, when she failed to menstru-
ate six months ago. Ceased nursing the child
because she thought she was pregnant. Had
no nausea or vomiting, no pain nor disturb-
ance of any kind. After a few weeks she
noticed a small lump in the pelvis just to the
the left of the midline, which has continually
but slowly grown larger. After amenorrhea
for four and one-half months she failed to
feel fetal movements, and began to wonder
if she was pregnant. She called her family
physician, who told her, after vaginal exam-
ination, that she was probably pregnant and
to wait awhile and she would very probably
feel the movements. She waited until she
had failed to menstruate for six months, then
again consulted her physician, who referred
her to me.
Physical examination showed a well devel-
oped, well nourished, white woman of about
40 years of age, color good. Only positive
finding a firm mass in the lower abdomen
slightly to left, slightly movable, not tender,
about the size of a five months pregnant
uterus. Blood pressure was 230/120. Va-
ginal examination showed a bilaterally lacer-
ated cervix with eversion of the lips. The
uterus was normal in size and firm to the
touch, but was markedly displaced to the
right by a mass on its left. This mass was
firm, not tender, slightly movable, and appar-
ently arose in the region of the left adnexa.
There was a slight vaginal discharge of a
thin, dark brown fluid, which showed many
red blood cells on microscopic examination.
laboratory Examination — Urinalysis re-r
vealed trace of albumin, no other abnormal-
ity. Leucocytes 5,600, differential count nor-
mal. Blood Wassermann and Kahn negative.
Conclusion — Tentative diagnosis of left
broad ligament cyst with beginning meno-
pause. Consultant's diagnosis, tubal preg-
nancy with dead fetus. Because of the hy-
pertension, it was decided to delay operation
a few days. Patient was kept quiet in bed
on milk diet and measures taken for thor-
ough elimination. Two days after admission
blood pressure was 190/100 and operation
was decided upon.
Operation — Ether anesthesia, iodine prep-
aration, midline incision from pubis to um-
bilicus. On opening the peritoneum, the
mass presented itself. It was free of adhe-
sions, of the consistency of a cyst, about the
size of a large cocoanut, and pinkish in color
in contrast to the usual bluish color of an
ovarian cyst. It seemed to grow from the
left side of the uterus and was contained
between the folds of the left broad ligament.
The left tube and ovary were small and dis-
placed to the extreme left of the mass. The
uterus was small, firm, and markedly pushed
to the right. The right tube and ovary were
normal in size, shape and position. Because
of the location of the mass, it could hardly
be dissected out; therefore, since this woman
was 38 years old, the mother of eight chil-
dren, and had an old bilateral laceration of
the cervix, it was decided to do a pan-hys-
terectomy. Appendectomy was then done
and the abdomen closed as usual without
drainage.
Gross Pathology — Specimen consisted of
uterus and connected right tube and ovary.
There was a mass of the consistency of a
cyst which seemed to be an outgrowth from
the left side of the uterus, and the left tube
and ovary were suspended from this mass.
The uterine cavity was opened and appeared
normal. The uterus was of normal size and
firm. The mass was opened and contained
a four months fetus in its amniotic sac, and
a well developed placenta. The fetus was
macerated and appeared to have been dead
for some time.
Diagnosis — Interstitial pregnancy, dead fe-
tus.
Comments— DeLee states that interstitial
August, 1929 SOUTHERN MEDICINE AND SURGERY SS9
pregnancy has the same terminations as tu- seemed to be an outgrowth from the left
bal pregnancy — rupture, mole, or abortion; uterine wall, and that the uterus was not
but because of the power of the uterus to hypertrophied to any extent. It is also in-
hypertrophy, it is barely possible that an teresting to note that this fetus had evidently
interstitial pregnancy may continue to term, been dead for some time, explaining the fact
He also states that the corresponding uterine that the patient had not menstruated for six
cornu is over-developed, greatly distorting the months but had not felt fetal movements,
organ. In this case, it is interesting to note The fetus probably died before it reached
that the cornu was normal and that the mass four and one-half months.
AN ADVERTISEMENT IN THE WORLD [LONDON], JANUARY 15, 1791
Such ladies as wish to dance (with ease and grace) at the Ball, which will be
at St. James' next Tuesday, are respectfully informed that wearing Martin Van
Butcheirs New Invented Spring Band Garters (by the King's patent) will help to
make them superbly happy.
The Marchioness of Salisbury, the Countess of Aylsbury and divers other ladies,
having had these garters many months now, can tell their friends how much they
like them. John Hunter, Esq., F. R. S., Surgeon extraordinary to His Majesty, has
six years used and recommended them.
— From "John Hunter, His Enemies & His Friends," by M. S. Guttmacher, in Bull. Johns Hop-
kins Hasp., July.
EXTRACT FROM "THE THYMUS OBSESSION"
(Dr. John Lovett Morse, in Anesthesia & Analgesia, July-August)
There is much doubt whether the deaths that are attributed to status lymphaticus during
anesthetization and operation are really due to it. There is no proof that enlargement of the
thymus is the primary or causative factor in the anatomic complex described as status lymphaticus.
There is no justification, therefore, for the assumption that shrinking of tha thymus with the
Roentgen ray will have any effect on status lymphaticus. There is much reason to believe that
many of the roentgenograms taken do not show the real size of the thymus and much evidence to
show that it is very difficult to decide from a roentgenogram whether the thymus is larger than
it ought to be in the given child at the given time. It does not seem either reasonable or justifiable,
therefore, to say that a roentgenogram should be taken of every child before anesthetization or
operation, that treatment with the roentgen ray should be given in every case before anesthetization
or operation, if the roentgenologist thinks that the shadow is enlarged, or that the physician or
surgeon who does not follow this course of procedure is negligent.
OVERWEIGHT AND CANCER
This analysis shows that men accepted for insurance between the ages 30 and 44 and who
were 50 pounds or more overweight at issue, show a subsequent mortality from cancer of 37 per
100,000. Persons who were in the group of "standard" lives, which includes all those less than
SO pounds overweight down to those who are not more than 24 pounds underweight, show a
subsequent mortality rate from cancer of i2 per 100,000; and those underweight, 25 pounds or
more, had a mortality rate from this cause of only 24 per 100,000. In like manner, persons who
were 45 years of age or over at the time of insurance and who were then 50 pounds or more
overweight had a mortality rate of 156 per 100,000 from cancer compared with 144 per 100,000
for "standard" lives and 120 per 100,000 for persons in the underweight group. In other words,
in the younger group, we find subsequent mortality rates amonc the overweights 15 per cent, in
excess of that among "standard" lives and 50 per cent, in excess of that among underweights. Among
the men who were 45 and over at issue, the subsequent cancer mortality rate of overweights is 8 per
cent, in excess of that of "standard" lives and 30 per cent, in excess of that of underweights,—
Proc. Ass. Life Ins. Dir. of Am.
S60
SOUTHERN MEDICINE AND SURGERY
August, 1929
PRESIDENT'S PAGE
Tri-State Medical Association of the Carolinas and Virginia
—CYRUS THOMPSON
"It is of some importance," said Sidney
Smith, the genial and witty Church of Eng-
land parson of some hundred years ago, "at
what period a man is born. A young man
now hardly knows to what improvements of
human life he has been introduced." He then
notes some changes that had taken place dur-
ing his own life-time. "Gas was unknown.
I groped about the streets of London in the
all but utter darkness of a twinkling oil lamp,
exposed to every species of depredation and
insult. I can walk now by the assistance of
the police from one end of London to the
other without molestation; or if tired, get into
a cheap and active cab instead of those cot-
tages on wheels which the hackney coaches
were at the beginning of my life. I paid
15.1 in a single year for repairs of carriage-
springs on the streets of London, and I now
glide without noise or fracture on wooden
pavements. I have been nine hours ,in sail-
ing from Dover to Calais before the invention
of steam. It took me nine hours to go from
Taunton to Bath before the invention of rail-
roads; and I now go in six hours from Taun-
ton to London. In going from Taunton to
Bath I suffered between 10,000 and 12,000
contusions before stone-breaking IMc.Vdam
was born. I could not keep my small clothes
in their proper place, for braces were un-
known. I had no umbrella! They were little
used and very dear. If I had the gout there
was no colchicum. If I was bilious, there
was no calomel. If I was attacked by ague,
there was no quinine. There were no banks
to receive the savings of the poor. I had no
post to whisk my complaints for a penny to
the remotest corners of the empire. And yet
I lived on quietly and I am now ashamed that
I was not more discontented and utterly sur-
prised that all these changes and inventions
did not occur two centuries ago."
What would this good parson think if he
were now here a few days with us? We
steam across the occ i;i in less than five days,
and we fly across in less than three, and we
motor everywhere at fifty or more miles an
me. I wish you would tell me. I have not
water-works and paved streets and a bank or
two; and every community has its mail de-
livered at its doors every day over roads better
than his wood-paved streets of London or his
IMcXdam roads ever were. There are mag-
nificent school-houses everywhere and the
children are carried to school.
And yet the popular unrest is no less and
crime is no less than it was in the early days
of Sidney Smith. "Why is that?" do you ask
space to undertake to answer. I know only
that contentment and happiness and inno-
cence are not born of external things. Knowl-
edge increases, wisdom is not grown corpulent,
and morals put on no weight.
"The good of ancient times let others state;
I think it lucky I was born so late."
Consider for a minute the changes that
have come about in the last fifty years, nay
the last twenty-five years. I would find it
very difficult to live in the barren environment
of my child-hood, youth and early manhood.
So much that we have that makes for our
comfort is the product of recent years. So
much that we know in medicine is the knowl-
edge that we have gained in the last thirty
years that we are surprised at how little we
knew, yet got along so comfortably with, be-
fore. I wonder if the next generation will
follow suit and smile compassionately at the
ignorance of this. Oh well, the times are
always changing and we are always changed
with them: Let every man be proud in his
own day. Any man of three score years an
ten has already lived more than a thousand
years and is older in fact than poor Methu-
selah who died at 9o9. He saw and knew
very little. Compared with us Methuselah,
poor fellow, died young. Fifty years now is
better than a thousand then — if we live them
well. JMcdxine has added some years to the
average span of human life; but science, in-
\cntlon, discovery and industries have given
us centuries more.
Aueust, 1920
SOttflEkN JtEbtClNE AM) StkceftY
J6l
PRESIDENT'S PAGE
Medical Society oj the State oj North Carolina
—L. A. CROW ELL.
^[y recent travels over the State have
brought to my mind more forcefully the high
standing and genuine worth of the rank and
file of our profession. It has been very pleas-
ant to note the esteem in which our physi-
cians are held, not only by the laymen among
whom they practice, but by medical men of
other States. I am convinced the esteem is
well deserved, for everywhere I go in the
State the physician is a man of high standing
in his community, a man of energy and
character. My present position has given me
the wonderful opportunity of knowing many
I would likely not have known otherwise.
The duties that have been placed upon me
and the new experiences that I have gained
have served as a liberal education. I have
learned much about the medical men of our
State; the ethical standards maintained have
been excellent. I have really been disappoint-
ed in only one particular. But the dark spot
or two which tends to mar the beauty of the
picture has not lessened my faith in the medi-
cal profession of this State, nor served to
dampen my enthusiasm. Therefore, I have
no doubt or fears for the future of the medical
profession of the State of North Carolina. I
am not alarmed by the activities of the quacks
and shysters, who go about preying upon an
ignorant public. The osteopath and chiro-
practor, and other cults do not constitute a
menace to the medical profession in my opin-
ion. Fads and foibles have ever risen and
passed away; they will continue to do so
while the world stands. The dangers that
seriously threaten any organization are those
within, rather than those without, its own
ranks.
If the glory of the medical profession is
dimmed or the reputation and standing in the
State marred, it will be because of those of
our own number who fail to measure up to
the high standard of our professional code;
those who are licensed to practice medicine,
having the endorsement of the medical pro-
fession and the State, refusing to take seri-
ously the duties and obligations of the pro-
fession. This creates a questioning attitude
on the part of the laymen toward the stand-
ing and integrity of all doctors. The most
dangerous and threacherous characters of his-
tory have been those who while enjoying the
protection and confidence of their organiza-
tions deliberately contributed to their un-
doing.
The Master was betrayed by one of the
trusted twelve. Benedict Arnold was one
of Washington's most trusted generals, but he
failed in a moment of crisis and his glory was
turned to shame and his name has become a
synonym for treachery and deceit. The
undoing of the great Caesar was wrought
by those within his own ranks who had
shared his secrets and enjoyed his confi-
dence. His cup of bitterness overflowed when
he found that his trusted friends had failed
him. Our government at Washington i.> not
endangered by the priests and Pope of Rome,
but should be more concerned over the De-
Priest from our own Chicago. We of the
Methodist faith are not especially concerned
as to what the leaders in the other denomi-
nations are doing, but we are vitally inler-
c.=tcd in the doings of those at the head of
our own church.
".\ man's foes shall be they of his own
household."
562
SOUTHERN MEDICINE AND SURGERY
August, 1929
- ■ ■ ■♦
Southern Medicine and Sur^er^
Official Organ of
jTri-State Medical Association of the Carolina^ and Virginia
(Medical Society of the State of North Carolina
Jaues M. Northington, M.D., Editor
James K. Hail, M.D
Frank Howard Richasoson, M.O..
W. M. RoBEY, D.D.S
J. P. Matheson, M.D.
H. L. Sloan, M.D
C. N. Peeler, M.D
F. E. Motley, M.D
V. K. Hart. M.D _.
F. C. Smith, M.D
The Barret Laboratorom
O. L. Miller, M.D..
Department Editors
-Richmond, Va..
-Black Mountain, N. C._
.Charlotte. N. C.
-Human Behavior
Pediatric!
Dentistry
Charlotte, N. C-
Diitase] of the
'Eye, Ear, Nose and Throat
Hamilton W. McKay, M.D..
John D. MacRac, M.D
Joseph A. Elliott, M.D
Paul H. Rincer, M.D
Geo. H. Bunch, M.D..
Federick R. Taylor. M.D._
Henry J. Langston, M.D
Chas. R. Robins, M.D
Olin B. Chamberlain, M.D..
Various Authors
Charlotte, N. C._
_Gastonia, N. C
_Charlott«, N. C._
_Asheville, N. C._
.Charlotte, N. C._
_Asheville, N. C
.Columbia, S. C
_High Point, N. C.
_ Danville, Va
.Richmond, Va
.Charleston, S. C._
-Orthopedic Surgery
Urology
.-Radiology
Dermatology
-Internal Medicine
-Surgery
-Periodic Examinations
Obstetrics
Gynecology
—Neurology
.historic Medicine
What Gave Us Our Disgraceful' Mater-
nal Death-rate? — Meddlesomeness:
What Keeps It From Being Lowered? —
Complacency
Deaths in child-bed have always concerned
us mightily. It is but natural to expect
pneumonia and tuberculosis to kill folks; but
why should the final step in the process of
reproduction be fraught with any more dan-
ger than attend any other physiological act?
We do not know why. We know there is much
danger attending the birth process. Our
problem is to reduce this to a minimum.
Spurred to action by reports that showed
the maternal death-rate in the United States
of America to be three and four times as
great as in some countries much less able to
provide for their women what attentions
money can buy, and whose doctors we are
unwilling to admit to be better than ours,
the Tri-State Medical Association of the Car-
olinas and Virginia devoted the greater part
of its 1928 program to a Symposium on this
subject, which was published in this journal.
Before and since that time we have repeat-
edly called attention to the large number of
deaths from attempts to bear children and
to the fact that there was much evidence to
show that those women who were made com-
fortable and allowed to bear their children,
had a much better chance to survive and to
be healthy and comfortable afterward than
those whose labors were hastened in any
way.
In the July issue of the New York State
Journal oj Medicine appears' a discussion of
this problem by the Commissioner of Health
of that great State. The second paragraph
reads:
This journal has gone on record to this
effect: It is a matter of some astonishment
to note how much more is written on cancer
than on child-bed diseases. Is it possible
that man's greater concern about the former
is due to his immunity from the latter.
"The problem of excessive maternal
deaths, notwithstanding the widespread in-
terest that it has aroused during the last
decade, the generous exptenditure of public
and private funds, and unceasing efforts on
the part of official and non-official health
1. "Maternal Mortality," Matthias NicoU, jr.,
M.D.
August, 1924
SOOTHEftN MEDICINE AND SURGERY
i6i
agencies, remains unsolved. Year after year
the maternal death-rate in this country and
in this State shows little or no decline."
Surely a terrible indictment!
And he goes on to say more which is to
the great discredit of the medical profession:
"First the large proportion of maternal
deaths caused by septic poisoning; and sec-
ond, the large number of cases in which
operative procedures, — instrumental or other-
wise— were employed. It is largely agreed
by those who are qualified to express an
opinion, that one of the chief causes of ex-
cessive maternal deaths is the increasing ten-
dency to interfere with physiological proc-
esses. This tendency would seem to be espe-
cially prevalent among city practitioners and
in hospital practice. I do not wish to be
understood as inferring that many cases do
not require such interference, but I am thor-
oughly convinced that many more in which
it has been employed, if left to themselves,
would have gone through their ordeal with
safety. Again, there can be no question that
there is an increasing tendency to make un-
necessary internal examinations, and this
would seem to be especially true in hospital
and city practice — the rural practitioner un-
der ordinary circumstances being satisfied to
let nature take its course. Under our system
of hospital management I think it will be
conceded that there is very little central medi-
cal supervision over the methods of practice
of individual physicians, and this is certainly
true in the case of obstetrics. Furthermore,
it has been brought to our attention that
clinical records in a number of institutions
are not available, so that it is impossible even
to venture a guess as to the actual cause of
the fatal outcome of a maternity case."
Dr. NicoU does not neglect to point out
the indisputable fact: "That this problem
is not insoluble is shown by maternal death
rates among a few foreign countries which
are one-third to one-half of that recorded in
the United States."
We may well bear this in mind for our
chastening and for the correction of our 100
percenters who belittle all things "foreign"
and boast so loudly of what "we Nordics"
have done.
The New York Commissioner is acutely
conscious of our disgraceful record and is
mildly hopeful of improvement:
"With the immense resources in money
and personnel at our disposal, it should be
possible in the not distant future to remove
from this country the stigma of inefficiency
and seeming complacency which results in
an unnecessary number of deaths in child-
birth. To that end I invite the heartiest co-
operation of the health officers, physicians
and nurses of this State with the State De-
partment of Health."
There is the key to the situation — that
word complacency. When this complacency,
this satisfaction with things as they are, this
unconcern about these women unnecessarily
dead, is replaced by a sense of guilty shame —
then, and not till then — will our obstetrical
results be brought to a decent showing.
This journal has gone on record to this
effect: It is a matter of some astonishment
to note how much more is written on cancer
than on child-bed diseases. Is it possible
that man's greater concern about the former
is due to his immunity from the latter.
Abstract reasoning would lead one to con-
clude that puerperal sepsis and eclampsia
would interest men and States far more than
would cancer. These diseases balk man's
vanity, as expressed in a kind of vicarious
immortality carried on in the p)ersons of his
children: these diseases bring to untimely
ends the lives of young women who have
demonstrated their willingness and their ca-
pacity for child-bearing, and thus sap the
strength of the State; while cancer attacks
mainly those who have passed the possibility
of producing new citizens or of doing much
useful work.
Dr. Nicoll deplores the fact that there is
in his State very little medical sup)ervision of
methods of practice of individual physicians.
Fortunately there is in our State recent pro-
vision for keeping accurately and comparing
carefully the records of cases in many of
our hospitals and under the care of different
doctors, and means for seeing that inexcus-
ably bad results are improved.
There are many ominous signs, too, that
the public is not satisfied with the kind of
medical service being rendered. Note the
increasing number of suits against doctors;
note the number of your best patients who
leave home for treatment at every reasonable
opportunity; note the statement of a few
days ago of the president of the Julius Ros-
SOUTHERN MEDICINE AND SURGERY
August, 1929
enwald Fund (which will soon be operating
in this State) "when the man in the street
looks at doctors he is not impressed that the
highest ideals of the best man of the profes-
sion dominate its every member. He sees
there may be gains in the service rendered
by the average physician through the super-
vision [italics ours.] and stimulus of organi-
zation in medicine."
It would seem wise to take warning and so
supervise our own methods of practice as to
satisfy the public that no other supervision
is needed.
In our issue for March, 1927, we urged
"Better Obstetrics in a Simpler Way" and
quoted the excellent results obtained at the
Henry Ford Hospital, where "operative inter-
ference is delayed until it becomes evident
that spontaneous delivery is out of the ques-
tion," and whose report says, "In well over
a thousand deliveries we have not lost one
baby whose death could be attributed to fail-
ure to apply forceps ; but we have lost several
who might have been saved, we believe, had
interference been further delayed." Thus it
would seem that non-intervention is nearly
always best for baby and for mother.
We know of no better conclusion than the
one we wrote then. It is repeated in the
very earnest hope that it will stay some med-
dlesome hands and thereby save some lives:
The rate in your practice will remain just
about where it is until you arrange for and
conduct your cases of labor with the same
care to avoid introducing infective material
into the birth canal that a surgeon e.xercises
to keep infection out of the abdomen; and
until the habit is firmly fi.xed never to use
any means for hastening delivery because
you are tired, because you have another pa-
tient waiting, or for any other reason than
because the patient needs delivery to be has-
tened. And when in doubt about the pa-
tient's need — wait.
A friend in attendance on the recent meeting of
the North Carolina Dental Society says a colored
friend concluded a letter with this bit of native
eloquence:
"I hope that successness and happiness will soon
spring out of the providence of God and this pres-
ent unfavorable condition of things shall be ex-
pired."
How Curable is Syphilis?
Frequently doctors are heard to make the
flat statement that syphilis is certainly cur-
able by modern methods. The majority of
doctors, we believe, have the confident opin-
ion that in practically all early cases perma-
nent cure can be brought about. Few indeed
there are who do not count on a perfect score
in cases discovered so early that the Wasser-
mann has not become positive, and in which
treatment is carried out as advised.
The conclusions quoted below, we take it,
can be accepted as just about average.
1. Of 444 patients with early syphilis who were
treated intensively, a total of 60 per cent were ap-
parently curedi.
2. The greatest number of cures, amounting to 90
per cent, was obtained in the primary seronegative
group. The golden opportunity in the treatment
of syphilis lies, therefore, during the seronegative
period.
3. In both the primary seropositive and early
secondary groups the number of probable cures was
61 per cent.
4. Delay in treatment beyond the third or fourth
month reduced the probable cures to 45 per cent.
5. The best results were apparently obtained with
the intensive plan of treatment (Scholtz, PoUitzer
and others)-.
6. The other plans of intensive therapy gave re-
sults which did not materially differ one from the
other.
7. Intensive therapy with rest periods between
courses apparently yielded as good results as treat-
ment by the continuous plan. Because of greater
safety and expediency, the former would appear to
be the method of choice in routine treatment.
8. A number of the patients were apparently cur-
ed after one or two courses. Since, however, it is
impossible to judge a priori how a patient with a
given condition will respond to therapy, it is advised
that prolonged intensive treatment be given to all
patients with early cases of syphilis.
0. The dark-field examination and early intensive
treatment are prime factors in the control of syphilis.
Louis Charcin and Abraham Stone, Arch. Derm.
& Syph., May, 1929.
Don't these figures startle and considerably
disappoint you? Forty per cent of cases of
early syphilis not even apparently cured by
intensive treatment! Ten per cent of fail-
ures when the best treatment known was be-
gun in the short period between the appear-
ance of the chancre and the time when the
Wassermann reaction could become positive!
And after three or four months of the disease
August, 1929
SOUTHERN MEDICINE AND SURGERY
only 45 per cent of probable cures!
Our impression is that doctors and laymen
hold a far more optimistic view than can be
borne out by these figures. Possibly some
reader has accurate records which will make
a better showing and justify a more hopeful
outlook; if so, we shall be glad to have such
a report for publication. Our sentiment is
expressed in the famous World War cartoon,
"If you knows of a better 'ole go to it."
Something like IS years ago Dr. W. P.
Cunningham, of New York City, wrote on
"Lues, the Incorrigible." It would seem that
the disease retains a good deal of its incorrigi-
bility, and that the doctor who says he can
cure any given patient of his syphilis, at the
time when the patient can reasonably be ex-
pected to present himself for treatment, is
rash indeed.
1. The patient was considered probably cured
when the following conditions were met:
(1) The patient came under care in the early stage
of the disease; (2) the patient received one or more
courses of treatment — of 6 to 8 injections arsphen-
amine and 12 to 15 or more of mercury or bismuth;
(3) a clinical recurrence did not manifest itself dur-
ing the period of treatment; (4) the Wassermann re-
action was negative at the end of the treatment;
(5) the patient was observed at least 18 months after
last treatment; (6) no cHnical recurrence in this
period; (7) results of repeated Wassermann tests
during this period were all negative.
2. In this plan the aim is to saturate the patient
with the arsenical at the beginning of each course of
treatment in order to effect rapid sterilization. The
injections of arsphenamine are administered in fairly
large doses and at very short intervals daily for the
first three days, or, according to modifications, every
second day, at the beginning of the course. This is
followed by a series of injections of mercury or
bismuth, and the course is terminated by another
series of injections of arsphenamine. Several such
courses are administered.
"I never robbed a man but once," said the honest
tramp, "and then I was straving. He would not give
me a penny, and I could not stand the gnawings in
my stomach any longer. So I knocked him down
and went through his pockets. What kind of a haul
did I make? Just one little bottle that read on the
label: 'Pepsin; for the full feeling after eating.'" —
Judge (35 years ago).
The North Carolina Workmen's
Compensation Act
We are always prejudiced in favor uf arbi-
tration. This measure is essentially an ar-
bitrament, in which there is mutual yielding
and mutual gain. So far as came to general
attention, most of the objections were made
in the name of employees, by persons who
have been deriving much revenue from ap-
jDearing in court for employees alleging inju-
ries. The relief being given promptly and
without shrinkage from legal expenses are
major points of excellence.
The fact that the vast majority of employ-
ers are obliged to carry liability insurance is
a feature which we deplore. The options of
making the required guarantee either —
"By becoming a member of some mutual
insurance association so authorized, or
By furnishing to the Industrial Commis-
sion satisfactory proof of financial ability to
pay direct compensation when due, and ob-
taining from the commission an order of ex-
emption from the necessity of taking out in-
surance"— we hope will be exercised by all
who can meet the requirement in these ways.
The State of North Carolina is carrying its
own insurance on its employees, and it is to
be congratulated on having officials whose
minds can not be befuddled by insurance
agents' specious arguments. The fact that a
State highway patrolman was killed within
a few days after the law went into effect
affects not in the least the validity of the
reasoning.
We do not know how the N. C. Industrial
Commission arrived at the conclusion: "The
employer secures his risk by a relatively
small annual payment for compensation in-
surance and figures this expenditure in his
cost of production just as in the case of in-
surance against fire or hail or any other un-
predictable hazard." Our understanding has
been that premiums are fixed on just that
basis, predictability, with a sup>erstrutture of
agents' commissions, office maintenance, gen-
eral headquarters expense, miscellanies, sun-
dries, contingencies, reserves and dividends.
Certainly if the rate of loss is not predictable
with a fair degree of accuracy, we know the
insurance companies will be led by ordinary
business discretion to place the premiums
high enough to to give themselves all the
benefit of the doubt.
566
SOUTHERN MEDICINE AND SURGERY
August, 1929
"If employee wilfully fails to use safety
appliances he is penalized 10 per cent." This
sentence could be much improved by substi-
tuting the word "negligently" for the word,
"wilfully." We can not see the justice of
society being compelled to pay for an injury
which is, to all intents and purposes, deliber-
ately self-inflicted. It is provided elsewhere
in the Act that "no compensation shall be
payable if the injury was occasioned
by the wilful intention of the employee to
injure or kill himself or another."
Section 14 (b) says "This act shall not
apply to casual employees, farm laborers.
Federal government employees in North Car-
olina, and domestic servants, nor to employ-
ees of such persons." That seems to mean
that if a post-master owns a cotton-mill em-
ploying hundreds of operatives these opiera-
tives do not come under the provisions of this
Act.
Section 27 contains a provision which ap-
pears needless and dangerous. It strikes us
as rather high-handed to enact that, "No fact
communicated to or otherwise learned by
any physician or surgeon who may have at-
tended or examined the employee, or who
may have been present at any examination,
shall be privileged, either in hearings pro-
vided for by this act or any action at law
brought to recover damages against any em-
ployer who may have accepted the compen-
sation provisions of this act."
The instances in which doctors would not
willingly give any pertinent information will
be few indeed; too few to justify placing the
power in the hands of any agency to compel
doctors to reveal anything they may have
learned in any way about a patient.
We hope the provision that "The employer,
or the Industrial Commission, shall have the
right in any case of death to require an au-
topsy at the expense of the party requesting
the same" will be the means of helping to
bring autopsies into more general use. Tact-
fully used this should prove a valuable pro-
vision, mostly as an example.
The fees submitted by the committee from
the Medical Society of the State of North
Carolina seem ample. Our understanding is
that the charges named for operations are
intended to cover after-care.
This is a valuable piece of legislation. As
time goes on doubtless there will be adjust-
ments made here and there which will add
to its value. We are confident that the doc-
tors of the State will give it the enthusiastic
and sustained support which President Crow-
ell requests. We hope they will work toward
improving it in many ways.
A New, Simple and Promising Treatment
FOR Convulsive State (Epilepsy)
It is worthy of note that, in many quarters,
the term, epilepsy, is being abandoned for,
convulsive state.. True it is that the latter
term is too broad to be distinctive; still it is
an improvement over the term so long in use
in that its use proclaims to all who hear or
see it that we realize and admit our igno-
rance, and thus take two long steps toward
the acquisition of knowledge.
Many investigators over the past two thou-
sand years have noted that the brains of
epileptics coming to the post-mortem table
have been found to be abnormally wet. A
very recent article* reports work along this
line, refers to the work of a great number
who have inquired into this difficult subject,
and cites the results of treatment by fluid
reduction.
Convulsions have been produced by intra-
venous injection of distilled water, and termi-
nated by spinal puncture. After five years
of experience in the control of intracranial
pressure, by means of dehydration and ad-
ministering hypertonic solutions by one
of the authors (Fay), the two undertook ti.
apply these principles of treatment to certain
selected cases of epilepsy (June, 1927). Pa-
tients treated were suffering from grand mal
and had failed to respond to bromides, lum-
inal or ketogenic diet.
Usual intake and output of liquids were
ascertained by recording over several days,
and an encephalogram was made to deter-
mine gross brain changes or fluid disturbance.
Fluid intake was then limited to a total of
from 8 to 20 oz. per days (water, milk, tea,
coffee, soup, fruit juices), depending on the
severity of the attacks. Epsom salts, V/y to
3 oz. in 6 oz. water, by mouth, on alternate
days for three doses, were given in some cases
to hasten dehydration.
The grand mal attacks were fewer after
three days and ceased before the tenth. In
one patient the attacks returned five weeks
after beginning this treatment, but she has
August, 1929
SOUTHERN MEDICINE AND SDHGERY
S67
had no attacks for the past ten months. "In
two patients the grand-mal attacks have given
place to petit-mal attacks which have per-
sisted in spite of rigorous dehydration, but
have not interfered with the patients' activi-
ties."
"One patient, who had from nineteen to
twenty-five attacks per month, has been free
from seizures for fifteen months. Another,
who had three to five attacks per week, has
been free for thirteen months, with only one
series of attacks during a ten-day illness with
influenza, during which time his medical ad-
viser forced fluids. Nineteen patients in all
have been placed upon this routine of fluid
limitation. Six have remained attack-free for
a period of over eight months, which justifies
their inclusion in the record. Seven are now
under control, with periods of freedom from
attacks which are not long enough to warrant
their consideration. Six patients have failed
to co-operate, or have abandoned their treat-
ment. When regulation of fluid was main-
tained and a satisfactory balance of intake
and output was established, there has been,
in the cases so far studied, a prompt change
in the character of the attacks.
The dehydration treatment must be con-
trolled with the same exacting care and co-
operation on the part of the patient as is
necessary in diabetes or in the ketogenic diet.
The method fails as soon as the patients ex-
ceed the fluid level of compensation estab-
hshed for them. This is best determined by
the urinary output per day. If output ex-
ceeds intake, fluid is being obtained either
through the food or surreptitiously. It may
be necessary to prescribe a dry diet until a
close approximation of intake and output lev-
els is established.
Patients have been maintained on a twelve-
ounce total liquid intake for a f)eriod of over
a year without deleterious effects, and six
and eight-ounce levels have been maintained
for weeks without difficulty. The period of
discomfort on the part of the patient is Um-
ited to the first ten days, after which time
the fluid level established is maintained with-
out marked thirst or annoyance."
Nearly every family doctor has at least one
epileptic patient whose condition is far from
satisfactory to himself, his family or his doc-
tor. The notice here taken of this investiga-
tion by reliable men, with lengthy quotations
from the report of their methods and results,
will, we believe, cause many patients to be
given a faithful trial of this method of treat-
ment.
We believe the results will be practically
as good without the encephalogram as with
it, and that is the only feature offering much
expense or difficulty. Some extra precau-
tions will be needed in the way of surveil-
lance for the first few days till adjustment is
made to the small ration of liquid. It is
surprising, though, how readily one adjusts
himself to the consumption of little liquid.
If results approximating those here report-
ed can be obtained in patients in whose cases
the usual remedies — bromides, luminal and
ketogenic diet — have had little or no benefi-
cial influence, it would seem that we have a
right to be very hopeful indeed of brilliant
results in cases of lesser severity and obsti-
nacy. Moreover, we can more cheerfully try
out a method which merely deprives of
fluids, supplementing in some Instances with
our familiar Epsom salts, than one which
has as its basis the prolonged administration
of stupefying drugs.
This journal will gladly welcome and pub-
lish reports of the results obtained.
1. "Present Day Conception of Epilepsy,"
Strecker, E. a., & Fav, T. S., Penn. Med. Jour.,
July, 1929. From Dept. Neurology Jefferson Med.
Col.
Echoes From Portland
Supplied by
An Occupant of a Bleachery Seat
Portland, being up in the fartherest corner
of the Great Northwest, its topography is not
favorable for attracting a large crowd. It is
a long way from the Atlantic to the Pacific
and no little distance from the Gulf of Mex-
ico to the Canadian line. The attendance at
the recent convention of the A. M. A. was
about three thousand.
The scientific program was too diverse and
was given in too many sections for anyone
to get more than a glimpse of it. Watching
the members of the profession manifesting
concern only for those things in which they
are particularly interested impresses one who
would like a broad persp)ective of medicine
as a whole with the wisdom of general ses-
sions in smaller societies. Whether or not the
pendulum has swung too far toward special-
SOUTHERN MEDICINE AND SURGERY
August, 1920
ism is an interesting question, but in North
Carolina, a state largely rural and small-
town, conditions demand a versatile knowl-
edge and a capacity for versatile service on
the part of medical men. If sections relating
to the specialties could deliver and discuss
papers within the hearing of the general prac-
titioner, a greater desire for versatility would
be stimulated in a large percentage of the
profession, and specialists in our own state
would come to be more keenly appreciated
by their confreres in general work, who not
infrequently refrain from referring cases be-
cause they do not know the specialists to
whom they would refer well enough to be
certain of their capacity.
The outgoing president, Dr. William Sid-
ney Thayer, gave vent to emphatic condem-
nation of all legislation seeking to direct and
prescribe "what we shall eat, what we shall
drink or wherewithal we shall be clothed."
He stated that we have no longer republican
government, we have tyranny; and he re-
minded his audience that the cosmopolitan
population of these United States was of such
force and libre as to refuse to endure. His
thought was presented in such a way as to
leave the impression on some that he was
pouring the vials of his wrath upon prohibi-
tion. The papers became full of it and one
Clarence T. Wilson, general secretary of the
Methodist Board of Temperance (sic) and
some other things, challenged the outgoing
president of the American iVIedical Associa-
tion to a public debate on prohibition; ac-
cused him of being railroaded into office by
the "wets" of Baltimore and evidenced to
the fullest extent that spirit of vindictiveness
and vituperation which too often comes from
certain enthusiasts who believe that they are
furthering the doctrine of The Great Physi-
cian.
To one on the bleachers watching the fray
with mixed sensations of interest and disgust,
there came a pathetic sympathy for both the
president of the American Medical Associa-
tion and the fanatical Methodist Dictator.
One was taught to face facts as they are; to
relieve human beings; to consider their proc-
livities in-bum traits and privileges; and to
place them on their feet so that they could
be made assets to themselves and to the com-
munities in which they live. The other was
taught to preach "thou shall not"; taught to
instill into the human family that they are
merely worms of the dust; taught to convince
the individual that this world is a temporary
affair — in fact nothing if not a training sta-
tion for "a better land." How can two such
souls developed in environments so different,
agree?
The second occasion for pyrotechnics came
because of one Dr. Schmidt, a urologist, be-
ing expelled from the Chicago Medical So-
ciety on account of the fact that as chief of
staff of the Illinois Social Hygiene League
he treated patients of Chicago's public health
institute, a clinic not operating for profit.
This institute advertised in Chicago papers
and paid a salary of twelve thousand dollars
to treat charity cases and Dr. Schmidt ac-
cepted nominal fees out of this twelve thou-
sand dollars.
It was contended that Dr. Schmidt unethi-
cally advertised for clients. The action of
the Chicago society in expelling Dr. Schmidt
was not reversed by the Illinois Medical So-
ciety, so Dr. Schmidt appealed to the A. M.
A. The A. M. A. after no little discussion
referred his case to a committee which is to
report next year.
This circumstance brought interesting ar-
gument pro and con concerning institutional
and group practice. To this argument Dr.
Harris, the incoming president, referred in
his inaugural address by saying:
"It is chiefly the press that has raised its
voice against the principle of medical ethics
which places the taboo on advertising by phy-
sicians. It is readily admitted that the lilt-
ing of the ban would result in a great finan-
cial gain to the press."
Dr. Harris recommended that doctors or-
ganize and incorporate pay clinics in their
counties, fees to be arranged according to the
economic status of patients; the community
to pay flat fees for charity which are to be
agreed to by county officials and doctors;
doctors to hold stock in the county clinics;
the profits of the clinic to be apportioned as
dividends in stock; which statement on the
part of the incoming president projected no
little argument concerning State Medicine and
certain tendencies of the times which appear-
ed to be forcing it. Discussion of this subject
came more nearly to agree in the opinion that
the coming of State Medicine would be ac-
centuated, retarded, made possible or impos-
August, 1929
SOUTHERN MEDICINE AND SURGERY
569
sible by the attitude of organized medicine
toward the furnishing of satisfactory service
to the man of small means. Plutocracy can
provide for itself; indigency has been, is and
will be provided for by organized charity; the
man of small means, the working man, the
stratum of humanity which makes both plu-
tocrat and pauper, is not getting the attention
that is its rightful due because of its inabil-
ity to pay for it.
These questions were the burning ques-
tions of the hour and the answer is yet to
come. However, Dr. Morgan, the president-
elect, expressed the opinion that the true dif-
ficulty may lie in the elaborate and expensive
diagnostic procedures which the public has
come to demand as well as the frills of the
nursing profession which the public has re-
garded as absolutely essential. He is among
those who believe that complaints on the cost
of medical care come more largely from the
idle rich than from the man of average means.
He hopes to succeed in clearing up the prob-
lem during the period which is measured by
his incoming administration as president and
the date of his retirement. May God help
him!
is that it may be useful in stimulating chronic
cases of tuberculosis which have not respond-
ed to the usual sanatorium treatment. Its
dangers outweigh the possible good that may
come from its use.
P. P. McCain.
Sanocrysin
Sanocrysin (thiosulphate of gold and so-
dium) was brought forward some five years
ago by Mollgaard of Denmark, as a chemo-
therapeutic agent for tuberculosis. His pre-
liminary reports indicated great success in a
large proportion of the patients treated. Moll-
raard's reputation was such that interest in
this treatment was universal and by some it
was hailed as the long-looked-for cure for
tuberculosis.
Noted scientists in various countries of the
world made careful studies and experiment.?
with sanocrysin. The results, as in myriads
of other such "cures," have been very dis-
appointing. It is not a specific agent in the
cure of tuberculosis. Careful clinical tests
have shown that it not only fails to effect a
cure in a majority of cases, but that it is
such a toxic substance that its use is consid-
ered dangerous, lis aflministration is fre-
quently followed by high fever, and not in-
f.'-equently with nausea, vomiting, diarrhea,
troublesome skin eruptions and albuminuria,
which is sometimes persistent.
The best that can be said for sanocrvsin
Results of Carelessness in Making Civil
Service Examinations
(St.itemont of U. S. Civil Service Com.)
Frequently, government medical officers
find in the examination at the time of ap-
pointment physical disqualifications which
must have existed when the preliminary medi-
cal certificate was executed by the private
practitioner, although no mention of such
physical defects is found in the private prac-
titioner's medical certificate. Such a situa-
tion presents a problem to the government,
especially if the appointee has traveled a con-
siderable distance to accept the appointment.
In many cases the appointment must be
cancelled, with resulting loss of time and
money to the disappointed applicant.
The Civil Service Commission feels that
the discrepancies between medical certificates
executed by private practitioners and those
made later by government medical officers
are due in some cases to carelessness upon
the part of the private practitioners and in
others to a liberal attitude deliberately as-
sumed in the mistaken belief that by ignor-
ing or minimizing physical defects the appli-
cant is assisted in obtaining employment.
The Civil Service Commission's forms for
medical certificates attached to application
blanks are comprehensive and clear. If all
private practitioners will exercise due care
when filling out the certificates they will not
only render a service to the government but
will also give the maximum service to the
applicant who pays the fee for the prelimi-
nary physical examination.
From the English Law
111 1S75 a girl, who was ultimately convicted, was,
uhilc in charpc, examined twice by a doctor. She
brought an action for assault, and recovered dam-
ages against the doctor and the manistrate and police
in-pcai-r who aulhorizcd the examination, thouch it
v.as admitted that all three had acted in good faith,
lilt had mi.'-taUen the law (13 Co.x C. C. bl^) .
In 1905 relatives who locked an accoucheur in the
pniirni's room to ensure his presence were convicted
(R.v. Linsbcrg, 69 J. P. 107).
SOUTHERN MEDICINE AND SURGERY
Aujcust. 1920
DEPARTMENTS
HUMAN BEHAVIOR
James K. Hall, MD., Editor
Richmond, Va.
Grim Business
At last — a department of the government
of the state of North CaroHna Is getting down
to brass tacks in its approach to the study
of criminal behavior in that commonwealth. I
have just got hold of Special Bulletin Num-
ber 10, issued by the North Carolina State
Board of Charities and Public Welfare, Kate
Burr Johnson, Commissioner, Raleigh, North
Carolina, 1929. The volume is sizeable — 173
pages, and I have not time at this moment tc
prepare a digest of it for this column in the
August issue, but I intend to do that for the
September journal.
Since early in 1910 North Carolina has
been making use of the electric chair as a
substitute for hanging in sending some of
her capital offenders into the grave. The
booklet presents a considerable amount of
d'spassionate information about certain forms
of criminal behavior in North Carolina tor
several years, and an account in detail is
given of many of the electrocutions in Raleigh.
The state is engaged in grim business in bar-
becuing alive from time to time a certain
number of her citizens, and I find myself
wondering, of course, if that condition that
we call civilization is being pushed forward
by the occasional use of the great wooden
chair.
The volume will scarcely afford the kind
of reading in which the summer vacationist
will like to indulge, but the honest, intelligent
men and women of the state, who are trying
to be good citizens should stiffen their backs,
grind their teeth, and slowly and carefully
read every word of every page of it from
Its alpha to its omega. That very thing I
propose to do before another week has rolled
by. I suppose that a request for a copy of it
addressed to Mrs. Kate Burr Johnson at
Raleigh will fetch the booklet to any interest-
ed person.
Rebellion in Prisons
I assume that the normal human being
objects to the imposition of restraints upon
his movements and upon his thinking. Often
the objection is not made verbal and the as-
sumption may be made that the interference
with activity of mind and of body is not ob-
jected to by the individual. But the assump-
tion is generally a mistake. It is inherent in
us to wish to do as we please and to think as
we can. Whenever external authority under-
takes to interfere with either of these phases
of life some fairly satisfying substitute for
absolute freedom must be offered to the indi-
vidual. Obser\'ance of irksome social con-
ventions brings the pleasing approval of one's
neighbors; obedience to standardized religious
requirements offers a means of escape from
hell and a residence in heaven; so-called good
citizenship brings to one the unctuous satis-
faction of feeling that one is categorized with
the civically righteous and is arrayed against
the wicked — but the human being who can
accept philosophically and cheerfully and
patriotically prolonged imprisonment is an un-
usual, and perhaps, an abnormal person.
Within the last few weeks there have been
tragic outbreaks amongst prisoners in several
of the largest penitentiaries in the United
States. Two of the prisons are in New York
state and another is a United States peniten-
tiary. It is not surprising that such disturb-
ances occur. Most prisons are crowded; the
attitude of organized labor to the sale of
prison-made goods tends to make it difficult
to find wholesome and helpful productive
activity for prisoners; institutional life of all
kinds becomes monotonous and de-individual-
izing and the rebellion that arises is probably
directed chiefly against the latter tendency.
The American citizen is taught from his
youth up to be individualistic, self-sufficient,
aggressive, democratic, independent, and to
make war against autocratic authority. How
can the adult American, often taught from
childhood to believe that all high officials are
untrustworthy self-seekers, suddenly bring
himself to believe that prison officials are
beneficent autocrats, interested only in the
comfort and the welfare and the ultimate
rehabilitation of the prisoner? If jail life and
penitentiary confinement are to bring any
beneficent results to the individual or to the
state the condition of most of the bastiles
August, 1929
SOUTHERN MEDICINE AND SURGERY
that I know anything about will have to be
revolutionized. The fig, a succulent and sus-
taining fruit, cannot be plucked from the
thorny and forbidding limb of a thistle.
Undivided Devotion
The American people, young and old, who
are much more inclined to look down upon
rather than up to those set apart, still have
a feeling close akin to that of reverence for
the members of at least two professions —
physicians and ministers. And I place the
physician first, because he undoubtedly oc-
cupies a position of greater trust and intimacy
than the minister. There are wailings and
lamentations because of the disappearance of
the good old family doctor, but that hallowed
benefactor has not gone at all. Every family
has its medical friend and adviser to whom it
instantly turns for advice and succor and
sympathy in time of sickness and sorrow and
distress. The clamorous call may come from
the family to the specialist — to the surgeon,
to the ophthalmologist, to the urologist, to
the dermatologist — even to the neurologist or
to the psychiatrist — and if the specialist be
ihe right sort of stuff instantly and magically
he transforms himself into the good old doctor
of olden days who bears all and knows all
and endures all and who becomes for the
family the bearer of all their woes even
as the Israelitish lamb became the bearer of
the troubles and sorrows and sins of that great
race.
Institutionalism is laying its heavy hand
upon the church as well as upon medicine and
the great congregation now has a large a
staff, and just as impersonal a staff, as a large
hospital or clinic. But when the body be-
comes diseased or the soul becomes distressed
the suffering individual cries out not for a
group or an organization, but a person —
for an understanding mind and a sympathetic
heart — for a friend. And in spite of what we
may think contrariwise, the people still insist
upon having their doctor and their preacher.
And they demand, quietly but powerfully
nevertheless, that these two must live some-
what unspotted from the world, devoted in
their thoughts as well as in their actions to
concern about mankind, and that they be not
diverted nor distracted from their high calling
by the ticker tape nor stocks nor bonds,
PEDIATRICS
For Ihii issue, G. W. Kutscher, M.D.,
Swannanoa, N. C.
Post-Natal Care of Infants
Today every physician from the most
orthodox specialist to the most indifferent
country practitioner has at least heard of
prenatal care of the pregnant mother. By
many, prenatal care is thought of only in
regard to the welfare of the mother, whereas
the welfare of the mother is only part of the
task. The unborn child reaps the benefits of
this care the same as the mother.
At a recent meeting of the Tenth District
Medical Society of the State of North Caro-
lina, the pediatric paper dealt entirely with
the appalling figures concerning the high
death rate of infants in that district. Those
figures will no doubt be published elsewhere
in this journal, but by those who heard the
statistics, it was realized that the plight of
the infant was anything but favorable. A
solution to the problem was not offered, but
it was made clear that the solution lay in the
hands of every physician who deals with chil-
dren.
The pregnant mother today receives the
routine attention of her physician at at least
monthly intervals. When she is delivered
this care is continued throughout her con-
valescence. But what of the baby? Possibly
a few casual remarks are made concerning
its care and then it is neglected until it is
overtaken by some malady. If it is necessary
for the mother to have monthly prenatal care,
which after all is nothing but the practice of
preventive medicine, then why is it not just
as important for the child to have regular
postnatal care to prepare it for life's strug-
gle?
When the mother has been taught to ap-
pear at the physician's office for a check-up
each month before the baby comes, it is a
simple matter to have her continue to return
each month witk the baby. On these visits
the baby can be weighed and the weight re-
corded for future reference. Every mother
w'll have problems to present at that time as
to nursing, sleep, habits; and later, diet,
traits and development. If the mother has
been advised to mark down on a slip of pa-
per all the questions which come nn between
these visits and brings the slip to the office
SOUTHERN MEDICINE AND SURGERY
August, 1929
with her, she will have plenty of interesting
and important problems to discuss with her
physician. In this way many ills and mal-
developments may be prevented as well as
early discovery made of cases of malnutrition,
development of bad habits and physical de-
fects. It is simply the applying of preven-
tive medicine to the earliest age of life.
Many physicians feel that they know so
little about the handling of very yountj in-
fants that these cases should be handled by
a pediatrician. The average infant is heir to
very few diseases! Common sense is usually
the best therapy — not drugs. In infancy the
most usual trouble is the development of bad
habits, especially as to diet and sleep. The
physician who really does want to know about
young infants will learn more through such
conferences with the mothers at these month-
ly visits than he can possibly learn from text-
books.
DENTISTRY
W. M. RoBEY, D.D.S., Editor
Charlotte, N. C.
pvorrhea from the standpoint of the
Generai, Practitioner of Dentistry
Hysteria on account of pyorrhea is compar-
able to hysteria on account of the dangers of
traffic conditions today. There are many de-
plorable accidents in both cases, many un-
avoidable accidents, many narrow escapes — •
and many more in which there was no need
for escape.
What is pyorrhea? Generally speaking, a
disease of the gums that ultimately leads to
the destruction of the alveolar process and
loss of the teeth. More specifically speaking
"the last stage of periodontoclasia." In fact
the confusion resultant from the misuse of
descriptive terms with reference to diseases
of gums and alveolar process has led to much
futile discussion. The term pyorrhea pictures
to the lay mind loose teeth, sore gums, with
a flow of blood and pus leading ultimately
to artificial dentures. In fact pyorrhea gen-
erally speaking may refer to any disease of
the gums from an acute gingivitis due to a
digestive disturbance to the last stage when
the teeth are elongated and on the point of
expoliation. Any variation from the normal
physiological gums of youth may be and is
referred to as pyorrhea by dentists, physicians
and the laity.
In attempting to clarify a cloudy situation
of nomenclature, the term periodontoclasia
has been substituted for pyorrhea used as a
general term, referring to "a disease process
that induces a breaking down of the tissues
suporting the teeth," with pyorrhea used as
the descriptive term of the last stage. There-
fore the careless use of the term pyorrhea
as descriptive of "a disease process that in-
duces the breaking dwon of the tissues sup-
porting the teeth" accounts for the high per-
centage of prevalence of the disease so often
claimed.
Of especial interest to the general practi-
tioner of dentistry is the fact that this break-
ing-down process has a beginning, and that
beginning usually starts under the observa-
tion of the general practitioner. It is possible
that even more than ninety per cent of the
dentistry needed is neglected, but it is prob-
able that the mouths of more than fifty,
per cent of the people in the United States'
are examined more or less by the general
practitioner at some time. A great many
patients are examined at intervals suggested
by the dentist and a great many more are
examined at irregular intervals as the spirit
moves them. The third class is driven to the
dentist by pain, fear, or the physician.
With the first class the responsibility for
the first breaking down of the supporting
structures of the teeth is very great. With
the second class the responsibility varies be-
tween the patient and the dentist, while with
the third class the responsibility rests almost
entirely upon the patient.
The cause of pyorrhea is unknown as at-
tested by a review of volumes of clinical and
research reports. Quoting Thomas {Journal
American Dental Association, July, 1927):
"As the causes stand for and obtain recogni-
tion today, we find five receiving especial
attention. To these causes groups of students
have attached themselves with considerable
devotion. The theories named are:
(a) The calcic theory;
(b) The infection theory;
(c) The occlusal stress theory;
(d) The theory of constitution disturb-
ance;
(c) The alveolar atrophy theory."
In spite of the fact that these theories are
old, and that there has been much research
August, 1929
SOUTHERN MEDICINE AND SURGERY
S73
by world-renowned pathologists, not one has
been proven.
Any one or all of these five suggested causes
of pyorrhea may be correct. Cohn in Dental
Items oj Interest, July, 1929 says: "Where
bone was at one time thought to be the most
stable tissue of the body, it is now known to
be one of the most changeable and susceptible
of tiisues. It is very quickly influenced by
many factors among the most important ones
be'n:
(a) Diet and metabolism;
(b) Stress, or lack of stress, which alters
the architectural structure:
(c) Infections and intoxications;
(d) Age;
(e) Endocrine disturbances;
(f) Change due to physiological func-
tions."
.Again we have found from clinical experi-
ence that drugs, from ijjecac to hydrofluoric
acid, have very little effect in the treatment
of periodontoclasia. Antiseptics of every
description and combination, gaseous, liquid
and solid, have been tried with indifferent
success.
But in all this hopeless confusion the re-
sponsibility of the general practitioner of
dentistry for periodontoclasia in his patients
mouth is increased. I'ilcher in Dental Cosmos,
March, 1929; "Should periodontoclasia de-
velop in a patient's mouth?" after quoting
\arious authorities, including Thomas B.
Ilartzeli, answers; "We say that it should not.
Then how can the development be prevented?
In those who have normal or near health,
prevention is accomplished by preventing the
accumulation of bacterial masses about the
necks of the teeth."
In other words we know that calcic de-
posits, rough fillings, foreign bodies, food
particles, etc., adjacent to the gingival area,
mechanical irritants, add the infection which
is constant in the mouth, and you have a
gingivitis which is called pyorrhea by the over
cealous, that becomes chronic if neglected, and
ir. the beginning of the most prevalent type
of pyorrhea, if there are different types. Re-
rponsibil ty rests very heavily u[)on the den-
ti'^t who fails to prevent the accumulation of
these bacterial masses by prophylaxis, not by
treatment of [lyorrhea.
EverylhinK lomcs by patient waitiiiR. It took
the Kartcr mure than nineteen centuries to win a
place in the sun. — Colorado Medicine,
EYE, EAR AND THROAT
For this issue. \. K. Hart. M.D., Charlotte
Gr.adenigo's Syndrome
This symptom-complex consists of (1) a
mastoid infection, (2) ipsolateral temporo-
parietal pain, (,?) paralysis of the external
rectus eye muscle of the same side.
Usually the mastoid symptoms are obscure.
The syndrome at once, therefore, becomes of
interest to the general medical man because
he is often consulted first. Recently a case
was seen of three weeks duration and finally
sent in because of persistent eye symptoms.
The mastoid was not suspected, particularly
since the middle ear had discharged a very
short while and had been dry for some time.
.Abductor paralysis may come on anywhere
from one to six weeks, depending on the rap-
idity of the extension of the infection.
Just what happens in these cases? The
usually accepted theory is spread of the in-
fection to the petrous portion of the tempo-
ral bone via the mastoid. Here the sixth
nerve is in intimate relationship, piercing the
dura just before the sphenoid bone is reached
and passing with the inferior petrosal sinus
into Dorello's canal. (This canal is formed
by the ligamentum petro-phenoidale extend-
ing from the spina sphenoidalis on the upi)er
margin of the petrous bone to the outer lip
and posterior surface of the lamina quadran-
gularis of the sphenoid.)
Consequently, this portion of the nerve is
subject to comjiression by a localized inflam-
matory condition of the petrous bone. It
probably progresses to a true localized serous
meningitis of the middle cranial fossa. The
spinal cell count, however, remains normal
unless other complications supervene, because
even if there should occur a cellular infiltra-
tion of the subdural area, the fossa is tightly
walled off from the lower areas by the tento-
rium.
This localized infection could also involve
the gasserian ganglion which lies in its dural
sheath on the jietrous bone. This would give
the pain in the distribution of the fifth.
There is one other explanation of the pain
and paralysis. This has not been seen in
jjrint but was brought out in a personal con-
versation with Dr. Temple Fay, of Philadel-
phia. The carotid passes through the petrous
bone and hence its symiwthctic sheath could
be involved by direct extension. This could
574
SOUTHERN MEDICINE AND SURGERY
August, 192$
give pain. The artery in the cavernous sinus
is in juxta-position to the abducens and there-
fore the latter is subject to involvement by
continuity.
The above is didactic but what of treat-
ment? .'\n immediate mastoidectomy is indi-
cated with thorough uncovering of the dura
of the middle fossa. With such treatment
most all cases recover, though the sixth nerve
paralysis may be some weeks in clearing. In
a few cases the patients may get well without
operation, but more serious intracranial com-
plications are much less apt to occur with
proper surgical drainage.
Therefore, when a sixth nerve paralysis and
neuralg'a in the course of the fifth follows a
recent middle ear infection, though the ear
may be dry or have never discharged, atten-
tion should be directed to the mastoid of that
S-de. Careful roentgen examination will
usually show trouble.
ORTHOPEDIC SURGERY
O. L. Miller, M.D., Editor
Charlotte, N. C.
Tuberculosis of the Hip — Operative
Treatment
The incidence of tuberculosis in the hip
joint is comparatively high. Of the joints,
only the spine is more frequently affected.
Hip joint disease is an alarming disease when
it is active, and chronic and disabling in its
course and termination. In the past, when
an accurate diagnosis of joint tuberculosis
was made, it meant a long and tedious stay
in bed and special nursing care. Abscess and
s^nus formation were not uncommon, and
lighting up of apparently healed lesions fre-
quently occurred.
In the last few years, intensive effort has
been put forth by orthopedic surgeons and
others, in the interest of curing tuberculosis
of the hip earlier and more surely by opera-
tive fusion of the joint. This practice has
been enthusiastically sponsored by Hibbs, of
New York, and he is considered the author
of the principle as it is now rather generally
practiced in .American clinics.
In a recent issue of the Journal of the A.
M. A. a rather comprehensive report of the
course and end results of operated hip joint
tuberculosis was m idc from the experience
of Cleveland and Pyle in the New York Orth-
opedic Hospital and Dispensary — Hibbs Clin-.
ic. In addition to proving the clinical ad-
vantages accruing from the surgical treat-
ment of joint tuberculosis, the authors re-
ferred to demonstrated that there were also
economic advantages in this method. In a
series of cases under treatment for joint tu-
berculosis, the community spent $3,246.00 on
each case, while so-called conservative meth-
ods were used, and $932.00 on each case
where an end result by surgical fusion was
attained.
After following a great variety of cases of
joint tuberculosis for many years, it is the
unqualified conclusion of the workers in the
New York Orthopedic Hospital that surgical
fusion of all tuberculous joints is indicated
just as early as the patient is considered fit
for operation. It has been demonstrated that
the patients get well earlier, more completely
and with the least permanent disability.
For the last several years many rather con-
servative workers hesitated to apply this pro-
cedure to such cases, but today I believe even
the ultra-conservative surgeons — those work-
ing with any energy — are committed to surgi-
cal fusion as the method of treating joint tu-
berculosis.
UROLOGY
For this issue. C. 0. DeLaney, M.D., F.A.C.S.,
Winston Salem, N. C.
The Significance of Albumin in the
Urine
The presence of albumin in the urine in
the experience of the writer has been one of
the most frequent causes of errors in the diag-
nosis of urinary diseases. Notwithstanding
the fact that we have been repeatedly remind-
ed of the numerous (ofttimes trivial) condi-
tions of the genito-urinary tract in which the
urine may show varying amounts of albumin,
it is occasionally revealed that, to many of
our professional brethren, the occurrence of
albuminuria means only nephritis (Bright's
disease). It would be just as plausible, not
to say accurate, to conclude that a pain in
the side is always due to appendicitis.
To emphasize the importance of correctly
interpreting the significance of albuminuria, I
shall report a case which recently cnm? to
my attention throu/h the courtesy of Dr. O.
E. Wright, of Winston-Salem.
A while iU"i'., 22, was admitted to LaW'
August, 1929
rence Hospital May 1, 1929, complaining
of "kidney trouble" for which he had been
treated since early childhood. The family
history disclosed that one aunt and an un-
cle died of pulmonary tuberculosis.
The patient had the common diseases of
childhood, none severe, and at four a se-
vere attack of "kidney trouble" character-
ized by excruciating pain in the left side,
chills, fever, frequent and painful urina-
tion, hematuria and rapid loss of weight.
He was confined to bed for more than two
years, then gradually improved but never
entirely recovered. He has always been
undernourished, anemic and sickly. Since
the original attack he has had frequent re-
current attacks of chills and fever, profuse
night sweats lasting from two to four days
and almost constant low fever in the after-
noons. For the last eighteen years he has
been practically confined to the house and
has never attended school. During this
time he has been under the constant care
of various physicians whose diagnoses of
Br'ght's disease were based upon the con-
stant presence of albumin in the urine. For
the past eight years he was under the care
and treatment of his family physician until
the time of the latter's death about three
months ago. .Another physician was then
called to see him and for the first time he
was advised to have a thorough genito-
urinary examination.
On May 2, 1929, a cystoscopic examina-
tion was made. The urine was turb'd and
contained an abundance of pus, epithelial
cells and a light ring of albumin. The
bladder showed diffuse chronic inflamma-
tion. The right ureteral orifice appeared
normal and a number seven French cathe-
ter was introduced to the kidney pelvis
without difficulty. The right kidney speci-
men was clear, contained an occasional pus
cell and no albumin. The left orifice was
practically obliterated and surrounded by
dense fibrous tissue. The smallest bougie
or catheter could be introduced only about
three cm. (1 in.) Radiogram showed the
right catheter in the normal position and
the richt kidney shadow was normal. In
the region of the left kidney there were
three larue irregular shadows with a clearly
abnormal kidney outline surrounding them.
A pyelo-ureterogram (right) showed a nor-
mal ureter ancj kicjney pelvis. Phthalein
SOUTHERN MEDICINE AND SURGERY
S7S
test (intravenous) for thirty minutes:
right fifty-five per cent, left none. By the
aid of a careful history and the x-ray a
diagnosis of putty kidney (autonephrec-
tomy) was made.
On May 6, 1929, left nephrectomy and
ureterectomy were done. Examination of
the specimen confirmed the preoperative
diagnosis. The normal architecture of the
kidney was completely destroyed, the renal
vessels obliterated, and the kidney sub-
stance almost entirely replaced by calcar-
eous putty-like material inclosed in a mark-
edly thickened capsule. The ureter was
about twice the normal size, its walls thick
ened and indurated and its lumen practi-
cally obliterated except for a dilated por-
tion about three inches above the bladder
which contained a calculus about two
inches long. The entire process was no
doubt the result of a massive occluding re-
nal tuberculosis which the history suggest-
ed at the age of four.
My object in reporting th's case is to call
attention to the folly of attempting to make
a diagnosis of genito-urinary diseases by
urinalysis alone.
This young man"s case has been in the
hands of the medical profession for nearly
twenty years, yet he has been denied the
relief he should have obtained years ago had
a correct diagnosis been made which a sim-
p]e examination would have easily revealed.
This unfortunate error has cost his family
several thousand dollars, has prevented h'm
from obtaining an education and has kept
him an invalid for nearly two decades.
While this is a rare and unusual example,
there are numerous other ca.ses in which the
significance of albuminuria has been misin-
terpreted.
.An important observation was made re-
cently by Peacock, of Portland, Oregon, who
rejiorted some twenty cases of orthostatic al-
buminuria occurring in patients who had
ne|)hroptosis. In every case, the albumin dis-
appeared permanentl\' from the urine when
the kidney was anchored in the luirnial po.;i-
tion.
I trust that these few remarks will serve in
a small way (at least) to emphasize the re-
s|)onsibility one assumes in applying the
[iractice of guesswork in trying to account
for the presence of albumin in the urine.
SOUTHERN MEDICINE AND SURGERY
August, 1920
RADIOLOGY
For this issue, J. Donald MacRae, jr., M.D.
Asheville
The Group Study and Treatment of
Cancer
From one point of view the only ideal unit
for the study and treatment of cancer is the
lartje clinic supported by the State or by an
endowment. The New York State Institute
for the Study of Malignant Disease, at Buf-
falo, Memorial Hospital in New York City
and Radiumhemmit in Stockholm are exam-
ples. There are a number of others. These
insftutes are well housed and have compara-
tively large resources. They are well equip-
ped in personnel and physical and hospital
facilities to give surgical, .\-ray and radium
treatment.
The medical staff of each consists of sur-
geons, internists, pathologists and radiolo-
g:sts. Specialists in gynecology, urology, oto-
laryngology and other lines are also on the
staff. The physical department is in charge
of a physicist, who with his technical assist-
ants, looks after the apparatus for collecting
radium emanation, generating x-ray and
measuring x-ray and radium dosage.
This department conducts research in sub-
jects of medical radiology. The record de-
partment, with its cross index and follow-up
S3 stem, enables the staff to make a survey of
any of the various conditions treated or
methods of treatment, and to get a real idea
of the results obtained.
The large institutes may be able to do
more for the patient in the long run than the
small group or physician at large, but it is
the physician at large who sees the early
cases. The smaller clinics away from the
large cities will be within the reach of more
of the patients afflicted with cancer or a fear
of cancer. Hence there should be more such
clinics or groups who give special attention
to the treatment of cancer. As Ewing says,
the treatment of cancer is a specialty in itself.
However, it is the kind of specialty best di-
vided up among other lines. I do not refer
to the temporary cancer clinic generally spon-
sored by the National Association for the
Control of Cancer. These are extremely val-
uable, chiefly educafionally, for the laity and
local physicians. For a few dws men well
known for their work on cancer come to speak
and present cases; cases are diagnosed a"^
treatment advised; people flock in with tu-
mors and tumor fears and about twenty per
cent have some form of malignant or poten-
tially malignant conditions.
The cancer clinic I refer to is composed of
a surgeon, interested in cancer and familiar
with the surgical pathology of benign and
malignant tumors; there must be an internist,
for not only the cancer but the patient who
carries it must be treated; a radiologist is
necessary to apply and superintend the appli-
cation of x-ray and radium treatments; and
a pathologist to diagnose the condition from
b'opsy and study it from the excised tumor.
There is much work being done toward cor-
relating the microscopic morphology and the
radiosensitiveness of cancer. Every one who
treats cancer and studies it with a microscope
can help by reporting his observations. Path-
ologists, well versed in diagnosing tumors, are
not always available.
The group I am trying to present need have
no other association than the common inter-
est and co-operation in the treatment of can-
cer. They have adjoining offices or be on
the staff of the same hospital, but this is not
necessary. They should have, however, suf-
ficient bed space available in hospitals to care
for the bed patients. This hospital should be
equipped to do general surgery and to give
deep and superficial x-ray therapy with volt-
age up to two hundred kilovolts. The group
should have a sufficient quantity of radium
available through ownership or rental, in the
form of radium element or radon; the more
the better.
The group should arrange for the keeping
of records of every case seen, whether treated
or not, with as complete follow-up as possi-
ble. Most patients will co-operate if the im-
portance of being examined for recurrence is
presented to them convincingly enough. They
may be reminded to return for examination
by form letters. Having certain evenings a
week devoted to recall examinations enables
the patient to return without losing time from
work. Without following the cases over years
the true value of the treatment cannot be de-
termined.
The consultation service offered by the
group in diagnosing the case and in planning
the treatment is perhaps its mast importan'
function. Next is its ability to apply the
treatment as planned in the study of a case.
It may be (jvtci|i)iued that the case should be
August, 1929
SOUTHERN MEDICINE AND SURGERY
Sir
treated only by irradiation or only by surgery.
The members of the group must be willing to
abandon the personal inclination of each to
use his own specialty. The best interest of
the p.itent is paramount. The best knowl-
edf^e on the subject should determine the type
of treatment.
The modern treatment of cancer is by no
means a cut-and-dried affair. Each case re-
quires careful consideration. If left alone a
cancer will surely lead to death. If attacked
early and by the best modern methods, a con-
siderable number can be saved and many
lives can be prolonged or made more com-
fortable.
During the preparation of this pap)er there
appeared in the Journal oj the A. M. A. of
July 20, 1929, an article entitled "The Medi-
cal Service Available for Cancer Patients in
the United States." It is a report of a gen-
eral survey with recommendations to the
American Society for the Control of Cancer.
The exact type of clinic I have suggested does
not appear in their recommendations. How-
ever, where the general hospital does not or-
ganize a cancer service, what I have suggest-
ed is a method of meeting the need for the
treatment of cancer, or it is one method that
the general hospital could use. Each locality
must work out its own salvation.
In October there will be clinics throughout
the country sponsored by the American As-
sociation for the Control of Cancer. Perhaps
some of these temporary clinics will lead to
permanent groups such as I have suggested.
This locality needs these clinics and there
are men in each local district who could fur-
nish the personnel for such groups.
SURGERY
Geo. H. Bunch, M.D., Editor
Columbia, S. C.
Snake-Bite
In 1906, while in general practice, the
writer saw a little girl who had two small
red marks close together on one ankle. They
were from snake-bite. A man who saw the
snake escape said it was a rattlesnake. A
tourniquet was applied above the knee, the
wounds were incised and potassium perman-
ganate crystals applied after the tissues had
been sucked with the mouth by the father
to remove the venom. The tourniquet was
JQ9senec} and reapplied several times. Th^
child never had any more trouble from the
snake b'te than from a briar scratch. It
could not have been a pwisonous snake. The
literature available gave practically no infor-
mation about snake-bite.
In 1920 a man was brought into the Bap-
tist Hospital with a badly swollen leg from a
snake-bite received some days previously.
The anterior tibial group of muscles became
gangrenous and sloughed from origin to in-
sertion leaving a disabling foot-drop. An-
other search of the literature failed to give
comprehensive information.
In 1928, in the Surgical Section of the
Southern Medical Association meeting at
Asheville, Col. Crimmins, of Fort Sam Hous-
ton, Texas, read a paper on poisonous snakes.
As he talked of having milked the venom
from many rattlesnakes in the preparation
of antivenin more than one eyebrow was
raised in doubt. But in conclusion a croker-
sack was removed from a suitcase by the
speaker. The chairman and the secretary
left the little platform as the Colonel turned
the sack upside down and an enormous dia-
mond-back rattlesnake fell u|ion the floor.
It was a dramatic moment. The platform
was only about a foot high and the audience
fairly fell away from it. The reptile coiled
as if to strike. There was the noise of dead
leaves being shaken by the wind. It was
the warning rattle. The Colonel, with a suit-
able right angle stick deftly pinned the
snake's head to the floor with his right hand
while he seized the reptile just back of the
head with his left hand. The snake was
lifted from the floor and the mouth forced
open by pressure from the left hand. I'res-
sure back of the eyes from a flnger of the
right hand forced the venom into a glass upon
the table.
This striking demonstration was followed
by a pa|>er on the treatment of snake-bite
by Dr. Jackson of San .Antonio, who had
treated fifty cases of bites by i>oisonous
snakes in two years and who had made a
scientiflc study of the subject. The i)aper,
published in the current number of the
Southeastern Medical Journal (July, 1929),
proves by experiment, with controls on lower
animals, the worthlessness of the ordinary
methods of treatment. Magnesium sui|)hate,
chloral hydrate and i)otassium |)ermanganate
was eatj) triecj antj foqnd to be practically
578-
SOUTHERN MEDICINE AND SURGERY
August, 1929
without benefit. Contrary to the accepted
belief venom was found to be slowly absorb-
ed by the lymphatic rather than by the venous
circulation. It reaches the vein only after
having passed up the leg through the inguinal
glands and into the thoracic duct. Venom
is an intense irritant and the swelling of the
leg is from the outpouring of lymph to dilute
the poison. If the venom is concentrated
hemolysis and gangrene result. Systemic ab-
sorption of the dilute venom causes prostra-
tion, bloody diarrhea, hematuria and death.
Many cases of snake-bite get well without
treatment but enough die to make the sub-
ject of interest to every medical man. The
automobile has made hunting, fishing and
camping so popular that snake-bite is apt to
become more frequent. Oertel of Augusta in
a paper before the Medical Association of
Georgia says there were 31 cases of bites by
poisonous snakes reptirted in Georgia in 1928.
The treatment recommended by Jackson is
giving antivenin in maximum doses as one
syringe of it only neutralizes 10 mgs. of ve-
nom in the animal body and the average
amount of venom injected by the Te.xas rat-
tlesnake is 220 mgs.
Dr. Jackson says . . . ''Release all tight
tourniquets and replace them by one just
tight enough to obstruct the lymph circula-
tion and not the free venous return. Under
novocain make a large cross cut at the fang
marks. Make a circle of cross cuts >4 by >4
inch about three inches from the original
wound. In the small incisions, inject several
hundred c.c. of a 1 per cent salt solution and
apply suction over the original cut to wash
out dilute venom. This is continued for
about one-half to one hour. If a vein is cut
the hemorrhage is controlled, as it is bloody
serum producing the swelling, and blood must
be conserved. Once every hour for from 10
to 15 hours suction is repeated for about 20
minutes, using cupping over first one incision
and then another. A small rubber bulb with
inverted glass funnel is usually used. How-
ever, Bier's hyperemic cup or suction ma-
chine used in tonsillectomy with an attached
ear speculum is found useful. Quite a quan-
tity of venom is diluted each hour and can
be extracted. Fluid also leaks from the
wound between extractions. If the swelling
progresses a bracelet of incisions is made
around the highest point of the swelling, and
Rew incisions are made where this fluid has
collected in large quantities. In most cases
treated by others, we have found that an
insufficient number of incisions was made and
suction was not continued for a sufficient
length of time. Morphine or paregoric is
given for pain, stimulants when indicated,
hypodermoclysis and blood transfusions if the
case comes to the physician late and shows
extensive destruction of red cells with count
below 3,000,000. The hemoglobin and red
blood cell counts are made every three hours,
sa saline cathartic is given and colonic irri-
gations of salt and soda once every four
hours. Between treatments the limb is kept
wrapped in hot fomentations, either bichlo-
ride of mercury (1 to 10,000) and magnesium
sulphate, or sodium citrate solution, to in-
crease the outflow of venomous serum and
help keep the wound from being infected.
It is believed that strict adherence to this
outline of treatment will result in the saving
of many lives that would be listed otherwise
as cases of fatal snake-bite."
OBSTETRICS
HiNRY J. Lancston, B.A., M.D., Editor
Danville, Va.
.•V Challenge and a Criticism
In the June issue of Harper's Magazine,
Dorothy Dunbar Bromley wrote on "What
Risk Motherhood?" In the last paragraph of
her article, which was written under the su-
pervision of Dr. Polak and Dr. DeLee, we
have this statement:
"Communities must wake up to the fact
that it is as much their civic duty to make
available the best grade of maternity care to
every woman as it is to protect their citizens
from murder and mayhem in the streets.
That so many thousands of women should
continue to die and to be invalided for life
in this country which boasts of its scientific
and humanitarian achievements is a dis-
grace."
This paragraph offers us not only a chal-
lenge but a just criticism which should force
the medical profession to rethink its thoughts
and react its acts.
Some of the troubles at the present time
are reflected in such expressions as these.
Some time ago we heard a general practition-
er say, "I deliver babies for the money I get
out of it and not for the pleasure of the
work." We hearc} another general practitjoi}-
August, IIJ'^
SOUtfifiRN MtebiCINfe AM) gtkGfiftV
SW
er say, "I deliver babies in order to keep my
patients from going to somebody else." We
heard still another say, "I disl ke obstetrical
work but I do not want anybody else to have
anything to do with my patients." These
men feel that the only duty they have is to
deliver a baby, collect the fee, and fervent
their patients from going to some other doc-
tor. Then after the baby is delivered he does
nothing about post-natal care. The same
physicians pay very little attention to pre-
natal care, regarding pregnancy as a normal
condition and labor as a normal process.
The profession can continue to travel along
such lines of thought and action, then one
day it will wake up to discover that the com-
munities of the nation have been properly
informed and they will begin to make certain
demands with which physicians will find
themselves unable to comply because they are
behind the times and unequipped to do first-
class work.
Frequently the obstetrician is criticised be-
cause he pays so much attention to pre-natal
care, to delivery and to post-natal care, say-
ing to the public that all these things are
unnecessary and incur expenses which can be
eliminated. The motive back of such ex-
pression and thought is wrong, unscientific,
and will sooner or later give the general prac-
titioner more trouble than he realizes.
Then the question arises as to what can we
can do as physicians who are interested in
the health and happiness of the women who
are now becoming mothers and who are to
become mothers.
First, we can change our attitude, which
means that we may in the immediate future
lose a few dollars, but in the long run we
will make more dollars than we would other-
wise. To change our attitude will cause us
to say to our patients, "Dr. Blank is equip-
ped to do scientific work in obstetrics but
we are not, and we, therefore, prefer that
you go to him for this s[)ecial work; let him
look after you, and we, ourselves will look
after your other troubles." Patients who
have a family doctor with an attitude of un-
selfishness will be loyal to that family doctor.
They will go to the man who is esjiecially
prepared to do obstetrics and have this work
done and then when it is all over they will
go back to their family physician for their
ether ailments.
Second, we will create a situation which
will demand a better standard of preparation
for the doctors who are to do obstetrics. Doc-
tors who want to do obstetrics and are not
well equipped, not only in the rural sections,
but in the villages and city communities, will
go away and become equipped so that they
can do first-class work in pre-natal care, de-
livery and post-natal care. Someone will say
that this will create a hardship on the doc-
tors. Well, suppose it does, the hardship is
well worth while, if it will cut down the ma-
ternal mortality and decrease the present ap-
palling morbid conditions that come directly
from the bearing of children. But as a mat-
ter of fact after the whole question has been
thoroughly analyzed it will not be a hardship
but it will be creating in the life of the phy-
sician the consciousness of the fact that he is
doing modern, scientific obstetrics, which is a
great satisfaction. Also, it assures women
who are to become mothers that they will be
properly cared for through this period which
is so difficult and hard; namely, pregnancy,
delivery and puerperium.
Third, we will change our thought and ac-
tion with reference to the place obstetrics
should have; we will lead the communities in
caring for women who are to be mothers of
the present and future generations; we will
take every opportunity both publicly and [pri-
vately to proclaim the imperative need for
pregnant women to be properly cared for
through the pre-natal jieriod; we will give
these women the benefit of our experience
and knowledge in taking care of their own
bodies and preparing for the coming of the
new members into the family; we will bring
not only into the forethought of our own
minds the care and welfare of these people,
but we will bring these things into the mindi
of the public at large. Should physicians
fail to become leaders in this important field,
sooner or later the laity, which is becoming
more and more informed about the care of
expectant mothers, will lake the lead. Should
the laity take the lead it may not only re-
buke us but place hardships on our shoulders
for having been so stupid as not to have
measured up to the needs and the demands
(tf our time.
The fourth thing we can do is to start an
educational movement which is so simple in
its plan and program that the most ignorant
580
SOUTHERN MEDICINE AND SURGERY
August, 1929
woman will understand why she should have
certain things done for her during the period
of pregnancy. This educational movement
need not be a demonstration or display, but
simply quietly informing all women in our
practice that if they are to come through
pregnancy, delivery and puerperium safe and
sound they must be looked after scientifically
and not in a haphazard manner.
When we go back to our text we are forced
to accept the facts as reported in the June
issue of Harper's, ''What Risk Motherhood?"
If the physicians of the nation do their duty,
in ten years no one will have a chance to
write such an article. In a way we wish it
were possible for this article to be broadcast
throughout the nation. It would help the
physicians and the general public.
Sir Patrick Manson and Dr. W. C.
GORGAS
(From "Life and Work of Sir Patrick Manson," by
Manson- Bahr and Alcock)
Manson had outlived most of his colleagues
and contemporaries. Some of those with
whom he had been most intimately associated
in his scientific work he had never met per-
sonally. Among them was General W'. C.
Gorgas, of Panama fame, director of the
American Army Medical Services, who pre-
deceased him by two years. When Gorgas
died in 1920, and received the signal honor
of a military funeral in London, it was noted
that the only wreath resting on the coffin
as it was borne through the cathedral was
one sent by Manson. "The work my hus-
band accomplished in yellow fever and ma-
laria," wrote the General's widow to Lady
Manson, "was founded on the discoveries of
your husband. Sir Patrick Manson. The
world will not forget him and the benefits of
his work every generation will know and ap-
preciate. Dr. Gorgas yielded to no man in
his love and admiration for Sir Patrick."
Urinary Antiseptics Not Valueless
(Kaufman in Journal of Urology, August)
Treatment of urinary infection demands primarily
recognition of the factor of drainage. Water is essen-
tial with certain physiological aids in combatting
pyrexia, toxemia, and renal failure, ttrinary anti-
septics serve an important purpose in the treatment
of both acute and chronic infections. They are now
clearly established on both scientific and clinical
grounds. In acute pyelonephritis and cystitis (simple
pyelitis of infancy or pregnancy, common pyelocy-
stitis) clinical cure follows the age-old treatment by
alternate alkalinization and acid hexamethylamine
therapy. But in this group of cases such measures us-
ually fail to bring about actual sterilization of the
uninary tract. In the chronic types of infection both
in the group of cases without serious organic patho-
logy and in the cases which show persisting infection
after operative removal of organic pathology, urinary
antiseptics offer promising assistance. No single anti-
septic has as yet been found which is universal
Hexylresorcinol is the nearest approach to a scien-
tific antiseptic. It must be prescribed in maximum
concentration with a low water intake without alka-
lis over long periods with the removal of all factor.;
of obstruction and retention. Hexamethylenamine
has a definite value especially as a phophylactic
against infection in instrumentation of the bladder,
in the simpler forms of acute infections, and in
general routine post-operative care. Acidifiers should
always be used and a safe combination is salol, uro-
tropin and sodium benzoate. We prefer, for maxi-
mum effect, to use it intravenously either as uritone
or salihexin.
.Action of Coffee and Tea on Stomach
(C. N. Myers, Jour, Lab. and Clin. Med., July, 1929)
The chemical action of a mixture of tea and
l.iead on the stomach secretion was found to be
practically the same as a mixture of bread with an
equal amount of water. A mixture of coffee and
bread produced a slightly greater amount of gastric
juice during the first two hours. The latent period
(the beginning of the secretion) was not affected in
either case. The increase in juice was very little,
0.3 c.c. for the first hour in the stomach pouch, or
about ,?.0 c.c. for the whole stomach. The nervous
element was eliminated by introducing the mixture
through a gastric fistula, and the collection of the
juice was from a miniature Pavlov's stomach. We
may conclude that the effect of even very strofig
coffee and tea on the stomach secretion depends
almost entirely upon the individual, i.e., upon the
nervous secretion, and upon the water content, there
being little or no chemical influence due to the tea
and coffee per se.
Syphilis of the Stomach Not So Rare
(Hayes, in Minnesota Medicine, August)
Formerly, syphilis of the stomach was considered
rare. Recent improved diagnostic methods, x-rays,
serology, etc., have brought out the fact that it is
not so rare. It has recently been estimated that it
occurs once in about 300 gastric lesions.
Durham county, the Morning Herald discovers, has
only one cow to l.S persons. But then it was not
the females of the bovine species that made Durham
anyhow. — Greensboro News.
August, 1929
SOUTHERN MEDICINE AND SURGERY
581
HISTORIC MEDICINE
J. RuFUS Braxton — Planter, Doctor,
Patriot, Gentleman of the Old
School
Autobiographical sketch of the First Fifty Years of
His Life, superscribed. "For my Children in
Future Life," supplemented by a Note on His
Later Years, by Mhs Margaret Cist, of York.
(Continued from July issue)
iments & I took my sick to Makeley's Church
on the Braddock Road, here I attended the
sick & sent away all that were able to Rich-
mond & other places & remained until the
ISth of Oct. when I was ordered to rejoin
my Regiment at Germantown & afterwards
at the Camp near Fairfax C. House. In a
few days we were ordered to fall back to
our Entrenchments around Centreville, where
we remained during the winter, whilst at
Germantown & Fairfa.x our Regiment whilst
on Picket had frequent skirmishing with the
Enemy, but with no loss to us. During the
winter Centreville was the muddiest, lilthiest
hole I ever saw & here I & Napoleon were
attacked with Pneumonia & lay in the tent
all the time. Meek, Barron, Bona & myself
slept together & so crowded were we that in
a cold night when one turned all had to turn
together to keep the cover on him. We with
Dr. T & his Brother the Major & their two
Boys, Bill & Dennis, & our two, Frank &
Sam, made our mess. Frank afterwards was
put in jail at Williamsburg for stabbing Dr.
Thomson's boy & Sam died with Pneumonia
at Centreville & was buried there under an
appletree. Many a sad thought ran through
my weary mind whilst here & I was glad
when we left on 8th March for Yorktown
by Richmond. We reached Yorktown down
the River by Boat, thence by land on or
about the 26th .April. Here we lay on the
side of Warrick Creek behind our fortifica-
tions for two weeks under daily shelling of
the Enemy.
Having remained with the Regiment for
more than two weeks over the expiration of
my time volunteered, (12 months) with the
consent of Col. Jenkins and Genl. Anderson,
comn'g Brigade, I left the Regiment for
Richmond with the view to get a position
in a hospital where I would not be so much
exposed to the weather as I had become sub-
ject to Rheumatism. I stood my Examina-
tion before the .Army Medical Board for .Asst.
Surgeons, passed favourably & was ordered
by the Surgeon Genl. to report to Dr. A. G.
Lane, Chief Surgeon of the Hospital on May
3rd, 1862. I was placed on duty at the 1st
Division, the rest of the buildings were called
barracks and were occupied by Soldiers,
many of whom were sick with Fever Typhoid,
Measles, Diarrhea, &c. I was ordered in a
few days to organise more Hospitals out of
the barracks building. Dr. Lane organised
the second division, whilst I organised the
3rd, 4th & 5th Divisions, repaired the build-
ings with men detailed for the pur[3ose, ar-
ranged the wards & their furniture, bedding
&c., appointed the officers, cooks, ward mas-
ters, nurses & attendants for the three hos-
pitals & then was placed by Dr. Lane in
Charge of the 4th Division May 24th, 1862.
During this year there were in this Hospital
4488 patients, many of whom were the
wounded sent in from the battle fields around
Richmond. I performed a number of ampu-
tations that year nearly all of whom
got well. In this year Drs. J. J. O'Bannon,
of Barnwell, S. Ca., and Frank Spencer, of
Maryland, were with me, whose society and
assistance I enjoyed very much. The Sur-
geon Genl. after promising Dr. Lane that I
should be promoted to the Surgeoncy, finally
refused to do so unless I stood my Exarfi.
for full Surgeon before the Army Med.
Board, still sitting in Richmond. I was ex-
amined the 2nd January, 1863 & received
my appointment as full Surgeon on the 6th
of same month and continued on duty in the
4th Division. The result of my Examination
was satisfactory to me since it made me in-
dep>endent of the Surgeon (ienl. & every one
else. I stood u[X)n my own merits, and by
these was willing to rise or fall. This is the
course I would advise you to adopt in life,
armed with all your Energy, put on all your
Efforts both of body & mind, regardless of
apparent obstacles and difficulties and with
the determination to succeed, and with a con-
sciousness of the rectitude of your course,
guided by an .All wise Providence let your
Motto Ever lie "Upwards & onwards."
I have still charge of this Hospital at this
time {Se[)tr. 16th, 1863) & will continue un-
less the winter climate affects my health,
leaving me with a cough. Up to this date
this Hospital has treated 2271 cases more
S82
SOUTHERN MEDICINE AND SURGERY
August, 10^9
wounded men this year than last, from Chan-
cellorsville and Gettysburg. The wounded
from Chancellorsville were badly wounded
& I performed a number of amputations both
of legs & arms & tied the Femoral Artery
at its middle third — with Success — the bra-
chial and the occipital arteries with Success.
One amputation died — a case from No. Car-
olina. Your mother with Andral then large
enough to talk & run about & Moultrie
nursing at her breast, with Mahala & Nancy
as Nurses visited me in Richmond in Sep-
tember, 1862, & I boarded them at Mr. John-
son's near the Hospital. We had a pleasant
time together. They came on the last of
August and stayed until the 6th of Octr.
1862. In January, 1863, I went home on
furlough, stayed thirty days & returned to
duty. On the 3r dof August, 1863, I also
visited home & although I was not well still
the pleasure of your Mother's Company and
you four boys, Louis, Jonnie, Andral &
Moultrie, gave me much consolation & com-
fort and I often wished that such times could
last longer or even always.
(To be continued)
I continued in Chg. of 4th Division untill
Octr. 12th, 1863, when Genl. Bragg, of the
Tennessee Army, having asked for more Sur-
geons for his Army, twenty Surgeons from
Richmond were sent by order of Secy, of
War to the .Army of Tennessee. I reported
to the Med. Director S. H. Stout, of that
Army who being then at Marietta, Geo., or-
dered me to LaGrange, Geo., to take charge
of a Division there. Here I found the Hos-
pital in need of much improvement both in
facilities for preparing food and other com-
forts for the sick and their bedding &c. —
all of this however I was Enabled to supply
in a few weeks. Dr. Williams (a nice old
Gentleman from Va. who was on duty with
me at Winder Hospital & who was sent with
myself to LaGrange) and I messed with a
Dr. Jones & his family & Dr. Annan, from
Baltimore, for two months (Novr. & Deer.)
when we discovered that they were consum-
mate rascals in stealing the candles & sugar
of the mess. We dissolved our association
with such men and determined never again
to be associated with any men north of the
Potomac unless we knew them well before-
hand. At LaGrange Dr. W. & myself board-
^4 wjtb a Mrs. Gay & her mother Mrs.
from the 1st Jany., 1864, until the
12th of May, 1864. With them we were liv-
ing Comfortably and I regretted leaving very
much. We paid $100 per month for board.
LaGrange was a beautiful and comfortable
little Town with fine residences and well cul-
tivated gardens of flowers and vegetables, a
sure index of wealth, intelligence and refine-
ment. On the 12th May, 1864, I was or-
dered by Surgeon Stout Med. Director to
proceed to Madison, Geo., and take charge
of all the Hospitals (named the Asylum,
Blackie and Stout Hospital) as Surgeon of
the Post. This promotion was as sudden as
it was unexpected as I did not seek it. I
found all the Hospitals here containing only
700 beds. I extended the Capacity imme-
diately to 1050 and added another Hospital
which I called "Rebecca Hospital" in honour
of your Mother and all other good women
like her. This was the Baptist College and
the boarding-house conected with it. It was
a favorite with the Ladies of the Town and'
they paid great attention to the sick and
wounded who were sent there. Madison was
also just a place as LaGrange. The Ladies
were very generous & kind, though the men
seemed very fond of money and asked high-
est prices for all their property. Sugar was
selling then for $10 per lb. One old Baptist
Elder asked me $10 for a Split bottom chair
— which prices, of course, I would not pay.
I made many pleasant acquaintances there
among them. Col. Walker's family, Mr.
Wade's, Col. Reese, Judge Burney's family
(whose daughter Julia very handsome and
intelligent often gave me some sweet music)
also the family of iMr. Holdermann refugees
from Kentucky and Col. Clarke & wife. The
Col. was wounded in the arm and I attended
him and saved his arm, also attended to his
wife during her sickness. I boarded at Mr.
Thomasson's, a very pleasant house, for
$125 per month and promised myself much
pleasure in the expected visit of Your iMolher
with Andral & Moultrie to me at Madison
in August or Septr., but the Yankee Army
having destroyed the R. Road between Mad-
ison and Atlanta thereby cutting the Hos-
pitals from communication with the iMed.
Director having burnt also the public build-
ings at Covington, a town twenty miles
above iMadlson, also a placed called Social
Circle and threatened every moment to at-
August, 1020
SOUTHERN MEDICINE AND SURGERY
583
tack Madison. Notwithstanding their ex-
pected attack I determined to remain with
the sick and wounded of my Hospital at all
hazards and not forsake my post of duty.
Here I remained until the Evening of the
23rd July when I received an order from
Dr. Stout, Med. Director, instructing me to
remove my Hospitals from Madison to Au-
gusta, on account of the Yankee Raiders who
threatened every moment to come into the
Town. I obeyed the order reluctantly and
sent out an order to all the Hospitals to get
ready all the Stores for Shipping to Augusta.
At one o'clock that night (Saturday) we left
Madison in the train for Augusta with our
Hospital Stores &c. All were unwilling to
leave but the order had to be obeyed. When
the Citizens heard I was going to move the
Hospitals they became much more alarmed
than before and began immediately to pack
up and take out with them all their valua-
bles into the Country. It was a trying scene
to witness, the Ladies in the Streets asking
what they must do and the waggons loaded
with furniture &c going at a rapid pace in
all directions.
When I looked upon these scenes — the
question would often present itself to me,
why are these things permitted to be so im-
posed upon us by the Yankees? I prayed
that the day of restitution would soon come
when justice long withheld should be meted
out to these worthless Invaders of our coun-
try. We arrived in Augusta with the Hos-
pitals 4 o'clock F. M. When I was tele-
graphed by Dr. Stout from Macon to re-
open my Hospitals in Milledgeville, Geo.,
where I arrived on the night of the 28th July
and the Hospital at Oglethorpe University,
the buildings of which are admirably adapted
for hospital purposes. I am boarding now
at the private house of Dr. W. R. Lanier
(who I forgot to mention began duty with
me at Madison July 6th, 1864) at $120 per
month. The board is very high considering
the quality but we must remember these are
war times & war prices.
(To be continued)
I was engaged with the Hospitals as Post
Surgeon when Genls. Sherman & Slocum en-
tered on the 19th Xovr., 1864, with their
army on the way to Savannah. I was taken
prisoner and remained so for 5 or 6 days
with permission to visit the Hospitals but
not to leave the lines. After Sherman passed
through and the Army of Genl. Hord fol-
lowed, there being no regular Army of the
West behind, I made application for trans-
fer from Georgia to the Armies then in South
Carolina — which was granted. I left Mill-
edgeville about the last of March, passed
through Washington, Ga., Abbeville, New-
berry & L^nion & by Sister Elizabeth Walk-
er'sS at Pacolet, where I got a carriage &
horses and came directly on home with the
Matron of the Hospital, Mrs. Campbell. This
route was made nearly all on foot, e.xcept a
few miles of railroad in Geo. & S. C. Arriv-
ing at home about the 9th of April I met
Soldiers coming from Ya. who stated that
Genl. Lee had surrendered his Army. I then
concluded to remain a few days at home to
learn all the particulars of the Surrender,
during these days President Davis and his
Aids & Cabinet came into Town on their
retreat to the Trans-Mississippi Army.
President Davis with aides. Cols. Taylor and
Lubbuck, stayed at m.y house all night. The
citizens gathered around the house to see
and offer their tokens of respect & sympathy
for him and the cause for which he contend-
ed. President Davis appeared to be some-
what fatigued in body and depressed in
Spirits, though easily aroused with his native
fire he caressed and sjaoke Kindly to my 4
boys, Louis, Johnnie, .\ndral & Moultrie
and when he left me in the morning & bade
us good bye he observed, "Do not expect
anything just or right from the abolition-
ists; they will never grant you your
rights.'' What became of him afterwards,
history will tell you. In a day or so more
Genl. Joseph E. Johnston's .Army surrendered
to Genl. Sherman in No. Ca. and thus ended
the contest. Knowing that the Abolitionists
would Emancipate the negro, and seeing the
necessity of going to work to make provisions
for another year I went daily to my planta-
tion, Sundays excepted, stayed & worked
with the negroes in the fields, made plenty
of corn and meat to do me the next year
(1866) together with 6 bales of cotton. On
the day before Christmas (1865) I killed
the last lot of hogs, brought them to Town
and told the negroes to go their way with
their freedom Either in peace or misery.
iCuii lilt mil in September isiue)
8. I^ater Mrs. James E. de Loach.
SOUTHERN MEDICINE AND SURGERY
August, 1929 ,
NEWS
{Items supplied regularly by Dr. J. K. Halt. Rkhmcnid and Dr. L. B. McBrayer, Southern Pines)
Medal and Prise Offered for Goiter
^^'oRK
The Executive Council of the American
Association for the Study of Goiter will
award a prize of three hundred dollars
($300.00) and a medal of honor to the au-
thor of the best essay based upon original
research work on any phase of goiter, pre-
sented at the annual meeting of the Associa-
tion at Seattle, Washington, in September
1930.
The Association hopes this offer will stim-
ulate valuable research work on the many
phases of goiter, especially on its basic cause.
Competing manuscripts must be in the
hands of the Corresponding Secretary by July
4, 1930, so that the award committee will
have sufficient time to thoroughly e.xarnine
all data before making the award.
Full particulars of other regulations gov-
erning details of the offer will be furnished
on application to J. R. Young, Corresponding
Secretary, Rose Dispensary Bldg., Terre
Haute, Ind.
Onslow Society Holds Good Meeting
(Reported by Dr. E. L. Cox, Jacksonville,
Secy.)
The Onslow County Medical Society met
at the Tarrymore Hotel, Swansboro, N. C,
July 25th, 1929, with forty-eight doctors
present, from Middle and Eastern North Car-
olina. The meeting was called to order by
the President, Dr. C. W. Sutton. Address
of Welcome by Mr. J. T. Bartley, mayor of
Swansboro, who not only gave us a cordial
greeting, but a brief history of the little City
by the Sea. Dr. Hardy of Kinston responded
in a very happy way. First on the program
was "Sterility," by Dr. Geo. Johnson of Wil-
mington, which paper elicited an interested
discussion by Drs. Patterson, Latham, Mur-
phy, McBrayer and Hardy. Dr. J. D. Free-
man next read a paper on "Observation of
the Sphenopalatine Ganglion Syndrome of the
Sympathetic Type," and report of cases. This
paper evidenced much study and was dis-
cussed by Drs. Koonce and Moore. Dr. John
Hamilton next read an interesting paper on
"Typhus-Fever," which was discussed by
Drs. J. .AI. Parrott, Whitaker, Latham and
I'atterson. Some new jcjeas on "Colitis ^1)4
Diarrhea" were presented by Dr. J. Buren
Sidbury, Wilmington, which were discussed
by Drs. Crouch, Freeman and Murphy.
Regret was expressed for the absence be-
cause of illness of Dr. Cyrus Thompson and
Dr. F. H. Blount.
During the last course, Dr. E. L. Cox,
toastmaster, called on many of the doctors
who responded in happy vein.
"Cancer, Its Cause and Control," as pre-
sented by Dr. H. H. Bass of Durham and
Dr. H. B. Ivey of Goldsboro, aroused much
interest and discussion by Drs. Bryan, Mc-
Brayer, Hooper, Byrd, Whitfield and Cox.
The last paper, "Organized Medicine,"
read by Dr. McBrayer of Southern Pines,
created an atmosphere of much concern and
the subject was well discussed by Drs. Whit-
field, Henderson, Ivey, Hooper, Murphy, Mc-
Custon, Dickey and Bryan.
It was moved and carried by the Society
that Dr. McBrayer 's paper go on record. This
Society and all visiting physicians approved
the same.
Dr. D. a. Garrison was elected President
of the North Carolina Hospital Association
at its recent meeting to succeed Dr. R. Duval
Jones, of New Bern, whose time expired. Dr.
Eva M. Locke, of White Rock, Madison
County, was elected Vice-President and Dr.
L. V. Grady, of Wilson, re-elected Secretary
and Treasurer. Dr. E. T. Olson, chairman
of the legislative committee of the American
Hospital Association, Chicago, attended the
meeting and delivered an address.
Cancer Week. — The second week in Octo-
ber has been set apart by the State Society
for the Control of Cancer, Dr. H. H. Bass,
Chairman, as Cancer Week. It is planned
to form a permanent committee on cancer in
each County INIedical Society and have this
committee assisted by the other members of
the Medical Society hold a clinic during the
entire second week of October. The National
Society for the Control of Cancer is to fur-
nish the literature and the County Health
Departments are to see to its distribution.
The newspapers of the state have promised
to lend their aid.
Vugust, 10:9
SOUTHERN MEDICINE AND SURGERY
S8S
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Against Imitation:
fhe *" "s present form, is scientifically designed and was
oAntiphlogistine
adopted after years of painstaking research. Drawn of
. special alloyed metal with neither seams nor joints and
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and ring, the physician is assured of a highly efficient container, on the one
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preserving them against oxidation or deterioration even under the severest
climatic conditions, and, on the other hand, furnishing a distinaly con-
venient method for heating the contents whenever and wherever the
emergency may arise.
Rigid laboratory control at all times and at every step in its pro-
duction guarantees uniformity of therapeutic action. That more and
more doctors are to-day turning to Antiphlogistine is convincing
proof that it meets the exacting requisites of the modern practitioner
for a safe and efficient poultice and dressing.
The originality and uniqueness of the Antiphlogistine container obviates
confusion and protects your patient against package imitation.
There is only one Antiphlogistine!
B? the Original!
The Denjver Chemical Mfg. Co., 163 Varick St., New York.
Dear Sirs: You may send me, free of all charges, one trade size
package of Antiphlogistine for trial purposes.
SOUTHERN MEDICINE AND SURGERY
August, 1929
The State Board of Medical Examin-
ers are in session this week at Raleigh, about
150 applicants are taking the examination.
The Board of of JNIedical Examiners are: Dr.
W. Houston Moore, Wilmington, President;
Dr. John W. MacConnell, Davidson, Secre-
tary-Treasurer; Dr. Paul H. Ringer, Ashe-
ville; Dr. Foy Roberson, Durham; Dr.
Thomas VV. M. Long, Roanoke Rapids; Dr.
William \V. Dawson, Grifton.
At the meeting of the Third District of
the Medical Society of the State of
North Carolina, held at the Babies' Hos-
pital at Wilmington, Thursday, June 20th, an
address was delivered by Dr. L. B. McBrayer
on the subject of Organized Medicine.
At the meeting of the Eighth District
of the Medical Society of the State of
1\0RTH Carolina, held at Mount Airy, the
following officers were elected: Dr. C. S.
Lawrence, Winston-Salem, president; Dr.
Fred C. Hubbard, North Wilkesboro, vice-
president; Dr. Harry L. Brockmann, High
Point, secretary.
Hospital for Tuberculous ^or Wayne
The Wayne County Board of Commission-
ers on July 17th, approved a $25,000 appro-
pr'ation for a tuberculosis sanatorium in
Wayne county. The approval was made after
a committee headed by Dr. W. H. Smith was
introduced by Dr. L. W. Corbett, Wayne
health officer, and had presented the subject.
IMembers of the board had previously visited
sanatoria of this kind in the state.
It is practically assured that with the com-
pletion of plans for the construction of the
building aid will be secured from the Duke
Foundation.
V^a.-N. C. Births and Deaths
Virginia's birth rate decreased and death
rate increased in 1928 as compared with 192 7
in line with a national birth rate decrease
and death rate increase.
The State's birth rate was 21.9 per 1,000
population as compared with 22.9 for the
previous year, while national figures were
19.7 for 1928 and 20.7 for 192 7. Although
North Carolina fell from 28.8 to 27. S, she
took the lead as highest in the Nation,
Dr. Warren T. Vaughan, Richmond, at-
tending the American Medical Association
convention in Portland, was elected to the
Board of Censors of the American Society
of Clinical Pathologists, meeting in conjunc-
tion with the A. M. A.
Other Richmonders in attendance at Port-
land were Dr. J. Shelton Horsley, of St.
Elizabeth's Hospital; Regina Cook Beck,
pathologist at Stuart Circle Hospital, and Dr.
William A. Shepherd, staff physician of the
Johnston-Willis Hospital.
At a recent meeting of the Board of Medi-
cal Examiners of the State of North Carolina,
Dr. Paul Ringer, Asheville, was elected
President.
Dr. John Powell Williams and Mrs.
Virginia Marshall Gregory were married
on July 15th. Dr. Williams is a graduate
of the Medical Department of the University
of Virginia, class of 1923, and he is a mem-
ber of the McGuire Clinic.
Dr. W. B. Lyles and brother, Thomas M.
Lyles, of Spartanburg, sustained minor inju-
ries July 22nd, when the car they were driv-
ing plunged into a railroad cut near Union.
Dr. B. B. Bagby, for several years health
officer of Henrico county, and later health
officer of the city of Richmond, has returned
to Virginia, and begun a term of office as
health officer of Southampton county. Dr.
Bagby left Richmond in July, 1926, to take
charge of an experimental health demonstra-
tion in Athens, Ga. The three-year experi-
ment ended July 1st of this year.
Dr. Charles E. Spoon, 48, Burlington,
N. C, died suddenly from a heart attack in
h's office, Thursday afternoon, July 4th.
Dr. Joseph F. Geisinger, member of the
Stuart Circle Hospital staff, Richmond, was
operated on recently at that hospital for ap-
pendicitis.
Dr. Thomas J. Sasser has moved to Char-
lotte, N. C, and has accepted the position of
school physician in the Department of
Heiilth,
August, 1929
SOUTHERN MEDICINE AND SURGERY
To maintain a slendor fi<;-
ure, no one can deny the
truth of the advice:
"REACH FOR A LICKY
INSTEAD OF A SWEET"
of Zicgfeld'e "Whoopee"
Lucky Strike is a bh-inl of the choicest tobac-
cos, matured hy nature, abounding in fragrant
aroma and bursting into delicious, satisfying
flavor when toasted for 15 minutes. This heat
treatment is the reason 20,67')'^ physicians
claim I.uckies to be less irritating than other
cigarettes. Toasting, the distinctive process,
makes Lucky Strike the cigarette of ilistinction.
^ ^ (SlGtiVD)
The fipures quoted '^ '
lliivc been checked
and certified tn by
LVUHANI), ROSS
BROS. AND M(»T.
COMKRY, Accoun-
lanl» and Auditor..
TTle Lucky Strike Dance OrcheKtrn
night in a coast to coast radio hook-up
"REACH FOR A LUCKY INSTEAD OF A SWEET'
"It's toasted"
No 1 hroat Irritation-No Couglv.
I 19^9, Tht American Tob.iccn Co., Manilla.
SOUTHERN MEDICINE AND SURGERY
August, 1929
Dr. E. Newton Pleasants, M. C. Va.
'27, for the past year associate surgeon at the
Memorial Hospital, Princeton, W. Va., has
recently removed to Richmond, \"a., where
he is associated with Dr. Alexander G.
Brown, jr., in the practice of internal medi-
cine. Dr. Pleasants will be remembered as
having served a one-year internship at Stuart
Circle Hospital previous to his service in
West \'irginia. Dr. and Mrs. Pleasants will
make their home on Fauquier avenue, North
Ginter Park.
Dr. Albert Parrot, Kinston, has purchas-
ed an airplane and will operate it himself.
Dr. Charles R. Robins, Richmond, re-
tiring president of the Rotary Club, was pre-
sented with a set of twelve silver bread and
butter plates and four silver candlesticks by
h's fellow-Rotarians.
Dr. R. K. Adams, formerly on the medical
Etaff of the State Hospital, Raleigh, N. C,
has accepted a position with the State Epi-
leptic Village, Skillman, New Jersey.
Dr. L. L. Whitney, of Gary,,W. Va., has
purchased Closeburn Manor, an old estate in
Campbell county, Va., on the Salem turnpike,
seven miles from Lynchburg. The property,
wh'ch includes a manor house and forty-five
acres I of land sold for $20,500. Dr. Whitney
is to use the property for his home.
De!. Ambler Baxter Patton, 45, until re-
cently head of Sanitariums at White Sulphur
Springs, W. Va., and Battle Creek, Mich.,
d ed July 8th, at Long River, N. J.
Dr. Patton once practiced at Henderson-
ville,;N. C.
Dr. John D. MacRae, Asheville, has an-
nounced the association with himself of his
son, Dr. J. Donald MacRae, jr., in the prac-
tice of X-ray and Radium Diagnosis and
Therapy.
Dr. J. W. Geiger, Med. Col. of the State
of S. C. — '57, aged 97, is still in limited prac-
tice at New Brookland, Lexington County,
South Carolina.
Children' Hospital for Greensboro
Through the generosity of Mr. and ]\Irs.
Edward Benjamin, of New Orleans, the Em-
manual Sternberger residence — childhood
home of Mrs. Benjamin — on Summit avenue,
Greensboro, has been given for conversion
into a hospital for sick children, and an en-
dowment of $100,000 provided toward de-
fraying operating expenses.
Dr. Cyrus Thompson, of Jacksonville, has
been laid up for two weeks by a pus infection
of h's right hand and arm. Despite this
handicap he sends in his usual spicy matter
for his President's Page. All will rejoice that
he is now about recovered.
Dr. J. Henry Bayles has been elected
president and Dr. Casper W. Jennings
secretary of the Clinic Hospital Staff, Greens-
boro.
CHUCKLES
TACT
"Father, what is tact?" asked Albert.
"Tact, my boy," replied his father, "is what pre-
vents a gray-haired man with a wrinlcled face from
rcmindinp a youthful lookins woman with a com-
plcx'on of a rose that they were boy and girl to-
gether."
EASY
Two pickpockets had been following an old man
whom they had seen display a fat wallet. Sudden-
ly he turned off and went into a lawyer's office.
"Good lor'," said one, "a line mess! Wot'll we
do now?"
"Easy," said his mate lighting a cigarette. "Wait
for the lawyer." — London Answers.
A London banker says he would enjoy running
a ncw-paper column for just one day. And what
we could do to a bank in just one hour! — New York
Evening Post.
Dr. William Louis Poteat addresses the Methodists
at Junaluska on the blessings of an honest ignor-
ance. Many of his hearer.i doubtless recalled the
time when they knew less about their bishops and
were considerably happier. — Greensboro AVus.
Teaeher: "Why was Solomon the wisest man in
the world?"
Pupil: "Because he had so many wives to advise
him." i
Teaeher: "That is not the same answer that is
in the book but you can go to the head of the class."
August, 1029
SOUTHERN MEDICINE AND SURGERY
(jukure /i/JonxxC /\s mDCo ntaai
^ D D a a
Thu central adnunisiraifon 6uil(Ji)\o of
iKe nexo /^ocke'JahoraTor/es a't}ialttyjt£w Jersey
essnQss
DOSAGE:
Tor Nervousness
I to 2 MblelB a
dav
For Pain
2 ubieti arc usu
•ufficient
ally
For Sleep
ALLONAL
•/fe
fic'n-nar<
■cotJL
is the remedy almost universally prescribed in place
of opiates. Allonal is routine in practically every
hospital in the country. To be certain that they
are employing the safest and the best sedative,
hypnotic, and analgesic for allaying nervousness,
insomnia and pain physicians order Allonal 'Roche'
HofFmann-La Roche, Inc.
SMahen of SMcdUinti o[ %aTe 3}uiHly
590
SOUTHERN MEDICINE AND SURGERY
August. 1929
BOOK REVIEWS
THE NOSE, THROAT AND EAR AND THEIR
DISEASES: In Original Contributions by American
and European Authors. Edited by Chevalier Jack-
scn.M.D.. Professor of Bronchoscopy and Esophago-
scopy in the University of Pennsylvania, in the Jef-
ferson Medical College, and in the Graduate School,
University of Pennsylvania, and George M. Coates,
M D., Profes:-or of Otology. Graduate School, Uni-
versity of Pennsylvania. Assisted by Chevalier L.
Ja^kscn, M.D., .Assistant in Bronchoscopy and Eso-
phagoscopy, University of Pennsylvania. Octavo
volume of 1177 pages with o57 illustrations and 27
inserts in colors. Philadelphia and London, W. B.
Saunders Co.. 1929. Cloth, $13.00 Net.
The editorship of this volume is sufficient
guarantee of its solid value. Each of the
rrnny contributors has presented his subject
after his own fashion which gives a fine flavor
cf individualism.
The knowledge of today is given rather
thin steps by wh'ch that knowledge has been
f?'ned. Those wishing to go into the histori-
cal phase of any subject will find ample ref-
erences for his guidance.
THE TREATMENT OF FRACTURES, by
/ 'renz Boh'er, M.D., Chief Surgeon and Director of
''-^ Vienna .Acc'dcnt Hospital. .Authorized English
Tr^nrlation by M. E. Steinberg, M.S., M.D., form-
Prlv Sen'cr Officer on the Surgical Service of the
U. S. Public Health Service Hospital and Consultant
f^urcecn to the U. S. \'eteran's Bureau at Portlana,
Oregon. 2M Illustration. Wilhelm Maudrich. \'ien-
na, 1929. $5.00.
E.xperience gained from the management of
more than ten thousand fractures and the
stiidy of seventy thousand roentgenograms
during nineteen years is set forth in this book.
These were years of practice under a great
diversity of conditions: general country prac-
tice, ship surgery, small and large hospital
practice, war practice and peace time pract'ce.
It also represents the teaching of many post-
graduate students.
The descriptions in the text are plain and
concise, the illustrations abundant and care-
fully chosen. Directions for treatment are
d'rcct, not to say emphatic, a feature which is
!i:art'ly commended. There are only 185
pages — all meat, no stuffing.
EAT, DRINK AND BE HEALTHY: An Out-
Kne of Rational Dietetics, by Clarence W. Ueb, M.A.,
AID. The John Day Company, New York, 1928.
$1.50.
There is a waggish introduction by Dr. C.
Ward Crampton, and the rest of the book
is only a bit less waggish. In its opposition
to food fads and cults is found the books
greatest value, and near to this is the lesson
of cheerfulness at the table. There is a good
deal of speculation.
.\ great many who base their reasoning on
general impressions, and some who reason
from carefully checked experimentation, dis-
agree with the author's italicized statement
yen can not trust your appetite. These be-
lieve unciualifiedly that, imperfect guide
though it is, the appetite is by far the most
reliable guide to be had, and, as checked by
the ind vidual's own digestive experiences, the
appetite's guidance is about as satisfactory
as any other human provision.
Food idlosyncracies are given prominence,
and it is will advised that variety be had at
d ffere. 1 meals rather than in any one meal.
Fredi milk, vegetables and fruits are given
as th? cheapest, simplest and richest sources
of vitamins.
Surprisingly, it is stated that bread should
not usually be taken at dinner. Bran evokes
no enthusiasm. The strict vegetarians are
given no comfort.
The author is forgiven much for this expose
of "The Folly of Spinach.'' "There is," he
says, "a growing group of physicians, who, by
both laboratory and clinical exjierience, have
come to believe that spinach is doing more
harm than good, particularly among children."
Those of us who believe in the rel ability of
the appetite have never thought there could
bo any good in so distasteful a weed.
Sugar is said to be undermining the na-
tion's health, and "taking candy from chil-
dren" to be one step in guarding health.
E.\T, DRINK .AND BE SLENDER: What
Evtry Overweight Person Sould Know and Do, by
C arenir W. Ueb, MA., M.D. The John Day Com-
;...;;,■. New York, 1929. $2.00.
August, 102Q
SOUTHERN MEDICINE AND SURGERY
OTOSCOPE SET
No. 075 Combination Set Contain? Otoscope
with three Speculac and Ophthalmoscope. A
popular model with the Welch Allyn principle
of direct illumination.
Complete in Case $37.50
This Otoscope has the largest lens disc and
best lamps used in instruments of its type,
and provides magnification and easy observa-
tion lor diagnosis, operative work or testing
the mobility of the car drum.
The Mirrorless Ophthalmoscope is easy to use
For Direct or Indirect Methods
POWERS & ANDERSON
503 Granby St.
Norfolk, Va.
603 Ma
Richmon
d. Va
Suri;ical Instruments. Hospital Supplies, Etc.
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DISULPI129MIN
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send for literature and samples.
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American Bio-Chem. Lab., Inc. A
27 Cleveland Place, New York City.
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Dr
i9i
Souther}^ MediciI^ aNd stJkGEkV
August, 10J4
Failing to find one book to meet the needs
of his overweight patient, the author pro-
ceeds to write a book to accomplish four pur-
poses: to engender fear, to emphasize the fact
that one can get rid of fat without becoming
a martyr, to warn against wrong ways, and to
point out that there is more than one type of
abesity each requiring different management.
These worthy endeavors are carried out in
considerable detail, and after a very common-
cense fashion.
Reduction fads are held up to ridicule, the
reader is told plainly that very fat folks do
not live as long as others and it is pointed out
that they are far more prone to a number of
serious and (or) painful diseases.
Water-drinking, exercises, baths, sweats,
sweets, alcohol, tobacco — all these and many
other things are discussed in a plain rational
way. Fat folks should derive much comfort
and lose much undesired excess from studying
and following the advice here laid down.
ASHBURNER ON Ch.^NCERV ( EQUITY ) CoURTS
(From Cohen's The Spirit of Our Laws)
It was a court of conscience in two senses. In one
sense the jurisdiction was exerciseable according to
the conscience of the chancellor, although his con-
science was fettered more and more by author-
ity; in the other sense the jurisdiction was exercised
ct the conscience of the defendants. The objects of
a court of civil judicature, as now understood, are
to determine proprietary rights, enforce obligations,
and redress wrong by granting damages. The earliest
descriptions of the equitable jurisdiction lay stress
upon a different principle. The object of the Court
of Chancery was, in the first instance, the purifica-
tion of the defendant's conscience. It was a cathar-
tic jurisdiction. If a person is allowed to remain in
posses.sion of property which it is against conscience
for him to retain, his conscience will be oppressed,
and the court, out of tenderness for his conscience
will deprive him, notwithstanding his resistance, of
what is so heavy a burden upon it. This principle
is at the bottom of the leading doctrines of the
court. If property is given to me in confidence
to deal with it for the benefit of another, or if I
declare that I will deal with the property for the
benefit of another, my conscience would be polluted
ii I denied the existence of an obligation, and at-
tempted to retain the property for myself
If I have undertaken to perform a duty, my con-
science might be affected if I acquired an interest
inconsistent with that performance; and a court of
equity, to prevent the slightest stain from attaching
to my conscience, disables me from retaining such
an interest if I have acquired it. If I obtain a bene-
fit by fraud, actual or presumed, or by undue in-
fluence, actual or presumed, it would be against con-
science that I should retain it. Moreover, it may be
against conscience for me to retain property, al-
though I did nothing against conscience in acquir-
ins; it. Thus property which I have obtained by an
innocent misrepresentation, must be restored to the
original owner.
ExTR.^CTS FROM Cohen's — The spirit oj our Laws
Gradual change of character from within i',
very, very slow, and perhaps the old stock of pri-
meval dispositions is never exhausted At
a very early stage the Greeks recognised the prov,?r')
that Custom is king of everything, and, as a mitter
of fact, in their language the word for law originally
meant custom.
In 1812 it was enacted that penalties under an .\ct
were to go half to the informer and half to the poor
of the parish, but the only penalty under the Act
is fourteen years' transportation. .\n incorrect ver-
sion is that the words ultimately ran — "fourteen
years' transportation, and that upon conviction, one-
h:'.lf thereof should go to the King and one-half
to the informer." There is a story that in a bill
for the improvement of the metropolitan watch in
the time of George III., there was a clause that the
watchmen should "be compelled to sleep" during the
day. A member of the House of Common,, who
suffered from gout, proposed that it should be ex-
tended to members of that House.
It may fairly be held that to attempt to prosecute
every one, would encourage such an amount of
spying and domestic treachery, and would lead to
such endless diversity of opinion- whether the ex-
treme limit of sobriety had been reached or not,
that such a moral law, pure and simple, could mt
be administered fairly and equally, and would prob-
ably fall into contempt.
TULAREMIA A POSSIBLE INFECTION IN
GAME BIRDS
(Health News, U. S. P. H. S.)
The possibility that tularemia infection rn'-i^i; be
the causative factor in epidemics that affect nitiv^
species of game bird; in various section-, of the
United States has been sugje^ted. The question i:
one of importance because of the resultant dan";er
of human infection and as a possible factor in game
bird abundance
It has been shown that quail are susceptible to
the infection of tularaemia and that thn- may
suffer from the disease. Two human cases of tulare-
mia have been reported (one in North Carolina, the
other in Tennessee) wh'ch indicate that the source
of infection may hive been quail. .Mthou-ih these
studies are not yet completed, it is of importance
that quail as a possibility of a source of infection
for tularemia, be borne in mind.
August, 105^
PkdFfeSStOK CAftbg
m
PHYSICIANS' DIRECTORY
EYE, EAR, NOSE AND THROAT
AM/.I ,1. IXIJ\(iT()\, M.I).
Diseases of ihe
r.VE. EAR, NOSE AND THROAT
PHO.XES: Office Q02— Residence 7bl
liiirliiigltiii XoHh CaruliiKi
-I. SIDNKV H(KH), .VI.I).
Diseases of the
EVE, EAR, NOSE AND THROAT
PHONES: Office lObO— Residence 12U)J
^rd Nalioiial Itaiik Itldy., (;a.sl(>iiia, .\. C.
U. J. HOUSEK, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
Telephones —
Office H.— 1672, Residence J.— 908-M
Hours — Q to 5 and bv Apointment
219-2a Professional BIdg. Charlotte
lIOLSKIt Ci.lMC
For Tonsils and Adenoids
415 North Tryon St. Phone Hemlock 4217
Consultation 219 Professional Bldg.
Phone Hemlock 1072
J. G. JOHNSTON, M.D-
EYE, EAR, NOSE AND THROAT
Hours — 9 to 1 and by Appointment
Telephones —
Office H.— 1883, Residence H.-^303-W
616-18 Professional Building, CliarloUe
H. C. NEBLETT, M.D.
Practice Limited to
DISEASES OF THE EYE
Telephone Hemlock 2361
Professional Building Cliarloltc
H. t. SHIRLEY, A.M.. M.D.
Practice Limited to
DISEASES OF THE EAR, NOSE
and THROAT
Professional Building
Charlotle
H. A WAKEFIELD, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
Telephones —
Office H— 727. Residence J.— 218-J
204 Norlli Tryon Street Charlotte
JOHN HILL TUCKER, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
Hours — 10 to 1 and by Appointment
Telephones —
Office H— 3884, Residence H.— 2513
309 Professional Building Charlotte
INTERNAL MEDICINE
A. A. BARRON, M.D., F.A.C.P.
INTERNAL MEDICINE
NEUROLOGY
M. L. Stevens, M.D. Clias. C. Orr, M.D.
DBS. STEVENS AND OKU
INTERNAL MEDICINE
DISEASES OF THE I.VNCS
Professional Building
Charlotte
17 Chureh Street
Asheviile, N. C.
\V. O. NISBET, M.D , F.A.C.P.
Professional Building
INTERNAL MEDICINE
CASTRO ENTEROLOGY
D. H. NISBET, M.D.
Cliarlutte
\V. C. ASH WORTH. M.D.
M. A. SISKE, M.D.
HABIT DISEASES, NEUROLOGY and PSYCHIATRY
Hours by .Appointment
Picdniont Building
(ireenshoro, N. C.
S94
PROFESSION CARDS
August, 1920
JAMES CABELL mNOR, M.D.
PHYSICAL DIAGNOSIS
HYDROTHERAPY
Hot Springs National Park Arkansas
JAMES 1\L NORTHINGTON, M.D.
Diagnosis and Treatment
in
INTERNAL MEDICINE
Professional Building Cliarlotle
OBSTETRICS and GYNECOLOGY
C. H. C. MILLS. M D.
ROBERT T. FERGUSON, M.D., F.A.C.S.
OBSTETRICS
GYNECOLOGY
Consultation by Appointment
By Appointment
Profrssional Building Charlotte
Professional Building Charlotte
William Francis Martin M. D.
GYNECIC & GENERAL SURGERY
Professional Building Charlotte
RADIOLOGY
X-RAY AND RADIUAI INSTITUTE
W. M. SHERinAN. M.D., Director
X-RAY DIAGNOSIS SVPERFICIAL AND DEEP THERAPY X-RAY TREATMENTS
RADIUM THERAPY DIATHERMY
Suites 208-209 Andrews Building Spartanburg, S. C.
Rohl. H. Lalferty, M.D., F.A.'C.R. C. C. Phillips, M.D.
DBS. LAFFERTY and PHILLIPS
Charlotte
X-RAY and RADIUM
Fourth Floor Charlotte Sanatorium
Presbyterian Hospital
Crowell Clinic
Dr. J. Rush Shull Dr. L. M. Fetner
DOCTORS SHI LL and FETXER
ROENTGENOLOGY
Roentgenologists to St. Peter's Hospital, Ashe-Faison Children's Clinic, Good Samaritan Hospital
Profe.ssional Building Charlotte
SKIN, GENITO-URINARY AND RECTUM
Merey Hospital
THE CROWELL CLINIC OF I ROLOOY AND DEIOIATOLOGY
Entire Seventh Floor Profe.ssional Building
Charlotte
Telephones— H.^OQl and H.-^092
Dermatology:
Hours — Nine to Five
Andrew J. Crowell, M.D.
Raymond Thompson, M.D.
Claude B. Squires, M.D.
CuNicAL Pathoiogy:
Lester C. Todd, M.D.
Joseph A. Elliott, M.D.
Lester C. Todd, M.D.
Roentgenology:
Robert H. Lafferty, M.D.
Clyde C. Phillips, M.D.
Aueust, 1029
PROFESSION CARDS
Fi-pd D. Austin, M.D. DcWitt R. Austin, M.D.
THE AUSTIN CLINIC
RECTAL DISEASES, UROLOGY, X-RAY and DERMATOLOGY
Hours— 9 to 5
Phone Hemlock 3106
Sth Floor Iiulepeiidence BIdg. Charlotte
W. W. CRAVEN, m.D.
GE.\lTO-l'RL\ARV and RECTAL
DISEASES
Hours — 9 a. m. to 1 p. m.
3 p. m. to 6 p. m.
Trofi'ssional Building Charlotte
R. H. McFADDEN. IVI.D.
UROLOGY
Hours 9 to 5
51-5-16 Professional BIdg. CliarloKe
L. D. McPHAIL, M.D
RECTAL DISEASES
405-i08 Professional BUIg. Charlotte
U YETT F. SL^IPSON, M.D.
GENITOURINARY DISEASES
Phone 1234
Hot Springs National Park, Arkansas
Dr. Hamilton McKay Dr. Robert iMcKa.v
DOCTORS MeKAY and McKAY
Practice Limited to UROLOGY and GENITOURINARY SURGERY
Hours by Appointment
Professional Building Charlotte
SURGERY
ADDISON G BRENIZER, M.D.
SURGERY and GYNECOLOGY
Consultation by Appointment
Professional Building Charlotte
RISSELE O. LYDAY. M.D.
GENERAL SURGERY ami SURGICAL
lUi GNOSIS
.fflfcrson S(d. Bhig., (ii'cciislioro. \. C.
I'ARRAN JARBOE, M.D., F.A.C.S.
GENERAL SURGERY
Siille 311 Jelferson Standard BIdg-
Greenshoro ,*
■"
R. B. M( KMGHT, M.D.
SURGERY
and
SURGICAL DIAGNOSIS
Consultation by Appointment
Hours 2:30—5
Professional Ruilding Charlotte
\VM. MARMN SCRUGGS, M.D., F.A.C.S.
SURGERY and GYNECOLOGY
Consultation by Appointment
Professional Building Clurlode
S96
PROFESSION CARDS
August, 1920
ORTHOPEDICS
J. S. GAUL, M.D.
ORTHOPEDIC SURGERY and
FRACTURES
Professional Building Charlotte
ALONZO MYERS, M.D.
ORTHOPEDIC SURGERY and
FRACTURES
ProfossionnI Building
Charlotte
O L. MILLER, M.D.
Practice Limited to
ORTHOPEDIC SURGERY and FRACTURES
Fifteen West Seventh Street
Charlotte
GENERAL
THE STRONG CLINIC
Suite 2, Medieal Building. Charlotte
C. M. Strong, M.D., F.A.C.S..
Surgery and Gynecology
J. L. Ranson, M.D.^
Genito-Urinary Diseases and Anesthesia
Oren Moore, M.D., F.A.C.S.
Obstetrics and Gynecology
Miss Pattie V. Adams, Business Manager
Miss Fannie Austin, Nurse
. HIGH POINT HOSPITAL
High Point, N. C.
(Miss Gilbert Muse, R.N., Supt.)
General Surgery, Internal Medicine, Neurology, Ophthalmology, etc., Diagnosis, Urology, Pediatrics,
X-Ray and Radium, Physiotherapy, Clinical Laboratories
John T. Burrus, M.D., F.A.C.S., Chief
Harry L. Brockmann, M.D.
Philip W. Flagge, M.D.
STAFF
0. B. Bonner, M.D.
Frederick R. Taylor, B.S., M.D.
S. Stewart Saunuers, A.B., M.D.
wanted for 150 BED TUBERCULOSIS HOSPITAL,
YOUNG SINGLE ASSISTANT PHYSICIAN WHO HAS COM-
PLETED HOSPITAL INTERNSHIP AND HAS SPECIAL IN-
TFREST IN TUBERCULOSIS. $150.00 A MONTH AND
MAINTENANCE . ADDRESS SUPERINTENDENT MECK-
LENBURG COUNTY TUBERCULOSIS SANA-
TORIUM, Huntersville, N. C.
For Sale- Tice's Practice of Medicine, complete,
with Index and all new revisions placed properly.
This set has not been used or injured in any way
Price $75.00 Address "MRD," care oj Southern
Medicine & Surgery.
SOUTHERN MEDICINE and SURGERY
Vol. XCI
Charlotte, N. C, September, 1929
No y
The Use of Bismuth-Violet in the Prevention of Wound
Infection
Irving S. Barksdale, M.D., Fellow A. P. H. A., Greenville, S. C.
For the past five years we have been at
work to prepare a bactericidal stain which
weuld prove destructive to as many of the
pathogenic organisms as possible, which at
the same time would prove to be of very low
toxicity to the tissues of the body. These
investigations, as one would presume, resulted
in many failures, and it was not until 1925
that a satisfactory dye was found, namely,
b'smuth-violet (hexamethyl - para - rosanilin -
b'smuth). Bismuth-violet occurs as a pur-
ple, crystalline powder freely soluble in wa-
ter, alcohol, glycerin and acetone. It has a
bitter taste and the odor of an anilin dye.
The reaction of a weak solution of the dye is
neutral to litmus; its composition is as yet
uncertain, as we have been unable to deter-
mine whether it is a new compound or
a mixture. The chemical evidence obtained
so far seems to point to a new chemical com-
pound.
PREPARATION OF THE DYE
Bismuth-violet is prepared by titrating a
weak solution of bismuth and ammonium
citrate with a solution of crystal violet at
room temperature. We have found the bis-
muth salt to be a very valuable synergist
when used with the stain, as crystal violet
itself will not kill staphylococcus in dilutions
pn"eater than 1:1,000,000, whereas the addi-
tion of this metal to the crystal violet causes
this organism to be killed in dilutions up to
1:1,000.000,000: that is, its efficacy is
stepped up a thousand-fold. See Tables 1
and 2.
TOXICITY
Bismuth-violet is used in 0.4 of a 1 per
cent solution in glycerin and water, the mat-
ter of surface tension in the liquid being ta-
ken into consideration. The glycerin is add-
ed in concentrations of 10-20 per cent, there-
by lowering the surface tension and allowing
of more complete diffusion of the germicide
in the wound.
We have shown that ralibits can tolerate
intravenous injections of bismuth-violet in
doses as high as 20 mgm. per Kgm. (1,6
prain per lb.) of body weight, no toxic effects
bc'ng noted. \Vc have g'ven doses as high
as 5 mgm. per Kgm. (1/24 grain per II).) of
bcdy weight to patients in the same manner,
that is, intravenously and have never ob-
served any untoward effects. It might be
added that this dye is not efficacious when
given intravenously to combat blood-stream
infections, because the drug is decolorized in
a few moments, also because there is too
much colloid matter in the blood to allow of
complete diffusion of the dye to all of the
offending microorganisms that may be pres-
ent.
BACTERiriDAL PROPERTIES IN VITRO
Numerous exjieriments were carried out to
determine its bactericidal [jroi^rties in vitro
in the following manner:
Dilutions of the dye were made in ruitrient
broth (pH-6.97) from 1:1,000 to 1:1,000.-
000,000, and inoculated with the particular
organisms under investigation: control tubes
containing none of the dye were run in every
experiment, and all tubes incubated together
from 24 to 168 hours at 37.7 degrees C.
Observations were made and carefully tabu-
lated as l)?low;
SOUTHERN MEDICINE AND SURGERY
September, 1920
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•2 "
Thus having considered a few of the lab-
oratory findings, we shall now endeavor to
show the practical value of this new drug in
the prevention of wound infections:
Case Reports
Case 1. — A negro man, SO, a zoo attend-
ant, came in with the complaint that he had
"got mixed up with" a large buck deer at the
Greenville City Zoo. Examination of the pa-
tient revealed numerous wounds on the hands,
a rather deep gash in the tissues of the right
hip, and a very large, freely bleeding lacer-
ated wound on the front aspect of the left
thigh about IS cm. (6 in.) x l.S cm. (3/S
in.), evidently inflicted by the horn of an
infuriated deer. The bleeding was easily
checked by mopping with sterile gauze
sponges. A 0.4 per cent solution of bismuth-
violet in IS per cent glycerin-aqueous solu-
tion was applied with an ordinary applicator,
and this was followed with a dry dressing.
Fifteen hundred units of tetanus antitoxin,
was administered as the patient's underclothes
were unspeakably dirty, and he was d'rected
to return for a redressing in about 48 hours.
On the patient's return, it was noted that
all of the wounds had healed per primiim,
with the exception of the large lacerated
wound on the left thigh, which only had a
small raw area about 1 cm. in diameter at
the upper extremity of the wound where the
dressing had stuck. The raw area was again
treated with the dye solution, and upon the
pat'ent's return the following day, complete
healing of all the wounds had taken place.
C.\SE 2. — A common laborer, 60, who had
been severely burned while in the act of han-
dling boiling pitch, was seen immediately fol-
lowing his accident. He was in much pain.
Four extensive second degree burns of both
forearms and the left cheek; many of the
blisters were so severe that they had ruptured
spontaneously. A 0.4 per cent solution of
b smuth-violct in IS p)er cent glycerin-aque-
ous solution was applied freely to the exten-
s'vely burned areas, and this followed by a
generous application of sterile boric acid oint-
ment (U. S. P.) This treatment was repeat-
ed four times during the ten-day period re-
qu'red for perfect healing. At no time were
the burns infected, and there were no com-
plications.
(,Z(,\ 'jsqtnaidss
SOUTHERN MEDICINE AND SURGERY
S99
TABU BO. 3.
BUntlOB of
la Aquaous 8«la«
«Al>flBllUii
V|_BillXtt
lAoajk-
Case 3. — A merchant, 50, was seen imme-
diately after receiving a fairly large incised
wound from a grass-cutting blade. As the
wound was a clean, uninfected one the dye
in the same strength was applied without any
preliminary cleansing, the patient being cau-
tioned to allow no water in the wound and
net to remove the dry dressing. Two days
later examinatujn revealed healing and per
primum union, and the dressing was remov-
ed. Patients should be cautioned not to allow
water in such wounds, nor to- remove the
dressings, as there is always the possibility
of infecting a wound from the skin and other
sources.
Case 4. — The writer had the misfortune to
drive the point of a desk spindle-file beneath
a finger nail for the distance of about 4 mm.
(1/6 in.) .As a preventive measure, the bis-
muth-violet solution (same strength) was ap-
pl'ed before the blood had had time to clot.
The following day, there was no sign of any
infection, which if it had occurred in this
punctured wound might have been of such
severity as to bring about the Ipss of \\\t fin-
ger nail.
Case S. — A child, 3, suffered severe second
degree burns of the left foot and leg from
an overflowing oil stove. An application of
balsam peru and "unguentine" was applied,
and three days later this treatment was fol-
lowed by -an application of the dye solution,
as it was apparent at that time that the
wounds were becoming infected. The dye
was applied by Miss Myrtle Ware, the City
Nurse, on three successive days, who report-
ed that complete healing occurred after the
lapse of one week. There was a very small
amount of scar tissue formation on the dorsal
aspect of the foot and none on the leg.
Note: — The treatment of this patient was
carried out under the supervision of Dr. A. C.
Watson, City Physician.
We have a number of other similar cases
to report but space will not allow of further
detailed case reports. .\n effort has been
made to report only those cases in which we
sought to prevent wound infection, and the
brief histories given above do not include any
examples of the many ones of actual wound
infection treated by the physicians of this
city.
SUMMARY
1. The properties of bismuth-violet have
been described briefly.
2. The toxicity of the dye is very low as
rabbits have been shown to tolerate intraven-
ous doses as high as 20 mgm. per Kgm. (1/6
grain per lb.) of body weight. Human be-
ings have received 5 mgm. per Kgm. (1/24
grain per lb.) of body weight without the ex-
hibition of any toxic effects.
3. Bismuth-violet has been shown to be
very destructive to a number of pathogenic
organisms in vitro; Gram-jxisitive organisms
are more readily killed than the Gram-nega-
tive. B. Pyocyaneus is not killed by the dye
in any strength.
4. \ few case reports have been given in
order to illustrate the value of this new bac-
tericide as a prophylactic against wound in-
fections.
Aeknowleclgineiil
I am indeed grateful for the interest mani-
fested and the assistance rendered by Drs.
J. L. Anderson, B. C. Bishop, R. M. I'ollit-
zer, G. R. Wilkinson, W. H. Powe, C. C.
Ariail, A. C. Watson, W. C. Stone, J. G.
Mvirray, E. W. Carpenter, J, L. Sanders, J. B,
SOUTHERN MEDICINE AND SURGERY
September, 1929
Hill, J. M. Fewell, W. S. Fewell, G. T. Tyler,
C. H. Fair, W. \V. Edwards, and Nurses
Myrtle Ware and Loee Bates, also to the Ta-
ble Rock Laboratories, Inc., of Greenville
S. C, for furnishing the drug.
BIBLIOGRAPHY
I. Smith, David T., Causes and Treatment of
Otitis Media, Amer. Jour. Dis. Chil., Vol. 28, July,
1Q24.
2. Ibid, Fuso-Spirochaetal Diseases of the Lungs:
Its Bacteriology, Pathology and Experimental Re-
production. Amer. Rev. of Tuberculosis, 16, No. S,
Nov., 1927.
3. Wilkinson, G. R., and Barksdale, I. S., The
Effect of Bismuth-Violet (Hexamethyl-para-rosani-
lin . . . bismuth) on Certain Pathogenic Organisms:
Preliminary Report, Sou. Med. Jour., Vol. XXI,
No. U, Nov., 1928. '
City Health Department.
The Relationship of Rest and Compression Therapy in the
Treatment of Pulmonary Tuberculosis*
J. \V. Dickie, M.D., Southern Pines, N. C.
Pine Crest Manor
More progress has been made in the treat-
inent of pulmonary tuberculosis during the
last two decades than in the preceding twenty
centuries. Previous to the Christian era, the
early Greek physicians, Aretaeus and Cel-
sus, and, in the second century A. D.,
Galen, advocated relative rest, moderate ex-
ercise and a diet of rich, easily digested food
(including raw eggs and milk), fresh air and
occasional changes of climate. Does this not
compare favorably with the prevailing method
of treatment at the beginning of the present
century?
The way was paved for progress in the
treatment of the disease when in 1882 Koch
d'scovered the tubercle bacillus. Trudeau
cmph-asized the importance of fresh air and
to a less degree the importance of rest.
Dunn and others of a later day brought rest
into its proper place as a therapeutic agent.
It remains for physicians of today to take
full advantage of the use of the latest devel-
opments in the treatment of tuberculosis. I
refer to the various forms of compression
therapy, chief of which are artificial pneumo-
thorax, phrenicectomy and thoracoplasty.
To emphasize the logical relationship be-
tween rest and compression therapy, I invite
your attention first to a brief considerat'on
of the sovereign remedy, rest. Rest is the
one method of treatment which has stood the
test of time and which still dominates the
therapeutic field.
As Krause has wisely stated in his admir-
able little book, Rest and Other Things:
"Until the time comes when every tuberculo-
sis patient (and he well might have added
every practicing physician), upon being asked
what is the most important element in the
treatment of tuberculosis, will unhesitatingly
answer 'rest,' the subject will always be time-
ly." As he pointed out, fresh air and putting
on weight, even at this late day all too fre-
quently take rank ahead of rest.
Realizing that the wish may be father to
the thought, I am constrained to believe that
the seed sown on good soil by the late illus-
trious Dr. William LeRoy Dunn and others
are bearing fruit, and that since the first pub-
lication of Dr. Krause 's book the importance
of rest is rapidly coming into its own. A
notable example is the recent radical change
in the treatment of our World's War veter-
ans.
But what of the appreciable number of
patients where time has been lost in estab-
lishing a diagnosis, or of the smaller number
where an early diagnosis and proper treat-
ment have not checked the ravages of the
disease? Have we anything more to offer
these patients, or is our therapy exhausted?
Emphatically, no I There is still hope for a
large percentage of such patients and it marks
the brightest chapter in the therapy of tuber-
culosis in recent years.
This leads to a discussion of the various
forms of compression therapy. In resorting
to these measures, we are prudently following
♦Presented to tb? Medical §Qciety of th? Statt of North Carolina, meeting at Greensboro, April
15-17, 19J9,
September, 1Q29
SOUTHERN MEDICINE AND SURGERY
601
nature's own suggestion. . In proof, observe
the retarded excursion of the diaphragm even
in minimal apical lesions. Again, in advanc-
ed lesions note the displacement of the
trachea and heart toward the affected side.
Artificial pneumothora.x offers the greatest
hope in the field of compression therapy. It
is of interest to note that it was first advo-
cated by Dr. James Carson of LiverpKiol in
1821. .Apparently nothing came of his recom-
mendation until the last two decades of the
nineteenth century, when, independently, Ital-
ian, English and .American physicians — nota-
bly Forlanini, Cayley and Murphy, made
practical and successful use of this method of
pulmonary collapse. Its therap)eutic value
did not meet with general favor until the last
decade.
In artificial pneumothorax we apply the
same principle used in the treatment of a
fracture or even a suf>erficial wound. The
natural elasticity of the lungs and the con-
stant motion of the heart and lungs retard
the healing process. This handicap is over-
come, for the surfaces of the lung are brought
into close contact where destruction of lung
tissue has taken place, and this immediately
favors the healing process. It tends to pre-
vent extension of the disease on the affected
side. It promptly reduces toxemia, to the
great relief and benefit of the patient.
The success of artificial pneumothorax de-
pends upon the suitable selection of cases,
proper supervision and close observation of
patients under treatment and reasonable skill
in the technique of the operation.
As to the selection of cases, I believe I am
conservative in the statement that at least ten
per cent of the average group of tuberculosis
patients may be distinctly benefited by its
use. Furthermore, frankness demands the
statement that most of the fatal cases of
tuberculosis were at one time in a favorable
condition for its use.
When the condition of the contralateral
lung is favorable, it is my present pwlicy to
recommend it in every case where the patient
fails to show improvement after three months
under a strict regime of sanatorium care.
This regime must include complete rest in
bed with bed baths. The progress of the dis-
ease may call for its use at an earlier date
and delay may be fatal. The danger of the
infection spreading into the good lung is very
real, especially in the presence of ulceration
and a positive sputum test. Delay invites
the formation of adhesions. In more than
three-fourths of the cases in which we have
failed to bring about satisfactory compression,
adhesions have been the cause.
The case of choice is one with extensive
and progressive disease in one lung, the other
lung being clear or nearly so. To this group
may be safely added a considerable number
where the better lung is the seat of a quies-
cent, arrested or even moderately active le-
sion, provided the latter is well circumscribed
in the upper lobe of the lung and does not
involve very much of the parenchyma. Ob-
viously the selection of cases in the latter
group calls for a finer sense of discrimination
and judgment.
I wish to place especial emphasis on the
good effect of artificial pneumothorax in pul-
monary hemorrhage. The results are little
short of the spectacular. It has dispelled the
nightmare of this distressing and not infre-
quently dangerous symptom. Every patient
with recurrent hemoptysis is entitled to its
benefits.
Usually it is not difficult to identify the
bleeding lung. When in doubt, the deciding
factor should be the evidence of more ad-
vanced disease in one lung. This is espe-
cially true in the presence of cavity forma-
tion.
The bleeding is arrested more by immobili-
zation than by compression. A dose of only
250 to 400 c.c. of gas is required. A larger
dose is distinctly contraindicated. Among
other things, it predisposes to aspiration pneu^
monia.
Artificial pneumothorax is contraindicated
when the better lung is the seat of a very
active or extensive lesion, particularly in the
lower lobe. In far advanced laryngeal and
intestinal tuberculosis it is of no avail. Ad-
vanced emphysema, asthma and serious dis-
eases of the heart or kidneys preclude its use.
Too much emphasis cannot be placed on
the necessity for closely observing and super-
vising the care of a patient receiving pneumo-
thorax treatments. Careful, although not ex-
haustive, chest examinations should be
made before and after each refill. 'I"he good
lung must be watched with the greatest care.
Serial x-ray pictures are indispensable. Suc-
cess of the treatment demands that the p9-
SOUTHERN MEDICINE AND SURGERY
September, 1929
tient be kept on a strict regime of bed rest
until such evidence of toxemia as anorexia,
excessive cough and expectoration, high fever,
night sweats and loss of weight have subsid-
ed; until repeated sputum tests are negative
for tubercle bacilli; and until the physical
examination and stereoscopic x-ray films show
conclusively that a fair degree of collapse has
been established. For the best form oj com-
pression therapy is an adjunct to, not a sub-
stitute for, bed rest.
The technique of the operation does not
come within the scope of this paper. It is
comparatively simple and within the reach
of any medical man. It may be administered
safely and successfully in any private home
with the need of surprisingly little nursing
assistance. From an economic point of view,
it can be performed at comparatively small
cost without undue hardship to patient or
physician.
Despite brilliant results obtained every day
by this form of compression therapy, I warn
against its adoption as a cure-all. Bearing
in mind always the tragedy of waiting too
long, it is well to remember that its employ-
ment is not without danger even in skilled
hands. Therefore, it should not be advocated
in early cases of tuberculosis that show rea-
sonably prompt response to rest.
The chief objection to artificial pneumotho-
rax is that a period of from one to five years
is required to effect a cure, although the pa-
tient may return to his former environment
and occupation long before the expiration of
this t!me limit. It has the advantage over
other forms of compression therapy in that
any harm done is not irreparable. Treat-
ments may be abandoned at any time without
harm to the patient.
Phrenicotomy is the severing of the phrenic
nerve and its accessory. It produces a tem-
porary paralysis of the diaphragm on one
side. The nerve regenerates in five or six
months so the effect is not permanent.
Phrenicectomy is the removal of a large
regment or all of the nerve and its accessory.
The effect is permanent. For the sake of
brevity, I shall consider them collectively.
The operation is performed under local an-
esthesia. To expose the nerve an incision is
made over the posterior triangle, either just
above and parallel to the clavicle, or along
the posterior border of the stemo-mastoid
muscle. In the hands of an experienced ojjer-
ator, there is little likelihood of harm to the
patient. By severing the nerve the diaphragm
is elevated from four to eight cm. (I 3/5 to
3 in.) on the right side and from two to six
cm. (2/5 to 23^ ins.) on the left side. There
is a corresponding collapse of the lung.
Used independently, perhaps its greatest
value is in basilar tuberculosis, where it is
very effective in relieving a troublesome
cough. It is used as an adjunct to pneumo-
thorax, or thoracoplasty, or both. In the
former, it is of special value when adhesions
retard or prevent a successful collapse. In
the presence of a suspicious lesion in the so-
called good lung, it is of value in testing out
its integrity as a preliminary to either of the
other procedures. By producing a partial col-
lapse, it tends to reduce toxemia and thereby
improves the general physical condition of
the patient as a preliminary to the more se-
rious ojDeration — thoracoplasty. It has a defi-
nite, although limited, field of usefulness.
In a limjtec}jiymber of cases radical surgi-
cal procedure^j^re indicated. I shall discuss
briefly , the ipuft most frequently used, para-
vertebra),^^J5J[rapleural thoracoplasty. It is the
logical sequel to artificial pneumothorax, al-
though preceding it by a definite interval.
The operation consists in the removal in the
paravertebral region of a small section of the
first ten or eleven ribs, a total of about fifty
inches from all the ribs. The size of the
section from each rib depends on the nature
and location of the disease in the lung. The
two-stage operation is the operation of choice,
if not of necessity. Sections from the lower
ribs — from the fifth to the eleventh — are first
removed; the remainder — from the first to
fifth — as soon afterward as the patient's con-
dition warrants it; generally in from two to
four weeks. Most of the operation may be
successfully performed under a local anes-
thetic. Gas-oxygen may be necessary at cer-
tain stages of the operation.
The indications and contra-indications for
its use are similar to those of pneumothorax,
although subject to a much stricter interpre-
tation. The integrity of the contralateral
lung must be established beyond a reasonable
doubt, for an additional burden is placed on
this lung suddenly, not gradually, as in the
case of pneumothorax. Whatever happen*
September, 1020
SOUTHERN MEDICINE AND SURGERY
unfavorably afterward, the damage is irrevo-
cable.
Contrary to the opinion of many physi-
cians and all patients, the lung does not cease
to function. In reality a complete and suc-
cessful thoracoplasty does not give the
amount of collapse obtained by a satisfactory
pneumothorax. The lung is never under com-
pression. It is in a state of fixed expiration.
The end results are the same as in pneumo-
thorax; success depending largely upon the
fibrous changes produced by the stasis of the
lymph and blood supply.
Th's procedure is not to be considered
I'ghtly by either patient or physician. It
has a very definite though limited field of
usefulness. It does save life; furthermore, it
may spare many patients the unhappy exp)eri-
encc of years of invalid'sm.
In conclusion, for the present at least, rest
remains the keystone of treatment, and a dis-
cussion of the various forms of compression
therapy serves to emphasize the importance
of early diagnosis and profjer treatment.
Finally, I hazard the prophecy that the
day is approaching when deaths from tuber-
culosis will no longer be taken as a matter
of course. With few exceptions, we shall ad-
mit that they are the result of ignorance or
of negligence.
This millennium in the therapy of tuber-
culosis will be brought about by the concerted
action of three forces which cannot be de-
feated: first, with the improvement in the
general economic condition of the masses and
a full awakening and quickening of interest
of the public in all health measures, the sus-
pect will go promptly to his physician for
examination; second, physicians will have the
skill, f)ossess the facilities and take the time
to establish a reasonably early diagnosis;
finally, this rich and powerful country will
make ample provision for the prompt treat-
ment of every indigent tuberculosis subject.
Institutional Care and After Treatment of Drug Addicts*
W. C. AsHWORTH, M.D., Greensboro, N. C.
Glenwood Park Sanitarium
I have ascertained, from twenty-five years'
experience in the treatment of drug addicts
that the first requisite for a successful treat-
ment is to secure the control of the patient,
that his volition must be subservient to that
of the physician, and that removal from
home is most essential to secure this con-
trol. .\s in other neuroses, only control by,
and contact with, strangers is effectual, since
this helps to break up the morbid trend of
reasoning and associations. This can not be
done at home and with relatives. Private
and special institutions, if properly managed,
have superior advantages which can not be
obtained elsewhere. In such places the stim-
ulating, tactful firmness of a stranger does
much to rouse a weakened will. The ques-
tion of restraint is dependent largely on the
condition of the individual. In some in-
stances it is stimulating and helpful; in oth-
ers irritating and depressing. In most cases.
however, a measure of watching and control
is absolutely necessary. The withdrawal of
the drug demands a revolution of conduct,
act and thought. The mind must be led
out of itself and turned away from old con-
ditions and dependences.
.Among the accessories which contribute to
success in treatment, none has so much im-
portance as a well-equipped institution in
which the patient must reside during the
period of treatment and convalescence. Con-
trol of the patient in every detail is essential
to success. This must not be the control of
coercion, but of confidence; the control a
medical man exercises over his patients by
reason of the unswerving confidence of those
patients in him. This must be based upon
the fact that the physician himself is really
in earnest in his efforts to cure the patient
and has an abiding interest in the welfare
of the patient. This mutual confidence can
•Presented to the Tri-State Medical Association of the CaroiiMJ upd Virginia meeting »t
Greensboro, N. C, February 19-?1, 19«.
SOUTHERN MEDICINE AND SURGERY
September, 1929
not exist so long as either party holds the
other to be untrustworthy.
In a well-equipped institution many meas-
ures are at hand which are of the greatest
value in treatment of these cases. Hydro-
therapy, electricity, massage, physical training,
and other such measures should be used in
the most liberal manner. Hydrotherapy
is of especially great value in the days
following the withdrawal of the drug. A
neutral bath given at bed time, will often
aid materially in securing a good night's rest
and in restoring the nervous system of the
patient. The vapor bath is valuable in some
cases, but, as drug patients are usually ane-
mic, they do not stand the vapor bath well.
A cold pack's antipyretic effect is usually
sufficient to reduce the fever which is pres-
ent for several days after the patient is taken
off the drug. A half-hour or an hour's sweat-
ing in the pack rela.xes the tension of the
nervous system and is often followed by
two or three hours of quiet, restful sleep. It
is a mistake for any physician to attempt to
treat narcotic drug patients at their homes
or in the wards of a general hospital. Under
such surroundings failure is more likely than
success. During the period of treatment and
for ten days or two weeks thereafter, at least
until considerable self-reliance has been ac-
quired, the patient should be separated from
his family, and from all others to whom he
looks for sympathy. Sympathy and over-
attention tend to the development of hysteri-
cal symptoms that are troublesome and re-
tard the acquirement of self-reliance which
is so essential to success in these cases. A
course of treatment to give the best results
must be disciplinary, as well as therapeutic.
The physician's control must be complete
during the early part of convalescence as
well as during the treatment, and he must
know, beyond peradventure, that he has no
access to his drug or any substitute for it.
Under this plan of treatment the therapeutic
measures necessary are soon completed, but
the end sought is not merely to take the pa-
tient off his drug and place him where his
physical condition will not require its use,
but, in addition, to so fortify him mentally
and morally that he will not return to the
use of the drug.
The psychological treatment is an import-
ant one and should be intelligently considered
and skillfully managed. The fixed habit of
dependence upon a drug is to be supplanted
by a counterhabit of independence and self-
reliance, and both time and discipline are
essential factors in that process. This is one
of the chief reasons why no tonic or after-
treatment should be given. So long as the
patient takes anything his mind clings tena-
ciously to the idea that his well-being de-
pends upon his receiving some support, some
outside assistance, and he is thus led away
from, rather than toward, self-dependence.
No patient of this class, under any treat-
ment, is secure from relapse if he is discharg-
ed taking even plain water, thinking it is
medicine. A protracted course of treatment
tends to perpetuate the habit of invalidism
and defeats the object sought. The patient
must be taught to rely entirely upon his own
resources and be fully convinced of his abil-
ity to do so. He must not only be cured of
the addiction, but thoroughly fortified against
relapse. This can certainly be done, but '
the time required varies with different indi-
viduals. Some will more completely regain
their mental and moral equilibrium in a few
weeks' time than others will in several
months, but until this has been attained, at
least to a fair degree, the patient should not
be discharged. Surveillance should be con-
tinued for a long time after the cessation of
active treatment, and the patient's condition
and surroundings should be a special subject
of inquiiy for the purpose of avoiding temp-
tation and causes which favor relapse. Thus,
the busmess or professional man should not
go back at once to his old life and subject
himself to all the strains and drains which
brought on his addiction. Nor should the
person of wealth return to habits of indo-
lence and excess. The effort of the physi-
cian should be to impress on the patient's
mind the need of a radical change in his
method of living. This should be done at
the beginning oi the treatment. The pro-
found neurasthenia associated with mental
eiileeblement and moral palsies are conditions
present in all cases. These facts should be
considered in the treatment.
We have no specific treatment for the
morphine habit, it is best to regard each
case as a problem unto itself. We must
always give due consideration to the personal
equation, temperament, and idiosyncrasies of
tne patient. I have found that the gradual
reduction method, coincident with the admin-
September, 1020
SOUTHERN MEDICINE AND SURGERY
66$
istration of such reconstructive nerve tonics
and substitutes as will best enable the pa-
tient to abandon the narcotic druc; with only
a negligible amount of discomfort to be satis-
factory in a large percentage of cases. I can
not emphasize too strongly, however, the im-
portance of an individual treatment based
largely upon the findings in the case. I re-
duce the drug very tentatively in order that
the nervous system of the patient may not
be unduly shocked on account of the sudden
deprivation of the drug. I am not an advo-
cate of the so-called quick cures, since it has
been my observation that most patients treat-
ed by this method relapse very early on ac-
count of the mental and physical weakness
which inevitably follow in the wake of the
sudden withdrawal of the morphine.
I administer to a number of patients, espe-
cially of the phlegmatic type, a modified Lam-
bert treatment, which I find to be reasonably
satisfactory provided the treatment is suffi-
ciently modified to make it humane. Eserine
and pilocarpine, as advocated by Dr. Stokes,
have considerable merit, and should be used
in selected cases. In view of the fact that a
large percentage of drug patients are malin-
gerers, we find that psycho-therapy or strong
mental suggestion is a great help in the treat-
ment of these cases. It is sometimes difficult
to differentiate the actual discomfort from the
hysterical symptoms which so often develop
during the final withdrawal period. The aver-
age drug patient can simulate about all the
symptoms of any disease. We must reckon
with all the symptoms of the withdrawal of
morphine, or many times our belief will be
erroneous and we will be led away from a cur-
ative treatment.
Occupational therapy plays a very import-
ant role in the successful treatment oi our
drug patients. The after-treatment with most
men may be equally perilous at home, though
it may be carried on with success where some
light business can occupy a small part of the
time. Each case should be governed by the
conditions present and the vigor of the pa-
tient. In some cases, travel for a few months,
visiting foreign countries in a leisurely way,
is the best possible tonic and nerve rest. For
some, idleness, seclusion on a farm, in the
mountains, or at the seaside, removed from
every form of excitement, is most heljjful.
Professional men who have been very actively
engaged, and can only be contented when oc-
cupied, should go to the country and engage
in horticulture, or some class of farming that
would d.vert energies and interest them along
new lines. Often the most successful cures
from the morphine addiction have been at-
tained by the patient's spending a year or
two on a farm or in the mountains away from
the scenes of his former activities. Others
have gone out to the mining regions, roughing
it, sleeping in the open air and having perfect
nerve rest.
As a rule, all brain-workers who have be-
come morphinists should, after withdrawal of
the drug, give up all intelectual work and
become muscle-workers as far as possible for
a long time. Teachers and women, all per-
sons with highly sensitive nervous organiza-
tions, should give up all occupations in which
there is strain on the nervous system.
The percentage of relapses is large, espe-
cially among physicians, since their armamen-
tarium embraces morphine and other habit-
forming drugs, the relapses in such cases con-
firming the rather true saying, "The oppor-
tions, should give up all occupation in which
done."
Within the last few years, through the ad-
vice of physicians, a number of morphinists
and alcoholists of wealth have been persuaded
to retire to the country, buying ab.indoned
farms and giving their time and energies to
build up beautiful homes and farms. In
many instances the most excellent results have
followed. Many have become restored, and
are now valuable, useful citizens. Other per-
sons of this class have gone to Florida and
the southern climates and have engaged in
fruit and cotton culture, and continued strong
and vigorous. This change is the best possi-
ble treatment for a large class of [>ersons.
In conclusion, I wish to state that we have
no specific treatment for narcotic drug addic-
tion disease. Narcosan, lipoidal substance
and such like have been e.xploited, in my judg-
ment, purely for mercenary motives. Horo-
witz exploited these preparations and, much
to the humiliation of the medical profession,
inveigled a number of very prominent physi-
cians into his exploitation of so-called specific
remedies for narcotic drug addiction.
SUMMARY
It is estimated, from various sources, that
we have in the United States more than 200,-
000 narcotic drug addicts.
SOUTHERN MEDICINE AND SURGERY
September, 1929
The number of physicians who are addict-
ed to narcotic drugs is appalhng.
The transition from synthetic or moonshine
whisky to narcotic drug habituation is very
easy.
A large percentage of narcotic drug habit-
ues can be permanently cured if proper envir-
onmental conditions surround them after they
have discontinued the use of narcotic drugs.
The government has at last realized the
momentous problem of narcotic drug addic-
tions, and a l.beral appropriation has been
made by Congress for the purjDose of coloniz-
ing drug addicts.
Surgery of the Prostate Gland and Bladder*
J. D. HiGHSMiTH, M.D., Fayetteville, N. C.
Highsmith Hospital
As a result of the development of the cys-
toscope and the x-ray the pxissibilities of es-
tablishing an accurate diagnosis of lesions in
the genito-urinary organs has been extended
beyond that in any other system of the body.
The visualization of the stone, the tumor, the
inflammation, the diverticulum and the ac-
cumulation of pus, the presence of which
has been suggested by the clinical history, the
physical examination, the chemical analysis of
the blood and the urine, and the functional
tests brings the comfort of certainty to the
surgeon operating in this particular field.
Recent advances made in the surgery of the
bladder, largely due to regional anesthesia,
have enabled us to obtain adequate exposure
and to apply accurate methcjds of hemostasis.
Accordingly, the functional results have im-
proved and the mortality rate has been re-
duced to that of general surgery.
SURGERY OF THE PROSTATE GLAND
The diseases of the prostate requiring sur-
gical intervention are benign and malignant
hypertrophy; approximately 85 per cent of
the obstructing enlargements of the gland are
benign and of the IS per cent malignant le-
sions of the gland: carninoma is by far the
most common. Surgery has seldom been pro-
ductive of permanent good results in these
cases, as metastasis to the bones, glands, blad-
der and surrounding structures has already
occurred in more than SO per cent coming for
operation. It is the benign enlargements of
the prostate that are of surgical importance.
The first step in the preparation of a pa-
tient suffering with prostatic hypertrophy is
bladder drainage, by means of the indwelling
catheter in some cases and of suprapubic cys-
totomy in others. The operation of supra-
pubic cystotomy and cystostomy as demon-
strated by Dr. Montague L. Boyd at the
meeting of the Southern Medical Association
in Atlanta, in 1926, does not interfere with
adequate exposure when we do the prostatec-
tomy. This method of suprapubic cystotomy
I perform under field block anesthesia with
little or no shock. Only a very small open-
ing' is m.ide in the upper portion of the blad-
der fur th? nsertion of a Pezzer catheter, the
mush; — n head of which is straightened out
and m ide smaller by means of an obturator.
Thror.i; ! ihis opening the interior of the blad-
der c:in b:' examined by means of a cysto-
fcopc cr Cameron light for stones, diverticula,
tumors, etc., and the size and character of
the prortate determined. Where drainage is
established by means of a urethral catheter,
as has been my custom in approximately SO
per cc t of cases in the past, it becomes nec-
essary to perform a cystosco^i'c examination
in order to determine the character of the
prostate, the condition of the bladder and the
presence or absence of stones, diverticula
and tumors, any one of which, when present,
will change the whole character of the case,
making a two stage operation advisable if
not imperative in most cases.
Epididymitis occurred in a large percentage
of our cases until Goldstein, McKay and oth-
ers called our attention to vas deferens resec-
tion and ligation. We do this routinely now
before operation, cither at the time of doing
'Presented to the Tri-State Medical Association of the C»rolin«s and Vir|inis meeting at
Gf««Aiboro, ^. C, Fetxuary (9-21, 1W«.
September, 192P
SOUTHERN MEDICINE AND SURGERY
the suprapubic cystotomy, or, if catheter
drainage is decided upon, at the time of the
cystoscopic examination.
Followino; the institution of drainage, the
blood-pressure is taken daily and the kidney
function checked up twice a weak and blood
urea once a week. The specific gravity and
total output of urine are taken daily. Water
is forced by mouth and subpectoral saline
and intravenous glucose given daily until the
condition of the patient is satisfactory. If
there is a large amount of residual urine it
is important that this be gradually reduced
to avoid congestion of the kidneys, with ure-
mia and death. Even with a small amount
of residual urine there is often risk, therefore
it is wise to drain gradually rather than pre-
cipitously. Often in the case of a patient
with complete retention of urine, if one drains
off all the urine at one time, he will go into
coma and die.
High blood-pressure is not a contraindica-
tion to prostatectomy, but a varying blood
pressure is a very marked contraindication.
The blood-pressure fluctuates markedly fol-
lowing the institution of drainage and we
require that a constant blood-pressure be
maintained at least five days before prostatec-
tomy is done. It is important to have a
stabilized kidney function and circulatory
system before operation. Every patient with
any cardiac weakness is thoroughly digitalized
before operation.
The suprapubic transvesical route ap-
proaches directly those lobes involved in be-
nign hypertrophy without jeopardizing the
external sphincter; furthermore, it possesses
the advantage of affording opportunity to deal
with associated lesions of the bladder, stones
and diverticula when present. From the
standpoint of mortality rate alone, there is
now no choice between the perineal and su-
prapubic operations. Hemorrhage is con-
trolled by means of ligatures and sutures, the
same as in any other operation.
Following operation the patient is given
300 c.c. of a 25 per cent glucose solution in-
travenously, and subpectoral saline. The
more water you give these patients the better
they do. W'e give water freely by mouth,
glucose solution daily intravenously, and sub-
pectoral saline daily. The sitting position is
maintained and convalescence is usually
rapid. In from four to seven days the supra-
pubic tube is removed and an indwelling ca-
theter inserted through the urethra. The
average length of time for the suprapubic
opening to close is three weeks.
DIVERTICULA OF THE BLADDER
Diverticula are now recognized as a not
infrequent cause of urinary difficulty, fre-
quency and retention. While localized weak-
ness of the bladder wall is necessary to the
development of diverticula, it is probable that
in most instances, they are not congenital in
origin, but result from mechanical obstruc-
tion at the neck of the bladder, due in most
cases to an enlarged prostate or fibrous con-
tracture of the vesical neck or some urethral
obstruction of long standing. They occur in-
frequently in the female, no doubt because
of the short urethra which is an infrequent
site of stricture and in which obstruction
rarely develops, and because of the absence
of obstructing lesions at the vesical neck that
are so common in the male.
A review of the five cases of diverticula of
the bladder treated surgically by me at the
Highsmith Hospital, shows that two occurred
in men seventy years of age who had pros-
tatic obstruction; one was in a man about
forty years of age who had a contracture of
the vesical neck. This patient who had for
more than a year been catheterizing himself
several times daily, was found to have a bro-
ken off piece of catheter and a stone lying
in a diverticulum of considerable size. The
other two cases were in men about thirty
years of age, one of whom had two diver-
ticula, which I attributed to a very bad
phimosis which interfered considerably with
urination. The other had chronic inflamma-
tory disease of the prostate gland and seminal
vesicles of three years duration. His diver-
ticulum I diagnosed two years before the
operation which was finally performed due to
residual urine and cystitis.
Surgical removal of diverticula is indicated
when they fail to empty with the bladder and
thus accumulate urine. With retention the
contents usually become purulent and gener-
alized cystitis ensues. It is a serious matter
to overlook the presence of a diverticulum in
dealing with a case of enlarged prostate or
any other form of urethral obstruction, for
operation will not be followed by relief of
symptoms and restoration of health if a diver-
ticulum of any considerable size remains; on
SOUTHERN MEDICINE AND SURGERY
<X)
0M««ln.1.< O^i^ue B.)o<c Tiul.^ U.. S>c
the contrary, pyuria will persist and disorders
of micturition will continue to exist. Most
diverticula are best removed transvesically by
the method of inversion as described by
Young. I have found that it is best for me
to free the sac bv means of extravesical dis-
C-x-U. iKC^sio.^ K>i b.cv >~>1.. no... J
-(U Jw.xU.^l.. o.;^..., >.J ^l. ..e xi
section and then invert it. The larger ones
demand extravesical dissections. If sepsis is
too great, or if the patient's renal efficiency
is too poor to risk immediate excision of the
(Jiverticulum, then it may be drainecj supra-
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pubically and excised later.
CARCINOMA OF THE BLADDER
In my study of the literature concerning
malignant growths of the bladder, I find a
great diversity of opinion both as to the path-
ology and method of treatment. It seems
that some are attempting to relegate radical
surgery to the background in the treatment
September. 1029
SOUTHERN MEDICINE AND SURGERY
609
of this condition. Judd says that surgeons
hive been too ready to give up radical opera-
tions for malignant disease which is for a
long time confined to the bladder and imme-
diately adjacent, and therefore pre-eminently
suited to surgical treatment.
My personal experience is limited to a very
\UU cUJ, s^1.> xau.-KW. Jt.iw wiU, y^jc^i^
nSUti, l.«Jli.^4o «»)«.ellJ. c«..«y ^"- wV.J.,
few cases in all of which I performed partial
cystectomy with fairly gratifying results, con-
sidering the extensive involvement present.
One patient lived for four years following
operation in comparative comfort, finally
dying from sepsis due to a severe kidney in-
fection. Six weeks prior to her death she
was examined cystoscopically and there was
no sign of any recurrence of the carcinoma
in the bladder. Another patient is living and
well one year following operation, her blad-
der is in good condition without any sign
of a recurrence of the tumor. A large per-
centage of our cases of carcinoma of the blad-
der, when first seen by us, were inoperable,
metastases having already occurred. In view
of the fact that it is generally admitted that
carcinoma of the bladder is very slow to give
off metastases, I cannot see any logical excuse
for these long untreated cases which we some-
time see. The cystoscope has made the diag-
noses so easy that every eflort should be made
to bring these patients for examination early
that we may get rid of the local involvement
before it becomes a general condition.
In considering tumors of the bladder from
the standpoint of treatment, they are sepa-
rated into three groups:
1. Benign tumors, mostly papillomas, best
treated by means of fulguration through the
cystoscope. If there is any question about
the nature of the tumor it is best to operate.
2. Malignant cases in whxh the process is
still confined to the bladder and all cases in
which the diagnosis is quest'onable. The
treatment indicated is resection, if the growth
is situated in an accessible portion of the
bladder, with the transplantation of one or
both ureters, if necessary.
I believe that complete cystectomy shf)uld
more often be performed, if there is a rea-
sonable prospect of eradicating the malig-
nancy. This operation has been relatively lit-
tle used, mostly due to the prelim'nary diffi-
culty of dealing with the ureters in a satis-
factory manner. Coffey, at the last meeting
of the American College of Surgeons, describ-
ed an improved method which he has devised
for transplanting the ureters into the lower
bowel, which is based on some experimental
work he d'd on the common bile duct a num-
ber of years ago and which he saw had a
bearing on urctero-enterostomy. He has
spent twenty years in perfecting the tech-
nique and says now that the operation will
SOUTHERN MEDICINE AND SURGERY
September, 1929
work satisfactorily. The essential thing in
the operation of Coffey is that the ureters
be made to run for an inch to an inch and a
half within the wall of the sigmoid between
its muscular and mucous coat before entering
the lumen of the intestine; this because the
intraintestinal pressure exerted laterally tends
to prevent the gross dilatation of the im-
planted ureters. Infection is minimized by
isolating the lower segment of bowel, irriga-
tion and dry gauze packing and by retroperi-
toneal drains protected from contact with
intestines by a quarantine of rubber tissue.
Coffey says that this operation may be con-
sidered justifiable in any condition in which
it is necessary to dispense with the bladder as
a reservoir for urine. I believe this proce-
dure is going to have a far-reaching influence
on the treatment of cancer of the bladder.
3. Those cases in which the malignant
growth is too extensive for removal. If the
lesion is confined to the bladder it may be
removed by a radical operation, but if it has
extended to the perivesical tissues, fixing the
bladder firmly to the prostate and seminal
vessicles or to the other organs in the pelvis,
it is not advisable to attempt to remove it.
For growths too extensive for radical removal,
Thomas says that surgical diathermy offers
the best prospect.
Repeated examination of patients who
have been treated for tumor of the bladder is
necessary because of the high incidence of
recurrence following all types of treatment.
VESICAL CALCULI
Stones in the bladder are usually the re-
sult of urinary retention from prostatic or
strictural obstruction, a foreign body as a
nucleus, a primary renal stone or ureteral
stone. Ninety-five per cent occur in males
in whom obstructive lesions have resulted in
retention. Suprapubic cystotomy should be
performed in all cases except where the stone
is small and can be easily grasped and crush-
ed by the lithotrite.
Dr. A. P. C. Ashhurst says the operation
of litholapaxy is not now in general use be-
cause the mortality of cutting op)erations is
less than when Bigelow's operation was in-
troduced and because recurrence of stone for-
mation is frequent, due to the fact that either
I he fragments are not removed at first or be-
cause urinary obstruction or vesical infection
are not relieved. But the primary mortality
is low. It is best reserved for very debili-
tated patients who have not cystitis. When
prostatic hypertrophy and large single stones
or multiple stones are associated, there is
usually considerable renal insufficiency re-
quiring the two-stage operation with prostat-
ectomy as the second stage.
ANESTHESIA IN SURGERY OF THE PROSTATE
GLAND AND BLADDER
It is in this class of surgery that regional
anesthesia has its chief field of usefulness.
Inasmuch as many of the surgical lesions of
the bladder are obstructing, varying degrees
of renal insufficiency are associated, particu-
larly in cases of prostatic hyF>ertrophy. It is
generally conceded that ether has a depres-
sant effect on the kidneys. When ether is
used accuracy in the conduct of the operation
must be sacrificed for speed, this results in
inaccurate and often incomplete operations,
and little attempt at hemostasis. The causes
of death following the operation of prostatec-
tomy are, in order of their frequency, uremia,
pneumonia, sepsis and hemorrhage. Because
of its depressant effect on the damaged kid-
neys, ether was a factor in producing uremia,
the sacrifice of accuracy prevented adequate
control of bleeding, and inhalation pneumo-
nia was often directly referable to the anes-
thesia. The avoidance of inhalation anesthe-
sia allows time for the accurate conduct of
the operation and for hemostasis, and if
pneumonia occurs it is not of the inhalation
type but embolic in origin.
Sacral nerve block associated with a supra-
pubic field block gives perfect anesthesia with
complete muscular relaxation, and has been
accepted an an ideal anesthetic in this field
of surgery. Recently I have employed spinal
anesthesia, preceding the spinal injection
with 1 c.c. of ephedrin, in two prostatecto-
mies and one operation for diverticulum. The
prostatics were old men with marked cardio-
renal-vascular changes. There was no spinal
shock or fall in blood-pressure and I believe
that the use of ephedrin with spinal injections
will make this form of anesthesia the ideal
one for use in the surgery of the prostate
gland and bladder.
REFERENCES
I. .\siriiiRST, .\. P. C, Principles and Practice of
Surgery, 1QI4.
li. BovD, Montague L., Suprapubic Cystotomy
and Cystostomy, Sou. Med. Jour., Sept., 1927.
Ill, Chute, Arthur L., Ureteral Transplantation
September, 102Q
SUUTIIKKN MhblLlMi AND bUKV-ilikY
in Bladder Carcinoma, Section on Urology A M. A.,
1Q26.
IV. CoFFEV, RoBT. C, Transplantation of the
Ureter into the Large Intestine, Surg., Gyn. & Otut.,
Nov., 1028.
V. DoDSON, Austin, Va. Med. Month., May, 1Q2,S.
VI. Goldstein, A. E., Bilateral Lifration of the
Vas Deferens in Prostatectomv. Jour. VroL. 1027,
XVIII, 25.
VII. Hint, \ernie C, Surgery of the Lower
Urinary Tract, Collected papers of the Miiyo Clinic
and Mayo Foundation. 1024.
VIII. JiDD, E. St.^rr, The Treatment of Carcino-
ma of the Bladder by Radical Surgical Methods,
Section on Urology .1. M. A.. 102o.
IX. JiDD. E. St.arr. and Meeker, Wm. R., The
Value of Sacral Nerve Block Anesthesia in Surgery
of the Prostrate Gland and Bladder, Collected papers
of the Mayo Clinic and Mayo Foundation, \92i.
X. Ji^DD, E. St.^rr, and Sciiull, .\i.bert J., Diver-
ticula of the Urinary Bladder, Collected papers of
the Mayo Clinic and .Mayo Foundation, 1023.
XI. Lower, \V. E., The Role of Cerlain Mechani-
cal Devices in the Diagnosis of Diseise; of the Gcn-
ito-Urinary Tract, Surg. Clin, of .V. .-!., 1024.
XII. Martin, H.arrv W., Diverticula of the Uri-
nary Bladder, Jour, of A. M. A., Jan. 24, 1025.
XIII McK.w. H.\MiLTuN W., Bilateral Ligation
of the \'as as a Prevention of Epididymitis in Pros-
tatectomy, Sou. Med. Jour., Oct., 1028.
XI\'. Young's Practice of Urology, 1027, Vol. 2,
page 347.
DISCUSSION
Dr. Hamilton \V. McKay, Charlotte:
I am very sorry that Dr. Lawrence was
called back to Raleigh. He made me prom'se
to pinch hit for him, but I shall talk for only
about two minutes.
I judge that every man referring cases has
a definite pride in making the diagnosis; in
other words, if you are referring your cases
to a urolog'st you certainly ought to be able
to make your own clinical diagnosis. There-
fore, I want to say a word about rectal e,\-
aminal'ons. I think that every general man,
'■pternst or surgeon, ought to make a rectal
c.\'jm'nation on every male patient with uri-
r.iry symptoms. There is no more valuable
p.ocedure that you or the urologist can carry
out, nor one that will give more information
about the prostate gland and adjacent struc-
tures. It tells you whether the patient has
acute or chronic infection of the prostate, tells
you how fixed the gland is, whether it is nodu-
lar or not; and you can generally say one of
three things (and this is my main {X)int), thit
a man around middle life or past middle life
has either a benign prostate, a suspected ma-
lipnai:cy, or a definite malignancy. I men-
t'on th'.s because a rectal examination can be
made by anyone of you and you should do it.
The amount of information that you get is
inarvelous.
Dr. Highsmith mentioned in his series ma-
lignancy of the prostate occurring in fifteen
per cent of the cases. In my experience it is
twenty to twenty-five per cent. With cancer
of the prostate, as of anything else, in the
incipient stage you may be able to do some-
thing for the patient.
Just why anyone should find calomel use-
less is not easy to say, but possibly it might
result from lack of knowledge of the drug and
also from poor observation in not giving the
drug a chance at the right time nor in the
proper case. Anyway there would seem to be
something radically wrong where a physician
who says an old standby drug that has been
used for centuries should be cast out of the
pharmacopoeia. — VVarbrick in Wcstrni Med-
ical Times.
Blood-lettin<; for Congestive Heart F.nilure
The immediate results from vene-ection of 500 c.c.
in congestive heart failure are frequently spectacular
and in a majority of instances, beneficial. I-'rom the
very nature of the cases selected for thi; pn;cedure
ultimate recovery is not anticipated in a high pro-
portion. Nevertheless, a survival of 45.4 per cent is
reported in this group and an apparent prolongation
of life claimed in an added 22.7 per cent. — W. S.
Mjddleton, The Am. Heart Jour., Aug., 1929.
Camphor for Breast En ;or~em?nt
In the Canadian Medical Assn. Journal for May,
PitiLPOTT reports excellent results from intramuscu-
lar injections of camphor in oil, for the relief of en-
uorgement of the lactating breast. The dosage was
1 ' J grains, twice the first day and once daily for
three da\'s.
Why Broken Bones Kail to Unite
The cause:, of non-union may be classified as
systemic and local. The systemic causes are rarely
of any significance. .Attempts to attribute the failure
of bones to unite to a diuurbed ratio of calcium and
phosphorus have not been convincing. Experience
with the carrying out of determinations of calcium
and phosphorus in ca^es of delayed union and non-
union indicated that this theory was not sound. The
local causes may be divided into physiologic and
mechanical. Physiologic causes offer an explanation
of some of the baffling ca.ses which are occasionally
seen. I'he local mechanical causes are by long odds
the most common, and explains the vast majority of
the cases of delayed union. — M. S. HtNUERSON,
Minn. Medicine, Sept., 1929.
SOUTHERN MEDICINE AND SURGERY
September, 1929
Treatment of Uremia*
A. Byron Holmes, Fairmont, N. C.
The conditions included in the term uremia
are very complex, having symptoms diverse
alike in mode of onset, etiology and path-
ology, and having but one thing in common —
their occurrence during the course of renal
disease and in conditions causing anuria.
If our work be general practice or one of
the specialties, we are constantly confronted
with the dreaded symptom-complex known as
uremia. Uremia may be defined as a passing
or permanent failure in one or more of the
kidney functions. It is obvious that to prop-
erly understand the treatment of uremia ne-
cessitates some knowledge in regard to its
ct'ology, pathology and symptomatology.
We divide uremia into two groups:' (1)
an acute type, with convulsions, occurring
miinly in acute nephritis, and (2) a chronic
type the usual mode of termination in chronic
nephritis, indicating a kidney damaged be-
yond all hope of repair. There is a condition
which resembles chronic uremia, in some of
its symptoms, but shows no evidence of kid-
ney disease and has a normal blood nitrogen,
very probably due to the effect of continued
hypertension which is sometimes unwisely
called "pseudo-uremia." The treatment of
this condition is that of hypertension, not
uremia.
Acute convulsive uremia is a complication
of acute glomerolu-tubular nephritis and oc-
casionally chronic nephrosis. Since evidence
of nitrogen retention in anything but a mod-
erate degree is lacking, the condition is not
strictly uremia but perhaps represents the
cerebral symptoms of acute nephritis. L.
Traube,- several years ago, advanced the the-
ory that the symptoms were very probably
due to the compression of the brain against
the rigid cranial wall due to the cerebral ede-
ma. This theory has been discarded until
recently. Always associated with it is a ris-
ing blood precsure, whose relationship to
cerebral compression has been shown in the
experimental work of Gushing,' and reported
clinically by Hamilton and Blackfan.'' The
edema of the brain as suggested by these
observations is an essential factor in this type
of uremia. A rapid encroachment on the in-
tracranial space from the increasing cerebral
edema results in a steady increase of intra-
cranial pressure, which in turn initiates the
vomiting, headache, convulsions and other
symptoms. The arterial tension increases cor-
resfxjndingly, being governed by the vaso-
motor mechanism to keep the arterial tension
in excess of the compressing force against the
arterioles and capillary vessels in the medulla.
Convulsions are the classical symptoms of
this type of uremia, but milder forms are
seen, such as vomiting, headaches, sudden
blindness, localized paralyses or hemiplegia,
hem'anopsia, hallucinations, delirium and
acute mania.
-Acute convulsive uremia is a medical emer-
gency that demands immediate and heroic
treatment. A prodromal stage during which
the blood pressure is rising is a valuable indi-
cation for treatment. The removal of from
ten to twenty ounces of blood is a treatment
of proved worth, and should be resorted to
without delay, either as a preventive measure
for the rising blood pressure or after convul-
sions have occurred.
The most effective treatment, also, one
bearing out the theory of increased intra-
cranial pressure, is the intravenous injection
of magnesium sulphate solution. A ten per
cent solution is very slowly injected, in
amounts equal to about two c.cm. per kilo,
of body weight. The injection is repeated as
often as the condition requires. This treat-
ment is usually followed by prompt fall of
the blood pressure with lessened intracranial
tension and subsidence of the cerebral symp-
toms.
Lumbar puncture is of great value, but be-
ing attended with the danger of medullary
pressure must not be undertaken without full
precautions and realization of this danger.
Drugs may be used to aid and supplement
the results obtained by the above methods.
♦Presented to the Medical Society of the State of North Carolina, meeting at Greensboro, April
15-17, 1929.
September, 1Q20
SOUTHERN MEDICINE AND SURGERY
Choice of these are chloral hydrate, the bro-
ni'des and the judicious use of morphine.
Headache and vomiting are due to the in-
cre:ised intracranial tension and usually re-
rp )nd rapidly to methods already described.
The d'et and general management of the
cases are part of the treatment of the ne-
phritis. The edema, if present, is due to a
ui' lurbance in the salt balance, and will very
often promptly disappear following the in-
jection of merbaphen and the administration
of larjje doses of ammonium chloride by
mouth. The aim in the treatment of acute
uremia should be the prevention of convul-
sions by recognizing the sic;nificance of a ris-
ing blood pressure and taking prompt meas-
ures for its reduction.
True chronic uremia is the final act in
chron'c glomerulo-tubular nephritis, and is its
most frecjuent mode of termination. What-
ever the cause may be, the diagnosis and
treatment of kidney disease, whether primary,
corollary or secondary, rests upon the evi-
dence of damage done the kidney parenchynn.
The condition (jf the kidney parenchyma
during or after an attack of nephritis stands
in the same relation to the prognosis and
treatment for the individual as does the con-
dition of the heart muscle during or after an
attack of carditis, vascular disease or hyper-
tension.
The amounts and specific gravity of the
uri^-e specimen formed during the usual
twenty-four-hour period, or under imp<3sed
cond'tions of moderate water restriction is
the best renal function test. The balance or
excretion test is universally used. The urea
lest of IMcLean and the dyes are the best
known. While the e.xcretion test is valuable,
especially if we carefully ascertain the time
of the peak of the excretion curve, the deter-
mination of nitrogen retention in the blood is
the most valuable.
The presence of albumin, blood and casts
in th.' urine are important, for when these
firdin-.'s are correlated with the concentration,
c.xcrei.'on test and nitrogen retention, it is
possible to form some idea of the severity and
extent of the lesions which have caused a les-
sened function.
In 18.53 Wilson'' advanced the theory that
v,sz Vv-as the responsible toxic substance in
tlie etiology of true chronic uremia. Urea has
b;cn regarded until quite recently as of little
more than historical importance, but we must
revise our ideas and accord to urea a more
important role than that of a harmless waste
pniduct. The experimental work of Hewlett,
Gilbert and Wickett" has demonstrated the
toxicity of urea. They were able to produce
symptoms of chronic uremia in healthy men
by administering urea by mouth to them. In
these experiments symptoms of chronic ure-
ni'a appeared when the blood concentration
of urea reached a level of one hundred and
sixty to two hundred and forty-five mg. urea
to one hiindred c.cm. of blood. Leiter", by
the intravenous injection of urea into dogs
produced similar symptoms, death occurred
from convulsions when the amount injected
had reached one per cent of the animal's
weight in grams.
Determination of the retention of non-pro-
tein nitrogen in the blood is very important.
Sometimes we will find retention of creatinin
wiiilc the urea level is still normal, but more
often urea retention is more helpful. We
arc thus enabled to determine whether treat-
ment will b? of much benefit. If the urea
nitrogen is increased to sixteen to sixty mg.
per 100 c.c. of blood, treatment should be
successful: those patients who have one hun-
dred to two hur.drcd mg. per 100 c.c. of blood
rarely live more than one year: those having
two to three hundred mg. per 100 c.c. of
blood rarely live more than a few months:
those having more than three hundred mg.
urea nitrogen per 100 c.c. of blood rarely live
more than a few weeks.s
The clinical symptoms of chronic uremia
appear insidiously and tend to assert them-
selves when one hundred and fifty mg. or
more of urea per 100 c.c. of blood has been
reached. When once established the course
is progressive, though temporary remissions
may occasionally delay the fatal termination.
Treatment is very unsatisfactory because we
know of nothing to stay the inevitable end,
but by anticipation and careful treatment of
outstanding symptoms valuable service may
be rendered in the patient's latter years.
In the majority of cases digestive symp-
toms are among the earliest to assert them-
selves and represent the so-called gastro-intes-
tinal type of uremia. The mouth should b?
kept clean by the frequent use of alkaline
washes and the removal of debris from the
teeth and gums to prevent stomatitis. Nausea
614
SOUTHERN MEDICINE AND SURGERY
September, 1029
and vomiting causes quite a bit of discom-
fort. Gastric sedatives, such as cerium oxa-
late, dilute hydrocyanic acid and bismuth-
liquor adrenaline hydrochloride, and minim
doses of iodine are useful; in stubborn cases
cocaine hydrochloride grain one-fifth in eight
c.c. of chloroform water may give relief. Gas-
tric lavage is often the most effective treat-
ment.
Constipation, often an annoying symptom,
is best treated by frequent large doses of the
salines. Sometimes a very troublesome and
serious diarrhea will demand the use of astrin-
gents with opium.
Hiccoughs is of grave import and proves
very resistant to treatment. Stimulating ap-
plications to the epigastrium, such as fomen-
tations of mustard leaves, should be tried;
nitroglycerine grain one-hundredth, drachm
doses of liquid extract of ergot and carmina-
tives, such as oil of turpentine ten minims in
capsule, will occasionally be helpful. The
symptom is usually a terminal one and there
is no good reason to withhold morphine.
Paroxysmal dyspnea, the so-called uremic
asthma, is frequently a prominent symptom.
It is thought to be due to acidosis. Drachm
doses of sodium bicarbonate every three or
four hours may prove useful. Inhalations of
oxygen are beneficial. The most certain relief
is the injection of morphine.
Itching of the skin, which is very terrify-
ing, is best treated by the frequent use of
warm alkaline baths and sedative drugs, such
3s bromides in full doses. The use of the
different methods of diaphoresis to eliminate
the toxins through the skin is not to be rec-
ommended. It adds to the patient's weakness
and discomfort and does no good.
The nervous symptoms consisting of de-
pression and irritation are often marked.
Mental depression is often extreme and there
may be increasing lethargy passing into coma.
Irritation is seen in the twitching of muscles
and cramps, in restlessness, delirium and
sometimes mania. Chloral hydrate grain five
to fifteen with fifteen grains of bromide is
useful, but morphine is the drug of drugs
and if its use be properly supervised it may
be used without undue risk.^
Headache can usually be relieved by as-
pirin, phenacetine or the like. If these fail,
especially if there is elevated blood pressure,
venesection should be done or the injection
of ten per cent solution of magnesium sul-
phate. Convulsions are rarely met with in
chronic uremia but may occur in the terminal
stage and should be treated along similar
lines.
The mode of treatment that has given the
best results in my hands, in both the acute
and chronic types, has been the duodenal
tube. For those patients who will not or
cannot take the proper amounts of fluids,
nourishment and medication we can introduce
the tube through the nose and leave in situ
until we have accomplished our purpose. The
liver being the organ of detoxication of first
importance it follows that anything to en-
hance liver function is beneficial. Lyon'"
presents evidence to show that drainage of
the gall bladder improves liver function. The
concentration of nitrogen in the bile depends
upon its concentration in the blood. The
bile being rich in nitrogenous waste products
we are enabled by biliary drainage to entirely
remove these products from the body. After
complete duodenal drainage, we lower the tip
of the tube into the jejunum and first give
a massive lavage. Ten to fifteen litres of
fluids can be given without undue discom-
fort. Following the lavage we get evacuation
of large volumes of liquid feces. It is known
that more nitrogenous waste is eliminated in
liquid than in solid feces. There will be a
complete change in the feces: they will lose
the odor of protein putrefact'on and assume
a nearer normal condition. After evacuation
is complete we then introduce the proper
amount of food to maintain the nitrogen equi-
librium. Peptonized milk with glucose or
lactose is the best food for this purpose. A
high carbohydrate intake is desirable because
it is a body protein sparer, and adds to the
liver store of glycogen, thus boosting liver
function. The carbohydrates also tend to
prevent acidosis and the milk will furnish
calcium which is very essential because there
is practically no calcium storage in the adult.
We are also enabled to maintain the acid base
balance of the blood by introducing alkalies.
This treatment will usually cause a lowering
of the nitrogen retention probably because the
excretions in the small intestine are not re-
absorbed in the large intestine."
I would :u^ge=t that we leave off the drugs
known as d uretics. Their action on the kid-
ney is first stimulation followed by exhaus-
September, 1029
SOUTHERN MEDICINE AND SURGER\
tion. I have never seen them do any perma-
nent good, but think I have seen some harm-
ful results following their use.
We know nothing definite about the toxin
or toxins responsible for the symptoms of true
uremia, but we know they are associated with
the retention of waste products of nitrogenous
metabolism in the blood and the inability of
the kidneys to concentrate: further, that with
the retention of these products the symptoms
of uremia may be prevented for a long time
by compensatory polyuria. The main indica-
tions are to lower and maintain as nearly as
possible the normal level of the end products
of nitrogenous metabolism, represented by
the non-protein nitrogen in the blood, and
to maintain the compensatory polyuria. The
first indication may be met by lowering the
nitrogen intake and sparing the body proteins
by a high carbohydrate intake. The second
indication is met by increasing the fluid in-
take and success here will depend upon
amount of kidney reserve strength left.
The increase in the number of cases of
cardio-renal disease during the last few years
should put us on our guard to try and diag-
nose a beginning uremia before the disease
is permanently established.
The treatment of pure chronic uremia is
purely symptomatic and our end is gained if
the sufferings of this lingering disease are in
some measure lessened.
REFERENCES
1. Hardy, T. L., The Lancet, March, 1027.
2. Traube, L., "Zur Lchrc von der Uremic," In
his: Tes. Beitr. z. Path, u Physiol., 187S.
S. CusHiNO, H., Bui. Johns Hopkins Hasp.. 1024.
4. Hamilton and Blackfan, Bui. Johns Hopkins
Hasp., 1026.
5. Wilson, T., Tice's Prac. Med.
6. Hewlett, Gilbert, and Wickett. Jour. A. M.
A., July 17, 1027.
7. Leiter, Louis, Arch. Int. Med., 1021.
8. KiDLUFFE, R. ,\., Clinical Interpretation Blood
Chemistry, 1027.
0. Osler, Sir Wm., Practice of Medicine.
10. Lyon, B. B., Jour. A. M. A., May 6, 1027.
11. Mc.Xrthltr, Killian and Stepita, Sou. Med.
Jour., Aug., 1028.
12. Shaw, Batty, The Practitioner, Aug., 1026.
Davenport, H. A., Jour. Lab. and Clin. Med., Dec,
1027. Miller, Knud, Klin. Woch., Jan., 1928.
Paroxysmal Tachycardia*
J. Morrison Hutcheson, M.D., Richmond
The disorder known as paroxysmal tachy-
cardia is characterized by sudden acceleration
of the heart beat to two or three times its
normal rate with an equally sudden return
to normal. The exact mechanism of such
disturbances is not known but is generally
regarded as a displacement of the pacemaker
by a series of ectopic impulses arising from
an independent focus elsewhere in the heart
muscle. The site of impulse formation may
be in the auricle, the A-V node or the ventri-
cle.
The important diagnostic point to bear in
mind is that the change from normal rate to
tachycardia takes place in one beat and that
the attack ends in the same way. Subject-
ively the onset is often marked by a sudden
thump or momentary standstill and the end
may be attended by a few slow irregular
beats. Once the attacks begin, they are apt
to recur.
During the attack, which may last from
a few beats to several days or more, the rate
is rarely under 150 and often reaches 200.
It is not influenced by posture, exercise, emo-
tion or deep breathing. The heart, though
rapid, is almost entirely regular, a feature
that distinguishes this type of tachycardia
from paroxysms of auricular fibrillation in
which there is total irregularity. In the at-
tack patients are usually nervous, restless and
weak, though occasionally they go about their
duties with little inconvenience. Palpitation
and breathlessness are the rule while precor-
dial pain, at times anginal in character, is
not rare. Vertigo is in some cases an out-
standing feature but is said to occur chiefly
in patients with cerebral arteriosclerosis.'
Syncope and epileptiform seizures have been
noted. The longer the attack lasts, the more
severe the symptoms become. Examination
reveals little of interest except the rapid rate.
'Presented to the Tri-Stttc Medical Auodation of the Clir*|inM WA Virginia meeting at
Greeniboro, N. C, February 19-21, 1M9.
616
SOUTHERN MEDICINE AND SURGER\
September, 102Q
Where signs of cardiac failure are observed,
investigation between attacks usually shows
a diseased heart.
Paroxysms of tachycardia may occur at any
age and, though rare in childhood, cases have
been observed in infants. The commonest
type, paroxysmal auricular tachycardia or
simple paroxysmal tachycardia, is seen most
often in young adults and may be associated
with definite heart disease, though usually the
heart is normal. It must be differentiated
from several other varieties with more or less
similar features but of diflerent significance.
Paroxysmal ventricular tachycardia, which is
comparatively rare, is practically always seen
in connection with grave myocardial disease
and is apt to be a terminal event It is a
frequent result of experimental ligation of
the coronary vessels and is observed clinically
in cases of coronary thrombosis and as a re-
sult of prolonged and excessive use of digi-
talis.- As a rule, this type is recognized only
by the electrocardiogram but, according to
Levine,'' it may often be identified clinically
if certain diagnostic criteria be kept in mind.
He emphasizes the slight irregularities in
rhythm, changing quality of the first sound
at the apex and failure to influence the rate
by vagal pressure. Auricular flutter at times
appears in brief attacks difficult to distin-
guish from auricular tachycardia. Willius
lourd it always associated with definite heart
disease, most frequently with mitral stenosis
and thyrotoxicosis.* Whenever I have been
able to identify paroxysms of flutter it has
been of the impure variety with pulse irreg-
ularity, more nearly resembling fibrillation
than auricular tachycardia. .Auricular fibril-
ht'on also occurs in paro.\ysnis but usually
it is easily recognized by the totally irregular
heart action and pulse deficit.
Final analysis in each case rests with the
electrocardiograph but, owing to t^e brevity
of attacks and their irregular occurrence, rec-
ords of them are not easily secured. In my
experience it has been necessary, in most
irstances, to arrive at a d'agnosis.^from the
description of the attacks given by the pa-
t'ent. In the case of paroxysmal auricular
tachycardia the history is quite characteristic,
ihe patient being aware of the sudden onset,
usually also of the abrupt termination, and
f.equently is able to state the rate noted. On
the other hand, I have o. jrved instances of
paroxysms of both flutter and fibrillation in
patients who were not ct)risciou*''of any car-
diac disturbance. u-'ir.
In the past few years I have S^en in pri-
vate practice 28 patients who "SRbWttl, "leither
from their histories or from of5servatiori dur-
ing the attack, the characteristic' ffeatiiffe of
paroxysmal auricular tachycardia.'' Op'fjtfft'iV-
nity was afforded for cbrnplete cardiac Aii'd
general examination of each case between at'-'
tacks, some were studied during attacks and
a number were followed with the idea of
determining the effect, if any, of treatment.
1 have been struck with the rarity with which
th's condition is seen in ward patients. I do
not recall having encountered a single case
on the teaching service of the Hospital Divi-
sion of the iMedical College of Virginia which,
otherwise, affords an unusual variety of car-
diac disorders. Examination of the records
for several years back reveals that among
more than 8,000 medical admissions no such
d'agnosis has been recorded.
In this group of 28 patients there were 12
males and 16 females. The youngest was
18, the oldest 78 years of age; the average
age being 45.4 years. Two patients were
seen in their first attack, the longest period
during which attacks had occurred was 51
years, the average period was 10.2 years.
Examination between attacks showed evi-
dence of heart disease in only 8 patients, 7
of whom were over 57, the average age fieing
62. Of these, 6 had hypertension with hyper-
trophy and 2 mitral disease. Electrocardio-
,r"-ams were cb.ained during attacks on only
4 patients and these showed auricular tachy-
card a. Of electrocardiograms made between
attacks on 21 patients, 15 were entirely nor-
mal. Premature contractions were seen in
2 cases, left axis deviation in 3 hypertensive
cases, and right axis deviation in one mitral
case. Other diseases were not common. iMi-
graine was noted in 3 patients, mild mental
d'sturbance in 3, pulmonary tuberculosis with
Eh'.'^ht activity in 2. In no case was thyroid
d tease found. None of this group showed
cv'dence of decompensation nor did the his-
tory irdicate that this had occurred during
attacks.
The onset of attacks was attributed to sev-
eral diffcr.:'it factors, but the majority of
p"t'c^ts h;d become convinced that they re-
sulted from no particular cause. Excitement,
September, 1020
SOUTHERN MEDICINE AND SURGERY
exertion, indigestion and overeating were
mentioned as exciting causes. Two patients
Ind attacks while asleep. In one, the first
and only attack observed began during ether
anesthesia. By various writers, indigestion
has been given a prominent role in the eti-
ology of paroxysms of tachycardia. This
may have been due in some measure to the
; ?nsatien of gastric distention that often ac-
companies attacks and to the occasional relief
from belching, or vomiting. In my series, di-
r^estive disturbances were conspicuous by
Ihe'r absence, nor did any other disorder ap-
I ear v.-ith sufficient frequency to suggest any
rlatlonship between it anjd, the attacks of
Mchycardia.
Demonstrable changes in, the heart were
L^b:erved in 8 patients. Six of these, ranging
from 57 to 78 years of a';e, showed hyperteii-
c on wilh cardiac hypertrophy and all had
suffered repeated attacks of tachycardia for a
raimber of years. It is likely that the attacks
b gan before card ac changes appeared and
unl kely that their association with a certain
d.-jree of hypertrophy was more than a o-
ir.cidence.
A consideration of Ih's group as a whole
supports the belief that paroxysms of auricu-
la.' tjchycard'a are compatible with long life
and good card ac function. One patient had
attacks for 51 years and finally died of apo-
plexy. While attacks may occur in a diseased
heart and contribute to its failure, there is
little evidence to show that the rapid rate po-
se is ever dangerous. Deaths have been ob-
served but rarely during attacks of paroxys-
mal tachycardia and, so far as is known, these
may have been of the ventricular type and
in gravely diseased hearts. Most of my pa-
tients, even some with mild attacks, were
unduly concerned about the possibility of sud-
den death or eventual cardiac breakdown.
Too frequently they had been unnecessarily
warned against exertion or excitement and in
several cases the restrictions practiced
amounted to semi-invalidism while the re-
sulting mental effect was that of extreme
gloom. To one unfam'liar with the attack
a heart rate of 200 may cause considerable
uneasiness, but where there is a history of
repeated attacks, no evidence of congestive
heart failure during attacks and no serious
heart lesion made out between attacks, a most
favorable prognosis may be given. When
heart disease exists, the frequency and dura-
tion of periods of rapid rate have to be con-
s dered and, also, -the behavior of the heart
during the paroxysm. On the whole, parox-
ysms of tachycardia have little weight in
prognosis which is determined largely by the
type and degree of the associated cardiac dis-
ease.
X'arious types of treatment had been ap-
plied during the attacks, such as holding a
deep breath, invert'ng the body by hanging
out of bed, drinking cold water, inducing
vomiting or stimulating the vagus by pres-
sure over the carotid or pressure on the eye-
ball. Xo one of these measures was gener-
ally effective, but one or another of them
usually succeeded in ending the attack. In
4 cages' shov/ing prolonged attacks, ouinid.n
culphate by mouth was g^ven with instruc-
tioiis to take ,? grains every half hour until
lb.? attack ceased. Two patients reported
that or.e or two doses ended their attacks. I
have not used quinidin intravenously but
would not hesitate to do so should circum-
ctirces seem to warrant it.
In the majority of my cases paroxysms
•v/erc iiOt sufficiently frequent to justify treat-
ment designed to prevent them. Eght pa-
tients to whom quinidin was given as a pro-
phylactic vvere heard from. .All experienced
rcief and in several instances this was strik-
ing. I'Yjr example, a patient having two to
five attacks daily, and incapacitated for work,
was able to remain entirely free so long as
he would take quinidin. If he left it off the
attacks would return, but only after se\cral
weeks. Th-^ dose' advised was 3 grains three
t'mes a diy to be increased rapidly until ef-
fective, p.ovided that no toxic effect was ob-
served. The largest dose required was IS
gfa'iiS ih;ce times a day. It must be remem-
bered that gocid results from quinidin depend
upon a certain degree of saturation. Like
digit.dls, it must be given until the desired
cffeci appears. Levine and Stevens'' have re-
ported g.ving as much as 1.5 grams five times
a day in a case of paroxysmal ventricular
tichycaid a associated with coronary 'throm-
ba.'jis before, normal rhythm could be main-
lainid.
Til iimh a number of patients had taken
dig.tal s in varying amount it cannot be said
that a ,y had been digitalized. I.ev'ne and
Diot.i. r ■ reported 2 cases in whicli attacks
SOUTHERN MEDICINE AND SURGERY
September, 1929
were controlled by digitalization after quini-
din had been tried and had failed. The dose
of quinidin mentioned, however, was hardly
sufficient to justify the belief that it had been
given a real trial. Sprague and White' men-
tioned a similar e.xperience with digitalis
when quinidin had been used in larger doses
without effect.
SUMMARY
Twenty-eight cases, presumably of parox-
ysmal auricular tachycardia, have been re-
viewed. So far as is possible clinically, cases
of ventricular tachycardia and auricular flut-
ter have been e.xcluded. The data obtained
fails to show any relationship between pa-
roxysms of tachycardia and known typ)es of
heart disease; nor is the influence of an ex-
citing factor in producing attacks suggested.
It is clear, however, that attacks are com-
patible with long life and good heart function
and that in the large majority of cases the
prognosis in this respect is excellent. Quini-
din, when given in sufficiently large amount,
has been found effective both for the purpose
of terminating attacks and for preventing
their recurrence.
20Q Professional Bldg.
REFERENCES
1. Barnes, A. R., and Willius, F. A., Boston
Med. and Surg. Jour., 1024, 191, 667.
2. Reid, W. D., Arch. Int. Med., 1Q24, XXXIII,
2i.
i. Levine, S. a., Amer. Heart Jour., Dec, 1Q27.
4. Willius, K. A., Amer. Heart Jour., Dec, 1927.
5. Levine, S. \., and Stevens, W. B., Amer. Heart
Jour., Feb., 1928.
6. Levine, S. A., and Blotner, Harry, Amer.
Jour. Med. Sci., Nov., 1926.
7. Spraguue, H. B., and White, P. D., Med. Clin-
ics of North America, 1925, page 1855.
DISCUSSION
Dr. F. C. Rinker, Norfolk:
Dr. Hutcheson has given us a clear descrip-
tion of the condition and has very clearly
brought out the most imp)ortant diagnostic
point, "sudden onset and sudden end."
He has also given us a thorough under-
standing of the usual symptoms. One symp-
tom which has been noted in two of my cases
is an onset with a sudden sensation of chok-
ing. This is followed by the symptoms noted
by Dr. Hutcheson.
The age of my series of 16 cases ranges
from 26 to 74. The average age is 48.
I have noted the same exjjerience as Dr.
Hutcheson, that none of my cases have been
among the ward class of patient. This sug-
gests the possibility of a taxed nervous sys-
tem as one of the predisposing causes of the
condition.
I found evidences of cardiac damage in
only five cases. These are past fifty-five
years of age.
As one of the causes of paroxysmal tachy-
cardia, I believe, from my own experience,
that chronic foci of infection plays a big role
and that in the majority of instances, if these
foci are removed and the patient's mental and
physical habits corrected, they will be reliev-
ed of future attacks.
I want to stress the point made by Dr.
Hutcheson, that many times the physician is
apt to unnecessarily alarm the patient leading
him to believe that he has some severe heart
disease.
From the standpoint of treatment of the
attack, I have had best results with morphia
and digitalis in massive doses. Pressure ap-
plied to the vagus has consistently relieved
the attacks in two of my cases. Quinidin has
not given me the same happy results as Dr.
Hutcheson has found but this is probably due
to the fact that 1 have used smaller doses
than he. I shall adopt his dosage in the fu-
ture.
In his message to the House of Delegates,
Dr. Frank I. Ridge, president of the Missouri
State Medical Association, recommended that
in addition to one-year hospital internships
being required, medical students spend the
vacation months between the second and third
and between the third and fourth years as ap-
prentices to general practitioners, preferably
rural. — Jour. Missouri State Med. Assn.,
Aug.
It is our belief that the most common cause
of severe acute pyuria in young infants, espe-
cially the type of case usually designated
pyelitis, is an acute inflammatory process of
the interstitial tissue of the kidney. — Wilson
and Schloss, Am. Jour. Dis. oj Children, Aug.
September, 1929
SOUTHERN MEDICINE AND SURGERY
rr
Meckel's Diverticulum*
WITH CASE REPORT
F. C. Hubbard, North Wilkesboro, N. C.
Meckel's diverticulum is a condition of
great importance not alone on account of the
fact that it is of relatively infrequent occur-
rence and is often confused from a diagnostic
standpoint with appendicitis, but because it
constitutes a serious menace to the health and
even the life of the individual who possesses
one. Keen reports eleven fatal issues out of
a series of twenty-three cases operated upon
in the acute stage.
I wish to present the history and findings
in a classical case of Meckel's diverticulum
recently observed and treated and to review
briefly the condition as a whole to the end
that we may reduce the mortality by earlier
diagnosis and operation.
The term Meckel's diverticulum implies a
congenital condition in contradistinction to
acquired diverticula which arise in later life
along the intestinal canal and which will not
be considered in this paper.
The malformation known as Meckel's di-
verticulum was first described by Ruysch.
In 1808, however, Meckel, the anatomist, first
described it accurately as a part of the ductus
mesentericus which had not undergone the
usual regressive process. As a rule it com-
municates with the lumen of the ileum about
two or three feet above the ileo-cecal valve.
It is usually from three to ten inches in length
and attached to the free border of the bowel,
although it is sometimes attached at the mes-
enteric border. It may have a broad or nar-
row base, may end in a blind or a conical pro-
jection, and may even be dilated into the
form of a sac. It occurs in 1 to 2 per cent
of bodies and is occasionally found to form a
part of the contents of a hernial sac. In
structure it corresponds closely to the intesti-
nal wall.
Richter gives the following explanation
and description of its mode of development:
"With the closing in of the abdominal plates,
the connection between the vitelline sac and
the cavity of the primitive intestine becomes
reduced to a tubular structure, the vitelline
duct, continuous at one end with the convex-
ity of the {/-shapjed primitive gut, at the
other with the vitelline sac. The structure
of the wall of the duct is, of course, identical
with that of the wall of the primitive intes-
tine. During the further evolutionary changes
the duct, during the second month, becomes
reduced to a mere thread, with finally a com-
plete solution of continuity between vitelline
sac and gut. No traces of duct are present
in the bowel wall of fetuses of four to six
months or in the cord by the end of six
months. Cell groups found in the cord at
term, and believed by Ahlfeld to be the vitel-
line remains, are considered allantoic remains
by Minot.
Accompanying the duct are its vessels, the
arteries arising in the primitive aorta and
passing along the duct to the vesicle, the veins
returning to empty into the mesenteric vein.
Retrogressive changes in the duct and vessels
should be synchronous. The primitive gut is
first an intra-abdominal organ. Traction by
the vitelline duct results in a hernia of the
gut into the base of the cord, beginning at
the end of the first month, reaching its maxi-
mum toward the end of the second month —
fifty-third day (Minot) — when, with the giv-
ing way of the duct, gradual reduction of
the hernia and complete closing in of the
ventral plates takes place. During the fur-
ther development of the {/-shaped primitive
gut the relative growth of the two legs is such
that the insertion of the duct is in the lower
portion of what becomes the ileum, with,
however, so much variability in exceptional
cases as to be placed at almost any part of
the small intestine, from the lower end of the
duodenum to the cecal end. Deviations from
the normal in the evolution of the vitelline
duct result in malformations that may be
grouped in two quite different types of con-
genital malformation: (1) that represented
by congenital diverticula and their remains,
congenital bands, etc.; and (2) that repre-
sented by congenital hernia into the cord."
It is evident, therefore, that we are dealing
with a congenital sac which is blind at one
•fresentet} to Bightl^ Pistrict (N. C.J We(Jic»| Society, m Airy, June Uth, \9i9,
SOUTHERN MEDICINE AND SURGERY
September, 1020
end and is continuous with the lumen of the
ileum at the other. The blind end may be
attached to the umbilicus or to another
knuckle of bowel, or may hang loose in the
abdominal cavity. It is always single, placed
at the lower end of the ileum, and has the
four coats of the intestines. It is more fre-
quent in males than in females. Keen reports
130 cases of vvh'ch 100 were in men. Opera-
tive statistics from several of the larger clinics
would indicate that one m^ght expect to find
one or two cases in about every tifteen hun-
dred to two thousand celiotomies.
COMPLICATIONS
Although most Meckel's diverticula nevei
inflame sufficiently to produce definite signs
and symptoms, still the potentialities of such
a case are great. Some of the commoner cnni-
plications which arise as the result of it are
as follows: (1) obstruction due to the tilum
terminale looping about a tjowel; (2) stran-
gulation in a hernial ring; (3) intussuscep-
tion; (4) volvulus of the diverticulum or the
ileum; (S) patency at the umt)J|licus; (o)
perforation in typhoid; (7) tuberculous ul-
ceration; (8) prolapse of bowel;; (9) pelvic
tumor; (10) rupture of diverticulum causing
obstruction from pressure of .abscess; (11)
diverticulitis from coproliths, Jish bones,
worms, etc.; (12) trauma may also be one
of the etiologic factors in the production of
a diverticulitis, since we are dpaling with an
organ that may be filled with no outlet at
one end, favoring rupture on an increase of
pressure.
SYMPTOMATOLOGY
Keen divides these cases clinically into
three classes, depending upon the severity of
the cases. They are as follows: (1) fulmi-
nating, a. without previous history, h. with
previous history; (2) subacute; (3) chronic.
The julmhiatin^ type comes on suddenly,
like an acute abdominal crisis, and early it is
impossible to diagnose it from similar lesions.
A torsion of a diverticulum gives the history,
symptoms and signs of acute appendicitis, not
located, however, at the proper site. To this
picture is soon added those of intestinal ob-
struction, from twisting or kinking of the
gut or from paralytic ileus. If a perforation
be present, we have the pain, tenderness, col-
lapse, and the succeeding signs of peritonitis
characteristic of that lesion elsewhere. Fre-
quently there is a history of previous attacks
as will be discussed under the chronic type.
The subacute type. — At times we meet
cases in which there has been a history of a
distinct attack leading to localized infection
about the diverticulum, presenting either ab-
scess formation or plastic adhesions. JNIore
or less tenderness is present for some time,
associated with gastro-intestinal symptoms,
just as in a subacute appendicitis. The ab-
scess ruptures into the intestine or, as in one
case reported, into the bladder. The adhe-
sions remain either temporarily or perma-
nently and may give rise to intestinal ob-
struction in various ways.
The chronic type. — In about one-fourth of
the cases reported the patients had complain-
ed of previous gastrointestinal symptoms,
often constipation and indefinite pains in the
ri:;ht para-umbilical region. This picture is
made complete by intermittent attacks of
acute pains and tenderness corresponding with
c:;acerbations of the local inflammation and
paralytic ileus, or temporary strangulation of
the diverticulum.
DI.AGNOSIS
The diverticulitis is most often mistaken
for appendicitis and intestinal obstruction.
The differentiation is most difficult. The
signs which should attract the attention of
the surgeon: (1) the localization of the ten-
derness above and inside of iNIcBurney's
point, or even in the median line below the
umbilicus; (2) rigidity in the same region;
(3) the presence of blood in the stools, often
found only on microscopic examination; (4)
the existence of an umbilical fistula or other
congenital malformation. These signs are
not at all definite and might easMy be present
in inflammation of an aberrant appendix. Be-
tween an intestinal obstruction and an in-
flamed diverticulum the diagnosis is difficult.
On the one hand, we have the evdences of
obstruction most marked; on the other, those
of intra-abdominal inflammation; with the
local'zed tenderness, temperature elevation
and rigidity.
TREATMENT
In uncomplicated cases there are two
methods of treatment commonly used. The
first is preferable and consists in removal of
the diverticulum by an elliptical incision
which is made transversely so as to avoid any
narrowing of the lumen of the bowel. The
intestinal wall is closed with two tiers of
September, 1020
SOUTHERN MEDICINE AND SURGERY
621
sutures in the usual way. The second method
is that of inverting the diverticulum into the
lumen of the bowel. Th!s is considered satis-
factory for small diverticula.
In complicated cases the treatment is alter-
ed as the condition demands. This may ne-
cessitate the dra'nage of a localized abscess,
the treatment of a generalized peritonitis, or
the resection of a portion of gangrenous
bowel.
CASE REPORT
i\Ian, 21, admitted to Wilkes Hospital
Xovemlier 8th, 1927, complaining of pain in
the epigastrium. He stated that he was well
up until two days previous when he developed
a dull, aching pain in the epigastric region.
The pain is continuous and radiates from the
umbilicus to the left side of the abdomen.
He has vomited several times. The bowels
have moved once. He states that he has dif-
ficulty in urinating, but has no burning fol-
lowing the act. He gives no history of indi-
gestion, but states that he has had several
attacks similar to the present one and always
associated with vomiting.
The family and personal histories are es-
sentially negative.
Examination reveals nothing abnormal ex-
cept marked tenderness on palpation in region
of the umbilicus, and marked rigidity of the
abd( mi'.ial muscles, particularly the right rec-
tus?, and a leucocyte count of 9,200, poly-
m.aphonuclears 75 per cent.
D'mguosis. — Acute inOammation of .Meck-
el's d verticulum.
Treatment. — Under ether anesthesia a
r ght rectus incision was made. The cecum
was found lying rather high. Upon further
examination a diverticulum was found com-
ing off from the ileum about two feet above
the ileo-cecal valve and stretching across to
the imibilicus where it was attached by its
d stal erd. The diverticulum was about the
same as the ileum and about five inches in
length. It was acutely inflamed and filled
with hard fecal concretions. An elliptical in-
cision was made around the base transversely
after intestinal clamps had been placed above
and below. Sutures were placed longitudinal
to th: axis of the bowel, two layers being
placed in the usual way. The patient's tem-
perature rose to 101 on the second day and
then descended gradually to normal at the
end of one week. The wound healed by first
intention and the patient made an uneventful
recovery.
CONCLUSION
In cases in which celiotomy is performed
for other cond tions and there is no reason
for haste the terminal two or three feet of
ileum should be examined for possible Meck-
el's diverticulum, and if found, it should be
removed if it would not too greatly increase
the risk for the patient. In cases of obstruc-
tion of the intestines of doubtful origin and
in cases considered as aberrant appendicitis
in which the diagnosis is doubtful IMeckel's
diverticulum should be considered.
:-\f: w..
SOUTHERN MEDICINE AND SURGERY
September, 1Q29
The Venereal Menace*
W. W. Craven, M.D., Charlotte, N. C.
One after another of the agencies which
have retarded the fuller and more satisfac-
tory development of society have come under
the condemnation of the masses and efforts
more or less successful have been aimed at
their suppression or extinction. After centu-
ries of uncurbed rampage the rum demon be-
came intolerable and society has taken a
stand, feeble though it be, against it. Then
came the fight against opium and its deriva-
tives and its path across time is being made
much more difficult than it once was. Today
an effort is being made to cause a recession
of the automobile speed menace perpetuated
by the reckless sfieed demon loaded with "fire
water," or perhaps only with the spirit to
kill. Finally public attention is becoming
more or less directed towards the so-called
social diseases, gonorrhea and syphilis. To-
day America as never before is faced with
the momentous question of how best to con-
trol these two diseases, to say nothing of the
swath being cut by the bacillus of Ducre.
Unless there is a slackening of the inroads
made by these diseases on the human econ-
omy disasters from these sources will inevita-
bly increase.
The exact origin of these diseases as to
time and place is not definitely known, but
it is probable that the peoples of the early
dawn of history were familiar with them.
Chapter XV of Chronicles refers to an ail-
ment whose symptoms as recorded are very
suggestive of gonorrhea. In the present era
with so many means of rapid transportation
the matter of limiting prostitution is a greater
problem than ever. The isolation and cure
of those infected seems to be an ideal well-
nigh unattainable. In times past when pop-
ulation was not shifting and drifting as it is
today there was far less chance for rapid
and widespread dissemination of venereal dis-
ease. Before the Civil War and for many
years thereafter, notably in the case of the
colored race, there was little change of resi-
dence and these diseases were rarely encoun-
tered. In Africa among the native blacks
we are told by medical missionaries these dis-
eases were unknown prior to the advent of
the white man and his "advanced" civiliza-
tion. Today in proportion to the increased
profjensity of the colored people to go to the
big centers of population has the venereal
menace advanced on this race. The well
known song that the colored man chants, "He
rambled, he rambled, he rambled till the
butcher man cut him down," is pathetically
true in more ways than one. The venereal
butcherman lays him low by the tens of thou-
sands annually. On the return of the prodi-
gal son from his travels there is a noteworthy
increase in the numbers of darkies applying
to the apothecary for medicines purported to
cure strains, running reins, etc.; nor is this*
limited to those of dusky hue, for there are
other prodigal sons of a different color that
are prolific sources of trouble. Probably
every nation under the sun is infested with
this particular breed.
Heretofore society has had no way of
knowing of the countless number of human
derelicts strewn along the highway of licen-
tiousnc::s. The public should know ot the
thousands of children in the world whose
eyes have been forever curtained by the gon-
ococcus and whose minds have been clouded
by the Treponema pallida. Dwarfed and de-
formed bodies harboring minds of imbeciles
are encountered every day in every part of
the world resulting more often than is sus-
pected from this curse on the human race.
The public should know of the thousands of
unsexed and sterile women made so in toll to
the inexorable depredations of the gonococcus.
It should be told that the larger per cent
of major gynecology is due to the ravages
of this same organism. One of the saddest
pictures that the doctor has ever known is
that of the ignorant and trusting bride who
marries "a man's man and a ladies' man,"
one who prides himself on being "a regular
fellow," and looks forward to a happy mar-
ried life, and — what is her rightful and happy
expectation — children of her own body All
♦Presented to Mecklenburg County Medical Society.
September, 1P29
SOUTHERN MEDICINE AND SURGERY
623
too soon comes the discharge that knowingly
or unknowingly the fam'.ly physician assures
her is a result of marital relations and will
adjust itself. Then follows the slight pain
in the pelvic region accompanied by a notice-
able tenderness. At first it seems that there
is little reason for apprehension, so uncom-
plainingly she travels her road of pain not
knowing the cause of her sui'fering, believing
it to be woman's portion. In the meantime
the errant husband goes on his way like the
proverbial lion seeking whom he may destroy.
Finally there comes a day when the wife
finds herself a bed-ridden invalid, and it
dawns on her that she is seriously ill. Next
comes the trip to the hospital with its at-
tendant dangers and mutilation for something
of which she is both ignorant and innocent.
In due time she leaves the hospital — if in-
deed she does not lose her life — unsexed and
with her most cherished hope — that of moth-
erhood— gone forever. Surely something
should be done to avert this appalling mis-
fortune that is befalling so many of our wo-
men day after day. Sympathy on the part
of the guilty party will never bring relief or
satisfy the demands of justice.
To attempt to give even approximate sta-
tistics on the prevalence of gonorrhea and
byphilis is manifestly impossible for thou-
sands of these patients never go to physicians
and a knowledge of their presence never
reaches the collector of statistics. The very
nature of these diseases insures knowledge of
their existence being scrupulously safeguard-
ed. Many of the sufferers never confide their
secret to any one, simply buying patent medi-
cines said to cure such diseases as they think
they have. It is safe to say that not less
than 60 per cent of males at one time or an-
other have had gonorrhea or syphilis, or both
simultaneously. As to their prevalence among
females it is far more difficult to arrive at a
conclusion. Some fifteen years ago Keyes
thought that there were perhaps sixteen cases
among males to each among the opposite sex.
Were he living today no doubt he would re-
vise his figures. Owing to inborn modesty
the woman is slow to consult a physician and
when ihe does he is often left in doubt as
to the presence or absence of the gonococcus.
Numerous mistakes in diagnosis are made in
this realm of medical science. Fortunately
nature unaided often brings these cases to a
safe conclusion. It is a curious fact, states
Keyes, that gonorrhea is either much more
mild or much more severe in the woman than
the man. Many women are unaware that
anything is wrong, while others are quickly
overwhelmed by salpingitis, pelvic abscess
and, sometimes, complicating peritonitis.
In the male one encounters an intlamma-
tory condition of the prostate gland in prac-
tically ail cases where the posterior urethra
has been invaded. Here it is frequently most
intractable and is a source of many grave
lesions within the gland itself, and here, too,
we iind the pwrt of entry of systemic gon-
orrhea. When there is a cessation of dis-
charge from the external meatus the patient
experiences a feeling of false security not be-
ing conscious of the fact that the deep ure-
thra in very many instances is still an ex-
creting surface that is unloading pus well
laden with the infectious organisms. This
very condition constitutes the greatest men-
ace on the part of the male. He, ignorantly
in most cases, transmits the infection to the
wife or prostitute. He is misled through the
circumstance of the pus being prevented from
appearing at the external meatus by the ac-
t.uii ol ilie n.inpressor urethrae or cut-off
muscle.
The last count in the indictment against
gonorrhea is systemic gonorrhea or gonorrheal
rheumatism, a condition comparatively rare
and fairly controllable. This cond'tion is
rather grave in that at times it is respons.b.c
for iritis and endocarditis. About one-half oi
one {jer cent of gonorrheal cases are suppjsjJ
to invade the general system. Then the
course of the disease is one of slow progress.
As to a man or woman being permanently
and hopelessly disabled by the venereal dis-
eases authorities differ widely. There are
some of large experience who believe, or at
least profess to believe, that no one is ever
thoroughly cured of gonorrhea. Any statis-
tics at all where the collector is both jud ;e
and jury should be carefully considered be-
fore acceptance. No man's opinion is infalli-
ble and no one has a monopoly on wisdom.
Certainly there is a reasonable exj:)ectation oi
cure in 75 per cent of all cases that take a
thorough course of rational treatment. We
vainly search for a remedy for the present
deplorable status of this menace. We ask
ourselves the question whether or not legal
SOUTHERN MEDICINE AND SURGERY
September, li329
measures will be efficacious. This is extreme-
ly doubtful. A standardized e.xamination of
the applicant for marriage made in a correct
and impartial manner by a board appointed
by the state medical authorities would be a
step in advance of the present slipshod meth-
od where the family physician is the arbiter
as to eligibility for marriage. The problem
of marital unfaithfulness and clandestine liv-
ing is wellnigh insurmountable and is ob-
viously beyond the pale of the law.
Women must learn, if indeed they do not
know, that men and women hold entirely dif-
ferent positions as to infractions of the laws
of sexual morality, both as to physical conse-
quences to themselves and public opinion.
No such appalling misfortune awaits the male
who has contracted gonorrhea as that which
threatens the life and character of the fe-
male. The guilty man belongs to that class
in the majority, but not so in woman's case.
In the eyes of society man is hurt little, while
under the same count the woman is rated an
outcast and often has to suffer, in addition
to social ostracism, ravages of disease that
are irreparable. Thus to some extent we see
that the wages of sin are less inexorable in
the case of the male. This unfairness is ap-
parent to all, yet it must be faced by society
in general. Women are often innocently and
accidentally infected by using unclean syr-
inge nozzles and unclean linen. All physi-
cians nowadays encounter vulvitis in young
females due to criminal carelessness on the
part of those responsible for their care. It
is highly probable that the number of vene-
real cases is on the increase and that these
diseases are penetrating strata of society
hitherto immune. It is becoming noticeable
that colored people are no longer prolific.
The gynecologist knows better than any-
one else of the enormous number of uterine
adnexa removed from the women of both
races on account of the inroads of venereal
diseases. Women generally and not a few
men know practically nothing of the nature
of syphilis and gonorrhea. In the case of the
young woman many times when the moral
issue involved is not sufficient to restrain her
from a plunge into the realm of venery the
fear of physical suffering dissuades her.
Every living thing seeks to evade anything
that will entail bodily suffering. If the pub-
lic could follow the doctor through the wards
of suffering ever present in all hospitals — and
after a manner this is possible through the
press — and there see the countless victims
doomed to the operating table through the
agency of venereal disease, it would take this
matter of the social diseases far more seriously.
Society in general would cons'der well before
taking any step that would lead into this
road at the end of which is only broken
bodies, heart-aches, and blighted lives. Num-
erous indeed are the sacrifices made each
year at the shrine of Venus. An improve-
ment in the moral tone of society offers the
best solution of the venereal menace. Our
ministers and welfare workers might be more
effective if they spoke more plainly, using
terms that could not be misunderstood. The
proper dissemination of literature bearing on
the subject would undoubtedly have a far-
reaching effect. Punishment for the guilty
parties would be efficacious could they always
be apprehended; small cash fines and sus-
pended sentences do little good towards re-
straining the hygienic law-breakers as well
as those who break criminal laws. Punish-
ments regardless of the offense aimed at are
practically worthless unless they hurt. The
prospect of real punishment would make the
infectious libertine consider well his step be-
fore advancing further along his road of con-
quest. Our present laws regarding venereal
disease are broken with the same impunity
and abandon that traffic laws are brolcen. As
to ind vjdual prevention there is no infallible
method. A better method of dealing with
prostitutes would be putting them to some
kind of hard work and seeing that they d d it.
The idea of work is od'ons to th's class.
Bringirg venereal disease and sexual matters
into the light of day and into public under-
standing seems practicable and promising.
The prostitute like the poor we have with us
always, still it is to be hoped that in the fu-
ture it will be in ever decreasing numbers.
Whether or not the social diseases are un-
dermining the physical and moral stamina of
this nation is a question worth deliberating.
Will mighty Uncle Sam, as did mighty Samp-
son, fall a victim to the lusts of the flesh?
Signs are ominous to sav the least.
A he-rmn is one who die; eirly because a little
germ or a little exposure can't scare a guy like him.
— Los Angeles Times,
September, 102Q
SOUTHERN MEDICINE AND SURGERY
Case Report
Thrombo-Angiitis Obliterans
Douglas Jennings, M.D., Bennettsville. S. C.
Marlboro County General Hospital
Allen and Brown, of Rochester, after a
study of 200 cases of thrombo-ansjiitis obliter-
ans, state that their experience tends to favor
conservative treatment. They have averted
amputation in many cases by carefully and
persistently carrying out medical and physical
measures for long periods of time. They fur-
ther state that they have been able to control
pain by the injection of foreign proteins. It
is because of this latter statement that this
case is reported. The writer has secured s m-
ilar results in two other cases; but, as the
records on these cases are incomijlele, they
are not included in this report.
October 10, 1927, white woman, 64, cams
under my care because of intense pain in right
band extending to elbow. This pain was as
■f the hand were being severely gripped and
lyas associated with alternate congestion and
pallor of the fingers of the hand. There were*
contractures of the thumb and forefinger.
The patient observed that the hand would be
blue and hot for a while, then pallid and
cold. She also described [jeriods of transi-
tory edema of the fingers. This trouble had
lajted for several weeks and she had first
taken coal-tar drugs for relief, and was now
taking opiates. These gave relief for only a
chert time. Keeping the hand immersed in
cold water gave mure relief than anything
else.
Examination showed an undernourished
and emaciated white woman, appearing age
given, blood pressure 160/80, urinalysis neg-
ative, Wassermann and Kahn negative. Phy-
sical examination not significant except for
very tender right hand, contractures of the
thumb and forefinger of right hand, alternat-
ing periods of congestion and heat with pal-
lor and coldness. The pain seemed to be
more intense with the pallor. The distal
halves of the thumb and forefinger seemed
(o be bloodless, even during the periods of
congestion of the hand.
Didt^iio.sis: Thrombo-an^iitis uhliUTans.
Treatment: Patient refused aniiniiatioii
of the bloodless fingers and stated that she
would go home and "tough it out." She
returned about four months later and request-
ed amputation of the bloodless fingers (thumb
and forefinger). The condition of the hand
at this time was unchanged and she stated
that she had suffered constantly since her
first visit. The thumb and forefinger were
amputated under local anesthesia at the
metacarpo-phalangeal joints. Tourniquet was
not used and there was no bleeding.
This patient was seen at intervals from
.Apr'l, 1928 to June, 1929. She obtained some
rcl'ef from pain after am[Hitation of the
firg^'rs and resumed her work (textile), but
returned in June, 1929, complaining that the
pain was as severe as ever and that it had
never been entirely relieved. On June 26th
the was given three minims of typhoid vaccine
■n the superficial veins on the wrist of the
r.'' ht arm. She suffered a violent reaction
with h'gh fever and general muscular aching
for two days after which she was entirely
relieved of Ih; pain in the hand (first relief
in two years) and the stiffness in the hand
had disappeared. Two weeks later she was
g ven a second dose of 2 minims, and again
on July 6th she was given the third dose of
2 minims.
Th's patient is now completely free of pain
and has been since the first dose of vaccine.
The hand is not sti!"f nor drawn and she uses
it constantly. The color is good and there
are no temperature changes. She has been
discharged but will be kept imder observa-
t'on for some time.
Hypoplasia of Enamel Showing Result
OF Treatment
p. L. CllLVALIEK, D.D.S.
.Associate Prufe;sor of Crown and Bridpe
Medical College of Virginia
Richmond, V'a
Patient, age 22, pre>^ented with upper and
lower anterior teeth badly deformed and dis-
colored, cv'dently a hypoplasia of the enamel.
Numerous pit cavities on the labial surface
were filled with s'licate. When the |K)sterior
((••ih were in central occlusion, the distance
between the upper and lower anteriors was
SOUTHERN MEDICINE AND SURGERY
September, 1029
Figure 1
three-sixteenths of an inch.
Treatment: The six upper and lower an-
terior teeth were ground down, without dis-
turbing their vitahty, and porcelain jacket
crowns made. These crowns completely cov-
ered the teeth and prevented further disinte-
giation and made them long enough to obtain
a normal occlusion.
Figure 2
Figure 1 shows the case before treatment,
Figure 2 after restorations were completed.
Hygienic Conditions Important for
School Buildings and Grounds
(U. S. P. H. S. Matter)
No grade school should have more than
three floors. The exits from
the building should be wide and it is very
important that all doors in the building — in
the rooms, in the halls, and to the outside,
should open outward. The doors leading
from the building should be equipped with
automatic fool-proof devices which will open
the door when pushed by any child. The
reason for this is to prevent the piling up of
children in case of panic. It is notable that
in all the disasters of recent years in school
buildings the great loss of life has been due
to this piling up, either behind locked doors
or in narrow stairways.
One fountain to about
50 children is the best proportion. The only
satisfactory fountain is the type which sends
the water from the side of the bubbler and
delivers the stream of water obliquely. Any
fountain which permits the child to cover
the bubbler with his lips is to be condemned.
If the proper drinking fountain can not be
provided, then paper cups should be used.
If the ready-made paper cups are too expen-
sive, children can readily be taught to fold a
paper cup.
When possible, wash bowls with hot water
and a supply of liquid soap should be pro-
vided in every toilet room. One bowl to each
20 children is the minimum number. The
bowls should be the proper height from the
floor for children's use. Up to the present
time the paper towel is the only satisfactory
drying material available for schools.
If children are to learn the fundamental
health habit of the proper care of the hands
after going to the toilet and before eating,
the lavatory facilities should be kept attrac-
tive.
Of course separate toilet facilities should
be provided for boys and girls. Few piersons
realize that there are actually at the present
time, schools in this country where boys and
girls are forced to use the same toilets under
unbelievable conditions.
It is unwise to use so-called disinfectants
and deodorants.
Cleanliness is the best deodorant and dis-
infectant. Soap and water are the best de-
odorants after all.
September, 1020
SOUTHERN MEDICINE AND SURGERY
627
— +
SOUTHERN MEDICINE AND SURGERY
Official Organ of
jTri-Sta(r Medical Association of the Carolinas and Virginia
( Vfcdical Socielj of (lie Stale of North Carolina
James M. Northington, M.D., Editor
James K. Hall, M.D
Frank Howard Richardson, M.D.
W. M. RoBEY, D.D.S
J. P. Mathf.son, M.D. .
H. L. Sloan, M.D
C. N. Peeler, M.D
F. E. MOTLEV, M.D
V. K. Hart. M.D
F. C. Smith, M.D.
Department Editors
Richmond, Va.
Bl.Tck Mountain, N. C—
Charlotte. N. C.
Human Behavior
Pediatrics
- Dentistry
Charlotte, N. C.
The Barret Laboratories Charlotte, N. C.
O. L. Miller, M.D. Gastonia, N. C
Hamilton W. McKay, M.D Charlotte, N. C. .
N.
Charlotte, N.
J. D. MacRae, M.D V . , .„
J. D. Macrae, jr., M.D. ' Asheville,
Joseph A. Elliott, M.D
Paul H. Ringer, M.D
Geo. H. Bunch, M.D
Federick R. Taylor. M.D
Henry J. Lancston, M.D
Chas. R. Robins, M.D
Olin B. Chamberlain, M.D..
Various Authors
.\shcvillc, N. C
Columbia, S. C
Hich Point, N. C. .
D.'nville, Va
Richmond, Va
Charleston, S. C...
Diseases of the
Eye, Ear, Nose and Throat
Laboratories
Orthopedic Surgery
Urology
Radiology
Dermatology
Internal Medicine
^Surgery
Periodic Examinations
„ Obstetrics
Gynecology
Neuro'ogy
Historic Medicine
On Appreciating and Applauding Original
Work of Home Doctors
(An Address to 7th Dist. Med. .\ssn. (S. C.)
Sumter, Sept. 12th)
In the first editorial under its present man-
agement th's journal had this to say:
The news columns will be open to any rep-
utable medical man offering a contribution
which appears to merit publicity. The sub-
ject matter itself will be given first considera-
tion. Facility and precision of expression are
seldom gained in the utilitarian courses of
today; therefore, they will not be rated pre-
requisites. I'reference will be given to
articles dealing with original work or per-
sonal clinical experiences. Research which
has direct clinical application is desired
above any other class oj essay. With a few
notable exceptions, the medical profession of
this section has almost entirely neglected this
field of medical science, and has been content
to quote northern, eastern, western and for-
eign investigators. Let us do mf)re investiga-
tive work and progress to the point where we
can quote ourselves and each other as final
authorities on special subjects.
Thus early and firmly we put ourselves on
record as heartily favoring original work by
our own doctors, and pled;::ed our utmost in
support of such work and such workers; and
the purfx)se thus pled-^ed has been steadily
borne in mind. We Southerners are in gen-
eral a modest lot, like our English forebears,
prone to under- rather than over-statement.
As a consequence of a half century of living
under straightened circumstances, having to
look to wealthier sections for most medical
training and per od cals, I rather fear we
have become afflicted with an inferiority
complex. Certainly we do not advertise each
other, our wares, or ourselves as we should.
Crawford W. Long d'scovers a ready means
of saving thousands daily the most horrible
suffering, and — most likely intluenccd by the
ultra-conscrvat ve Philadelphia school of the
period — gives his discovery only very restrict-
ed publicity; and the same general tendency
may be seen minifcsted by succeeding gener-
ations of Southern doctors all along to this
day.
Against this habit of mind and action I
wsh to protest by word and example. I
shall say something in praise of the excellent
SOUTHERN MEDICINE AND SURGERY
September, IQJQ
original work of same of our own doctors, the
investigative spirit which they manifest, and
the evidences which they disclose of full con-
sciousness of the fact that opportunities for
making additions to our means of making
proper diagnoses and applying effective treat-
ment are not limited to certain sections, or
to cities or towns of a certain size.
It will be noted that our first preference
was given to research work which has direct
clinical application. This in no sense belittles
other research. It only indicates that research
having no, or only remote, clinical applica-
tion, can be more appropriately published in
a journal other than one devoted to helping
the family doctor solve his daily problems.
It was a rare privilege to publish Dr. Wm.
deB. MacNider's studies on "The To.xic Ef-
fect of Certain Alcoholic Beverages on the
Kidneys," "The Pharmacology of Veratrum
\'iride with Certain Therapeutic Suggestions"
and "The Toxaemias of Pregnancy." The
lessons derived from such reseirches, put into
practice even very sc?.Ueringly th'-ough our
Taction, can not have failed to make better
doctors and save many lives. The work done
by Dr. Edward Jenner Wood in pellagra and
rprue was valuable in its direct results and
even more in the stimulation and encourage-
ment it afforded other doctors, in private
practice and without the resources of a teach-
ing institution behind them, to undertake in-
vestigative work. Some think of research as
restricted to laboratory specialties. Not very
long before his death Dr. Wood wrote me "I
like to recall the view of Sir James Macken-
zie, which we had repeated to us so often by
him, that each bedside observation was a
problem in original research"; and that
brings me to the point of saying each of us
can and should not only be dong the medicine
of today, but doing something toward making
the medicine of tomorrow.
In May, two years ago, we published a
statistical study on obstetrics for Dr. A. B.
Holmes, of Fairmont, N. C. In the following
year a medical journal in Helsingfors, the
capital of Finland, requested a copy of the
issue for May, 1927, and, in reply to an in-
quiry, stated, "We would advise you that a
client of ours was interested in an article by
Holmes, 'A Comparative Study of Obstet-
rics!'" Dr. Holmes is a family doctor in a
town of one thousand souls: his research
work in clinical medicine — the report cover-
ing less than two pages — attracts favorable
attention many thousands of miles away in a
country widely d'ffering from his — racially
historically, culturally, linguistically — but the
same in avidness for increase in power over
disease.
Now for two instances which are literally
of today.
Last year a generous North Carolina doc-
tor gave Southern Medicine & Surgery $500
to be used as cash prizes for the best essay,
written by a doctor in either of the Carolinas
or \'irginia, on "How the Family Doctor Can
Best Increase His Usefulness and His In-
come." One of the prize-winners was Dr.
Wingate M. Johnson, of Winstori'-Salem.
About a year ago Harper's Magazine publish-
ed h s, "A Family Doctor Has His Say,"
wh'ch received wide acclaim. In the issue of
(he Journal oj the A. M. A. of August 31st,
many of you will have noted a clinical study
of h's on "Tobacco Smoking," a line piece of
work which goes far to set at rest many points
of controversy which are generally argued
back and forth with much more of warmth
and prejudice than of knowledge.
The second achievement mentioned as of
today will be given a background of yester-
day. .\ little more than three years ago I
received the offer of a report of certain "Clin-
ical Observations on the Blood Capillaries,"
an opportunity which was eagerly grasped.
Perusal of the manuscript did not disappoint.
The spirit of investigation was revealed along
with abundant evidence that the investigation
was intelligently directed; and some clinical
application was made with bright hope held
out for wider usefulness.
Six months later came a reiMrt of the ef-
fects of certain drugs on the capillaries, the
list embracing such everyday drugs as atro-
p'ne, eserine, spartine, digitalis and caffeine,
and an unusual one — cucurbocitrin, from the
iced of our lowly watermelon. Here, too,
was evidence of usefulness at the bedside,
and of a new (at least new to most of us)
aid in a condition among the least amenable
to msd'cation — high blood-pressure.
Six weeks ago, in the morning mail wa;
found the record of another study, one which
inay prove far more productive of good than
any wh'ch has been made in our time. Ever
since Lister's day it has been well recognized
September, 102Q
SOUTHERN MEDICINE AND SURGERY
that antiseptics may do vastly more harm by
lowering the natural resistance of the tissues
to infection, than good by killing or crippling
the b iclerial invaders. The record received
in July is of results obtained in the laboratory
ai'.d in patients, and these results are such as
to hjld out the highest hope that there has
been worked out a well-nigh perfect bacteri-
cide.— ijismuih-Violet. If, in a large series
of cases, results can be obtained comparable
to those obtained in the cases entering into
his pieLminary report, a new era will have
dawned in the history of JMedicine's war
against infection.
The doctor who has done these things to
the added renown of his profession and his
State is a brilliant former teacher in the Med-
ical College of the State of South Carolina,
the present Health Officer of the City of
Greenville, Dr. Irving S. Barksdale.
.\nd if it should turn out that bismuth-
violet will not do all that it now appears ca-
pable of, I shall entertain a lively hope that
this worker who has gone so far will continue
to his goal; and whatever the verdict of ex-
tended e.vperience with the agents which he
has given us, we can all well be proud of Dr.
Barksdale's work, and seek to catch the spirit
which inspires him to it.
Search your minds right now and see if
you would not be much more impressed if
you had heard of such a valuable agent be'ng
worked out in Paris or New York, or even at
Medicine Hat or Wounded Knee. Our habit-
ual attitude is one of bearishness on our own
market. Excellent automobiles have been
made in N'irginia, North Carolina and in your
own Rock Hill: but distance lending enchant-
ment to the Detroit view, our own companies
went to the wall. Excellent tires are being
made in Charlotte, and more of them are
tunning in California th;in in North Caro-
lina.
But this attitude is undergoing ch?.nge. For
instance, South Carolina, having reason to
believe her vegetables to be superior, had this
established as a fact by a pro[)er investigation,
and now there are many evidences that this
natural advantage will be developed to the
material profit of the State and to the
betterment of health conditions inside and
outside the State.
There is no place in Medicine for a spirit
of setting the men or the products of our
own section above better men or products of
aiiolher section. I urge only that we rid our
minds of the ingrained idea that distant
things must be better, and thus make it possi-
ble lo do justice to our own men: and then,
when equally as good service can be rend?red
at home, have home men render it to the
mutual advantage of our patients and nur
d')Ctors, and a great falling off in deaths far
from home.
In concluding I would revert to the passage
in a letter from Ed Wood, already quoted in
p:i,rt: T like to recall the view of Sir James
iNlackenzie, which we had repeated to us so
often by h'm, that each bedside observation
was a problem in original research *****.
Every practitioner of medicine should require
of hmself that twice a year at least he report
something coming under his own observation
in a decent m"d cal journal." .\nd when the
cases are minutely studied at the bedside, re-
ported to a medical society and published in a
medical journal, let us be prompt to appre-
ciate and applaud the original work of our
own home doctors.
Dr. William Haines Wakefield
Dr. Wakefield was born in th? tnwn of
.\rkcll, Wellington county, (ilntario, Canada.
November 19, 1855.
He v.'^s d:scei!ded from English parents
who emigrated from England to Canadi,
about the year 1822. The family moved to
the United States and the Southland when
he was sixteen years old. on account of the
severity of the Canadian winters. 'I'hey lo-
cated at Friendship, a village between
Greensboro and Winston-Salem, N. C.
He was educated at the New (kirden
Board'ng School, a Quaker schoul, imw Guil-
ford College. He taught school two years,
and then began his business career as <i hard-
ware merchant in Greensboro in the year
1879, and built up a large and successful
business.
On November 2?,. ISSl, he was married
to i\Iiss Mary .Adams, of Greensboro. In
former days he had wished to study medi-
cine, but the opportunity was denied him,
St 11 the desire lingered and he determined
to carry out his wish. He read medicine one
year under Dr. Herbert Beall, of Greensboro,
as [irecejitor, which was often customary in
those days. He then entered Jefferson iMedi-
cal College, J'hiladelphia. He afterwards
SOUTHERN MEDICINE AND SURGERY
September, 1929
took a course in eye, ear, nose and throat dis-
eases in Louisville, Kentucky, and graduated
with honors in 1890.
Dr. Wakefield located in Greensboro and
practiced his specialty there two years. It is
said that he was the first physician in North
Carolina to make a specialty in diseases of
the eye, ear, nose and throat. In 1892 he
moved to Winston-Salem. In 1895, he moved
to Charlotte, N. C. He was associated with
Drs. C. A. Misenheimer, R. L. Gibbon and
John R. Irwin in 1896, in organizing and
conducting the Charlotte Private Hospital,
which later became the Presbyterian Hos-
pital. He was professor of Eye, Ear, Nose
and Throat Diseases in the North Carolina
Medical College, which was moved from Da-
vidson College, N. C, to Charlotte. In 1897
he took a post-graduate course in New York
to still further prepare himself for his chosen
work and specialty. In 1899 he was chosen
editor of the North Carolina Medical Jour-
nal, and under his guidance and editorship it
was improved and grew in favor with the
profession. He retired from practice in 1923,
on account of declining health. Then in 1924
he engaged in the florist business as a diver-
sion, having always been extremely fond of
flowers, and built up a profitable business.
He died of cardio-vascular disease August
12, 1929, after having been confined to bed
seven v.eeks. He was a member of and an
older in the Second Presbyterian Church,
Charlotte, N. C.
Dr. Wakefield is survived by his widow,
three sons. Dr. H. A. Wakefield, Archie
Wakefield, Dr. R. F. Wakefield, all of Char-
lotte, N. C; three daughters, Mrs. L. M.
Ham, of Greensboro, Mrs. E. R. Smith and
Mrs. O. L. Stevens, of Charlotte, and several
grand-children.
His mantle has fallen on the shoulders of
h:s son, Dr. Harry A. Wakefield, who is a
prominent and successful specialist in eye, ear,
nose and throat diseases.
Dr. Wakefield possessed the essentials for
success in his profession; integrity, industry
and good habits. The medical profession is
better for his having lived and practiced.
He was especially skillful and successful in
the treatment of children. He was genial,
social, cultured and interested in every good
word and work, and devoted to his fam ly,
his friends, his city and state.
— Dr. John R. Irwin,
Is Undulant Fever Carried by Milk?
For a number of years, indeed since our
attention has been directed to Malta fever
and the closely related undulant fever, it has
b:en generally accepted as true that convey-
ance is through m Ik of goats or cows. The
m'lk of goats is so little used in this section
as to lay all the blame locally on cow's milk;
and, as boiling or even pasteurizing is de-
structive to the causative organism, the blame
is narrowed to raw cow's milk.
Naturally, any suspicion attaching to so
generally used and valuable an article of food,
and one for which there is no satisfactory
substitute, is a matter of grave concern.
Especially is this true when the food is ac-
cused of being the bearer of bacteria which
cause a disabl'ng disease, prone to relapses,
the termination of which can not be foreseen
except as at a time vaguely stated in months
or years. When cases of undulant fever are
reported, the tendency is for careful doctors
to look into conditions under which the milk
supply of their own and their patients' fam"-
I'es are derived. Intelligent heads of fam'lie^
take the initiative themselves, often in con-
s'derable confusion as to how they may fol-
low the advice they have had, from Boards
of Health and their own doctors, that milk
should make up a large part of the daily
ration of their children, without, by so doing,
expos'ng them to serious disease.
It seems hirdly feasible to have all milk
pasteurized; be=Jd:s, there are many who can
not be induced to take milk which has been
heated. To shake confidence in an essential
food is a serious matter indeed, from the
viewpoint of the certain injury to the health
of the commun ty; and, going hand-in-hand
with this is the loss to dairymen who have
laid out great sums in money and in labor,
— in many instances at the insistence of
health authorities — that the milk needs of the
country mght be met. If distrust of milk
were to affect any considerable proportion of
the populace, the dairying industry would be
ruined; and then where would we get milk for
the babies, for the tuberculous, for all of us?
Fortunately, it seems that a review of what
has been learned about undulant fever tends
to weaken th; hzV.ei that it is often — if ever —
trar.sm tied by means of milk. In the issue
for August of Annals of Internal Medicine,
there is an article' by Dr, George Blumer, of
September, 1029
SOUTHERN MEDICINE AND SURGER\
Yale University, based on a careful survey
of the field, which is worthy of earnest study. -
Dr. Blumer found that there were large
areas of the country from which no cases
have been reported, that undulant fever is
least common among those who drink most
milk — children; and he quotes Madsen as
saying: "No case has ever been observed in
the hospitals and asylums for children in Co-
penhagen where raw milk is used in large
quantities." Theobald Smith has been unable
to find an organism taken from a human case
which corresponds with the bovine type, and
other observers state that all organisms they
have studied of human origin have proven to
be of the type which infects hogs.
We heartily agree with Dr. Blumer's con-
clusion that it is important that we obtain
accurate knowledge of the method of spread
of the disease, "lest, in their enthusiasm, leg-
islatures begin to pass unwise laws relating
to infected cattle and to the distribution or
handling of milk and milk products;" and,
we will add, lest unwisely instilled fears of
a shadow deprive us of a very necessary sub-
stance.
1. "Undulant Fever in the United States." Read
before the .American ColIeRc of Physicians, Boston,
.\pril, 1929.
2. Write him at New Haven, Connecticut, request-
ing a reprint.
Fee Splitting — Unnecessary Operations
Charlotte, N. C, .'Kuk. S, 1Q29.
My Dear Dr. Cabot:
I hope you will write an editorial for this journal
somewhat after the fashion of the one from your
pen in the AuRUst issue of Colorado Medicine. If
you can be prevailed upon to make it so, I would
be glad to have it somewhat more comprehens've.
My opinion is that fee splitting, directly or indi-
rectly, is by no means prevalent in this section.
However, I believe it to be on the increase.
The granting of this request will be in the interest
of Medicine and those it serves. I trust you will
comply.
Sincerely yours.
Jus. M. Northini^ton.
Schoolhouse Ledge
Northeast Harbor, Maine
Dear Dr. Northington:
I enclose an editorial as you request. But you
are of course under no obligation to use it if you
think it will hurt your circulation.
Yours cordially,
Richard C. Cabot.
Aug. 16, 1929.
Now that I have retired from active prac-
tice I am in a position to hear the opinions
of the laity about the medical profession very
freely, and nothing seems to me to be doing
us so much harm as the fear of unnecessary
operations, especially for that non-e.xistent
disease, chronic appendicitis, but also for
gall-bladder trouble and duodenal ulcer. Peo-
ple often refuse or postpone operation when
they sorely need it, because they have become
aware that unnecessary operations are now
being done with considerable frequency in a
good many parts of this country.
The greatest temptation to unnecessary
operatons comes, I think, from the practice
of fee splitting. No operation, no surgeon's
fee. No surgeon's fee, no percentage fee for
the general practitioner. So the general prac-
titioner urges operation and arranges with a
complacent surgeon to get a share of the
m.oney that is stolen from the patient, stolen
because no corresponding value is received.
It is strange that so many physicians who
are indignant at burglaries and holdups
should themselves take part in thefts that
are accompanied by more danger to life than
most burglaries. But I know that such is
the case because physicians have themselves
confessed and even defended the practice of
fee splitting in my presence, usually covering
it up with the pretense that they "assisted"
the surgeon at the operation. Of course com-
petent surgeons have their own assistants and
do not endanger the success of an operation
by trying to work with an amateur, which
is all that the general practitioner can be in
the field of surgical technique. So long as
jjhysicians continue to excite in the public
m'nd the well warranted fear that they are
not working solely in their patient's interest,
the osteopaths and the chiropractors will con-
tinue to flourish and to increase in numbers.
— Richard Cabot.
Noah's Ark E.xpedition .\ssociation has asked
Turkey to permit to hunt for the first navigator's
boat. Bishop Cannon probably had it confiscated
when he found that Noah had wine aboard. —
Greensboro News.
Georgia legislators get wrought up because news-
paper writer referred to them as "flop-eared jack-
asses." Flop-ears must have some significance in
Georgia not appreciatecj cls?whcr?. — Greensboro
News.
SOUTHERN MEDICINE AND SURGER\
CORRESPONDENCE
September. 1Q20
Charlotte, N. C, August 1, 1929.
Dr. Joseph Colt Bloodgood,
Baltimore.
Dear Dr. Blocdgood:
For a number of years I have been much
concerned about what appears to me to be a
state of stalemate in our warfare against can-
cer.
In ^Nlarch, 1928, I wrote an editorial in
this journal under the caption, "What Evi-
dence is There That We Are Curing Any
Patients of Cancer?", from which certain par-
agraphs are here quoted:
"The editor would like to have for presen-
tation to his readers evidence — evidence
which will bear the closest scrutiny — that
surgery, x-ray, radium, or any other measure
we are now using is preventing the develop-
ment of cancer, curing patients of cancer, pro-
longing the lives of those having cancer.
"Some say operation should be done in the
pre-cancer stage. What evidence is there of
the existence of a pre-cancer stage, except
that gained, in each instance, by looking back
from the cancer stage?
"We are told that only in its early stages
will surg,?ry cure cancer. Will it cure it
then?
"We believe that most doctors and intelli-
gent laymen are concerned about these mat-
ters, and that straightforward answers will
cerve a good purpose."
Will you not contribute an article for pub-
I'cat'on in an early issue coverin-^ this point
?s definitely and concisely as possible? I am
confident that it would find a very hearty wel-
come.
With cordial regard.
Yours,
JAS. jNI. NORTHINGTON.
Fairhiilt, Burlington, Vermont,
(until Sept. 15th)
August 17, 1929.
Dear Doctor Xnrthingtnn:
I am of the opinion that there is no "stale-
mate" in our warfare against cancer. Up to
.'900 Emong all the cases that came to Johns
Hopkins Hospital with troubles in the breast,
;k'n, mouth, abdcmcn, uterus, at least 80 per
cent were cancer, and 20 per cent benign,
and less than one per cent in the stage that
precedes cancer and in which cancer can be
prevented without operat'on. Over 50 per
cent of cancers were hopeless, and less than
10 per cent were cured for five years. Since
1920 that has bjen reversed. The percentage
of cancer had been reduced from eighty per
cent to twenty per cent; the cures have been
increased from ten per cent to sixty per
cent; and the percentage of lesions for
wh'ch operat'on is not indicated have been
increased fr:m less than one per cent to
more than s xty-five per cent. .\nd th's is
not due to Eu.gery, x-ray. or rad.um, but
to the applxit'.on cf these al a much earlier
period of d'sease. A wari is an incipient
cancer. If you remove a wart properly, the
cures are one hundred per cent, for they
are classed as a benign tumor. Neglect a
wart until it is cancer and it will be clas ed
as "cancer" and the chances of a cure w If
not be a hundred per cent. There is no
question as to the complete excision of can-
cer when it is like a local disease: the m'cro-
scope cancer offers seventy per cent, or more,
chances of a cure. When the neighborinf^.
or near, glands are involved, the five-yeiir
cures drop at once to twenty per cent. When
metastasis has taken place iiiternally there
are practically no cures.
You may publ'sh th's letter a;:d if you like
I w.ll later write you an article; but just
now I am very busy. That is the best I
can do for you ju;t now, because I have just
started a great resjirch laboratory in connec-
t on with the Surjical Pathological Labora-
tory of Johus Hjpkins Hospital.
Your letter of August 1st has been re-
ferred to me, hciC, and I am glad to say it
is cool enough to give me sufficient energy
to answer it; and I wish 1 could send some
of the cool breezes to you in the south.
\'ery sincerely yours,
JOSEPH COLT BLOODGOOD.
Charlotte, X. C, August 28, 1929.
Dear Dr. Bloodgood:
The stubborn fact which troubles me abnit
the cancer ::ituation is the markedly increas-
ed death r_;te. If we contend that our efforts
are sav.ng 1 vcs which would otherwise b?
loEt by the ca:xer route, we must admit th^t
the natural increase is something tremen-
Sept"mhcr, 102Q
SOUTHERN MEDICINE AND SURGERY
dous: since the net result is a markedly in-
creased death rate.
Do you have any statistics which go to
show that the death rate from cancer of the
cervix is less in countries or sections in which
a great proportion of the cervical tears are
rcpa'ied than in countries in which no or few
torn cei vices are repaired? Or any such fig-
ure;; on the death rate from cancer of the
skin or breast in relation to the total number
of so-called precancerous warts, moles or
lumps removed? Some such figures as these
aie those in which I am not interested.
I cm going to take advantage of your kind
ofi'er to write me an article at your conveni-
ence, whch article I hope will approach the
subject from a statistical angle, somewhat as
sui-gcited in the questions asked.
With cordial regard and appreciation,
Yours,
J AS. M. NORTHIXGTON.
llijii^c of Representatives, United States
Washington, D. C.
July 18, 1929.
?vly Dear Di)ctor Northington:
I have in course of preparation a b'll
£tre;ip;lhcn'ng the narcotic laws in the light
of our experience since the passage of the
Harrison Act, and I appreciate very much the
article which you enclosed relating to codeine.
I am trying to enlarge the right of physi-
cians to prescribe these drugs and relieve them
from some of the present annoyances. I
know ynu will realize it is extremely difficult
to do so.
I investigated codeine very carefully on
several occasions, with the result that there is
considerable conflict on the question of
whether or not it is habit-forming, but it
is likely the matter will be fietermined during
the consideration of my bill.
Very sincerely yours,
STEPHEN G. PORTER.
TWO .MLMENTS
Kind I.aily: "What'? trnuhlinc \nii, my little
man?"
l-ittk- Willie (on his way home from school):
"Dyspepsia and rheumatism."
Lady: "Why, that's absurd at your ape: how
can that lie?"
Willie: "Teacher kept me after school because I
coulrln't spell 'em." — Nebraska Med. Jour.
Meeting American College of Surgeons
The .American College of Surgeons will hold
its nineteenth annual Clinical Congress in
Chicago, October 14-18. Headquarters will
be at the Stevens Hotel. An intensive pro-
gram is being planned to make this home-
coming event the greatest in the history of
the College. The Hospital Standardization
Conference will consist of morning and after-
noon sessions on Monday to Thursday iiiclii-
sive. There will be a series of clinical demon-
strations given by: George \V. Crile, Cleve-
land; John B. Deaver, Philadelphia; : John
M. T. Einney, Baltimore; Charles H. Mayo,
Rochester, and others. Monday evening's
jjrogram will include an address of welcome
by the Chairman of the Chicago Committee
on Arrangements, Dr. Herman L. Kretschmer,
the address of the retiring President, Dr.
Eranklin H. Martin, Chicago, the inaugural
address of the new President, ISIajor-General
Merritte W. Ireland, Washington, D. C, and
the John B. IMurphy Oration in Surgery by
Professor D. P. D. Wilkie of Edinburgh.
Among the foreign visitors will be; Dr. James
Heyman of Stockholm, Dr. Thierry de Martel
of Paris, V'isconte Aguilar of iMadrid, and Mr.
Herbert Tilley of London. A rate of one and
one-half the regular one way fare has been
granted on railroads of the United Slates and
Canada to those holding convention certifi-
cates.
Dr. McGuire Honored
In recognition of his long service as presi-
dent of the Medical College of Virginia, Rich-
mond, from which Dr. Stuart McGuire re-
tired on July 1, 1925, the board of visitors
of the college has established the McGuire
Lectureship which will be filled annually by
an invited speaker. The subjects of the lec-
tures will usually cover topics related to medi-
cine, dentistry, pharmacy, or nursing, the
fields covered by the several sch<iols of the
inE:titution.
"When did the first Scotchman learn to swim?"
"When the first toll bridge was built," — Colorado
Atedicine,
Dr. Wm. deB. MacNider, jirofessor of
pharmacology in the University of Xorth Car-
olina and a scientist of international renown,
received new distinguished recognition in be-
ing invited to present a communication to the
International Physiological Congress, meeting
in Bo. ton in the last week of August.
SOUTHERN MEDICINE ANB SURGERV
DEPARTMENTS
September, 1920
HUMAN BEHAVIOR
James K. Hail, M.D., Editor
Richmond, Va.
A Study of Capital Offenders in North
Carolina
Henry Spivey and Walter Morrison, both
distinguished colored citizens of North Caro-
lina, lie in graves probably unmarked, if in-
deed their bodies lie buried at all. The for-
mer has the distinction of being the last man
to be legally hanged in the State, and the
latter was the first citizen of the State to be
legally electrocuted. Spivey was killed by
the State on March 12, 1910, and Morrison
felt the vengeance of the state's citizenship
in the electric chair six days later. In that
interim the old method of killing had given
way to the new. There is progress in killing
as in other forms of civic activity.
From early in 1909 until the latter days of
January, 1928, 200 persons were committed
to the state prison at Raleigh after having
been convicted of capital crimes. One hun-
dred and forty-nine of them were negroes
and 51 were whites — 74 per cent as against
25 per cent, and of the 200, 94 were put to
death in the chair. Eighty-one of those who
suffered death were negroes. It is to be noted
that of those convicted of capital crimes 74
per cent were negroes, and of those who were
actually electrocuted 86 per cent were ne-
groes. Is it to be inferred that the whites
are less apt to be charged with capital crimes,
or less apt to be convicted? If tried, do the
negro's chances of escaping the chair seem
relatively poorer than the chances of the
white person?
."Mmost three-fourths of those who were
actually electrocuted had been convicted of
first degree murder; almost one-fourth were
guilty of rape; and two individuals gave up
their lives in atonement for first degree bur-
glary. Almost 60 per cent of those electro-
cuted for murder were negroes, and 95 per
cent of the rapists were negroes. Of all the
negroes convicted of capital crimes 40 per
cent went to the chair; but of all the whites
convicted of capital offenses only 6 per cent
were electrocuted. In the year 1909 only
one person was electrocuted: in 1912 none;
in 1913 only one; in 1924 the highest num-
ber— 9; and in 1927 only 4 were put to death
by the State. In the year 1914 there were
12 commutations against 5 electrocutions,
and again in 1922 there were 12 commuta-
tions and 5 electrocutions. Of the 200 per-
sons who were sent to Raleigh to be electro-
cuted an even hundred escaped the electric
chair by commutation of the sentences to life
imprisonment, or to a shorter period, in the
penitentiary. In this way the one woman —
a white woman — was saved from death. Even
thouph one might infer that juries experienced
little hesitation in finding negroes guilty of
capital crimes, a detailed study of the figures
ind'cates that Governors dealt generously
with the negroes in commutations. Indeed,
two-thirds of all the commutations went to
negroes. Ingratitude finds its symbolization
in the figures. Of the even hundred who
were given the privilege of service in the peni-
tent'ary rather than occupancy for a few mo-
ments of the great chair 18 ran away, and
almost half the number of elopers were
whites, and not a single person who escaped
has come back into prison, willy nilly. A
small number of those convicted were event-
ually pardoned, and a smaller number still
were transferred to the resjsective departments
for the criminal insane.
The average age of the convicted negroes
was 30 years; of the convicted whites 35
years. The ages of most of those when con-
victed was between 20 and 40 years. Mar-
riage, it would seem, did not act as a deter-
rent to criminal conduct, as more than half
of all those who were convicted had been mar-
ried.
The educational status of these capital of-
fenders is interesting and their handicap in
this direction probably throws light upon
their conduct. Out of all the 200—149 of
whom were black and 51 of whom were white
— 142 were wholly illiterate. One hundred
and twenty of these were negroes, and 22
were whites. In other words, more than 80
per cent of the convicted negroes were unable
to acquire any information from the printed
page, and to more than 40 per cent of the
convicted whites not even the alphabet meant
anything at all. Less than one-fourth of the
negroes could read and write, and scarcely
September, 1020
SOUTHERN MEMCINE AND StRGERY
655
more than half the whites could read, and of
those who could read the educational re-
sources were most meager.
The former occupations of those convicted
indicate that few of them had received any
technical training. A few of the negroes
were locomotive firemen. One white man
was an engineer, and a few others had some
trade. But most of the offenders were far-
mers and laborers.
The most interesting feature of the report
is carried in the detailed medico-sociological
study made of 26 of the convicted persons —
6 of them white and 20 of them negroes. Not
a single prisoner so studied was found to be
mentally normal. Most of them were feeble-
minded, and a number of them e.xhibited defi-
nite mental disorders. But of this number 5
Vvcre electrocuted. One of this number had
been confined as insane in another state and
the superintendent of a State Hospital in
North Carolina also pronounced him insane.
But the State went along and killed him just
as if he had been sane. (And as if to keep
step at least in one particular, the Common-
wealth of Virginia not long ago electrocuted
a prisoner who had been regularly adjudged
insane a short time before he committed a
capital crime.)
Figures are peculiarly distasteful to me,
but each of these symbols represents a hu-
man being, and each of the human beings
was dealt with by the State of North Caro-
lina, and 94 of them were killed by the State.
Most of those killed were negroes, most of
them were illiterate, most of them were poor
and friendless, most of them had been with-
out opportunities, and a large number of
them were so circumscribed in mental capac-
ity as to make it impossible for them to stand
alone in the complexities and difficulties of
modern life. They became criminals prob-
ably because they were relatively helpless in
the life-struggle with those who were fit and
efficient.
I commend to you for careful study Capi-
tal Punishment in North Carolina, being Sp)e-
cial Bulletin Number 10, of the North Caro-
lina State Board of Charities and Public
\\'elfare, Kate Burr Johnson, Commissioner,
Raleigh. I hope the citizenship of the state
will read it carefully and prayerfully.
In 1746 England convicted of treason,
hanged, partially, and dismembered com-
pletely, and quartered, three lords and earls.
In 1787 a negro man was legally burned at
the stake in Duplin county and his ashes
were scattered over the courthouse green. In
1926 North Carolina electrocuted a 24-year-
old negro whose mental age was less than 5
years, although the superintendent of one of
North Carolina's State Hospitals had exam-
ined the prisoner and had testified that the
prisoner was incurably insane because he had
dementia praecox of the paranoid type. But
in spite of such a blunder some degree of
progress is being made. In Colonial days
in North Carolina about 20 crimes were pun-
ishable by death; shortly before the Civil
War more than a dozen different crimes con-
stituted capital offenses, but in recent years
only four are punishable by death — murder
in the first degree, rape, arson, and first de-
gree burglary.
I invite your attention to the concluding
paragraphs in Special Bulletin Number 10.
The language is more arresting and more elo-
quent than any words of mine;
"The most striking fact brought out by
these case histories is the prevalence of men-
tal deficiency among the prisoners convicted
of capital crimes, a considerable proportion
of whom were executed. There are, more-
over, several cases of actual insanity among
them, and it is safe to say that in the 26 case
histories studied, hardly one is the history of
a normal man. It should be especially noted
that one prisoner, declared by an alienist to
be definitely insane, a victim of dementia
praecox, was electrocuted.
"Although the sentiment of a civilized
State is now opposed to the infliction of the
death penalty upon the insane, this sentiment
does not yet officially condemn the execution
of the feeble-minded, despite the frequency
of commutation of the death sentence by the
Governor in cases in which mental deficiency
has been definitely proved.
"What is happening at present in North
Carolina, as probably in most of the other
States, is that the death penalty in a large
majority of cases is inflicted upon the sub-
normal and the psychopathic who, through
their innate deficiency or abnormality, are
unable to cope with their environment, and
many of whom from birth are predis[X)sed to
the commission of crimes.
"Aside from its injustice, this is a very
SOUTHERN MEDICINE AND SURGERY
September, 1029
questionable method of treating the mentally
defective. These histories suggest primarily
a more constructive. State-wide program of
prevention for dealing with the members of
this group; clearer recognition of such defi-
ciency, and more adequate institutional pro-
visi(m, if not sterilization as well.
"The wide breach between the psychopath-
ological theory of insanity and the legal the-
ory has often been remarked. Equally con-
spicuous is the absence of legal recognition
jf dangerous mental deficiency. Modification
of the law is necessarily slow, and until such
modification takes place, whereby the mental
defective may be legally regarded as irrespon-
sible for the commission of criminal acts, the
least the State can do is to try to prevent,
as far as poss ble, his commission of acts of
this sort.
"Left to themselves, especially in poor en-
vironment, like that of the majority of these
prisoners, persons of this subnormal type con-
stitute one of the most serious menaces to so-
ciety, a menace which is not effectively met
by sending a few of them to death, since for
every one e.xecuted, there are probably scores
of other potential criminals like hini at large.
"Another fact brought out by these case
histories is the conspicuous lack of education
of most of the members of this group. This
is directly related to their mental deficiency,
as well as to the limited opportunities for
Lchool'ng wh'ch many of them had.
"Moreover, the environment of most of the
prisoners — that of practically all of the N'e-
[^roes — was noticeably poor, with few influ-
ences tending to check a disposition toward
the commission of crime.
"Judging by this group which, as has been
•stated, was selected only on the basis of con-
viction for capital crimes, we find that in
r,'orth Carolina at present we are sentencing
to death the poor and the ignorant, the men-
tally defective, the insane and the psycho-
pathic, and not only sentencing them, but
executing a considerable number, about half
of those sentenced."
And then the following paragraphs from
the introduction to the statistical presenta-
tion should be studied:
"The primary object of the study is to
present to the people of North Carolina, and
to the State's judicial and penal officers and
social workers, material which hitherto has
not been conveniently available and which, it
is hoped, they will find valuable in its bearing
on the grave problem of capital crime and
the State's method of dealing with those of-
fenders who are guilty of it. The facts pre-
sented here are eloquent in themselves. These
facts strongly suggest the necessity of further
serious study of the subject of capital punish-
ment and other social problems with which it
is related, especially that of mental deficiency.
This study does not pretend to be e.xhaustive,
but is suggestive, rather than conclusive.
"A visit to the death row in the State
Prison at Raleigh is an experience which
every citizen of the State should have at
least once. The prisoners in the death row
are there because the people of North Caro-
lina wish them to be or are indifferent to or
ignorant of the social factors responsible for
their situation. That many persons con-
demned to death eventually received commu-
tation of sentence does not lessen the respon-
s b.lity of the individual citizen in regard to
the death penalty. As uncomfortable as it
may make him, he should be willing to face
the concrete results of whatever attitude, or
lack of one, he has had toward capital pun-
ishment, as it is found in that depressing
group at Raleigh.
"It is hardly conceivable that a ]5erson can
have the experience of such a visit without
asking himself some very pertinent questions.
he will see ainong these condcm.ied men the
poor and the ignorant — for the affluent and
educated are seldom found in the death cells
— the feeble-minded, the insane ar.d the
psychopathic. By talking with them he will
discover that some of them are so s mple in
mind that they have little conception of the
seriousness of their situation, or the signifi-
cance of the electric chair only a few yard;
away, as the one who naively remarked,
'This 'iectrcushion's shorely gwuie leach me
a lesson.' He will find that many of them
are illiterate, that others have no meinory of
a home, a church, a school or a community
whose influence might have led the wander-
ing feet of childhood along a path that had
a happier end. He will see that, if they are
not also the victims of mental deficiency, these
are for the most part children of ignorance
and neglect. He may come to the conclusion
that the end, as bad as it is, is not the worjt
aspect of the.r situation, and that death is
September, 10^0
SOUTHERN MEDICINE AND SURGERY
not the epitome of punishment.
"He may be led to wonder whether ther?
may not be children in his own community
who are starling on the sam: path, and if so,
whether he cannot do something about it.
And if these impressions give him a feeling
of personal res;x)nsib'lity, the purpose of this
study will h.;ve been largely accomplished.
For its prime object is not an arraignment
of capital punishment per se, but an efft)rt
to present to the people of North Carolina a
true picture of what capital punishment
means in th!s Stale. The Xorth Carolina
State Board of Charit'es and Public Welfare
hopes thereby to stimulate a sane, popular
interest in a tragic human problem, from
which, it is hoped, will come an enlarged so-
cial program of prevention. If the racial
aspect of this study seems conspicuous, it is
because it inevitably enters largely into this
question in a Southern State."
The conclusion of the matter would seem
to be that a thorough study should be made
of those who commit grave crimes. We know
little of the meaning of crime, and we know
even less about the general make-up of so-
called criminals. But crim.e must b? the re-
sponse of a human organism to a particular
environment — to a specilic sltunt.on. The
individual who has committed a serious crim-
inal ofiense should be thoroughly studied, and
a study equally as exhaustive should be made
of tne situation and the circumstances under
Vvhich the crime was committed. Such a
study should be made of all prisoners who are
charged with grave crimes, rather than of
an occasional prisoner as the result of some
emotional, last-minute demand. And the in-
vestigation should be made not by one per-
son, but by a group of trained investigators —
sociologists, educators, physicians — to the end
that every phase of the individual's life might
be thoroughly gone into. And on such a
commi.^iion there should be at least one
mother. Such a woman would know instinct-
ively more about what constitutes pro[:)er
early environment and early training than any
number of men could know. The work of
such a commission would eventually reveal
the relationship existing betwi.xt criminal
behavior and mental unsoundness, and it
would illuminate the pathway that would
lead to the discovery of the circumstances
ard the predicament under which much crime
s comm tted.
PEDIATRICS
Frank Howard Richardson, M.D., Editor
Black Mountain, N. C.
Initial Session Southern Parenthood
Institute
.'\n interesting and instructive example of
what a community can do to extend the ad-
vantages of instruction in the care of its chil-
dren to the parents who wish to profit by
such opportunities, was afforded by the first
scss on of the Southern Parenthood Institute
held at Black Mountain in August. The
problem set was that of providing a short
course in parenthood that would be compre-
hensive, well-balanced, and not too technical;
and that would be available without serious
financial outlay to those who might feel the
need of such instruction in what has come
to be regarded as a fairly learned occupation,
at least, one in which some degree of training
is not am!ss.
If an organization has fairly generous
sums at its disposal, it is not a difficult mat-
ter to bu'ld u 5 an attractive program, paying
thj expenses of the lecturers chosen, and
offering them a reasonably remunerative
honorarium. In the instance under discus-
sion, there were no financial sources to be
tapped; yet it was believed that this need
not necessarily make the solution of the prob-
lem impossible.
The community of which Black Alounta n
is the geographical center has some advan-
tages over some other places for the working
out of such a plan; and yet there are un-
doubtedly many other localities that c.iu'd
muster equal advantages. The fact that ihre:
summer assemblies are located within a Eliorl
radius (two or three miles) made it easier
to secure speakers than might otherwise have
been the case; and yet, as it happened, of th?
total fourteen, but three speakers were cho-
sen from this source. Three more were sup-
plied by our own State Board of Health,
always generous of its personnel in further-
ing any movement that will help along health
education. Six more were secured from Black
Mountain itself, and from the nearby city of
.•\sheville; while three cames from cities
more or less distant, as a matter of personal
friendship and willingness to get behind a
6^8
SOUTHERN MEDICINE ANt> StJRGERY
September, 1020
worthv.hile educational movement.
In the effort to build up a program that
would appeal to parents who needed help in
many d fferent lines, a number of professions
were represented. As was to be expected,
physicians predominated, — eight of the fif-
teen were doctors. There were three workers
with boys, one dentist, one clergyman, one
educator from the public school system of
this state, and one hospital technician. Of
the doctors, there were three pediatrists,
two public health men, one psychiatrist, one
obstetrician and one teacher of preventive
medicine from a medical college.
It has seemed worth while to go somewhat
into detail in this matter, for the reason that
the Institute was designed, not only as a piece
of educational work for a definite group of
parents, but as well to be an experiment in
the possibilities open to a locality anywhere
in the state, which if successful might be
followed elsewhere, varied to fit into varying
local conditions. A list of the speakers, to-
gether with their affiliations and their sub-
jects, will perhaps aid in showing what in the
present instance proved a most acceptable
program, as well as in suggesting 'the sort of
thing that might well serve elsewhere. This
was the line-up:
\V. L. Stone, professor of boys' work, Y. M.
C. A. Graduate School, Nashville: "How
Character Comes."
Dr. L. G. Beall, psychiatrist. Black Moun-
tain: "Handling the Nervous Child."
Dr. Lewis W. Elias, pediatrist, Asheville:
"Sunlight."
C. B. Loomis, secretary National Council,
Y. M. C. A., Atlanta: "Self Determination
for the Adolescent."
Dr. Paul Eaton, professor of Preventive
Medicine, Univ. of Ga. Medical College, Au-
gusta, "Preventive Inoculations."
Rev. Clarence Stuart ^IcClellan, rector of
Old Calvary Episcopal Church, Fletcher, N.
C: "The Wise Use of Vacation Time."
Dr. G. W. Kutscher, jr., pediatrist, Swan-
nanoa, N. C: "Fatigue."
Dr. Chas. O'H. Laughinghouse, secretary
N. C. Board of Health: "Some Obligations
of Parenthood."
Vance Thompson, A.B., technician, Ham-
let, N. C: "The Message of the Clinical
Laboratory to the Parent."
Dr. Oren Moore, obstetrician, Charlotte;
"Prenatal Care."
Mrs. Elizabeth C. Morriss, superintendent
of elementary education for Buncombe coun-
ty, .Asheville: "What the School Expects of
the Parent."
Dr. George Collins, chief of Division of
Maternity and Child Hygiene for N. C. Board
of Health, co-operating with the Federal Chil-
dren's Bureau: "The Economic Value of the
Child."
J. J. King, physical director, Lee School.
Blue Ridge, N. C: "Teaching Religion to the
Adolescent Boy."
Dr. D. Lesesne Smith, pediatrist, Spartan-
burg and Saluda: "Acute Diseases of Child-
hood."
Dr. Ernest A. Branch, director Oral Hy-
giene, State Board of Health: "Care of Chil
dren's Teeth."
Just what good does such a piece of parent-
hood instruction do? It emphasizes as noth-
ing else could do the importance that is com-
ing to be placed upon preparation for
parenthood, when a group of outstanding
people like these will come together at their
own expense to devote time and thought to
placing before thoughtful parents the best
that they have to give in their respective de-
partments. It gives parents an opportunity
to discuzs with leaders of current thought,
some of their problems with their own chil-
dren; for throughout the course the most
popular feature seemed to be the discussion
periods, where listeners and teachers joined
in the consideration of specific cases that
some one was dealing with right at the time.
Best of all, perhaps, was the demonstration
of what any locality can do to meet the needs
of the parents who make up such a large pro-
portion of its citizenship. Apparently this
phase of it impressed the officials of the State
Parent-Teacher Association, which had sent
representatives to study the movement. They
have adopted it enthusiastically; and it is to
be taken up as a definite feature of their
health committee, at the annual meeting of
the association in Hendersonville this fall
The recommendation will be made that simi
lar institutes be put on in various parts ol
the state; and the help to be secured from
the generous co-operation of the State Board
of Health, the extension departments of the
teaching colleges, the Federal Bureau (which
sent abundant literature for free cjistribution,
September, 1929
SOUTHERN MEDICINE AND SURGERY
6i9
together with a number of excellent movin";
picture health films), and the local public
school authorities. All these, ar.d other or-
ganizations, can be depended upon to spon-
sor such institutes, and to further their activj-
ties to a remnrkable extent, if the experience
of the institute just completed is any crite-
rion. The local press, as well as that of the
various other cities of the state which were
appealed to, proved remarkably generous
both in giving advance notice of the pro-
grams, and in carrying daily write-ups of the
addresses.
It is planned that next year a more elab-
orate program will be offered, with the inten-
tion that registrants may enroll in sections
whose activities will be devoted to the prob-
lems of specific age levels, thus making it
possible to secure special instruction for those
particularly interested in some one phase of
childhood. Group leaders are already being
chosen, to make this feature of the work
more valuable, .-^dult education in this coun-
try has not yet reached the high degree of
efficiency that it has gained, for instance, in
Denmark: but parenthood education is fast
catching the attention of the publ c, and its
possibilities for good seem almost undreamed
of. The medical profession can well afford
to take the lead in directing its course.
EYE, EAR AND THROAT
For this issue. C. N. Peeler, M.D., Charlotte
Direct Laryngoscopy as a Method for
Cultural Studies of Pulmonary
Secretions in Infants and
IN Children*
The author states, "Because infants and
children fail to expectorate or have a ten-
dency to swallow their coughed-up secretions
and sputums, various indirect methods have
been employed for the purpose of obtaining
material for cultural studies. These have
varied from that of tickling the pharynx and
having the patient cf)ugh into Petri dishes
containing culture mediums, to that of intro-
ducing an aspirating needle directly through
the wall of the chest to obtain material for
study."
He points out the ease with which speci-
mens are collected by direct laryngoscopy.
Such a procedure is carried out quickly, with
no anesthesia and no shock to the patient,
using the direct laryngoscope. The secretions
a-c aspirated through a suction tube to the
tub'ng of wh'ch is attached a sterile specimen
collector.
Care must be taken in introducing and
withdrawing the suction tip so as not to
asp' rate pharyngeal secretions. This is
avoided by not starting the suction until the
tube is in the larynx or trachea and removing
the vacuum pressure before withdrawal.
Residual secretions in the tube may be re-
moved by aspirating sterile bouillon through
the tube into the collector. By such pre-
cautions, Uiicontaminated material is at once
available for smears and cultures. If pneu-
mucoccus typings are desired, the fluid may
be injected into the peritoneum of a mouse
in the routine way.
Similarly, smears may be made directly
from the larynx or trachea. This is espe-
cially desirable where diphtheria or tubercu-
losis is suspected.
It is a well known fact that pneumonias
will frequently give abdominal pain. The
differential diagnosis between an obscure
chest condition and an acute affection in the
abdomen is greatly aided by direct laryngo-
scopy. The latter condition gives a normal
larynx; the former probably a congested
larj'nx.
The author epitomizes as follows:
"1. Direct laryngoscopy is a simple method
for obtaining secretion from the larynx,
trachea or bronchi of infants and children.
"2. Aspirated secretions may be studied
bacteriologically.
"3. Smears may be made and studied, e. g.,
tuberculosis, diphtheria.
"4. Pneumonias in children may be classi-
fied in this way.
"S. Laryngeal pictures of pneumonias may
be utilized as aids in differential diagnos's."
♦Abstracted from an article by Irving R. Gold-
man in the American Journal of Diseases of Chil-
dren, for July, 1929.
NO GOLD BRICK PROSPECT
The little group had been watching the band play
for several minutes. They had never seen a trom-
bone before, and the player of that instrument re-
ceived particular interest. Finally, one little hick
nudged another with his elbow. "Come on," he
said; "it's a fake. He don't swaller it every lime." —
Okla. Whirlwind.
The sultan of Turkey sleeps in a bed eight feet
wide and twelve feet long. That's a lot of bunk.—
Elevens Stone Mill.
SOUTHERN MEDICINE AND SURGERY
September, 1029
OUTHOPEDIC SURGERY
0. L. Miller, M.D., Editor
Charlotte, N. C.
Progress in Orthopedic Surgery
In (he thirty-sixth report of Progress in
Oithopcd c Surgery, recentl}- issued, the fol-
lowing subjects are discussed and commented
on. The conclusions reported on each sub-
ject represent obiervations of experienced
workers and should help to guide us in many
clinical cases.
GONORRHEAL ARTHRITIS
The incidence of arthritis as a metastatic
complication of gonorrhea is not great, aver-
aging only from 2 to 3 per cent. In one au-
thors series of 107 cases, the distribution
according to sex was males, 97; females, 10.
This author believed that the precipitating
factor is not infrequently trauma, either
directly to the joint or indirectly in the form
of ill-advised or careless urethral instrumen-
tation and treatment, excessive activity or
sexual excitement during the acute stage of
the u.ethritis. The arthritic symptoms
usually manifest themselves during the sec-
ond or third week; the earliest case recorded
is five diys. However, involvement of the
joints may supervene at any time throughout
the acute or chronic course of the disease or
in the presence of urethral or uterine adnexal
complications. The symptoms were polyar-
ticular in 58 per cent and monarticular in 42
per cent. The joints were involved in the
following order of frequency: knee, 58 cases;
hip, SO; wrist, 21; shoulder, 19; phalangeal,
17; elbow, 13; metatarso-phalangeal, 8;
spine, S; metacarpo-phalangeal, 7; sacro-iliac,
1 ; tempxiro-maxillary, 1 ; and sterno-clavicu-
lar, 1. In respect to treatment, the author
called attention to what he believes is a cur-
rent mistake on the part of the orthopedic
surgeon and the genito-urinary surgeon;
namely, that they center too much on the
treatment of the joint or the prostate or the
seminal vesicles as the foci of infection, with
apparent lack of appreciation of the fact that
the condition is a septicemia. It was felt
that the first step should be to treat the
blood-stream infection either by biologic ther-
apy or by chemotherapy; second, to eradicate
the focus or foci of infection in the genito-
urinary tract, and third, to treat the involved
joint or joints by local methods.
operative treatment of FRACTURES
Discussing the treatment of persons with
fractures by open operation, from the devel-
opment of v/hich he expects future progress
in the treatment of persons with fractures,
Scudder stated his belief that under present
conditions fractures can be divided into three
groups: (1) those never operated on, such
as Colles' fractures, fractures of the clavicle,
many fractures in childhood or the adoles-
cent period, and many fractures occurring at
birth; (2) those always operated on, such as
fractures of the patella with wide separation
of the fragments, fractures of the head or
neck of the radius with such displacement of
the small proximal fragment that there would
result without operation great limitation of
pronation and supination, certain spiral and
oblique fractures of both bones of the leg in
the middle or lower third, fracture of the os
calcis in which the line of fracture enters
the astragalo-calcaneal joint, fractures of the
olecranon with wide separation, fracture of
the shaft of the radius with displacement and
irreducible fracture of the shaft of the femur;
(3) those in which operation must be looked
on as of doubtful applicability, such as frac-
trrcs of the humeral shaft above the middle
and near the shoulder joint, of both bones of
the f; :;~rm and, of course, manv others.
UROLOGY
Hamilton- VV. McKay, M.D., Editor
Charlotte, N. C
Coiicerning Lesions of the External
Genitalia in the IVIale
The fundamental, well known, rather aca-
demic remarks wh'ch follow are not intended
for t'le conscientious venereologist or any
careful or well trained clinician who has ac-
quainted himself with the clinical aspect and
laboratory diagnosis of all sores or ulcers that
commonly occur on the male genitalia.
The following comments are intended for
the ignorant, the wilfully negligent and the
passively indifferent practitioner of medicine
who, when confronted with a venereal sore,
aware of his limited clinical experience and
knowledge of present-day laboratory method >
of d'agnosis, is still willing to take a chance
with the patient, and satisfies himself with
the hit-and-miss diagnosis.
For seme unknown reason, the class of
physicians referred to in the previous para-
September, 1<'2Q
SOUTHERN MKDICINE AND SUKGERV
graph seems to always assume that the gen-
ital sore or ulcer is a harmless lesion and it
is usually referred to in a light vein as a
tear, a friction rub, a hair-cut or some abra-
sian of minor or no importance. At least,
this is the impression that some doctors leave
on the mind of the patient. The patient
never seems to be aware of the fact that his
genital lesion might be the primary stage of
syphilis, or a mixed infection, or some other
les'on of serious import.
It has occurred to me that, in attempting
to make a diagnosis of a sore or an ulcer of
the genitalia or a suspicious sore elsewhere
on the body, our usual approach to the task
may be wrong psychologically.
On approaching all dangerous railroad
crossings, we are constantly confronted w th
a "stop, look and listen" sign! Th's is th:?
mental attitude that I assume on going about
the task of attempting to diagnose a genital
::ore. I believe that, if you will assume that
every sore or ulcer on the genitalia may be pri-
mary sj'philis until definitely proven othcr-
ivise, we will take a distinct step forward in
the diagnosis and management of venereal
ulcers.
Each year I am more and more surprised
and astounded at the apparent indifference
of soiTie of the medical profession on this
particular question.
.\pproaching this subject, we ought to have
very clearly in our minds, first, what con-
ditions cause ulcers or sores on the genitalia,
and secondly, when confronted with su;h
lesions we should have a definite routine
which should be adhered to in making a diag-
nosis. The common conditions usually found
on the e.xternal genitalia of the male are:
1. The ordinary traumatic sore which
usually starts as a friction rub or a detinite
iear in the mucous membrane of the foreskin.
These traumatic sores go under many differ-
ent names — hair-cut, etc. They usually be-
come infected with pyogenic organisms, or
they may be infected with .Spirochaeta |ial-
lida.
2. Balanit'-s. This may be primary jjut it
is often secondary to some other infection,
f:>r exam|)le gonorrhea.
a. Simple balanitis is a most common
condition in patients with long fo.-cskins,
and it often gives rise to cons'derible local
irritation, h. The erosive type of l)alanitis
commences as a circular grayish patch and
as inore of the epithelium becoines erod?d,
the lesions become red and moist and all
of the abrasions may begin to coalesce, r.
Balanitis gangrenosa is really an advanced
stage of the erosive type in which there is
gangrene present and a profuse foul dis-
charge.
The best treatment for all forms of balan-
itis is to leave the ulcer uncovered, exposed
to the air, and if this is not possible, employ
hyd'ogen peroxide in proper strength, fol-
lowed by irrigations of some mild antiseptic.
3. Condyloma aciuiiination. This lesion is
practically always multiple, the individual le-
sions resembling ord'nary warts, except they
are moist and grow very rapidly, spreading
ss they grow. The treatment is simple and
varied. First, the parts should be kept clean
ai.d dry. The warts themselves may be re-
moved by any surg'cal means. Circumcision
is usually indicated.
4. Herpes genitalis. The most common lo-
cation for herpes is on the skin of the penis,
on the under surface of the prepuce and on
the glar.s. It is most common in patients
v.ho have had some venereal infection, espe-
c'ally gonorrhea, but it may occur in anyone.
Herpes may become f|u"te a troublesome con-
dition and is often d rficult to diagnose from
a chancre as, in mast instances, some irritant
has been appl'ed. Resinol ointment, some
evaporating lotion v/h'ch is m Idly antiseptic,
or a ni Id d'sinfectart powder may be used.
5. Granuloma ingu ivi\e. in th: ma'e the
groins, prepuce, g!:'.-:s, penis and a'.iUi are
often involved. L ::uaiiy the penis is ai'fectcd
first. The granul niatous masses are often
accompanied by ulcers ar.d it is cju'te easy
to understand how tlie condition could bo
confuted with ulcus m:-lle.
The treatment is varied. Surgical rem ivai
has been recommend; d, or tartar emetic tli:
latter both as a lic;il d-e's'ng and intraven-
ously.
b. Lichen planus ap;;ears as an inllammi-
tory disease of the glans penis, the erupti ki
usually be'ng made up of violaceous papules,
wlrich usually become confluent. The dia':-
nos's srmel'mes is confusing but is not d.-^Ti-
cult. Hygienic treatment with arsenic or
mercury by mouth is pr.iiiably the best treat-
ment. If mercury is given, it should be u.'^cl
intramuscularly.
SOUTHERN MEDICINE AND SURGERY
September, 1920
7. Ulcus moUe (soft sore). By this we
mean a specific sore caused by Ducrey's ba-
cillus. There are numerous types of this
ulcer which, under certain conditions, are very
destructive and very difficult to control. The
usual treatment is cauterization and, as
usually applied, it is unsuccessful in many
cases. Zinc or copper ionization will, in
some cases, cause the soft sore to heal more
rapidly.
8. Chancre. Chancre may occur on any
part of the body, but, for convenience, we
usually divide the primary sores into genital
and extragenital. It is generally taught that
the primary sore is characterized by its be-
ing single and indurated, having a definite
period of incubation and a marked tendency
to early involvement of related lymph glands.
While all four of these are very valua-
ble clinical points, I am quite sure not enough
lus been written in explanation. In a large
percentage of primary syphilis, there is more
than one primary sore: induration, if present,
is valuable, but the value to be placed on
'I'duration as an absolute diagnostic sign has
been overstressed. The incubation history is
often of little value and in a small number of
cases there is very little palpable change in
the lymphatic glands.
What I am trying to emphasize here is
that because the sore does not present the
above named clinical points is no reason to
suspect that it is not a chancre. A routine
dark field examination for the Spirochaeta
pallida should be made by a trained patholo-
gist in all suspicious lesions; not one exam-
ination, but at least three, should be made at
intervals, in all sores of doubtful character.
Dr. G. E. R. McDonagh, of London, feels
that the dark-field examination will fail to
show the Spirochaeta pallida in from 2i to
41 per cent. To quote him exactly:
"I feel positive that a man who knew his
cl'nical work and relied on the naked-eye ex-
amination would not make so many mis-
takes." Dr. McDonagh feels that, before
advising a routine examination for the
Spirochaeta pallida, the examiner should
clearly have in his mind:
" ( 1 ) what to do in an undoubted case
(clinical diagnosis of syphilis when no
spirochaeta is found);
(2) which examination is open to the
greater error?
a. clinical, or
b. microscopic."
In the early part of the primary stage, the
blood Wassermann test is valueless. The so-
called mixed ulcer or sore is an ulcer which
combines characteristics both of chancre and
chancroid. It is probably the most difficult to
diagnose. This type of sore should be kept
clean by using pressure irrigations of sterile
water, normal salt solution, boric acid. Wet
dressings of normal salt solution or boric acid
should be applied on a thin piece of cotton
and kept wet between treatments. During
this period of observation, repeated studies
for the Spirochaeta pallida should be made
and the clinical changes in the sore noted
day by day.
If the Spirochaeta pallida can not be dem-
onstrated and the examiner feels that the
sore is an undoubted case of primary syph-
ilis, I believe the patient should be apprised
of the result of the whole study and then ad-
vised to hive one intensive course of anti-
syphilitic treatment followed by careful ob-
servation.
To recapitulate — I believe every open sore
or ulcer appearing on the genitalia to be a
potential danger, on account of the possibility
of primary syphilis going unrecognized until
it becomes generalized. I, therefore, believe
that no open lesion on the genitalia should
be considered lightly without both a thorough
clinical study and repeated microscopical ex-
aminations— that all patients, with few ex-
ceptions, having a genital sore or sores should
be apprised of the possibilities of primary
syphilis, cautioned and warned to have re-
peated follow-up blood Wassermanns at stated
intervals.
.\lthough extragenital chancres are without
the scope of this paper, we should constantly
be on the alert for primary syphilis manifest-
ing itself in any part of the body, especially
is this true when the patient is a physician
or other attendant on the sick.
OR WITH THORNS
We refuse to become e.-?cited over the fact that a
ncwrpaper man by the name of W. 0. Saunders
walked the streets of New York, clad in his pajamas.
So far as we are concerned about the man's dress,
they can pin a h'ppin on him and turn him loose in
Kalamazoo. — Brevard News.
September, 102Q
SOUTIIEK.N MEDlCINi: AND SURGERY
64^
RADIOLOGY
John D. MacRae, M.D., Editor
Ashcville, N. C.
Hodgkin's Disease
This condition is fairly common, and al-
most, if not always, it is fatal. Its course is
acute or chronic. It may terminate qu'ckly
or be prolonged over a number of years.
Hodgkin's disease is characterized by hyper-
plasia of lymph glands which is at first local-
ized but tends to become general in distribu-
tion. Anemia is present and progressive.
Itching is often present in the early stan;es,
also fever of an intermittent character.
The disease, in its early manifestations, is
difficult to differentiate from acute tubercul-
ous adenitis, from syphilis when there is ex-
tensive gland involvement, and from other
types of infectious adenitis. It simulates
lympho-sarcoma, to which it is closely re-
lated. The blood picture is not typical.
Biopsy furnishes reliable data for diagnosis.
One of the smaller enlarged glands should be
d'ssected out and studied microscopically.
There is a strong resemblance between Hod';-
kin's disease and tuberculous adenitis but
their clinical course is very different except
in the beginning.
The presence of some infecting organism
is strongly suggested by the symptoms and
behavior of the affected tissues, but no spe-
cific organism has been isolated: neither is it
known what irritant is acting on the lym-
phatic system to bring about this particular
hyperplasia.
There is no tissue in the body more sensi-
tive to x-rays and radium than the lymphat-
ics and it has been noted that the hyperplas-
tic glands of Hodgkin's disease respond in
an almost spectacular manner to radiation
treatment. In fact their rapid shrinking un-
der the influence of x-rays is almost pathogno-
monic. The enlarged glands of syphilis, tu-
berculosis and other infections will become
smaller when treated with x-rays, but the re-
sponse is much more prompt in Hodgkin's
disease.
Most cases are recognized by the appear-
ance of a chain of enlarged glands just above
the clavicle. Other glands become enlarged
very sf)on but as there is no pain in the be-
ginning patients are prone to put off consult-
ing a physician. The axillae, mediastinum,
inguinal regions and abdomen are apt to be-
came involved sooner or later and the first
noticeable enlargements may be in any region.
I have seen a case where the manifestations
were first in the orbit, then in the tonsil and
then in the mediastinum. Primary involve-
ment in mediastinal glands is rather fre-
quent. The spleen and liver are enlarged in
;:b ut half the cases. Digestive disturbances
and deb'lity occur as the disease progresses.
Pain and distress are the result of mechanical
interference. Dyspnea is produced by the
encroachment of lymph glands on the lungs.
Pain in the arm results from pressure on the
brachial plexus, .\bdominal pain results in
the same way from pressure.
For a long t'me arsenic has been the drug
most used in treatment, but it has done very
I'ttle good. Surgical excision of enlarged
lymph glands is of no use except as an aid
to diagnosis. X-rays and radium are the best
remedial agents which we have and because
of the large areas to be treated x-rays are pre-
ferred.
In planning a course of treatment for
Hcd-;kin's disease remember that, as the hy-
perplasia is to become general sooner or later,
}'ou should attack those groups of lymph
glands which are not yet marked by enlarge-
ment at the same time that the primary le-
s on is treated.
The areas to be treated are to be marked
off and two or more areas exposed to x-rays
each day till all are treated. The right and
left supraclavicular regions, each axillary re-
gion, the med.astinum and abdomen from
each side, and the ingui.ial regions. Six areas
on the back must also be given x-ray expos-
ures. These are right and left of the lower
cervical spine, the med astinal region from
each side, and the back of the abdomen from
each side to reach the posterior mesenteric
glands.
The great sensitiveness of lymphatic tis-
sues makes it unnecessary to give full doses
to each area. When a series is ended a rest
period of sixty or ninety days may intervene
before repeating the dose. Exacerbations will
occur and the patient is to be kept under
observation and further treatments given as
needed.
By this method of treatment patients with
Hodgkin's disease have been kept alive and
in fair health for five-year periods and in
some instances considerably longer. It has
SOUTHERN MEDICINE AND SURGERY
September, 1920
b?en the rule that treatments hive been lim-
ited to the large visible masses and the sus-
pected areas have not had benefit of x-ray
treatment and it is hoped that the more thor-
ough rad'ation of the lymphatic system and
more careful management of cases will result
in greater comfort and longer life to sufferers
with Hodgkin's disease and even that cures
may occasionally be accomplished.
DERMATOLOGY
Joseph A. Elliott, M.D,, Editor
Ringworm of Hands and Feet
Eczematoid ringworm of the hands and
feet is one of the most common skin diseases
met with today. In some sections of the
country dermatologists report that SO per
cent of their patients have this disease. In
cur practice about 10 per cent of our patients
hive this infection. Due to the fact that the
d rsase is so prevalent and affecting the hands
crd feet to such an e.xtent that the patient
is often compelled to stop work, it has become
rj. economic as well as a health problem.
Th.' d sease no doubt has been present for
a very long time, but was usually considered
cither as a trade dermatitis, dyshidrosis, or
eczema until Ormsby and Mitchell presented
iheir e.xcellent paper on the subject in 1916.
They reported si.xty-five cases with photo-
p.raphs of their cultural findings. This work
aroused a great deal of interest among derm-
atologists and since that time a vast amount
of work has been done in isolating the causa-
tive organisms and in determining the effi-
cacy of different drugs in the treatment of
the disease.
The clinical manifestations of ringworm of
the hands and feet are divided into three
groups: (1) acute vesicular — onset sudden
v.'Ith the characteristics of acute eczema or
dyjh'drosis; (2) chronic intertriginous of the
toes — secondary to the acute vesicular type,
characterized by whitened, sodden mass of
cpthelium between toes; (3) chronic hyper-
leratotic — enormous overgrowth of the horny
layer.
The initial lesion in all of these cases is a
vesicle. The vesicle may occur singly or in
; roups. It is deep seated in the epidermis
r.'d has been accurately described as having
..le appearance of a sago grain embedded in
i''.c skin. The vesicle usually arises from a
clear skin without the appearance of a sur-
round'ng erythema until secondary infection
takes place, which also changes the content
of the vesicles from a clear to a cloudy fluid.
This fluid is strongly alkaline and oj a muci-
laginoiis consistency. The latter characteris-
tic is of some diagnostic importance, as most
other vesicular lesions are more watery. The
content of the vesicle may be absorbed leav-
ing a brown macule. Within a few days the
top of the macule pulls off leaving a shiny
surface with a collarette of scales around the
border. Where the vesicles are numerous
they frequently become confluent, forming
large bullae. These occasionally become sec-
ondarily infected forming a pyo'dermia. These
lesions may be so extensive on the feet that
the patient is incapacitated, being unable to
bear the weight on the feet. Lymphangitis
is not an uncommon complication of the pyo-
dermia cases.
The hyperkeratotic lesions are very rare in
our e.xperience, the pyodermias less rare, while
the acute vesicular and chronic intertrig'nous
are very common.
While the clinical appearance of eczema-
toid ringworm is sufficient for a diagnosis in
some cases, it is often necessary to find the
mycel'a in order to make a positive diagnosis.
This may be attempted in two ways: (1)
by direct examination of material from the
eruption; (2) by cultural methods. At times
it is necessary to resort to both methods. Ma-
terial is obtained by clipping off the tops of
the vesicles in acute cases, and obtaining
scales from the borders of the chronic cases.
A portion of the material is placed on a glass
slide to which is added a few drops of a IS
per cent sodium hydroxide. This is heated
until the scales are thoroughly macerated. A
cover-slip is placed over the specimen and
pressed down firmly. The specimen is then
ready for a thorough microscopic study. If
moulds are present the mycelia can usually
be found. The other portion of the material
is soaked in 9S per cent alcohol for thirty
minutes, in order to destroy the bacteria nor-
mally present, and is then planted on Sabou-
raud's proof medium. .\s soon as the growth
appears it is transferred to other media, in
order to get a pure culture. The culture is
then ready for careful microscopic study.
Hodges, in his extensive cultural work of
these cases, demonstrated three distinct
moulds. He classified these as trichophyton
September, 1029
SOUTHERN MEDICINE AND SURGERY
64S
A, B and C. The colony of trichophyton A
is white at first, but later becomes pink.
There are present pyriform conidia and plu-
riseptate fusseaux. Trichophyton B shows a
white, downy growth at first, but later be-
comes yellowish. Pyriform conidia were ob-
served, but there were no fuseaux. Tricho-
phyton C is white at first, later becoming
cream-colored. This organism has conidia
and fuseau.x, but also has numerous spirals
characteristic of gypseum group.
In other cultures we were able to demon-
strate a number of moulds that correspond
to Hodges A and B groups, but did not find
any of the C group. One must be careful not
to overlook the contaminating moulds. These
are quite common and frequently appear in
the cultures.
The treatment of ringworm of the hands
and feet is often attended with considerable
difficulty. In pyodermia cases it is best to
clear up the secondary infection by opening
the lesions and applying moist dressings of
Burow's solution (alum 5 parts, lead acetate
25, water 500) or some other mild antiseptic.
All crusts and dead tissue should be mechani-
cally removed. Small doses of x-ray are
usually well borne and are frequently effi-
cient. The dosage should be small and the
number of treatments limited. Various oint-
ments have been used but Whitfield's, modi-
fied as to strength according to the acuteness
of the condition, has proven one of the best.
INTERNAL MEDICINE
Paul H. Ringer, A.B., M.D., Editor
Asheville, N. C.
Rheumatic Fever
In The Journal of the American Medical
Association for June 22, 1929, there is a most
interesting paper on "Rheumatic Fever" by
Dr. Homer F. Swift, of the Rockefeller Insti-
tute for Medical Research.
Dr. Swift has long been in the forefront of
clinical research workers and anything from
h's pen is worthy of attention. He stresses
that rheumatism has long remained one of the
riddles of medicine; and that as the incidence
of other d'seases has decreased, the economic
importance of rheumatism has assumed
greater proportions. In the minds of most
laymen and many physicians, the term "rheu-
matism" indicates pain, tenderness and stiff-
ness in the muscles and joints, and a condition
of disability due to these symptoms. Prob-
ably this idea will persist, but the derivation
of the word rheuma, rhco, to flow, which
arose at a time when the humoral theory of
disease was prevalent, will probably suggest
a more precise conception of its essential char-
acteristics. Especially is this true of the con-
dition known as rheumatic fever, as we appre-
ciate more and more that its nature is to
flow in the blood stream, not only from joint
to joint but to many other structures.
Rheumatic fever is a long-drawn-out affair,
and it is well to regard every case as poten-
tially, if not actually, chronic; and to cons'der
cond'tions regarded by many as complications
rather as essential manifestations of the dis-
ease itself. There is no doubt that the so-
called antirheumatic drugs, while rendering
the patent more comfortable, alter the pic-
ture of the infection to such a degree that it
is diffcult to imagine just what it would do
if allowed to pursue its normal course.
There are various types of infection, the
simplest being the monocyclic, with r'sing
fever, toxemia and drenching sweats lasting
for from six to ten days, accompanied by a
m'gratory polyarthritis involving continually
rew joints until practxally all of the large
articulations are affected. In the majority
of cases there is a second cycle following this
first ore with a recurrence of the essential
symptoms and far more likelihood of cardiac
involvement. These cycles may repeat them-
selves frequently, there being each time
greater danger to the heart. If the medical
profess'on and the laity could completely rid
themselves of the idea that "the patient had
an attack of rheumatism from which he re-
covered but now has a complicating endocard-
itis," a distinct advance in correct thinking
about the disease would be achieved. For
more than a century the importance of the
visceral so-called complications has been dis-
cussed, but more recent studies have empha-
sized the fact that these visceral involvements
are just as much part and parcel of the in-
fection as arthritis.
Dr. Swift then gives a long and detailed
description of the pathology of rheumatic fe-
ver, both as regards the occurrence of .Xschoff
bodies, subcutaneous nodules and joint
changes. He then proceeds to d scuss the
pathology of rheumatic valvulitis. It is im-
SOUTHERN MEDICINE AND SURGERY
September, 1Q29
possible in the abstraction of such a paper
to take this up in detail. He is, however, a
strong advocate of the occurrence of the in-
flammation of the valves as a whole and con-
cludes his discussion of the pathology of the
condition with the following paragraph:
"It is not my intention either to deny the
occurrence of primary endothelial lesions or
to underrate the importance of verrucae in
the development of chronic valvular deformi-
ties, but rather to indicate the importance of
diffuse valvulit's. Edema and infiltration of
the cusps, either diffuse or focal, doubtless
account in part for transitory murmurs and
for other evidence of imperfectly functioning
valves. With a picture of an active diffuse
valvulitis in h's mind, the physician will
realize better the necessity for prolonged rest
as a therapeutic measure."
Etiology: The etiology of rheumatic fever
is as yet obscure. Practically all investiga-
tors in this field have been forced, at one
time or another, to a consideration of the
role of the streptococci in this disease. With
regard to the causative role of the strepto-
cocci, three hypotheses may be mentioned:
1. Elective localization
2. Specific streptococci elaborating a spe-
c'fic toxin
3. Rheumatic fever as an allergic phenome-
ron.
The first two hypotheses are hardly ten-
able. The allergic theory seems to appeal to
Dr. Swift as a possible explanation of the oc-
currence of rheumatic fever. It does not
c-tabl'sh unequivocally the etiolo:!;ical role
of streptococci in rheumatic fever, but only
furnishes us with the best explanation of
how the different strains could all induce a
s'milar clinical microscopic picture. It also
furnishes a hypothesis for continued investi-
gation of the disease from which further ad-
vances may be anticipated. Detailed discus-
s'on of the allergic origin of rheumatic fever
is too involved to be satisfactorily abstracted.
Dr. Swift concludes as follows:
"Up to the present the methods at our dis-
posal of decreasing the hypersensitiveness of
infection are ( 1 ) stopping the production of
new foci of infection: (2) elimination of foci
already present: and (3) intravenous desensi-
t!zation or immunization with suitable anti-
genic substances. The eradication of infected
tonsils and teeth has been a standard of treat-
ment since the importance of focal infections
was pointed out by Billings. While appar-
ently brilliant results follow this treatment in
certain cases, in others they are disappoint-
ing, perhaps because of the impossibility of
el'minating all such foci. It appears, then,
that an important problem is to devise some
method of building up the immunity so that
the liability to renewed infection will be les-
sened, or if new infection occurs the reactiv-
ity of the tissue will approximate that of im-
munity without hypersensitiveness."
We in the South do not see rheumatic fe-
ver as frequently as do our Northern col-
leagues, nor are its manifestations in as vio-
lent a form. It occurs, however, and more
particularly in children. It is probable that
many cases of the infection are overlooked
because of the absence of a polyarthritis and
because of the preponderance of the so-called
visceral lesions of the disease.
A paper such as that of Dr. Swift is most
instructive and will well repay repeated and
careful reading.
SURGERY
Geo. H. Bunch, M.D., Editor
Columbia. S. C.
Pieces of Broken Instruments as Foreign
Bodies
The many diagnostic and therapeutic pro-
cedures of modern medicine have resulted in
a new class of foreign bodies. Parts of surgi-
cal apparatus while in use may break or be-
come disconnected and remain in the patient's
body after the rest of the instrument has been
withdrawn. An instrument for use in deep
and inaccessible regions should be tested be-
fore using to be sure that imperfection or
deterioration has not made it unsafe. After
use careful inspection should be made to be
sure that no part of the instrument has been
left in the body.
In this part of the south concentrated lye
is commonly used for scouring and for clean-
ing purposes. Statistics are not available,
but instances of the drinking of lye by small
children are not infrequent. -As scar contrac-
tion takes place in the esophagus after heal-
ing the lumen becomes more and more con-
stricted until only liquids pass into the stom-
ach. The pat'ent loses weight and becomes
a living skeleton from starvation and dehy-
dration. Weak and listless, with pinched
September, 1020
SOUTHERN MEDICINE AND SURGERY
features and wasted body, the child is ad-
mitted into the hospital to begin the tedious
efforts at esophageal dilatation. W thout
financial means to compensate the physic'an
for his work these little negroes make strong
appeal to his sympathy and skill.
The treatment of esophageal stricture is
stretching with a dilator which his been
threaded on a silk cord several yards long,
one end of wh"ch has been swallowed past
the stricture. The cord acts as a guide to
the instrument. We have seen one case in
which the d'stal end of the dilator broke com-
pletely off the shaft and remained in the
stricture still threaded on the silk. The phy-
sician fortunately was able to e.xtract the
broken part with long forceps through an
esophagoscope.
.After dilatation has been done at suitable
intervals for several weeks the cord is re-
moved and the dilator is passed without a
guide. We have had to remove by laparo-
tomy the end of a dilator used in this proce-
dure. The end of the shaft broke, leaving
more than two inches of the distal (dilating)
end of the bougie in the stomach. After ten
days the foreign body became lodged in the
second portion of the duodenum, causing
symptoms of obstruction. The four-year-old
negro child had an uninterrupted convales-
cence after laparotomy.
E^nfiliiiK'iil Houk'h- Olislnicliiiii Duodiniim in
Child 4 vr,s. old
With ])erfcction of the cystoscope and dila-
tation of the ureter under local anesthesia,
most stones in the ureter are passed without
operation. Crowell of Charlotte has been a
leading advocate of this method. When a
stone causes obstruction to the urinary How
with retention and back pressure, the kidney
Dilator Tip Obstrucling Left Ureter
may be permanently injured by undue delay
in waiting for the passage of the stone. When
a stone is impacted it is apt to cause ulcera-
t'on and stricture of the ureter. Some stric-
tures are congenital, but it is not reasonable
to think of a congenital stricture first causing
symptoms in adult life. Many so-called stric-
tures are really edema and spasm, not true
strictures at all.
We have removed by operation upon the
ureter the dilating tip of a bougie. Wh'le the
instrument was being used in a case of ure-
ieral col'c the tip bec;ime disconnected from
the shaft (jf the dilator and could not be re-
moved with the cystoscope. It obstructed the
ureter and when removed four days later a
small stone not shown by .\-ray was above
ar.d in contact with it.
Hypodermic needles are often broken off
in the tissues and, although ordinarily of but
Title danger, should be removed. Incision
for their removal should be at a right angle
to the needle so that the knife will come in
contact with it. if the patient changes posi-
tion or moves before the removal is attempt-
ed the muscle planes may be so changed that
the needle is an inch or more from the iJO'nt
of entrance in the skin. Lahey has an illus-
trated article on the removal of broken spinal
anesthesia needles in the Journal oj the A.
M. A. for .August 17, 1929.
PERIODIC EXAMINATIONS
Frederick R. Taylor, B.S., M.D., Editor
High Point, N. C.
Hk.altii E.naminations of I'uvsici.ans
We have repeatedly stressed the idea that
piiysicians need to avail themselves of health
examinations. Before publishing any statis-
tics on the subject we have waited to collect
SOUTHERN MEDICINE AND SURGERY
September, 1029
data on at least 100 physicians. We submit
herewith a report of the results of the exam-
ination of 106 physicians, covering all sec-
tions of the state.
In a previous article we noted 1,555 defects
in 436 persons — some of them physicians,
most of them not, giving an average of 3.57
defects per person. It is interesting to note
in this study that in examining 106 physi-
cians, we found 474 defects, or an average
of 4.49 per physician. In other words, the
number of defects per physician was about
30 per cent greater than the number of de-
fects per person in the general group exam-
ined, including a considerable number of
physicians.
There are probably several reasons for this.
In the first place, the number of persons ex-
amined is rather too small to be very dog-
matic about, yet it is interesting to note the
close correspondence of frequency of most
defects in the physician group and the gen-
eral group. Physicians show about double
the frequency of harmful habits as do those
in the general group, but as one-half of these
consist of excessive hours of work and insuf-
ficient sleep — occupational hazards of the
practice of medicine that are in some measure
unavoidable — there is otherwise no essential
difference between the harmful habits of doc-
tors and those of the people as a whole.
Physicians as a class make notoriously poor
patients. It is very difficult for a doctor to
use good judgment regarding his own condi-
tion. Sometimes, especially when really ill,
he worries over trifles. More often, especially
when free from symptoms, he shows the fa-
miliarity that breeds contempt, and neglects
his own physical condition in a way that
would cause an outpouring of the vials of his
wrath were some of his patients to follow his
example. This last jxiint may explain the
physician's tendency to neglect the type of
defects found in health examinations.
There may possibly be still another reason.
Health examinations involve considerable
time and careful work. One doctor may hesi-
tate to ask another to spend so much time
on him annually when he knows he will not
receive a bill for services. Once, however, the
profession becomes aroused to the real value
of health examinations, a doctor will no more
object to calling on his professional confrere
for a health examination than he will for an
appendectomy. Many doctors will be able to
reciprocate in this matter. The more physi-
cians have health examinations, the more
will the public see the value of them. The
specialist in some field that does not cover
health examinations certainly should not feel
that he is imposing on his confrere in asking
him to give him a health examination, for
can he not send that same confrere others
for health examinations if he does not make
them himself? Let us practice what we
preach !
The total number of physicians exammed
is too small for the percentage of physicians
involved to be of any value where only one
or two cases of a given defect were found.
However, those defects involving over 5 per
cent of the total number of physicians are, we
feel sure, frequent enough among the profes-
sion as a whole, to be of real significance.
NUMBER OF KINDS OF DEFECTS ACCORD-
ING TO FREQUENCY OF PHYSICIANS
INVOLVED
Total Number of Kinds of Defects Found 140
No. of kinds of defects involving only 1 physician
(less than 1 per cent) _ 86
No. of kinds of defects involving 1 to 2 per cent
of those e.xamined 14
No. of kinds of defects involving 2.1 to 5 per
cent of those examined _ 2i
No. of kinds of defects involving 5.1 to 10 per
cent of those examined 8
No. of kinds of defects involving 10.1 to 20 per
cent of those examined 5
No. of kinds of defects involving 20.1 to Si per
cent of those examined 4
DEFECTS INVOLVING OVER 5 PER CENT OF
PHYSICIANS EXAMINED
7c of
No. of Physicians
Defect Cases Involved
Refractive errors, uncorrected 34 32.08
Dental infection (oral sepsis), all
kinds - 28 26.42
Tobacco, excessive 27 25.47
Obesity -- 25 23.58
Eczematoid ringworm of feet- 21 10.81
Hemorrhoids 21 10.81
Work, excessive hours of 21 10.81
Sleep, insufficient 20 IS. 87
.\ppendicitis, chronic 13 12.26
Prostate, hypertrophy of — 10 0.43
Varicose veins of legs 10 0.43
Malnutrition 0 8.40
Corns, severe 8 7.55
Tonsils, infected 8 7.55
Gall bladder disease, chronic 7 6.60
Hernia, inguinal _ _ 7 6.60
Terticle, atrophy of, due to mumps „ 7 6.60
Seventeen different kinds of defects involve over 5
per cent of the physicians examine4.
September, 1929
SOUTHERN MEDICINE AND SURGERY
OBSTETRICS
HiNRY J. Lancstox, B.A., M.D., Editor
Danville, Va.
Postpartum Hemorrhage
It is estimated that in the United States
we are losing annually from five thousand to
six thousand women from hemorrhage. Most
of these hemorrhages occur after delivery.
We have no way of ascertaining the detailed
facts about these cases. Also, we do not know
the number of hemorrhage cases which do
not terminate in death but which leave other
complications as result of hemorrhage. The
fact that we are losing such a large number
of women from hemorrhage should cause all
of us to study more carefully each individual
case with a view to preventing hemorrhage.
DeLee reports in his last Principles and Prac-
tice oj Obstetrics two cases lost in his own
practice from postpartum hemorrhage. Prac-
tically every doctor who has done much ob-
stetrics has had some form of postpartum
hemorrhage though he may not have had
any fatal cases.
The probabilities are that we do not yet
know all the causes of postpartum hemor-
rhage. Some of them that we frequently meet
are these: extensive laceration of the cervix;
long, exhausting labors after which the uterus
refuses to contract properly after all the
products of gestation have been expelled; pla-
centa previa; abrupto placenta; and infec-
tion of the uterine muscles. In order to pre-
vent postpartum hemorrhage we must, first,
study carefully how to prevent long-drawn-
out labors. We must use some sort of me-
chanical means to assist delivery in such
cases. Placenta previa and abrupto placenta
should be recognized early, when, by proper
treatment, hemorrhage will largely be escap-
ed. Infections should be recognized and
treated early. Extensive lacerations should
be looked for and repaired.
There is another type of case which we
would like to classify as placenta previa un-
recognizable. This is the case where you
have no hemorrhage during pregnancy, or
during the first and second stages of labor;
and even in the third stage of labor there
may be no hemorrhage. After all the prod-
ucts of gestation have been expelled and the
cervix has been inspected and repaired, the
vagina repaired proj^rly and the patient put
back to bed, she suddenly develops profuse
Jjemorrhage; and this bleecjing is not the
gushing spurty kind but is the venous typ)e,
which indicates that the sinuses in the lower
uterine segment in the region of the internal
OS are not closed down. The probabilities
are that this is one group of cases in which
we have tragedies which can be averted only
by allowing the patient to remain in the de-
livery room a longer time than usual and
watching carefully; then, when hemorrhage
starts, pack the uterus with sterile gauze be-
fore she is put back to bed.
In all cases where there is hemorrhage,
pituitrin, 30 mms., should be given hypo-
dermically, and immediately following this,
10 to 15 mms. of ergotole hypodermically.
Pituitrin acts quickly and the ergotole will
follow up the action of the pituitrin so as to
maintain uniform contractions of the uterus.
There is nothing more disturbing to the
physician than a patient in postpartum hem-
orrhage. After we have been most careful
in our technique of delivery, watched the pa-
tient most carefully, have given pituitrin and
ergotole, and have used all sorts of mechani-
cal means to check hemorrhage, even then
some of these patients die.
Treatment of postpartum hemorrhage, as
of most conditions, is (1) prophylactic, and
(2) curative. In prophylactic treatment we
should remember that any patient may have
hemorrhage, and that, this being true, we
should instruct all our patients to inform us
immediately if the slightest evidence of hem-
orrhage appears. In abrupto placenta or pla-
centa previa the prophylactic measure is cesa-
rean section.
Active treatment when the hemorrhage has
occurred should be intravenous saline, pitui-
trin and ergotole by hypodermic; firm pres-
sure on the uterus kept up twenty or thirty
minutes if necessary. If this does not stop
the hemorrhage, pack the uterine cavity with
sterile gauze, using the most rigid surgical
technique; prepare to give patient 500 to 700
c.c. of blood in the vein. If your patient does
not d.e within the first hour of postpartum
hemorrhage you have a good chance to save
her life, but if the hemorrhage continues and
you are unable to stop it within the first hour
then the chances for the patient are very
slight. In such cases which will not respond
to any of these measures and where life is
still maintained, the wise thing to do is to
remove the patient to the o[)erating room,
open the abcjomen and promptly remove the
SOUTHERN MEDICINE AND SURGERY
September, lQ2g
Uterus.
We believe that the profession at large is
counting too much on the mechanical perfec-
tion on the part of the uterus in every case;
that trusting too much to nature to take care
of these cases of postpartum hemorrhage, is
the reason we are losing so many women an-
nually from hemorrhage. At any rate we
feel the condition is one that demands on the
part of all of us more careful study and the
most modern scientific measures in the han-
dling of it. Xo physician can well sense the
seriousness of postpartum hemorrhage until
he has had the experience of losing a patient
right under his eyes from such a mechanical
defect on the part of the uterus. After such
an e.xperience you will probably not rely alto-
gether on the uterus doing its work perfectly
in every case.
HISTORIC MEDICINE
J. RuFus Bratton — Planter, Doctor,
Patriot, Gentleman of the Old
School
Autobiographical sketch of the First Fifty Years of
His Life, superscribed. "For my Children in
Future Life," supplemented by a Note on His
Later Years, by Miss Margaret Gist, of York.
(Concluded from August Issue)
June & .Augiist the following negroes left me
and I had to work out the crop with the
remainder — Lancaster, Allston, Ted & his
wife left me in June. Lewis & Henry left
me in August. Bill left me in Xovr. On
7th Octr. of the same year the negro man
Bill through accident while attending the
Cotton Gin and smoking his pipe set fire to
my Ginhouse and burnt up fully 100 bales
of cotton without saving a single bale. I
think this is the way that the fire originated
though I can't say positively as the boy
denies the use of the pipe at the time. This
was a heavy blow amounting to a loss of
about ? 12, 000 dollars, cotton being worth
about 30 cents per cwt. in Specie. .\11 this
I endured with patience, & continued to work
with redoubled Energy. Soon after this
burning old \Vm. Boggs came to my Farm
houses, and after being warned previously
not to come on my place, and still being told
to leave the house, he not only refused to
leave but struck me with his Stick, when I
quickly drew my pistol and put three balls
into his iron sided breast — then his friends
who came with him there bore him out of
the house bellowing like a mad bull. For-
tunately he did not die, and the lesson he
got on that day has made a reformation in
his conduct.
In Octr., 1865, The State Convention, in
accordance with Compulsion and ^Military
orders met and Emancipated the negro, a
serious act both to the negro and the coun-
try. Observations from that time to the
present (1868) fully show that the negro race
in the South is fast hastening to moral and
physical destruction. \\'hat awful destiny
awaits them and what ruin has been brought
upon the country by the fanaticism, wicked-
ness & folly of the Abolitionists, all done
under the garb of humanity, religion and
philanthrophyl In Jan., 1866, I again began
to practice medicine with Dr. Barron and
continued to do to this time. The crops
made by the negroes on the farms for 1866
& 67 were not sufficient to pay fully for the
meat, bread &c. advanced to them to work
out the crop. V^ery few negroes were able
to meet the claims against them. None of
my old negroes stayed with me except Bob,
with his family. He is still there and though
he will fall in my debt by Jany., with his
family this year, still he has agreed to try it
again for another year & I prophesy it will
be just as bad next year, 1868.
The years 1868 & 1869 presented nothing
of Special interest. The crops were rather
defiicient both in Cotton & Corn. The price
of both was high & yet the negro laborer
was not able to pay for the advances made
to Enable him to make a crop. The man
Bob & his family I sent away from the
farm Early in 1868 on account of his radical
politics — and worked the farm with white &
black hired labor. In 1869 old Hannah and
Heyward came back to my farm and have
been there to this date, Jany., 1871. They
both do as well as you could expect for ne-
groes to do surrounded as they are with so
many other negroes badly demoralized. The
practice of JVIedicine for the past two years
has been good though money was rather
scarce.
This past year 1870 has been for the
farms a most favorable season both for work-
ing & gathering the crop. The rains came
in the summer almost at the very time when
needed. The fall was dry and late and made
September, 1920
the late cotton perfect.
this year as in all the past since his freedom,
notwithstanding the fine growing seasons
during the year, has failed in many instances
to make a return in payment of the advances
made to him. The low price of cotton how-
ever and the time lost in running after politi-
cal meetings will account for the difficulty
in not meeting his just debts, and thus will
it be with him through all his life however
promising and favorable the circumstances
surrounding him.
In the year (1870) the practice of medi-
cine was good, much sickness — with chills
;ind fevers pretty much everywhere over the
county, F^specially on Fishing Creek and
around Gordon's Mill Pond.
SUPPLEMENT
During the period of Reconstruction the
men who formed the Ku Klux Klan of that
time were obliged by the necessities of the
sitiiation, Negro domination and carpet-bag-
gers' rule to take the administering of law
and order into their own hands. York coun-
ty was under military rule, the writ of habeas
corpus was taken away and no justice could
be obtained in the corrupt courts. So, threat-
ened with arrest. Doctor Bratton, with many
other citizens, had to leave the state. He
tnially went to London in the province of
Ontario, Canada. There in 1872 he was kid-
napped by a detective who was after the
reward for the doctor's capture, offered by
the United States government, and he was
brought back to Yorkville for trial. After
several weeks of imprisonment in jail crowd-
ed with the best citizens of the county he
was released on bond. The English govern-
ment demanded of the government of the
I'nited States that he should be released and
returned to Canada on the ground that he
had i)et'n unlawfully removed. After a sharp
diplomatic correspondence between the two
countries, this was done. Doctor Bratton re-
turned with his family to London, Canada,
where he lived and practiced his profession
for eight years. In 1878, after a white man's
government had been re-established in South
Carolina, Doctor Bratton and family came
back to their home in York, where he had
a large practice until his death, Septemi)er 2,
1897. The South Carolina Medical .Associa-
tion honored itself by choosing Dr. Bratton
president and he served as chairman of the
SOUTHERN MEDICINE AND SURGERY
But the negro labor State Board of Health for many years.
Of Doctor Brat ton's five sons two are doc-
tors. Col. Thomas Sumter Bratton. of the
Medical Corp, U. S. Army, and Dr. R. .A.n-
dral Bratton, of York, S. C.
You're miphty late this mornint;, John Henry.
Well, sah, when Ah looked in de glass dis mornin'
.\h couldn't see mysef dcre, so .\h thought .\h'd
gone to work. 'Twas a houh cr so fo .^h found out
dat de glass had dropt out ob de frame, yes, sah.
Poiiit.s ill Pliy.sieal Diannosi.s
Let mc describe to you how I teach my students
how to approach the chest. I take four students
and one patient, all stripped to the waist, I have
them palpate the trachea and record its position,
and record the point of maximum impulse; then
carefully percuss the diaphragm dullness from spine
to sternum on forced inspiration and forced expira-
tion and record. By this time, the student has had
an opportunity to carefully inspect and palpate the
entire chest. He then percusses the paraspinal dull-
ness and maps out Koenig's isthmus. He then per-
cusses the rhomboid and trapesius dullness just inside
the midscapular line and turns to the anterior che'-t
wall. The heart and pectoral dullness is recorded.
Thus any abnormalities which he has found over the
front or back have been noted and compired with
the normal chests of his three associates. The x-ray
plate of the patient is always at hand for compari-
son. He has learned that the trachea is easily palp-
able; that the normal point of maximum impulse is
sometimes difficult to determine in the healthy indi-
vidual; that there is great movement of the dia-
phragm dullness in the healthy individual; that the
width of Koenig's isthmus over one apex is not so
important as the comparative width over the right
and left apex; that paraspinal dullness is easily
elicited and in the healthy student is never below the
second dor.-ial spine, but that at times it will descend
that far; that when paraspinal dullness is delmitcly
unequal on the right and left, that pathology is
strongly suggested; that he can detect the rhomboid
dullness, and that when it is not found he must look
for the explanation ; that it is easy to determine the
heart dullness of the average student with accuracy,
but that his heart outline of the tuberculous patient
is generally far from where the heart is actually
placed.
Breath sounds are now considered, and he spends
the greater part of two hours learning to record
intensity, pitch, duration, rhythm and quality, which
he hears under one area of the bell of a Ford sletho
scope. This area is chosen for the student a* the
right or left suprascajjular fossa. He listens and
recc rds what he hears over this >mall area on his
three associates and then listens to the [lat-ent's
chest. He listens during quiet and moderately rapid
breilhng both with the mouth shut and open and
finds that it is much easier to record the difference
(Concluded on p. 663)
SOUTHERN MEDICINE AND SURGERY
September, 1920
PRESIDENT'S PAGE
Tri-State Medical Association oj the Carolinas and Virginia
—CYRUS THOMPSON
My eighteenth century friend, Henry Field-
ing, judge, rollicking playright and superb
novelist, divided his volumes into books and
wrote a prefatory essay to the beginning of
each book. Do you recall his wonderful
Life oj Torn Jones, a story full of wisdom and
humor, and the essay wherein he sets out to
prove, and does prove conclusively, that a
man will always write better for having some
knowledge of the subject upon which he
writes? I have always acknowledged the
truth of his conclusion and I shall not fret,
therefore, if when you have read this page
you agree with us.
In this day of psychiatrists and alienists
what right has a general practitioner, a com-
mon man, to advert to the matter of human
behavior? I am moved hereto by the fact
that this generation seems inclined to coddle
children and criminals. The older generation
felt the necessity of training children in the
way they should go and were not content to
turn the child loose to follow his hereditary
and circumstantial bent. The older genera-
tion felt that punishment was the fitting con-
sequence of crime. This generation is in-
clined to turn the child loose to make what
he will of himself and to consider the crim-
inal the product of his own mentality and,
therefore, to be reformed rather than worthy
of punishment.
The acts of the insane are right from his
point of view. He is mentally irresponsible
and is not, therefore, to be punished for his
acts, but if possible to be restored to mental
health. The acts of criminals are also right
from their point of view. Shall we accept a
criminal's point of view and treat him ac-
cordingly? It is a fact that all the ways of
a man are right in his own eyes. Even the
way of a fool is right in his eyes, but shall
we give the criminal and the fool their way?
Shall we say that the punishment of the
criminal, poor fellow, shall not be punitive
and deterrent, but only reformative, because
he acted as reasonably as the sane from his
wrong point of view? Can we change a crim-
inal's point of view? Can we give him,
when he is grown, new standards of measure-
ment for his conduct, new ideals, new aspira-
tions? Crime steadily increases and the gov-
ernment sees the necessity of creating com-
m'ssions for the study of crime. There are
rebellions in our prisons, rebellions of unre-
formable, unregenerate criminals who fight
against all authority and order, seeing, of
course, from their own view point. They
make no confession of crime, they show no
penitence for sins of which they cannot be-
come conscious. They are against the law
and against society, and not one in a hundred
by whatever kindness will be converted to a
new and wholesome vision of things.
Society has the right to establish order,
protect and preserve itself; and it cannot do
it, it never has done it, without infliction of
punishment upon the offender, punishment
which may possibly be deterrent if it cannot
change a viewpoint.
In this modern dealing with criminals we
are taking hold of the wrong end of the line.
If primarily we set out to reform them, we
must remember the difficulty of teaching old
dogs new tricks. We shall never lessen crime
by a consideration of the source of human
behavior until we confess that the source of
this behavior lies in early childhood. As long
as the family is as careless of training as it
is now, crime will increase and kind-hearted
students of human behavior cannot undo the
results of parental negligence.
The family as a social institution is not
as good as it used to be. I am afraid that
the family as a governmental adjuvant is
progressively dwindling. Unless the family
trains human beings to good citizenship and
obedience to authority, I know no reasonable
excuse for the existence of the family.
I might have written better if I had had
better knowledge of the subject about which
I have written. But every man sees with his
own eyes.
September, 102Q
SOUTHERN MEDICINE AND SURGERY
PRESIDENT'S PAGE
Medical Society of the State of North Carolina
—L. A. CROW ELL.
Is prescriptiun writing bccomino; a lost art?
Is medicine becoming a sort of rule-of-tlumib
trade? In this mass-production, chain-indus-
try, combiHation age, is the practice of the
physician in prescribing treatment through
pharmaceutical preparations becoming a
standardized project on a standard scale?
But in the creation of humanity The Omnip-
otent preferred to give each person a distinct
individuality.
As long as drugs are given and human be-
paau aq hjav ajaqi jaqjo qoEa uiojj jajjip sSui
'uouduDsajd Y 'jajUiW uoijdiJJsajd s\\\ joj
properly made, is a scientific achievement.
The thoughtful physician who sits down by
the bedside of his patient to write directions
to the pharmacist for the intelligent com-
pounding of certain substances to remedy
certain pathological conditions, should have
as good a picture of the patient's condition as
can be obtained by complete and carefully
made observations. Next, he should have a
thorough knowledge of the physical and
chemical properties of the drugs he uses and
their incompatibilities.
Especially during the last few years the
maiket has been tlooded with various concoc-
tions of commercial houses for every ailment
to which man is heir. Every doctor's mail
is burdened with samples and glaring adver-
tisements extolling the virtues of s<jme new
mixture. Many doctors are falling into the
slovenly habit of prescribing such hodgepodge
without knowing or caring anything about
the ingredients or pharmacological action; ac-
cepting blindly, as a layman would, the claims
on the label.
So long as man possesses individual bio-
logical idiosyncrasies, no standardized formula
compounded at long range may be satisfac-
torily employed for each individual case. In-
diviflual reactions to specific drugs, personal
habits and a number of other factors will re-
quire individual prescriptions
Frequently these proprietary panaceas are
given merely to appease the patient, many of
whom think the doctor has done them no
good unless he gives some medicine. Very
often nothing is needed, but only a brave
and wise doctor will refuse to give drugs
when hiS patient expects and desires them.
I am not condemning the standardized
products of reputable drug houses which are
of proved and recognized value. Some of the
pharmaceutical houses have very materially
assisted the modern scientific advance of med-
icine.
But haphazard methods are not becoming
to intelligent, trained professional men. My
plea is for a scientific attitude and a pains-
taking attention to details, for we need these
today in the maze of our competition with
the varied "healing" and "manipulating" cults
and fads, more than ever before in the realm
of iMedicine.
One offers to rub out the pain,
.Another treats it thru the "brain",
Another says it don't exist,
Another yanks it with his wrist.
Veracolate will make the bile
Behave in fastidious style;
And Scabicide will make the Itch
Fly quicker than the broom-strode witch.
If you can't sleep Somnos's the thing,
.And Pantopan is iMorpheus' wing.
If sleep is what you do alone.
There's Nuxacole and Metatone.
If you are indisposed to purge
Petrolagar will give the urge;
Arsenoferratose is good.
They say, to bolster up the blood.
Calreose is to stop the wheeze
Of Bronchitis, a sore disease;
For Uterine contractions sore
Some drops of Pitocin you pour.
In fact, with lodex, .Asac,
Sedatole, Metophen, Shellac,
Viosteral, and Liquezyme,
The doctor's job's gone, it would seem.
That is, of course, unless we use
The brains to study and to choose
The remedies to fit each ill.
And thus our highest function fill.
SOUTHERN MEDICINE AND SURGERY
September, 1Q2P
NEWS
Dr. Morton Prince died August 31st in
the Peter Bent Brigham Hospital at the age
of 74.
Dr. Prince, who was born in Boston in
1854 and was graduated from Harvard Col-
lege in 1875 and from the Medical School
four years later, was widely known as an au-
thor and consultant on diseases of the nervous
system.
He served as professor of nervous diseases
at Tufts College Medical School from 1902
to 1912, and was lecturer on abnormal psych-
ology at the University of California in 1910.
In 1903 he became editor of the Journal of
A bnormal Psychology.
His activities during the war included man-
agement of the Massachusetts Soldiers and
Sailors Information Bureau in Paris. He
represented the State of Massachusetts in
France from 1918 to 1919. Instigated and
organized the "Address (of the 500 Ameri-
cans) to the Peoples of the Allied Nations"
in 1916, and was chairman of the Serbia Dis-
tress Fund.
Dr. Prince's decorations included Order of
Chevalier of St. Sava (Serbia), 1916; Order
of the Rising Sun (Japan), 1918; Cross of
the Legion of Honor (France), 1919, and
Royal Order of Red Cross and Order of the
White Eagle (Serbia), 1920.
Dr. Arthur H. Dodge, of Westchester, N.
Y., pathologist at Grasslands Hospital, died
.'\ugust 30th in that hospital. He was head
of the pathology department at Grasslands
Hospital and a special lecturer at Cornell
University Medical College.
He was a graduate of Tufts College and of
Jefferson Medical College. Following gradua-
tion he passed two years on the staff of the
Philadelphia General Hospital. Dr. Dodge
served as Lieutenant Commander in the navy
for many years, including the entire period
of the World War, and saw service in the
war area.
Dr. Dodge's navy service began with his
appointment as pathologist of the Ancon Hos-
pital, operated by the United States (ijvern-
ment in Panama City. He remained in Pan-
ama during the building of the Canal and
was a participant in the successful struggle
to clean up the Canal Zone and to make it
safe for the engineer and workman.
In 1919 he retired from the navy to become
pathologist in charge of the Rhode Island
State Laboratory. After two years in Rhode
Island, Dr. Dodge served a year as patholo-
gist of the Brooklyn Hospital and then went
to Grasslands.
Dr. L. a. Crowell, President of the Med-
ical Society of the State of North Carolina,
has appointed the following to represent the
Society at the Eleventh Decennial Conven-
tion for the Revision of the Pharmacopoeia
of the United States of America: Dr. R. O.
Lydav, Greensboro; Dr. W. C. Bostic, For-
est City; Dr. I. M. Procter, Raleigh.
The Fourth District Medical Society
held its recent quarterly session at Eu-
reka, Wayne county. Dr. Henderson
Irwin was host at a barbue supper served in
the Eureka school building, following which
the business session was held.
Dr. T. W. M. Long, of Roanoke Rapids,
presided. Dr. L. A. Crowell, president of the
North Carolina Medical Society, delivered the
address of the evening. He vigorously de-
nied that the days of the doctor who engages
in general practice are about over. "Don't
turn specialist too soon," he advised. "Study
the body as a whole and that thoroughly and
from the standpoint of broad experience first."
He stated that there will always be the need
for the bright, earnest, young man who gives
his talent to ministering to the familv.
Dr. H. C. Salmons, Elkin, N. C, has re-
turned from a visit to clinics in London, Paris
and Berlin. The trip was made in company
with a conducted party of American physi-
cians and surgeons.
Dr. Benjamin Meade Bolton, 73, a na-
tive of Richmond and for years one of the
country's leading bacteriologists, died Aug.
12th at his home in New York.
Dr. Bolton received his degree from the
University of Virginia in 1879, and later
studied at South Carolina College, and at the
September, 1929 SOUTHERN MEDTriNE AND SURGERY 651
A NEW BACTERICIDAL DYE
BISMUTH-VIOLET
[Ilcxiinutliyl-triiimin-li'iphtnyl-inrbiiiol . . . bismuth]
A triphenvlmethane dve which is very destructive to the common pathogenic
bacteria. It is NOX-IRRITATIXG AND NON-TOXIC. It contains no mercury,
and may be applied to large denuded areas of the body such as burns and lacerations
without danger of toxic absorption by the patient. It has also been long known that
many of the aniline dyes sl'mulile ejjilhelialization in wounds.
BISMUTH-VIOLET
Is (if value in the Ircalnient of:
Infected Wounds
Infections of the Soft Tissues
Impetigo CoNTAtuosA — after all crusts and scabs are removed
Tinea (Ringworm) — after an ointment of salicylic has been applied and allowed to remain
from 12-24 hours
Infected Leg Ulcers
Conjunctivitis
Sinusitis
ANY INFECTION' to which the dye may be applied directly
USE IT AS VOU WOULD TINCTURE OF IODINE OR OINTMENT OF
AMMONIATED MERCURY
The l((lli)\\iii(| p:illin(|('iiic (iinaiiisms are killed by |{|S.>aiTH-VIOLIi;T in .lie
t'ollouinji (liliilioris:
Stap/iylocnccus alhus, aureus and citreus.
Strrptncvccus pyogenes
B. Typhosus
B. Panitvphosus A and B
B. Coli '
B. Tetani and spores
B. Welchii and spores __ .._..
B. Antlirnris and spores
1,000,000,000
1,000,000,000
1,000,000
100,000
1,000,000
100,000
100,000
100,000
Six ounce buttles, I'liysician's office size. One-half ounce bottles for the trad
Siimfilr.s (iiul lilrnilurr K'/V/ be sent on request
Manufactured solely by
TABLE ROCK LABORATORIES, INC.
Greenville, South Carolina, U. S. A.
SOUTHERN MEDICINE AND SURGERY
September, lo:o
uthern Medical Association — IN the South,
OF the South, FOR the South
GET IN THE
SWIM/
irS MIAMI
•IN NOVEMBER
SOUTHERN MEDICAL
ASSOCIATION
MIAMI FLA. NOV. IS^h 224 \929
A MEDICAL MEETING that will EXCEL — that's
the Miami meeting. EXCEL in its scientific ac.
t!vi;ies — modern scientific and practical medicine and
surgery will be brought up to date in the clinical and
general sessions and the twenty sections and conjoint
meetings, making up the Miami program. EXCEL in
entertainment and recreational features — unique and
unusual — and amid tropical loveliness. Golfing,
boating, swimming, fishing, hunting, trap shooting —
w'hatever the favorite sport or recreation, it's at or near
Miami. "Get in the swim" and ride high on the
waves of a great meeting — Miami, Florida, November
19-22, 1929.
AFTER MIAMI, CUBA. There wiU be an official
S M A post-convention trip to the "lovely land
of Cuba" truly a land of beauty and charm. De-
lightful entertainment will be provided. Never again
such an opportunity to see Cuba under circumstances
so favorable and at so low a cost.
ARE YOU A MEMBER of the Southern Medical
Association? Every forward looking physician in
the South who is a member of h.s state and county
medical society can be and should be a member. The
Association dues of ?4.00 include the Association's
own Journal each month, the Southern Medical Jour-
nal— the equal of any, better than many. "Here 'tis
again, my check for ?4.00 in payment of my dues for
another year — the best investment of the year,*' Bo
writes a prominent North Carolina physician. You
wMl EVENTUALLY make that "best investment" —
why not NOW?
SOUTHERN MEDICAL ASSOCIATION
Empire Building
Birmingham, Alabama
Southern Medical Association — IN the South,
OF the South, FOR the South
Un'.versities of Heidelberg, Gottingen and
Berlin. He became a professor in the Johnslj
Hopkins Medical School in 1886, and later
taught at South Carolina College, the Uni-
versity of Missouri and St. Louis University.
In late years he had been director of the
Philadelphia Board of Health laboratory and
the Xew Jersey State Board of Health lab-
oratory and served as pathologist at St. Jo-
seph's Hospital, Paterson, N. J., until 1924.
Contract has been let for the City Memo-
rial Hospital in Thomasville at a cost of
$100,000.
The .\nne Penn Hospital at Reidsville
is supposed to be completed by April 1st,
1930. This hospital is a gift to the City of
Reidsville by C. A. Penn and Jefferson Penn
as a memorial to their mother. The hospital
will cost $125,000. I
Dr. W. F. Crouse, aged 40, of Crouse, N.
C, died August 11th at Cocasola, the Pan-
ama Canal Zone, where he was in charge of
the United States Naval Base Hospital. He
was buried at Crouse, N. C, his home, Au-
gust 28th.
Dr. Hugh Brantley York, of Williams-
ton, died .August 30th at 3 o'clock from a
stroke of apoplexy wh'ch occurred August
18th.
The marriage of Dr. William Russell
Jones and Mrs. Anna Simmons Talley,
both of Richmond, Virginia, was solemnized
on August 17, 1929.
Dr. Fred M. Hodges and Miss Louise |
Maury .Anderson, both of Richmond, were
married at the home of the bride's parents,
Dr. and Mrs. Meriwether L. Anderson, Sep-
tember 3rd.
Dr. Ryland a. Blakey has opened offices
in Professional Building, Greenville, S. C, for
the practice of Orthopedics and Traumatic
Surgery.
Minister — "I hear, Paddie, they've gone dr\' in
the village where your brother lives."
Paddie — "Dry, man! They're parched. I've just
had a letter from Mike, an' the postage stamp was
stuck on tvith a pin." — Scbaefer AfajasM*.
n
classical
symptoms of
inflammation
rioK over a third of a century, leading practitioners in every
^ part of the civilized world have considered Antiphlo-
gistine as "Inflammation's Antidote" and as synonymous with the
prompt alleviation of pain and congestion, both superficial and
deep-seated.
Rubor Calor
Tumor Dolor
Sffectively Controlled with
Acute Laryngitis in Children
Inflammation ofthe larynxis always
a serious affection in childhood, and
produces acute symptoms^ — dysp-
noea, cyanosis, and tendency to
spasm — more quickly than in
adults. Hot applications of
Antiphlogistine over the
larynx will be found a dis-
tinctly valuable auxiliary
to the general treatment.
Parotitis
In inflammation of the parotid
glands, associated with congestion,
swelling and infiltration of serous
fluid, hot Antiphlogistine applied to
the affected area will hasten the
decline ofthe parotid symp-
toms, restore the gland to
its normal condition, and
add to the greater comfort
of the little patient.
SOUTHERN MEDICINE AND SURGERY
BOOK REVIEWS
September, 1929
HANDBOOK OF PHYSIOLOGY, by W. D. Hal-
i.biirtcn, M.D.. LL.D., FRCP., F.R.S.. Emeritus
Professor of Physiology, King's College, London, and
R. J. S. McDoiL'ell. MB., D.Sc. F.R.C.P. (Edin),
Dean of the Faculty of Medicine and Professor of
Physiology, King's College, London. Eighteenth
Edition. Over 500 illustrations, many colored, and
3 colored plates. P. B'.akhlon's Son k Co., Philadel-
phia, 1929. $4.75.
A Publisher's Note gives the very interest-
ing history of this work from its first appear-
ance in 1848 as Kirkes' Physiology, through
the period under the editorships of Savory,
Baker, Klein, Harris and Murray to that of
Professor Halliburton.
Those of us who used Kirkes' as a text in
the early 1900's will remember it with mixed
feelings. "It was rich feeding, but sair mixed
an' no verra tasty;" and its index was a sore
tr'al. The rich feeding has been retained, un-
n'xed and sn'ced most appetizingly; and the
''rdex is excellent.
The introduction is easy and natural. Dig-
nified emphasis is placed on the fact that
Physiology is not a study to be put aside and
forgotten when a certain examination has
been passed, and the practical relationships
between physiology and the practice of medi-
cine are frequently pwinted out. The chapter
on the animal cell is superb, yet so simply
written that it would serve well as a high-
school text. Tissues, organs and systems are
treated after the same fashion in regular or-
der. Just enough is given of embryology and
anatomy. Descriptions of apparatus are plain
and concise. Paragraphs on the electro-
cardiogram and nutrition of the heart, blood-
pressure, pulse, tissue respiration, vital capac-
ity, phagocytosis, salt requirement, endo-
crines, vitamins and reflexes are but a few of
the number having every-day application to
cl'nical medicine. And the statements here
g'ven are based on scientific observation and
experiment; and critical, intelligent unbiased
judgment.
Every practitioner needs just such a book
to remind him of that part of what he has
'"arned of physiology which is slipping from
h'm, to inform him of recently acquired
knowledge, to winnow the bushels of chaff
from the few grains of wheat in the writings
of enthusiasts.
The style of the work is one of such sim-
ple, orderly elegance as to make its study as
pleasing as it will prove profitable.
A SURGICAL DIAGNOSIS, by J. Leu-i Don-
kanser. A.B.. M.D.. F.A.C.S., Clinical Professor of
Surgery, .\lbany Medical College (Union Univer-
sity); .\ssociate Surgeon, Albany Hospital; Attend-
ing Surgecn, Child's Hospital, Albany. Illustrated.
D. .[ppleton & Co.. New York. 192Q. $10.00.
The author is to be heartily commended
for the v'gorous manner in which he cham-
pions the necessity for a knowledge of an-
atomy ard physiology in making a surgical
diagnosis, and condemns the dramatic diag-
nosis by "intuition." The book is primarily
for students and men doing general practice,
though containing much of value to those in
special fields.
The tabulations are excellent, especially
those of differential diagnosis. jMost of our
gross errors in diagnosis are due to failure
to examine the patient, or to failure to think
of the actual condition as a possibility. Don-
hauser reduces the second factor of error to
a minimum. A copy in the hands of every
practitioner would greatly improve the ser-
vice of surgery to patients.
THE MODERN PRACTICE OF PEDI.\TRICS.
by Williom Palmer Liicas, M.D., LL.D., Professor of
Pediatrics, University of California Medical School;
Author of "The Health of the Run-About Child,"
etc. Tlic MacMillai! Co.. New York. $8.50.
The first chapter deals with fundamental
principles, and, with the second on the devel-
optnent of preventive pediatrics, builds a
biickground against which the definite lessons
taught stand out clearly. All the way from
prenatal life through infancy and childhood
the student is taken along with the developing
human being and taught how to keep him in
the way of health, and, if he will stray from
it, how best to bring him back to that way.
The text's treatment of the different sub-
jects is sufficiently exhaustive for all ordinary
occasions; for the benefit of those who seek
wider information, a reference list is given at
September, 1Q29
SOUTHERN MEDICINE AND SURGERY
AN ANCIENT PREJUDICE
HAS BEEN REMOVED
"TOASTING DID IT"-
Gone, too, is that ancient preju-
dice against cigarettes . . •
Progress has been made . . . We
removed the prejudice against
cigarettes when we removed
harmful irritants from the
tobaccos . . .
It's toasted'
No Throat Irritation-No Cough.
O 1929. The American Tobacco Co.. Muiufacli
SOUTHERN MEDICINE AND SURGERY
September, 102Q
the end of each chapter, and an index of au-
thors cited appended.
AMERICAN ILLUSTRATED MEDICAL DIC-
TIONARY. \ complete Dictionarv' of the terms
UEed in Medicine, Surgery, Dentistry, Pharmacy,
Chemistry, Nursing, Veterinary Medicine, Biology,
Medical Biography, etc. By W. A. Nfwman Dor-
land, M.D., Member of the Committee on Nomen-
clature and Classification of Diseases of the American
Medical .Association. Fifteenth Edition, Revised and
Enlarged. With the collaboration of E. C. L. Milltr,
M.D., Professor of Bacteriology and Biochemistry,
Medical College of Virginia. Octavo of 1427 pages,
525 illustrations, 107 of them in colors. Philadel-
phia and London, W . B. Saunders Co., 1929. Flexi-
ble binding. Plain $7.00 net; Thumb Index $7.50
net.
Even among those who love words most
there are few who utilize a dictionary to best
advantage. In addition to the usually sought
information on spelling, pronunciation and
derivation, we have here for reference a treat-
ise especially arranged for ready location of
at y desired word, giving the historical aspects
ci" words, anatomic tables and tables of the
exanthemata and of dosage, a list of serums,
the technic of operations and of clinical and
laboratory tests, dental and veterinary terms
and much of medical biography.
The addition of more than 2,000 new
words to this edition will recommend it to all
doctors who would read understandingly.
CLINICAL LABOR.ATORY MEDICINE: A
Text-Book of Clinical Laboratory Diagnostic and
Therapeutic Procedures, by Henry M. Feinblatt,
M.D., Director of Laboratories, United Israel-Zion
Hospital, and Assistant Clinical Professor of Medi-
cine, Long Island College Hospital, Brooklyn, N. Y.,
and Arnold H. Eggerth, A.B., A.M., .Associate Pro-
fessor of Bacteriology, Long Island College Hospital,
Brooklyn, N. Y. Illustrated by 2 colored plates and
87 engravings. William Wond k Co., New York.
S5.00.
A standard work on clinical laboratory
med'cine which places more than usual em-
phasis on the fallibility of all laboratory pro-
cedures, and thereby gains the esteem of the
clinician, tending to cordial co-operation to
the great gain of the patient.
clinic Medical School, Fellow and Past President,
.American Proctologic Society; .Attending Surgeon.
New York Polyclinic Hospital, and New York City
Cancer Institute; Proctologist, The New York Hos-
pital. 417 illustrations and 4 colored plates. D.
Appleton & Co., New York, 1929. ?12.O0.
In meetings of general medical societies
and in articles in general medical journals
attention is frequently called to the neglect
of rectal conditions, starting with failure to
make rectal examinations. The great increase
in the number of specialists in proctology is
undoubtedly largely due to neglect of this
field on the part of the general practitioner.
The author takes cognizance of this neg-
lect and writes a work, comprehensive, with-
out being encyclopedic. He lays a founda-
tion with a profusely illustrated chapter on
the anatomy and physiology, which is fol-
lowed by one on embryology and (a natural
grouping) developmental defects.
Methods of examination are taught by
lucid text and well-thought-out and well-exe-
cuted illustrations. Local and regional anes-
thesia is well covered. Hemorrhoids, fissures,
abscesses, fistulae and pruritus are disposed
of amply in fewer pages than might have
been expected. Chronic constipation — and
even amebic dysentery — is given extended
consideration. The major surgical conditions
are described in detail, as are the operations
indicated. .\ feature which will win the high
approval of practitioners and the gratitude
of patients is attention paid to valuable meth-
ods of treatment by drugs and other measures
less radical than surgery and more generally
available than x-ray.
PROCTOLOGY: A Treatise on the Malforma-
tions, Injuries and Diseases of the Rectum, Anus
..nd Pelvic Colon, by Frank C. Yeomans, A.B., M.D.,
F.A.C.S., Professor of Proctology, New York Poly-
A SYNOPSIS OF SURGERY, by Ernest W. Hey
Groves. M.S.. M.B.. B.Sc. Uond.), F.R.C.S. (Eng.),
Surgeon to the Bristol General Hospital; Professor
of Surgery, Bristol University; Examiner in Surgery,
Universities of London, Liverpool, Leeds, and Shef-
field. Eighth edition. Illustrated. William Wood
& Co., New York. $5.00.
The declared aim of this work is to provide
the undergraduate with aids in retaining the
vast array of facts in an orderly manner, and
the graduate student with a ready means of
revising his knowledge in the light of latest
information.
Here is a synopsis of what is known today,
sufficiently detailed to meet the daily needs
of doctors in diagnosing and choosing prop-
SOUTPIERN MEniCINE AND SURGERY
September, 1929
erly the treatment for the vast majority of
surgical diseases and accidents.
PHYSIOLOGICAL CHEMISTRY; A Text-Book
and Manual for Students, by A'bert P. Matthews,
Ph.D., Professor of Biochemistry, The University of
Cincinnati. Fourth edition. Illustrated. William
Wood & Co., New Y'ork, 1028. J7.00.
In putting out his first edition, the author
e.xpressed the hope that it would raise in the
minds of its readers more questions than it
answered. The fourth edition follows the
same plan; notwithstanding it is an e.xcellent
te.xt.
Part I teaches of The Chemistry of Proto-
plasm and the Cell, Part II of The Mam-
malian Body as a Machine, Part III of Prac-
tical Work and Methods. Those who have
not had acquaintance with previous editions
will find a peculiar significance in certain
chapter subjects: The Circulating Tissue —
Tiic Blood; The Contractile Tissues — Mus-
c'e; The Cryptorhettic Tissues — [Glands of
Internal Secretion]; The i\Iaster Tissue of
the Body — The Brain.
The treatment of the vast subject of meta-
bolism, although exhaustive, is, because of
the author's remarkable insight into a stu-
dent's limitations, neither confusing nor te-
d'ous. The instruction in practical work and
methods teaches how and whv.
OUTLINE OF PREVENTIVE MEDICINE: For
Medical Practitioners and Students. Prepared under
the auspices of the Comm'ttee on Public Health
Relations, New York .Academy of Medicine; 21
contributors. Editorial Committee, Frederic E. Son-
drrn, Charles Cordon Heyd, E. H. L. Corwin, Puil
B. Hoeber, Inc., New York. 1020. $5.00.
Periodic health examinations are warmly
rdvocated, to be given from birth to death.
A promising prospect held out is that of the
re-establishment of the delightful relationship
which formerly existed between the family
and its doctor. Fittingly there is a chapter
on "Laboratory Aids" instead of "Laboratory
Diagnosis."
In the chapter on General Medicine are
given recommendations toward preventing
typhoid, diphtheria, dysentery, meningitis,
1 oliomyelitis, scarlet fever, measles, influenza,
pneumonia, smallpox, rabies, malaria, septi-
cemia, erysipelas, tetanus, arthritis, cardio-
vascular-renal, and a number of rarer dis-
eases. Prompt isolation and local quarantine
is the recommendation in influenza. Atten-
tion is properly called to the fact that every
blood infection is a septicemia.
It is admitted that it is not feasible to com-
pletely protect civilized society from infection
with the tubercle bacillus. A carbuncle on
the back of the neck and furuncles about the
face should always be regarded seriously.
The administration of iodine has markedly
reduced the incidence of goiter. Precancer-
ous lesions should be removed. Forty per
cent of all cases of indigestion arise from
causes outs'de the abdomen: think of tuber-
culosis, cardio-renal disease, diseased teeth,
tonsils, sinuses. Only 20 per cent of all cases
of indigestion are due to changes in the
stomach Itself. Don't give a purgative to a
patient who has a pain in his belly; he may
have append'citis or intussusception.
Usually no more than one vaginal examina-
t'on is needed in the course of a labor. The
avoidance of unnecessary interference will
greatly reduce the death-rate from puerperal
sepsis. The family doctor, at routine pre-
marital examinations, can forestall inhibitions,
frigidities and physical maladjustments.
Preventive medicine could limit avoidable
and unskilful surgery by insistence that oper-
ations be performed only after consultation
with recording of opinions, except in grave
emergency. Providing proper surroundings
and inculcating proper habits are offered as
means of keeping infants and children well.
Preventive measures are well considered
with special reference to eye, nose, throat and
ear diseases, the oral cavity, the skin, vene-
real and industrial diseases, and self-medica-
tion is inveighed against.
The foregoing are samples from a book
v^hich contains much of value to the practi-
tioner who is trying to do his duty by his
patients without enlisting for life to work
without remuneration under salaried officials,
or under more or less balmy and more or less
rich meddlers into matters which are beyond
them.
A HOST OF MEMORIES
While in Davie, I want to spend some days at the
home of childhood and mother, and in the same
house 20 of us brothers and sisters were born, and
14 of us raised. It is one of the most sacred spots
on earth to me. — Goods Box Whitller, Catawba
Neii.'S.
September, 1920 SOUTHERN MEDICINE AND SURGERY
FROM
L
Lt/JL/Lh
TO
DAILY
USE
Sugar tvas once the
prized relish of
kings and queens
The use of sugar affords a good example
of the service of science to man and tlie
changes that we may expect in our food
supply in this country. Sugar has been all
around us for countless ages, but we did
not know how to get it. In Queen Eliza-
beth's time, a pound of sugar cost as much
as a quarter of veal. One of the principal
expenditures of King John of France
when, following the battle of Poitiers,
he was being taken to England, was for
sugar, one of the kingly luxuries of the
day. In the present day, of course, few
foods can compete in price with sugar in
their economy of fuel value.
The chief dietary interest in sugar to-
day, however, with the exception of active
children and physically active adults, cen-
ters in its value as a condiment. Scientific
and medical authorities insist upon the
mixed and varied diet. Most food sub-
stances if eaten alone would be bland and
unpa]ata})le. A dash of sugar in milk
desserts, on berries and in stewed fruits,
on cereals, in vegetables and meats while
they are cooking may result in a regimen
that is relished by both children and
adults.
No one should gorge or overeat of sugar
or sugar-containing foods, or any other
food. Neither need anyone, without the
advice of a physician, undertake to elimi-
nate sugar or any other valuable food
from the diet. Variation, diversity, variety
and balance are the requirements of tlie
healthful diet.
Most foods arc more delicious .'.lul
nourishing with sugar.
The Sugar Institute, 129 Front Stn.t,
New York, N. Y.
(.Concluded from p. 561)
of sound over the patholoRJcal lunn than those sounds
heard over the lunus of his fellow stud'nts.
He has learned that he can make fine distinctions
and that he can make them accurately. He has
Icarnerl that the greater differences are in expiration.
I!ut he has learned also two important facts: that
the sounds are not as he was led to expect from his
study of the books and that he does not know how
to interpret these sounds.
It is our opinion at the tuberculosis s- mlorium
tliat the next great cut in the tubcrcu'oils death
rate mu.-t be made by teachin; our pnifc s'nn Lnl
the public the prcs.'.ing neod of belter :'.n 1 Ion -er
care of all tuberculous patients under thirty year,-
of age than we are now Rivinu.
(Ke.n.no.v Du.viiam, Jour. Iowa Stale Med. Soc,
SOUTHERN MEDICINE AND SURGERY
Septembtr, 1929
Clinical evidence is being daily received in con-
firmation of the Laboratory claims for
-ox,l>enznyl.suli,h<,n-ni,<le,nn.formnl.ioriium
•tradimelhylaniino'anlipvrui - liicamplioraltif
If you wish to control Febrile Diseases of Sepsis
send for literature and samples.
Orally
Administered
American Bio-
chemical Laboratories, Inc. .
27 Cleveland Place, New Yort City
American Bio-Chem. Lab., Inc. A
27 Cleveland Place, New York City.
Please send sample and literature.
Dr.
2^0 D^^Freel^al
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September, 192Q
PROFESSION CARDS
66S
PHYSICIANS' DIRECTORY
EYE, EAR, NOSE AND THROAT
AJIZI J. ELLINGTON. M.D.
Diseases of the
EVE, EAR, NOSE AND THROAT
PHONES: Office 0Q2— Residence 761
lUirlinglon Nortli Carolina
3. SIDNEY HO(H). M.D.
Diseases of the
EVE, EAR, NOSE AND THROAT
PHONES: Office 1060— Residence 1230J
IJrd National Bank BUIg., (iastonia, N. C.
0. J. HOUSER, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
Telephones —
Office H— 1672, Residence J.— 998-M
Hours — 0 to 5 and bv Apointment
219-23 Professional Bidg. Charlotte
HOUSER CLINIC
For Tonsils and Adenoids
415 North Tryon St. Phone Hemlock 4217
Consultation 219 Professional Bldg.
Phone Hemlock 1672
J. G. JOHNSTON, M.D-
EYE, EAR, NOSE AND THROAT
Hours — 9 to 1 and by Appointment
Telephones —
Office H.— 1883, Residence H— 4303-W
f>16-18 Professional Building, aiarlotle
H. C. NEBLETT, M.D.
Practice Limited to
DISEASES OF THE EYE
Telephone Hemlock 2361
Professional Building Charlotte
H. C. SHIRLEY, A.M.. M.D.
Practice Limited to
DISEASES OF THE EAR, NOSE
and THROAT
Professional Building Charlotte
JOHN HILL TUCKER, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
Hours — 10 to 1 and by Appointment
Telephones —
Office H— 3SS4, Residence H.— 2513
.■509 Professional Ruilding Charlotte
H. A- WAKEFIELD, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
Telephones —
Office H— 727. Residence J.— .nS-J
20i North Tryon Street Charlotte
INTERNAL MEDICINE
A. A. BARRON. M.D., F.A.C.P. .VI. L. Stevens. VI.I). Chas. C. Orr, MI).
DBS. STEVENS AND ORR
INTERNAL MEDICINE INTERNAL MEDICINE
NEUROLOGY DISE.iSES OF THE LUNGS
Professional Building Charlotte \ 17 Church Street Asheville, N. C.
VV. 0. NISBET, M.D , F.A.C.P. D. H. NISBET, M.D.
INTERNAL MEDICINE
GASTROENTEROLOGY
Professional Building Charlotte
U. C. ASHWORTH. M.D.
M. A. SISKE. Ml).
HABIT DISEASES, NEUROLOGY
and PSYCHIATRY
Hours by Appointment
Piedmont Building (ireenshoro, N. C.
CRAVStJN E. TARKIN(;T(»N,
\l.l).. F.A.C.P.
INTERNAL MEDICINE AND SYPHILIS
Ducan & Stuart Building Hours: 0-12. 3-5
Hot Sr.rings National Park Arkansas
PROFESSION CARDS
September, 1929
JAIVIES CABELL MINOR, M.D.
PHYSICAL DIAGNOSIS
HYDROTHERAPY
Hot Springs National Park Arkansas
JAMES M. NORTHINGTON, M.D.
Diagnosis and Treatment
in
INTERNAL MEDICINE
Professional Building Cliariotle
OBSTETRICS and GYNECOLOGY
t:. H. C. MILLS, M.I).
OBSTETRICS
Consultation by Appointment
Professional Building Charlotte
ROBERT T. FERGUSON, M.D., F.A.C.S.
GYNECOLOGY
By Appointment
Professional Building Charlotte
WILLIAM FRANCIS MARTIN, MM.
GYNECIC & GENERAL SURGERY
Professional Building Charlotte
RADIOLOGY
X-RAY AND RADIUM LNSTITUTE
W. M. Sheridan, M.D., Director
X-RAY DIAGNOSIS SUPERFICIAL AND DEEP THERAPY X-RAY TREATMENTS
RADIUM THERAPY DIATHERMY
Suites 208-209 Andrews Building Spartanburg, S. C.
Robt. H. LalTerty, M.D., F.A.C.R.
DRS. LAFFERTY and PHILLIPS
Charlolte
A' .R.ir and RADIUM
Fourth Floor Chaj'lotte Sanaloriuni
Presl).v(rrian Hospital
Crouell Clinie
C. C. Phillips, M.D.
Mere.v Hospital
Dr. J. Rush Shull Dr. L. M. Felner
DOCTORS SHULL and FETNER
ROENTGENOLOGY
RoentRenologists to St. Peter's Hospital, Ashe-Faison Children's Clinic, Good Samaritan Hospital
Professional Building Charlolte
UROLOGY, DERMATOLOGY and PROCTOLOGY
THE CROVVELL CLINIC OF UROLOGY AND DERMATOLOGY
Entire Seventh Floor Professional Building
Charlotte
Telephones— H.-WOl and //.-4092
Hours — Nine to Five
Urology:
.Andrew J. Crowell, M.D.
Raymond Thompson, M.D.
Claud B. Squires, M.D.
t^iiiieal Pathology:
Lester C. Todd, M.D.
Dermatology:
Joseph A. Elliott, M.D.
Lester C. Todd, M.D.
Roenlgenology
Robert H. Lafferty, I\LD.
Clyde C. Phillips, M.D.
September, 102Q
PROFESSION CARDS
667
Kred D. Austin, M.D. DcVVitt R. Austin, M.U.
THE AUSTIN CLINIC
RECTAL DISEASES, UROLOGY, X-RAY and DERMATOLOGY
Hours 9 to 5 — Phone Hemlock 3106
8tli Floor Independence BIdg. CharloKe
Tiios. Broeknian, JI.D., 25 Emma S(., Gi'cer, S. C
BROCK.MANS RECTAL CLiNiC
More Commodious Quarters in Colonial Apartments.
Improved Facilities.
X-Ray and Clinical Laboratories.
Recovery Beds for Ambulant Patients.
Surgical Cases Hospitalhcd at Chick Sp/lngs Sanitarium
Dr. Hiunilton McKay Dr. Robert McKay
DOCTORS McKAY and ^IcKAY
Practice Limited to UROLOGY and GENITOURINARY SURGERY
Hours by Appointment
Professional Building CiiarloUe
W. W. CRAVEN. HLD.
R. H. McFADDEN. M.D.
GENITOURINARY and RECTAL
DISEASES
0 a. m. to 1 p. m. — 3 p. m. to 6 p. m.
UROLOGY
Hours Q to 5
Professional Building CiiarloUe
.^)14-1G Professional Rldq. CharloKe
L. D. MePHAIL, M.D
RECTAL DISEASES
40.5-'«08 Professional BIdg. CiiarloUe
U YETT F. SMIPSON, M.D.
CENITO URINARY DISEASES
Phone 1234
Hot Springs National Park, Arkansas
SURGERY
ADDISON G BRENIZER, M.D.
SURGERY and GYNECOLOGY
Consultation by Appointment
Professional Building CiiarloUe
Rl SSELL O. LYDAY. M.D.
GENERAL SURGERY and SURGICAL
DIAGNOSIS
Jclferson S(d. BIdg.. Greensboro. N. C.
Geo. W. Presslv, M.D., F.A.C.S.
DRS. PRESSLEY \ KENNEDY
GENERAL SURGERY
Office Hours-,i lo 5
.■JOi-? Profe.ssional Building
Joii.N P. Kenneov, M.D.
CharloUe
R. B. Mcknight, m.d.
SURGERY
and
SURGICAL DIAGNOSIS
Consultation by .Appointment
Hours 2:30 — 5
Professional Building CharlnUc
\\M. M\H\l\ SCRUGGS, M.D., F.A.C.S.
SURGERY and GYNECOLOGY
Consultation by Appointment
Professional Building Charlotte
PROFESSION CARDS
September, 1929
ORTHOPEDICS
J. S. GAUL, M.D.
ORTHOPEDIC SURGERY and
FRACTURES
Professional Building Charlc
ALONZO MYERS, M.D.
ORTHOPEDIC SURGERY and
FRACTURES
Professional Building
Charlotte
HEimEKT F. .\RIIVT, M.D.
FRACTURES
ACCIDENT SURGERY and ORTHOPEDICS
Wachovia Hank ISiiildiiiji
AVinston-Salem, N. €.
O L. MILLER, M.D.
Practice Limited to
ORTHOPEDIC SURGERY and FRACTURES
Fifteen West Seventh Street
Charlotte
GENERAL
THE STRONG CLINIC
Suite 2. Medical Buildiiiii
C. M. Strong, M.D., F.A.C.S. '
Siirgerv and Gvncco'.ogv
J. L. Ranson, M.D.
Genilo-Ur'nary Diseases and Anesthesia
Charlode
Oren Moore, M.D., F.A.C.S.
Obstetrics and Gynecology
Miss Pattie V. .Adams, Business Manager
Miss Fannie Austin, Nurse
HIGH POINT HOSPITAL
Hijih Point, N. C.
(Miss Gilbert Muse, R.N., Supt.)
General Surgery, Internal Medicine, Neurology, Ophthalmology, etc., Diagnosis, Urology, Pediatrics,
X-Ray and Radium, Physiotherapy, Clinical Laboratories
STAFF
John T. Bukrus, M.D., F.A.C.S., Chief
Harry L. Brockmann, M.D.
Philip W. Flacge, M.D.
O. B. Bonner, M.D.
Frederick R. Taylor, B.S., M.D.
S. Stewart Saunders, A.B., M.D.
DR. H. KING WADE CLINIC
Wade Buildini;
Hot Springs, Arkansas
H. Ki.NG Wade, M.D.
Charles S. Moss, M.D
Urologist
Surgeon
O. J. MacLaughlin, M.D.
Oplhalmologist
Oto-Laryngoloisl
H. Clay Ciienault, M.D.
Associate Uurologist
M;ss Etta Wade
Pathologist
SOUTHERN MEDICINE and SURGERY
Vol. XCI
Charlotte, N. C, October, 1929
No 10
The History of the \'aginal Speculum*
R. E. Seibkls, M.D., Columbia, S. C.
Much of the material for this paper was derived from the Presidential Address of Dr. Wm. L.
Reid before the Medico-Chirurgical Society of Glasgow in 1S06. The speculum devised by Dr.
Reid was published in the Ameriam Journal of Obstetrics. March, 1SS3. This speculum as shown
by the illustration has manv of the mechanical features of those commonly in use at present.—
li. E. s.
The belief is general that J. Marion Sims,
of Lancaster County, South Carolina, was
\\\2 inventor of the vaginal speculum, and
this belief is probably due to the fact that
in describing the use of his famous pewter
spoon, he states that "I saw everything as
no man had ever seen before." This has
been accepted as indicating that he was the
first to use a speculum. "The fistula was as
plain as the nose on a man's face." It is
rbvious from these two sentences, taken
iGgcther, that he referred to seeing the fis-
tula clearly and that he, himself, d'd not
suppose that he was the first one to have a
v.'ew of the cervix. In his article on the
"Treatment of Vesico-Vaginal Fistulae," he
speaks of the use of a speculum to which
Charriere's name is attached.
It is difficult to determine just when the
vaginal speculum originated. The earliest
specimens to which we can attach a definite
dite are those from Pompeii, which was de-
stroyed A. U. 79.
In 1818 there were found in a house lab-
elled "The Surgeon" in the ruins of Pompeii,
many specula (or as they were called in the
Greek, Dioptra), which are unquestionably
from their design intended for use in the
e.xploration of the vaginal canal. Since these
are of such perfect workmanship and of such
excellent mechanical structure, it is incon-
ceivable that they were not in general use
for years previous and that these specimens
are not the result of many improvements.
(Srr Figs. 1 and 2.)
-(>ia(irivalve S))eciilum
From l'<mipeii
Let us take a brief look at the history of
the school at Alexandria. This was founded
by the liberality of the Ptolemys about 320
B. C, and in its earlier years was scholared
by Greek and Roman literati. In its won-
derful library were gathered the classical
writings of the preceding centuries and to it
came the students of all the great Mediter-
'Presented to tht Tri-Stite Medical Association of the Carolina! and Virginia meeting at
Greensboro, N. C, February 19-21, 1929.
SOUTHERN MEDICINE AND SURGERY
October, 10?0
Fit;. 2. — Tri\alvc Speculum'
From Pompeii
ranean cities. In the matter of learning it
dominated the East and furnished the ma-
jority of the thinkers of the then civilized
world. When the Saracen hordes over-
whelmed the Empire of the West it was
destroyed (640 A. D.), and we are told that
its library was burned to heat the baths of
the Mohammedan conquerors. To us, there-
fore, come only the names of some of the
great members of this Alexandrian school
and some of their precepts, due largely to
the efforts of two energetic copyists, Aetius
of .\m!da (S.xth Century A. D.) and
Paul of Aegina (end of Seventh Century
A. D.), whose writings are compilations of
the writings from the libraiy as well as the
teachings of the faculty at .'Mexandria. The
following excerpts show the use of the va-
ginal speculum at this school.
This is an extract copied from the writ-
ings of Soranus of Ephesus, who lived about
the year 87 A. D., "The surgeon should seek
first of all by means of the Dioptra, the
cause of the dystocia, which may be excres-
cences, prominent callosities or some other
of the cited causes." Aetius gives a passage
from .Arch genus who lived in the first and
second centuries of our era. "The ulcers
may be brought to light by means of the
Dioptra." The same author quotes to us
the opinion of the celebrated midwife Aspa-
sia, who lived in the latter part of the second
century, on hemorrhoids of the uterus. "It
happens that hemorrhoids develop at the
orifice of the uterus, in the neck, sometimes
in the uterus itself, more rarely in the genital
parts. They may be demonstrated by the
touch, but it is better to make use of the
Dioptra." Hemorrhoids probably here refer
to ulcers which bleed at the touch.
We find in Paul of Aegina, a new proof
of the existence of a Dioptra in the first and
second century of our era. He reports in
Chapter lxxviii, page 319, concerning
anal fistulae, the opinion of Leonidus, who
pract'ced at Alexandria and was either the
contemporary or predecessor of Soranus. On
the subject of hidden fistulae, Leonidus says:
"When a deep fistula has perforated the
sphincter, either one that has commenced in
the anus or one that has begun higher up, it
may have been stopped in the sphincter.
.-\fter the exploration before mentioned one
dilates the anus, just as one dilated the va-
gina of a woman, with the anal dilator, and
by th's we mean to say the Dioptra."
It is only sufficient to examine the uterire
specula and the anal specula of Pompe'i
{Fig. 3) to understand this distinction. The
uterine speculum is a great deal larger than
the anal speculum, and the latter is obviously
intended for use in the lower bowel while th^
former would be entirely unsuited to other
than vaginal exploration. If the Alexandri-
ans made use of the speculum in the first
century as an instrument so usual that it
was not necessary to give a description of it,
it must have been very well known and had
been so long in use that it was suTficient only
to name it.
Aetius spoke of the Dioptra in the sixth
century but he gave very slight description
of it as one would do with an apparatu")
known to everyone. Here is what he says
in Chapter cviii, page 908, "as to miliary
tubercles developed on the neck or on the
lips of the uterus one will be able to recog-
nize them by touching them but better by
use of the Dioptra." Again concerning uter-
October, 1929
SOUTHERN MEDICINE AND SURGER\
.i. — Rectal Speculum
From Pompeii
ine calculi, "These calculi sometimes are
formed in the uterus. If they form on the
neck of the orifice, the vulva and vagina
being dilated by the Dioptra, one removes
the calculus by means of a scalpel." By
this we suppose he is referring to fibroids.
Concerning abscesses about the neck of the
womb; Aetius was a conservative. Ponder
this thought from 22 centuries ago. "We
must not be too prompt in having recourse
to incision, but wait until the disease is ma-
tured and the inflammation has increased to
its utmost, and the parts pressing on the pus
are thinned. Then to operate, place the
woman supine on a seat, with the legs drawn
up on the abdomen and the thighs separated
one from another. Let her arms be brought
down under her haunches and secured by
appropriate ligatures, which pass under the
neck. This will give full illumination of the
parts. The surgeon stands to the right and
makes use of a Dioptra appropriate to the
age of the patient after having measured
with a sound the depth of the vagina, in
order not to compress the uterus by using a
Dioptra which is too large. And if it is too
large use some linen before the vaginal lips
and let the Dioptra rest on this material."
We must conclude that the speculum was in
daily use at the Alexandrian school and by
its alumni throughout the Greek and Roman
world.
In India there were three medical writers
whose works come down to us, Charaka at
the beginning of the Christian era, Susruta
(Fifth Century A. D.) and Vagbhata (about
Seventh Century A. D.) These authors de-
scribed specula and hemorrhoids but they do
not mention specifically the vaginal specu-
lum, and, whatever our opinion may be of
the knowledge they had of the female genital
apparatus, we cannot be sure that they used
a vaginal speculum.
In Egypt proper we have no evidence that
there was much scientific thought. The .Al-
exandrian school was the high point in Egyp-
tian culture and south of this city there was
a firm adherence to traditions and customs
rather than any effort to absorb the knowl-
edge of neighboring cultures. Medical prac-
t'ce was priest- and witch-ridden.
Among the Hebrews, the vaginal speculum
was used at an early date. Here is the de-
scription in the Babylonian Talmud, Xidda
Treatise, by Mar Samuel, who was born in
160 A. D.
"How could the woman examine herself?
She introduced a tube made in the shape of
a trumpet, then she inserted an applicator
with a tampon of cotton on its extremity
through the lumen of this tube. On with-
drawing the applicator if she found blood
on the tampon she would be assured that
the discharge came from the uterus; but in
the contrary case, it could be considered
that the blood was due to a hemorrhage from
the vaginal wall." Samuel states that the
tube was made of metal (lead) and the
edges were turned inward toward the lumen
of the tube. It is thus established that the
Hebrews possessed a special metallic instru-
ment of tubular form resembling a sort of
trumpet permitting them to examine the neck
of the uterus and the vaginal wall.
To the Arabs we owe the preservation of
the sciences and arts, for with the fall of
(Ireek and Roman civilization astronomy,
mechanics and medicine were lost and it is
due to the translation of Greek and Latin
texts into Arabic that they are in existence
672
SOUTHERN MEDICINE AND SURGER\"
October, 1920
today. While all other nations were sunk
in ignorance, the Saracens were the only
people with a true literature and real learn-
ing.
The Mohammedan religion forbade the
examination of women by men, so gynecol-
of;y and obstetrics were turned over to mid-
wives. The speculum was barely more than
mentioned by the majority of the Arabian
v/riters on medicine. Rhazes in the tenth
century says, "If the violent delivery of the
baby produces a tearing of the uterus, you
will perce've it by means of the speculum."
Guy de Chauliac in 1363 showed that the
cpeculum employed by Avicenna in the elev-
enth century was an attachment with a mir-
ror which opened the vulva and the surgeon
saw the parts as they were reflected some-
what as the laryngologist uses the throat
mirror.
Albucasis (1085) described and figured a
E:-:eculum exactly like the one of .\etius seven
centuries before. "Treatment of abscesses
cf the uterus: .^fter having placed the pa-
t ent on the bsd in the usual dorsal position,
(he widwife stands to the right using an in-
strument with which one opens the vulva.
If you wish to make use of this instrument
you should first introduce a stylet into the
vaginal cavity for fear that it may prove too
long. If it should be too long it is necessary
to apply some compresses to prevent the in-
strument from penetrating too deeply into
the vaginal cavity. The screw of the instru-
ment should be placed at the top and the
assistant turns the screw in such a manne.-
as to dilate the vaginal cavity."
ter of brass, of v/hich the straight extremity
is introduced into the vagina while the larger
extremity is towards the cautery. One may
repeat this treatment if God wills."
In medieval years (1098-1438) thinkers
were under the ban of authority, largely ac-
clesiastical. Thus Galen with his devout
monotheism became almost a divine person.
There was neither inductive logic nor experi-
mental research. Through the influence of
.^vlcenna, me/dical authority depended en-
tirely on Galen and clung closely to his dic-
tum that surgery was only a mode of treat-
ment. The Arabian copyists and commenta-
tors were governed by the Oriental idea that
it was unclean to touch the human body with
the hands. "The genera! practice of surgery
in the end was relegated to the barbers, bath
keepers, sow-gelders and mountebanks."
(Garrison.)
It is not surprising then that we have no
changes in the form or use of the vaginal
speculum and surprisingly few references to
it in the writings of even the better surgeons
of the time. Guy de Chauliac (1363) de-
scribed its use in difficult labor and indeed
th's seems to have been its only and occa-
sional value to these authors. {Fig. 5.)
Fig. 4 - -S'l'-'-ul.T i>f .\lhucas:s
(Arabian School)
Albucasis made use of another instrument
cractly like our plain speculum. {Fig. 4.)
"One makes use of fumigation with appro-
priate substances; the instrument which
should be used in cases of suppression of the
menses and retention of the secundines re-
sembles a funnel made of light wood, or bet-
Fig. 5. — Left tu right: Specimen of end of 15th
Century, of I4th Century, oi 16th Century
With the revival of learning (1431-1600)
there was at the same time a great expansion
of both the art and science of surgery, and
the vaginal speculum came again to play its
important part in both diagnosis and treat-
ment. Ambroise Pare published in IS 73 his
treatise on surgery and in this work in
speaking of ulcers at the mouth of the womb
he states that these may be shown by Intro-
October, 1020
SOUTHERN MEDICINE AND SURGERY
6^5
ducing the uterine speculum "in order that
one may both see and touch them."
In the year 1500 Jacob Xufer, a sow-
gelder, performed a successful cesarean sec-
tion upon his own wife and this gave opera-
tive gynecology a new impetus. In 1587 Ja-
cob Rueff showed a trivalve speculum but
speaks of it only as to be used to dilate the
uterine cervix in difficult deliveries. Another
somewhat similar instrument was intended
to be used to dilate the vagina and to seize
the head of the infant by means of sharp
hooks. Jacob described it, but he considered
lh!s a dangerous instrument and states that
before using it the physician should encour-
age the woman greatly and should himself
send up a prayer to Heaven. Had he left
out the cross-bars on h!s instrument and flat-
tened the blades and removed the hooks of
it, he would have invented the obstetrical
forceps and would have e.xtracted a living
instead of a dead child.
In 1650 Scultetus shows a bivalve specu-
lum as well as a trivalve. He states that
the former may be used either for the anus
or for the vagina and the latter for the va-
gina only. {Fig. 6.)
Fig. 6. — Left to risht: Specimen of beginning; ol
17th Century, of end of same centurv
One of the earliest comi^lete treatises on
the diseases of women was the work of a
Scotchman, Jacobus Primrose, who studied
in Paris and at O.xford and practiced at Hull.
He sp>eaks of the speculum as associated with
the diagnosis and treatment of the diseases
of the uterus as later authors spoke of the
slethescope in cimnection with the diseases
of the heart. Levret in 1766 first proposed
to use the vaginal speculum for the cure of
recto-vaginal fistulae.
In 1812 Recamier, surgeon at the Hotel
Dieu in Paris, introduced the use of the tu-
bular speculum. His speculum was modified
by Sir William Fergusson (1808-1877), a
Scotch surgeon and really the founder of
conservative surgery. He taught and prac-
ticed that it was "a grand thing when even
the tip of a thumb can be saved." His spec-
ulum with minor modifications continues to
be used and it is essentially the speculum
with the addition of a water cooling appar-
atus used in the Percy treatment of carci-
noma of the cervi.x.
Dr. Howard A. Kelly in a personal com-
munication makes the following comment:
"One of the best of those early specula, yet
very limited in its applicability, was the Fer-
gusson— a glass speculum which later was
silvered on the inside and painted black
without and in different sizes gave a fairly
good view of the vagina and when cut ob-
liquely at the inner end enabled one to iso-
late the cervix in the upper lumen and to
treat it independent of the vagina. I have a
conical speculum made of metal, shorter than
the old Fergusson, with a stout handle and
a flared opening; I find this of the utmost
advantage in the knee-chest posture when the
vagina balloons out with air. Campbell of
Georg.a deserves a great deal of credit for
insisting on the value of this position."
1 he circumstances surrounding the discov-
ery by S.ms of h.s speculum and of the posi-
tion wh.ch was essential to the correct use
ol the speculum may be of interest. He had
just prev.ously seen several cases of vesico-
vaginal fistulae, and had decided that they
v.c.e incurable largely on account of his in-
abil.ly to see them clearly and to operate on
them by sight.
Be ng called to see an elderly patient who
was stout and who had recently been thrown
from a pony following which she suffered
agonizing pain in the lower back, upwin ex-
amination he found that there was complete
retroversion of the uterus. "The question
was, what I should do to relieve her. I re-
membered, when a medical student in
Charleston Medical College, that old Dr.
Prioleau used to say: 'Gentlemen, if any
of you are ever called to a case of sudden
version of the uterus backward, you must
place the patient on the knees and elbows—
6?4
SOUTHERN MEDlCmE AND SURGERY
October, 1929
in a genupectoral position — and then intro-
duce one finger into the rectum and another
into the vagina, and push up, and pull down;
and, if you don't get the uterus in position
by this means, you will hardly effect it by
any other.' Strangely enough, all that Pro-
fessor Prioleau said came back to me at once
when the case was presented. So I placed
the patient as directed, with a large sheet
thrown over her.
"So, as she raised herself and rested on
her knees, just on the edge of the bed, and
putting one finger into the vagina I could
easily touch the uterus by my pushing, but
I could not place it in position, for my finger
was too short; if it had been half an inch
longer, I could have put the womb into place.
"So I introduced the middle and index
fingers, and immediately touched the uterus.
I commenced making strong efforts to push
it back, and thus I turned my hand with
the palm upward, and then downward and
pushing with all my might, when all at once,
I could not feel the womb, or the walls of the
vagina. I could touch nothing at all, and
wondered what it all meant. It was as if I
had put my two fingers into a hat, and
worked them around, without touching the
substance of it. While I was wondering what
it all meant Mrs. Merrill said, 'Why, doctor,
I am relieved.' My mission was ended, but
what had brought the relief I could not un-
derstand. I removed my hand, and said to
her, 'Vou may lie down now.' She was in
a profuse perspiration from pain and the un-
natural position and in part from the effort.
She rather fell on her side. Suddenly there
was an explosion, just as though there had
been an escape of air from the bowel. She
was exceedingly mortified and began to apolo-
gize, and said, 'I am so ashamed.' I said:
'That is not from the bowel, but from the
vagina, and it has explained now what I did
not understand before. I understand now
what has relieved you, but I would not have
understood it but for that escapement of air
from the vagina. When I placed my fingers
there, the mouth of the vagina was so dilated
that the air rushed in and extended the va-
gina to its fullest capacity, by the natural
pressure of fifteen pounds to the square inch,
and this, conjoined with the position, was
the means of restoring the retroverted organ
to its normal place.'
"Then, said I to myself, if I can place the
patient in that p>osition, and distend the va-
gina by the pressure of air, so as to produce
such a wonderful result as this, why can I
not take the incurable case of vesico-vaginal
fistula, which seems now to be so incompre-
hensible, and put the girl in this position
and see exactly what are the relations of the
surrounding tissues? Fired with this idea, I
forgot that I had twenty patients waiting to
see me. I jumped into my buggy and drove
hurriedly home. Passing by the store of
Hall, INIore and Roberts, I stopped and
bought a pewter spxjon, I went to my office
where I had two medical students and said,
'Come, boys, go to the hospital with me.'
"You have got through your work early
this morning,' they said.
'I have done none of it,' I replied; 'come
to the hospital with me." Arriving there, I
said, 'Betsy, I told you that I would send
you home this afternoon, but before you go
I want to make one more examination of
your case.' She willingly consented. I got
a table about three feet long, and put a cov-
erlet upon it, and mounted her on the table,
on her knees, with her head resting on the
palms of her hands. I placed the two stu-
dents one on each side of the p)elvis, and
they laid hold of the nates, and pulled them
open. Before I could get the bent spoon-
handle into the vagina, the air rushed in
with a puffing noise, dilating the vagina to
its fullest extent. Introducing the bent han-
dle of the spoon I saw everything as no man
had ever seen before. The fistula was as
plain as the nose on a man's face. The edges
were clear and well defined, and distinct, and
the opening could be measured as accurately
as if it had been cut out of a piece of plain
paper. The walls of the vagina could be seen
closing in every direction; the neck of the
uterus was distinct and well defined, and
even the secretions from the neck could be
seen as a tear glistening in the eye, clear
even and distinct, and as plain as could be.
I said at once, 'Why cannot these things be
cured? It seems to me that there is nothing
to do but to pare the edges of the fistula
and bring it together nicely, introduce a
catheter in the neck of the bladder and drain
the urine off continually, and the case will be
cured.' (Figs. 7, 8, 9.)
Thus we have seen that the vaginal spec-
October, 1920
SOUtHEfeN M£t)ICt*Jfe AMb StfeGtftV
Fig. a.
6>S
Evolutionary Steps
ulum may be traced back to the early days
of the treatment of disease and the relief of
su.Terins; in gynecology' and that Sims cannot
be said in any way to have invented it. On
the other hand, it is perfectly clear that com-
bining a retractor with the Sims position and
the silver sutures Sims is the founder of mod-
ern conservative and plastic operations on
the female genito-urinary tract. In giving
surgeons a method by which they could see
clearly the lesions that existed and the re-
sults achieved by treatment directed to them,
he removed from gynecology many of the
false theories which were based on lack of
observation. In his pioneer work in New
York and abroad he did more to place gyne-
cology on a firm basis than have any of the
inventors of mere surgical instruments.
BIBLIOGRAPHY
Sims, J. Marion, Clinical Notes on Uterine Sur-
gery, New York, 1871.
Sims, J. Marion, "The Storv of Mv Life," New
York, 1888.
Sims, J. Marion, On the Treatment of Vesico-
Vaginal Fistula, Amer. Jour. Med. Sci., XIV (New
Series), 54, Jan., 1852.
M(Kav, W. J. S., The History of .'\ncient Gyne-
cology, I^ondon, 1001.
Kki.i.v, Howaro a.. Personal communication.
TRiAiRK.-l/ANTinini.', (lu Speculum. Citron. Med.,
Paris, ll:.!0.i, 1004.
3issei.i., PouGAi., The Sims Memorial Address on
Fig. 8. — Instruments used by Sims for vesico-vaginal
fistula. (Savage, "Sur -crv of Female Pelvic Organs,"
Wm. Wood & Co.)
Gynecology, Amer. Jl. Surg., V, 526, Nov., 1028.
Reiij, W. L., The History, Forms and Theories of
the Vaginal Speculum. Glasgow Med. Jl., XLVI,
Sept., 1896.
Ueneffe, Le Speculum de la Matrice, Paris, 1901.
DISCUSSION
Dr. H. a. Royster, Raleigh:
Discuss.ons of discoveries in medicine
have always been interesting to me from one
point of view, namely, bringing out the facts
of medical history. Dr. Seibels has done this
in a most admirable manner. On the other
hand, I have never been interested in per-
sonal, acrimonious debates among members
of our profession as to whether one man or
another originated an idea, first discovered
a scientific fact, invented an instrument, or
first performed a certain operation. Knowl-
edge is a progressive thing. Somebody has
to begin, and others have to continue the
amount of knowledge which is passing on
from time to time to each one of us. (Jrigi-
nality is only a comparative virtue. Some*
676
SOttHERN MEDICINE AND SURGERV
October, 19^9
Fig. 0, — Sims Operating with Margaret, the nurse,
holding the Speculum. (Savage, "Surgery of Female
Organs," Wm. Wood & Co.)
body said that next to the inventor of a fine
phrase is the man who quotes it correctly.
The question of priority in the invention of
the vaginal speculum is of lesser importance
than the principles established by Sims. He,
of course, knew of the uses of the vaginal
speculum, and he had tried a great many
of them; and he confesses, as quoted by
the essayist, that he knew of specula which
were similar to his. To Sims, I think, must
be given the credit of immediately grasping
the significance of air entering the vagina;
and, when he grasped that significance, he
immediately put it into practice and gave
the world not only a new operation but one
which had never been successfully performed
before. The circumstances of it have been
described by Dr. Seibels. We do not need
to discredit Sims' originality of the speculum
in order to keep up the romance of his dis-
covery. I might quote here what John A.
Wyeth said in 1895: "I have often won-
dered over what womankind would have suf-
fered through all these years, had not that
immortal Alabama hog laid itself down to
sleep in that particular fence corner by the
roadside on that eventful day in June, 1845.
The animal, awakened and frightened by the
nearness of a lady on horse-back, started up
with considerable noise; the horse sprang
from under its rider, who struck heavily
upon her pelvis. She was carried to her
home and, when Dr. Sims reached her, she
complained of great pain in her back and
pelvic organs. A careful examination re-
vealed a backward displacement of the uterus.
Placing her in the genu-pectoral position and
in the further manipulation to replace the
uterus, the accidental advent of atmospheric
aid dilated the cavity [vagina] and at the
same time suddenly restored the uterus to
its normal position. The quick eye of the
genius at once took in the entire significance
of this accident. Almost overcome with the
discovery, he said to himself, 'If I can ac-
complish this by the use of atmospheric
pressure, why can I not employ the same
agency in attempting to relieve these incur-
able cases of vesico-vaginal fistula?' En-
thused with this idea, he hurried back to his
office, only stopping at a hardware store on
the way to buy a large pewter spoon, and
from this was evolved at once the speculum
which bears the name of its inventor."
Of the Sims' speculum the illustrious Em-
met said: "From the beginning of time to
the present, I believe that the human race
has not been benefited to the same extent
and in a like period, by the introduction of
any other surgical instrument. Those who
did not fully appreciate the value of the spec-
ulum itself, have been benefited indirectly to
an extent they little realize, for the instru-
ment in the hands of others has probably
advanced the knowledge of the diseases of
women to an extent which could not have
been done for a hundred years or more with-
out it."
So, while I think that Sims did not himself
claim to be the originator of the uterine spec-
ulum, he did make use of a type of speculum
which did then, and does now, expose the
vaginal wall better than any other which has
been invented. We cannot do without the
duck-bill speculum.
In closing I wish to make this observation.
October, 1929
SOUTHERN MEDICIKE AND SUftGERV
611
The younger generation, particularly those
in the South, do not realize the greatness of
Sims as a surgeon. He is spoken of and
recognized as the father of gynecology, but
he was a great and resourceful general sur-
geon. He was an early pioneer in gall-blad-
der surgery, did plastic surgery of the face,
and performed many operations of which he
had never heard. His one invention, how-
ever, placed him in the front ranks. Born
in South Carolina, he practiced in Alabama
and later moved to New York. Still later
in Paris, he was known at the four corners
of the globe not only as one of the leading
surgeons of his time, but as the man who up
to his period had done more than any other
for the relief and comfort of womankind.
Dr. James K. Hall, President:
I have an idea that one of our invited
guests. Dr. Joseph L. Miller, of Thomas,
West Virginia, probably knows more about
historical obstetrics and gynecology than any
other man present. Will you not speak to
us a minute, Dr. Miller?
Dr. Joseph L. Miller, Thomas, W. Va.:
I think Dr. Seibel's paper is one of great
interest to anyone who is interested in medi-
cal history, gynecology especially. Dr. Sei-
bels has covered the ground most thoroughly.
I believe, however, our old father of medi-
cine, Hippocrates, described and used the
rectal speculum, and from his descriptions
we infer that he probably knew and used the
vaginal speculum.
Dr. Seibels has covered the ground very
thoroughly, but I think he has overlooked
possibly the earliest of the medieval surgeons
who described and used the vaginal specu-
lum, namely, Guy de Chauliac. In the eight-
eenth century Heister invented a sjjeculum
which is very much like the modern bi-valve.
I believe \orth Carolina claims to ante-
date Sims, as Williams Thomas, of Tarboro,
operated successfully and relieved vesico-va-
ginal fistula, using wire sutures and a "duck-
bill" speculum made for him by a local black-
smith.
Dr. Julius H. Taylor, Columbia:
I think you have touched on a subject in
medical history that should be emphasized
very much more than it is in medical schools.
Certainly it should be the text for a lecture
to young men in medical schools. As Arnold
Bennett says, we are pretty deeply imbued
with that universal human passion, the love
of Dr. Seibels has given us
here the history of the development of the
speculum o*^ back to the Greek days. You
remember after old friend Homer got through
talking about the great heroes of Troy, etc.,
he ends up by saying, "There were great
men before Agamemnon." I think that e.\-
presses pretty well what has happened with
regard to the vaginal speculum. As regards
Sims himself, I heard a man speaking a few
years ago who did not approve of him at all.
His main objection was that he once had a
bird dog which he had hunted with for years,
and he was mean enough to sell it. I think
that is a severe criticism of any man. The
Medical Association of South Carolina will
unveil next month a classical Greek memo-
rial to Marion Sims, who graduated from
South Carolina College. He was born near
Lancaster. I am on that commitee, and we
have had an exquisite bust executed. I have
some photographs of it which I shall pass
around. One of the most distinguished
firms in .America has designed this
for us, and I think perhaps some of you men
will be interested in seeing it.
Dr. James M. Northington, Charlotte:
Some two years ago I wrote in the official
organ of this society, an editorial which was
based largely on a paper in the Transactions
oj the Medical Association oj New York in
1896, on the contributions of America to
surgery. I found there an enormous amount
of data, a very exhaustive article; and some
twenty-five or thirty surgeons of the South
were there paid honor of whom I had never
heard. I called attention at that time and
want to call attention again to the fact that
it is our own fault that Southern men who
accomplish a great deal in surgery or in any
other branch of medicine or in the arts or in
literature do not attain the same recognition
as do those in other parts of the country,
particularly New Kngland. Here was a New
Yorker telling me, and through me a great
many others who read about it, about men
who practiced in Virginia and North Carolina
and South Carolina and Tennessee and Geor-
gia and Louisiana and all the other states,
men who had made notable contributions to
the advancement of surgery. I wish to repeat
6ik
SOUtHfekN MBbtdtNfe AM) StfeGfefeV
October, 1020
again a request that I made at that time,
that all of you gentlemen look around you
and get information from the old persons,
from the records, about the great men in
your community and send it in to Soidhern
Medicine and Surgery for publication.
Dr. James K. Hall, President:
During this talk about Dr. Sims it oc-
curred to all of you, of course, on hearing
that he was born in Lancaster, South Caro-
lina, that another great disturber of the peace
was born not far from there. .Andrew Jack-
son was born in North Carolina not far from
where Marion Sims was born.
(Someone: .\ndrew Jackson was born in
South Carolina.)
You are wrong; he was born in North
Carolina. I admire South Carolinians; they
are always seceding from something; they
are enemies of the status quo.
I am going to say something to the shame
of Carolinians, North and South. The
mother of .Andrew Jackson was buried about
two miles west of Charleston, on the plain
there near the railroad underpass. No one
knows just where she lies. She contracted
camp fever from nursing the soldiers and
died. The medical societies of North and
South Carolina ought to put up a marker
somewhere there for her.
Dr. Northington is wrong in saying that
Southern heroes go unsung, because Andrew
Jackson and Marion Sims have both placed
themselves on the front page. Both were
born near Lancaster, South Carolina.
Some Parasitic Diseases That May Be
Transmitted by Dogs and Cats
(U. S. p. H. Service)
The two most important parasitic diseases trans-
mitted to man by docs in North .America are hydro-
phobia, or rabies, and hydatid di;ease.
Mad dogs, and, le;.s frequently, mad cats, can by
their bite transmit hydrophobia to human beings.
Generally, pet dogs are not likely to transmit the
disease. If, however, a pet dog is bitten by a street
dog it must be regarded as in danger of developing
the disease for at least six months.
Hydatid disease is a serious problem in some coun-
tries where dogs are numerous and live intimately
with people; but, fortunately, it is one of the minor
problems in the United States. Dogs and, more
rarely, cats have in their intestine a small tapeworm,
usually less than a quarter of an inch long. This
tapeworm produces eggs which the dog scatters
around the field. When these eggs are swallowed
by pasturing cattle, sheep, or swine, the embryo
breaks loose from the egg shell and bores to the
liver, lungs, or some other portion of the body of
the pasturing animal. It then develops into a cyst
which may grow to be as large as a man's fist or
even larger. In this cyst numerous tapeworm heads
form; and when the cyst, discarded at some country
slaughterhouse, is eaten by a dog, each tiny worm
head develops into a small tapeworm. If, by chance,
eggs from the dog-tapeworm are swallowed by
persons, either through too great an intimacy with
dogs or through the medium of contaminated food,
man contracts the cyst, or hydatid, which is more
usually found in cattle, sheep, or swine. Dogs and
cats which have no opportunity to eat the infected
organs of other animals do not harbor the tapeworm,
and, therefore, cannot transmit hydatid disease.
In some parts of the United States both cats and
dogs harbor a special intestinal parasite known as
the Brazilian hookworm. This same hookworm is
occaionally reported as an intestinal parasite of
man, but the worm has gained special disrepute as
cause of a sk.'n disease of man. In some of the
warmer localities there is a condition known as
creeping eruption. Not only is this a very irritating
condition, but its presence in certain localitie.; has
been an economic factor in driving away tourists
and in decreasing real estate viluo",. Creeping erup-
tion in man can be caused by various different
immature worms and by larval insects. The ill-
famed creeping eruption of warmer localities in the
United States is due to the fact that if a person
come in contact with soil, as in the garden, which
has become contaminated by dogs or cats with
young larvae of the Brazilian hookworm, the young
worms penetrate the human skin and produce creep-
ing eruption.
Cats miy have a skin di:ea;e caused by a mite
which is closely allied to the parasite which causes
itch in persons. This cat parasite may pass from
cats to persons, especially to children, and cause a
special form of itch. Sometimes this cat itch be-
comes almost epidemic among the children in or-
phanages, but it is a rare condition in the general
population.
The saying, "Love me, love my dog," is not an
exaggeration of the affection of many persons for
their canine friends. Some dog owners take proper
precautions that their dogs shall be a nuisance
neither to themselves nor their neighbors; but, un-
fortunately, too frequently dog owners, through a
lack of reasonable care, permit their pets to be
neighborhood nuisances and public health dangers.
The fault in these cases is chargeable more to the
owners than to the dogs.
October, 1929
SOUTHERN MEDICINE AND SURGEftY
67«
Granuloma Inguinale
Don C. Eskew, M.D.. and S. Douglas Craig, M.D., Winston-Salem, N. C.
Granuloma' may be defined as a chronic
infectious ulcerating disease occurring in any
part of the body but mostly around the geni-
tal organs with no tendency to glandular in-
volvement, or serious impairment to health.
Granuloma inguinale has definitely been
established a clinical entity, new cases are
appearing daily as our knowledge of the dis-
ease progresses; it is rapidly acquiring a lit-
erature of its own.
The disease is in no sense venereal; while
affecting genital and perigenital tissue chiefly,
it is not a venereal disease; transmission by
se.xual intercourse has not been proven.
Geographically it is a subtropical disease.
Analysis of one hundred and fifty cases in
the United States as reported by Fo.x- showed
there were ninety males and si.xty females;
the patients' average age was thirty years.
The duration of the disease varied from ten
days to twenty-six years, the average being
3^4 years. There were 135 negroes and 15
whites, a ratio of 9 to 1. In every case the
disease occurred near the genitalia, and in
nine cases lesions were present on other parts
of the body.
First described by Conyers and Daniels in
1895, the etiology remains uncertain. In
1905 Donovan'' described peculiar ovoid
inclusions within the large mononuclear
cells present in the lesions; morpholog-
ically these inclusions are encapsulated
gram-negative coccoid or cocco-bacillary
forms whose place in the bacterial kingdom is
uncertain. Donovan believed the germ to be
a protozoon; Flu, a chlamydozoon ; Siebert,
an encapsulated diplococcus; Aragao and
Vianna, a separate genus of schizomycetes.
Experimentally, so far, uniformly negative
results have been obtained in the reproduc-
tion of the disease by bacterial injection.
Koch's postulates have not been fulfilled.
Tissue grafts have taken and the disease has
been reproduced.
According to Cam[)bell' there seems to be
nothing characteristic in the histologic pic-
ture. There is a marked round-cell infiltra-
tion with large numbers of plasma cells and
eosinophils. Early lesions show proliferation
in the endothelial cells and capillary growth
containing much fibroblast production in the
older lesions. Surface epithelium is thin and
delicate and the superficial portions of the
tissue show the picture characteristic of in-
flammatory reaction with marked polymor-
phonuclear invasion. Absence of giant cells
and caseation is noteworthy.
The primary lesion consists of a moist
papule or papules which soon ulcerate, leav-
ing an area of granulation somewhat elevated,
sharply circumscribed, indurated, painless ex-
cept on pressure and bleeding quite easily,
which shows no tendency toward spontaneous
healing."' Lymphatic involvement is rare un-
less pyogenic secondary infection occurs over
the areas involved, and as soon as that is
controlled the glands readily subside. The
ulceration is usually superficial and rarely
involves tissue beneath the dermis.
The diagnostic features are: chronic, ulcer-
ating lesions, involving the genitalia or groin,
covered with exuberant granulations which
bleed easily; the surface exudes a scanty se-
cretion which has a sour, fetid odor; no hy-
perplasia of the regional lymph glands; no
pain, but some local discomfort; and smears
from the surface of the lesions show deeply
stained granular accumulations that have
been termed Donovan bodies."
This condition must be differentiated from
(1) chancre — a sharply defined punched-out
ulcer, with firm induration and associated
adenopathy; (2) chancroid — acutely tender,
ulcerated area with marked glandular involve- ,
ment; (3) gumma — deeper involvement, does ,
not bleed easily and gives the usual serologi-
cal tests; (4) tuberculosis — biopsy is the
most certain; (5) epithelioma — more indu-
rated; bi(jpsy will show histologic picture of
an infiltrating neoplasm.
Tartar emetic is a specific. It is usually
employed intravenously in 1 per cent aqueous
sterile solution, beginning with 1 c.c. and.
increasing 1 c.c. each time up until a dose of
10 c.c. is given. The injections are given on
alternate days.
680
SOUTHERN MEDICINE ANt) StkGEftV
October, im
Giglioli" has reported fifteen cases treated
with "stabinyl," Heyden, in British Guiana
and states it is active in cases that resist
tartar emetic; it brings about a rapid cure
with courses of 6 to 10 intravenous injections
on alternate days and is well tolerated.
Shattuck** has reported results with thio-
glycollate of antimony.
Roentgen ray has been advised by Wil-
mott," he has not found either tartar emetic
or antimony thioglycollamid a specific.
Vaccine has been used prepared from a
culture of B. vcncreogranuloniath (isolated
by Goldzieher and Peck from previous cases).
Following the vaccine treatment there was
complete epithelization of the lesion.'"
Thierfelder and Thierfelder-Thillot'' re-
ptort tartar stibiatus has given good results in
Dutch Guiana, where 5,000 cases were treated
in a period of three years. One per cent
aqueous solution was employed in intravenous
injections for adults in doses up to 10 to 12
c.c. This amount may cause coughing and
nausea.
Local treatment except to keep the lesion
clean is not necessary.
As a resume, tartar emetic is considered a
specific by most authors; "stabinyl," Hey-
den; antimony thioglycoUate, roentgen ray
and vaccine or venerogranulomatis have been
used with good results. Surgery is necessary
at times.
CASE REPORT
Colored man, 35, born in the State of
Georgia, and occupied as a laborer, came to
our office on .April 29, 1929, complaining of
sore on the penis that would not heal. The
patient stated he had been to several places,
including the hospital, and had been told
they did not know his disease.
In the interim he had tried patent medi-
cines and various salves and ointments, but
the lesions persisted and continued to grow.
Family history was negative.
Marital history: He was married in 1917,
wife is at present alive and well; has one
child alive and well. Separated from wife in
1926.
Past history was essentially negative. He
denies all venereal infection.
Present complaint — For the last four
months he has been cohabiting with a wo-
fnan, anc} flatly denies all intercQurse other-
wise. One month after beginning his clandes-
tine relations, developied small sore on the
corona of the penis, this burst and gradually
began to grow. On the shaft of the penis
about one week later another small papule
arose, burst and has gradually grown larger.
No pain was experienced, except discom-
fort of his clothes. He feels perfectly well
but lesions continue to enlarge and have for
the last three months.
Examination: The patient was a robust,
healthy negro with essentially negative find-
ings with exception of the lesion on the penis.
On the corona, posteriorly, a chronic lesion
was found 2 cm. x 1'4 cm.; on the shaft of
the penis there was a lesion of the same type,
134 ciTi. X 1 cm. in size, both lesions having a
secondary pyogenic infection. The inguinal
glands were enlarged and tender.
5/7/29 — Lesion on Side Before Treatment. Top of
Corona; can See Edge of Other Lesion.
The blood-pressure was 105/70, pulse 72,
temperature 98.6, upon admission.
Laboratory findings:
Urine — amber, clear, acid, 1022, no albu-
min, no sugar, scattered pus cells.
The erythrocyte count was 4,728,000; leu-
cocytes, 6,400 — polymorphonuclears, 50 per
cent; small mononuclears, 35 per cent; large
mononuclears, 10 per cent; eosinophils, 4 per
cent; basophils, 1 per cent — hemoglobin, 85
per cent.
October, 1Q29
SOUTHERN MEDICINE AND SURGERY
681
The Wassermann reaction on May 2nd and
on May 9th was negative; smears showed
"Donovan bodies."
Diagram of "Donovan Bodies" observed in large
mononuclear cells from genital ulcer.
Wright Stain.
A diagnosis was made of granuloma in-
f;uinale and treatment instituted.
5/7/29 2y2 c.c. tartar emetic I'i, intra-
venously.
5/9 iYz c.c. tartar emetic I'J, intraven-
ously.
5/11 5 c.c. tartar emetic, X'.'i , intraven-
ously.
Marked improvement was noted in the le-
f'ons; the secondary infection had disappear-
ed and the inguinal glands had become nor-
mal in size and painless.
5/15 5 c.c. tartar emetic given.
5/17 8 c.c. tartar emetic given.
The small lesion on this date had com-
pletely healed, the large lesion was less than
one-half the original size.
5/19 10 c.c. tartar emetic, intravenously.
5/21 10 c.c. tartar emetic, intravenously.
5/25 10 c.c. tartar emetic, intravenously.
5/29 10 c.c. tartar emetic, intravenously.
5/ 13/ 29 — Same Lesion 6 Days Later, After Treat-
ment.
S/29/29 — Same Lesion at End of Treatment, Twen-
ty-Two Days Later.
Both lesions at this time had completely
healed and a clinical cure was produced as
far as we can say. Whether or not there will
be recurrence is beyond our knowledge. Tar-
tar emetic proved to be a specific in this case.
REFERENCES
Ross, Clyde F., Virginia Med. Month., Sept., 1923,
p. 401.
Fox, Howard, "Granuloma Inguinale; its occur-
rence in the United States. A report of IS cases,"
/. A. M. A., Chicago, 1020, lxxxvii, 1785.
Donovan, C. "Medical Cases from Madras Gen-
eral Hospital," Indiiui Med. Gnz., 1Q05, xi,, 414
Campbell, Meredith F., "Etiology of Granuloma
Inguinale, with report of 18 cases," Am. J. Med. Sci.,
Philadelphia. 1927, CLXxiv, D70.
Frontz, W. a., Tennr<^iee Venereal Bulletin,
Nashville, Sept., 1923.
Cornwall, Leon H., and Peck, Samuel, "Etio.
oi Granuloma Inguinale, with Clinical report of
three cases," .ireh. Derm, and Syph., Chicago, 1925,
XII, 613.
GiGLioLi, Geo., "Granuloma Venereum — its diag-
nosis and treatment," Jour. Trap. Med. and Hgy.,
London, 1928, xxxi, 245.
SuATTucK, G. C, Little, H. G., and Coughlin,
682
SOUTHERN MEDICINE AND SURGERY
October, 1929
W. F., "Treatment of Inguinal Granuloma with
Thioglycollate of Antimony," Am. Jour. Trap. Med.,
Baltimore, 1026, vi, 307.
WiLLMOTT, C. B,, "Ulcerating and Sclerosing
Granuloma, so called Granuloma Inguinale" South.
Med. Jour., Birmingham, 1028, x.xi, 872.
Kingsbury, "Granuloma Inguinale Treated with
Vaccine." Case presented Atlantic Dermatological
Conference Meeting. Arch. Derm and Syph., Chi-
cago, 1026, XIII, 702.
Thierfelder and Thierfelder-Thillot, Munchen.
Med. Wochnschr., Munch., 1026, Lxxiii, 561.
The Importance of Diagnosing Effort Syndrome*
W. Bernard Kinlaw, IVI.D., F.A.C.P., Rocky Mount, N. C.
Park View Hospital
The heart action can be accelerated by
any emotion. Fear is probably the strongest
emotion, and can act as the stimulus for a
more forceful or a more rapid heart action,
when it has as its background a damaged
heart. The public is being told repeatedly
that heart disease is increasing the number
of deaths annually and has surpassed even
tuberculosis as a cause of death, and they
know that the National Heart Association,
county, state, and national public health
workers and others are making efforts to re-
duce the mortality from heart disease. Is it
unnatural, therefore, for any normal person
to be alarmed, when unusual heart action
attracts attention or any symptom appears
which he believes to be associated with heart
disease?
There are certain individuals who have
inherited and others have acquired through
coddling and restraint from physical effort
during youth a susceptibility to reactions to
various stimuli such as to favor the develop-
ment of a neurosis. This type of person,
plus mental or physical strain, a prolonged
sickness or infection — anything that brings
about repeated spells of heart consciousness — ■
is prone to develop the condition that we
speak of as effort syndrome. If he continue
to work or play rapidly, he will sooner or
later consult his physician, complaining of
palpitation, dyspnea, e.xhaustion, heart-pain,
dizziness, or even syncope. He will appear
anxious, perspire freely, and state that he
his a frequent desire to take deep sighing
respirations. This latter symptom is very
suggestive.
DaCosta first noticed and reported three
hundred cases during the Civil War and
termed the condition The Irritable Heart of
Soldiers. The term Soldier's Heart devel-
oped from this. Very little was written or
said about the condition from then unt 1 the
World War, when Thomas Lewis termed it
Effort Syndrome. It is also called The Nervous
Heart, The Irritable Heart, Neurocirculatory
Asthenia, and Sir James ^lacKenzie called
it X-Disease. As e.xcitement often produces
the symptoms as markedly as does effort, the
term, X-Disease, is apt in that it admits
that we know but very little about it. Even
though there were thousands of cases seen
and studied during the World War, and
numerous articles written about it, there is
very little that is satisfying in the way of
explanation; however, it seems fairly well
agreed that there is no organic heart disease
present or impending.
It is by far the commonest functional dis-
order of the heart. I have seen a fairly good
number of cases during the past few years
that I diagnosed as effort syndrome. I can-
not help but be impressed with the large
percentage of these patients who have been
told they had a leaking valve or a myocard-
itis, and the majority of them have been
given digitalis. The patient is always made
worse by the mention of heart disease and
also by the administration of digitalis.
.•\ny patient under forty who confronts a doc-
tor with a complaint of "heart disease" or
any symptoms which the patient thinks are
due to a diseased heart, has a high percent-
age of chance in his favor that he does not
have organic heart disease. The patient with
organic disease does not usually seem wor-
*Presented to the Medical Society of the State of North Carolina, meeting at Greensboro, April
15-17, 1929.
October, 1P2Q
SOUTHERN MEDICINE AND SURGERY
683
ried, and it is often difficult to get him to
take enough rest or proper care of his dam-
aged cardio-vascular system, whereas, the
effort syndrome patient will exert himself
but very little. Points in the history that
especially favor effort syndrome are fainting
spells, dizziness, a desire to take deep sighing
respirations, and the complaint of being
made nervous by coffee. The heart will be
lapd, usually during examination and espe-
c aily after the slightest exercise; but, even
after an exerc'se test such as hopping, the
he:;rt will usuall}' return to its previous rate
v.ilhin two or three minutes. It may be
roted that the respirations are quite rapid
before exercise and become about normal dur-
ing or shortly after exercise. The most out-
standing thing to my mind in this type of
patient is the noticeable absence of physical
signs as compared to the very numerous and
pronounced symptoms of heart disease.
This paper is not on differential diagnosis
but only a plea to every doctor who exam-
ines a heart, especially of a person thinking
his heart is diseased, first, to give the patient
a thorough physical examination, and sec-
ondly, not to mention heart disease or give
medicine for heart trouble until you are cer-
t lin that the heart is really at fault, or that
the definite indications for digitalis are pres-
ent. A careful, painstaking examination of
the cardio-vascular system will put confidence
in the patient and, if he is found to have
effort syndrome, half the battle is won in the
way of treatment because he will believe
you when you tell him that he does not have
heart disease. If he does not get a careful
study from his doctor, he will surely drift to
fome one else, and finally land in the hands
f)f a chiropractor or some other cultist — and
it is this type of case that may receive a
cure in their hands. Careful study is also
important because occasionally one finds ef-
fort syndrome complicating organic heart
disease. It is usually the effort syndrome
and not the organic lesion that produces the
symptoms. This is a bad combination and
is difficult to handle. The case of effort
syndrome most often diagnosed as organic
disease is probably the one that presents
some other functional disturbance, such as
an insignificant systolic murmur or an occa-
sional drop beat.
An electrocardiogram is not needed to diag-
nose effort syndrome. I believe that the gen-
eral practitioner is the one to diagnose and
treat this condition, because he, at all times,
holds the utmost confidence of his patient.
I have made an electrocardiographic study,
however, on the cases which I have diagnosed
effort syndrome, because I wanted to do
everything that I could to rule out any evi-
dence of true organic disease, as most of
them had been treated for it. I have in two
cases — both intelligent young ladies — gone
into detail explanation of the tracing, showing
each how her tracing was normal, and com-
pared it with some abnormal ones. By djing
this and allowing them to read a few para-
graphs in a text book about "effort syn-
drome," and "cardiac neurosis," I was able
to make them realize that their hearts were
not diseased. In these cases the tracings
were helpful to them as well as giving a cer-
tain amount of satisfaction in diagnosis.
The term cardiac neurosis should not be
confused with effort syndrome, as the former
should be used only in patients who have a
fear of heart disease but present no other
symptoms or signs of it.
One other point I want to mention, as it
may have a bearing on the importance of
careful study in these cases, which is, the
d'fference between exhaustion and breathless-
ness. Some of those patients complain of
exhaustion, some of breathlessness, and some
of both symptoms. Sir James MacKenzie
was of the opinion that practically all cases
of effort syndrome were due to some type of
infection and that when the focus was re-
moved or the infection overcome, the effort
syndrome would clear up. I think it is
agreed by all cardiologists now that there
is no such thing as the influenza heart, the
pneumonia heart, or the athletic heart.
These cases are considered as pure effort
syndrome. Studies on the subject of exhaus-
tion, made at the St. Andrews Institute in
Fife by the medical staff under the direction
of JMacKenzie and presented by James Orr,'
showed that in the vast majority of cases a
patient will recognize from his own sensa-
tions that he is ill long before any examining
physician can say what the nature of the ill-
ness is, and that this sense of ill-being is
almost invariably a sensation of exhaustion.
They also concluded that the sensation of
exhaustion (that is, exhaustion on much less
SOUTHERN MEDICINE AND SURGERY
October, 1929
effort than was previously required to cause
exhaustion) is regarded as evidence of the
invasion of the body by a toxin, though the
nature of the toxin may not be recognized
for a long period. Exhaustion is never a
direct cardiac response, and when a person "s
capacity for effort is diminished on account
of the limitation of the reserve force of his
heart he may be stopped by breathlessness
or pain, but never by exhaustion. It would
seem particularly important therefore to con-
sider the effort syndrome patient who first
noticed exhaustion as his primary symptom,
as a one who is harboring some infection or
absorbing some toxin, and to have a more
hopeful outlook for a cure in this patient.
The symptom Exhaustion should stimulate
frequent, careful examinations and steer one
away from the heart as the seat of trouble.
Breathlessness is the earliest and most fre-
quent of symptoms which indicate limitation
of the reserve force of the heart muscle and
was the chief complaint in 279 out of 320
cases of failing hearts studied by Dr. Paul
White.- The true heart patient gets a feel-
ing of depression as if his breath is cut off.
In the congestive type the puffing and blow-
ing is different from the rapid breathing,
sighing, etc., of effort syndrome.
CONCLUSION
It is the purpose of this paper to recall to
your attention the fact that the three com-
monest symptoms of organic heart disease —
dyspnea, pain in the heart region, and pal-
pitation— may be produced by the condition
known as effort syndrome. It is necessary
therefore in diagnosis to note whether there
are physical signs to correspond with the
patient's symptoms. The exception to this
of course is the angina case that often pre-
sents no physical signs, making it therefore
important to go into every heart examination
in a careful painstaking manner. If this is
done I am confident that more diagnoses of
effort syndrome will be properly made. It
was stated that during the recent war the
only way to stop effort syndrome was to stop
the war. It is often a difficult condition to
treat but not nearly so hard to effect a cure
when it is diagnosed effort syndrome' instead
of heart disease.
REFERENCES
1. The Response to Effort. Report of the St.
Andrew Institute for Clinkal Research, Vol. 1, page
128.
2. Personal conversation.
A Century of Progress
From Science Advisory Coniniittep
40 West 40th Street. New York City
Professor Stanhope Bayne-Jones, of the University
cf Rochester, N. Y., says:
"The Chicago centennial celebration offers a great
opportunity to show how closely bacteriology is
connected with many of the most important phases
of modern life. The century of progress from 1833
to 1Q33 includes almost the whole development of
bacteriology. During this time bacteriology has
5wept aside the superstitions about infectious dis-
eases and made possible a great reduction in sickness.
Clean aseptic surgery reached its present state of
perfection during this time. The control of infec-
tious disease., the modern sanitary handling of
water, milk and other foods and the safe disposal
of sewage are elements of present-day life which
ccme largely from bacteriology.
"It is inconceivable that the present type of large
city could have developed without the aid of bac-
teriology, or continue to exist without the protection
g^ven to it by the bacteriologist. In addition to
providing medical and sanitary benefits, bacteriology
has become important in many industries. Farming
has been improved by the use of bacteria which fix
the nitrogen of the air and has been enriched by the
bacteriological control of some diseases of plants.
Valuable solvents are produced on a large scale by
the use of bacteria and there are many industrial
processes in which bnctcria arc essential or in which
they are employed to convert waste matcrijl into
useful products.
"On the other hand, elaborate precautions to ex-
clude undesirable bacteria must be taken by those
engaged in pr2:crv!nT and canning foods, and in
many industrcs. The connection of bacteriology
with medicine, surgery, sanitaticn and with the in-
dustries can be demonstrated clearly by the means
which will be provided at the centennial celebration
and the special scientific aspects of bacteriology can
be exhibited in an equally interesting manner."
Calcium for Urticaria
We are now treating a group of chronic urticarias
with calcium by mouth and by intravenous injec-
tion. So far all but one case Lhow marked im-
provement. RULISON &■ /.ICHTENSTEIN, in A'. Y.
State Jour. Med.
October, 1929
SOUTHERN MEDICI^fE AND SURGERY
Functional Constipation '
Roy D. ]\Ietz, M.D., Taylors, S. C.
Chick Sprinjis Sanitarium
Osier once said, "Old men should read new
books; young men should read old books."
The inference is that one should not only be
conversant with things that are new, but that
he should turn back a few pages now and
then and familiarize h'mself with the things
that were popular yesterday. Functional
constipation has therefore been chosen for
presentation at this time.
Constipation may be defined as infrequent,
difficult, or incomplete evacuation of feces.
One class only will be given consideration.
This is simple, uncomplicated constipation
representing fifty per cent of all cases. Be-
fore such a diagnosis is made, there should
be a thorough study, feces examinatiim,
proctoscopy and x-ray, and no evidence of
organic trouble found. In other words, the
mechanism necessary for the production of
normal colonic function is intact; still,
through neglect or abuse, it has become in-
effective.
It is perhaps advisable here to dwell upon
the normal physiology of the large bowel.
The digestive and absorptive activities of the
human colon have not been worked out with
the degree of precision that it has in other
animals. In carnivora these activities are
essentially complete when the intestinal con-
tents reach the cecum, while in herbivora this
is not true. The human colon, it is thought,
occupies an intermediate position.
The intestinal contents enter the cecum
through the ileo-cecal valve, their passage
being facilitated by periodic peristaltic move-
ments of the ileum. By peristalsis they pass
to the ascending colon, where alternating
antiperistaltic waves forces them back into
the cecum. This process of churning con-
tinues for sf)me time until the contents have
lost most of their water and gradually escape
in a semisolid state into the transverse colon.
The more liquid portion continues to re-enter
the cecum where the process of dehydration
progresses.
Finally, all is lodged in the transverse
colon, which acts as a sort of storehouse, since
it is relatively quiescent and the fecal col-
umn is held by the haustrations. About
three or four times a day these haustrations
disappear temporarily and allow the column
to progress a varying distance. This pro-
gression continues until the column reaches
the recto-sigmoidal apparatus, where it meets
with resistance. This is the narrowest part
of the large intestine and is comparable in
function to the cardia and ileo-cecal valve.
Here the column lags and the colon is filled
from below upward. After a time a peris-
taltic wave rather suddenly pushes the col-
umn into the rectum which is normally
empty. The pressure of the feces on the rec-
tal musculature causes the impulse to defe-
cate. Further progress intensifies the call.
The act itself is initiated by the increase
in intra-abdominal pressure brought about
voluntarily by simultaneous contraction of
the abdominal muscles and diaphragm. The
pressure is also increased by the natural
crouching position: firm flexion of the thighs
on the abdomen, and the flexion of the spine
approximating the sternum and the pubes.
The increased pressure causes a bulging of
the perineum and gives rise to nervous im-
pulses resulting in strong peristaltic contrac-
tions of the colon so that there is complete
emptying distal to the splenic flexure. The
final expulsion of the mass is brought about
when the levatores ani contract and draw the
anal canal upwards over the mass as it is
forced through the relaxed sphincters. By
contracting tightly behind, they clear out the
last trace of feces and constrict the bottom
of the rectum. Normally there results a stool
about the size, shape, and consistency of a
jjeeled ripe banana.
It is now opportune to consider some of
the factors which enter into the etiology of
functional constipation. Because of inade-
quacy of the gaslro-ileal or gastro-colic re-
Ilexes intestinal movements may be too weak
to force the material out of the cecum. Mass
SOUTHERN MEDICINE AND SURGERY
October, lOjq
pcr.'stalsis of the colon may be lacking due
to the consumption of an improper quantity
of food with resultant ileal or colonic stasis.
Lack of physical exercise plays an important
role. Physical activity acts indirectly on the
colon. It causes increased consumption of
food, especially of coarse articles which stim-
ulate intestinal activity. It further main-
tains the tonus of the abdominal musculature
and keeps the diaphragm in the habit of
making wide e.xcursions.
There may be a spasmodic contraction of
the pelvo-rectal flexure due to defiicient re-
laxation. This is considered by some au-
thors the main cause of constipation. It is
aggravated by exercise and purgatives. The
feces are passed in small, dry, hard, round
masses — fragmentary constipation. It is
caused by too irritating food, purgatives, an
unstable nervous system, etc. It is thought
by some to be due to the absence of the nor-
mal orderly propulsive activity which is re-
placed by irregular spasmodic contractions
of some parts of the colon, other parts re-
maining completely inactive.
The bulk and consistency of the feces may
offer abnormal resistance so that -excessive
force is required to carry the feces to the
distal colon. Mastication may be impropier
so that the resultant lumps impede normal
progression. Excessive force may also be
required when the feces are dry and hard
from the ingestion of too little water, exces-
sive loss of water by increase of urine or
sweat, or to excessive water absorption.
Food, too, may be too completely absorbed
to afford sufficient chemical and mechanical
stimulation of intestinal activity. Cooking
softens cellulose. .'\ greater part of it may
be removed and there is a general tendency
to eat such vegetables and fruits as the p)o-
tato and banana, which are poor in cellulose.
A reduced residue is, of course, natural in
starvation, voluntary or involuntary, and
when there is anorexia. The food may be
too completely digested especially when it
has been retained too long. The colonic ab-
sorbing power may be excessive; the so-called
greedy colon will more or less completely ab-
sorb cellulose.
There may be an inability to defecate com-
pletely. This is called dyschezia or obstipa-
tion. In this the intestinal contents pass
along normally to the rectum and, although
there may be a daily or more frequent evac-
uation, there is a cumulative retention with
resultant excessive absorption of water. The
rectum is not empty even after defecation.
This is due to habitual disregard to the call
to defecation. A bulky diet and purgatives
serve only to tease the intestinal tract. Re-
peated calls are neglected from modesty, ig-
norance, laziness, or inconvenience, and as
time goes on the call which was at first a howl
becomes a whisper.
The high toilet seat impairs efficiency be-
cause the normal squatting position cannot
be assumed; but this can be corrected by
the utilization of a small foot-stool. The
bulk of the feces may be so small that an
inadequate stimulation is produced to give
rise to the call to defecation. The feces may
be too hard and too bulky to pass through
the rectum. A mass may even collect in the
rectum and act as a ball valve allowing only
liquid feces to pass.
The symptomatology of functional consti-
pation cannot be discussed with any degree
of satisfaction. Lane says that the harm
done by intestinal stasis is infinitely greater
and more far-reaching than that done by
alcohol. It cannot be denied that a large
number of pathological conditions may be
associated, but we must not be too radical
in our attitude. We must distinguish be-
tween the concurrence of phcncmena and
the sequence of phenomena. It may, how-
ever, cause a considerable variety of symp-
toms; some purely reflex, others due to me-
chanical pressure. Some symptoms are due
to the absorption of poisons, bacterial and
otherwise.
Many minor symptoms are produced rc-
flexly by irritation of the mucous membrane,
by distention of the muscular coat, and by
retained feces, the symptoms varying as the
vitality and the general condition of the
nervous system. Fecal masses may cause
symptoms by direct pressure on the veins
such, e. g., as hemorrhoids, varicocele, pelvic
discomfort, or edema. Pressure on the nerves
may cause pruritus ani, sacro-coccygeal or
testicular neuralgia. Hard feces may cause
excoriation of the mucous membrane of the
rectum and straining may lead to rupture of
d'seased arteries. Constipation may even
cause an acute illness with rise of tempera-
ture, perhaps rigor, with vomiting, flatulence,
October, 1929
SOUTHERN MEDICINE AND SURGERY
abdominal pain, headache, and even delirium.
Headache from any cause may be aggra-
vated by constipation. There may be mental
and physical fatigue, insomnia and vertigo.
In neurasthenics these are made worse be-
cause they exaggerate the slightest dyspeptic
symptoms. Arising from constipation in the
upper gastro-intestinal tract, there may be
loss of appetite, a consequent loss of weight,
discomfort or pain after meals, pyrosis, re-
gurgitation, flatulence, nausea, vomiting, dys-
peusia, or halitosis. We do not know how
these are produced, whether by intoxication
or reflexly, but we must not forget that gas-
tric disorders and constipation may both be
secondary to a common cause. Among other
conditions which we find associated with
constipation with an indefinitely established
relationship are: jaundice, congest'on of the
liver, cholelithiasis, asthma, hives, acne,
relationship are: jaundice, congestion of the
prostate, leucorrhea, joint disease, muscular
rheumatism, appendicitis, diverticula, volvu-
lus and mucous colitis.
.After thorough investigation of the symp-
tomatology with especial reference to the
hab'ts at stool, it is often necessary to resort
to more technical procedures for accurate
diagnosis. X-ray is very helpful but expen-
sive. When it is used, there must be an ac-
curate correlation of the findings after both
the ingestion of barium and the barium
enema. The mobility, the motility, the ease
of canalization, the spasticit}', the roominess
of the rectum, etc., can thus be accurately
ascertained. Ten grains of carmine or char-
coal, taken half before and half after the
evening meal, is of great value. The stool
passed the next morning should show a trace
of color; on the second morning there should
be complete coloration, and there should be
no trace on the third morning. Proctoscopy
is also helpful. It should be done after the
morning defecation when the rectum is empty
fir contains only a trace of feces adhering to
the mucosa. The size of the rectal ampulla
is first noted. The recto-sigmoidal apparatus
should dilate and contract synchronously
with respiration. When the examination is
carried out before defecation, there should be
a column of feces above this point. Lastly,
the 'itool examination is of greatest import-
ance. The first examination should be com-
plete in every detail, Thereafter careful in-
spection will be sufficient. The normal stool
should be about the size, shape, and consist-
ency of a peeled ripe banana. A liquid or
mushy stool would mean that the contents
passed through too rapidly, and a hard and
lumpy stool would mean that the activity
was too slow.
Now the question of therapy arises. The
patient must be instructed in the rudiments
of colonic physiology — taught that the colon,
under normal conditions, is an efficient sew-
age system and not a cesspool. They should
stop taking "dynamite" orally and stop turn-
ing in the city water supply rectally. A col-
umn of feces should be allowed to form in
the lower colon. Of course, apprehensive
patients will not acquiesce in this without
reassurance. Digital or proctoscopic exam-
ination on the third day will usually result
in an evacuation. Subsequent dilations
should be done when indicated. Function
should be fully restored in four to six weeks.
Two glasses of cold water on rising will stim-
ulate the gastro-colic reflex. It is a good
plan to prescribe a glass of water every two
hours systematically throughout the day.
This may be increased or decreased accord-
ing to the water content of the stool. Fif-
teen minutes of active exercise directed to
the abdominal muscles will reflexly stimulate
intestinal activity and maintain the tonus of
the abdominal muscles. After breakfast, fif-
teen minutes should be allowed for an at-
tempt at defecation. This may fail at first
but subsequent trials will, after a time, be
successful.
The diet is of especial importance. There
was a time when everyone was advised to
eat freely of bulky fruits and vegetables. The
pendulum has swung back to a more rational
and kigical procedure. The dietary should be
regulated by the character of the stools.
When the stool is bulky the cellulose content
of the dietary should be decreased; when it
is small increase the cellulose ration. In
other words, the diet should be general and
well balanced and then modified to be suit-
able in each individual case.
.•\t times, it will be necessary to resort to
other means. Mineral oil is an efficient lubri-
cant for the intestinal tract. .A,gar-agar pre-
vents drying and facilitates passage. These
may be used separately or in the form of an
emulsion. In recto-sigmoidospasm due to
SOUTHERN MEDICINE AND SURGERY
October, 1920
enemata or laxatives, the spasm may be re-
laxed by the application of one or two ounces
of saturated magnesium sulphate solution in-
troduced through a tube in the knee-chest
position. Belladonna and hyoscyamus are
valuable antispasmodics. Retention oil ene-
mata of four to six ounces of some vegetable
oil taken at bedtime will usually cause an
efficient evacuation when expelled the next
morning.
CONCLUSIONS
1. Fifty per cent of all constipation is
functional or idiopathic.
2. There is a definite physiologic basis
for it.
3. The diagnosis can be made by simple
procedures.
4. The varied symptomatology may be
due to toxins or be caused reflexly.
5. The treatment should be a readjustment
of physiologic processes.
BIBLIOGRAPHY
Hurst, \. F.. Constipation and Allied Disorders,
Edition 2, 1021. Oxford University Press.
Burton-Opitz, Textbook of Physiology, 1920, page
1017.
."Karon, C. D., Diseases oj the Digestive Organs,
Edition 4, page 675. Lea and Febiger.
SoPER, H. W., Amer. J. Med. Sc., Vol. 156, page
205, .'Kug., 1918. "Magnesium Sulphate in the Treat-
ment of Spastic Contractures of the Rectum and
Sigmoid Colon."
Ibid, Amer. J. Roentgenology, Vol. 0, page 412,
July, 1922. "Rectosigmoid Apparatus."
Ibid, Cincinnati J. of Med., March, 1926. "The
Diagnosis and Treatment of Chronic Constipation."
Ibid, Southern Med. Jour., V'ol. 14, page 97, Feb.,
1921. "Physiologic Basis for Treatment of Chronic
Constipation."
RvLE, J. A., The Lancet. Vol. 215, page 1115, Dec,
1928. "Chronic Spasmodic .Affections of the Colon
and Diseases which they Simulate."
.\lvarez, W. C, The New Eng. J. Med.. Vol. 199,
page 858, Nov., 1928. "What Causes Constipation?"
Page, N. .\.. Can. Med. Assn. Jour, Vol. 19, page
652, Nov., 1928. "Constipation, Its Cause and Cor-
rection."
Maher, J. J. E., Med. J. and Record. Vol. 127,
page 349, April, 1928. "Etiology of Constipation."
Gaston, C. D., Jour. S. M. A., Vol. 21, page 380,
May, 1928. "A Proctologic View of Constipation."
Durham, F. M., Jour. S. M. A., Vol. 21, page
378, May, 1928. "Importance of Proper Ano-rectal
Examination."
Defining Some Terms Used by the
Psychiatrist
(Ingham, in California & ]Vestern Med'cine. Sept.)
.Attention might be called the focus of intelligence,
or perhaps better, its spotlight, illuminating either
the untravcled path through the forest, the familiar
road to the office or the dusty recesses of memory.
But as a spotlight illumines only a limited area of
the landscape, so attention reveals to consciousness
only a spot in the field of intelligence.
If we pursue our simile in regarding intelligence
as the bureau of information, and attention as the
spotlight, we might conceive that consciousness is
the illumined area of intelligence. Consciousness has
been described as the state of awareness and, return-
ing to our simile, we are aware only of the things
that are in focus and illumined. In general it might
be said to deal with the awareness of the relation of
things to each other in our environment, and with
ourselves in relation to the environment in general.
Since it depends upon the normal activity of the
fense organs, memory, thought associations and
other processes of the intelligence, it would seem
that whatever else it may be consciousness might be
considered as one manifestation of intelligence. Emo-
tions, on the other hand, do not appear to be factors
of consciousness, and active emotions even tend to
inhibit by limiting its field as they do the field of
intelligence.
If consciousness be conceived as the area in the
field of intelligence illumined by the spotlight of
attention, the subconscious may then be considered
as the vast unillumined areas of the same fie'd
which lack the light of attention. That activitie:,
tal e place in these dark areas there can be no doubt,
as attested by modern literature and common ex-
pcr'cnce. Exploration beyond the frontiers of con-
sciou nc s has become a popu'ar indoor sport.
It is worth'.- of special comment th:it everyone
who devotes some attention to psychology soon be-
comes a psychologic bi.got in that he believes ag-
gress:vcly in his own theories and is intolerant of
other;.
Causation of Seborrhea
The weight of evidence as to the cause of sebor-
rhea seems to point to a coccus that is arranged in
diplococcus and tetracoccus formations. Moreover,
the size of the organism and the cultural characteris-
tics seem to place it in a grouping somewhere be-
tween bacteria and yeasts. From the hygienic con-
sideration, these experiments seem to indicate that
reborrhea is an infectious disease of the hairy sca'p
and is capable of being transmitted. The wide-
spread nature of the disease among the human race
can be explained by the fact that barber shops are
constantly using the same instruments on all clients,
which offers a means of transmitting the infection
of the scalp. — F. M. Duffy, Arch. Derma, and
Syph., Sept., 1929.
October, 10^0
SOUTttERN MfiWCtNE A^rt» StJftGEftY
AS9
Endemic Goitre in Its Relation to North Carolina*
Louise M. Ingersoll, M.D., Asheville, N. C.
In presenting the topic chosen there are
several factors to be considered as possible
sources of error in making any assertions or
drawing conclusions:
1. Some difference of opinion among au-
thorities regarding what constitutes
endemic goitre; that is, there is no gen-
erally accepted classification of goitre.
2. No absolute standard of what size a
gland must reach to be classified as
goitre.
3. Lack of uniform methods of examina-
tion.
4. So few reports or surveys on the subject
have been made in North Carolina.
1. After considering various classifications
as those of Jackson, Marine, Levine,
Plummer, Else,' and others it seems
safe to say that endemic goitre in-
cludes:
(a) Simple hyperplasia which is a phy-
siological response to some unusual
demand upon the thyroid gland.
This type may show some symp-
toms of hyperthyroidism and
(b) The colloid goitre or resting stage
in which there may be an equilib-
rium of supply and demand or a
mild hypothyroidism, myxedema
or cretinism.
2. According to Dr. Allen Graham-, path-
ologist at the Cleveland Clinic, the
average size of a normal thyroid gland
is from twenty to thirty grams in the
Cleveland district, while authorities
over the country state that it varies
from fifteen to forty grams. Even the
largest figure, forty grams — one and a
half ounces — of solid meat spread out
into two lobes and an isthmus make
very little to be palpated especially in
a thick neck.
.After starting the examinations which
suggested this paper we felt that too
many large thyroids were being found,
so wrote to one of Crile's assistants
who was known personally to the writer
asking what was there considered a nor-
mal thyroid. The reply came, "The
normal thyroid gland is barely palpa-
ble.- In the determination of this
the personal factor must necessarily
enter very largely. Else' regards a
small palpable thyroid normal when the
lower pole is not blunt; a blunt lower
pole means either goitre present at the
time of examination, or remains of a
previous goitre.
3. The only two standardized methods of
examination found among the various
papers read and communications re-
ceived were those of Else' and Lahey.-*
The important factor in all cases seems
to be that of having a patient swallow
while the gland is being palpated.
4. The only North Carolina report avail-
able was that of the Public Health Re-
ports^ showing the incidence of goitre
among the drafted and enlisted men
during the war.
ETIOLOGY
Definite statements regarding etiology of
endemic goitre are not so easily found as are
those regarding incidence from which theo-
ries of etiology are deduced. Even here,
though, there is sometimes found conflicting
evidence, as in a section in the Philippine
Islands and a very high percentage of goitre
in the Pacific Northwest. Chatin"' in 1850
advanced the theory that iodine deficiency
was the cause of goitre. Kimball" says:
"Endemic goitre is a deficiency disease. The
enlargement of the thyroid which is termed
goitre is a compensatory hypertrophy due
immediately to iodine deficiency." Jackson'
states: "In goitrous belts the colloid goitre
is due to iodine deficiency plus excessive de-
mand on the thyroid by muscles, the osseous
tissues, and especially by the reproductive
organs during puberty." Marine" says that
"deficiency of iodine may result from
1. P'actors that increase demand
(a) Puberty
♦Presented to the Medical Society of the State of Noft|i Carolina, meeting at Greensboro, April
SOUTHERN MEDICINE AND SURGERY
October, 192Q
(b) Pregnancy and lactation
(c) Menopause
(d) Infections and intoxications
(e) Injuries to the adrenals (see Crile's
fascinating monograph on The Re-
lation of the Thyroid to the Adre-
nals)*
(f) Following diets composed largely
of fats or proteins.
2. Factors which interfere with absorption
or utilization of the normal intake, pos-
sibly certain intestinal flora and fauna
may divert the supply.
3. Factors affecting the amount of iodine
in food and water."
Jones," of Atlanta, cannot associate goitre
with drinking water as the etiologic factor
else why only one in the family all drinking
the same water? Plummer," in discussing
Kimball's paper, remarks, "I don't think
iodine is the only factor in the etiology of
goitrous conditions. I say I don't under-
stand them at all but at various times have
tried to point out the physiological relations
present." McCarrison'" claims the active
role of infection as the cause of endemic
goitre. He reports a school at Sanawar,
where for ten years si.xty-si.x to eighty per
cent of the children became goitrous. He
changed the water supply to that from
Kausuli, making no change in the diet, and
in one year's time he found only two and
two-tenths per cent positive — no more than
in non-endemic areas. The new water sup-
ply was pure, the old grossly contaminated.
He found both water supplies were poor in
iodine, the old containing appreciably more
than the new. Cantero," from the jMayo
Foundation, says: "Since the work of Far-
rant and McCarrison there has been no
doubt that a 'contagium vivum' plays an im-
portant part in diseases of the thyroid gland."
Houda,'- of Tacoma, Washington, advances
the idea that the genetic factor of goitre is
an infection of the thyroid gland and that
degeneration changes involving the many-
sided thyroid pathologies are all consequen-
tial and directly connected with these infec-
tive agents.
INCIDENCE
Lncality. — There seems to be, as Kimball"
states regarding Michigan, an almost univer-
sal agreement tJiat "the incidence of goitre is
inversely proportional to the iodine content
of the water supply." This he shows plainly
in his survey of the various counties in Mich-
igan. Chemical analyses of water in certain
sections of the lower Mississippi valley has
shown an iodine content of from ten thou-
sand to eighteen thousand times the amount
contained in Lake Superior districts. Con-
versely no endemic goitre is found in the
same districts of the lower Mississippi valley
while sixty-four per cent of the school chil-
dren in the Lake Superior region were goit-
rous in 1924. In Massachusetts it was found
that gotire increased in almost direct propor-
tion as the distance from the sea.
Sex. — It is generally conceded that the
proportion of goitres is considerably larger
in females than in males. Jackson^ gives
five women to one man. Among school chil-
dren the percentages are nearer, as shown
by Kimball's" figures, one boy to two or three
girls. Kerr,'-* of Cahfornia, states that "In
centers of high endemicity the ratio of males
to females approaches unity." Beatty and
Wallace'^ found in Utah among the Indians
more males than females are affected, but of
the white population thirty-eight and two-
tenths per cent males and sixty-one per cent
females were positive.
Heredity. — Kimball" replies to the ques-
tion regarding heredity "we do not see in
our endemic goitre district anything that
could be called hereditary goitre or condi-
tions inherited from previous goitre. In older
and more severe endemic districts, as Swit-
zerland and the Himalayas, are deaf-mutism,
cretinoid states and cretinism due directly or
indirectly to endemic goitre." Yet Crile'"
states that endemic goitre may be prevented
by feeding iodine to pregnant women.
MORBIDITY OF ENDEMIC GOITRE
.\side from pressure symptoms and disfig-
urement, the incidence of toxk goitre un-
doubtedly bears direct relation to that of
endemic goitre. Figures of the War Depart-
ment'' show that in the United States Army
exophthalmic goitre is most prevalent in
areas of greatest endemicity. McCIendon'"'
says that the incidence of exophthalmic
goitre is proportional throughout the United
States to the incidence of endemic goitre.
There is not infrequently seen in endemic
goitre regions a state of mild hypothyroid-
October, 1920
SOUTHERN MEtHCINE AND SURGERV
601
ism, especially in school girls who, while not
mentally deficient, are not up to normal.
INCIDENCE IN NORTH CAROLINA
The Public Health Reports^ referred to
above showed among the drafted and enlisted
men during the war 1.81 per thousand hav-
ing goitre as against 26.91 in Idaho — the
h ghcst incidence — and 0.25 in Florida —
lowest incidence. Olesen places North Caro-
lina in the shaded area in his graphic chart,
not black but gray.
In reply to a questionnaire sent to some
thirty or more surgeons throughout and near
the state but fifteen responded and from them
the following statistics have been compiled.
The map shows the distribution in counties
or districts of the 1,096 cases reported, 900
in the mountain and piedmont, a very defi-
nite increase in these areas over the eastern
part of the state. We note also that in gen-
eral the largest number of cases do not come
from the counties showing greatest popula-
tion, so the greater incidence showed is not
due to the denser population.
Dr. Marjorie Lord and the writer have
recently made health examinations of 724
school girls for the local Y. W. C. A. The
majority of these were between the ages of
12 and 19 years. 9.5 per cent were found
to have goitres, not large in most cases, but
according to the standard suggested above,
definitely plus. Dr. Lord in 150 high school
g!rls found 7.3 per cent positive. Among
the 771 adult women — 19 years and upward
— examined by me 13 per cent were found to
have enlarged thyroids and a further 30 per
cent slightly enlarged. No attempt is made
to explain these figures. They were indeed
a decided surprise to the writer, who ex-
pected to find more among the school girls
than among the adults. The only figures ob-
tained for the percentage of goitre among
school children in non-endemic areas are
those ciuoted previously by McCarrison'" —
2.2 per cent. Girls alone would undoubtedly
show a considerably larger proportion.
PATHOLOGY
The pathology of endemic goitre may be
simply stated as follows: a greater demand
by the body f(jr iodine supply as made by
pregnancy, infection, puberty, menopause,
and nervous strain causes hyi^erplasia, usually
associated with increase in the colloid
(iodine-carrying element). This, if excessive,
causes pressure, thus preventing the normal
functioning of the cells but continuing as a
stimulant to overgrowth. One of two things
happens following hyperplasia:
(1) If iodine deficiency is not met the
process goes on to cellular degenera-
tion and atrophy, or
(2) if met, the gland returns to the resting
stage in which it may function nor-
mally. This cycle of changes may
take place many times resulting in a
very large gland.
TREATMENT
Preparations of thyroid glands were used
by the Chinese four thousand years ago in
ttie treatment of goitre." Sea-weed and burnt
sponges were used by Roger de Palermo in
1180. Coindet painted goitre with tincture
of iodine in 1820. The treatment of endemic
goitre is almost wholly preventive. Crile"'
says "The pKjssibility of prevention of goitre
has been firmly established by the work of
Marine and his collaborators. It has been
abundantly proved that by administration of
iodine throughout the period of adolescence
and during pregnancy thyroid diseases may
be prevented in this generation and the next,
and in this statement malignant tumors are
included since they develop in fetal adeno-
mata." The work of Kimball"* and Marine
at Akron, O., that of Kimball" in Michigan,
the public health measures in ^Montana,''-* in
Cincinnati,-" in Switzerland, -** Italy and
orther foreign countries seem to prove beyond
a doubt that whatever may be the relation
of iodine deficiency to the etiology of ende-
mic goitre it can be prevented by giving
iodine in small quantities in some form.
Charles Mayo-'' says "iodine is almost an
absolute preventive of goitre; that has been
proved beyond all question. Given in table
salt it is a preventive for goitre." There has
been some discussion as to the wisdom of
giving iodine to adults with any form of
goitre. Harstock-'' found definite evidence
of hyperthyroidism precipitated in many
cases at the Cleveland Clinic by the general
use of iodized salt, and this view is still main-
tained there- in spite of Kimball's''' scholarly
defense of the safety of iodized salt used
generally as a prophylactic in endemic re-
gions. Kimball says "It seems to be univer-
69i
SdUtltEbN MEblCtNE ANt) StfeGEfeV
October, 19i9
sally accepted now that there is no possibility
of producing disease in children by the con-
tinuous use of iodine in sufficient amount to
prevent goitre," and further that "none of
the statements that iodine in such amounts
induces hyperthyroidism in adults with
goitre is based on sufficient scientific data to
be of much value." Plummer-'' states that
nearly SO per cent of the rare cases of hyper-
thyroidism associated with adenomata that
have come under his observation before 20
years of life have followed the administration
of iodine. Kimball-'' induced hyperthyroid-
ism in susceptible patients by e.xcess of
iodine.
The method employed by Kimball and
Marine after considerable work was the ad-
ministration to school children of .01 gram
of iodo-starin daily for a period of two weeks
twice yearly, or as advocated by Phillips- — -
.01 grams weekly through the year. This
seems a wiser method, as known quantities
are given and may be administered only to
those needing iodine, while in the use of
iodized salt an unknown quantity is given
and the father, for instance, who generally
uses the most salt in the family, may get
more iodine than is good for him, 'while the
child who needs it receives less than he should
have.
There was brought to our notice while
reading, the possibility that in chlorinization
of the water so freely done everywhere, the
chlorine might displace the iodine and thus
make the water lacking in preventive quali-
ties. The Chlorine Institute in New York
replied to queries regarding this: "J. W.
EUis-^ says that the chlorine used would have
a tendency to decompose the sodium iodide
introduced into the water and liberate iodine;
while this element would not be loose, its
combination with organic matter, or its reac-
tion with other mineral constituents might
adversely affect its therapeutic value."
Crile, in his classic volume, The Thyroid
Gland, asserts that the peculiar function of
the thyroid gland appears to be the splitting
up of the iodine-containing molecules of any
compound which enters the organism, and the
conversion of iodine into specific thyroid
product, thyroxin.
Kimball says the thyroid will take up
iodine from the most stable compound, i. e.,
mercuric iodide. Therefore, it matters not
in what combination the iodine is present in
water. Kimball-*' concludes from von Fel-
lenberg's experiment on himself that "the
body uses up or excretes a definite amount
of iodine regardless of intake; that the aver-
age size young adult with normal metabolism
on a minimal amount of physical exertion,
all factors reduced to a minimum still ex-
cretes .0143 mg. daily and that the average
retention in a normal case is .012 mg. daily.
Therefore we might assume an intake of .03
mgs. sufficient for balance. The colloid
goitre should be treated surgically if it pre-
sents sufficient pressure symptoms or causes
enough deformity to bring about self-con-
sciousness. In many instances endemic goitre
has been cured, as well as prevented by giv-
ing iodine to adolescents.-' Since one in four
adenomata become toxic before fifty years of
age, according to Jackson and Levine,' ex-
cision would seem a safer way of treatment
here. Hypothyroidism, or functional defi-
ciency— so frequent in endemic areas — found
in adults may be controlled by supervised
administration of iodine, thyroxin or thyroid
extract. In children sometimes iodine will
control the situation, sometimes thyroid ex-
tract or thyroxin is indicated.
CONCLUSIONS
1. Endemic goitre can and should be pre-
vented by the prof)er use of iodine.
2. There is apparently a mild endemicity
in western North Carolina.
3. Further surveys and investigations
should be made ocncerning this.
4. Steps should be taken to control it
through the medical profession.
BIBLIOGRAPHY
1. Jackson. .Arnold, Annals of Surgery, Phila.,
June, 1024. Marine, D., J. A. M. A., Vol 87, No
18. Levine, Archives of Int. Med. Plummer, J. A
M. A., .Aug. iO, 1013. Else, J. E., Med. Sentinel,
Sept., 1025. CoLLER, Fred, J. A. M. A., Vol. 82,
No. 22.
2. Through personal communication to writer.
3. Lahev. J. A. M. A., Vol. 86, No. 12.
4. Olesen, Robt., Public Health Report, 1^27.
5. McClendon, J. F., Ph\siological Revieu\ Vol.
7, No. 2.
6. Kimball, O. P., /. A. M. A., Vol. 91, No. 7.
7. M.ARiNE, D., J. A. M. A., Oct. 30, 1926.
S. Crile, N. E., /. of Med., Vol. 108, No. 19.
0. Jones, Ed., J. A. M. A., Aug. 31, lOIS.
10. Lynn-Thomas, Sir Jno., British Med. J., Jan.,
15, 1027.
11. Cantero, Surg., Gyn. and Obs., Jan., 1926.
12. HouDA, E. C, Amer. Med., New Series, Vol.
2i. No. 10.
13. Transactions of Amer. Phys., Vol. 42, p. 326,
U.Utah Stale Board Goitre Survey,
October, 19i9
SOWHERK MEblClMt AM) StftGEftY
693
15. McCiENDON, J. F., /. A. M. A., Vol. 82, p.
1668.
16. International J. of Med. and Surg., 1924,
April.
17. KtMBALL, 0. P., /. Mich. State Med. Sac,
Sept., 1923.
IS. Archives oj Int. Med., June, 1920.
IQ. Mont. Health Report, J. A. M. A., Vol. 89,
p. 17S9.
20. Olesen, J. A. M. A., Vol. 00, p. 100.
21. /. ,-1. M. A., Vol. SO, p. 460 abs.
22. Hygiea, Feb., 1926, What Well Known Medi-
cal Men Say.
2.1. H.\RSTOCK, Iodized Salt in the Prevention oj
Goitre, jrom the medical division oj the Clevekmd
Clinic.
24. Smith, Puilip, Va. Med. Monthly, Oct., 1924.
25. Kimball, O. P., Ohio State Med. J., July,
1024.
26. Crile, /. A. M. A., Vol. 83, p. 813.
27. Letter to Editor, Fire and Water Engineering,
March 19, 1924, p. 553.
28. A'imball, O. p., J. oj PubUc Health, May,
192S.
29. /. A. M. A., Aug. 30, 1913.
DISCUSSION
Dr. a. G. Brenizer, Charlotte:
I had the opportunity of writing to Dr.
IngersoU, and I want to congratulate her on
her paper again. It is a most excellent pa-
per. There has been practically nothing done
in North Carolina to prove the endemicity
or not of simple goitre. If you remark on
this paper, you will see that she has em-
braced all of the work that has been done of
importance, and that she has done some in-
vestigations herself, and she has sought to
find out the prevalence of goitre in the West.
Another impressive thing about her paper is
the beautiful English in which it was written
and how well it was delivered.
Now as to the thyroid gland and being
able to palpate the gland, I think the normal
thyroid gland, of its consistency and size,
would likely not allow palpation. I think
any thyroid gland that can be at all readily
palpated so that you are aware of the pres-
ence, either by pushing the trachea over to
one side, and slightly out from the sterno-
mastoid, one side or the other, and that you
are sure that you are palpating rather hard
elastic lobes, then your enlargement of your
thyroid gland is real and when you are not
certain at all that you are palpating the
gland, the gland is likely not enlarged. That
is vague of course. It depends a good deal
on the one palpating and the e.xperience of
the person d<jing it.
.As to the prevalence of goitre in North
Carolina, of course we have no such concen-
trated areas of endemicity as you find in
the West, in the neighborhood of Cleveland,
and so on, and likely the goitre being more
thinned out in certain areas, the prevalency
of it in the female over the male is much
greater, because there is another factor that
comes in with the female. Now my experi-
ence has been that goitre occurs in North
Carolina in a ratio of something like ten to
one in the female, and as I say, in these
concentrated areas, where the goitre is cer-
tainly markedly endemic, there the preva-
lence in the male probably rises.
I have always been firmly of this belief
(and I believe that in the statistics of now
something like about seven thousand cases,
that I can prove it), I think the thyroid
gland enlarges not only from a shortage in
iodine, but just in the female who is slow
in development or who has a cystic ovary,
who has a retroflexion with interference in
blood supply, or something that speaks for
a hypo-ovaria. So many of these cases have
had ovarian cysts, the ovaries have been
tampered with in some way, sometimes re-
moved, and just in those cases too have an
enlarged thyroid gland. They pause for a
while with this thyroid gland and then rather
suddenly break into an exophthalmic goitre.
Considering these cases, as to the use of
surgery in the pelvis, I think any pelvic
surgery should be laid very carefully, cer-
tainly not be treated as bulk surgery, and
certainly not bring about any further reduc-
tion of ovarian secretion. It should be a
restorative surgery, because when you reduce
the ovary, you are going to place that patient
liable to develop some symptoms from the
thyroid gland.
The giving of iodine — unfortunately I
have seen a great many young girls with
exophthalmic goitre who should not have had
it. They had enlarged thyroid glands some-
times quite meaty and bulky, not merely
through the physician, but in their efforts to
reduce the mass, they would push iodine to
considerable extremes, and in doing that they
would go into exophthalmic goitre. I have
seen that quite often, so that I am sure that
that comes about. Of course the old colloidal
included adenomata, and adenomata causes
the symptoms in enlarged colloidal goitres,
but the girl in her effort to get her neck flat
will probably not follow the directions of the
«<»4
SOUtHERN MEbtClNfi AND SURGEkV
October, 192^
doctor, and wanting her neck to get flat in a
hurry will push iodine. I have seen cases
that have taken iodine right straight along
for eighteen months, and I have seen them
end just there, with marked hyperthyroidism.
We are not dealing of course in this paper
with exophthalmic goitre or adenomata, or
the bulky colloidal goitres, but we are dealing
here with simple goitre. I guess the path-
ological picture of simple goitre is a mild
hypertrophy and hyperplasia with an increase
in watery colloid, and most of those cases,
as the author has indicated, will do well un-
der very small doses of iodine, and I think
they should be very small. Even in exoph-
thalmic goitre they should be very small. It
has been proven later — and we are trying it
and finding it is true — that exophthalmic
goitre cases yield just about as well on one
drop three times a day as they did on the
ten drops. So the amount of iodine is not
to be very great, and also as Dr. IngersoU
has indicated, there should be sufficient time
between the giving of iodine. It should be
broken up in very small doses, and given
occasionally during the year to satisfy the
iodine demand.
The question of infection, not only in sim-
ple goitre, prompting it and if not relieved,
it makes the treating very difficult and much
against the stream. This also applies to ex-
ophthalmic goitre. Sometimes an exophthal-
mic goitre is removed, a sufficient amount,
almost all of it, and sometimes symptoms re-
cur, or the case is not quite as satisfactory
as it should be. The focus of infection is
later removed with the tooth or tonsil or
cervix or what not, or a colitis, and the case
promptly gets well.
So I think there are several factors both
in simple goitre and in exophthalmic goitre
that are very important. The question of
the woman with a lowered ovarian secretion,
the lack of iodine, and the infectious process
— these three factors should be looked into in
the treatment of any simple goitre, and that
treatment should always be carried on under
the direction of a physician, with an original
check-up of the metabolic rate, and frequent
check in metabolic rates. Of course from an
economical standpoint that is not always
practicable, but be sure that too much iodine
is not given and that the patient is well steer-
ed and guided.
From the disasters that I have seen, I
would certainly not want iodine given out
by the grocery store or scattered around
through the city water. Of course it is a
well known thing that lots of non-toxic ade-
nomata are stirred up markedly on a mini-
mum amount of iodine. It is a tendency of
everybody, the man who has it or the physi-
cian, to say, "Here is a goitre, an enlarge-
ment of the neck. We will try a little iodine."
Well, trying a little iodine in adenomata is
sometimes absolutely disastrous.
From Dr. Ingersoll's town we had a young
girl about eighteen years old with a small
adenoma, an insignificant thing scarcely to
be seen, and she was put on a very small
amount of iodine, and within ten days" time
her pulse rate had climbed to 160, metabol-
ism was about 70 which is very high. There
was no preparation at all to bring the girl
down for operation, and so she took an oper-
ation under those conditions and immediately
on the removing of this small adenoma, her
pulse came down to normal, the girl gained
weight, and was again stabilized. So as to
the diagnosis of the gland: any lumpy gland,
however small the adenoma might be, be
cautious in the giving of iodine, because you
will lead that person into a disaster, and then
certainly the pushing of iodine hsavily to
avoid exophthalmic goitre. I have enjoyed
Dr. Ingersoll's paper and am glad to have
had this privilege of hearing her.
Dr. Ingersoll, closing:
Dr. Brenizer has added very much and
said many things worth while. In his saying
that he thought that any goitre which is pal-
pable is abnormal, I would like to read just
a line which I received from Dr. Kimball,
who I suppose has done more work in ende-
mic goitre than any other man in the coun-
try. I wrote to him about the number I was
finding, and the standard I was using. He
says:
"From my experience I think you are
grading the thyroids a little too close. A nor-
mal thyroid if fairly firm can easily be felt
in a thin neck, so I have learned to give them
the benefit of the doubt and unless they are
definitely enlarged, I call them normal."
Does your car have a worm drive?
Yes, but I tell him where to drive-
-The Wheel.
October, 1020
SOUTHERN MteDlClNE AND SURGERY
695
Elimination of Pain in Childbirth and Proper Care of the
Birth Canal*
Henry J. Langston, JSI.D., Danville, Va.
HISTORY
A review of history tells us of many wars
between tribes and nations and races in all
of the past. The devastation, destruction,
human suffering and loss of life of all these
ages is beyond the range of calculation. At
our present stage of development we are able
more or less to analyze and understand why
we have had such wars, and the human fam-
ily has had to pay such terrible prices for
the wisdom and knowledge it now possesses.
I call your attention to these facts in order
to contrast with them another side of human
life. We theorize and try to understand the
origin of the human race and the progress
it has made, but our knowledge is slight as
compared to the unknown things about it.
During all of these ages of human develop-
ment the female of the human family has
not been considered from a humanitarian
point of view. One has only to read history
very slightly to be impressed with the fact
that more women have died from the causes
connected with the effort of the human spe-
cies to reproduce its kind than have soldiers,
sailors and civilians been cut off prematurely
by all the wars of the past. The total death-
rate from child-bearing is up into the hun-
dreds of thousands annually. In our own
United States the mortality from causes con-
nected with childbirth is so great that it
should cause all of us to hang our heads in
shame. In Sweden, where practically all of
the babies are delivered by midwives, the
mortality is less by three or four times than
in the United States. This, of course, is
due to the fact that all midwives in Sweden
are well trained, first-class nurses, and when
they have complications they immediately
call in a doctor to assist them. In this
country we have thousands of midwives un-
trained and many practitioners practicing
obstetrics for a side-line; when they have
complications they wait until the critical hour
arrives and then they call in the doctor
•Prcsentffl by invitation to .■\lamance-Caswell
Medical Societv, meeting at Yancevville, N. C, Au-
gust 13, 1929.
whose skill is not sufficient to save the baby
and mother because the vital forces of the
mother have been burned up and infection
has its golden opportunity.
Much evidence can be gathered from his-
tory that gives us reasons for the slow prog-
ress in assisting the mothers of each genera-
tion to come through childbirth safe and
sound. The things that have handicapped
progress are these: prejudice, ignorance, su-
perstition and the narrow-minded religious
atmosphere. All of these things have been
cloaked in the one sentence, "Let nature take
its course."
We can gather much evidence from his-
tory of some of the religious leaders who
have used the Bible to fight progress in this
field. I should like to remind ourselves of
two significant facts dealing with the Scrip-
tures with reference to the creation of man.
I think we can deduce the following: There
apparently was no human suffering experi-
enced in the creation and birth of the body
and spirit of Adam. He was strangely con-
structed so that there was in one part of his
body an abnormal structure which is de-
scrib(^d as a rib. After the Creator had
looked upon his human construction and was
satisfied with it, he caused a deep sleep to
fall upon Adam and Adam became uncon-
scious for a period not named. During this
period of sleep the Creator removed from
his side a rib which had within it all the
cells that form the various systems of the
human body and from this he made the body
of a woman with all her organs properly
placed. There was no pain, no suffering to
either Adam or the woman that was made.
The second description is that of the con-
ception of Christ without the usual prelimi-
nary event, and at the end of nine months
Mary gave birth to Him apparently without
any pain, for she was immediately able to
look after her child and in a short time she
was able to ride on an ass a long distance
over a rugged country.
There was something very unusual about
both of these events. They suggest to me a
SOWHEkN MEbtClMfi AND StJkGEftY
October, 1029
trend of thought which should cause us to
reaHze that our present knowledge of repro-
duction is decidedly limited and our under-
standing of the process of labor is not at
all clear; and there is unlimited field of op-
portunity for obtaining knowledge as to the
elimination of pain in childbirth and man-
agement of these cases thereafter.
HISTORY OF ANESTHESIA
The human race lived through many thou-
sands of years without knowing anything
about anesthesia in our present conception
of the term. With the discovery of the use-
fulness of ether as an anesthetic and the vio-
lent controversies over claims for priority,
you are all familiar. Suffice it to say that
a bust of Long, of Georgia, has been placed
in the Hall of Fame, in Washington, and
the accurate French long ago erected a statue
to him in their beautiful capital city, because
of ths exploit. In 1847 James Y. Simp-
son, of Edinburgh, Scotland, demonstrated
the first use of chloroform in labor, and met
with considerable opposition by the people
of the nation was fought this usage bitterly.
Subsequently a baronetcy was conferred
on h!m for this service to humanity.
Oliver Wendell Holmes suggested the terms
anesthesia and anesthetic. From 1846 until
now there have been rather remarkable strides
in the use of anesthesia. When "twilight
sleep" was first used it was an advance in
this field, and, if it could have remained in
the hands of men who were competent and
capable, it would probably be in use today.
At the present time we are using ether, gas
and o.xygen, chloroform, ethylene gas, local
anesthesia, block anesthesia, spinal anesthe-
sia, and so on. In my opinion the ne.xt
twenty years will bring wonderful advances
as to anesthesia in the geld of obstetrics,
which will save their lives, preserve their
bodies and give them babies uninjured.
THE ATTITUDE OF THE PROFESSION
To anything different from what we have
thought or been taught, we react unfavora-
bly. There is as much sense, reason and
humanitarian feeling in doing an operation
of major proportions without an anesthetic
as there is in helping a woman have a baby
without an anesthetic. Both are shocking,
nerve-racking, and the experience burns up
in many cases structures of the body which
cannot be replaced. Also the morbid condi-
tions resulting therefrom are well-nigh be-
yond comprehension. The expenses thereof
can never be known. My attitude is that
the patient who is to have a baby should
have the same guarding against infection as
a patient who has is to have a major opera-
tion. That means that she is not to be
exposed to any infection of any sort. Every-
thing done for her is to be done with the
cleanest hands possible, and with a heart of
sympathy and patience which will endure
through the experience without irritation.
Dirty hands, carelessness and neglect are the
things that have caused many patients to
die of infection, of hemorrhage and other
accidents and to develop chronic conditions
which last them to the grave. Analyzed to
the finest point, this means that we are re-
sponsible for premature deaths.
THE PREPARATION OF PATIENT FOR DELIVERY
The best of care should be given during '
pregnancy. I am amazed to discover that
many fairly competent men are doing nothing
except delivering the babies; they are paying
no attention to the diet, to the weight of the
patient, blood pressure, urinalysis and elimi-
nation. The following things should be
done: The patient's weight should be studied
from start to finish; pelvis measured; blood
pressure taken regularly; el.mmation of both
bowels and kidneys should be watched; urin-
alys.s every ten days or two weeks and the
patient kept on a proper diet, well balanced,
for proportionate, even development. Pa-
tient s mind should be kept on wholesome
and cheerful things. If this patient is man-
aged properly she is ready for the hour of
labor. The hospital is the ideal place for
delivery, and if possible the patient should
be there. If not in the hospital then she
should be prepared in the same manner as if
in the hospital: clip or shave the vulva, empty
large intestine with a high hot soda enema,
make vaginal examination to determine the
exact condition of the cervix. This examina-
tion should reveal evidence which would tell
the attending physician the number of hours
ahead of him for the first stage of labor.
MANAGEMENT OF LABOR
If patient is suffering with backache and
utes she should be given '4 gr. morphine and
little short pains every fifteen or twenty min-
October, 1920
SOUTHERN MEDICINE AND SURGERY
1/150 gr. atropine hypodermically and there-
after when patient begins to suffer very much
she should be given by rectum: quinine hy-
drobromide, IS or 20 grs.; alcohol, 2 drams;
ether, 2>2 oz., and enough mineral oil to
make 4 oz. Patient should be placed on the
left side and this mixture inserted well up
into the colon. Very slight pressure should
be made on the sphincter ani to prevent the
patient from expelling the anesthetic. The
room should be darkened and quiet should
prevail. If an interval of from one to three
hours has passed from the time the hypoder-
mic is given until the administration of
th's enema the patient should be given
's gr. morphine and 1/200 gr. atropine. Pa-
tient can now turn any way that will be com-
fortable. Uterine contractions will continue
and in from two to four hours ordinarily the
cervix will be completely dilated. If the
baby is in a normal position, if anesthesia is
insufficient, 1 to 2 oz. of ether may be given
with about II 2 oz. of mineral oil in
the rectum. This will give you almost com-
plete anesthesia and the second stage of labor
will begin. When the head is well down on
the pelvic floor the patient may be removed
to the delivery room.
At the end of the first stage of labor, when
I am certain that the birth canal is large
enough for the passage of the baby, I take
my patient into the delivery room and if the
rectal anesthesia is not complete I have pa-
tient given ether by inhalation until we have
complete anesthesia. With the assistance of
two nurses, one to hold each leg, the patient
is now scrubbed thoroughly with green soap
and water and is draped. I put 5 per cent
solution mercurochrome in the vagina. At
this point the vagina is thoroughly ironed
out so as to get complete physiological dila-
tation. With hands gloved to the elbows I
<',n up into the uterus and dissect the amnio-
tic sac off all way around to the placenta.
The hands of the baby are crossed, both feet
are located, the amniotic sac is ruptured, the
feet are caught between the thumb and index
fmger and middle finger of the left hand and
baby is turned around very slowly, and grad-
ually the feet are brought down. M this
point I allow the baby to sit on the i^elvic
floor one or two minutes. As it sits on the
pelvic floor it usually rotates either to the
right or left. As it rotates the crest of the
and as the shoulders appear under the sym-
physis pubis. Now very gently the baby is
rotated so that its back is next to the abdo-
men of the mother. Usually the uterine con-
tractions will expel the trunk of the baby
and as the shoulders appear under the sym-
physis pubs gentle pressure is made on the
Ix)Sterior axillary fold until the shoulder is
completely out of the vagina. When th"s is
finished th? arm of the baby is cauiht just
above the elbow and it is lifted out of the
vagina with the hand. With the baby rest-
ing either on the right or left arm pressure
is made on the posterior axillary fold and
the anterior shoulder is pulled very gently
around, rotating the posterior shoulder ante-
riorly, shoulder and arm delivered in the
same manner as the anterior shoulder. Now
pressure is put under the symphysis pubis
to see that the cord is not around the baby's
neck. Cord not being around baby's neck,
gentle pressure is put on the chin of the baby
with the left hand while the baby rides on
the arm, and with the right hand pressure is
placed on the occiput of the head of the
baby. It is now in the superior strait. Pa-
tient's limbs are brought down in the Wal-
cher position and with this gentle pressure
on the occiput usually the head passes down
through the superior strait and the baby's
head is now in a position where it can be
allowed to breathe. From this point on I
keep the head of the baby flexed. If there
is any mucus or fluid in the mouth or throat
of baby this is expressed, keeping the head
of the baby flexed and putting gentle pres-
sure under the shoulders of the baby the
head can now be slowly delivered.
If the baby is delivered "normally" or by
the process just described we find it is usually
pink, breathing, and there is no necessity for
doing anything to the baby except letting it
alone and keeping it warm. I usually place
the baby on the abdomen of the mother and
let it remain there from five to ten minutes.
The patient is now given ,S0 m. of obstetrical
pituitrin and the vagina inspected for tears.
.After five minutes the cord is severed and
the baby is placed in a warm blanket to be
left alone. After the pituitrin is given
usually the placenta is spontaneously expelled
in from 10 to IS minutes.
Now that the baby and placenta are both
out of the uterus, patient's limbs are flexed
SOUTHERN MEDICINE AND SURGERY
October, 1Q29
on the abdomen, patient is washed with ster-
ile water and soap, redraped, and with sponge
sticks the cervix is brought down for inspec-
tion. Whether the patient delivers herself
or is delivered by version or forceps I alv/ays
find the cervix torn, whether it is the first
baby or the fourth baby. If it is the first,
sometimes it is necessary to trim the cervix
up and repair it. I use continuous lock su-
tures on each side. It usually takes about
four minutes to do this repair. If it is an
old laceration, all surfaces are made smooth
and clean and the same technique of repair
used. The vagina is now repaired with what-
ever number of sutures is necessary. The
patient is then put back to bed and watched.
CONCLUSIONS
1. The form of anesthesia described in
this paper is safe for both baby and mother.
If each patient is studied and treated as an
individual, this form of anesthesia can be
made satisfactory to the physician and the
patient. It will require more time and
thought on the part of the doctor and less
hard work; it will give comfort to the patient
and be safe for the baby, and the baby will
cry as soon after being delivered, under this
anesthesia as it will if you do not use any
anesthesia at all. With this form of anesthe-
sia you are able to eliminate the pain, pro-
tect the birth canal and protect the baby.
It enables the doctor to use all the skill and
knowledge he has to do easy and scientific
work; it gives him an opportunity to do any
repair work necessary without any discom-
fort to the patient.
2. In the work I have done up to date
which covers all the various forms of anes-
thesia and the various methods of delivery,
I find this technique satisfactory for delivery
and repair and, in something over seven hun-
dred deliveries, I have had only one septic
infection, that after cesarean section, and
this patient got well. How she became in-
fected I am unable to say, for I feel there
was no break of technique in the delivery.
She was highly toxic, in the state of threat-
ened eclampsia; her blood pressure was 180;
she was almost completely blind, and the
urinalysis showed solid albumin, hyaline and
granular casts. In the cases of repair of
both the cervix and vagina I have had no
infections and no morbidities.
The satisfaction patients get out of this
technique of anesthesia and the comfort I
get out of being able to do what ought to
be done for the patient cause me to recom-
mend this method as safe, if the physician
who is using it studies his patient and does
not try to standardize the method or the
patient, because what will do for one patient
will not do for another.
3. With proper technique, there is almost
no danger of infection in version, forceps
delivery, normal delivery, or in the repair
of the cervix and vagina. For almost two
years now I have done these routinely, and I
have had no cases of infection or morbid
conditions resulting therefrom. I think the
reason we do not know more about the birth
canal immediately following delivery is that
we have been taught not to examine it, and
our ignorance as to the natural condition
there is appalling. It is the opinion of many
of th ebest men of the country now that
routine examination of the birth canal should
be made after each delivery and whatever
damage found — and there is always some
damage — should be repaired immediately.
Iodine Educational Bureau
A new organization known as the Iodine
Educational Bureau has opened offices at 64
Water Street, New York City. Mr. J. J.
Xichols is director of the Bureau, which is
supported by the Iodine Producers Associa-
tion of Chile, South America.
The Pureau will collect and disseminate
dependable information about iodine and
iod'ne com[.x)unds. .A large amount of re-
search work \''ill be undertaken, a fellowship
already being established at iNIellon Institute
and several other fellowships will shortly be
established at other institutions to follow up
special lines of research investigations. The
Bureau will be ready to co-operate at all
times with others doing research work on the
application of iodine in agriculture, industry,
animal husbandry and in the professions of
medicine, dentistry, pharmacy and veterinary
medicine.
October, 1029
SOUTHERN MEDICINE AND SURGERY
Surgical Indications in Certain Arterial Vascular Diseases
of the Extremities*
Case Reports
R. B. McKnight, A.B., M.D., Charlotte, K. C.
\'ascular affections of the extremities in-
volving the arteries are of fairly frequent oc-
currence. A study of a series of the so-called
vasomotor neuroses will reveal the fact that
there are a number of distinct clinical entities
therein, and that the group as a whole can
be subdivided into several distinct diseases.
Recently I have observed several cases of
arterial vascular diseases of the extremities,
each fairly typ'cal of different types of this
group of affections. I shall present these
cases in abstract and give a brief discussion
on the pathological physiology involved, and
the treatment, particularly the surgical indi-
cations.
thrombo-angiitis obliterans (buerger's
disease)
A young white man, aged 30, a heavy
smoker, was referred to me by Dr. William
.Mian, complaining of excruciating pains in
the left foot and toes. Three years previous-
ly he noticed lumps and rather marked pain
in the calf of the left leg; on discontinuing
the use of garters, the lumps disappeared,
but at times since there has been severe pain.
Si.xteen months previously, after a long auto-
mobile ride, the foot became exceedingly cold.
.After bathing it in hot water severe aching
developed which was not relieved by narcot-
ics. The following day the foot was red
and swollen and the pains more stinging in
character. Three days later an ulcer ap-
peared on the great toe. Shortly after, "rest-
pains" set in. These became so severe that
he lost sleep night after night. Six months
before I saw him claudication in the calf and
superficial phlebitis appeared. He became
progressively worse until the stinging, aching
rest-pains were practically unbearable. Ul-
cers which healed sluggishly — or not at all —
appeared on four of the toes.
Examination was essentially negative ex-
cept for the affected left lower extremity.
The distal half of this foot was edematous.
•Presented by invitation to the Tri-County Medi-
cal Society, Lincolnton, N. C-, July 9, 1929.
reddened, became blanched on elevation and
markedly reddened when placed in the most
dependent pos tion. On the dorsum of the
foot was an area of superficial phlebitis in-
volving the vein accompanying the dirsalis
pjedis artery; an area of old phlebitis extend-
ed higher. Tropic changes were pronounced
in all the toe nails; the great toe was par-
tially gangrenous and several non-healing ul-
cers were present between the other toes.
Pulsation was decreased in the left femoral
and popliteal arteries and entirely absent in
the left dorsalis pedis. The foot was cold
and clammy.
The pathological physiology in this condi-
tion is dependent on two factors: primary
arterial occlusion, and, in addition, vasomotor
spasm with a resulting contraction of the
arteries in the affected area.
Treatment is instituted in the hope of se-
curing an increased blood supply to the part.
This is attempted through the use of postural
exercises, contrast baths and heat, and the
induction of systemic fever by the intraven-
ous administration of a non-specific protein —
typhoid vaccine. It is well to determine the
vasomotor index. This is done by noting
the normal mouth temperature and the tem-
perature of the skin of the affected area;
when the height of the febrile reaction fol-
lowing the administration of the vaccine is
reached, again the temperatures are noted.
The increase in skin temperature subtracted
from the increase in mouth temperature and
the resulting figure divided by the increase
in skin temperature, will give the vasomotor
index.
Surgical treatment may be grouped under
three headings: (1) periarterial sympathec-
tomy, (12) lumbar sympathectomy and
ganglionectomy, and (3) amputation.
Periarterial sympathectomy as advocated
by Leriche and (jthers consists in stripping
the adventitia from the femoral artery in
Hunter's canal. It is based on the presump-
tion that the sympathetic nerves supplying
vasoconstrictor fibres to the vessels of the
SOUTHERN MEDICINE AND SURGERY
October, 1929
extremities run down in the adventitia of the
arterial wall. The results from this opera-
tion have been discouraging and it has been
largely abandoned.
Lumbar sympathectomy and ganglionec-
tomy is indicated in about 12 per cent of
cases. These cases constitute that group in
which the vasomotor index is well above 1.0.
The operation is not curative; it is prophy-
lactic. The factor of arterial occlusion can-
not be handled by the operation, yet, by
inhibiting vasoconstriction through section
and removal of the sympathetic trunks, it is
possible to secure sufficient blood supply to
the part to keep it alive and allow sufficient
time for the development of collateral circu-
lation. The approach to these nerves is
made through an abdominal incision in the
midline, packing the intestines upward, incis-
ing the posterior peritoneum and locating the
sympathetic trunks which lie lateral to the
bodies of the vertebrae.
Probably the majority of cases will come
to amputation. Intractable pain, the exten-
sion of gangrene above the toes, failure to
improve under a medical and physiothera-
peutic regimen and a vasomotor index of less
than 1.0 are probably clear-cut 'indications
for amputation. The question of where to
amputate necessarily arises. That must be
decided on the basis of careful study of the
individual case. Probably the best site — ■
certainly in many cases — is above the knee.
In the case just cited I performed peri-
arterial sympathectomy with absolutely no
benefit. A few days subsequently I had to
amputate.
ENDARTERITIS OBLITERANS (RAYNAUD's
disease)
A young, white, single woman, aged 21,
was seen by me in consultation with Dr. R. F.
Leinbach. Her chief complaint was numb-
ness and coldness of the fingers which symp-
tom she had noticed for about two years.
She seldom, if ever, had any trouble in warm
weather. Qu'te frequently on waking in the
mornings the index and ring fingers of the
right hand and the middle and ring fingers
of the left hand felt cold and dead, and were
perfectly white. The condition would persist
for varying lengths of time — maybe only a
few m'nutes, or, at times, several days. She
has never experienced any real pain — only a
feeling of deadness without loss of the sense
of touch. She did not think that the condi-
tion had grown any worse, but it had not
improved. Immersion of the hands in hot
water would give immediate temporary relief.
Examination revealed nothing of signifi-
cance in the hands. Her general condition
was good. Roentgen pictures of the chest
showed what was apparently a healed child-
hood tuberculosis. The arteries of the upper
extremities pulsated normally.
This case undoubtedly comes under that
group representing vasomotor neurosis of the
spastic type. Adson and Brown recognize
several gradations of this condition, merging
one into the other. The case is a mild form
of Raynaud's disease. Many of us perhaps
associate Raynaud's disease with a picture
of gangrene, marked color changes and severe
pain. Indeed such is not the case. These
symptoms are rare in th's condition and illus-
trate a terminal event in only a very few
cases.
The altered physiology is due to a single
process, functional vasomotor disturbance.
The factor of arterial occlusion is not present,
thereby sharply differentiating this disease
from thrombo-angiitis obliterans.
Treatment in the case of this young lady
will consist entirely of observation for the
time being. Should the condition become
markedly aggravated, I would have no hesi-
tancy in advising resection of the thoracic
sympathetic ganglia and trunks. To quote
Adson and Brown: "The striking, main-
tained and unequivocal therajDeutic effects of
lumbar and dorsal sympathetic ganglionec-
tomy in Raynaud's disease seem to warrant
the belief that surgical control of this disease
is an accomplished fact.'' From a physio-
logical standpoint operation should be cura-
tive. Resection of the sympathetic trunks
carrying vasoconstrictor fibres should, by
allowing vasodilation, not only arrest the dis-
ease, but entirely cure it. The approach to
the dorsal sympathetic trunks is made
through an incision from the tip of the sixth
cervical spine to the tip of the fourth dorsal,
a fascia-muscle incision on each side parallel
with the spinous processes, exposure and sub-
periosteal resection of the second rib, and
careful dissection and retraction of the lung
and pleura. This procedure will expose the
sympathetic trunk between the second thor-
October, 1929
SOUTHERN MEDICINE AND SURGERY
701
acic and cervico-thoracic sympathetic gan-
glia.
THROMBOSIS OF THE POPLITEAL ARTERY DUE
TO EMBOLISM
A white man, aged SO, seen in consulta-
tion withr Drs. Vann Matthews and William
Allan, complained chiefly of pains in the left
foot. Four months previously he suffered an
attack of coronary thrombosis which nearly
proved fatal. A month later an embolus to
the brain produced a partial paralysis with
mental aberration which state persists. Four
weeks before I saw him he developed a sud-
den severe pain in the left foot with a sense
of coldness from the ankle downward. This
pain has persistented intermittently — at times
so severe that he would beg for narcotics,
and on two occasions he insisted that his
foot be amputated then and there. Position
did not seem to influence the pain or its at-
tacks. The foot became swollen and red;
in the most dependent position it assumed
an ugly bluish red color. A sharp line of
demarcation was present at the junction of
the lower third and upper two-thirds of the
leg. It is now eight weeks since the leg was
affected and the condition has become pro-
gressively worse. The foot and leg up to the
line of demarcation feel cold.
Examination of the affected limb revealed
a grayish discoloration of the foot and lower
third of the leg when in a flat position on
the bed. It became a tense bluish red in a
few seconds on hanging down. The foot was
cold regardless of its position. There was
apparently no attempt at canalization or de-
velopment of collateral circulation. No pul-
sation can be felt in the kft dorsalis pedis
artery.
Here, of course, the pathological change is
due to a thrombus occluding the popliteal
artery, probably at the point where the pero-
neal artery is given off. The condition is
one of arterial occlusion without the vasomo-
tor factor.
The surgery indicated in such a condition
depends on the stage of the disease when it
is first seen. It is possible that embolectomy
could have been performed within the first
few days with a successful outcome. .Xfter
eight weeks, however, with no evidence of an
attempt to establish collateral circulation,
and with the condition growing steadily
worse, it seems that amputation is impera-
tive. In consultation, Drs. Matthews, Allan,
Parran Jarboe of Greensboro and I all con-
curred that amputation offered him his best
chance.
.Amputation at the junction of the upper
and middle thirds of the left leg was done by
me the following day under spinal anesthe-
sia.*
eryihromelalgia (weir mitchell's
disease)
A white man, 27, referred by Dr. O. L.
Miller, complained of intense burning in the
feet and hands. During his high school and
college days he noticed in the course of an
athletic contest that his legs did not seem as
strong as the other boys', and that he would
tire more readily than he thought he should.
Six years ago he first noticed a burning sen-
sation in both feet and occasionally in the
calves. This symptom has progressed until
it has become almost unbearable. He de-
scribes it as a dull ache in the plantar sur-
face of the heels and an intense burning in
other parts of the feet. In winter he has
practically no symptoms except when his of-
fice is unusually warm. In summer the only
relief he can get is when he immerses his
feet in cold water. At times they become a
bluish red color. During the past year and
a half similar symptoms have appeared in
the hands, although not as severe as in the
feet. He has become nervous and apprehen-
sive. His history is otherwise negative except
for what were apparently two attacks of ap-
pend'citis several years ago.
Examination revealed possible dental and
marked tonsil sepsis, slight tenderness in the
right lower abdominal quadrant and an ex-
quisitely tender prostate. A smear from the
prostate showed pus cells and a culture re-
vealed a green-producing streptococcus. The
hands showed nothing abnormal except defi-
nitely increased redness when in a dependent
position. On hanging down the feet became
markedly reddened and definitely warmer,
and the dorsalis pedis arteries pulsated vig-
orously.
Erythromelalgia is a functional, locally
♦Hcalinc wn^ slu'ru'i^h and after scvnl (1h\s it
was ohvious that amputation was ncrformi-d too
low. Subscqucntiv 1 dirl a (lisarticulation Ihroueh
the knee joint under spinal anesthesia, Rcttini; well
above the area of circulation. Barring a minor in-
fection, healing was normal.
SOUTHERN MEDICINE AND SURGERY
October, 1Q2Q
distributed, vasodilating type of vascular dis-
ease. It is probably the direct antithesis of
Raynaud's disease in so far as the influence
of the nervous system on the phenomena
characteristic of the two conditions is con-
cerned. Here we are dealing with a primary
vasodilation instead of vasoconstriction.
Sajous believes that the central vasomotor
centers in these persons are abnormally ready
to respond to vasodilator impulses arising
from stimuli to certain afferent nerves.
Treatment is aimed at promoting the con-
tractile power of the arterial musculature and
thus enable it to oppose, more efficiently, the
vasodilator impulses. Strychnine, adrenal
gland and digitalin in the way of drugs, and
rest, elevation, massage and cold packs — each
is of some possible value. Foci of infection
should be eradicated.
In the case above treatment is consisting
of clearing up every possible focus of infec-
tion. The teeth are being looked after by a
competent dentist. Dr. H. C. Shirley has
recently performed tonsillectomy. I am giv-
ing the patient prostatic massage and a vac-
cine made from a culture of the prostatic
secretions. I think appendectomy is entirely
justifiable in view of the history of two dis-
tinct attacks. This, however, has not yet
been advised.
The patient informs me that a group of
doctors in a distant city advised lumbar sym-
pathectomy about two years ago! .Appar-
ently the underlying aberrant physiological
changes were not recognized. Fuel would
only be added to the fire, and an infinitely
more serious condition naturally result. Re-
section of the motor nervej to the affected
area has been performed in such cases, but.
in view of the fact that spontaneous cure
often occurs when the cause of irritation has
been removed, such a radic:;l measure is not
justified.
There are other conditions having to do
with disorders of the arterial vascular system
affecting the extremities: diabetic gangrene,
arteriosclerosis, acroparesthesia, aneurysm,
cond'tions due to hypertension and hypoten-
sion, obscure vasomotor neuroses and other
organic types — arteritis, for example. I have
made no attempt in this paper to differen-
tiate between the functional or vasomotor
types on the one hand and the organic types
on the other. They are fairly evident. The
main point I wish to bring out is that this
group of conditions as a whole, is not un-
common. They should be anticipated and
differentiated by very careful study. A care-
ful differentiation is essential for proper treat-
ment— especially for proper surgical treat-
ment.
REFERENCES
1. .^DSii.N', A. W., and Brown-, G. E., "The treat-
ment of Raynaud's disease by resection of the upper
thoracic and lumbar sympathetic Kanglia and
trunks." Surg.. Gyn. and Obst., 1Q20, xlviii, 577-
60.i.
2. .\li.ex. E. v., "The result of lumbar ganglionec-
tomv in thrombo-angiitis obliterans"; Proc. Staff
Meet.. Mayo Clin., 1028, iii, 30.^-394.
3. Brown, G. E., .\li.en, E. V., and Mahorner,
H. R.. "Thrombo-angiitis Obliterans," 192S. W. B.
Saunders Co., Philadelphia.
4. Lericiie, R., "De la sympathectomie peri-arter-
ielle et de ses resultats"; Presse med., IQIQ, xxv, 513-
515.
5. McKnicht, R. B., "Studies in a fatal case of
thrombo-angiitis obliterans." Trans. Med. Soc. Slate
of N. C. 1Q29.
6. Sajous, C. E. deM., and Sajous, L. T. dcM .
Analytic Cyclopedia of Practical Medicine. 1027, \ ol.
8. F. A. Davis Co., Philadelphia.
Epsom Salts for Strychnine Poisoning
.\ case of acute strychnine poisoning was success-
fully treated by injecting 3 c.c. of 25 per cent solu-
tion of magnesium sulphate intraspinally, 50 c.c. of
2 per rent intravenously and 20 c.c. of 25 per cent
in'.ramuscularly. The patient presented a transient
ab ence of knee jerks, and on the second day devel-
oped pruritus and a skin rash. The jaundice which
developed on the fourth day might be attributed to
th.e chloroform given. The stomach contents when
injected into a frog produced convulsions. The
chemical test for urine using sulphuric acid-bichro-
mate was proved to be non-specific. — C. S. Yang,
National Medical Journal of China, .\ugust, 1929.
ficdium Thiosulfate and Mercuric
Chloride
The length of life of dog; receiving a fatal dose
of mercuric chloride cannot be prole nged by the
subsequent injection of sodium thiojulfate. The
diuresis produced by mercuric chloride alone is not
affected by the simultaneous injection of sodium
thiosulfate, thus indicating that the action of mer-
cury in the body is not affected by the thiosulfate.
In other words there is no evidence that the mercun
is converted to an insoluble and inactive sulfide. —
Melville and Bruger, Jour. Pliarmac. and Exp.
Tkera.. Sept., 1020.
October, 192Q
SOUTHERN MEDICINE AND SURGERY
Urology Day by Day*
John P. Kennedy, M.D., F.A.C.S., Charlotte, N. C.
Treating certain disease conditions rather
frequently we come to form opinions about
these diseases and their treatment which
might be useful if passed on to others. Some
facts concerning a disease seems to stand out
so conspicuously as to justify mention of re-
sults from certain lines of treatment which
have proved more than ordinarily satisfac-
tory and so give an increased confidence in
their use. It has seemed to me that it would
be a good thing for doctors to make short
reports from time to time of such points of
practical interest that come up in their work.
They would often be more readable than long
essays.
A doctor is frequently confronted with the
question: Should a stone in the kidney pel-
vis causing few or no symptoms be removed?
A man 54 years of age has repeated attacks
of pain in his left loin brought on usually by
the e.xertion of working his garden or long
riding in his car, but the pain is never severe
enough to require a hypodermic and does not
cause any loss of time from his work as a
traveling salesman. A plain x-ray shows a
shadow in the region of his left kidney pelvis
smooth in outline and the size of a robin's
egg. A pyelogram confirms the presence of
a stone in the kidney pelvis. A p-s-p test
reveals normal function on both sides and
urine from the left kidney shows an occa-
sional red cell but no pus. Should he have
the stone removed? My advice was to have
the urine examined every few months, which
he did. At the end of a year he showed more
ijliiod, considerable pus and an occasional
hyaline cast, with the pain remaining about
the same. He is now advised to have the
stone removed by a pyelotomy.
.•\n x-ray film reported negative for kidney
store which, because of gas or for some other
reason, does not show the kidney outline is
not reliable in ruling out a small stone in
the pelvis or ureter. In such a case the x-
ray examination should be repeated after a
flose of castor oil and possibly pituitrin.
lAcn after such preparation I have seen four
♦Presented to the Mecklenburg County Medical
Society, June 18, 1929.
patients in as many months with small stones
in the lower ureter which did not show on
the x-ray film.
The ureter admitting a number 6 or 7 ca-
theter and presenting a normal uretero-
pyelogram does not necessarily mean there
is no stone present. A young man of 26
passed two stones after 1 had ruled out stone
to my own satisfaction. It is well to re-
member W. W. Keen's trite saying: "With
all our varied instruments of precision, useful
as they are, nothing can replace the watchful
eye, the tactful finger and the logical mind
which correlates all these avenues of infor-
mation and so reaches an exact diagnosis."
A catheter which is well oiled will go
where one less well oiled will not go. I have
succeeded in catheterizing patients after in-
jecting olive oil into the bladder by means
of a urethral syringe where I had failed be-
fore.
Xovocaine 3 per cent held in the urethra
a short time will often relax the muscle
enough to let a soft catheter in and avoid the
trauma of a metal catheter.
Very acute cystitis with marked strangury
responds nicely to instillation of one ounce
of 3 per cent novocaine once or twice a day.
This is very grateful to the patient and
makes her well satisfied with her doctor.
Only later after the acute symptoms subside
do I use the silver salts. Silver nucleinate
is the least expensive but slightly more irri-
tating than neosilvol. I have it put up in
IS gr. capsules and use it fresh by adding
one capsule to 20 c.c. of cold water making
a 5 per cent solution.
Caudal anesthesia proves more satisfactory
in my hands the longer I use it and the
more adept I become in entering the hiatus.
I am now convinced that failure in anesthe-
sia means failure to enter the hiatus. 15 to
20 c.c. of 3 per cent novocaine injected slowlv
through a small needle gives good anesthesia
in 20 minutes. What would be a satisfactory
anesthesia is often spoiled by haste in start-
ing the operative procedure and thereby los-
ing the patient's confidence. A number 22
two-inch spinal-puncture needle is well
704
SOUTHERN MEDICINE AND SURGERY
October, 1929
adapted to this work, and being short is not
apt to enter the spinal canal. I have found
that it is well to aspirate frequently during
the injection not so much to see if there is
spinal fluid escaping as to see if there is any
bleeding due to trauma by the needle. In
those cases where there is even a very small
amount of discoloration of the fluid with-
drawn from the sacral canal it is best to
inject slowly, for it has been my experience
that such cases are more apt to exhibit toxic
symptoms. These symptoms are fairly uni-
form and begin with an increase in respira-
tion, then sighing, next sweating, then nausea
and vomiting. The injection should be
stopped when the first symptoms appear, to
be continued after the symptoms subside. A
large amount of novocaine can be injected
provided it is done slowly and provided there
is no direct absorption into the veins. ."Ml
cystoscopies on greatly inflamed bladders
and most of my cystoscopies on men are
done under caudal anesthesia. It greatly fa-
cilitates the necessary work where there is a
stone or stricture in the lower ureter. Hem-
orrhoidectomies, excisions of fistulae and ure-
teral caruncles, and other operations may be
done with caudal block.
All the cases of urethral caruncle I have
seen have been associated with a stricture
near the external orifice. The advanced cases
that have had many things done to them,
that have been cured many times by opera-
tion, may be satisfactorily treated under
caudal anesthesia by thorough dilatation and
cauterization of the exuberant portion of the
caruncle. These patients are very grateful
for the relief this gives them.
Many cases of trigonitis or cystitis that
yield readily to treatment only to recur
rather promptly after treatment is discon-
tinued may be permanently cured following
eradication of cervical infection by means of
the electric cautery needle. A cautery put
out by the Wappler Electric Company has
proved quite satisfactory for this work.
.An alkaline urine may be quickly changed
to an acid one with a clearing up of phos-
phaturia by the administration of acid so-
dium phosphate which is conveniently pre-
scribed in ten-grain tablets. Many patients
object to the cloudy urine and appreciate
the clearing up of the sediment even though
it has been giving no symptoms.
The use of the Cameron "Surgilite" in the
bladder in prostatectomy greatly facilitates
adequate hemostasis, allows proper placing
of suture ligatures when needed, and precise
trimming away of tags of mucous membrane
which if left might later interfere with urina-
tion. The use of the suction tube in the
bladder replaces much sponging and both
the suction piece and the light may be used
as deep retractors.
.•\ few prostatics who do not tolerate well
an inlying catheter may be quite comfortable
when the ordinary catheter is replaced with
a Robinson catheter which is considerably
softer and more pliable. It has the added
advantage of having two eyes and therefore
is less likely to become clogged with mucus.
.'Vt times one of these patients will tolerate
a very small catheter for the first few days
and later the ordinary size. ]\Iore care and
patience in the use of the indwelling catheter
will often mean a one-stage rather than a
two-stage operation. I have several times
given caudal anesthesia and once low
spinal in order to insert an indwelling cathe-
ter, and thus was enabled to do the opera-
tion in one stage much to the satisfaction of
both the patient and the surgeon.
In doing catheterizations the use of a ster-
ile hemostat for handling the catheter will
obviate the necessity of sterilizing the hands.
Th?re are always bed clothes to be pulled
down, doors to be closed, or other non-sterile
things to be handled between the time the
hands are sterilized and ihe catheter is to bo
inserted.
A low p-s-p excretion should not be given
too much dependence but should be repeated,
particularly if it does not agree with other
findings. There are many chances for error
in the report of a low excretion and this ap-
plies particularly to the differential test with
ureteral catheters in place.
Chancroids which tend to extend in spite
of your best care will respond quickly to the
intravenous use of tartar emetic. I recently
treated such a condition of five months
standing in a young man in whom the con-
dition had become so extensive as to cause
him to lose his position and so painful as
to g've him very little sleep for three weeks.
Tartar emetic seems to be specific for chan-
croidal infections and also for granuloma in-
guinale, in which it was used prior to its
October, 1020
SOOTttEftN MEbtClNE AM) SttlGfiftY
?6S
use in chancroids.
During the past three years I have seen
many women suffering with rather protracted
bladder symptoms, some of them quite se-
vere, who were greatly relieved following dila-
tation of the urethra. Urethral stricture in
women is a fairly common condition, is at
times quite annoying to the patient and is
qu'ckly relieved but requires some follow-up
treatment to prevent contraction of the stric-
ture.
.A diagnosis of rupture of the urinary blad-
der is important since the earlier these cases
are operated upon the better the prognosis.
Obtaining clear urine through a catheter is
not reliable evidence that the bladder is un-
ruptured, as has been noted frequently. Fail-
ure to realize this caused a delay in operation
in one of our cases, a man whose pelvis was
fractured by a falling tree. The cystoscope
may give more reliable information than the
catheter in cases of suspected rupture. It is
important to distinguish two forms of blad-
der rupture, intraperitoneal and extraperito-
neal. Both forms require operation but only
in the former should the peritoneum be open-
ed. In case of a suspected bladder rupture
the wisest plan to pursue is to make a supra
pubic incision and inspect the prevesical tis-
sues for signs of extravasation. If none are
found then the peritoneum should be opened
and search made for the intraperitoneal rup-
ture. Such a rupture is apt to take place
low down on the bladder wall where it is
difficult to repair.
Edema caused by chronic nephritis, as well
as that due to cirrhosis of the liver or cardiac
failure, is often quickly cleared up following
the use of novasural or salyrgan. The latter
drug in my experience has proved less toxic.
The effect of either may be enhanced by the
administration of large doses of ammonium
chloride or nitrate. In several cases the
quick relief afforded has been very striking,
the urinary output being greatly increased
over a twelve-hour period with rapid disap-
pearance of the edema.
Dr. T. McC. Davis reports the very rapid
clearing up of gram-positive organisms and
pus from the urine following the intravenous
use of neoarsphenamine, with a corresponding
subsidence of symptoms. I have not had
enough experience with this method to have
an opinion as to its value.
The most important aid in urological ma-
nipulations is gentleness, the second is lubri-
cation and the third is anesthesia. Were
more attention paid to these, less harm would
result from the manipulations and fewer pa-
tients would fail to return for necessary treat-
ments ? nd to dread them as they would an
operation.
— 505 Professional Bldg.
Gas-Treated Tomatoes Lower in
Vitamins
(U. S. Dept. of .^firiculture)
Tomatoes that are allowed to stay on the vine
until they are actually ripe are superior in vitamin
content and food value to those picked preen and
then treated with ethylene pas to pive the fruit the
color that is characteristic of th-,' ripe fruit, but the
ethylene treatment apparently has no harmful effect
on the vitamins already formed in the preen fruit
that is treated. The ethylene colorinp process, dis-
covered only recently, ha.s been adopted so widely
that a considerable proportion of the lemons, or-
anpes, bananas, and tomatoes w-hich arc shipped
from warmer to colder repions of the United States
in advance of the local season are colored by means
of it. The process makes possible a material lenpth-
eninp of the time the fruit can be kept in storape
or transit, and makes it possible for the consumers
to pet the fruit earlier than they could otherwise.
Tomatoes rate very hiph amonp hcalth-pivinp foods,
containing large amounts of vitamins A, C, and B,
hut more of .1 and C than of B, and bcinp rich in
mineral salts which are escential in nutrition.
Preparation of Solutions
(ISrv.-nt, in Pnintylvniiin MnL Jour., Sept., '20)
I fee' sure that at least some of the unsuccessful
results from sacral anesthesia have been due to the
fact that the principles of osmosis referred to above
have not been properly appreciated. My personal
experience has demonstrated that I pet better results
wl'en I use normal salt solution prepared by a re-
liable chemist rather than that prepared routinely at
the hospital. Both novocain and normal salt solu-
tion can be procured in sterile ampoules, and the
operator can prepare the solution in a few minutes.
No boilinp is required, and this is also a matter of
importance, because prolonped boilinp not only al-
ters the molecular concentration of the solution but
has some effect on the anesthelizinp properties of
the novocain.
?06
SOUTHERN MEblCtNE AND SURGERY
Octob-jr, 1920
The Conservative Treatment of Chronic Purulent Otitis
Media
Davis S. x^sbill, i\I.U., New York City
Manhattan Eye, Ear and Throat Hospital
The chronic running ear is an annoying,
embarrassing, often foul smelUng and danger-
ous affliction to patients and has long been
noted as one of the most stubborn and in-
tractable conditions which the otologist has
to treat. Often a patient endures for many
years the disgusting discharge, always in dan-
ger of a fatal meningitis or brain abscess of
otic origin. He is like one carrying a live
bomb which may explode at any time with-
out warning. Most life insurance companies
realize this fact and either refuse to accept
applicants with chronic purulent otitis media
or else impose a much higher rate.
From time to time numerous methods of
treatment — some conservative, some radical
— have been devised. The radical methods
include the radical, modified radical and
other operations for which there are definite
well known indications, but these will not
be discussed in this paper.
The conservative mode of treatment may
be used in the absence of indications for radi-
cal procedures and consists of general and
local measures.
The general measures include:
Firstly, general history, physical and lab-
oratory examinations to detect the presence
of any eradicable systemic disease or debili-
tating influences which might be factors in
keeping up the aural discharge — as syphilis,
tuberculosis, diabetes mellitus, lack of proper
diet, insufficient sleep, poor ventilation.
Secondly, the treatment of such diseases
and the removal of such debilitating influ-
ences as may be found; for example, syphilis
must be treated and sufficient outdoor exer-
cise must be had.
Thirdly, a careful nose and throat exam-
ination to detect and make possible the elimi-
nation of such etiological factors as chronic
nasal obstruction from whatever causes, in-
fected nasal accessory sinuses, adenoids, or
diseased tonsils. Such pathological condi-
tions must be got rid of.
It is absolutely essential that the general
physical condition be brought up to the high-
est possible state of excellence by appropriate
measures, preferably under the supervision of
a general practitioner; and that all predis-
posing causes in the nose, naso-pharynx and
throat be removed. No patients should be
given local treatment who refuse to submit
to preliminary measures as outlined above
when these measures are indicated.
Locally, a searching history and careful
examination of the ear should be made. The
parts must be made clearly visible by syring-
ing the external auditory canal with normal
saline at or slightly above body heat. The
functional tests should also be made. Bac-
teriological examination of the aural discharge
may be done as a matter of record, though it
is not usually of practical importance in
chronic cases since contamination wi'.h va-
rious bacteria has generally occurred.
In chronic purulent otitis media there is
considerable variation in the pathological pic-
ture. There is a variable degree of affection
of the membrana tympani ranging from a
pin point opening in it to complete destruc-
tion. The lining membrane of the tympanic
cavity may be thickened even to the extent
of becoming polypoid. Sometimes polyps ex-
tend through a perforation in the drum from
within the middle ear to the external audi-
tory canal. Often there is a destruction of
the tissues lining the middle ear and an in-
volvement of its bony walls with varying de-
grees of necrosis of bone which may lead up
to the meninges or into the inner ear. Some-
times the ossicles are the seat of a necrotic
process. Often bands of adhesions stretch
between or overlie various structures of the
middle ear. In certain cases epithelium from
the canal wall invades the middle ear. When
this epithelium desquamates it may collect
in the middle ear and give rise to cholestea-
tomatous masses.
If polypi originating in the middle ear be
present in the external auditory canal they
must be cut off — not pulled out — as close as
possible to their attachment and the resulting
stump cauterized by careful touching with
SO to 100 per cent solution of silver nitrate.
If the hole in the drum is less than 3 mm.
October, 1929
SOUTHERN MEDICINE AND SURGERY
707
in area it should be enlarged with a myringo-
tomy knife and kept open during the course
of treatment by careful touching of the edges
only with 50 per cent silver nitrate solution.
It IS desirable to have the opening near but
not in contact with the periphery of the
dium and in the posterior-inferior quadrant.
It is necessary to have an adequate opening
in the drum, otherwise fluids cannot readily
jiass from the canal into the middle ear and
m the reverse direction and the treatment
about to be described will be unduly pro-
longed.
Dozens of local measures have been advo-
cated from time to time, most of which have
proved partially successful; but no non-elas-
tic routine can ever be e.xpected to prove suc-
cessful in all cases. !Most treatments hitherto
advocated have not produced more than SO
to 65 per cent of cures.
Among the local measures that have been
used w'ith some degree of success may bj
mentioned diathermy, ionization and irriga-
tion followed by instillation or insufflation of
solutions or powders whose names are legion.
The author has used no new substances, but
by following out conscientiously and persist-
ently, in addition to the preliminary meas-
ures already outlined, the five steps described
in the same order as given below, a much
higher percentage of cures has been obtained.
The external auditory canal having been
cleaned of detritus, the local treatment is
carried out in the following way:
The patient, sitting or lying down, turns
his head so that the ear to be treated is up-
permost and the axis of the external auditory
canal roughly vertical. This is the first posi-
tion. The steps of the treatment follow:
1. In order to remove as much detritus as
possible from the middle ear, the external
auditory canal is filled with hydrogen dioxide.
This liquid is churned by alternately sucking
it into and expelling it from a medicine drop-
per. Such churning facilitates the entrance
of the dioxide into the middle ear through the
hole in the drum. At the end of two minutes
the hydrogen dioxide which has not already
bubbled out, is emptied by causing the pa-
tient to turn his head so that the ear being
treated looks downward and the axis of the
external auditory canal is nearly vertical (po-
sition II).
Upon emptying the contents of the ear
any remaining moisture is removed from the
canal by cotton-tipped applicators, position
I being resumed by the patient.
2. In order to shrink down any polypoid
granulations in the middle ear, the canal is
hlled with 1-1000 adrenalin chloride solution
which is agitated for three minutes, then re-
moved, and the canal dried as prev.ously de-
scribed.
J. In order to dry all the water possible
from the middle ear, 95 per cent ethyl alco-
hol is placed in the canal where it is agitated
in the same way as was the adrenalin. M
the end of one minute the alcohol is removed
and the canal dried in the manner already
described.
4. To further dry the middle ear by re-
moving the alcohol the canal is filled with
pure ethyl ether which is agitated for one
minute then removed and the canal dried as
previously described. The patients often
state they can taste the ether in their throats,
showing that the eustachian tube on that side
is open. For about half a minute after ether
is instilled into the ear the patient says that
it burns. However, even young children tol-
erate the burning well as it is quite transient.
5. Boric acid dusting powder containing
0.69 per cent iodine (Dr. Sulzberger) is now
blown sparingly into the external auditory
canal by means of an insufflator.
The patient is instructed to return daily
for treatments until the discharge ceases,
then every second day for two weeks. There-
after, the patient is seen every week for a
month and every month for 10 months or
immediately at any time should there be a
recurrence of the discharge.
Briefly stated, the chemical agents work,
in the author's opinion, as follows: The pe-
rox'de cleanses the middle ear by bubbling
out, on repeated instillations, all loose mate-
rial from every penetrable recess. The adre-
nalin chloride solution being aqueous readily
m'xes with the remaining small amount of
hydrogen dioxide. This allows the adrenalin
to flow into every crevice and cfime in contact
with granulations or polypoid masses which
are shrunk down by the adrenalin, thereby
facilitating the entrance of subsequently used
solutions into all parts of the middle ear.
Ninety-five per cent alcohol is a powerful
dehydrating agent. Hence, when it is instill-
ed, it rapidly takes up the residue of the
?08
SObtHEkK &tEbtCIN& A^rt) SURGEkV
October, l9i4
adrenalin solution, and therefore when the
alcohol is removed there is practically no
moisture left. Ether will not mix with an
aqueous solution but it is readily miscible
with strong alcohol. Ether is hence used to
remove the alcohol. On account of the vola-
tility of ether it soon evaporates leaving the
middle ear dry. Most pathogenic bacteria
thrive in the presence of ample moisture, but
dryness tends to inhibit their growth and to
en dthe discharge which depends on their ac-
tivity. The iodine dusting powder is mildly
antiseptic and absorbs small quantities of
moisture which may collect in the canal.
In all, 107 patients were treated in the
manner described. These patients ranged
from 4 to 79 years of age and were about
equally divided as to sex. The duration of
the discharge varied from 4 weeks to 61 years
with an average duration of about 2^/2 years.
Scarlet fever, measles, influenza and diphthe-
ria were the diseases most often named by
patients as the starting points of their aural
discharge. Most of the patients gave a his-
tory of having been treated by a number of
different doctors or clinics.
Of the 107 patients, all but three became
free of the discharge within 8 Weeks, the
average duration of treatment being 5 weeks.
The patients who did not get rid of their
discharge in 8 weeks had very minute open-
ings in their ear drums which they refused to
have incised until they had been under treat-
ment for from 3 to 4 months. Upon submit-
ting to myringotomy all 3 of the cases ceased
to have any discharge after from 5 to 7 addi-
tional weeks of treatment.
Nine of the 107 patients had a recurrence
of the discharge within 2 months after it had
ceased. All but 2 of these cases cleared up
finally and remained so for a period of at
least 10 months when these patients were
discharged and instructed to return only on
recurrence of the otorrhea.
By the use of the methods commonly de-
scribed in standard textbooks on otology the
writer has been able to secure a lasting ces-
sation of the otorrhea in only about 60 per
cent of cases of chronic purulent otitis media,
whereas by the method herein set forth, a
cessation of the discharge lasting not less
than 10 months was secured in over 90 per
cent in a series of 107 cases treated. It is
not claimed that these cases are perfectly
cured, for often the pathology present causes
irreparable damage to the sound conducting
mechanism and improvement in the hearing
was by no means constant. However, a
method which has been successful in getting
the results above stated seem worthy of re-
port.
CONCLUSIONS
1. Patients with chronic purulent otitis
media which does not present complications
requiring immediate radical operation can be
freed of the discharge in the vast majority
of cases by conservative treatment.
2. It is of primary importance to build up
the general health of the patient to the high-
est degree. It is, therefore, desirable to have
consultation with a general medical practi-
tioner.
3. All causes in the nose, naso-pharynx and
throat which predispose to chronic purulent
otitis media should be eliminated; otherwise,
local treatment of the ear had better not be
begun.
4. Much patience, thoroughness and per-
sistence in regular treatments are required
but the results obtained in most cases war-
rant the necessary effort involved.
REFERENCES
1. Poi.itzer's Diseases of the Ear. btti Kd., 1926,
pp. 377-646.
2. The Nose. Throat and Eur and Their Diseases,
J.UKSON and Coates, 192Q, 1st Ed., pp. 511-525.
i. Diseases of the Ear, Kerrison, 1923, 3rd Ed.,
pp. 192-218.
Richer Than Duke
The club members were discussing laziness. One
finally told about his hiking trip. Coming to a
stream he saw a figure folded against a tree, hat
over face and a fishing pole stuck, under one knee,
the line in the water.
"Hello," said the visitor, "been here all day?"
"Yep."
"Catch anything?"
"Dunno."
Lad to Take Edison's Place
A woman teacher, in trying to explain the mean-
ing of the word "slowly" illustrated it by walking
across the floor.
When she asked the class to tell her how she
walked, she nearly fainted when a boy at the foot
of the class shouted, "Bow-legged, ma'am!"— TAf
Wheel.
October, 1929
SdtJtttEftN MEbtClMfi ANt) SttlGEftY
766
The Importance of Early Recognition and Treatment of
Squint in Infants and Young Children
H. C. Neblett, M.D., Charlotte, N'. C.
Squinting eyes, alternating squint except-
ed, early lose useful vision. This is partic-
ularly true of infants and children up to the
age of three years. An infant less than a
year old, with a constant unilateral deviation
will, in the absence of proper treatment, lose
useful vision in this eye within a few months.
The young child under similar conditions will
require a slightly longer period for a like
result. In consideration of these facts early
treatment of these subjects is imperative.
The physician whose advice is sought, or
whose attention is directed to such cases, is
generally in a position to decide what shall
be done — whether vision is to be saved by
promptly instituted treatment, or lost through
neglect.
It is generally conceded that infantile
squinters, and most young children with a
unUateral deviation, can be saved from ulti-
mate loss of vision by early treatment. It is
imperative that this be instituted upon the
earliest manifestation of a deviation. Like-
wise, in the absence of squint early treatment
is an important preventive of motor anoma-
lies whenever there are signs and symptoms
indicative of errors of refraction. In this
respect children who present such findings
in early school age are especially liable to
develop a deviation in the eye with the great-
er error. At this period of the child's life,
and earlier, the e.\tra work placed upon the
eyes e.xacts an increasing accommodative ef-
fort for close work. Thus the increased effort
to accommodate, hence to converge, rapidly
eliminates the greater involved eye from ac-
tive participation in binocular fixation. As
a result this eye deviates and early becomes
amblyopic from non-use. When this condi-
tion has developed to an advanced degree
and the child is from five to seven years of
age or older very little if any hof)e can be
had for restoration of useful vision by any
method of treatment. Operations done at
this time to correct the squint are largely
for cosmetic reasons, useful vision having
long since been lost. Having these factors
in mind children — esj^ecially school-children
— who complain of frequent headache, pain
referable to the eyes, fleeting attacks of diz-
ziness, dimness of vision for either near or
distant work; or who display signs of eye
irritation, of unstable emotions or physical
depletion; who are backward in their school
work, and show perhaps a distaste for school
are often the subjects of errors of refraction
or a muscle imbalance or both.
However, there are other factors which,
while not necessarily responsible for such
symptoms, may materially influence them.
.\mong these are disease or abnormalities of
the sinuses, nose, throat and ears, faulty
nutrition, poor elimination, and unhygienic
surroundings. Determination of the presence
or absence of these conditions by careful ex-
amination is important.
A potential squinter may complain of only
one or several of these symptoms. In any
event attention should be paid his com-
plaints, and his status carefully investigated
in an effort to determine the cause of his
trouble. If errors of refraction are found,
with or without mus i imbalance, appropri-
ate measures should be instituted promptly
for their correction.
It is not enough that a cursory examina-
tion be given these patients. Nothing less
than painstaking — and sometimes rejjeated —
examinations suffice to establish the absence
of an error of refraction, or muscle imbal-
ance, even in the presence of normal visual
findings, near and far. In many of these
subjects a latent error of refraction is the
causative factor, and requires for its detec-
tion and correction a thorough examination
of the eyes before and while under the influ-
ence of a cycloplegic. Whatever the etiology
found the result possible of attainment is
materially enhanced by prolonged treatment
with measures applicable to the particular
case.
—316 Professional Bldg.
ho
SOtJtttERM MEbtCINfe AM) SttlGERY
October, 1920
Case
XoTES From the Practice
C C. Hubbard, M.D., Farmer, N. C.
In 1891 I was called to see an old man 72
years near the foot of the Blue Ridge in the
"State of Wilkes." I saw him Wednesday
afternoon. Sunday he had drunk large
amounts ,of still beer and his bowels and
k dneys neither one had acted till I saw him.
I used an enema of soapsuds with an ordi-
nary bulb syringe and got bowels to act. I
used a silk (soft) catheter but it would fill
with blood clots. I tried to wash' it out but
to no purpose. I removed and reintroduced
but only more blood clots. I was 16 miles
from other medical aid — Wilkesboro. Finally
I coupled up my bulb syringe to my cathe-
ter, put my finger over the end of nozzle
and began to pump, soon blood clot and
urine began to spatter all over me, but I
had ga'ned my point. He had a beautiful
external hemorrhoid of recent formation
which I opened, letting out the clot. I col-
lected my "X K and 10 cents"*, took a good
drink of spiritus frumenti and went home.
I have had several cases of girl children
being "grown-up" — no vulvar opening ex-
cept opening to urethra. Have had two cases
of old women, 68 and 72, in same condition,
both married and the one 72 years old had
born a child.
I see in books and journals a lot about the
treatment of poison ivy or poison oak. I
have been using, for over 40 years, only one
treatment.
R Plumbi Acetat 1 oz.
.\cid Boric 2 oz.
Aquae q. s. ad 1 Pint
M. et Sig. --Vpply often. Rub hard enough
to break blisters. In moist parts keep cloths
damp in it over the parts.
I have one case it does not do any good,
but in all other cases never fails. Have used
it in dozens of cases and on my own skin
repeatedly. Indeed I see no need of any
other treatment.
If it gets in eyes I tell them to take 1
spoonful of the solution and 4 spoonfuls of
plain water and drop in eyes every 2 hours.
*Col. Wex. Whittington, of Wilkes, could not read
nor write. He ran a little store, and to make it
appear that he could read, etc., would say, "I can't
Reports
let you have this for less than _„., as it cost me
■X K. and 10 cents' or 'X K and 20 cents,' " etc. It
pot to be a saying around Wilkesboro when speakers
of money, "I got the X K," etc. — merely a local
idiom. — IH. I
Health Hazard of Exposure to Silica
Dust in the Granite Industry
(U. S. p. H. S.)
The study was of such a character as to present
a rather definite picture of what happens to men
working for many years under a dust hazard of the
extent described. The salient points may be sum-
marized as follows:
(a) The long period of service before the lia-
bility to tuberculosis becomes manifest (generally
20 years or more).
(b) The sharp correlation between length of ex-
posure to the dust and the prevalence of tuberculo-
sis and also the death rate from this disease.
(c) The close relation between the extent of dust
exposure and the health of the men.
(d) The universal occurrence of silicosis amonu
the workers.
(e) The large proportion of workers finally sue-
cum'jin;; to tuberculosis.
(f) The almost invariably fatal form of the dis-
ease within a short time after the onset.
(g) The different character of silicosis as mani-
fested by x-rays compared with that shown where
there is exposure to a dust with a much higher
content of free silica.
(h) The location of the tuberculous lesion,
usually basal, where the disease complicates silicosis.
(i) The absence of deaths from silicosis pi-r se,
tuberculosis apparently always intervening.
(j) The failure of workers to recover from their
cond'ticn upon going into non-dusty trades.
(k) The high incidence of sickness of a revere
nature from causes other than tuberculosis.
(1) The rising sickness and mortality rates from
tuberculosis due to longer use of the hand-pneu-
matic tool.
(m) The high death rate; at the present time
from tuberculosis, compared with normal industrial
experience.
This investigation paralleled in its method the
studies which are being conducted in other dusty
trades and included a record of the sickness and
mortality occuring among granite cutters for a period
of more than two years, complete physical exam-
inations with special reference to the development
of tuberculosis, x-rays, sputum analyses, and autop-
sies, together with a careful analysis of the atmos-
pheric dustiness under varying conditions. A study
of mortality among such workers based on death
certificates was also made.
(Write V. S. P. S., Waslijif^ton. D. C. jor P. H.
Bulletin No. 187)
October, lOJO
SOUTttERM MEDICINE AND StJRCERV
?11
The New Grace Hospital
Cuts kindly lent by Miss Beatrice Cobb, Ihe Xr-iZ's-Herald of Morganton, frum whom (or which)
the story is derived also.
On September 18th, a new Grace Hospital
(if Morganton, X. C, was dedicated with im-
pressive exercises. Prior to the dedicatory
exercises the cornerstone, for which provision
had been made in the building, was laid by
Hishoj) Junius M. Horner, of Asheville. In
the repository in the stone were placed ap-
propriate articles, including a prayer book, a
Grace Hospital cross, reports of the hospital
for each of the 23 years since its establish-
ment, photographs of the founder, the Rev.
Walter Hughson, and of Mrs. Hughson, cur-
rent copies of newspapers.
.Mr. E. M. Hairfield, mayor of Morgan-
ton, extended a welcome to the visitors pres-
ent, and expressed appreciation of the worth
and wonderful wcjrk of Grace Hospital.
The Rev. C. E. Gregory, pastor of the
First I'resbyterian church of Morganton, paid
a glciwiiig tribute to the late Mrs. Hughson
and to Miss .Mien and cfimmended Grace
church for the active and protective interest
shown in the hospital.
The Rev. W. R. Bradshaw, representing
the local Baptist churches, spoke in terms of
highest appreciation of Grace Hospital and
the work of local physicians.
The Rev. E. N. Joyner, beloved and ven-
erated Episcopal minister, made a touching
and inspiring talk and gave his blessing to
the new building. Following a few remarks.
Bishop Horner closed the exercises with the
reading of the regular dedication service of
the Episcopal Church.
The Rev. A. W. Farnum, of Asheville,
made a brief talk, and the Rev. LeRoy Jahn,
rector of Grace church and chaplain of the
hospital, who presided over all the exercises,
read a history of the hospital from which we
quote:
.About .August 1st, 1906. Grace Hospital
was opened under the direction of the Rev.
Walter Hughson, then rector of Grace Church
Parish. The organization was: The Rev.
Walter Hughson, trustee: Miss Maria Pur-
don Allen, sui)erintendent; all the local phy-
sicians and surgeons on the medical staff o(
lii
SOWHetlK MEbtCttJfi AMb StkGtftV
October, 19^0
The Reverend Walter Hughson, Founder
the hospital; E. \V. Phifer, M.D., resident
physician; Isaac M. Taylor, M.D., and A.
Al. Kistler, advisory trustees.
During the first year the superintendent
reports 71 patients admitted, ihe average
hospital cost per patient per day was $1.40.
In September, 1908, the Rev. Mr. Hugh-
son died, leaving the infant institution to the
hands of co-workers to carry on.
Early in the year 1908 the first nurses'
home became a reality. Before this date,
the nurses used the rooms in the hospital
when not occupied by the sick. As the report
for the year states, "During the summer
months, particularly, we have been so crowd-
ed that the nurses, at times, were forced to
sleep on the piazzas and sometimes in the
etherizing room.'
In October, 1910, the training school for
nurses was opened. In the year 1920 a cot-
tage was fitted up in which to care for pa-
tients suffering with tuberculosis. This serv-
ed until about 1927. when it was deemed wise
to close it, as the state was making more
provisions to take care of such patients.
To meet ever increasing demands, in 1923
the last addition to the old Grace Hospital
was completed.
Puring this same year another great
Mrs. Hughson, Nourhher
After the death of her husband, she, in 1Q08, took
over the management of the hospital to which she
devoted her time an! efforts until her death in 1924.
During her many years of work among the moun-
tain people Mrs. Hughson gathered a store of amus-
ing anecdotes and the following was her favorite
(we will attempt to tell it in her own words):
"One afternoon I was having prayers in the hirne
of an old withered mountain women. There were
about eight people in the room and I was sitting on
an old wooden chest. We were about finished with
our service when we heard a knock at the door.
The old woman hobbled to the door and the follow-
ing hispered conversation ensued. I could not help
but overhear it.
Strange male voice: Got any liquor?
Old woman: Yes, but you will have to wait — I
cain't git it fer ye now.
Strange male voice: Why cain't ye git it now?
Old woman: Because the old missus is a setting
on the chist."
forward step was taken. The late board of
trustees, who for all these years superintend-
ed the affairs of the hospital, at last saw the
way clear to transfer the property, and elect-
ed as their successors, the rector and vestry
of Grace church, Morganton, and Mr. An-
drew Kistler, of the same town.
fiarly in 1924 Mrs. Hughson tjiet}. No
October, 1929
SOUTHERN MEDICINE AND SURGERY
m
Dr. E. W. Phifer
Physician in Charge since organization.
Board of Trustees.
IMiss Maria P. Allen, R.N.
First Superintendent. Long associated with Mrs.
Hughson. Services invaluable.
matter into what secluded coves of these
mountains one may wander or what moun-
tain top one may climb, ^Irs. Hughson has
been there before, malting friends by reliev-
ing the suffering and distress. .-Ml who
sought her help and comfort looked upon her
as a tower of strength. As Dr. Phifer once
said, "Through all the stress and strain of
life Mrs. Hughson was staunch and firm and
never found wanting." With her passing
Grace Hospital lost a most efficient manager
and a powerful influence few institutions
-Mr. .Andrew M. Kistlkr
Member Board of Trustees since organization, and
generous contributor.
Miss .Alice W. W'ilus, Siipcrintriidnit
Succeeded Miss Allen. Had been a nurse at Grace
Hospital many years before taking charge.
714
SOUTHERN MEDICINE AND SURGER\
have ever known.
A few months later Miss Allen, Mrs. Hugh-
son's most able superintendent, resigned be-
cause of ill health, after nineteen years of
faithful and devoted service to Grace Hos-
pital.
iNIiss Alice Wilds was chosen to fill the va-
cancy left by Miss Allen. Miss Wilds had
been in close touch and a^ociation with
Grace Hospital since 1912, therefore when
the time came for Miss Wilds to shoulder
the burden she was well qualified to do her
part in the upbuilding of the institution.
The Rev. L. A. Jahn, Chaplain
Rector Grace Episcopal Church.
M the same time Deaconess Ruth Wilds
was given the position of assistant secretary
and treasurer. The deaconess had long been
a friend of Grace Hospital and closely asso-
ciated with it and its workings. It was no
easy inheritance and the task was a hard
one. To her Grace Hospital owes a debt of
s-ncere gratitude for her splendid work.
The hosp'tal is rated at fifty beds, but in
an emergency will take care of sixty-five pa-
tients. There are seventeen private rooms —
two for colored — and six wards as follows:
Men's Surgical, Women's Surgical, Men's
Medical, Women's Medical, Children's, Col-
ored Men's and Colored Women's.
The hospital equipment is of the very lat-
est and most improved type and the arrange-
October, 1P29
ment of the hospital is a marvel of efficiency.
The chart desks situated in the hallways of
the three upper stories are connected with
each private room and ward by an electrical
light signal equipment.
The |»-ray room, physiotherapy room,
fluoroscopic room and laboratory on the
basement floor are equipped with the most
modern - machines and are in charge of a
trained and experienced technician.
There are three dispensaries in the hos-
pital, the largest of which is located in the
;\Iiss Ruth M.acX.aughton, Secretary
basement and is equipped with a sterilizer
as well as other modern dispensary equip-
ment.
Diet kitchens are located on every floor
of the hospital and each one is equipped with
an electric stove and Frigidaire. The largest
of the kitchens which is in the basement in
addition to other equipment has a steam
table for keeping cooked foods at an even
degree of heat. Each of the three small
kitchens is connected with the main diet
kitchen by a dumb waiter.
The main kitchen on the basement floor is
newly equipped throughout; a novel feature
being the chute leading to the incinerator
which burns all refuse.
The refrigerating and cold storage plants
in the basement are of the most modern type.
October, lQ2g
SOUTHERN MEDICINE AND SURGERY
Dr. J. B. Riddle, of !Morganton
The refrio;eratinCT unit run at capacity will
p.oduce two thousand pounds of ice daily.
Leading from the cold storage room is a com-
mssary for storing canned goods and pro-
v-'sions.
.AH rooms and wards in the hospital are
wired for radios which can be plugged in at
Dr. Herbert Kibler, of Morganton
a moment's notice.
The four sun parlors are spacious and com-
fortably furnished and will provide ample
space for nurses, guests and^ convalescing pa-
tients.
Last year, out of a total of &,449 patient
days, 3,232 days were free days which boiled
Dr. G. M. Billings
.\ member of the staff of the State Hospital for past
ten years, has moved to Morj;anton to engage in
general practice.
Dr. J. J. Kirksev, of Morgantnn
down means that approximately half of the
work of the hospital in 1928 was charity
work.
716
SOUTHERN MEDICINE AND SURGERY
October, 1929
Dr. John E. Taylor, newly of Morganton
For every free day the Duke Endowment
allows the hospital $1.00. The last available
reports show that it costs $4.75 to care for
one patient for one day. Figured on this
basis, 3,232 free days at $4.75 per day, it
cost the hospital $15,352 less $3,232, allowed
by Duke Endowment, net $12,120 to do char-
ity work last year.
Dr. F. O. Foard, of Valdese
furniture finished in walnut, mahogany and
pastel shades. The furniture in the children's
ward and nursery is worthy of note in that
it is a miniature of the regular hospital fur-
niture.
The doors which were especially designed
for the hospital are of built-up construction
and guaranteed not to warp. All doors lead-
ing to private rooms and wards are equipped
with patented door pulls which enable the
nurses to open the doors with their forearms.
.■Ml hall floors in the hospital are of "Tile-
Te.\," an insulated composition flooring which
is practically noiseless when walked upon.
The heating unit in the basement is newly
equipped and has an automatic stoker. You
start the fire, fill the stoker or "iron fireman"
with coal and it automatically feeds the fur-
nace. Another advantage of the stoker is
that it enables the user to burn the lowest
grade of coal effectively.
The hospital is well constructed and mod-
ernly equipped throughout and it is doubtful
if there is a better arranged hospital to be
found anywhere in the country.
Dr. B. L. Long, of Glen Alpine
Practically all the furniture in the private
rooms and wards is the new metal hospital
From a sketch written by Mr?. HukHsoii in 1920
for a special edition of The Neivs-Herald:
During the incumbency of Archdeacon
Hughson as rector of Grace church, Morgan-
ton, he felt most deeply the need in sickness
October, 1929
SOUTHERN MEDICINE AND SURGERV
Grace Hospital started in a tiny frame cottage. After a time it was enlarged to the proportions
shown here, still later a two-storv frame addition was added.
of the people among whom he worked in the
missions under his charge in the rural dis-
tricts around the town. The people were of-
ten remote from the town, the roads were
pwor, and any modern theory of disease was
quite unknown. All of the mission workers,
constantly in touch with the sick and afflict-
ed, particularly those who had few if any of
the comforts necessary in illness, came to
him with pathetic stories of special cases.
The money for the salary of a vis'ting nurse
was first given, and Miss Maria Purdnn Al-
len, a graduate of the Enisconal Hosnital in
Philadelphia, came to do the work. With
her trained knowledge of conditions, the need
seemed even more pressins;. Finally, in re-
=nonse to an appeal, and in direct answer to
nraver as the archdeacon alwavs felt, the
monev for the erection of a buildint? and the
niirrhase of three acres of land, was "iven
h\' a penerous woman in New York. .As it
stood at first, the main building contained
accommodations for eight beds in wards, and
one private room, and the annex, given in
memory of the Rev. E. Walpole Warren, of
New York, had two wards, of four beds each,
for colored patients. A well equipped oper-
ating room, and a dispensary were included.
The need was so great that the hospital was
opened before it was quite completed. There
was, of course, much prejudice to overcome
among people who knew nothing of hospital
methods, but during the first year seventy-
two patients were cared for. Where people
have been able to pay, they have been asked
to do so, but in all the years of its existence,
no needy person has ever been turned away,
where the case was one which it was possible
to admit.
Never in the twenty-three years of Grace
Hospital's existence has there been there a
single penny of indebtedness, and never has
a patient seeking comfort and relief been
turned away.
0.
I
r
SOUTHERN MEDICINE AND SURGERY
October, 192Q
■ .._. +
SOUTHERN MEDICINE AND SURGERY
Official Organ of <^ '^'■'■^''''•' '^**''"'"' Association of (he Caroliiias and Virginia
I .^ledical Sociclj of the Stale of North Carolina
James M. Northington, M.D., Editor
Department Editors
James K. Hall, M.D Richmond, Va _
Frank Howard Richardson, M.D Black Mountain I
W. M. RoBEY, D.D.S . Charlotte. N. c'.
J. P. Matheson, M.D. \
H. L. Sloan, M.D I
C. N. Peeler, M.D \ ri,n,i„..o xt n
c T7 m ^» T-. > Lnar otte, N. C—
F. E. Motley, M.D . ( , v,. -
V. K. Hart. M.D \
F. C. Smith, M.D )
The Barret Laboratories Charlotte N C ^
a L. Miller M.D Gastonia.'N. C.J.^
Hamilton W. McKay, M.D ,
Robert W. McK.av, M. D. ( Charlotte, N. C...
J. D. MacRae, M.D _ _ ..
J. D. M.^vcRae, jr., M.D. > Asheville, N. C.
Joseph A. Elliott, M.D Charlotte, N. C. ..
Paul H. Ringer, M.D Asheville, N. C..._-
Geo. H. Bunch, M.D. Columbia, S. C. ._
Federick R. Taylor. M.D High Point, N. C.
He.nry J. Langston, M.D Danville, Va
Chas. R. Robins, M.D Richmond, Va
Olin B. Chamberlain, M.D Charleston, S. C
Various Authors
James .^dam.s Hayne, M.D „ Columbia, S. C. -
-Human Behavior
— Pediatrics
Dentistry
Diseases of the
Eye, Ear, Nose and Throat
Laboratories
..Orthopedic Surgery
Urology
, Radiology
Dermatology
Internal Medicine
_ Surgery
-.Periodic Examinations
Obstetrics
Gynecology
_ Neurology
Historic Medicine
Public Health
Belated Recognition of Organized So-
Called "Charities" as ^Ienaces to
Medicine and to the Health of
the People
Many thoughtful doctors — and some among
the laity — have, over many years, viewed
with grave concern the never-ceasing en-
croachment of so-called "charities'" and "be-
nevolences" on the field of medical practice:
and some have sounded warnings. These
warnings have usually fallen on deaf ears.
We were soothed by sweet words, uttered
to medical graduates and about the open
graves of doctors, as to the nobility of our
profession and our self-sacrificing devotion to
the best earthly interests of mankind; we
were told that the treatments rendered our
patients without cost — or even at our own
cost as tax-payers — would serve only to "ed-
ucate" the community as to the need, and
that we would rean the benefit. Over many
vears these kindly folks — who go the Good
Samaritan one better by going out to look
for afflicted ones who may be set on beasts,
taken to inns, and their care provided for —
have been careful to include in their public
pronouncements praise of the competency of
"your own doctor." With few exceptions
doctors in private practice all over the coun-
try welcomed these health betterment move-
ments— and did practically all the work; but
the credit went to this or that "philanthropy"
and its well paid staff.
Of late we see a change of tone. They
tell us what great things they have accom-
plished— forgetting that the most of this ac-
complishment was by ourselves; and they
tell us what a poor lot we are! Verily, "Low-
liness is Young Ambition's ladder"!; and
verily he "scorns the base degrees by which
he did ascend!"
The Chairman of the Rosenwald Fund
takes up a page in many daily papers in tell-
ing us that we are ignorant incompetents,
practicing the medicine of bygone centuries;
Mr. Ford includes Medicine in his all-inclu-
s've knowledge, and offers "mass production"
as a cure for all our ills; Mr. Dempsey tells
us what we should eat, how long we shou'd
sleep, and wherewithal we should be clothed!
October, 1929
SOUTHERN MEDICINE AND SURGERY
719
And who is there so bold as to say an Amer-
ican millionaire doesn't know everything
about everything; even when he had nothing
to do with the accumulation of the millions
and is clothed only with the glamor which
attaches to disbursing them, or when they
fell into the lap of an ignorant, selfish, hypo-
critical mechanic, or of a prize-ring bruiser?
In the "Homely Ladies' Journal" for Sep-
tember is an article called "Before you take
a glass of milk," which shows, besides the
utmost eagerness to abuse the medical pro-
fession with little regard to information or
reason, a callous unconcern for the conse-
quences of causing folks whose lives depend
on the taking of milk to refuse it for fear
of getting a disease which may never have
been transmitted through cows' milk. (See
Editorial this journal, Sept.)
Life-extension institutes set up offices, con-
ducted by highly paid publicity men, and
engage in the practice of medicine, through
poorly paid doctors, in unfair competition
with other doctors who have no such printers'
ink aid as that afforded by such institutes
to the doctors in their employ.
On the whole, it seems to us, the activities
of the various State Boards of Health nave
been conducted with studied fairness to the
rights of doctors in private practice. How-
ever, it behooves all of us to take note of all
new proiects and to give health authorities
the benefit of our opinions while such plans
are in the making.
We have reliable reports that the Veterans'
Bureau has patients of doctors who them-
selves were in the service, — patients who are
entirely able to pay for any kind of treat-
ment— ODerated on or otherwise treated by
doctors in U. S. employ, for conditions the
relationship of which to service is not at all
apparent to those outside the bureau. The
activities of all other health bureaus in Wash-
ington, such as that concerned with ^Taternal
.Aid. we view with grave susn'cion. The less
of our government or other kind of interfer-
ence thnt comes from Washington the better
are we pleased. .And we are distrustful of
anv ai'pncv. no matter how benevolent, which
has in its hands enormous nower.
If annears to us that only in th's vear. at
lp->st in North Carolina, has there been mani-
fested officially a spirit of uneasiness and
apprehension at what was happening to, and
threatening, the medical profession. This
journal in January, 1925, in an editorial
"Medicine Militant," expressed itself in part
as follows:
P'or centuries one of the most import-
tant of the Christian denominations has
divided the Church into: (1) The
Church Militant; (2) The Church Ex-
pectant; and, (3) The Church Trium-
phant. This is a natural, sequential or-
der. We medical men have fatuously
assumed that we have arrived at the third
stage without having passed the first.
We have folded our hands and compla-
cently assumed that our virtues would
be so outstanding that all would per-
ceive and laud them. In this we have
been grievously disappointed.
We are glad the Secretary-Treasurer of the
Medical Society of the State of North Caro-
lina is expressing similar sentiments.
Within the past few weeks we have had
an invitation to join a new medical organi-
zation. A reprint accompanying has the title,
"Wanted: Members for a New Militant
Medical Organization." The objects as stated
are:
To institute reforms in the clinic sys-
tem, through group action; to establish
medical control in the distribution of
charitable medical services; to establish
freedom of choice of physician to char-
itable and insurance cases; to reduce cost
of post-graduate study and provide for
its greater efficiency; to maintain pro-
fessional morale, and discourage the
commercialization of medicine; to en-
force adequate compensation for salaried
physicians.
It is said to be planned as a militant sister
organization to the A. M. A. It is called the
.American .Syndicate, and its headquarters
are at 47 W. 69th Street, New York City.
This is all we know about the organization.
Its platform looks sound, lender proper wise
leadership, such an organization should be
able to effectively check the encroachments
of lay organizations on the practice of med-
icine, and to safeguard the professional and
economic rights of doctors — rights now
gravely imperiled.
How does the present situation menace the
120
SOUTHERN MEDICINE AND SURGERY
October, 1929
liealth of the people? The answer is easy
and simple. Any influences which tend to
make dependents of doctors, take the hearts
of these doctors out of their work and so
reduce its efficiency; and certainly such in-
fluences will keep young men of bold and in-
dejjendent minds from entering a profession
which is being systematically robbed of its
dignity and its emoluments.
The Medical Society of Virginia's
Program
The Medical Society of our Sister State
on the north will hold its sixtieth consecutive
annual meeting from the 22nd to the 24th
of this month, under the pres'dency of Dr.
Boiling Jones of Petersburg. Dr. Joseph L.
Miller, of Thomas, W. Va., says the old
Medical Society of Virginia numbered 450
in 1854 and in that year passed a resolution
pledging all its members not to receive any
individual as a student "who is deficient in
that preliminary education, which is neces-
sary to fit him for entering a profession re-
quiring high intellectual and moral qualifica-
tions," which is sufficient evidence of the
existence of a flourishing Medical Society of
Virginia at that time.
Miss .'\gnes Edwards, the able and amiable
Executive Secretary-Treasurer, favors us
with a preliminary program from which we
gain knowledge which we wish to pass on to
our readers.
.Among the Committees of the Society,
which we have not in the Medical Society of
the State of North Carolina, and which it
seems we should have, are those on Medical
Economics, on Maternal Welfare and on His-
tory of Medicine in the State. Economic
problems are confronting, and in some cases
enveloping, the members of the medical pro-
fession. These problems demand careful
study, serious thought and vigorous action.
Maternal welfare cries out for attention, as
the most promising means of reducing our
mortality rates, by preventing the loss, un-
necessarily, of the lives of society's most
valuable members — women who are both
able and willing to bear children. Much of
what would make brilliant pages can be
gathered from available records of the lives
of North Carolina doctors. Each year's pass-
ing adds to the difficulty of collecting such
data. Old folks die, old houses burn, old
inscriptions become undecipherable.
The Medical Society of Virginia has also
a Membership Committee. Such a commit-
tee may not be an urgent need of the N. C.
State Society; but the idea is passed on to
the Tri-State membership as worthy of con-
sideration, as a means of easing somewhat
the load carried by the secretary-treasurer —
rather as a means of helping the secretary-
treasurer to add to the membership of the
best medical organization in the country.
The showing made by the list of scientific
exhibits on the program is such as to provoke
emulation. Clinics will be held on the 22nd
between 2:30 and 6 on a wide range of medi-
cal and surgical conditions. Dr. Ray Lyman
Wilbur, Secretary of the Interior; Dr. Hugh
S. Cumming, Surgeon General U. S. P. H. S.;
Dr. Chas. R. Stockard, of Cornell; Dr. Edwin
A. .Alderman, President of the University of
Virginia; Dr. Wm. Gerry Morgan, Washing-
ton, D. C, President-elect of the A. M. A.,
and Mrs. Walter J. Freeman, Philadelphia,
President of the Woman's Auxiliary to the
Medical Society of the State of Pennsylvania,
will deliver addresses.
A special feature of much promise is made
up of two addresses, one on Recent Progress
in Internal Medicine, by Dr. Mulholland of
the University; and the other, on the same
in General Surgery, by Dr. LaRoque, of the
Medical College of Va.
The regular program consists of essays
covering well the field of medical practice,
after a well thought-out plan.
Doctors from other states will find a hearty
welcome to this feast of good things. We
hope to be there.
Recent District Medical Meetings
ideas on repealing the privilege tax
Over a number of years the impression
has been growing on us that it is to the
County and District societies that we must
look for most of our accomplishment advanc-
ing the cause of organized medicine. Of
course the State Society can give its confirm-
ation and blessing after the component so-
cieties have brought important projects to
accomplishment; but the appreciation of the
desirability of doing certain things out of the
ordinary and initiation ^nd carrying out of
October, 19i0
SOtTttEkM MEblCtKE A^Jt» SCfeGEfeV
»21
the actual work must fall on the smaller
bodies.
Several District societies, notably the
Ninth, have shown marked initiative in the
way of improving their programs in ambi-
tious ways, and in resisting encroachments
on the rights of doctors.
Last year the Iredell-Ale.xander County
Society (in Ninth District) passed a resolu-
tion setting forth the unfairness of the privi-
lege tax on doctors, and sent copies over the
state to other county societies requesting co-
op)eration. At this year's meeting of the Ninth
District Society a private discussion of this
subject brought forth a reason which holds
much promise of proving persuasive to law-
makers.
The reason first advanced, that we should
be excused from payment of this tax because
we do so much charity work, while ample
to logical minds, suggests the idea that 25
dollars is about the value of the average doc-
tor's charity work per year — which all of us
know to be absurd. Then other folks resent
having us tell them how good we are, and
decide the case against us as a rebuke for our
lack of modesty. In the days of the great-
ness of Greece an orator opened a speech in
his own defense by asking his hearers not
to bear it against him when "in order to
defend myself I must speak well of myself,
which is distasteful to all men.''
The proposal made is that we base our
demand for rep)eal of this tax on the ground
of compensation for services rendered the
State at the command of the State, in report-
ing births and deaths, making out health
repwrts, sick and accident claims, certificates
for shipment of bodies, and the other ways
in which we serve the State directly without
receiving payment — leaving out entirely the
matter of professional service rendered
through charity. Think over this, put the
two arguments bef(jre a few intelligent lay
friends, then write the journal the results.
Dr. Dewey Davis, of Richmond, and Mr.
\V. H. Neal, of the Wachovia Bank and Trust
Company, Winston-Salem, were invited
speakers at the Ninth District meeting. Dr.
Davis on "Hypertension" and Mr. Neal on
"The Doctor and His Investments." Both
these addresses and some other features of
the excellent program will appear in these
pages. It is a novel, but highly sensible,
idea to have advice from one who knows
sound investment principles, and can give
facts about the thousand extravagantly pro-
moted ventures which fail for everyone that
succeeds.
Dr. Wm. B. Porter, of Richmond, delight-
ed the Seventh District Society's member-
ship and guests in Charlotte October 8th,
with a series of clinics in the afternoon and
an illustrated lecture in the evening on ane-
mias. The success of the meeting teaches
us all over again what we learned in our
years in medical college, but which tends to
sink out of mind, that the presence of the
patient adds tremendously to the interest in
his case. We predict that more and more
our meetings will be taken up with clinics and
our journels filled with case reports.
It is with keen regret that the editor dis-
covers that he is unable to accept Dr. O. L.
McFadyen's invitation to attend the Fifth
District Meeting. Dr. McFadyen always ar-
ranges an excellent program and we shall
hope to have notes on the meeting for our
next issue.
•The reason was offered by either Dr. J. F.
Miller, of Marion, or Dr. G. P. Bingham, of that
same well-known town. Cretjit is hereby gladly
|lV»fl. .
When You Read a Paper
(Editorial in Perm. Med. Jour., Sept., '29)
If you are scheduled to read a paper at the
annual session of the State Society, remember
that it will be useless to read it unless you
speak clearly and loudly enough that all
those in the hall can hear it.
There has been much complaint that so
often speakers, especially at the larger meet-
ings, are inaudible. If you want your paper
to make a good impression, hold up your
head, talk to the audience in the rear rather
than the front seats, speak slowly and dis-
tinctly, pronounce not only the vowels, but
give the consonants due emphasis, and take
time enough and open your mouth wide
enough to enunciate properly. Not every
one can be an accomplished public speaker;
but there is no one who cannot at least make
hmself heard if he will make the effort.
(E.xtracts from "Why Does the Editor Return
Manuscript?", same Journal)
It may be helpful for authors to know
sofTie of the criteria by which articles are
722
SOUTHERN MEDICINE AND SURGERY
October, 1029
judged:
Scientific value is the first point to be con-
sidered when a paper is offered for publica-
tion.
Material compiled from textbooks and dic-
tionaries has no place in a current publica-
tion, unless it is used only to provide a back-
ground for the original matter submitted or
to form the foundation for a new theory or
technic. A single-column report of an un-
usual case has more value than the most
learned textbook dissertation. It is the func-
tion of the periodical to provide news of medi-
cal and scientific current events and develop-
ments; not to teach foundation principles.
Given two papers of equal value, the short-
er paper will be chosen. The briefer paper
would stand the better chance of being read
by the subscribers. Life provides too little
leisure to read necessary words. Unneces-
sary ones have little chance of securing a
hearing.
A poorly prepared manuscript stands little
chance beside a well-written one, unless the
former is of outstanding scientific merit.
A paper frequently has to be returned be-
cause another on the same subject had been
published or accepted previously. The sec-
ond paper may be the better of the two, and
in that case the editor returns it with consid-
erable regret.
The editor would like to please every one.
Failing to do the impossible, he must realize
that his responsibility is to his readers. He
must compute his calories; measure and
weigh his proteins, fats, and carbohydrates;
assure himself that adequate mineral elements
are supplied; add a few condiments for fla-
vor; and not forget that most vital part of
the literary diet of the readers for whom he
is called upon to prescribe^the vitamins.
If he is a good editor he will supply a palata-
ble and properly balanced diet. If he is not,
his publication will suffer from malnutrition,
and will eventually join the dodo in its shad-
owy retreat.
snap and an abundance of hot water." — Wm. H.
Taylor, M.D. (M. C. V., 1856), to his Class in
Chemistry, M. C. V., in the year 1901.
Important Facts About "Disinfectants'
Thi.'-- new.*. letter is prepared under the supervis-
ion of the Health Committee of the State Medica
Society of Wisconsin. Kverv effort is made U) ha\t
every fact tested in the light of the latest develop
ments in scientific medicine.
This service to the Press was endorsed bv th<
State Board of Health, January, 1927.
"The best general antiseptic is an abundance ot
Most disinfectants used in homes are no more
effective in killing disease germs than the burning of
incense would be to appease the pagan Gods.
"If people would use soap and water more freely
and less disinfecting concoctions they would be better
off," declares the Bulletin of the Wisconsin State
Medical Society. "Ample light admitted into rooms
will kill more germs than any spray or smudge.
"Disinfecting solutions are of value for disinfec-
tion of the hands, and persons having the care of
cases of communicable disease may use them to
advantage after the hands have first been carefully
cleansed. But under ordinary circumstances it is
not necessary to use disinfectants. Most soaps have
disinfecting powers. A hand brush and strong suds
used on the hands with particular attention paid to
removing the dirt which collects beneath the nails
will usually render the skin not only clean, but free
from harmful germs. Would that more cooks would
bear this fact in mind. Soaps advertising as contain-
ing disinfectants have been shown to have little, if
any, stronger action than ordinary soaps.
"Dishes and table silver need to be rendered sterile
after use in order to prevent the spread of colds and
other infections from person to person. Here again
special disinfectants are not necessary, for washing
with hot suds, followed by scalding water, will render
these articles clean and free from all common disease
germs. Unfortunately both dish water and rinsing
water are commonly used too cool to be effective.
"A great deal is heard about the danger from
dust in the home or in the streets. This has been
greatly over-rated, for by the time dangerous germs
have become sufficiently dry to float around in the
air. drying and sunlight have rendered them harm-
less.
"It was formerly the custom to fumigate rooms
after the recovery of a case of diphtheria. Some
communities even went so far as to require that an
entire house be disinfected whenever it was vacated
whether any person in the family had been sick or
not. Such practices may be compared to the heathen
custom of burning incense to appease the gods of
disease so far as any good resulting from it is con-
cerned, for diphtheria germs and many other disease
organisms die very quickly outside the human body.
"Enough has been said to show that disinfectants
are not needed for everyday use in the home. How-
ever, some good disinfectant should be kept on hand
for the treatment of wounds. Tincture of iodine or
mcrcurochrome are excellent for sterilizing cuts or
bruises, but a physician should be consulted if such
injuries become infected.
"One thing should be always remembered; chemi-
cal disinfectants are usually injurious or poisonous;
and all poisons should be so labeled, and kept be-
yond the reach of children, preferably under lock
and key."
October, 1029
SOtJTHERN MEDtCI^rfi Atrt) StJkGEfeY
DEPARTMENTS
I2i
HUMAN BEHAVIOR
James K. Hall, M.D., Editor
Richmond, Va.
Fear Enthroned
A strike has been in progress for several
weeics amongst some of the textile workers
in North Carolina and a good deal of violent
behavior has been one of the results. Indi-
viduals and officials of organized labor have
come into the region for the purpose of union-
izing the mill-workers. Some of the visiting
agents have expressed disapproval of the ex-
isting forms of government and some of them
have been anti-religious in their opinions. In
consequence of the clashes between groups,
a city officer has been killed and, more re-
cently, a woman member of a crowd was
killed by gunfire, either accidentally or pur-
posely. There have been kidnappings and
Hoggings. One man reported himself carried
forcibly from his room by a group of men,
taken far into the woods at night, stripped of
his clothing, and whipped. After he was
treated for a few days in a hospital he was
brought, by judicial order, before a trial judge
for interrogation about the episode. During
the process of the investigation it came to
light that the man was foreign-born, that he
was a British subject, that he did not believe
in the Bible, and that he did not believe in
God. His statements were being made or
were about to be made under oath; where-
u[X3n he was informed by the judge that if
he did not believe in God he could not take
the oath, and that if he could not take such
an oath he could not tell the court who his
captors and his assailants were.
It would seem that the law about oath-
taking in North Carolina is old, and that it
has been upheld by an opinion of the State's
highest court. The judicial interpretation
arises out of the opinion that if the witness
denies belief in the existence of God he would
be lacking in the fear of a visitation of d'vine
wrath should he tell a lie, with the probable
inference that the atheistic witness would lie
unrestrainedly.
.About two thousand years ago a three-
word question was asked which still remains
usually unanswered, and the mutism thus in-
duced has caused continued embarrassment
to this day. But, in spite of Pilate's historic
interrogatory, a procedure has been adopted
in judicial quarters whereby efforts may be
made in the search for this obscure and elu-
sive phenomenon called Truth. But a judi-
cial opinion rendered in North Carolina more
than half a century ago would debar from
the group of searchers those who deny the
existence of God.
Contemplation of the recent judicial pro-
nouncement in Charlotte, on account of
which the God-denying British subject found
himself unable, in the presence of the court,
to make audibly articulate the names of those
who he thought had dragged him out of his
room and beaten him, has a tendency to
cause one to have more dignified respect for
Fear than one should like to have. The as-
sumption would seem to be that one tells the
truth because one is afraid of divine punish-
ment (either here or hereafter) for being un-
truthful. And that causes one to wonder
whether a human being is naturally truthful
or untruthful. Would one lie always and
habitually were it not for one's ever-present
fear that God would strike him dead? And
is it difficult always for one to be truthful?
My own feeling is that truthfulness is natural
and that it is, therefore, a quality of a whole-
some individual and that the constant inclina-
tion to lie is pathologic and unnatural.
A good many eminent citizens probably
could not take the oath in North Carolina
which would permit them to testify in court.
But should that disability deprive them of
the protective influence of the State's law?
.And what is one's belief — religious or other-
wise? Is it a wished-for, conscious formula-
tion, or is it an expression of one's inherent
being? Should one change one's opinion out
of respect for one's geography and one's
neighbors? iMost people undoubtedly do that
very thing — unconsciously. iNIay not respect
for self keep one truthful? If their religious
philosophy is so unfortunate as to make it
impossible for atheists to expect any favor
of (iod that sad plight should entitle them
all the more to considerate treatment by their
fellowmen.
.And by what process of propriety can any
individual in this country of religious free-
>24
SOOTHERN MEWCINE AND SURGERY
October, 1929
dom be questioned in a court-room about his
religion of his irreligion?
Thomas Carlyle, I believe, said that one's
religion is what one really believes — or dis-
believes.
Emotional Ups and Downs
That a drop or an elevation in the feeling-
tone may be so marked as to constitute dis-
ease does not seem to be known, even by
physicians. The changes in the temperature
of the atmosphere are scarcely more varied
than are the feelings of a human being. Much
sorrow, suffering and infinite tragedy arise
out of those departures from the normal feel-
ing plane. Almost invariably there are asso-
ciated with emotional depression wretched-
ness, despair and hopelessness, and a strong
inclination to bring one's own life to a ter-
mination. On the other hand, elevation of
the feeling-tone well above the normal level
is accompanied by many evidences in behav-
ior of lack of the normal degree of inhibitory
restraint, with all the excesses that poor judg-
ment makes pnassible. All those individuals
whose emotional activity is appreciably low-
ered may be spoken of as depressed. The
first exhibitions of elevation are elation, with
a fine feeling of well-being; but pronounced
elevation leads into mania. Internists — many
of them — continue to be unable or unwilling
to believe that consequential sickness can
arise except through disease of some organ
of the body. But it must be true that at
least half the patients who find their way to
the diagnostician are not organically diseased
at all: most of them are only functionally dis-
ordered, and the disorder lies in the domain
of the emotions.
The most pronounced sub-thyroid state
can not evolve a depression more mark-
ed than that which accompanies melancholia
or the depressive phase of a manic-depressive
psychosis; while mania, in the other direc-
tion, can liberate a behavior as wild and as
disorderly as the extremest alcoholic intoxi-
cation or the delirium arising out of the most
virulent infection. But in between profound
depression, on the one hand, and violent
mania on the other hand, there is an infinite
variety of feeling abnormalities that make
individuals a nuisance either to themselves
or to others. The depressed introvert who
misinterprets Jjis bad feeling state as an evi-
dence of organic disease is apt to be miser-
able himself: the mildly exhilarated person,
whose elevation simply persistently intoxi-
cates him sufficiently to make his world seem
to be a paradise, is certain to be a nuisance
to all his acquaintances. But the internist
has not yet learned that many of his com-
plaining patients are only emotionally de-
pressed and not organically diseased, and
that many other individuals, who feel the
urge to do the work of two or three pjersons
and whose judgment about their own output
is highly favorable, are in that other phase
of the manic-depressive situation: they are
elevated, mildly maniacal.
In the Annals oj Internal Medicine for
September is published the paper read before
the American College of Physicians in Boston
last April by Dr. Lewellys F. Barker on "The
jNIilder Aftective Disorders." In this cate-
gory he embraces all' those pathological dis-
turbances of the feeling-tone, the mood, and
the emotional life of patients. The life his-
tories of five patients were reviewed. Even
though a careful physical survey brings to
light evidences of infection or other sort of
disease, the conclusion is reached that the
feeling state is of more profound origin and
that surgical intervention or chemical therapy
do not go far in the way of bringing about
restoration. Dr. Barker properly calls atten-
tion to the danger of attempts at suicide even
in those who seem to be only mildly depress-
ed. It is not amiss for me to add that the
danger from suicide is greater in mild de-
pression than in the deeper degrees. Great
depression often robs the individual of all
initiative, in consequence of which, at the
deepest level of the despwndency, practically
all voluntary activity is absent. But, as the
individual is sinking into profound despond-
ency, or is emerging from it, then he is ex-
ceedingly likely to end his unbearable suffer-
ing by ending his life. Consequently, intern-
ists, who are without psychiatric training,
should be alive to this danger in their work
with despondent introverts. And such intro-
spectives, who are altogether materialistic in
their medical philosophy, occasionally, either
wittingly or unwittingly, induce an unwary
or a conscienceless surgeon (if there be any
such) to remove a healthy appendix or to
manipulate some other robust organ. Many
manic-depressives undoubtedly go through
October, 1929
SOUTHERN MEDICINE AND SURGERV
?i5
the tortures of repeated operations probably
because the attendant physical suffering
brings temporary diversion from the more
agonizing emotional distress.
The conclusion of Dr. Barker's admirable,
brief paper would seem to be that mind exer-
cises its influence over matter, and that such
a theory is capable of demonstration daily in
the offices of all internists and surgeons.
PEDIATRICS
For this issue, G. \V. Kutscher, jr., M.D.
Swannanoa, N. C.
Impetigo Contagiosa
Schools have opened again and are now
well under way. The annual crop of impe-
tigo contagiosa has also started in, and to
one doing e.xaminations of school children
this year's crop of the disease seems plentiful.
The average physician shrinks from diagnos-
ing all but a few diseases of the skin. As
small as any such armamentarium might be,
it should include impetigo. This disease is
one of the simplest of accurate diagnosis.
Beginning as a small papule, in a few
hours the papule becoming filled with a clear
fluid, then changing to a pustule, the disease
is readily diagnosed. The following day the
pustule is usually broken and a yellow crust
forms over the lesion. The base of the lesion
is erythematous and weeping, the size in-
creases as does the overlying crust. Multi-
plicity of the lesions over distant areas of the
body is another diagnostic help. This dis-
semination is due to the pruritus causing the
patient to scratch and then to carry the caus-
ative agent to another site.
The etiology of imjjetigo seems to be under
dispute; whether it is of parasitic or bacte-
rial origin makes little difference. The treat-
ment is comparatively simple in early uncom-
plicated cases.
The frequent use of a hand scrub to cleanse
beneath the finger nails is of paramount im-
portance. The next step is advising the use
of separate wash cloths and towels. Soak the
crusts off with a warm oily compress, using
olive oil, castor oil, wesson oil or any other
available oil. When the crusts have been
removed apply 6 to 10 per cent ammoniated
mercury ointment 6 to 8 times daily. Do
not bandage. Ultraviolet ray treatment used
in conjunction with the mercury ointment will
rapidly hasten a complete cure.
Xo attempt has been made to present the
subject in a scientific manner. Drawing at-
tention to the subject at this time is all that
is anticipated. Many school teachers are to-
day buying ammoniated mercury ointment
and applymg it themselves to their pup Is.
Impetigo of the face is a hideous sight which
probably prompts the teacher to do some-
thing for her pupils. It seems that the pa-
rents have exhausted all the home remediej
with no results, and because the disease does
not incapacitate the child, he is allowed to
"wear it out."
EYE, EAR AND THROAT
For this issue, V. K. Hart, M.U.
Charlotte, N. C.
Obscure Oral Bleeding: Its Endoscopic
Importance
Bleeding from frank and easily demon-
strated pathology of the gastro-intestinal
tract, of course, does not come under the
above heading, viz., gastric or duodenal ulcer.
There occur, however, cases of hematemesis
or hemoptysis where the cause is not demon-
strable even with intensive x-ray study.
In such category is a small peptic ulcer of
the esophagus. Likewise an esophageal varix
or gumma may be put in the same class.
Occasionally an ordinary esophagitis will
produce some bleeding.
Such obscure conditions may temporarily
puzzle the medical man or surgeon. An
esophagoscopy, however, quickly and easily
done under local anesthesia, will reveal any
of the above conditions. In the case of the
ulcer a biopsy may be done if malignancy is
suspected.
Of primary importance in bleeding from
the respiratory tract is tuberculosis. A pul-
monary lesion sufficiently advanced to give
bleeding is usually quickly found on physi-
cal examination, or x-ray, or both. Tubercu-
losis of the larynx is seen easily with a mir-
ror. Rarely a tuberculosis of the trachea
occurs, evinced endoscopically and by tissue
examination.
Hemoptysis may occur due to new growths
(non-s|)ecific) in the larynx, trachea, or
bronchi. Fungi occasionally attack the res-
piratory tract with production of areas of
ulceration, (iranulation tissue from long
contained lung foreign bodies bleeds easily.
Bronchoscopy under local anesthesia allows
>26
SOUTHERN MEDICINE AND SURGERY
October, 19^9
direct vision of the pathology, sections to be
taken for study, or secretions to be aspirated
for bacteriologic study.
These endoscopic aids in diagnosis are now
of every-day occurrence. Failure to use them
when indicated is not giving the patient the
benefit of up-to-date medicine. If necessary,
both esophagoscopy and bronchoscopy may
be done at the same time with no great in-
convenience to the patient.
ORTHOPEDIC SURGERY
O. L. Miller, M.D., Editor
Charlotte, N. C.
Dr. Nachlas' Letter on American Orth-
PEDic Association's Meeting With
British Association
The annual meeting of the .'\merican
Orthopedic Association was held this year in
England. The British Orthopedic Associa-
tion was host to the Americans. About sev-
enty members made the trip across and Dr.
W. I. Nachlas of Baltimore very kindly
agreed to report something on the meeting
for this department of Southern Medicine &
Surgery.
His comprehensive letter follows.
Dear Dr. Miller:
I am enclosing the resume of our Euro-
pean trip that you asked for. Needless to
say, one can hardly congregate in so short a
paper the numerous details and interests
brought out by such a meeting. I am not at
all sure that it will look well in print. I can
say, however, that it will hurt no one's feel-
ings.
Though officially scheduled to begin on
July 4th, the pilgrimage of the .'\merican
Orthopedic Association to England actually
began in Liverpool on July 3rd. There, un-
der the hospitality of Sir Robert Jones, the
members of the association met at the Mt.
Pleasant Medical Institution. The clinic be-
gan with a classical discussion on "Fractures
and Bone Setting," delivered by Sir Robert
in his interesting and delightful manner. The
two hours that elapsed from the beginning of
this discussion until it was through held the
continued interest of all present. Beginning
with a general discussion of the handling of
fractures. Sir Robert called attention to the
rarity of occasions when open operations are
necessary. The speaker presented such fun-
damental principles as the complications that
follow malunion in angulation, contrasted
with the satisfactory results obtained with
fractures that heal in parallel alignment al-
though some overlapping is present. He
stressed the importance of early reduction.
Attention was called to the frequency with
which delayed union occurs and warnings
were given to avoid operation for such con-
ditions which would ultimately heal of their
own accord. The application of these general
principles to specific bony injuries followed.
Following Sir Robert's talk, Mr.i T. R. "W.
Armour spoke on "Hallu.x V^algus," JNIr. B.
L. MacFarland on "Fractures of Lower Tibial
Epiphysis" and Mr. Watson Jones on "Pri-
mary Nerve Lesions in Injuries of the Wrist
and Elbow." A luncheon given by Sir Rob-
ert was followed by an operative clinic under
Sir Robert Jones and Mr. T. P. ]\IcMurray
at the Northern Hospital. After this there
was a demonstration of cases including con-
genital dislocation of the hip treated by open
and closed method, club feet, paralytic foot
deformities and other cases of special interest.
The entire day under the direction of the
orthopedic master and his associates proved
delightfully instructive.
The official meeting of the British and
American Association in London began on
July 4th at the Royal Society of Medicine.
The opening of tlie meeting by Professor E.
Hey Groves, the president of the British
Orthopedic .Association, was followed by an
address by Dr. Fred Albee, president of the
American Orthopedic Association. The reg-
ular program began with a discussion of the
"Treatment of Fractures of the Neck of the
Femur with special reference to the End-
Results." With such authorities as Hey
Groves, Royal Whitman, Obenshaw, Tubby,
Albee and others to help the discussion on
this important subject, an excellent survey
of the various types of treatment and their
efficacy was afforded the audience. While no
final conclusions were reached officially, it
might be noted that there was strong senti-
ment in favor of the closed abduction treat-
ment as described by Whitman. Professor
Putti continued the program with a lecture
on the "Early Treatment of Congenital Dis-
location of the Hip." He called attention
to the advisability of recognizing the dislo-
cated hip joints before the patient begins to
walk. Treatment at that time is relatively
October, 1929
SOUTHERN MEDICINE AND SURGERY
in
simple and efficacious. Various points of
diagnostic aid were presented and illustrated
by lantern slides. This paper was followed
by a scholarly paper on "The Basic Princi-
ples Involved in the Treatment of the Com-
mon Spinal Conditions as well as the Func-
tioning of the Viscera," by Dr. Joel E. Gold-
thwaite. That evening at a reception given
at the Royal College of Surgeons, Sir Arthur
Keith and Lord Moynihan presented very
interesting facts on early medicine and the
Hunterian display available in the museum.
The next morning was devoted to a dis-
cussion of "Reconstructive Surgery in Para-
lytic Deformities of the Leg." The discus-
sions were entered into with considerable
vigor by Americans and British alike. In
general the discussion may be summarized by
noting that there seems to have been a dis-
tinct tendency on the part of orthopedists to
discard the muscle transplant in favor of
bone stabilization. This is particularly true
of the American surgeon. The afternoon was
spent in various hospitals such as Guy's,
King's, St. Bartholomew's and St. Thomas's,
where operative, clinical, and pathological
demonstrations were given. The Association
banquet that night served further to cement
the friendship that had been begun during
the precedmg days. The final session of the
meeting consisted of the presentation of a
number of short paf)ers by members of the
American Orthopedic Association. Brackett
spoke on "The Treatment of Disabilities Re-
sulting from Low Back Derangement," Orr
on "Defects in ^lodern Antiseptic ^Methods
as .Applied Especially to Infections of Bones
and Joints, " Campbell on "End Results in
Operation for Drop Foot," Steindler on
"Compensation Treatment of Scoliosis" and
Kidner on "Pre-Hallux in Flat Foot.'"
The combined meeting of the two societies
was distinctly a success. Aside from the fact
that it brought together the leaders of the
orthopedic surgery of two of the largest coun-
tries for the purpose of furthering a common
interest, it succeeded in giving each group
the point of view held by the other. The
broader aspect permitted by this closer co-
i)[)eration will undoubtedly prove helpful in
the improvement of orthopedic study and
practice.
It is hoped that the future will see many
more such congresses.
Wm. I. Nachlas.
1. Generally, in England, the students of surgery
take the Master's degree. — M. Ch. — rather than the
Doctor's.
UROLOGY
For this issue Rdiium W. McKay, M.D.
Ciarlotte, N. C
Prostatic Abscess
The great Osier once said to a class of
medical students that the difference between
a good doctor and a poor doctor lay in the
fact that a good doctor made an intelligent
rectal examination, while the poor doctor
made none at all. The purpose of this state-
ment, probably, was to impress upon the
medical student's mind the necessity of de-
tailed examination in making a diagnosis.
However, one is constantly confronted with
the fact that in the practice of medicine, very
few doctors explore the rectum as a part of
the routine physical examination. This is
especially true in those cases which run an
unexplained fever, as frequently a rectal ex-
amination would disclose the prostate as being
the offending organ.
Prostatic abscess occurs either from direct
extension of the organism into the gland
through the prostatic ducts after involvement
of the prostatic urethra has taken place, or
it is the result of local metastatic implanta-
tion of organisms from the blood stream.
Naturally, a great majority of direct ex-
tension abscesses of the prostate gland are
gonococcal in origin, occurring in the course
of a posterior gonorrheal urethritis. However,
they may be secondary to infection of the
prostatic urethra by organisms other than
the gonococcus. Such organisms usually
have their origin in the upper urinary tract.
The metastatic type of abscess is more
serious than the gonococcal. The offending
organism in this type of involvement is
usually Staphylococcus aureus and occurs
with localized staphylococcus infections else-
where in the patient, such as boils, carbun-
cles, osteomyelitis or infected tonsils. Fre-
quently a rectal e.xamination will disclose the
cause for the continued systemic evidences
of non-draining infection.
A number of cases are reported in the lit-
erature of typhoid fever, in which the recov-
ery of the patient was prolonged and the
fii
SOUTHERN MEDICINE AND SURGERY
September, 1929
problem was finally solved by a rectal exam-
ination which revealed typhoid abscess of the
prostate.
It should be stressed that not always does
the patient who has a metastatic type of ab-
scess have urinary symptoms. If the abscess
is deep in the substance of the gland, well
away from the mucous membrane lining the
prostatic urethra, it may not produce any
urinary symptoms at all, and the urine may
be even free of pus cells. Usually, however,
the patient does manifest symptoms relative
to a posterior urethritis, as dysuria, fre-
quency and burning on urination. Early in
a large number of cases information of value
may be gained by a rectal e.xamination. If
the abscess points toward the lumen of the
urethra and tends to encroach on it, great
difficulty in urination will be immediately
experienced, very frequently leading to com-
plete retention of the urine. So frequently
does prostatic abscess cause complete reten-
tion in young males, that it has become al-
most an axiom among urologists to first think
of prostatic abscess in a young man, under
the hypertrophy age, who suddenly develops
complete retention. It requires only slight
interference at the vesical neck to completely
cut off the flow. The patient with an almost
filiform stricture of his pendulous urethra, if
given enough time, will empty his bladder,
but the slightest encroachment on the lumen
of the prostatic urethra or region of the in-
ternal sphincter will immediately make uri-
nation difficult, or impossible.
To diagnose abscess of the prostate gland
is usually not very difficult. There are pres-
ent, of course, the systemic symptoms of in-
fection, as fever, leucocytosis, etc. The fin-
ger introduced into the rectum feels the pros-
tate to be larger than normal; the enlarge-
ment may be bilateral and symmetrical or
confined to one lobe; the gland is tender,
smooth, and, if the abscess has progressed
far enough, fluctuation will be made out.
It is important to emphasize the fact that
the digital examination should be done with
as little discomfort to the patient as possible,
for undoubtedly, many prostatic abscesses
are produced by rough rectal examination or
by enthusiastic, injudicious prostatic massage,
carried out too early in the course of an in-
fection. The trauma of a vigorous massage
of the prostate gland in the presence of an
acute infection, certainly produces a local-
ized area of lessened resistance.
The differential diagnosis between an acute
diffuse gonorrheal prostatitis and a prostatic
abscess is rendered difficult at times by the
fact that the abscess may be localized in the
portion of the prostate farthest from the ex-
amining finger, namely, near the floor of the
urethra. At times it is quite difficult to dif-
ferentiate this condition from abscess of
Cowper's glands or an abscess of rectal origin
lying in the space between the rectum and
prostate. There should be no difficulty in
distinguishing it from other conditions caus-
ing enlargement of the prostate, such as ade-
noma, carcinoma and peri-prostatic neo-
plasms.
Tuberculous infections of the seminal tract
with resulting cold abscesses will not be dis-
cussed. They should, however, offer no dif-
ficult problem in differential diagnosis.
Prostatic abscess should be drained, as
should any abscess occurring elsewhere in the
body.
-An acutely inflamed, enlarged, tender, non-
fluctuating prostate should have palliative
treatment. The patient should be put at
complete rest and no medication should be
given by urethra. Hot rectal douches are
given every three to four hours and some
bladder sedative should be given by mouth.
If under this treatment the inflammatory re-
action of the prostate subsides the patient is
indeed fortunate. However, in a large num-
ber of cases, if a systematic series of rectal
examinations are carried out, the presence of
fluctuation will gradually be detected.
With the advent of fluctuation the problem
changes from a medical to a surgical one. If
let alone the abscess will rupture into the
urethra, or, if it pwints posteriorly, it will
rupture retrovesically, maybe into the rectum
itself. In either event the condition produced
by its rupture into either the urethra or rec-
tum is a serious one. We have recently re-
ported a number of such cases of rupture of
prostatic abscesses into the urethra as the
cause of diverticula of the posterior urethra,
.^fter the abscess has ruptured, there is left a
dependent non-draining pus-filled cavity, ly-
ing adjacent to the internal sphincter and
trigone, which tends to opening the
internal sphincter and thus initiating
the act of urination. Diverticula of the
October, 1929
SOUTHERN MEDICINE AND SURGERY
posterior urethra, produced in this man-
ner, interfere greatly with the normal
action of the verumontanum, and the
well known picture of sexual neurasthenia is
produced. Those pointing posteriorly and
lupturing into the lumen of the rectum pro-
duce that bane of the life of every urologist,
recto-uielhral fistula. To any surgeon who
has gone through the laborious surgical pro-
cedures necessary to close a recto-uiethral
fistula, there constantly recurs the question,
"Why was not the abscess properly drained?"
To evacuate the contents of the abscess
cavity several different procedures may be
carried out. Perhaps the oldest method is
to forcibly press down upon the fluctuating
prostate, per rectum and pray that it will
rupture into the urethra and not into the
retro-prostatic or recto-vesical space. This
method is mentioned only to be condemned.
\ few years ago, there was brought out
what is known as the Bellevue treatment. A
sound is passed into the bladder and, with
one finger in the rectum, the sound is reversed
so that the pointed end comes in contact
with the floor of the urethra, and an attempt
is made to perforate the abscess cavity by ma-
nipulating the point. This procedure is done
blindly and it does not seem necessary to
emphasize its dangers. When it is successful
the condition resulting is essentially the same
as that occurring when the abscess runtures
spontaneously into the urethra.
.Another method, probably suggested from
the introduction of radium needles into car-
cinoma of the prostate, is to place one finger
into the rectum as a guide and, after cocain-
izing the skin, pass a large hypodermic needle
into the abscess cavity, through the perineum
and aspirate its contents. Those surgeons
who have attempted to treat perinephritic
abscesses by the aspiration method will not
be very enthusiastic over this procedure.
The most logical manner of attack is to
diain the abscess perineally. Various refine-
ments of technique and methods of approach
have been advocated. Our choice is to effect
drainage by using a similar approach to that
employed in perineal prostatectomy. /\n in-
cision is made through the skin encircling the
rectum, the central tendon divided and, with
blunt and sharp dissection, the rectum is
stripped from the posterior surface of the
prostate. In large abscesses, it is frequently
advantageous, while stripping the rectum off,
to use one finger in the rectum as a guide to
prevent opening the rectum. When the pos-
terior surlace ot the prostate is seen, the incis-
ion to open the abscess cavity should be made
well av.ay fn,m ihi m;d!an line to avoid the
Uiethr.i. A sou^.d with a long curve or some
form oi long prostatic tractor is usually first
p.issed in tn? u.ethra to stabilize the gland
and to act as a gu.de. The abscess cavity is
always multilocular and the finger should be
introduced into it to break up the septa. A
small rubber drainage tube is then placed in
the abscess cavity and sewed with plain cat-
gut to the prostatic capsule. This is brought
out one lateral corner of the skin incision.
The object of the operation is to insure the
ma.ximum of dependent drainage; therefore,
we do not attempt to bring the levator mus-
cles together. If there is too much bleeding,
the cavity may be packed with a strip of
iodoform gauze and this brought out the
perineum, along the side of the rubber tubing.
The skin and subcutaneous tissues are then
closed loosely with interrupted sutures of silk-
worm gut. If iodoform gauze packing has
been used it is removed at the expiration of
two days. The abscess cavity is irrigated
through the tube with one-half per cent mer-
curochrome or other suitable antiseptic and
the tube gradually withdrawn. By using this
method of drainage, unless the abscess has
already ruptured into the prostatic urethra,
there should be no drainage of urine through
the perineal incision, if sufficient care is ta-
ken not to damage the urethra during the
operation.
The entire perineal operation is routinely
done under caudal anesthesia, 25 c.c. of two
per cent solution of procain injected through
the sacral hiatus, outside the dura. This has
proven highly effective and satisfactory and
is fast becoming the routine method of anes-
thesia employed in all prostatic and perineal
surgery. There is no dancer of incontinence
as the sphincters are not damaged.
The patient is able to sit up in a chair
about the third day, the stitches are removed
on the sixth or seventh day and he should be
ambulatory and out of the hospital, barring
other complications, in one week.
It is a very interesting fact, to those doing
SOUTHERN MEDICINE AND SURGERY
October, 1Q29
perineal prostatectomy for hypertrophy, that
loss of sexual power seldom occurs in patients
who have been operated on perineally for
prostatic abscess, although quite a large por-
tion of the gland itself may have been de-
stroyed by the condition.
A number of patients with senile hypertro-
phy of the prostate will run a septic fever
during the period of their preparation for
operation. This is frequently explained by
finding pus, localized between the true cap-
sule of the prostate and the adenomatous tis-
sue. Thus frequently the perineal prostatec-
tomy is followed by a fall in the fever
that the patient has constantly had. The de-
pendent drainage in such cases is very advan-
tageous.
In metastatic abscesses of the prostate em- .
phasis should be laid on the necessity of fre-
quent blood cultures and, if there are organ-
isms present in the blood stream, vigorous
intravenous therapy should be used to com-
bat the condition.
Before the patient has been discharged, a
routine examination of the prostatic urethra
should be carried out with the cysto-urethro-
scope. Naturally, any remaining infection in
the lower urinary tract should be overcome
by the proper treatment.
We wish to emphasize the following
points:
1. Necessity of intelligent rectal examina-
tion in unexplained fever and as a routine
procedure in infection of the urinary tract.
2. No force should be used in the rectal
examination, neither should massage be car-
ried out in an acutely inflamed prostate.
3. Acute infections of the prostate without
fluctuation should be treated palliatively as
described above.
4. When definite fluctuation occurs, the
prostate should be drained surgically. The
best method to be employed is some form of
dependent extra-urethral perineal drainage.
INTERNAL MEDICINE
Paul H. Ringer, A.B., M.D., Editor
A^iheville, N. C.
Nephrosis
In the Journal oj the A. M. A. of July 6,
1929, is a most interesting paper from the
pen of Dr. Henry A. Christian, Professor of
Medicine at Harvard, on the subject of
nephrosis.
While it is twenty-four years since Fried-
rich Mueller first suggested the word "neph-
rosis," it is only very recently that the sub-
ject has commanded very much attention.
Mueller suggested the word to signify degen-
erative renal changes, whereas the more com-
monly used "nephritis" denoted inflammatory
and proliferative kidney changes.
Dr. Christian entitles his article "A Cri-
tique," and diagnoses the situation with the
clarity and directness which is characteristic
of all his publications. He gives as the char-
acteristic symptoms of nephrosis the follow-
ing:
"Insidious onset, marked edema, decreased
basal metabolism, oliguria, marked albumi-
nuria, decreased blood proteins with relative
increase in globulin reversing the usual albu-
min: globulin ratio, lipo'demia ( hyoercholes-
tremia), good phenolsulphonphthale'n excre-
tion, no increase in non-protein nitrogen of
blood, cylindruria but no hematuria, doublv
refractile lipoid droplets in urine and normil
blood pressure. .^ number of observers re-
gard this cUnical syndrome as a general meta-
bolic disturbance rather than essentially a
disease of the kidney analogous to chronic
nephritis or Bright's disease."
There are very few cases of nephrosis that
have been followed through to their fatal
termination and upon which necropsy repxjrts
are available. There are patients with the
clinical syndrome of nephrosis but they are
few in number. Christian repxjrts from the
literature eighteen cases in adults with the
clinical course and postmortem observations
consistent with the diagnosis of nephrosis. In
these reports the average duration of the dis-
ease has been 8.8 months in these patients
from onset of edema to death. One wonders
about these patients, just how much of the
pathologic picture has been determined by
the elements of bacterial infection and what
would have been the appearance had the dis-
ease not been terminated after so brief a
course, brief in comparison with the majority
of kidneys that we have for study from pa-
tients with chronic nephritis.
Besides these cases, surprisingly few in
number when one considers the great interest
in the subject, the larger majority of patients
with nephrosis must have either recovered
completely or progressed under some other
clinical picture to an ultimate death, since so
very few autopsies have been reported in the
October, 1929
SOUTHERN MEDICINE AND SURGERY
literature.
Some authors describe in their cases of
nephrosis definite glomerular lesions and be-
lieve that, even in these patients dying early
with renal lesions essentially degenerative in
nature, there are evidences of glomerular le-
sions similar to those found in the earlier
stages of glomerular nephritis (Govaerts and
Cordier, iMcN'ee, possibly ISIcElroy). Then
(here are described mixed cases, in which
clinically and pathologically there are evi-
dences of both nephrosis and nephritis, cases
which seem to progress along the lines of los-
ing the clinical evidences of nephrosis and
gaining more and more of the clinical features
of glomerular nephritis
As one reviews the various reports of pa-
tients with the clinical syndrome of nephro-
sis, one gains the impression that two features
are strikingly common to all of these patients
in the earlier stages, edema and very marked
albuminuria, and that the rest of the features
of nephrosis come later. When the picture
is fully developed, an almost constant feature
is lowered blood protein, which is a reversal
of the albumin : globulin ratio of normal indi-
viduals. When one recalls the edema of star-
vation and that occasionally seen in perni-
cious anemia in the stage of severe anemia,
there might seem to be a correlation between
the lowered protein of the blood and the ede-
ma, an idea that numerous observers have
expressed in various ways and for which
there is some evidence already addured.
Dr. Christian concludes, as a result of his
'■tudies. that fundamentally there is no justi-
fication for regarding nephrosis as other than
a variety of kidney disease, a form of chronic
nephritis ( Bright'? disease). He has no par-
ticular objection to the term "nephrosis," but
sees no great advantage that it possesses
over the term he has used in his classification
<if nephritis — subacute or chronic nephritis
"ith edema. If used clinically, he thinks it
should be used as the name of a syndrome
occurring during the course of chronic ne-
phritis.
This brief but exceedingly able paper
should be read and studied by every man
interested in renal conditions. It brushes
away the cobwebs which are so apt to gather
in the minds of many of us, and presents the
case — not only of nephrosis but also of ne-
phritis— clearly and succinctly, and empha-
sizes the important [xiints, disregarding the
non-essentials, with that boldness which can
only be attempted by one who probably has
as profound and scientific a clinical knowl-
edge ol renal conditions as any medical man
of today.
OBSTETRICS
Henry J. La.ncsion, B.A., M.D., Editor
JJanvUle, Va.
Puerperal Infection
Puerperal infection is unquestionably one
of our biggest problems of today; it vitally
affects the reproduction of the species. The
total number of deaths in the registration
area of the U. S. in 1927 from puerperal sep-
ticemia was 5,353; from puerperal albuminu-
ria and convulsions 3,556, and from other
puerperal causes 3,472. In checking over the
records for 1925-6 we find that in 1926 there
were 4,484 deaths from puerperal septicemia;
3,091 from puerperal albuminuria and con-
vulsions, and 3,282 from other puerperal
causes; in 1925, 4,569 deaths from puerperal
septicemia; 3.256 from puerperal albuminu-
ria and convulsions, and 3,096 from other
puerperal causes. For this period of three
years these figures give us no encouragement.
We do not know the number of women who
died from these causes in the unregistered
area of the United States, but we can esti-
mate the number to be about 1.000 from
puerperal septicemia; probably 800 from
puerperal albuminuria and convulsions, and
about 800 to 1,000 from other puerperal
causes. This represents the number of wo
men who die from childbirth. The number
is large and is unquestionably a challenge to
the entire medical profession, not only to seek
out ways of prevention but means of cure.
We do not know how many women have
some form of puerperal infection which re-
sults in more or less permanent morbidities.
This group will add very materially to our
burden of prevention and permanent cures
and proper management of those cases with
an expensive long-drawn-out convalescence
from puerperal infection: for if these cases
are not looked after most carefully and
guardedly the result will be crippling for life.
Unquestionably many of these infections
are due to improper prenatal care. Patients
are brought to the hour of labor unprepared
for the ordeal and, because of poor physical
SOUTHERN MEDICINE AND SURGERY
October, 1929
condition and unpreparedness, they fall prey
to any strain of bacteria they may encounter.
Many physicians give very little thought to
the patient other than delivering her and
leave it entirely to nature to take care of her.
These cases should be more carefully guard-
ed than those in which the patient has had
the best preparation for labor: then our tech-
nique of delivery should be as nearly perfect
as it can possibly be made.
We have emphasized from time to time
the importance of prenatal care, so we feel
that at this point we need merely to mention
it again and stress the point, ''the most care-
ful and scientific prenatal care is the smallest
thing we can do in our work in human repro-
duction."
We can think of this condition fiom two
points of view:
1. Prophylactic treatment of puerperal in-
fection.
2. Active treatment of the condition after
we have it.
If the patient has done her duty and
the phys'cian has given most carefully the
proper advice, are ready for the fight with
any strain of bacteria that we may encoun-
ter.
Up until the present time we have not
been able to work out a satisfactory method
of treatment. A great many drugs have been
used: mercury in the vein, mercurochrome in
the vein, gentian violet in the vein. Some
of the physicians who have used these drugs
report satisfactory results, and some report
rather discouraging results. The probabilities
are that the best method of managing these
cases is as follows: Fowler's position: abund-
ance of fluids, by mouth, by rectum, by hy-
podermoclysis, or by vein: morphine to keep
the patient comfortable; digitalis to keep the
heart steady and regular: locally one or two
ice caps to the abdomen: carefully chosen
nurses: no company.
Some of us have obtained very fine results
by giving one to three hundred c.c. of blood
every day or every other day. This is probably
the best thing that we have done up until
now. We give this blood every day or every
other day until the symptoms have subsided.
Metaphen, manufactured by .Abbott Lab-
oratories, North Chicago, 111., has been used
by many with most gratifying results. We
have had occasion to use metaphen in two
patients, and for these two patients this prep-
aration worked beautifully. We are going
to test metaphen out and if the patients in
the future respond as the patients which we
have treated, we bslieve metaphen will help
us greatly in the treatment of puerperal in-
fection.
We cannot escape the fact that the total
number of deaths which we are having an-
nually from puerperal infection and the fact
that these deaths increased during this three-
year period we have reviewed; we have noth-
ing to encourage us. On the other hand, the
methods and management of these cases need
most careful study to find out why this in-
crease, and if we have an increase in deaths
we certainly have an increase in the number
of infections with the morbid conditions pro-
duced thereby. The indications are that the
1928 statistics are going to tell us that the
number of deaths from puerperal infection
in 1928 is greater than in 1927. The profes-
sion at large must seek out the causes and
remove them. W'e believe that we are going
to discover, first, that one of the biggest rea-
sons for so many puerperal infections is the
lack of prenatal care; and, second, that we
are not practicing the proper technique and
being perfectly clean in our deliveries, both
in the home and in the hospital; third, that
many of these infections are due to improper
treatment of the injuries to the mother — ex-
tensive wounds are left wide open and the
bacteria which constantly inhabit the vulva
and the vagina invade these open wounds as
fertile fields: and fourth, that too many phy-
sicians and midwives are paying no attention
to the puerperal period. .After the patient is
delivered she is left with her own physical
forces to take care of herself: she is given
no advice as to just what she should do dur-
ing the nine or ten days in bed, or as to how
she should take care of herself after the
lying-in period is over and she is up on her
feet. These patients, during the nine or ten
days in bed, should be seen regularly; breasts
watched and examined; abdomen felt of to
see if the uterus is involuting properly; atten-
tion should be paid to elimination by way
of kidneys and bowels and temperature should
be taken routinely: also pulse and respira-
tion. '*
The problem of puerperal infection is here
and it is big. The cost of the lives of young
October, 1929
AHaoaas oNv aNiDiaaw N^ianxnos
women is great; the expense that families
are put to is an economic burden; the cost
of hospitalization during these infections is
high; the morbid conditions of many women
whose trouble dates back to puerperal infec-
tion is enormous; and the problem is so big
and far-reaching that every physician who is
doing any obstetrics should be keyed up to
the point of doing nothing short of the very
best work, day in and day out, and calling
upon any and all of his fellow-practitioners
to help him with this problem. We can
stamp out puerperal infection to the point,
practically, of extinction. Our job is to do it.
It demands that we enlist all the forces of
education and all the branches of science, the
churches, the public at large and the profes-
sion in particular to re-study our results and
to correct our mistakes and thereby approach
scientific methods and management of all our
cases of labor. If we can do this, then we
may not only be able to stamp out infection
but to prevent the many morbid conditions
resultant on labor.
SURGERY
Geo. H. Bunch. M.D., Editor
Columbia. S. C.
.\ruTE Pancreatitis
Because of its inaccessible location in the
UDper abdomen back of the stomach and
transverse mesocolon, recognition bv surgeons
of the pancreas as the seat of disease was
rnmn^ratively late. Fitz of Boston in the
l\Irdicnl Record, 1889, first described acute
pTncreatitis. Even now, with the abdomen
onen. inexperienced operators mav not rec-
oi^n'ze the disease. Because of its sudden
onset, illimitable agony and hieh mortality
Movnihan describes it as being the most ter-
rible of all the calamities that occur in con-
nection with the abdominal viscera.
Infection of the pancreas in acute pan-
creatitis may come from the blond stream
or the Ivmphatics or it may develop from the
recursitation of infected bile or duodenal
contents into the pancreatic ducts. Eydall
found call-stones in half his cases and symp-
toms of infection of the gall-bladder in 75
per cent of them.
Jj'nder and Morse in Annals nf Surprrv
rSent.. 1929) report a studv in detail of 88
cases of acute pancreatitis. Ninetv-seven per
cent complained of constant intense epigas-
tric pain which extended to the right in 67
per cent and to the left in 40 per cent. In
19 per cent there was general abdominal pain
and in 66 jjer cent there was pain in the left
lumbar region. Forty per cent were cyanotic.
The temperature was normal in 29 cases; 28
cases were mildly jaundiced; 17 were in
shock on admission and 39 had general ab-
dominal distention. Vomiting was persistent
unless relieved by lavage. The pulse-rate
was high.
The preoperative diagnosis may often be
made with reasonable assurance if the possi-
bility of acute pancreatitis be remembered. It
may be differentiated from acute perforation
of duodenal or gastric ulcer by the history
of biliary infection, by the cyanosis, by the
rapid pulse and oy the profoundness of the
shock of onset. It may be distinguished from
acute intestinal obstruction by the non-pro-
pressive vomiting. In pancreatitis the stom-
ach when emptied by lavage remains empty.
In obstruction it refills. In acute cholecys-
titis there is a globular mass under the right
rib margin with tenderness in the epigastrium
or in the left costo-vertebral angle. In left
kidney colic the pain is referred towards the
genitals and down the thigh. The urinary
and cystoscopic findings differentiate it from
pancreatitis.
At laparotomy turbid odorless fluid fills
the peritoneal cavity. In acute hemorrhagic
pancreatitis the fluid is sanguineus. With
either there may be seen areas of fat necrosis
in the omentum from the digestion of the fat
by the escaping pancreatic exudate; these lit-
tle opaque areas are pathognomonic of the
disease. The pancreas is swollen, boggy and
edematous. It be partially gangrenous.
The treatment is surgical and consists of
early drainage of this as of any other acute
phlegmon. The pancreas may be exposed
through the gastro-hepatic omentum or
through the gastro-colic omentum. We pre-
fer exposure through the transverse meso-
colon after the transverse colon has been de-
livered and the posterior wall of the stomach
exposed as is done in posterior gastro-enter-
ostomy. There is no true capsule of the
pancreas; its peritoneal covering should be
carefully incised with scissors almost from
one end of the gland to the other. Contrary
to what might be expected there is but little
bleeding and this is readily controlled by the
SOUTHERN MEDICINE AND SURGERY
October, 1929
rubber protected gauze pack that is used for
drainage.
After operation food should not be given
for four or five days. Glucose intravenously
and salt solution subcutaneously should be
given to support the patient and to prevent
dehydration. After the drain has been re-
moved many of these wounds discharge
pieces of necrotic pancreas for weeks. While
active suppuration of the gland continues
the patient becomes very weak and emaciat-
ed and has high fever. One young married
woman lived four weeks after operation, with
fever and progressive loss of weight. Massive
hemorrhage from the wound caused her death
in spite of blood transfusion. Autopsy show-
ed the entire pancreas sloughing and necrotic.
Even with e.xtensive destruction of the gland
we have never seen glycosuria.
We believe that the 50 per cent mortality
of acute pancreatitis can be materially re-
duced by the use of spinal anesthesia at oper-
ation.
NEUROLOGY
Olin B. Chajiberlain-, M.D., Editor
Charleston, S. C.
Impressions From National •Hospital
(Neurologic), London
The editor of this department has had the
opportunity, during the past summer, of
working in the National Hospital, Queen
Square, London. This comparatively small
hospital, of 250 beds, has long been the cen-
ter of neurological study in England. Found-
ed during the last half of the nineteenth cen-
tury, it became the working-place of Hugh-
lings Jackson and Sir William Gowers, who
made English clinical neurology so famous.
In the writer's possession is a "Manual of
the Diseases of the Nervous System" by Gow-
ers, published in 1891. On one of the fly
pages in front is this quoted review from the
American Journal of the Medical Sciences.
"It may be said, without reserve, that this
work is the most clear, concise, and complete
text-book upon diseases of the nervous system
in any language. -And when the large num-
ber of such works which have appeared in
Germany, France and England within the
past ten years is considered, this implies high
praise."
As to Jackson, every time we speak of
Tacksonian epilepsy we pay homage to his
keenness of observation. Not only a finished
clinician, but a medical philosopher as well,
he advanced the idea of levels of activity of
the nervous system, a concept just lately be-
ginning to have its full appreciation.
If one goes into the record room of the
hospital, there will be seen row after row of
large books, each containing the charts of
former years, arranged as to the visiting phy-
sicians. In the '80s and '90s the two names
just alluded to stand out. Then one sees the
charts of Bostian and Ferrier. Bostian's law,
which had to do with the reactions of a to-
tally severed human cord, was only over-
thrown, in its full enunciation at least, by
the observations of the Great War. And so,
as we look over the record books we see that
this hospital has been the proving ground for
English neurology.
The present staff has a tradition to uphold,
and it does so most admirably. Gordon
Holmes, an inspired teacher, an indefatigable
student, and an outstanding clinician, is the
most popular figure with visiting students.
James Collier, Grainger Stewart, Hinds How-
ell are names familiar to every student in
neurology. Kinnier Wilson, Walshe, Rid-
dock, .\die have made material contributions.
Indeed it is a remarkable tribute to the visit-
ing staff of this small hospital to be able to
state that out of a total of 27 English con-
tributors to two famous systems of medicine,
10 are on the staff of the National Hospital.
Now, as to the impression made on a visit-
ing .\merican who, in the capacity of clinical
clerk, was able for a few months to take part
in the work of this hospital with its staff of
keen neurologists. The first continuous and
final impression is the thorough and detailed
knowledge of medical science possessed by
these men. The term "medical science'' is
used purposely and advisedly. They are not
merely clinical neurologists. One is forcibly
reminded of the words of Francis Bacon. "I
have taken all knowledge for my province."
They are thorough and at the same time ver-
satile. The pre-clinical sciences of anatomy,
bacteriology and pathology form an integral
part of their working equipment. It is an
inspiration and, it must be confessed, fills
one with a vivid sense of one's own shortcom-
ings, to hear Holmes comment on an in-pa-
tient, to see Walshe work out a sufferer in
the out-patient department. iMinute and de-
tailed questions of neuro-anatomy and neqrQ'
October, 1929
SOUTHERN MEDICINE AND SURGERY
V3S
pathology are brought out with illuminating
knowledge and confident acquaintance. There
is not the limitation to the clinical aspect
solely, which too frequently is evident in
American clinics. One does not hear "that
is a question for the anatomist," or, ''the
pathologists must decide that point." These
men are themselves anatomists and patholo-
gists and bacteriologists. And the visitor
comes away from a clinic or demonstration
with a feeling that the entire matter has been
as well covered as existing human knowledge
can cover it.
The material for study and teaching at the
National Hospital is unsurpassed. Attracted
by the brilliancy of its staff, the neurological
cases of not only Greater London, with its
8 million human beings, but of southern Eng-
land with many millions more, assemble at
its doors. Brain tumors, multiple sclerosis,
and the degenerative diseases of the cord fur-
nish perhaps the majority of the cases. One
sees in a few weeks' time, practically every
known neurological condition. It may be il-
lustrative to enumerate, from notes kept at
the time, the series of cases seen in an out-
patient clinic one afternoon: Myoclonic epi-
leosy, amyotrophic lateral sclerosis, two cases
of multiple sclerosis (called there dessimi-
nated sclerosis), tabes dorsalis, Parkinson's
disease following encephalitis, chorea, serra-
tus magnus palsy. Bell's palsy, multiple neu-
rit's (alcoholic), frontal lobe tumor, acoustic
nerve tumor, juvenile paresis, hereditary
cerebellar degeneration and narcolepsy. And
this array was by no means extraordinary.
.After this rather enthusiastic description
of the thoroughness of English clinical meth-
ods, and the high quality of their diagnostic
acumen, one must in all fairness state that,
in neuro-sureery, America is far in advance.
The writer dares not attempt a general criti-
cism of English surgery of the nervous sys-
tem. He can only say that the examnles seen
bv him would compare very unfavorablv with
those encountered in the average good .Xmeri-
can hosD'tal, to say nothing of such masters
PS Cush'ng in Boston and Dandv in Balti-
more. The reasons for this difference are
minyfold. and it ill befits a visiting Ameri-
cin who was uniformly treated with courtesv
• nnd consideration, to enter into an analysis
of the defects of English surgery. That these
defects e.Nist can hardly be argued, and it is
significant that the young Englishmen who
aspire to neuro-surgery, are more and more
coming to America to learn the technique of
their craft.
HISTORIC MEDICINE
For this issue, Oscar Fitzali.en' Nortiiincton, jr.,
.■\.M., LaCrosse, Va.
Doctor J.ames McClurg, of Virgini.a
Dr. James ilcClurg was born at Hamp-
ton, Elizabeth City County, Va., in 1746.
His father was Dr. Walter McClurg, a native
of England, who bore an excellent name as a
physician and as a man of affairs. Nothing
is known of Dr. James IVIcClurg's boyhood,
but it is supposed, from later events, that he
received excellent rearing, and a firm ground-
ing in the classics.
He entered William and ]\Iary in July,
1756, at the age of ten and withdrew October
4, 1757. He again matriculated on May 29,
1758. In 1762 he sailed for England on ac-
count of his health: he recovered quickly, for
he returned to William and Mary in time
to graduate on November 29, 1763. No
mention is made of Dr. !McClurg's scholastic
rating at William and Mary. Only one ref-
erence is made to his professors, namely, that
McClurg and Thomas Jefferson studied math-
ematics under Dr. Small in 1758. An inter-
esting sideliEfht is shed by a record that, in
176.?, Dr. McClurg and another student were
suspended from AVilliam and IMary from
October 6 until November 10 "for iniurious
behaviour to a family in town." Note that
this suspension ended only nineteen days be-
fore he graduated.
After graduating from William and ]Mary
James McClurg spent several years at the
University of Edinburgh, receiving his degree
in 1770. While a student at Edinburgh he
was noted for his intellect, and his thesis "De
Calore" set forth many advanced theories in
chemistry. From Edinburgh he went to Paris
to observe French methods, and in 1772 we
find him a practicing physician of London,
whose fame had been established by the pub-
lic-ition of a treatise entitled ".Xn Essay on
Bile."
In 1773, despite the remonstrances of his
London friends, he returned to Virginia,
where he settled in Williamsburg and be-
came one of the foremost medical authorities
in America. He became professor of medi-
SOUTHERN MEDICINE AND SURGERY
October, 1929
cine in William and Mary College in 1779;
the first chair of medicine in America. His
salary as a professor was eight hogsheads of
tobacco from the college and one hogshead
from each pupil he taught.
On May 22, of this same year, 1779, he
married the amiable Miss Seldon of Hamp-
ton. Two children were born of the mar-
riage; Walter, who died in his seventh year,
and Betsy, who married John Wickham of
Richmond.
He moved to Richmond in 1783 and be-
came one of the most prominent citizens of
the new capital. When Patrick Henry de-
clined to serve in the Constitutional Conven-
tion of 1787, Dr. McClurg was appointed to
fill the vacancy. He attended the convention
but, on account of private business, he was
not present at the adoption of the Constitu-
tion. Some writers credit Dr. McClung with
originating many of the conservative sections
of the constitution. This is plausible enough
when we recall that he was an ardent Tory.
He was killed when his horses ran away,
(in July 9, 1825. His body lies in St. John's
Churchyard in Richmond.
Dr. ^McClurg's work was in great part that
of a consulting physician; however, he was
one of the greatest anatomists of his day. He
was as learned in letters as in medicine, a bold
talker, a profound thinker, a laborious stu-
dent— gifted and intellectual.
In a long line of distinguished physicians
of the country. Dr. McClurg deservedly holds
a place of first rank.
.\ few further facts to give an idea of Dr.
McClurg's place in the community:
1. Received Master Mason degree from
Williamsburg Lodge in 1774.
2. Was one of Committee to choose Grand
Master of Masons in 1778.
3. Lost almost all of small servants when
Cornwallis occupied Williamsburg in 1781.-
4. Mentioned as present at faculty meet-
ings 1779-80-81-82-83.
5. In charge of military hospital of Vir-
ginia in 1778.
6. Member of Executive Council of Vir-
ginia, 1783-1793.
7. Received land grants for services to
Virginia.
8. Prominent in banking business in Rich-
mond: instrumental in having branch bank
of The Bank of the United States established
in Richmond in 1791.
9. Gained local popularity as a poet. The
best known poem, "Belles of Williamsburg,"
being circulated in 1777.
1. k related study by the same author, "The First
Century of Tobacco in Virginia," won the Society
of the Cincinnati Award (and Medal) for the 1928-
9 Session of William &• Mary College.
2. When Lord Cornwallis occupied Williamsburg
he confiscated much property; those of Dr. Mc-
Clurg's slaves, who could not escape to the woods
were carried off by the British Army.
BIBLIOGRAPHY
Vol. III. The National Cyclopaedia of American
Biography. Edited by Distinguished Biographers
and revised and approved by the most eminent His-
torians. Scholars, and Statesmen of the day. Jas. T.
White & Co., of New York, printers, 1S93.
The William and Mary College Quarterly and
Historical Magazine. Established in Julv, 1892.
Edited by Lyon Gardiner Tyler, M.A., LL.D., at
that time President of William and Marv College.
Vols. 1, 4, 7 ,S, 9, 10, 12, 14, 15, 16, 18, i9, 20, 21,
and 22.
The William and Mary Quarterly — Historical
Magazine — Second Series. Established 1921. Edited
by J. .\. C. Chandler and E. G. Swem. Published
quarterly by William and Mary College. Vols. 1, 5,
and 6.
The Virginia Magazine of History and Biographv.
Established 1893. Edited by Dr. Philip Alex. Bruce
and Dr. Wm. Stanard. Published quarterly by The
Virginia Historical Society. Richmond.
Clycopedia of Biography, Vol. II. Edited by
Lyon Gardiner Tyler, LL.D. Lewis Historical Pub-
lishing Company, New York.
Virginia Mcdica' and Surgical Journal for the
year 1854. Vol. II, p. 465-482 inclusive. Edited by
Drs. Otis and McCaw. Published in Richmond in
1854.
Curious Epitaphs
.\ Rh"dc Islander was buried under a stone mark-
ed cniv "This Is On Me."
Curtest and most significant of all is, perhaps, the
epitaph of a prize-fighter, buried in a London
church-yard. His grave is marked by the single
w^ord, "TIME."
The grave of the Rev. Thomas Morris, in Worces-
ter cathedral, England, is also inscribed with a single
word, "Miserrimus" — "Most wretched man."
Most satirical is Byron's epitaph for Pitt:
With death doomed to grapple
Beneath this cold slab, he
Who lied in the chapel
Now lies in the .\bbey.
One to be found in Richmond marks the grave of
a man whose "spirit returned to his Creator at the
White Sulphur Springs."
October, 1920
SOUTHERN MEDICINE AND SURGERY
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itie nox) /^ocke'JahoraTor/es af'Mutfey.necoJerjcy
IT was 'Roche* chemists, with their exacting skill
and unlimited facilities, who made possible the
6r8t use of digitalis by injection. Di^alen has long
been in extensive uae. Its use is world-wide. When-
ever the heart is still responsive to digitalis Digalen
maybe counted on to give prompt support. That is
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A trial villi for your bag on request
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SOUTHERN MEDICINE AND SURGERY
BOOK REVIEWS
October, 1929
MINOR SURGERY, by Frederick B. Christo-
pher, M.D., Associate in Surgery at Northwestern
University Medical School, Chicago. With a Fore-
word by Allen B. Kanavel, M.D., Professor of Sur-
gery, Northwestern University Medical School. Oc-
tavo of 694 pages with 465 illustrations. Philadel-
phia and London. W. B. Saunders Company, 1929.
Price $8.00 net.
Some surgeons have been known to say all
surgery is major. The author says "JNIinor
Surgery is the surgery which has a low mor-
tality; which requires but few assistants;
which is generally done in the out-patient de-
partment or in the office." All along he de-
lines his terms, and gives reasons. Illustra-
tions are abundant and well conceived and
executed. Emphasis on the importance of
faithfully caring for even minor conditions is
timely.
ACUTE INFECTIOUS DISEASES, by Jay Frank
Schamberg, A.B., M.D., Professor of Dermatology
and Syphilology in the Graduate School of Medicine,
University of Pennsylvania; CorrespondiVig Member
of the British, French and Danish Dermatological
Societies; Member of the German Dermatological
Society; and John A. Kolmer, M.Sc, M.D., Dr.P.
H., D.Sc., LL.D., Professor of Pathology and Bac-
teriology in the Graduate School of Medicine of
the University of Pennsylvania ; Head of the De-
partment of Pathology in the Research Institute of
Cutaneous Medicine. Second edition, thoroughly
revised, illustrated with 161 engravings and 27 full-
page plates. Lea and Febiger, Philadelphia, 1928.
.■SIO.OO.
Certainly no subject is of more general
interest to doctors than that of the acute
infectious diseases, and certainly it would be
impossible to think of authors more compe-
tent to deal with the subject. Each of the
authors is known both for his learning and
for his ability to set it forth. The pungent
style may be seen from a paragraph in the
preface: "It will be observed that consider-
able space is allotted to the subject of Vac-
cination. This is due to the unnecessarily
controversial character of the subject."
For knowledge to date of the most wide-
spread diseases, to the knowledge of which
additions are being constantly made, put out
after having been passed through minds
among the very ablest to separate the true
from the false, and then to express the true
forcefully, this treatise may be relied on with
confidence.
EDEMA AND ITS • TREATMENT, by Herman
Elwyn, M.D., Assistant Visiting Physician, Gouver-
neur Hospital. Tlie MacMillan Company, New
York, 1929 $2.50.
Attempts at explaining the causation of
edema have been legion. Until less than a
hundred years ago, under the name dropsy,
it was treated of as a disease entity.
The author departs from the usual con-
cept of edema as a resultant of abnormal in-
teraction of local chemical and physical
forces. He discusses the influence of electro-
lytes and nerves, central regulation, and the
influence of hormones; the edema of cardiac
disease, of nephritis, of nephrosis, of under-
nutrition. The final chapter, on treatment,
will prove of great help generally, for hardly
is there a medical man who does not fre-
quently encounter edema.
THE TRE.^TMENT OF DIABETES MELLI-
TUS WITH HIGHER CARBOHYDR.\TE DIETS:
h. Textbook for Physicians and Patients, by William
David Sansiim, M.S., M.D., F.A.C.P.; Percival Al-
len Gray, Ph.D.. M.D.; Ruth Bowden, B.S. Harper
and Brothers, New York, 1929. $2.50.
An attempt is made to point out means
by which fundamental dietetic rules even in
cases of diabetes, can be more closely ad-
hered to than is now generally done. Princi-
ples are clearly stated and dietary tables are
included in such number and variety as to be
most helpful.
TULAREMIA, History, Pathology, Diagnosis,
and Treatment, by Walter M. Simpson, M.S., M.D..
F.A.C.P., Director of the Diagnostic Laboratories,
Miami Valley Hospital, Dayton, Ohio; Formerly
Senior Instructor in Pathology, University of Mich-
igan ; Foreword by Edward Francis, Surgeon United
States Public Health Service. 53 text illustrations
and 2 colored plates. Paul B. Hoeber, Inc., New
York, 1929. $5.00.
The story of tularemia as told by Simpson
is a fascinating and stimulating chapter in
American medicine. Painstaking persever-
ence and willingness on the part of investiga-
October, 19^9
S6ttHEk^I MEDICINE AND SUkGEbV
h^
An Ancient Prejudice
Has Been Removed
''toasting
did it''-
Gone is that ancient
prejudice against
ciga rettes — Prog-
ress has been made.
We removed the
prejudice against
cigarettes when we
removed harmful
corrosive ACRIDS
{pungent irritants)
from the tobaccos.
YEARS ago, when cigarettes were made without the
aid of modern science, there originated that ancient
prejudice against all cigarettes. That criticism is no longer
justified.
"TOASTING," the
es fr
most modern step in cigarette manu-
LUCKY STRIKE harmful irritants
present
■igarettes manufactured in the old-
Everyone knows that heat purifies, and so "TOASTING"
— LUCKY STRIKE'S extra secret process — removes harm-
ful corrosive ACRIDS (pungent irritants) from LUCKIES
which in the old-fashioned manufacture of cigarettes cause
throat irritation and coughing. Thus "TOASTING" has
destroyed that ancient prejudice against cigarette smoking
by men and by women.
It's toasted"
TUNE IN-The Lucky Strike Dance Orch
P 1929. The Ainirknn Tnh.n.cn Co.. Mfr^
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?40
SOUTHERN MEDICINE AND SURGERY
October, 1929
tors to risk their own lives in the pursuit of
knowledge of disease are points of similarity
between this story and that of yellow fever.
The book is highly valuable not only as a
remarkable achievement in medical research,
but as a store of information on a disease
liable to be found in the practice of any doc-
tor.
A STUDY OF MASTURBATION AND THE
I'SYCHOSEXUAL LIFE, by John F. W. Meagher,
M.D., F.A.C.P., Neurologist to St. Mary's Hospital,
Brooklyn; Member of the American Psychiatric
Association, New York Neurological Society, etc.
2nd edition. William Wood & Co., New York, 1929.
$2.00.
A middle course is steered between the
teaching that all pathology has a se.xual basis,
and that which ignores or denies the import-
ance of the se.xual factor.
Cogent reasoning, based on extensive ob-
servation and mature reflection, is here ex-
pressed in wholesome teaching.
THE STRUGGLE FOR HEALTH, by Dr. Rich-
ard H. Hoffman. Illustrated. Horace l^iverighl,
New York, 1929.
The book opens with a speculation on the
circumstances of the origin of the Dawn-Man
and proceeds with his gradual and painful
advancement in knowledge of effective means
of defense and offense, of wise choice of foods
and places of shelter, knowledge essential
to the continuation of life. Only a step re-
moved at that time was a knowledge of how
to continue in health, for, where only the
strongest survived, one weakened for only a
short period succumbed.
The earliest ideas of religion are represent-
ed as having been born out of terror inspired
by illnesses and deaths which had no obvious
cause. The domestication of animals is at-
tributed to an idea on the part of some of
these early men that animals should not be
killed, but made companions of.
From an .American newspaper of 192 7 and
an Egyptian scroll of 1700 B. C. are quoted
extracts manifesting the same belief in the
cure of all manner of illness, casting off spells,
removing enemies, etc., etc., by magical for-
mulas, incantations and the like. The Ebers
papyrus, perhaps the oldest writing in exist-
ence, contains sentences strangely like Coue's,
"Every day and in every way." The whole
chapter "From Myth and Magic to Moses"
abounds in legends from all parts of the world
and speculations of the most entertaining
kind.
The survival of the Jews is attributed to
the sections on hygiene of the Mosaic law,
the principles having been learned from the
priests of a land into which all the world's
knowledge and wealth flowed because of its
never-failing grain crops, and then written
down as religious commandments which they
dared not disobey. The various plagues of
Egypt are accounted for in a way which must
appear a fanciful attempt to account for hap-
penings highly improbable in themselves.
The chapter "Twilight of the Gods" is
made up of Esculapian, Pythagorean and
Empedoclean myths and legends, and then,
with the advent of Hippocrates "The Sun
Rises in the West." Medical practice in Ire-
land at the hands of the Druid priests five
centuries B. C. takes up a few pages.
Rome is said to have got on well enough
without doctors for 600 years, and then the
first Greek doctors who came in were such a
lot of blunderers and plunderers as to inspire
few to regret the old ways. Their usefulness
as poisoners of enemies may have been very
great. Galen, as greatly as he has been ven-
erated, did far more harm by setting himself
up as a medical Pope than he did good by
the not inconsiderable advances he made in
medical art.
A chapter is devoted to Arabian Medicine,
under the title "Oasis," the next to "Brewing
Cauldrons and Brewing Storms," — terrible
epidemics of plague and syphilis. Other
chapters which are as interesting as their
names would imply are: "The Skeleton
Comes Out of the Closet," "Heart Interest
and Circulation," "Science Lays its Egg,"
"Science Cracks its Shell," "In the Arms of
Morpheus," "The Kindest Cut of All," "Reg-
ulators of Life," "The Soul Reveals Itself."
THE ESSENTIALS OF MEDICAL DIAGNO-
SIS: A Manual for Students and Practitioners, by
Sir Thomas Harder, Bart., K.C.V.O., M.D.. F.R.C.P.,
London. Physician in Ordinary to H. R. H. the
Prince of Wales, Physician to St. Bartholomew's
Hospital, and .4. E. Goiv. M.D., F.R.C.P., London,
Physician with Charge of Out-Patients and Demon-
...In the Management of Hemorrhoids
palliative treatment is generally directed to removing congestion
of the portal circulation and diminishing the size of the piles.
Applied as hot as can be comfortably borne, Antiphlogistine consti-
tutes a palliative par excellence in the alleviation of the pain,
inflammation, and distressing tenesmus caused by external piles.
The thermotherapeutic and bacteriostatic properties of
will prevent the development of ulceration, induce relaxation of the In-
flamed hemorrhoidal veins, relieve the discomfort due to local pressure and
thereby facilitate the normal act of defecation. Coupled with appropriate
diet and exercise, the routine application of this plastic dressing will usu-
ally suffice to yield positive results in the management of hemorrhoids.
Sample of Antiphlogistine and
Clinical Data mailed to the
Physician on request.
THE DENVER
CHEMICAL MFG. CO.,
163 Varick Street,
New York City.
^
>42
SOUTttEfeN MEt>iCl^fte AM) StmcfeftY
October, i9i9
strator of Practical Medicine at St. Bartholomew's
Hospital. S color and 11 black and white plates, 22
figures in the text, and S charts. William Wood &
Co., New York, 1929. $5.00.
In the Department of Neurology of this
issue of this journal, the Editor pays a great
compliment to the abilities of English clini-
cians. Such abilities are represented in this
work under review. The descriptions through-
out amply illustrate the truth of the adage,
all men can talk well on subjects on which
they are well informed. One instance only
will be cited, that of the description of the
technic of lumbar puncture. Every detail of
what to do, what not to do, and why?, is so
clearly described, as to make the description
entirely adequate preparation for undertak-
ing the procedure. A comparison with other
texts will demonstrate the rarity of these
qualities, — and they characterize the whole
work.
"What Characterizes a Functional Cardiac
Murmur"?, "Are the Apex Changes the First
Detectable Signs of Pulmonary Tuberculo-
sis"?
THE DOCTOR IN COURT, by Edward Hunt-
ington Williams, M.D. The Williams & Wilkins Co.,
Baltimore, 1929.
Dr. Wm. H. Taylor, for many years Pro-
fessor of Medical Jurisprudence in the Medi-
cal College of Virginia, said a doctor had
nothing to fear in court if he followed a few
simple rules: "Approximate nothing that can
be weighed or measured"; "Be sure you un-
derstand the question"; "When you don't
know say so and stick to it"; "In your deal-
ings with lawyers, follow the Scriptural ad-
monition 'Resist the devil and he will flee
from you.' "
"The Doctor in Court" is a post-graduate
course in the same school of thought, illus-
trated by numerous examples.
INTERNATIONAL CLINICS, A Quarterly of
Illustrated Clinical Lectures and Especially Prepared
Original Articles, edited by Henry W. Cattell, A.M.,
M.D. Vol. III. Thirty-ninth Series, 1929. /. B.
Lippincott Co., Philadelphia.
Features thought deserving sfiecial men-
tion are those on clinical applications of vita-
mines, control of hypertension, the spastic
colon, treatment of anemia, indications for
operative treatment of fractures, and a num-
ber of questionnaires on everyday medical
problems of such practice importance as
MATERIA MEDICA AND THERAPEUTICS,
Including Pharmacy and Pharmacology, by Reynold
Webb Wilcox, M.A., M.D., LL.D., D.C.L., Lieuten-
ant Colonel, Auxiliary Reserve, United States Army;
Professor of Medicine (retired) at the New York
Post-Graduate Medical School and Hospital. 12th
edition, revised in accordance with the United States
Pharmacopoea X and the National Formulary V
with an index of symptoms and diseases. P. Blakis-
ton's Son & Co., Inc., Philadelphia. $5.00.
Drug therapy has withstood the assaults of
skeptics, cynics and plain smart-alecks. Ac-
cumulated, carefully checked experience at
the bedside and improved facilities for lab-
oratory expyerimentation have separated the
valuable from the worthless, delimited the
fields of usefulness of the valuable, gone far
toward proving that drugs shall be of a defi-
nite potency, and added new elements to our
armamentarium.
Wilcox has come through all this to his
12th edition, and through wise evaluation
has subtracted on the one hand and added
on the other, to provide a dependable guide
in therapy.
EXPERIMENTS .AND OBSERVATIONS ON
THE G.ASTRIC JUICE AND THE PHYSIOLOGY
OF DIGESTION, by William Beaumont, M.D.
Surgeon in the United States .'\rmy. Facsimile of
the original edition of 1833 together with a bio-
graphical essay, A. Pioneer American Physiologist,
by Sir William Osier. Harvard University Press,
Cambridge, 1929. $3.00.
Osier says the meeting of the oppor-
tunity— Alexis St. Martin, and the man — U.
S. Army Surgeon Beaumont, accounts for
this first great research in digestion. Equally
truly the opp>ortunity afforded by the dra-
matic features of this research and the versa-
tility of the genius of Sir William Osier, join
to account for the charming address, "Wil-
liam Beaumont, A Pioneer American Physi-
ologist," which serves as an introductory.
The detailed account of Dr. Beaumont's
observations and experiments made by using
this living test-tube over many years, as he
carried St. Martin with him from post to
post, is of absorbing interest. It is notewof-
October, 1929 SOUTHERN MEDICINE AND SURGERY i^
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without' danger of toxic absorption by the patient. It has also been long known that
many of the aniline dyes stimulate epithelialization in wounds.
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USE IT AS YOU WOULD TINCTURE OF IODINE OR OINTMENT OF
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folluwiiig dilutioiiis:
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SOUTHERN MEDICINE AND SURGERY
October, 1929
thy, too, that the general body of doctors
could not keep up any sustained interest in a
long-continued scientific experiment, even
one having such close association with so
great a need and so generally pleasing an act
as that of eating; for they cried out to be
delivered "from Beaumont and his old fis-
tulous Alexis."
YOU— AND THE DOCTOR, by John B. Hawes.
2nd, M.D. Houghton-Mifflin Company, The River-
side Press, Cambridge, Boston and New York, 1929.
$2.00.
The public demand for information about
disease, in general supplied as m/jinformation
or plain nonsense by "Health Columns" is
here met by an honest, enlightened discussion
of ethics, economics, when not to call the
doctor, and such important symptoms as
headache, backache, chest pain and hemor-
rhage. Tumors and cancer, temperature and
pulse, constipation, kidney trouble and
nerves, as chapter heads, suggest how acutely
Dr. Hawes has discerned what to write to
laymen about.
SURGICAL AND MEDICAL GYNECOLOGIC
TECHNIC, by Thomas H. Cherry, M.D., F.A.C.S.,
Professor of Gynecology, New York Post-Graduate
Medical School and Hospital; Director of Gyne-
cology, Pan-American Hospital. New York City;
Visiting Gynecologist, St. Mark's Hospital, New York
City; Consulting Gynecologist, Morristown General
Hospital, Morristown, N. J.; Major Medical Corps,
U. S. A. R. 558 Half-tone and L!ne Engravings,
from photographs and pen and ink drawings by the
author. F. A Davis Company, Philadelphia, 1929.
$8.00.
The book is written from the experience
of a teacher of graduate students over a fif-
teen-year period and definite ideas of their
needs. Not written as an undergraduate
textbook, it has little of anatomy, physiology
or even diagnosis. Operations are described
step-by-step from "Step 1" to "Step 12,"
or more, which, with abundant illustrations
to which timely references are made in the
text, makes the meaning unmistakable.
The chapter on anesthesia gives the au-
thor's own ideas as to different methods of
anesthesia. Gas-ether, gas-oxygen, ethylene,
morphine-novocaine-magnesium, spinal anes-
thesia. He has discarded caudal and para-
sacral regional anesthesia for spinal anesthe-
sia, which latter is most minutely described.
Pre- and post-operative care is treated of as
deserving the most careful attention.
The gynecological examination is discussed
and described from a broad viewpoint, speci-
men of author's examination blank and list
of instruments and other paraphernalia given.
There is a chapter on diathermy. Pre-can-
cerous conditions and uterine displacements
are given much space. The gas inflation test
and uterosalpingograms described as to tech-
nique and comparative and supplementary
value.
Throughout there is evidenced the idea of
the author to subordinate all other considera-
tions to that of making a book of every-day
usefulness to the doctor who has ailing wo-
men to treat, and it is clear that he has suc-
ceeded remarkably.
VARICOSE VEINS, With Special Reference to
the Injection Treatment, by H. 0. McPheelers, M.D.,
F.A.C.S., Director of the Varicose Vein and Ulcer
Clinic, Minneapolis General Hospital; Attending
Physician New Asbury and Fairview Hospitals;
Associate Staff of Northwestern Hospital, Minneapo-
lis, Minn. Illustrated with half-tone and line en-
gravings. F. A. Davis Co., Philadelphia, 1929. $3.50.
Most of us remember the results obtained
in the treatment of varicose veins, with or
without complicating ulcers, as very unsatis-
factory. Usually the stay in the hospital
was long and expensive, and in only a few
cases was the result all that could be desired.
McPheeters gives the fundamental facts
about the structures and principles involved
and then minutely describes the technique of
the injection treatment, which he has found
to be productive of results far surpassing
those obtained in other ways and at far less
cost to the patient.
WHY WE ARE MEN AND WOMEN or Factors
Determining Sex, by A. L. Benedict, A.M., M.D.,
F.A.C.P., Major, Medical Reserve, U. S. A. Allen
Ross Company, New York. 1929. $2.50.
It is clearly set forth that, under certain
circumstances, the determination of sex
would serve desirable ends; also that this
would contravene no ethical principles. More
than 500 hypotheses have been offered as to
why one fertilized ovum becomes a male
an4 another a female, and a variety of ente):-
October, 192Q
SOUTHERN MEDICINE AND SURGERY
Clinical evidence is being daily received in con-
firmation of the Laboratory claims for
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taining superstitions are recorded. The near
equality in numbers of human males and
females strongly suggests that whatever be
the manner of determining sex, it works re-
markably well without interference and that
monogamy is best suited to the needs of man-
kind. The chapter on the distribution of
sexes in the typic family and that on origin
of sex are of particular interest. The rela-
tion of conception to the period in the men-
strual cycle at which intercourse takes place
is illuminated by figures on 1756 pregnancies,
each the result of a single intercourse. With-
out claiming to have solved the problem of •
determining sex, the author has written a
readable, instructive and thought-provoking
book.
THE CLIM.'\CTERIC (The Critical .\ge), by
Gregorio Maranon, Professor of Medical Pathology
in the Madrid General Hospital, Member of the
Royal National Academy of Medicine; Translated
by A'. S. Stevens; Edited by Carey Culbertson, A.B.,
M.D., F.A.C.S., Associate Clinical Professor of Ob-
stetrics and Gynecology, Rush Medical College of
the University of Chicago, C. V. Mosby Company,
S't. Louis, 1029. $6.50.
The author would have it kept in mind
that menopause and climacteric are not syn-
onyms. Emphasis is placed on the fact that
insufficiency of the genital gland is not the
whole thing but that the symptoms are the
expression of a complex endocrine crisis.
There are ovarian, thyroid, suprarenal and
hypophyseal factors at the least, and the veg-
etative nervous system is vitally concerned.
The normal menopause is contrasted with
the pathologic. Usual and unusual emotional
manifestations at the critical age are ana-
lyzed. There is said to be no chronologic
relation between the beginning and end of
menstruation. Kylin, of Stockholm, is quot-
ed as having reported excellent results from
the use of testicular extract in hypertensions
oi men coinciding with the decline of sexual
power. Psychic symptoms are enumerated
and explained over a wide range from the
slightest manifestations to complete mental
breakdown, and metabolic disturbances are
also many and varied. Differences in the
phenomena of artificial menopause and those
of the critical age are explained on the
ground of the former being a total and sud-
den ovarian insufficiency and the latter a
pluriglandular crisis.
It is boldly proclaimed that there is such
a thing as the critical age in the male, coming
much later than in the female. Metchnikoff
is cited as having obtained active spermato-
zoa from a man 103 years old. A thoughtful
sentence is, ''It is not the vigor, the joy the
youthful freedom from care for which we
envy this age; it is rather the mere fact of its
being the farthest removed from our own
death."
The final chapter deals with treatment of
climacteric symptoms and incidents. Whole
ovarian extract is praised for its influence on
the menstrual irregularities, thyroid extract
in the hypothyroid. Mammary extracts by
mouth or injection are said to have an in-
hibitory action on uterine hemorrhage. Bel-
ladonna to regulate the autonomic nervous
system. Testicular and spermatic therapy
for the climacteric of the male.
An interesting book which does what
Mathews said he hoped his Physiological
Chemistry would do — "raises more ques-
tions than it answers."
THE CHILD'S HEREDITY, by Paul Popenoe,
author of Problems of Human Reproduction, Con-
servation of the Family, etc., illustrated. The WH-
liams and Wilkins Company, Baltimore, ?2.00.
The author calls this a guide-book for pa-
rents. It might also truthfully be called an
instruction-book to all who have an intelli-
gent craving for the most important of all
knowledge, that which helps to establish
man's relation to the other animals, to other
things, and to the laws of nature.
Chapter heads are:
The New-Born Babe, The Child's Relation
to His Ancestors, Brothers and Sisters, The
Skin, The Eyes, The Ears, The Hair, The
Teeth, The Blood, Growth, Errors of Devel-
opment, Lefthandedness, Diseases of the
Body, Intelligence, Different Kinds of In-
telligence, Different Levels of Intellect, To
Him That Hath, Body and Mind. Constitu-
tion, Temperament, Intellectual Deficiency,
Diseases of the IVIind, The .Arts. Sexuality
Is It Hereditary?, The Origin of New Traits.
Illustrations are:
Fig. 1. (Half-tone) Illustrating the capacity
October, 1929 SOUTHERN MEDiaNE AND SURGERV
SOUTHERN MEDICAL ASSOCIATION
Miami, Fla., November 15-21, 1929
via
SEABOARD AIR LINE RAILWAY
Low round trip fares in effect for this occasion. One
and and one-half fare for round trip. $42.48 round trip
fare from Charlotte to Miami. Tickets on sale Nov. 15th
to 21st inclusive, with final return limit Nov. 30th. Pur-
chaser of these tickets must hold identification certifi-
cate. Lower berth Charlotte to Miami $9.75. Upper
berth $7.80.
Leave Charlotte ._ 7:40 PM 4:00/lil/l5/ day
Arrive Miami, Fla. 11:15 PM 8:45 AM 2nd day
For pullman reservations and information call on your
nearest Seaboard ticket agent, or
B. Harriss, D.T.A., John T. West, D.P.A.,
Charlotte, N. C. Raleigh, N. C.
1 -A Course of Lectures and Clinics in Physical
Announcing Therapy and Ambulant Proctology in
2 Charlotte, N. C.
INSTRUCTORS
ARTHUR LA ROE, M.D.
Late Actinp Assistant Surgeon, U. S. P. H. S., Fox Hill Hospital, Long Island, New York
JOHN HALLIDAY, M.D.
Formerly Assistant to Major Frank B. Granger, M.D., Professor of Physical Therapy
Harvard Medical School
HENRY \V. ALLEN, M.D.
Specialist in Proctology, .Author "Ambulant Proctology"
OCTOBER 21st TO NOVEMBER 2nd IN THE OFFICE OF
DR. L. D. WALKER, MA'A N. TRYON ST.
This course of lectures and clinical work offers the physicians an opportunity to learn the
latest methods of treatment in Ambulant Proctology and to secure a practical knowledge of the
various modalities in the field of Physical Therapy.
There is a splendid opportunity for one practitioner in each populous county in the two
Carolinas to perfect himself in this Combined Specialty. The course is open to accredited
physicians and their regular assistants and the class in the Combined Specialty is
limited to twelve members. The special Diathermy Class is unlimited.
SCHEDULE
Oct. 21 — Open Sessions. Lectures. Clinics. Physical Therapy. Proctology.
Oct. 22-23 — Lectures. Instruction. Diathermy. Arthur La Roe, M.D.
Oct. 24 to Nov. 2 — Instruction. Clinics. Physical Therapy, John Halliday, /b. t. Walker. Sec,
M.D. Ambulant Proctology, Henry W. Allen, M.D. ^^ 3341 jg Tryon St.!
Physicians are requested to bring their patients to supply clinical ^/ Charlotte, M. c!
material for these clinics. The first day's sessions are free and all >^
physicians are invited to attend. The fee for the special two- ^^ Plea.sp send me full jmrtiiu-
day course by Dr. La Roe is S15.00. Full information re- /^roA'^floKy Course "in" Chark'.Ue;
garding this special course or the combined two weeks' /n. C.
course can be had by addressing /Name
The Secretary -Address .-—
W. T. Walker
334 '/2 N. Tryon St., Charlotte, N. C.
748
SOUTHERN MEDICINE AND SURGERY
October, 1929
An Echo of the Past
A healthy Portuguese girl — (a number of children in
the same family show no reversion or other abnor-
many babies have at birth (they lose it a
little later) for supporting their own weight
by clinging to a bar.
Figs. 2, 3. {Half-tone) Showing a vestigial
tail. (Reproduced herein.)
Fig. 4. (Line-drawing) Showing the human
chromosomes. (Inheritance-carrying bodies).
Fig. 5. (Line-drawing) The separation of the
sex chromosomes.
Fig. 6. (Line-drawing) The 24 pairs of hu-
man chromosomes,
mality) born with a tail. It contains no bone.
— From The Child's Heredity
Fig. 7. (Half -tone) The Mendel Memorial at
Brunn.
Fig. 8. (Half-tone) Illustrating the inheri-
tance of color-blindness.
Fig. 12. (Half-tone) An inherited white blaze
in the hair.
Fig. 13. (Half-tone) Hippocrates the "Father
of Medicine." He was bald with the "pat-
tern" baldness often alleged to derive from
the wearing of modern male headgear. But
Hippocrates wore no hat,
October, 1929
SOUTHERN MEDICINE AND SURGEftV
Fig. 14. (HalJ-tonc) Illustrating inheritance
of the double crown.
Figs. 15, 16. {Half-tone photomicrographs)
Illustrating agglutination (clumping) of
the blood.
Fig. 17. (Half-tone) A child who goes on all
lours.
Fig. 18 (Line-drawing) The famous Habs-
burg lip.
Fig. 19. (Half-tone) Living quadruplets. (Re-
produced herein.)
Fig. 20. (Half-tone) Illustrating the accom-
plishments developed in an imbecile.
Figs. 21, 22, 23. (Half-tones) A series of
photographs of 12 boys of like age with a
wide range of intelligence from the idiot up
to exceptionally brilliant. No one yet has
been able to range the boys in order of
intelligence from looking at the pictures.
(One group reproduced herein.)
Fig. 24. (Line-drawing) Different types of
shoulder blade.
Fig. 25. (Half-tone) The famous Siamese
twins.
Figs. 26, 27. (Half-tones) Photographs of the
casts of "The Student Prince" and "The
Toreadors" as presented by the students
in a school for mental defectives.
fy
SOUTtltRN
MEDICAl
association;
A
IN the South, OF the South, FOR the South
M'
EDICINE and SURGERY in every phase will be
covered in the general and clinical sessions and
the twenty sections and conjoint meetings making up
the program for the Miami meeting — modern scientific
medicine brought up to date. Unique and unusual
entertainment and recreational features — golfing, boat-
ing, swimming, fishing, hunting, trap shooting or
whatever is the favorite sport or recreation. A meet-
ing that will EXCEL — Miami, November 19-22.
FTER MIAMI, CUBA. Perhaps never agiin will
there come to physicians in the South such an
jrtunity to see Havana and Cuba under circum-
that will charm,
3een arranged.
"lovely land of Cuba
ARE YOU A MEMBER of the Southern Medical
Association? If not, you should be and can
be if you are a member of your county and state
medical societies — that is the only neccr.sary require-
ment plus ?4.00 annual dues which include the As-
sociation's own Journal, the Southern Medical Jour-
nal — the equal of any, better than many. "Here 'tis
again, my check for ?4.00 in payment of my d ics for
another year — the best investment of the year," so
writes a prominent physician of North Carol. :,a. You
will EVENTUALLY make that "best investment" —
why not NOW?
SOUTHERN MEDICAL ASSOCIATION
Empire Building
Birmingham, Alabama
^;
V^^^y^ ~
Speculum (Reid's) 1883.
Get allsef/orthebi^Vacation/ f
Mental and physical Relaxatioa; i
MIAMI'S ina^c alluTements becKoti; I
Will y&abe there? Well I should recKoa/
MIAMI, FLA. NOV. 19'!,.- 22'? 1929
SOUTHERN MEDICINE AND SURGERY
October, 1929
NEWS
New Director Richmond Mental
Hygiene Clinic
Dr. J. Whitman Newell was recently ap-
pointed director of the Mental Hygiene Clinic
of the Virginia State Department of Public
Welfare.
Dr. Newell is a graduate of Amherst Col-
lege and the Ohio Wesleyan Medical School.
For the past three years he has been a spe-
cialist in mental hygiene work, having spent
a year on the staff of the Pennsylvania Hos-
pital department of nervous and mental dis-
eases, and a year with the New York Child
Guidance Institute, where he was a Common-
wealth Fellow.
The staff of the clinic now consists of Dr.
Newell, psychiarist; Dr. Virginia T. Graham
and Miss Mary Hinton Duke, psychologists:
Miss Elizabeth Rice and Miss Anne Ward,
psychiatric social workers, and Miss Doris
Jenkins and Miss Naomi Puckett.
The mental hygiene clinic is a division of
the mental hygiene bureau, of which Dr. Wil-
liam F. Drewrv is director.
Dr. W. Price Timmerman, of Batesburg,
S. C, a Tri-State Councilor, was declared the
democratic nominee for mayor of Batesburg
by the committee in the regular election in
November.
The final result of the committee meet-
ing gave Timmerman 303 votes, against
,?04 in the first count made by the managers,
and Wesberry 298, against 300 allowed him
result of the decision.
Thus ends one of the warmest elections
Batesburg has had in many a year, for Mr.
Wesberry announced after the committee had
made its findings that he would abide the
result of the meeting Thursday night.
An addition to Tucker Sanatorium
FOR Nervous Diseases, Richmond, Va.,
The first floor of the addition
will be devoted to executive offices, waiting-
rooms, doctors' rooms and other offices, and
the second floor will be occupied by patients'
rooms, each room having its private bath.
An elaborate physio-therapy and hydro-ther-
apy equipment will be installed in the base-
ment.
Greenville County, S. C, is soon to
HAVE a Tuberculosis Sanatorium, modern
in every respect, costing $175,000, with ac-
commodations for both races. The funds
have been provided and work begun.
Dr. O. L. Suggett, who first came to Ashe-
vllle on account of tuberculosis developed
while in the service in the Medical Corps of
the Army in the World War, has returned to
Asheville to resume the practice of his spe-
cialty, urology, which he practiced in St.
Louis, Mo., for 20 years. During the greater
part of this time he was Professor of Genito-
urinary Diseases and Syphilology in the
Barnes Medical College, consultant in Genito-
urinary Surgery to the City, Female, and
Centenary Hospitals, and Chief Surgeon to
the Ricord Urological Hospital, owned and
operated in association with Dr. R. B. H.
Gradwohl. He has been a member of the
American Urological Association since 1907.
Dr. Gradwohl and he formerly edited and
published The General Practitioner, a journal
devoted to Urology and Laboratory Tech-
nique.
Dr. p. a. Yoder, Penn. '23, for the past
several years a member of the medical staff
of the North Carolina Sanatorium, and re-
cently acting as a clinic physician, has re-
signed his position to accept that of superin-
tendent of the Forsyth County Sanatorium,
which is now nearing completion at Winston-
Salem. Mrs. Yoder will become superintend-
ent of nurses.
Dr. Goode Cheatham, N. C. Med. Col.,
'95, of Henderson, N. C, was elected presi-
dent of the .Association of Seaboard Air Line
Railway Surgeons. He succeeds Dr. C. D.
Christ, of Orlando, Fla.
Dr. J. W. Jervey, jr., has become asso-
ciated with his father. Dr. J- W. Jervev, in
Greenville, S. C, in the management of the
latter's private hospital for the treatment of
eye, ear, nose and throat conditions.
Dr. W. R, Berryhill, who has been agso-
October, 1929
SOUTHERN MEt>lClN£ AND StJRGEtlY
?S1
ciated with Dr. J. M. Pressly, Belmont, N.
C, in the practice ol medicine the past tew
months, and a native of Steel Creek, Meck-
lenburg county, has accepted a teaching posi-
tion in tne medical department of the Univer-
sity of North Carolina. Dr. Berryhill was
graduated from the University several years
ago, leading his class.
being completed. He is a native of this sec-
tion. The hospital will be opened about the
first of December and will have cost about
$150,000.
Dr. John Cotton Tayloe, son of Dr. Da-
vid r. Tayloe, of Washington, N. C, and
Miss Nellie Holt, daughter of the late
Judge Stephen Holt, of Smithfield, N. C,
September 9th.
Dr. James A. Haizlip, of Alberta, Va.,
and Miss Frances Elizabeth Carlisle, of
Reidsville, N. C, September 19th.
Dr. William Jordan Thigpen, Tarboro,
N. C, Jefferson, 1900, 54, died of pneumonia
September 20th. Dr. Thigpen was a member
of the staff of Edgecombe General Hospital,
a past president of the Edgecombe County
Medical Society and prominent in the affairs
of the Medical Society of the State of North
Carolina.
Members of the profession from Greenville,
Farmville, Rocky Mount, Scotland Neck,
and Raleigh attended the funeral.
The Ninth District Medical Society
held its annual meeting in Hickory, Septem-
ber 26th, under the presidency of Dr. C. Roy
Tatum, of Statesville. At the business ses-
sion the following officers were elected for
the next year: Dr. Glenn R. Frye, Hickory,
President; Dr. B. W. McKenzie, Salisbury,
Vice-President; Dr. James W. Davis, States-
ville, re-elected Secretary-Treasurer. More
than 100 were in attendance. Addresses
were delivered by Dr. J. T. Burrus, Past
President of the Medical Society of the State
of North Carolina, of High Point; Dr. H. R.
Black, Spartanburg, S. C; Dr. H. H. Bass,
Durham; Dr. L. B. McBrayer, Southern
Pines, Secretary-Treasurer of the Medical
Society of the State of North Carolina, and
others.
Dr. J. P. Monroe, of Sanford, was shot
by a man supposed to be insane on the streets
of Sanford on the afternoon of October 2nd.
Four or five bullets took effect. It is believed
that Dr. Monroe will recover. Dr. Monroe
has conducted a private hospital at Sanford
for many years and is one of the leading
physicians in this section of the state.
The Seventh District Medical Society
met with the Mecklenburg Medical Society
at Charlotte, October 8th, about 200
doctors being in attendance. Dr. J. R. Gam-
ble, of Lincolnton, the President, presided.
Dr. Wm. B. Porter, of Richmond, Va., Pro-
fessor of Medicine in the Medical College of
Virginia, was guest of honor and held a clinic
in the afternoon and delivered an address in
the evening, showing the results of some
original research in anemia. Dr. L. A. Crow-
ell, of Lincolnton, President of the Medical
Society of the State of North Carolina, made
an address. Concord was selected as the next
meeting place and the following officers were
elected: Dr. John H. Tucker, Charlotte,
President; Dr. Richard M. King, Concord,
Vice-President; Dr. C. H. Pugh, Gastonia,
Secretary-Treasurer, .^mong the 3 -minute
contributors of after-dinner wit and humor
were Dr. R. E. Lee, Lincolnton; Dr. L. B.
McBrayer, Southern Pines; Dr. C. L Allen,
Wadesboro, and Dr. J. C. Montgomery, Char-
lotte.
Dr. Clement R. Monroe has accepted
the position of Superintendent and resident
surgeon of the Moore County Hospital, just
Dr. Herbert Fritz has returned to Phil-
adelphia after spending several days with his
parents, Dr. and Mrs. R. L. Fritz, near Le-'
noir Rhyne College. Dr. Fritz is now on the
staff of Bryn Mawr and Jefferson Hospitals
and is physician to Woman's College of Med-
icine.
In addition to his work as physician and
surgeon, he teaches one class in Jefferson
Medical College and one in the Woman's
Medical College.— Hickory Record.
Dr. H. J. Gorham, Surry county health
officer, has resigned to accept a position with
iSi
SOtJTHERN MEDICINE AND SURGERY
October, 1920
the Durham city and county health office.
Dr. p. p. McCain, head of the tuberculo-
sis sanatorium of Sanatorium, N. C, was
elected president of the Southern Tuberculo-
sis Conference at its recent meeting in Nash-
ville, Tenn. Atlanta was chosen as the 1930
convention city.
Dr. Charles 0"H. Laughinghouse, state
health officer, has been put on the national
committee on milk production and control
and Mrs. Kate Burr Johnson, commis-
sioner of public welfare, was named chairman
of the national committee on state and local
organizations for the handicapp)ed.
Dr. J. B. Bullitt, Professor of Pathology
in the University of N. C, is back at Chapel
Hill after a year in Europ)e.
Dr. W. p. Ferguson, 55, of Premier, W.
Va., Medical College of Va., '98, died at Sa-
lem, Va., October 4th.
Virginia Doctors at N. & W. Meet
Among the 250 attending the annual con-
vention of Norfolk and Western Railroad
surgeons, October 3-4, were:
From Richmond: Dr. William B. Porter,
Dr. C. C. Coleman, Dr. Beverley R. Tucker,
Dr. William K. Graham, and Dr. Frank S.
Johns.
From Norfolk: Dr. Southgate Leigh, Dr.
H. R. Drewry, Dr. A. A. Burke, Dr. E. C.
Branton, Dr. W. E. Driver, and Dr. C. W.
Doughtie.
Dr. Oscar W. Holloway, 55, M. C. Va.
"01, died suddenly of heart disease at his
home in Durham, N. C, October 2nd.
Dr. Frederick R. Taylor, late Director
of Health Maintenance Bureau of the North
Carolina State Board of Health, has resumed
his private practice in Internal Medicine, at
High Point, N. C. Facilities include equip-
ment for electrocardiographic Studies. Dr.
Taylor will devote special attention to pe-
riodic health examinations.
That's a small engine for such a big car, isn't it?"
"Oh, it's small, all right. You see it smoked a lot
when it was young."— Carolina motorist.
CHUCKLES
Maybe That is the Explanation
"My regular doctor knows I've got a family to
support, but from the size of that specialist's bill I
guess he thinks there's nobody dependin' on me
except him." — Claude Callan in Charlotte Observer.
Knew His Coins
In a little Scotch town there lived old Andy who
was what is called in some parts, a "natural." He
was simple-minded and the villagers used to show
him off to the visitors by offering him two coins, a
big copper penny and small silver sixpence. Andy
would invariably take the penny.
One day an .\merican said to him: ".\ndy, don't
you know the difference between a penny and a
sixpence?"
".\ye," said Andy, "I ken the difference but gin I
took the saxpence aince, niver anither chance I'd
get at aither."
Intelligence Test No. 194,613
Three bears emerged from a cave into w'hich only
two had gone for the winter hibernation. Coming
to a stream the fond mother shoved her offspring in
for his first bath. The cub clambered out, wiped
the cold water out of his eyes, and indignantly de-
manded, "What! no soap?" — Dick Kerr.
No Unusual Case
A newcomer to town asked the lawyer, "Why do
you have that sign up. 'A Fraud Lawyer'? Why
don't you at least put in your first name?"
"My first name's .^dam." — Pathfinder.
Seems Reasonable
"Don't you think the water is awfully hard here?"
'Yes, but it rains harder here. — Wisconsin Octo-
pus.
Henry Ford says he would quit making cars if
prohibition were repealed. It would be a great pity
to have Detroit's two leading industries destroyed
at one blow. — The New Yorker.
No Metes? No Bounds?
Dead heart has been set to beating at a Boston
demonstration. We suppose the next subjects for
this pepping-up process will be the Sacred Codfish
and Calvin Coolidge.— Greensboro News.
We are told that a really happy man is one who
feels as important at home as he does at lodge meet-
ing in full uniform. — Boston Transcript.
"Your uncle seems rather hard of hearing?"
"Hard of hearing! Why, once he conducted fam-
ily prayers kneeling on the cat!" — Tit-Bits.
October, 1929
pRGFfiSSIdM CAfebS
tS3
PHYSICIANS' DIRECTORY
EYE, EAR, NOSE AND THROAT
A.^IZI J. ELLINGTON, M.D.
Diseases of the
EVE, EAR, NOSE AND THROAT
PHONES: Office 992— Residence 761
ISiii'linc|(un North Carolina
J. SIDNEY HOOD, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
PHONES: Office 1060— Residence 1230J
Srd National Bank BIdg., Gastonia, N. C.
O. J. HOUSER, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
Telephones —
Office H.— 1672, Residence J.— 998-M
Hours — 9 to 5 and bv Apointment
219-23 Professional BIdg. Charlotte
HOUSER CLINIC
For Tonsils and Adenoids
415 North Tryon St. Phone Hemlock 4217
Consultation 219 Professional BIdg.
Phone Hemlock 1672
3. G. JOHNSTON, M.D
EYE, EAR, NOSE AND THROAT
Hours — 9 to 1 and by Appointment
Telephones —
Office H— 1883, Residence H.— 4303-W
616-18 Professional Building, Qiarlotte
H. C. NEBLETT, M.D.
Practice Limited to
DISEASES OF THE EYE
Telephone Hemlock 2361
Professional Building Charlotte
H. C. SHIRLEY, A.M.. M.D.
JOHN HILL TUCKER, M.D.
Practice Limited to
DISEASES OF THE EAR, NOSE
Diseases of the
EYE, EAR. NOSE AND THROAT
Hours — 10 to 1 and by Appointment
and THROAT
Professional Building Charlotte
Telephones-
Office H— 3884, Residence H.— 2513
309 Professional Building Charlotte
H. A WAKEFIELD, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
Telephones —
Office H— 727. Residence J.— 218-J
20'i North Tryon Street Charlotte
INTERNAL MEDICINE
A. A. BARRON, M.D., F.A.C.P.
INTERNAL MEDICINE
NEUROLOGY
M. L. Stevens, .M.D. Clias. C. Orr. M.D.
DRS. STEVENS AND ORR
INTERNAL MEDICINE
DISEASES OF THE LUNGS
Professional Building
Charlotte
17 Cluireh Street
.Asheville, N. C.
W. O. NISBET, M.D , F.A.C.P.
Professional Building
INTERNAL MEDICINE
GASTRO-ENTEROLOG Y
D. H. NISBET, M.D.
Charlotte
M. A. SISKE, .VI.D.
\V. C. ASHW tmiH. M.D.
HABIT DISEASES. NEUROLOGY
and PSYCHIATRY
Huurs by Appointment
Piedmont Building (irecnshoro, N. C.
(JRAYStKN E. TAHKIMiTON,
M.D., F.A.C.P.
INTERNAL MEDICINE AND SYPHILIS
Du^an & Stuart Buildini; Hours: 0-12, 3-5
Hoi Sitrings National Park Aj'kansas
7S4
PROFESSION CARDS
October, 1929
J.WIES CABELL MINOR, M.D.
PHYSICAL DIAGNOSIS
HYDROTHERAPY
Hot Springs National Park Arkansas
JAMES M. NORTfflNGTON, M.D.
Diagnosis and Treatment
in
INTERNAL MEDICINE
Professional Building Charlotte
OBSTETRICS and GYNECOLOGY
C. H. C. JULLS, JLD.
OBSTETRICS
Consultation by Appointment
Professional Building Charlotte
ROBERT T. FERGUSON, M.D., F.A.C.S.
GYNECOLOGY
By Appointment
Professional Building Charlotte
VV1LLLA.VI FRANCIS MARTIN, M.D.
GYNECIC & GENERAL SURGERY
Professional Building Charlotte
RADIOLOGY
Merey Hospital
X-RAY AND RADIUM INSTITUTE
W. M. Sheridan, M.D., Director
X-RAY DIAGNOSIS SUPERFICIAL AND DEEP THERAPY X-RAY TREATMENTS
RADIUM THERAPY DIATHERMY
Suites 208-209 Andrews Building Spartanbui'g, S. C.
Robt. H. Laffertj , M.D., F.A.C.R. C. C. Phillips, M.D.
DRS. LAFFERTY and PHILLIPS
Charlotte
X-RAY and RADIUM
Fourth Floor Charlotte Sanatorium
Presbyterian Hospital
Crowell Clinic
Dr. J. Rush Shull Dr. L. M. Fetner
DOCTORS SHULL and FETNER
ROENTGENOLOGY
Roentgenologists to St. Peter's Hospital, Aslie-Faison Children's Clinic, Good Samaritan Hospital
Professional Building Charlotte
UROLOGY, DERMATOLOGY and PROCTOLOGY
THE CRO« KLL CLINIC OF IROLOGY AND DERMATOLOGY
Entire Seventh Floor Professional Building
Charlotte
Telephones— H. -4091 and //.-4092
Hours — Nine to Five
I roiojiy:
.-Indrew J. Crowell, ]M.D.
Raymond Thompson, M.D.
Claud B. Squires, M.D.
C.linieal Pathology:
Lester C. Todd, M.D.
Dermatology:
Joseph A. Elliott, M.D.
Lester C. Todd, ]VLD.
Roentgenology
Robert H. Lafferty, M.D.
Clyde C. Phillips, M.D.
October, 1929
PROFESSION CARDS
I'red D. Austin, M.D. DeVVitt R. Austin, M.U.
THE AUSTIN CLINIC
RECTAL DISEASES, UROLOGY, X-RAY and DERMATOLOGY
Hours 0 to 5— Phone Hemlock 3106
8th Floor Independence Bldg. Charlotte
Thos. Brock-man, M.D.. 25 Enuna St., Greer, S. C
BROCKMA.N'S BECTAL CLIMC
More Commodious Quarters in Colonial Apartments.
Improved Facilities.
X-Ray and Clinical Laboratories.
Recovery Beds for .Ambulant Patients.
Surgical Cases Hospitalized at Chick Springs Sanitarium
Dr. Hamilton McKay D>'- Robert McKay
DOCTORS ^IcKAY and McKAY
Practice Limited to UROLOGY and GENITO-URINARY SURGERY
Hours by Appointment
Professional Building Charlotte
Residence Phone 1858
DR. \\. B. LYLES
221 East .Main Street
Practice limited to
UROLOGY and UROLOGICAL SURGERY
Hours Q-.v Sundays by .Appointment
Office Phone 1S57
S|tarlaiil»iir(|, S. C.
W. W. CRAVEN, M.D.
GENITO-URINARY and RECTAL
DISEASES
0 a. m. to 1 p. m. — 3 p. m. to 6 p. m.
Professional Building Charlotte
R. H. McFADDEN. M.D.
UROLOGY
Hours 9 to 5
514-16 Professional Bldg. Charlotte
L. D. McPHAIL, M.D-
RECTAL DISEASES
405-408 Professional Bldg. Charlotte
WYETT F. SIMPSON, M.D.
GENITO URINARY DISEASES
Phone 1234
Hot Springs National Park, Arkansas
DR. O. E. SI GtiETT
UROLOGY
Caslanca Building, .Xslicv illr, \. <',.
Hours— 3 to .■; ; Phone— 2443
FOR SPACE RATES
Address
806 Professional Building
SURGERY
ADDISON G BRENIZER, M.D.
SURGERY and GYNECOLOGY
Consultation by Appointment
Professional Building Charlotte
Rl SSELL O. LYDAY, M.D.
GENERAL SIRGERY and SURGICAL
DIAGNOSIS
.lelVei'son S(d. Bldg., Grecnshoro. .\. C
R. B. .Mcknight, m.d.
SURGERY
and
SURGICAL DIAGNOSIS
Consultation by Appointment
Hours 2:30 — 5
Professional Buildlnq Charlotte
U M. MARVIN SCRUGGS, M.D., F.A.C.S.
SURGERY and GYNECOLOGY
Consultation by Appointment
Profe.ssional Building Charlotte
PROFESSION CARDS
October, 1929
ORTHOPEDICS
J. S. GAUL, M.D.
ALONZO MYERS, M.D.
ORTHOPEDIC SURGERY and
FRACTURES
ORTHOPEDIC SURGERY and
FRACTURES
Professional Building Charlotte
Professional Building Charlotte
HERBERT F. MLINT, M.D.
FRACTURES
ACCIDENT SURGERY and ORTHOPEDICS
Wachovia Bank Building
Winston-Salem, N. C
O L. MILLER. M.D.
Practice Limited to
ORTHOPEDIC SURGERY and FRACTURES
Fifteen West Seventh Street
Charlotte
GENERAL
THE STRONG CLINIC
Suite 2, Medical Building
C. M. Strong, M.D., F.A.C.S.
Surgerv and Gynecology
J. L. Ran-son, M.D.
Genito-Urinarv Diseases and Anesthesia
Charlotte
Oren Moore, M.D., F.A.C.S.
Obstetrics and Gynecology
Miss Pattie V. Adams, Business Manager
Miss Fannie Austin, Ntitsc
HIGH POINT HOSPITAL
High Point, N. C.
(Miss Gilbert Muse, R.N., Siipt.)
General Surgery, Internal Medicine, Neurology, Ophthalmology, etc.. Diagnosis, Urology, Pediatrics,
X-Ray and Rad.um, Physiotherapy , Clinical Laboratories
John T. Burrus, M.D., F.A.C.S., Chief
Harry L. Brockmann, M.D.
Philip W. Flagce, M.D.
0. B. Bonner, M.D.
Frederick R. Taylor, B.S., M.D.
S. Stewart Saunders, ,\.B., M.D.
DR. H. KING WADE CLINIC
Wade Buildinc
Hot Springs, Arkansas
H. King Wade, M.D.
Charles S. Moss, M.D
Urologist
Surgeon
O. J. MacLaughlin, M.D.
Opthalmologist
Oto-Laryngoloist
H. Clay Chenault, M.D.
Associate Uurologist
Miss Etta W.\de
Pathologist
SOUTHERN MEDICINE and SURGERY
Vol. XCI
Charlotte, N. C, November, 1929
No 11
Essential Hypertension*
Dewey Davis, M.D., Richmond, Va.
Hypertension is a condition, not a disease,
about which we know little etiologically and
our fnethods of treatment must necessarily be
empirical. We are aware that it is a symptom
of vascular disease in just the same sense
that fever usually indicates infection in the
body. We look back on our predecessors of
past ages with a distinct sense of superiority
at their carefully planned treatment of fever.
May not our children hold the same view
with regard to our present ideas of hyper-
tension? Our exact knowledge of the con-
dition is largely confined to the figures as
given us by mechanical means, the sphygmo-
manometer. As a result of statistical studies
derived from large groups of normal individ-
uals we are able fairly satisfactorily to decide
what is and what is not a normal blood pres-
sure reading. For purposes of comparison we
may say that a systolic pressure of over ISO
mm. and a diastolic above 90 mm. constitute
an abnormality at any age, provided the find-
ing is constant. You are all perfectly fa-
miliar with the marked variability of the
blood pressure in different individuals, and
in the same individual at different times. The
statement, then, that this or that person has
hypertension cannot be made with certainty
except after repeated observation. A single
blood-pressure determination is about as val-
uable in diagnosing hypertension as is one
counting of the pulse in suspected hyperthy-
roidism.
I will not burden you with extensive ref-
erences from the literature, and, indeed, an
excellent sentence to impose on one of you
for wrnnedoing would be a complete perusal
of the existing articles dealing with hyper-
tension. I fear, too, that after you had
waded through the maze of observations and
opinions your real knowledge of the subject
would be little improved. With this rather
pessimistic attitude, I will attempt to give
you some idea of what we know, or think we
know, about the condition. I will confine
my remarks to essential hypertension or hy-
perpiesis.
A workable classification of any disease is
of distinct value in a study of its manifesta-
tions. There are unquestionably several
types of essential hypertension. Keith has
divided cases of hypertension into benign and
malignant, with an intermediate class of se-
vere benign, and this classification may be of
value if we are able to make the proper
distinction. However, one cannot help feel-
ing that the type is largely determined by
the rapidity with which the causative factor
exerts its pathological influence. The ex-
tremes are quite definite and all of you can
recall individuals who have lived for years in
comfort with considerably elevated pressure.
On the other hand, cases will come to mind
of patients who have died within a few
months of the inception of hypertension.
Moschcowitz has suggested that we mav
speak of hvnertension as psychic, endocrine
or mechanical, based on the probable etiolo-
gic factors.
There appears to be no one specific etiolo-
gic factor. We find a good many advocates
of the hereditary theory as a cause, and
among them Barrack has made some careful
studies. On the other hand, Moschcowitz
believes that environmental factors play the
largest part. He has pictured the fvpical
hypertensive individual as soft-muscled,
pudgy, short-necked, ungraceful, non-athletic
and overweight. Psychically, he is the anti-
thesis of the child. He does not play, is
♦Presented by invitation to (he Ninth District (N. C.) M?d'cal Society, meeting at Hickory,
Sept. 26, 1929.
SOUTHERN MEDICINE AND SURGERY
November, 1020
tense, irritable, introspective and has a single
track mind. He pursues his aims with a
grim desperation. He often achieves success
as determined by wealth and power, but he
frequently spends the rest of his days and
much of his means in the vain search for lost
health. Some, incapable of achieving success,
perhaps because of insufficient mentality, still
live a hard life in the attempt to exist. In
spite of this viewpoint, however, we cannot
escape the impression, as Osier said, that
some individuals are born with too little rub-
ber in their arteries. In other words, they
are constitutionally prone to develop hyper-
tension and inelastic vessels at an early age.
Such families are not infrequently encoun-
tered. Barrach has gone so far as to suggest
that intermarriage between hypjertensive fam-
ilies should be discouraged.
The long continued discussion as to
whether arteriosclerosis causes hypertension
or hypertension causes arteriosclerosis is far
from settled, but the weight of evidence
points to the latter sequence. We may even
venture to think that the two are not so
closely associated as was formerly thought.
The vasoconstrictor nerves have a profound
effect on blood pressure, not only in main-
taining it at a certain level but in producing
deviations from that level. As evidence of
this we may cite the prompt effect of adre-
nalin in causing a rise. A strong emotion,
as fright, produces a similar effect possibly
through an increase of this substance in the
circulation. May not other emotions such as
anxiety, worry and the drive of modern ex-
istence, produce a continued mild vasocon-
striction attended by thickening of the walls
of the smaller blood vessels leading event-
ually to the pathological levels which we re-
gard as hypertension?
The increase of peripheral resistance is
for practical purposes, except possibly in
cases of aortic regurgitation, the only cause
of hypertension. This mechanical resistance
is grossly evident in those cases of narrowing
of the isthmus of the aorta in which pres-
sure may be very high in the upper extremi-
ties and scarcely possible of estimation in
the lower. Hypertension of the pulmonary
circulation is almost invariably mechanical
and due to mitral stenosis or emphysema.
Bordley and Baker have found marked
sclerosis of the arterioles of the pons and
medulla in patients with hypertension, while
these changes are lacking in those with nor-
mal pressures. They believe this to mean
that a compensatory elevation of blood pres-
sure is necessary to force sufficient blood
through these important vessels. Moschco-
witz thinks that they have interpreted the
effects for the cause and that their conclusions
support the idea that arteriosclerosis is the
effect of pressure changes.
Among the endocrine causes may be men-
tioned hyperthyroidism, tumors of the supra-
renal glands and diabetes mellitus. The oc-
currence of a menopause hypertension as a
result of changes in the internal secretions,
particularly from the ovaries, is subject to
considerable doubt. This change occurs at
the period when elevation of blood pressure
so commonly becomes manifest in both sexes.
-Also, the menopause period is quite indefinite
in length, varying from a few months to five
or more years. Is it not possible that the
vasomotor symptoms so common at this time
may e.xert their influence on the blood vessels
leading to hypertension? All of you can
certainly recall individuals in whom artificial
menopause was produced at a comparatively
early age without the immediate development
of an elevation in the blood pressure.
Obesity, per sc, as a factor in hypertension
has never been proved, although it is per-
fectly evident that the extra load of fat se-
riously handicaps an already embarrassed
heart.
The presence or the retention of pressor
substances in the blood has been long and
eagerly sought by biochemists. The investi-
gations of Major, and of Howard and Rabin-
ovitch, have suggested that certain products
of metabolism, as guanidine, may exert such
influence when occurring; in the blood in ab-
normal amounts, but their stud'es are far
from conclusive.
Certain intoxications, as lead poisoning,
may cause a rise in blood pressure, and the
toxins of infections may produce widespread
capillary damage leading eventually to hyper-
tension. It has been suggested that the ex-
tensive capillaritis associated with glomerulo-
nephritis explains the hypertension seen in
this cond'tion. Certainly many ind'v'duals
with this kidney lesion maintain compara-
November, 1929
SOUTHERN MEDICINE AND SURGERY
lively normal tensions.
The symptoms of hypertension vary so
with the degree of underlying pathology that
it is difficult to enumerate them. The pre-
monitory symptoms are worthy of some con-
sideration. These are almost entirely of the
so-called vasomotor type and consist of flush-
ing, paresthesia, dizziness, what the laity
often designate as hot steams, throbbing sen-
sations in the head and palpitation of the
heart. These symptoms are most apt to oc-
cur during periods of worry or excitement,
or after e.xercise. As the pressure, at first
very variable, becomes established at a con-
stantly high level, we see a retention of these
symptoms with the addition of headache,
which is particularly apt to be present when
the patient awakes and be dispelled by a
cup of coffee or simply moving around a bit.
Another frequent and quite troublesome
symptom at this stage is a sensation of fa-
tigue, the patient awaking in the morning
just as tired as when he went to bed. Visual
disturbances, as spots before the eyes, make
their appearance and epistaxis is frequent.
The disease process progresses and we be-
gin to notice signs of myocardial failure, less
often cerebral accidents occur with tempo-
rary or permanent paralysis, and more rarely
kidney insufficiency dominates the picture.
Combinations of these may be found.
If we examine one of these patients in the
early stages the only significant physical
change we find is an increase of the blood
nressure. The pulse tends to be raoid, is
hard to obliterate on pressure; but there is
no palpable thickening of the larger vessels.
The earliest evidence of arterial thickening
'S seen in the eyegrounds where the arterioles
show tortuosity with accentuation of the
white line. .All kidney function tests are
usually normal and not infrequently the
nhenolsulphonephthalein test shows a two-
hour excretion better than the average indi-
vidual. Of course, later when visceral degen-
eration has occurred, the changes of a so-
ralled chronic interstitial nephritis may be
found in the urine: but again I wish to em-
nhasize that this is part and parcel of a
f-eneral vascular disease and not primarily a
nenhritis.
Too frequently, however, the patient con-
siders himself well until he is struck by an
attack of angina pectoris, or coronary occlu-
sion, or a cerebral hemorrhage occurs leading
to medical consultation. The prevalence of
insurance examinations brings many unsus-
pected hypertensive patients to their physi-
cians. "^
.\n accurate prognosis in the face of es-
sential hypertension is impossible to formu-
late. The individual may be dead in six
months or he may live out his normal life
expectancy. Only after prolonged observa-
tion can any idea be gained as to the likeli-
hood of immediate or remote complications.
It has been said that a rising diastolic pres-
sure is indicative of early serious manifesta-
tions, but this is open to question, as we
never know when the rise will cease, and in-
dividuals often live a surprisingly long time
with diastolic pressures of 120 mm. or
higher.
The importance of treatment of hyperten-
sion may be gathered from the statistics of
Fahr in which he shows that 23 per cent of
all deaths in persons over fifty years of age
are the result of hypertension. With the ever
increasing age expectancy we may expect this
figure to correspondingly rise. There is no
question that a lowering of the pressure is
desirable, because if it persists, tragic conse-
quences are certain to ensue. There are some
who regard the disease as persistent and re-
lentless and they advocate no treatment.
Others advocate specific cures, but to date
none is available. It is desirable, as iMosen-
thal says, to take advantage of our existing
state of knowledge and carry on with these
patients as best we can. We cannot expect
too much because, firstly, we do not know
the cause, and, secondly, the causes are so
diverse as to defy identification.
The outstanding therapeutic indication in
hypertension is to produce nervous relaxation
in the patient. How this is to be accom-
plished is a question which only time and
patience can disclose. We need to study the
patient's environment and habits much more
th:in we do his physical makeup. T know
of no one so well niialified to do this as the
f.'im'lv physician. He is in much better nosi-
ticin to know the man as well as the patient
th;in is the specialist who is hnndlcanned b^'
n Iqrk nf proper observation. Does he wo"-';-
long hoiirs under nervous tension, does he
SOUTHERN MEDICINE AND SURGERY
November, 1929
work all day and play half the night, is his
source of anxiety the vagaries of the stock
market or the torment of a nagging wife, is
he striving with might and main to provide
bread and lodging for his family with the
spectre of the bill collector ever before him?
These are questions that are pertinent with
every patient. If we can guide him from
these sources of anxiety into quieter channels,
that will be a great accomplishment. At least
eight hours of sleep at night with a rest pe-
riod in the middle of the day is of distinct
benefit. In more severe cases a prolonged
period of rest in bed or a routine of one day
in bed each week will be beneficial. The
habit of periodical vacations should be culti-
vated. These should be spent under circum-
stances to the liking of the patient. Some
nrefer fishing, others the seashore and others
the mountains. The place where most relaxa-
tion is obtainable should be recommended.
The cultivation of a hobby, provided it is not
ridden too hard, has helped many individuals;
but in the hypertens'on type of individual
we frequently find that they have as their
hobby their life work and lack interest in
other things.
Exercise within the limit of cardiac reserve
's unquestionably beneficial, especially since
Foster has shown that hypertension is more
apt to occur in sedentary individuals. Walk-
ing, setting up exercises, golf or even more
strenuous exercise, as horseback riding or
tennis, may be permitted. I wish a further
word in regard to golf. \ quiet, friendly
round is about as relaxing as anything I
know; but, with the bets placed high or low,
I have seen individuals go at their game v-ith
a bull-dog determination wh'ch leaves *'iem
on the verge of nervous collapse at the end of
eighteen holes.
Many and varied diets have been advo-
cated, but there is grave doubt as to whether
they accomplish anything more than to serve
as a reminder to the patient that he is ill.
The reduction of weight with an anti-obesity
diet is quite appropriate, as it lessens cardiac
strain, but no one has ever proved that it will
in itself lower the blood pressure. Here we
may have to exercise our greatest persuasive
TX)wers, because these individuals are often
hard eaters as well as hard workers.
No adequate proof has ever been advanced
that proteins are harmful. Thomas found
that Eskimos on a purely carnivorous diet
show no increased tendency to develop hy-
pertension. A low protein diet may produce
undernutrition with physical weakness and a
slight fall in blood pressure, but the loss of
efficiency and well-being rarely justifies such
measures. Should kidney complications be
present the restriction of proteins is indicated
only in proportion to the degree of nitrogen
retention in the blood.
Salt restriction, so strongly advocated by
Allen a few years ago, has little if any influ-
ence on the hypertension and may be ex-
tremely disagreeable to the patient. In the
presence of congestive heart failure this rela-
tively simple dietary change may help a great
deal in alleviating distressing symptoms.
The old idea that high blood pressure was
caused by intestinal autointoxication is prob-
ably incorrect and certainly the frequent and
prolonged administration of purgatives w'll
do more hirm than good. Proper elimination
through the bowels by dietary measures or
mild laxatives is desirable here as in normal
individuals. Except in emergencies, such as
threatened apoplexy or acute pulmonarv
edema, blood letting should not be practiced,
especially since it has been fairly conclusively
shown that the blood volume is not increased
in hvpertension.
Outside of sedatives to heln promote nerv-
ous relaxat'on, drups are of limited value in
hypertension. In threatened or aooarent
mmol'cations they have a definite nlace.
Nitrites are excellent in an attack of an"'"-?
pectoris, digitalis is invaluable in myocardial
fa'lure, and certain of the diuretics miy heln
reduce edema; but none of them has any
helpful influence on the hypertension. Par-
ticularly have I been disappointed in the pro-
longed administration of nitrites with the
idea of maintaining the pressure at a lower
level. Sulphocyanates, especially of sodium
or f)otassium, have been advocated, and from
personal experience in a limited number of
cases I feel that with careful selection of
snbiects some good may be accomplished.
They seem to have more effect where the
pressure has not established itself at a hi-^h
level, but here the variability with no treat-
ment makes proper interpretation of resn't'--
yery difficult. The special Uver extracts ad-
November, 1030
SOUTHERN MEDICINE AND SURGERY
761
vocated by Major may eventually be of some
vaiue, nowever, coiuiicung reports with their
use snow them to be still in the experimental
stage.
in conclusion, I wish to warn against a
pernic.ous habit so often seen in patients
with hypertension. That is they constantly
think and live high blood pressure. They
run to their physician at frequent intervals
to have their pressure taken, either from
an.xiely or curiosity, or a mixture of the two.
If the pressure is a few points higher they
are despondent, if correspondingly lower they
have a sense of false security in their fancied
improvement. I sometimes wonder if a pa-
tient should ever be told the height of the
pressure in figures. If he must know, per-
haps it is better to tell him that it is slightly,
moderately or markedly elevated. By all
means discourage frequent visits for the sole
purpose 01 estimatmg the pressure unless
some experimental work necessitates it. A
semi-yearly or yearly general examination
will be quite helpful in the early recognition
of complications and is advisable.
My pessimistic attitude toward hyperten-
sion is engendered by our lack of knowledge
as to its cause and proper treatment, but this
does not preclude optimism for the future.
Scarcely a year passes without some outstand-
ing discovery being made in the field of medi-
cine, and there is great probability that many
in this audience will live to enjoy the fruits
of the solution of this problem. In the mean-
time, except in the presence of our fellows,
it is wise to conceal our pessimism and do all
in our power to instill justifiable optimism in
our patients.
Hot Baths to Produce Hyperpyrexia
In comparint; the results produced by hot baths
and the malarial treatment, the latter is simpler. It
rt quire:- less co-operation on the part of the patient.
The temperature can be maintained for several hours
out of the 24. There may be valuable factors in the
toxemia apart from the fever. Fever produced by
baths is under perfect control. It can be maintain-
ed at any degree or for any length of time up to
two hours; it may be applied on alternate days cr
even on every third day if necessary. Baths may
bj continued daily for at least six weeks and the
patient may still gain in weight and maintain his
strength. They may be applied alone with anti-
syphilitic therapy ; it is even probable that the
hyperpyrexia tends to intensify the therapeutic
effect of the antisyphilitic medication.
Fever resulting from baths can be maintained for
one or even two hours without danger to the
patient. It is necessary to raise the mouth tempera-
ture to at least 104 F., sometimes as high as 107 F.,
and to maintain it for one hour in order to obtain
clinical results. Most patients gain in weight, and
show an increase in hemoglobin and reticulocytes and
in their permeability quotient. Neurosyphilis seems
t(. offer the most favorable field for treatment by
hyperpyrexia. The results compare well with those
obtained by malaria therapy. Frequent amelioration
of individual symptoms was obtained in Parkinson's
syndrome following encephalitis, as well as in com-
bined sclerosis. Pain resulting from minor disturb-
ances in muscle, nerve and joints proved especially
amenable to treatment by heat. No results were
obtained in amyotrophic lateral sclerosis. Fever
therapy may be used to intensify the effect of anti-
syphilitic medication,
Technic. — Our technic consisted of immersing the
patient in a bath at 110 F. With timid patients or
on the occasion of the first bath, the temperature
'.'.as sometimes started at 105 F. Ordinarily, 110 F.
was maintained until the temperature of the patient
reached a point within a degree and a half of the
fever desired. Then the temperature of the bath
water was gradually reduced until it corresponded
with the temperature of the patient. The ordinary
hath lasted one hour, but when indicated, it is feasi-
ble to maintain the patient's fever for another hour
by wrapping him in blankets and placing a few hot-
water bottles in the bed. Liquids may be administer-
ed by mouth, but they must be hot. Most of our
patients received one bath daily. A few patients
received two daily, but we were not convinced that
this was good practice except in unusual cases. The
ordinary series was fourteen baths followed by a
period of rest. At times, twice this number were
given consecutively with no added difficulty. In
Some conditions other than neurosyphilis, it seemed
preferable to give a bath every other day, or rarely,
every third day. — H. G. Mehrtens and P. S.
PciiPPiRT, Arch. Neurology and Psychiatry, Oct., 1920.
DIDN'T WANT JOB: WIFE SENT HIM
Lemuel shuffled into the employment office down
in Savannah one morning and said hopefully:
"Don' spose you don' know nobody as don' want
nobody to do nothin', does you?" — Boston Tran-
script .
KEEPING THE COUNT CORRECT
Golfer — "Hi, caddie! Isn't Major Pepper out of
that bunker yet? How many strokes has he had?"
Caddie — "Seventeen ordinary, sir, and one apo-
plectic!"—/"aum J Show.
HI
SOUTHERN MEDICINE AND SURGERY
November, 1920
The Iodine Content of South Carohna Foodstuffs*
Hugh Smith, M.D., Greenville, S. C.
A man with ideas, if no idle dreamer, may
by dint of hard work develop his ideas and
live to see them materialize. In Columbia,
S. C, Dr. William Weston, one of our states
leading pediatricians, has for the last ten
years been dreaming and working. Tonight
it is my hope to familiarize you gentlemen
with some of the work being done by the
South Carolina Natural Resource Commis-
sion: an idea of Weston's come true. .,;
Brietly, the origin of this commission dates
back to the legislative session of 1928. At
this time money was appropriated for an in-
tensive investigation of the mineral elements
in South Carolina grown products. A com-
mission was appointed with Dr. Weston as
chairman. Dr. Roe Remington, a chemist
of national recognition, associated with the
University of Minnesota, was employed by
the commission to direct this survey. A lab-
oratory was established by Dr. Remington at
the Medical College in Charleston. He has
been actively engaged in this work now for
several months. The results, so far obtained,
are in many ways astounding: and one may
only conjecture the ultimate outcome of this
investigation.
I am not going to talk of thyroid disease
in any usual sense, but to offer some the-
ories on the development and prevention of
goiter, which to many of you may be of in-
terest.
"Historically, goiter is as old as our knowl-
edge of the human race. Fifteen centuries
before Christ it was a problem in China.
They learned to use burnt sponge and, it is
said, to use the thyroid substance of animals
in its treatment. Hippocrates, Galen, and
Pliny wrote of the use of sponge ash in such
cases. "^
The symptoms of goiter in its many phases
we pass over as irrelevant to our subject.
The prevalence of goiter is so world-wide that
any contribution to its control becomes at
once of international importance.
.\ recent estimate places the number of
jjersons with goiter in the United States at
30 millions. Those of us who practice medi-
cine in South Carolina have long known that
goiter is relatively a negligible factor in our
work. For instance, in a practice made up
of referred patients entirely, I have a goiter
incidence of less than 2 per cent. What is
the answer? You are all familiar with the
failure to prevent or control goiter by the
use of inorganic salts of iodine in such forms
as iodinization of municipal water supplies,
iodized salt, and the therapeutic use of iodides
in school children. Recent studies by Ma-
rine, Lenhart, McClendon and others suggest
that the iodine to be effective must be taken
in some organic form. The science of nutri-
tion shows that plant metabolism prepares
the various minerals, iodine, phosphorus,
manganese, copper, iron, etc., in a form highly
suitable to human economy. For instance.
Marine has demonstrated that rabbits fed
e.xclusively on a diet of boiled cabbage,
grown in goitrous areas, develop goiter:
whereas feeding the same cabbage raw, or even
with the raw juice over the boiled cabbage,
prevents goiter. Certainly the heat neces-
sary to boil cabbage does not destroy the
iodine, but either it materially alters its
chemical structure or it destroys plant vita-
mines or enzymes essential tor its proper
metabolism.
In 1811 iodine was discovered by Courtois
of Paris.
In 1820 Coindet, of Geneva, first used it
deliberately in the treatment of goiter.
In 1852 Chatin made the observation that
goiter was more common in those regions
where the soils and waters were deficient in
iodine. This observation has been frequently
confirmed.
From 1922 to 1927, McClendon, of the
University of Minnesota, published a series
of articles which were largely responsible for
crystallizing the relation between soils and
foods deficient in iodine and the geographical
incidence of goiter.
.Anyone familiar with the incidence of
goiter recalls at once that in the midwest.
♦Presented to Buncombe County (N. C.) Medical Society, Asjieville, June, J929,
November, 1020
SOUTHERN MEDICINE AND SURGERY
763
Great Lakes section, .and northwest, there is
a very nigh percentage oi young people witn
goiier. i'or instance, in a survey of high
bcnooi girls tne incidence ranged from 40
per ceiii in Grand Kapids, and in Cincinnati,
iiirougn 3U per cent in Topeka, 54 per cent
lor iiie iiaic 01 Utah, and to 73 per cent in
bi. laui. ine war dratt in 191/ revealed
liie reiiiarkaoie lact that men Irom ijoutn
Laioi.i.a ai.u uie ouit btates were practically
\vuiioui gouer. H recent survey of Soutn
Laiuiuia ii.gn scliool girls, undertaken by our
biaie i>oaiu oi Healtn througn its held rep-
reseniauves, showed less than 6 per cent with
any perceptible thyroid enlargement. If
L'hatm s observation is true and AlacLendon's
work seems absolutely contirmatory — the
cause must be in natural resources of South
Carolina.
Remington's earlier observations disclosed
remarkable variations in the iodine content
of foods grown in different localities.
Parts per billion, dry basis:
S. C. Call). Oregon
Spinach 694 26 19.S
Asparagus 285 12
Carrots 107 8.S 2.3
Other joods grown in South Carolina show a corre-
spondingly high iodine content:
Lettuce 761 Potatoes 211
bquash 716 Cucumbers 523
binng beans 429 Okra 433
Turnip greens 433 Cabbage 300
and so on to Broccoli showing 1,603.
Apparently, the South Carolina Natural
Rcbource Commission has proven that the
reason South Carolina has so few goiters is
because South Carolina grown foods contain
sufficient iodine in projjer form to prevent its
development. VVe believe that there would
be no goiters in our state if all our people
ate a proper amount of native grown leafy
vegetables and tubers. Unfortunately, we are
cursed with the common faulty diet based
largely upon a meat and starch intake, and
therefore, a large number of our people sub-
sist on a diet deficient in many essentials.
This is only too clearly shown by the high
incidence of pellagra in South Carolina. Still
it is remarkable, when one considers the fact
that with so many of our people living on a
diet grossly deficient in many factors, that
we do have so few people with goiter. The
jocjine requirement necessary to maintain an
lodaie balance has been e.xperimentally de-
iciiiiiiiea uy ur. J:''eilenDerg, of Switzerland,
at 14/ micrograms per day. Remington has
determined, on this basis, that a diet con-
taining 4 oz. green vegetables, 8 oz. potatoes,
ana t oz. root vegetables would yield ^lu
micrograms, or 15U per cent ot Felienberg s
lequueiiieius. inerciore, a simpie way ui
preveutiiig goiter is to eat dauy one root
vegeiauie, one leaty vegetable, and one potato
giuvm ill a region where the iodine suppiy is
ciuequaie.
11 iiicse observations are true, and South
Carolina grown vegetables do contain suiii-
cieiu iodine to prevent goiter, you can readily
appreciate the duty and obligation oi this
state to the country at large. VVe must ac-
quaint tne people in the goiter area with the
peculiar virtues ot our loods, and then must
be prepared to supply the demand that will
result. (July last week 1 was told that one
Laiining plant in lower South Carolina had
shipped to Calilornia and Oregon four car-
loads ol canned string beans, wrapped in a
label stating the fact that they were grown
in South Carolina.
We do not know as yet a great deal about
pernicious anemia and sprue. I tell you con-
lidently that they are rare in South Carolina.
I have seen only one case of sprue and four
cases of primary anemia in the ten years I
have practiced in the state. Dr. Robert
Cathcart, of Charleston, tells me that South
Carolina has the lowest cancer incidence in
the United States. Is it not possible that
our natural resources may explain these
facts? While, so far, the commission has
done no work on the other minerals, such as
iron and manganese, some preliminary deter-
minations give us reason to believe that they
will be found correspondingly high.
Gentlemen, I represent no part in this in-
teresting work, and have quoted extensively
from Weston and Remington throughout.
The hypersensitive individual comes early
for treatment and begs relief; the insensitive
person is relatively unconscious of his afflic-
tion and appears only when a major compli-
cation makes it impossible longer to deny the
existence of a morbid process. — B. B. Crohn,
Amer. Jour. Surgery, Oct., 1929,
SOUTHERN MEDICINE AND SURGERY
November, 1929
Mastoiditis as a Cause of Diarrhea in Infants*
William Lett Harris, M.D., Norfolk, Va.
Wiihin tlie lasi lour or live years ttiere
iias oecii a gieaL deal wrmeu upon uie suD-
jeci oi lotai imecuoiis oi uie upper respira-
lory iract iii nuaiits and young cnildren, and
especially nave we oeen struck Dy tne claims
ui many writers oi tne middle west . . . nota-
Diy, uoctors Marriott, Lyman, Dean, Jeans,
noyd, Aiden and otHers, as to tne relation
01 mastoiditis to tne gastro-intestinal disturb-
ances oi intants. ine especial syndrome
tney reier to tney call cholera inlantum —
an acute watery diarrhea with nausea, anhy-
dremia, vomiting and rapid loss of weight,
accompanied by great prostration, high fever,
103-1U5, and an inabihty to retain food or
nuids by mouth or bowel. Some writers refer
to a milder type of infection, producing
anorexia, failure to gain, excoriated buttocks,
marasmus, athrepsia or infantile atrophy.
Most of their cases have occurred in the late
lall and winter months, and are chiefly in
iniants under one year of age. The great
majority of these cases are among artiiicially
led babies and, of course, being chiefly in
St. Louis and the adjacent territory, they
probably are for the most part taking lactic
acid milk and Karo corn syrup. I wonder
if this could possibly have any bearing upon
the prevalence of this condition?
The chief claim of all these writers is that
when you see this peculiar chain of symp-
toms, if you examine the ear carefully, you
will see either nothing at all unusual, or a
sagging of the posterior-superior canal wall.
If you open the ear drum you will probably
get nothing at all, but if you open the an-
trum you will often find pus; and, in a cer-
tain number of cases, you will get a most
spectacular relief of symptoms. The opera-
tion— antrotomy or post-auricular drainage —
is best done under local anesthesia. The in-
dications for operation are not at all clear-
cut. It is often referred to as masked, oc-
cult, obscure, or hidden mastoiditis; but
always to be found by going in and looking
in the right place. The x-ray does not show
anything; the bioud count is usuauy n^gii,
but tnat gives no special assistance as it may
be hign in many severe leeding disturoauccs.
Ihis IS not based upon my own personal
experience in the matter; parapnrasing
wnat Will Kogers might say, an i know
upon tne subject is what 1 nave read in ine
journals and what little i have lound out m
treating many thousands of cases oi diarrnea
of all kinds and descriptions during the last
twenty-five years.
Since Doctor Marriott's first article upon
the subject, I have watched faithfully for the
kind of case he describes and several times 1
have thought that I had a real case; but in
each instance the condition cleared up under
infusions, transfusions and other dietetic
measures.
The shocking thing about most of the sta-
tistics is the frightful mortality recorded by
the various writers on the subject. Some of
the earlier operators record a 90 per cent
mortality. Many of even the most recent
articles upon the subject record a mortality
from 25 to 40 per cent. This is horrible. 1
know of no such mortality from any
disease except tuberculous meningitis.
The operators try to console themselves by
saying more would have gotten well had they
operated earlier and that without operation
practically all would have died. Doctor Mar-
riott has undoubtedly proved his case in a
certain number of instances, but I think the
prevalence of the condition is greatly exag-
gerated. Doctor Marriott in some of his most
recent articles is not quite as radical as he
was, but some of his followers seem to be
more so, due f)erhaps to immature experience
which further study may tone down.
My search of the literature on the subject
makes it evident that the writers on this sub-
ject do not always convince the readers that
the diagnosis of mastoiditis has been estab-
lished beyond a reasonable doubt. These
cases are treated vigorously in a medical way,
both before and after operation, by infu-
*Presented to the Seaboard Medical Association, meeting at Washington, N. C, December,
November, 1929
SOUTHERN MEDICINE AND SURGERY
76S
sions, transfusions, etc., so why are we jus-
tified in giving the small surgery the credit
for the cure? We know that a child may
recover on account of a mastoidectomy; we
know that he may recover without an opera-
tion, and we further know that he may re-
cover in spite of an operation!
Retained pus such as boils, abscesses,
empyema, and mastoiditis with frank, clear-
cut symptoms, does not cause any such cham
01 sympcoms. It is so easy to follow a leader
m any field lor sometfting new; it is very
nara lor enthusiasm to be unbiased, and we
seem always able to lind cases to ni our bias,
loo many men alter hearing papers read
upon the subject by the St. Louis school,
become over enthusiastic and want to operate
upon every gastro-intestinal disturbance that
does not get well, regardless of clinical find-
ings.
Diarrheal diseases have almost disappear-
ed since better feeding has been introduced.
It is no longer a problem with us either
winter or summer. There is practically none
from October to May, except an occasional
epidemic of a mild type which we often see
during an epidemic of influenza or other up-
per respiratory infections. I have never seen
a fatal case of this type and my patients are
not fed upon lactic acid milk and Karo, nor
are their mastoids operated upon unless a
1 don't know why we do not have the cases
that so many men in other sections say they
find. I am sure we have as many colds as
ever. I cannot claim that our babies are
better fed. I do claim though that since we
have had a high class local milk supply and
have paid greater attention to proper feeding
among every class of society, our serious
diarrheal diseases have disappeared. Its
causal relation cannot well be disputed in the
light of these proven facts.
Deaths from diarrheas and enteritis under
two years in Norfolk (a city of close to 200,-
000) during the last five years:
White
Colored
Tot;
1923 -. . .
. 15
2i
38
1024
■;
20
39
25
1925 . - .. _
9
48
1026
S
25
30
1927
3
37
40
The mortality from mastoiditis and its com-
plications does nut reach two per cent of cases
operated upon, so how can we account for
the cases iiiai are louiid lu oiuer sections oi
ine country in wiiicn mere is sucn a irigntlUi
iiiorianiy under sucn raOicai, moacm and
scieiiiuic treatment as tne writers describe.''
jjoctor inairiOLi Claims tnat in uis e.>;pen-
eiice, oj per cent oi an cases oi diarniea is
due to parenteral causes. lUis is ceriaiiiiy
iioL in accord With our experience aruunu
iNonoik, else wny snouio better niiiK auu uci-
ler leeduig reduce our mortality iiioie ihah
two-tniros witnin the last twenty years .'■•"'•'''
ihe term, cholera iniantum, to express thik
gastro-intesiinal syndrome seems to me a
most uniortunate one, tor the older men nere
who have seen true cholera inianium' as 1
saw It twenty-five years ago, know it is a
disease of hoi weather and due to a gastro-
enteric intoxication which experience has
proven beyond a doubt to be of dietetic
origin.
A recent issue of the Virginia Medical
Montnty nad this to say on tne subject oi
tne passing oi cnoiera intantum. "iwenty
years ago, 4,uUu children under five yeai's
oi age died in i\ew iork City each summer
01 cnoiera iniantum. in 19/7, tnougn tne
population was bU per cent greater than in
ivul, only 240 children under hve years died
ol this cause. Compulsory pasteurization of
the city's milk supply inaugurated in 1913,
and the work of the division of child hygiene
since it was organized in 1914, have con-
tributed largely to this decrease. " It seems
that antrotomy or mastoidectomy is not even
mentioned.
To give you a clearer idea with what skep-
ticism many of the leading pediatricians of
the country view this subject I wish to quote
freely from some of the discussions of soivie
of the most recent papers on this subject:
Doctor Abt (discussing Doctor Marriott's
paper, "Observation Concerning Nutritional
Disturbances in Infants.") "There is a large
group of nutritional disorders which depend
upon food disturbances and another group
that depend u|X)n enteral infectiims. These
facts have not been disproved and I am sure
the essayist would not wish to be understood
as saying that the diarrheal diseases occurr-
ing in the summer months are due for the
most part to parenteral infection. It seems
to me it is timely to call attention to the
766
SOUTHERN MEDICINE AND SURGERY
November, 1929
role of the mastoid infection as a cause of
intestinal disturbances, but on the other
hand, it would be a mistake to exaggerate
the Situation. A great many mastoids might
be opened unnecessarily. It is not always a
sample operation to open the mastoid. Often
the condition which follows the operation be-
comes more serious than if a more conserva-
tive plan had been followed."
Doctor Morse (discussing Doctor Mar-
riott's paper) : "Doctor Marriott has un-
doubtedly proven his case in a certain num-
ber of instances. This does not indicate,
however, that all cases in which there is
dehydration, fever, prostration and diarrhea
are due to mastoid infection. If the mastoid
were opened in all the cases in which these
symptoms were present. I feel sure we would
be jumping out of the frying pan into the
fire. Again, why is it that if these symptoms
are due to mastoid infection, they are not
present in many cases of known mastoid in-
volvement? .As a matter of fact they are
most unusual in mastoid infections secondary
to acute otitis media."
Doctor Morse (discussing paper by Doc-
tors Jeans and Floyd . . . "Cholera Infan-
tum."): "The point is not that when there
is a diarrhea it is due to mastoid disease, be-
cause the chances are that it is not due to
disease of the mastoid or sinuses. The im-
portant things to remember are that diseases
of the mastoid and sinuses are more common
than is usually realized, and they may be
accompanied by a diarrhea. We ought to go
away, not with the idea that every diarrhea
is caused by a disease of the mastoid or
sinuses, but that the disease of the mastoid
and sinuses may be accompanied by a diar-
rhea."
Doctor Mitchell of Memphis (discussing
paper by Doctors Jeans and Floyd . . . "Chol-
era Infantum."): "I am glad the authors
state that they do not attribute all cases of
alimentary intoxication to this type of paren-
teral infection, as I fear the good points in
the paper might have been overruled by this
statement and an erroneous impression
gained. I cannot consider the drainage of
the mastoid a minor operation and I fear
that, unless a careful analysis is made in
each case, many mastoids would be drained
vselessly. The salient point in this paper is
that this type of infection sometimes does
produce cholera infantum, and that unless a
careful and routine e.xamination is made this
condition is overlooked."
Doctor Gengenbach, Denver (discussing
paper on "Cholera Infantum" by Jeans and
Floyd) : "It seems that the authors made a
rather pointed remark when they said that
practically all of their patients were artifi-
cially fed babies. If the immediate cause of
diarrhea is the mastoid, why should not there
be diarrheas more frequently in the breast
fed, too, despite their increased resistance to
infection . . . they also have frequent head
colds?"
Doctor De Buys, New Orleans (discussing
Doctor Sidbury's paper on the subject): "I
have about come to the conclusion that New
Orleans is about the best place to live. With
the population we have, we do not see as
many of these cases as these excellent observ-
ers are finding in other sections of the coun-
try. I do not think it is due to our lack of
ability or neglect of the ears in making a
diagnosis, for we do not simply look at the
ear one time, but we make daily observa-
tions. Just how frequently this condition
does occur, I do not know, but it is a clinical
condition which requires a great deal of con-
sideration."
Doctor Helmholtz (discussing same pa-
per): "Undoubtedly, you can find in any
number of cases of athrepsia or marasmus
some material that looks like pus in the cells
of the middle ear and mastoid . . . some is
undoubtedly pus, some when examined micro-
scopically is not pus. There can be no doubt
that infection . . . not necessarily of the head,
but anywhere in the body, plays a very much
larger role in nutrition than we pediatricians
have realized in the last ten years. The em-
phasis that has been put on the mastoid by
Doctor Marriott, should be put on infections
in general."
Doctor J. Ross Snyder (discussing same
paper) : "The members of this section
should weigh very carefully what has been
said here today by our leading pediatricians,
or some very false impressions will go out.
Until today I have regarded myself as a pro-
gressive pediatrician, but I find that I am
away behind when I am told that every child
who is sick . . . except club-footec} chil4ren,
November, 192Q
SOUTHERN MEDICINE AND SURGERY
767
should be transfused. I find that I am away
behind when if lactic acid and Karo syrup
do not cure a child, 1 am told that you should
turn him over and bump open his head, and
if no pus is found open up the other mas-
toid."
Doctor Marriott states that at one time
there were il infants (feeding cases) in one
of the wards of one of the St. Louis hos-
pitals, and twenty-eight of them had been
operated upon for the drainage of the an-
trum.
Dixon of Kansas City . . . "The Cause of
Death in Mastoiditis" . . . } . A. M. A., Octo-
ber 27, 1928, takes up the subject of mas-
toiditis in general and handles it in a most
practical, intelligent and common-sense man-
ner. He says that the anxiety aroused by
this disease has been entirely out of propor-
tion to the mortality rate. He quotes Kerri-
son as stating that in any large series of pa-
tients operated upon by competent aural
surgeons, the mortality rate does not exceed
one or two per cent. This fact should be
borne in mind if a balance that is necessary
for the fair and honest treatment of all cases
is to be maintained.
Doctor Dixon refers to the startling claim
made by Marriott and others that 85 per
cent of all gastro-intestinal and nutritional
disturbances in recent years have been due
to infections of the ear, nose and throat.
Granting that this is true, is it fair to assume
that operations on the mastoids of these in-
fants is the proper treatment when Renaud
reports that he lost nine of his first ten cases;
Lyman and Alden had eight deaths and seven
recoveries out of their first series, and eight
deaths out of 42 in a later series.
Coates in a recent discussion on infantile
mastoiditis, makes the following concise
statement: "That a bilateral mastoid oper-
ation should be performed by the otologist
on apparently normal ears, on the simple
demand of the pediatrist, as I have heard
recommended in open meetings is, I think,
dangerous to reputations of both specialists,
to say nothing of the welfare of the patient."
Dixon further states in reference to pcjst-
auricular drainage or antrotomy: "In recent
years the comparative safety of operative pro-
cedure has, however, in my opinion, prompt-
ed the over zealous use of surgery out of all
proportion to the benefits derived. Diagnos-
tic skill and surgical judgment seem to be
having trouble keeping pace with the thera-
peutic demand and surgical technique."
Doctor Dixon further states after review-
ing the subject of the gastro-intestinal com-
plications of mastoiditis: "The only reason
for operating upon these sick infants that I
have been able to see is that they would
probably have died anyway. This, of course,
always leaves much room for speculation and
argument, and I appreciate full well my in-
ability to prove or disprove the proper plan
of management of these children. Surely,
however, a study of the clinical course of
the disease, the months in which it occurred,
the prevalence of gastro-enteritis in babies
at the time, the operative observations, and
particularly the observations at autopsy,
should make one reluctant to accept the
small amount of infection in the middle ear
as a primary cause of death in these chil-
dren." He then quotes Doctor F. C. Helwig,
pathologist at the Children's Mercy Hospital
in Kansas City: "I have been forcibly im-
pressed by certain striking facts which have
been brought by routine post-mortem exam-
inations of infants at the Children's Mercy
Hospital in Kansas City in the past two
years. There is an appallingly high per-
centage of infections of the middle ear and
antrum in infants dying from every variety
of acute, subacute and chronic infections (for
example, broncho-pneumonia, long standing
feeding cases, rickets, congenital syphilis and
other congenital diseases) in which there is
a marked lowering of resistance and extreme
debilitation. In these cases the ear involve-
ment is obviously secondary and in many
cases terminal, which can readily be shown
not only from the gross appearance, but from
microscopic examination of the living mem-
brane and bone from middle ear and antrum.
In view of the astounding high percentage
of chronic secondary and terminal infections
and the histological picture delineating a
probable secondary or terminal infection
even in acute diarrhea, I feel we have not
yet made sufficient study to warrant our ad-
vocating mastoidectomy in these cases."
In conclusion I wish to state that I have
not attempted to prove or disprove that mas-
toiditis may cause diarrhea of the kind de-
768
SOUTHERN MEDICINE AND SURGERY
November, 1929
scribed. However, in the light of my own
experience and study of the subject, and the
experience of a number of most careful ob-
servers, both in pediatrics and otology in
Norfolk, I am forced to conclude that the
condition is exceedingly rare in Norfolk.
In the light of what has been proved in
regard to focal infections in general, I think
we are not prepared to deny any special claim
by anybody, but why a vague infection of the
antrum, which is no larger than a small pea,
should cause such a fantastic chain of symp-
toms is a little more than I am able to under-
stand.
In our zeal and enthusiasm to ride a hobby
or pursue a fad, do not let us forget what is
known about the chemistry of foods and the
phys'ology of digestion. If we know meta-
bolism and foods and if we study our patients
a little more thoroughly, in my opinion,
fewer of our cases of diarrhea will seem to
need the help of surgery.
BIBLIOGRAPHY
Observations concerning the nature of nutritional
disturbances in infants, Marriott, read before the
American Pediatric Society, May 5, 1925.
The relationship of certain focal infections to gen-
eral disease in infants and young children, Mar-
riott, Annals Internal Medicine, \'ol. 1:1.
Further observations concerning the nature of nu-
tritional disturbances. Marriott, Trans. Amer.
Pediatric Soc. Vol. 37;3S, 1925.
Upper respiratory infection as a cause of Cholera-
Infantum, Jeans and Floyd, J. A. M. A., 87:220.
Mastoiditis in infants ; report of forty operated
cases, Sidbury, Southern Med. Jour., 20:713.
Infantile mastoiditis with gastro-intestinal symp-
toms, Lyman, Tmns. Amer. Laryng., Rhino, and
Olol. Soc. 1927, Vol. 33:354.
Gastro-intestinal disturbances in infants as a re-
sult of obscure infection in the mastoid, Alden, The
Laryngoscope, .■\ugust, 1925, 586.
Masked mastoiditis simulating alimentary into.xi-
cation, Floyd, Arch. Oto-Larvngology, Vol. 1:411,
.'\pril, 1925.
Gastro-intestinal disturbances in infants as a re-
sult of streptococcus infection in ears, Alden, South-
ern Med. Jour., 19:360.
Gastro-intestinal disturbances in infants as a re-
sult of obscure infection in the mastoid, Lyman and
.\lden, Titans. Amer. Laryng., Rhino, and Otol. Soc,
1925, page 67.
Systemic manifestations of chronic nasal sinus
infections in childhood, Byfield, J. A. M. A., 71:
511.
Mastoiditis as a cause of gastro-intestinal disturb-
ance in infants, Lyman, Jour. Missouri Med. Assoc,
August, 1925, 293.
The causes of death in mastoiditis, Dixon, /. A.
M. A., 91:1280.
Mastoid infection in the infant, Coats, Anns. Otol.
Rhino, and Lar\ngo., December, 1927; Vol. 36, page
921.
Paranasal sinusitis in infants and young children,
Jeans, Amer. Jour. Dis. Children, Vol. 32:40.
Complications of paranasal sinus disease in infants
and young children. Dean, Annals Otol., Rhino, and
Laryngo., March, 1923, 285.
THE BEST DOCTOR. — A good clinical history
obtained by or discussed by oneself with the
patient, and a careful physical examination
made by oneself, are still the basis of all good
diagnosis. Only one well versed in these
methods of diagnosis can find the answer to
most questions which come to him. Only
such a man can utilize intelligently the in-
formation brought by other procedures.
There are few short cuts in diagnosis. De-
sirable as it is that the time may come when
our necessary methods of diagnostic study
may be shortened, that day has not yet ar-
rived. The proper training of the student in
the fundamental methods of diagnosis, those
which he can practice, unaided, with his
hands and eyes and ears, unaided save by
stethoscope, ophthalmoscope, laryngoscope,
otoscope and microscope, is still the most
important function of the school of medicine.
Their conscientious employment in daily
practice is necessary for him who would be
a good doctor. Co-op)eration is increasingly
necessary in medicine — but intelligent co-op-
eration implies individual responsibility, and
a recognition of the like responsibility of
those with whom we co-operate. The best
doctor today is still he who can best stand on
his own feet. — W. S. Thayer, Jour. Tenn.
State Medical Asso., Oct., 1929.
VISCEROPTOSIS CAUSES FEW SYMPTOMS.
The ability of the abdominal viscera to func-
tion does not depend on their pwsition. Low
viscera function as normally as high viscera;
therefore low viscera should not be consid-
ered a cause of disease. Low stomachs, low
colons, low cecums, low livers and low spleens
are so common in healthy young adults that
diagnoses of enteroptosis, gastroptosis and
coloptosis are seldom or never justifiable. —
R. O. Moody, Amer. Jour. Surgery, Oct.,
1929.
November, 1Q29
SOXTTHERN MEDICINE AND SURGERY
Descensus Uteri*
C. S. Lawrence, M.D., F.A.C.S., Winston-Salem, N. C.
Lawrence Clinic
Since women began to bear children they
have suffered more or less from disorders of
the genital organs. Thousands of years had
elapsed before a definite plan of relief, based
upon scientific knowledge, was offered them.
J. Marion Sims of South Carolina (then
practicing in Alabama) published his results
of successful treatment of vesico-vaginal fis-
tula in 1852.
I cannot pass without mentioning the
names of a few noted southern surgeons who
blabed the trail in the treatment of gynecol-
ogical conditions which led up to the high
efficiency now obtained.
Thomas Addis Emmet of Virginia, a pupil
of Sims, was noted for his classic plastic work
on the vagina.
Nathan Bozeman of Alabama paid espe-
cial attention to pyelitis and cystitis and ca-
theterized the ureters through vesico-vaginal
fistulae in the treatment of pyelitis.
Prevost of Louisiana and William Gibson
of Maryland did much toward perfecting ces-
arean section.
Josiah Clark Nott of South Carolina de-
scribed coccygodynia.
Theodore Gaillard Thomas of Edisto Is-
land, S. C, did the first vaginal ovariotomy
and gastro-elytrotomy.
Robert Battey of Augusta, Ga., first ad-
vocated the removal of ovaries and uterine
appendages in neurotic women.
Dr. Howard A. Kelly of Baltimore was the
first to drop the stump of the cervix back
into the pelvis after abdominal hysterectomy.
Dr. J. W. Bovee of Washington, D. C,
was the first to anastomose the ureters and
shorten the utero-sacral ligaments.
In 1898 Dr. Thomas J. Watkins of Chi-
cago devised his "interposition operation."
This was one of the greatest steps forward in
g>'necology in the nineteenth century.
.\s a result of the outstanding work of
these and many other noted gynecological
surgeons, several classifications of procidentia
uteri (or descensus) have been published,
none of which has been universally adopted.
Practically every gynecologist has his own
classification. It would be well for some
definite classification to be adopted. One
well known gynecologist reserves the term,
procidentia uteri, for the final and last de-
gree of prolapsus, in which the uterus hangs
entirely out of the body, pulling with it the
bladder and rectum: another equally as good
reserves the term prolapsus for this condi-
tion. In order to systematize our records we
have adopted the following classification:
1. Retroversion oj the uterus. — In this
condition the fundus is in the cul-de-sac with
other pelvic structures normal.
2. Retroversion of the uterus with partia'
descensus. — Here the cervi.x reaches about
mid vagina and is freely movable, the vag'nal
outlet being relaxed.
3. Reversion oj the uterus with comf>!''fe
descensus. — When the cervix uteri reaches
the introitus vaginae. Relaxed vaginal out-
let and cystocele.
4. Comt>lcte procidentin. — The bodv of the
uterus with the cervix hanging outside the
vagina. Cystocele and rectocele.
TREATMENT
The successful treatment of descensus
uteri, whatever the stage, depends entirely
upwn the surgeon's knowledge of the anatomy
of the parts and the principles involved in
repair.
Briefly, the pelvic cavity is a two-story
affair; the upper represented by the broad,
cardinal and utero-sacral ligaments, the lower
by the triangular ligament or pelvic plite of
fascia, levator muscle and its fascial covering.
An organ from the (pelvic or abdominal civity
passing through these structures constitutes
a hernia, and if we keep in mind the treat-
ment of hernia of any part of the anatomy
we will be more successful in treating H">;c"n-
sus uteri. The treatment that we follow is
based upon our classification.
With retroversion, the vagina and [)e'ineum
•Presented to the Medical Society of the State of North Carolina, meeting at Greensboro, April
15-17, 1929.
SOUTHERN MEDICINE AND SURGERY
November, I020
being in good condition we simply do a short-
ening of the round ligaments, usually after
the Webster-Baldy method. If the cul-de-
sac is extra deep and utero-sacral ligaments
elongated, we shorten these ligaments after
the method of Bovee.
If the uterus is retroverted and cervix in
mid vagina and freely movable, we often do
the same operation and also repair the p)eri-
neal floor. If there is a cystocele present we
repair it at the same time, but as a rule we
do not find cystocele in type two descensus.
For type three the Watkins operation is
most usually performed, a well constructed
perineum usually resulting.
In type four (procidentia uteri) we prac-
tically always perform vaginal hysterectomy
after the method of C. H. Mayo. This oper-
ation is simple and easy to perform, usually
taking about thirty minutes. It has given
such good results that we do not care to de-
part from it.
RESULTS
This paper includes the report of fifty-five
cases operated on by us. The youngest was
21, oldest 68 — average 33, all multipara.
Eleven shortening round ligaments and peri-
neorrhaphy. Thirty-two Watkins interposi-
t'on operations. Twelve cases of type four
(complete procidentia) hysterectomy. Of the
eleven cases of shortening of round ligaments
and perineorrhaphy none has shown recur-
rence. General health has improved, pain in
the back has improved and general condition
is good. Of the thirty-two interposition oper-
ations the mal position has been corrected
in all cases, and none has recurred. One pa-
t'ent continues to be troubled with a chronic
trigonitis: this chronic condition, however,
his existed since the patient was twelve years
of age: she is now forty-one and comes back
to the clinic for treatment about once a year.
The other patients have been heard from
and most of them seen and re-examined, and
all report most satisfactory results.
The cases in which hysterectomy has been
nerformed have also been entirely satisfac-
tory. Residual urine has cleared up, the
bladder fimction is good.
Dr. C. Teff Miller. New Orleans, renorts 93
ner cent excellent results following interposi-
tion operation.
Dr. Roland S. Cron (5. G. & 0., Nov.,
1926) reports 90 per cent excellent results.
Dr. Edward Arthur Bullard {A. J. Obs. &
Gyn., May, 1926) reports satisfactory results
in 96 per cent of 77 cases interposition and
satisfactory results of 94 per cent of series
operated on after the Bissel technique.
Dr. Leo Brady, Johns Hopkins Gynecol-
ogical Clinic, 48 cases, 93 per cent excellent
results.
Dr. C. H. Mayo (operation by Bullard),
50 cases, 94 per cent excellent results.
In the treatment of this condition the ques-
tion of child-bearing must enter into the sub-
ject. In women of child-bearing age, when
the Watkins operation is performed, section-
ing of the fallopian tubes is essential, burying
the stump in the corresponding cornu of the
uterus and fixing the cut distal ends of the
tubes on the posterior wall of the uterus.
.After the menopause this need not receive
consideration.
The condition of the bladder and kidneys
must receive careful attention if one is to
get the best results in this class of work. We
find that practically all of the patients com-
ing to us with cystocele have a residual urine
with cystitis. This in turn very frequently
produces a pyelitis lowering the kidney func-
tion. We have had a few cases in old wo-
men that showed a phthalein output as low
as 10 per cent for the two-hour period. Such
cases have been going from bad to worse for
many years. We try to keep in mind a simi-
larity between this type of case and that of
the old man with a prostatic obstruction, and
to give them practically the same line of
preparatory and after-treatment. Keep the
bladder clean, flush out the kidney pelvis if
necessary and measure the kidney function
until we get it well up, before operation. The
treatment of the bladder and kidneys follow-
ing operation is most essential, the patient
should be discharged with little or no residual
urine and kept under observation until the
bladder is free from infection and residual
urine.
SUMMARY
1. It is not the obiect of this paper to pre-
sent anything new but more especially to call
attention to those procedures, the value of
which have been proven. So many opera-
tions have been devised by various surgeons
November, 1929
SOUTHERN MEDICINE AND SURGER\
771
for the correction of gynecological troubles
that I could not find tissues enough for me
to devise a new procedure. It is my opinion
that if we use a good technique already well
described we will be able to relieve more and
more of these horrible conditions, a majority
of which can be cured to stay cured.
2. .\ plain, workable classification is of-
fered.
The Rectum, With Special Reference to Carcinoma and
Hemorrhoids*
Chalmers M. \'an Poole, M.D., Salisbury, N. C.
Due often to the patient's reluctance and
sometimes to the physician's hurry, the rec-
tum is frequently overlooked both in diag-
nostic and in periodic health examination,
when it should be remembered that the rec-
tum is not merely the proctologist's concern.
To the urologist it makes possible prostatic
massage and diathermy, and is related to kid-
ney and other urinary infections. To the
obstetrician as well as to the surgeon, it is
of vast importance. To the general practi-
tioner the rectum is of interest because of
its relation to focal infection, referred pains
of reflex or pressure origin, anemia, loss of
blood, constipation, pruritus, nutrition by
enema, diagnosis by thermometer and diagno-
sis by feces examination.
When examining the rectum by inspection
we should keep in mind inflammatory swell-
ing, openings of fistulae, ulcerations, changes
in the skin, discharges, worms, condylomata,
venereal warts, fissure, polyps, prolapsing
hemorrhoids, prolapsing rectum.
Careful digital examination may reveal ab-
normal tone of sphincter — if tight suspect
fissure; or blind, internal fistula; if relaxed,
suspect constant dilatation of the canal by
prolapsing hemorrhoids or prolapse of the
bowel itself — hypertrophied papillae, inflam-
ed crypts, openings of fistulae usually in the
posterior commissure or directly opposite the
external opening, polyps, thrombosed internal
hemorrhoids, tumors, stricture, narrowing of
the lumen as a result of scar tissue, condition
of neighboring organs — cervix, uterus, adnexa,
prostate, base oi bladder, seminal vesicles,
prolapse of sigmoid, etc.
Many times the rectum is considered only
in relation to common pathological manifes-
tations, such as hemorrhoids, pruritus, fissure,
fistula, parasites, tumor or cancer. Indeed
cancer of the rectum, which early should be
differentially diagnosed from piles by the
practitioner, is all too often left to the proc-
tologist or surgeon when, alas, diagnosis is
too late. Fifty per cent of all cancers occur
in the alimentary tract, and of these fifteen
per cent are primarily in the sigmoid or rec-
tum. The most frequent site is the recto-
sigmoid juncture, and in the early stages this
condition presents few symptoms other than
bloody stools. As cancer in this location
metastasizes comparatively slowly, there may
be considerable involvement without accom-
panying cachexia and loss of weight. If
found early, chances of operative removal
are good. Age is no factor; cancer occurs
as early as the age of fifteen.
Rectal cancer tends to occur under certain
predisposing conditions, among them chronic
inflammation of the anus and simple benign
tumors of the rectum, notably adenomata.
Sixty per cent of all cases of cancer of the
rectum had a previous history of hemorrhoids.
Xext in order of frequency is polypus, then
fistula. The earliest symptoms of rectal
carcinoma are evidences of predisposing
pathologic conditions plus additional danger
signs. Early signs are a feeling of d'scom-
fort in the rectum not relieved by defecation
and bleeding; pain usually present, and
either constipation or morning diarrhei. In
the intermediate stage of development the
symptoms are constipation, or alternate con-
stipation and diarrhea; discharge of blood,
alone or mixed with mucus or pus; pain, and
Presented to the Ninth District (N. C.) Medical Society MectinR at Hickorv-, Sept. 26, 1929.
SOUTHERN MEDICINE AND SURGERY
November, 1929
moderate weight loss. Erroneous diagnosis
of cancer may result from bleeding or benign
rectal lesions, presence of tumor masses, in-
durated ulcer, and benign strictures with
weight loss, discharge of blood and pus, and
annular ulcerated tumors. The simplest diag-
nostic check in cases of doubt is radiography
of the colon, which shows distinct narrowing
and straightening of the entire rectum due
to p)erirectal fibrosis.
All cases of malignancy of the rectum
should at once be referred to a competent
radium specialist.
HEMORRHOIDS
S'nce it has been shown that a vast ma-
jority of all cases of malignancy of the rec-
tum are preceded by hemorrhoids, it is of the
utmost importance that no case of hemor-
rhoids should be lightly regarded, that all
cases snould be promptly cured. There are
many types of successful treatment of hem-
orrhoids, such as clamp-and-cautery, ligature,
injection. The majority of general surgeons
prefer the clamp and cautery method, while
many proctologists consider ligature the pro-
cedure of choice. It would be impossible to
treat hemorrhoids successfully by any single
method. My records show that of the many
cnses treated, seventy per cent were cured by
the injection method. The remaining thirty
per cent required operation and in almost
every case the clamp-and-cautery method
was used. In simple, uncomolicated cases of
hemorrhoids, either internal or protruding,
the injection method is an absolute cure; but
where there is a predominance of connective
tissue elements or indurated nodules the
needle treatment is a failure, and nothing but
removal should be undertaken.
The kind of clamo used has much to do
with the success obtained in these cases. I
have used a number of different clamos,
amone which is one of Gantt's own inven-
tJon: but of them all I have found nothing
to equal, for General use. the slmole. serrated
rlimo made bv the Frank S. Betz Co. It is
very simnle and is easilv aoolied and re-
moved. With this clamo it is not necessary
tr> le^ve suff''-'Vnt tissue to suture, for the
notrhed rond'tJon on the inner curved side
of thp bl?des allows the needle to oass a
siiffi'cjpnt denth into the tissues to suture sat-
isfactorily. I have never had a serious hem-
orrhage to follow when the suturing was
done with this clamp properly applied.
As to the injection method there are a
number of solutions which have been used
and heralded to the world by their advocates,
but, in my experience, I have found nothing
to equal the phenol solution properly com-
pounded: Phenol, 8 parts. Refined Sperm Oil,
92 parts. There is one handicap, however,
in making up this mi.xture, that is, it is not
always possible to find refined sperm oil.
Crude oil is always on the market but I
would hesitate to inject this into the veins of
any man.
THE RECTUM AS A SOURCE OF INFECTION
Common types of infection alone or in
combination are general proctitis, usually as-
sociated with colitis; infected hemorrhoids;
rectal ulceration; cryptitis, and sinuses lead-
ing from the rectum. Bacteria of rectal foci
have selective affinity for joints and occasion-
ally the heart. The most common types of
rectal foci are ulcerated internal hemorrhoids,
blind internal fistula and acute or chronic
ulceration of the anal canal.
ABNORMAL STOOL CONTENTS
Blood in stools indicates internal hemor-
rho'ds, prolapse, polyps, malignant growths,
ulcers. Organized blood suggests lesions
higher uo in the gastro-intestinal tract; un-
organized, thin blood would suggest that the
trouble is lower down.
IMucus in stools suggests ascaris infesta-
tion, cancer of the rectum, mucous colitis,
ulcerative colitis, diarrhea, duodenal catarrh,
dvsentery. enteritis, foreign body, hemor-
rhoids, impacted feces, intussusception,
polypus, proctitis, prolapse, or ulcer of the
large bowel.
Fat in stools in excess suggests occluded
bile-duct, celiac disease, cancer of the duode-
num, dyspepsia in infants and also in enteric
fever, gout, iaundice, calculus in the pancreas,
cancer of the pancreas, pancreatitis, perni-
cious anemia, or tuberculous enteritis.
IN CONCLUSION
It might be worth while to say that many
cases of sciatica and other leg pains are
caused by hemorrhoids or other rectal disease.
These pains are usually connected with weak-
ness of the legs. The two nerves related to
these pains are the small sciatic and pudic,
both of spinal origin, which simply react to
diseases of the anus and rectum.
November, 1929
SOUTHERN MEDICINE AND SURGERY
773
Resection of Prostate Gland Obstructions*
T. M. Davis, M.D., Greenville, S. C.
I wish to discuss with you a subject which
has occupied all of my spare time during the
past two and one-half years. My pursuit of
knowledge of this subject has been most in-
teresting and illuminating to me, and it has
been most gratifying to my patients — in
many cases even to the extent of a godsend.
I present to you a new method of dealing
with obstructions at the vesical orifice, which,
collectively, is called prostatic obstruction or
prostatism. A practical classification is into
(1) benign, and (2) malignant conditions of
this gland. Benign conditions are bilateral
enlargement of this gland, enlargement of
the middle lobe, and contracture of the vesi-
cal orifice.
Since Bnttini presented his instrument in
1874 urologists have endeavored to relieve
(ib'^tructions of the vesical orifice with va-
r-nus instruments designed to relieve these
obstructions without resorting to major sur-
"'(-al onerations. In 1927 Dr. Maximilian
S'prn of New York presented an instrument
'■•hirh would permit of visualization of everv
detail of the operative procedure. This in-
strument had its defects, which defects it has
been my endeavor to correct. The greatest
difficulty was found in the control of hem-
orrhage during and after the operation; many
d'fferent methods were tried and discarded
as not meeting the requirement. (It should
be remembered that all methods had to be
tried on actual cases to prove their worth;
this gives some idea of the obstacles to be
surmounted.)
I have succeeded in developing my tech-
n'cjue and armamentarium to where it is pos-
sible to resect any type of gland or obstruc-
t-on and to control the hemorrhage during
I lie operation and upon its completion to
leave the operative field absolutely free from
hejnorrhage. I hope that in the near future
it will be possible to present a generating
machine which will produce a current that
will resect and control hemorrhage at the
same manipulation.
The instruments used in resection consist
of the Stern resectoscope, which has a sheath
with a fenestrum three-fourths of an inch
long, an obturator, an observation telescope
and the working parts — a direct vision tele-
scope, a light carrier, a water conduit for
continuous irrigation, and a loop electrode.
The sheath carries a receptacle for the in-
active electrode. The loop is made of tung-
sten wire connected to the instrument by
means of a specially insulated shaft, which
is connected to a rack-and-pinion in such a
manner as to cause the loop to traverse the
entire length of the fenestrum when desired.
I have improved the loops, that a heat-pro-
ducing current for coagulation may be used
through them without damage to the loops;
this current is used to control hemorrhage. I
have also designed a special telescope which
works within the Stern's sheath and permits
the use of a fulgurating electrode to coagu-
late the bleeding points, at sites of hemor-
rhage which cannot be controlled by the
loop.
The currents used are generated by spe-
cially designed machines which produce an
oscillating current of such great rapiditv as
to rupture the tissue cells between the loop
and the sheath. The tissue removed through
the loop is not changed histologically and
permits of an accurate pathological study of
each trland removed for the determination
of malignancy. Diathermy current of the
bipolar DWrsonval type is used either
throufih the loop or by special electrode for
the control of hemorrhage by coagulating the
bleeding point.
The operation of resection is limited only
to cases in which sacral anesthesia is contra-
indicated, as cases with grave cardiac com-
plications which do not respond to treatment,
cases in which obstruction has so badly dam-
aged the renal function that uremia is im-
pending regardless of preliminary treatment,
cases with very low blood pressure in which
sudden fall would be dangerous.
Sacral anesthesia, induced by injecting
through a si)inal needle [)lace(l into the sacral
♦Presented to the Third District (S. C.) Medical Society Meeting at Laurens, Sc|)t. .3rd, 1929.
774
SOUTHERN MEDICINE AND SURGERY
November, 1920
canal 20 c.c. of three per cent novocaine
solution, is used in all cases. This produces
ample anesthesia for about there hours, per-
mitting of all manipulations necessary with-
out pain to the patient.
In middle lobe enlargement and contrac-
ture of the vesical orifice sufficient sections
are removed from the floor of the sphincter
to relieve the obstruction, usually from IS
to 25. In lateral lobe cases one or both
lobes may be enlarged. Sufficient sections
are removed from the enlarged lobes to com-
pletely remove the offending tissue, from
50 to 200 sections may be removed from
each lobe. In several cases of extremely
larw lateral lobes the time of anesthesia
would only permit of resection of one lobe,
the other being removed several days later.
Fig. 1 — A sheath; B obturatur; C examining telescope; D working parts, consisting of direct
vision telescope, water conduit, light carrier and cutting loop; E end of working parts enlarged;
f instrument assembled; loop may be seen in fenestrum. (Courtesy Dr. M. Stern.)
In malignant conditions tissue is removed at
random to give as large an opening as is
possible within the time permitted by the
length of anesthesia.
A retention catheter is left in for from 24
to 48 hours, depending upon the size of the
area resected. .\11 these resections are done
in my office as the elaborate equipment nec-
essary can not readily be moved to the va-
rious hospitals; patients are sent to the hos-
pital for several days following the operation
and allowed to return home 24 hours after
the retention catheter is removed, if they are
vo'ding a large stream. A few of the very
large bilateral lobe cases that require addi-
tional tissue removed are usually re-operated
upon in about one week following the initial
resection.
Fig. 2 — Instrument in operation. B shows instrument in urethra; enlarged cuts, upper tissue
protruding within fenestrum, loop resting upon tissue. Lower loop has passed through tissue.
In practically all cases there is freedom
from pain or even discomfort from the time
of operation; in a few there is some tenesmus
which is easily controlled with tincture of
belladonna and possibly codeine.
Eighty-nine such resections have been
done up to the presentation of this paper;
there have been no complications due to the
oneration; only one case has required cys-
totomy, this for hemorrhage in a cauliflower
carcinoma which could not be reached
through instruments on account of its posi-
tion. With the e.xception of those having ma-
lignant disease, all report that they are free
from symptoms and are enjoying a normal
sexual life. I have several in their eighties
who report a normal sexual relation.
I have had to re-operate in six of my ear-
liest cases, in which sufficient tissue was not
removed. This should hav^ Ije^n expected
November, 1929
SOUTHERN MEDICINE AND SITRGERY
lis
Fig. 3 — Cutting loop as seen through direct vision telescope in various stages of operation,
resulting in gutter formation.
Fig. 4. — Artist's sketch of prostate, a lateral lobes, vesical aspect; /) lateral lobes encroaching
upon posterior urethra; c diagram showing lateral sections, several sections in floor of sphincter;
e, j vesical and urethral views showing reduction of lateral lobe encroachment.
Fig. 5 — Component parts of author's instrument lor the control uf hemorrhage; A
resectoscope sheath; B right-angled vision telescope with light carrier; C electrode deflector and
water conduit; D electrode conduit; E Bugbee cold cautery electrode.
SOUTHERN MEDICINE AND SURGERY
November, 1Q20
Fig. 6 — Author's instrument assembled and inserted within resectoscope sheath.
rating electrode tip projecting from fenestrum.
Fig. 7 — Detail of author's improvement in loop electrode; A electrode as mid? by minu'ac-
turer, straight shaft to loop on tip; B electrode made by author. Note bend n;ir loop, in silver
tubing. C insulating shaft for electrode, made of metal w^th hard rubber cor,; except for ihor'
length quartz tubing at loop end for mounting loop. D completed electrode.
Author's Note — Manufactured article depended upon shellac to hold loop rigid within quartz
tubing. Bending the silver tubing holds loop r'gid regardic s of shellac which mc'.tcd when a heit-
producing current was used allowinc loop to wobble and short.
Fig. S — Double throw triple pole switch constructed by author for changing from cuttini
current to diathermy current or the reverse. This switch permits of controlling hemorrhage
without changing wires, instruments, etc., by using diathermy current imposed through the im-
proved loop electrode.
November, 102<5
SOUTHERN MEbtClNfi ANt) StJRGERY
111
vvllh an operative procedure in which the
operator was pioneering and had to develop
h.s technique and learn from experience upon
the liv.ng subject the amount of tissue to
be removed, and in which the armamenta-
rium was not perfected as at present. Sev-
eral of the malignant cases have had to be
resected again to keep the channel open on
account of the rapid growth of the tumor, re-
gardless of the amount of radium and deep
roentgent therapy used.
It is interesting to note that not one case
which has had resection in the two and one-
half years since their operation has termi-
nated fatally. All are living and most of
them are pursuing their usual vocation. In
some of the malignant cases a prognosis of
six months appeared to be very liberal.
The success of any treatment depends upon
an accurate diagnosis: in this work it is of
unusual importance. If I leave only one idea
with you today I would prefer it to be that
it is absolutely impossible to determine the
presence of prostatic obstruction by rectal
palpation of the prostate gland: in many a
case in which palpation appears to reveal an
enlarged gland there is no obstruction, and
in median lobe obstruction and contracture
of the vesical orifice there may be a prostate
that is smaller than normal to palpation. It
is only by cysto-urethroscopic observation of
the actual conditions of the vesical orifice
and posterior urethra that conditions as they
actually exist can be determined. In many
cases there is obstruction which is not sus-
pected until revealed by cystoscopic exam-
ination.
In conclusion I wish to emphasize:
1. That the operation of resection is a
minor one as compared to the major opera-
tion of prostatectomy, and may be performed
in cases that could never be converted into
satisfactory surgical risks for prostatectomy.
2. That relief of obstruction has been as
adequate in my series of cases as would have
been afforded by prostatectomy.
3. That patients are rarely confined to bed
for more than three days following the oper-
ation. (Many have resumed their usual vo-
cations within a week.)
4. That resection does not preclude the
normal sexual existence which prostatectomy
practically destroys.
John O. McReynolds, Dallas, Texas {Journal A.
M. A., Oct. 12) says the visual organs of some birds
arc infinitely superior to those of the human species.
The enormous amplitude of accommodation,
amountinj in some cases to 90 diopters, and its mar-
ve'ous flexibility, would be absolutely necessary to
the swift fiyins bird that can liRht with accuracy on
a swincing telephone wire or catch in its beak a
minute insect moving rapidly in an ever-chanRinR
direction. The refraction of the large fast flying
birds of prey must be telescopic, and the swift and
alert martin or swallow, microscopic. In many spe-
cies the eyes are both telescopic and microscopic and
rapidly interchangeable. Turning now to the fishes,
there is a vastly different type of vision required and
one that is much inferior to that of birds. In the
ca-c of terrcstial and aerial animals, the medium
through which the vision must penetrate is for the
mi)^t |)art a highly transparent atmosphere favorable
fcr accurate vision at all distance, while the medium
for fi.shcs so definitely obstructs the passage of light
that distant vision is impossible. For these reason;
aerial animals are generally hyperopic while marine
an:mals arc myopic or emmetropic. \ somewhat
similar change may be noted in the human species,
as shown by a contrast of the myopic book reading
blond race-, of northern Europe with the .\merican
Indian and other brunet people whose activities are
outdoors and concerned chiefly with distant vision.
Among fishes the lens is almost uniformly a perfect
sphere in all states of accommodation. It has fixed
definite geometric proportions throughout the life of
the animal and retains this form after death. Its
influence in accommodation therefore depends on its
relation to the retina, its position within the globe.
In the avian eyes which McReynolds presented there
were two remarkable specimens which showed
marked differences in conformation. The owl's eye
is interesting because of the prominent part which
the cornea plays in its refraction. The cornea, being
extremely thin in its central area, yields to the
increased intra-ocular pressure and bulges forward
in a somewhat cylindrical form, thus enormously
increasing its refractive power. The crystalline Icn-.
likcwj.se is carried forward during the compression
of the vitreous and likewise contributes to the in-
crease in the refraction. The ostrich eye is in mark-
ed contrast with this, because the accommodative
requirements of this bird are much less; although
the ostrich eye is one of the largest to be found
among all terrcstial animals, it has not attained the
vi ual perfection of many of the smaller avian eyes.
The principal factor, however, in increasing the re-
fractive power in avian eyes is the change in the
anted • curvature of the crvstalline lens.
778
SOUTHERN MEDICINE AND SURGERY
November, 1929
The Treatment of Lobar Pneumonia
G. W. Black, M.D., Charlotte, N. C.
iivery one rememoers tnat Osier says
pneumonia is a aisease wnicn can not oe
lermmatea aorupny and naiuraiiy in tlie
majority ot tne cases, inis is largely true
01 tne management oi a maternity case, but
we would like to make botn classes oi pa-
tients more comlortable, and at tne same
time shorten the period of suffering in the
one case and of fever in the other.
In diagnosing pneumonia we rely upon the
history and physical findings. The blood
count with a differential is a great help and
often, in central pneumonias, establishes the
diagnosis. The initial chill after a history
of exposure is very important. Sometimes
you will find neither. The temperature
ranges from 101 to 104 in most cases. Pain
in the side and a severe cough are present.
The pulse is above 120, with a respiration
around 40 per minute. The chest shows some
restriction of expansion. In the early stage
you will have crepitant rales, with a tym-
panic note on percussion. Later you will
have dullness, still later flatness. The blood
count is usually above 20,000, with a high
percentage of polymophonuclears.
Among the therapeutic measures are open
air treatment, cold packs, anti-pneumococcus
serum, pneumococcus vaccine, and many
drugs. None of these is sjiecific, and most
of the cases will run the usual course. In
the treatment of pneumonia the combination
of some of these therapeutic measures is the
best.
After the diagnosis is made the patient
should not be bothered. A light nightshirt
is sufficient, with enough cover to keep warm.
The windows should be open so as to insure
plenty of fresh air. Do not allow more than
two persons in the room at a time. A sponge
bath once a day with tepid water is neces-
sary. If the temperature is unusually high
a tepid sponge followed by an alcohol rub.
Ice bag to head. Allow your patient to as-
sume his own position. Old patients should
not be allowed to remain in one position long
at a time.
The diet in pneumonia is sweet milk. Al-
low very littie water. Give milk when water
is caueu lor. Also give miiK wiUi tne medi-
cine, iviost ot tne patitenis do not want any-
tning at nrst. it is Dest not to lorce u upon
tnem. l never give anytning e.xcept imiK.
until after i discontinue tne medicine.
beldom is anything needed lor pain and
cough. Codeine sulpHate in y^ grain doses
hypodermically is best. Never give sedatives
or morphine sulphate. No symptomatic
treatment is needed.
SPECIFIC TREATMENT
The first time I see a suspected case of
pneumonia I give a calomel purgative and
follow this with a saline. Then 1 start the
patient on optochin (neumoquin base), 4
grains every 5 hours in sweet milk. No other
drugs are given orally. After the first few
doses the patient becomes more comfortable,
breathes easier, and the temperature falls
about one degree a day. The pain in the
side is lessened. I use mustard plasters over
the affected lobe and hot water bottles con-
tinually to the side. In addition to the neu-
moquin base I use pneumococcus immuno-
gen, 1 c.c. every 24 hrs., in some cases every
12 hrs. This produces very little reaction
and I think it does some good. For stimu-
lants I never use anything. The tempera-
ture goes by lysis and nothing is needed.
When the patient is clear of fever I
start him on cod liver oil extract or elixir
of iron, quinine and strychnine. Make him
eat plenty. Generally the patient will be out
in a chair in 7 days from the initial chill.
SUMMARY
1. Calomel followed by a saline.
2. Fresh air.
3. Tepid baths daily.
4. Mustard plasters over affected lobe and
hot water bottles to side.
5. Neumoquin base every five hours.
6. Very little water and no foods except
sweet milk.
7. Pneumococcus immunogen 1 c.c. every
24 hrs.
I have followed this treatment for the last
November, 1020
SOUtHEftM MEDtCl^rE AND SURGERY
>70
two years. My mortality in lobar pneumonia
is less than 3 per cent. I have tried other
treatments, then after 5 or 7 days start on
above and in 72 hours the patient's temper-
ature is normal. If this treatment were
given generally I believe the mortality of
lobar pneumonia would be lowered to much
less than 5 per cent.
An Investment Program for the Professional Man*
W. H. Neal, Winston-Salem, N. C.
Manager Department of Public Relations, Wachovia Bank and Trust Co.
ine greatest need in investment matters is
lor Licdr inmKmg. In these days ot Irenzied
uuaiice, 01 e.xcited discussion ot market tiuc-
tuatioiis, stock dividends, and call-money
rates, tne lundamental principles of sound
mvesiment practice have been put aside, with
tne result that the minds of the inexperienced
nave been confused and the attention of pro-
fessional men has been diverted from those
vital factors which they should hold, at all
times, of supreme importance.
In order to accomplish worthwhile results,
we must look beyond the confusion and dis-
traction of the moment, forget the disturb-
ances of the money markets and ticker tape
and consider an investment program which
leads along the clear path to financial inde-
pendence through wise, prudent and syste-
matic investment procedure.
If we could take a look into the safe de-
posit boxes of the professional men of this
state, we could there find, I dare say, speci-
mens of stock certificates revealing unkept
promises of rich returns. We could find
bonds which have failed to yield the stipu-
lated return of interest, and perhaps notes
representing personal loans to friends whose
appeal has been based entirely on sentiment
and whose friendship has been lost when
they were unable, or unwilling, to meet their
obligations. Hundreds of millions of dollars
are lost each year in the United States
through worthless investments. Imagine the
possibilities of such vast sums if they were
turned from the channels of waste and spec-
ulation into safe and sane investment man-
agement; the homes happy in modest ambi-
tion realized; the children educated, and the
comforts provided for declining years.
A DEFINITE PLAN
Clear thinking will inevitably result in the
establishment ot a definite plan, and it seems
that the lack of such a plan is one of the
major problems in the investment program
of the professional man. There are many
men with abundant incomes and with sur-
pluses to invest who have no definite ideas
with reference to their investments, and have
outlined no program for the attaining of that
goal to which so many aspire, namely, an
independent estate. Sometimes things are ac-
complished by haphazard methods, but, if
so, the accomplishment should be attributed
to luck and should in no way minimize the
importance of an organized plan. Sometimes
a person makes a lucky purchase that nets a
fortune, but for every fortune built in that
manner a dozen are lost. Our task is to work
out some method whereby a person may con-
sistently invest his money, year in and year
out, and gradually but surely come nearer to
the goal which he has set for himself. Too
many of us purchase a stock on a tip, buy
something because Bill Jones bought some
of it, or perhaps we have been on somebody's
sucker list as one who will swallow hook,
line and sinker. This is being done every
day, and would that our foresight were as
keen as our hindsight so that we might in-
vestigate before we invest. In the light of
our needs (real — not imaginary needs) we
should consider our income and the possibili-
ties of setting aside from it a fixed portion
to invest definitely and regularly according
to a pre-established plan, changing and en-
larging the plan to suit the adjustments in
our income and the changing of our needs.
There are two things to be kept in mind
♦Presented by invitation to the Ninth District (N. C.) Medical Society, meeting at Hickory,
Sept. 26, \9i9. ^
780
SOUTHERN MEDICINE AND SURGERY
November, 1929
concerning this independent estate which we
so desire. First, it must be created; then it
must be conserved. It can be created by reg-
ular additions of income derived from pro-
fessional services, by the purchase of income-
producing investments, by enhancement in
value of these investments, and by the pur-
chase of life insurance. It can be conserved
by careful management, constant analysis of
investment values and proper provision for
e.xpert attention when the owner passes on.
COOPERATION OF TRUST COMPANIES
With these thoughts in mind, I want to
discuss briefly the way in which the modern,
up-to-date trust company may work with a
professional man in helping him both to cre-
ate and to conserve the estate which he dili-
gently strives to build up. Today the well
equipped trust company is a department store
ol hnance, and its various functions are de-
signed to meet the financial needs of all those
who seek its services. P'or example, there is
the bond department, handling high grade
securities only, and with men in charge who
are experts in investment matters. These
men are not employed merely to sell the par-
ticular offerings of the bank, but their time
is at the disposal of the bank's clientele, to
help with their problems, to consult and ad-
vise, willingly and impartially, with those
seeking investment facts. If you are consid-
ering the purchase of securities it would be
well to discuss the proposed purchase with
the bond department of your bank, let them
analyze the security, its history, its market
record, its safety, its yield, its possibilities
for enhancement, and answer a number of
Cjuestions which the average person would
never think of asking. This department not
only has extensive information on hand, but
through numerous connections in the large
financial centers it can secure information
about any security that has ever been offered
to the investing public.
TRUST DEPARTMENT
The trust company which has a trust de-
partment managed by a trained and experi-
enced personnel offers to the professional man
a most valuable service, both in helping to
create an estate and in conserving that estate
as and when it is created. This service is so
designed that it not only functions during the
period of normal life, but may be extended
beyond that period to the care and protec-
tion of those loved ones who may be called
upon to carry on.
A service of the trust department which
is rapidly growing in favor with the profes-
sional man is that offered by the living or
voluntary trust plan. According to a pre-
arranged trust agreement, which may be
made to suit the particular needs of the indi-
vidual, a man may deposit with the trust
company property in the form of cash, se-
curities or real estate, provide for the man-
agement, sale or reinvestment of the property
by the trustee, allow the income to accumu-
late or be paid to himself or other designated
beneficiaries, add additional property to the
trust at regular or irregular intervals, and
provide for its final distribution in case of
death. Furthermore, the agreement may be
revoked at any time, or it may be made ab-
solutely irrevokable. Perhaps this sounds
complicated, but in reality it is a very simple
plan whereby a professional man may hand
over to the trust company the perplexing
problems of managing and investing liis prop-
erty, and yet retain the right to take back
the property at any time. Hy adoptmg a
plan ol regular additions to the principal oi
the trust he may gradually but surely bund
up a substantial estate, turning over the
troublesome details to a group oi specialists
in finance, and leaving his own mind free to
follow the practice of a high calling. By
establishing a living trust he creates a nest-
egg which is free from the ordinary vicissi-
tudes of life. The temptation to speculate
or spend foolishly is removed. While no
trustee would attempt to guarantee an in-
crease in the value of the principal trust fund,
yet there are numerous instances in which
such a fund has been greatly enhanced in
value by the careful and prudent management
of an experienced trust company.
The great advantage of the living trust is
its flexibility — the ease with which it may be
adapted to varying circumstances or designed
to accomplish any one of a number of worthy
objects. Perhaps the creator of the trust de-
sires to accomplish some specific purpose
other than merely building up a separate es-
tate. He may want to set aside a fund to
insure the education of his children or to
provide an independent income for his wife
November, 1020
SOUTHERN MEDICINE AND SURGERY
V81
or a minor child until it reaches maturity.
He may desire to establish a foundation for
an income to be applied to some educational
or religious object, or provide a means of
support for an invalid relative or friend.
These and many other worthy objects may
be accomplished most effectively through a
living trust.
LIFE INSURANCE TRUSTS
Professional men, as well as others, are
creating today potential estates at an enor-
mous rate through the purchase of life insur-
ance in ever increasing volume. We have all
learned to appreciate the value of insurance
and the protection it affords our families, par-
ticularly during that period in which we are
building up an independent estate. We cre-
ate a potential estate whenever we purchase
a life insurance policy, but I wonder how
many of us go a step further and plan for
the conservation of that estate if and when
the potentiality becomes a reality. The trust
department offers a plan known as the life
insurance trust, which will fit in with any
life insurance program, providing for the
proper use and investment of insurance pro-
ceeds, and at the same time giving protection
and aid to the benel'iciaries. We usually
make our life insurance payable to our wives,
but how many of them would know what to
do with a check for ten, fifty or a hundred
thousand dollars if it were handed to them
tomorrow? I wonder if, instead of protecting
them with insurance payable in cash, we are
not really making tnem a target for the un-
scrupulous stock salesman and the get-rich-
quick promoter. The insurance companies
have realized this danger and have offered to
pay the proceeds of policies in instalments.
This is an improvement, but it is not a flexi-
ble plan and cannot be adapted to take care
of emergencies or unusual circumstances.
By establishing an insurance trust the in-
sured may direct the proceeds to be paid to
a bank or trust company, and in the trust
agreement instruct the trustee to invest the
funds and to pay the income to the benefi-
ciaries, and in addition, to use, in the discre-
tion of the trustee, such a part of the princi-
pal as may be necessary for unforeseen cir-
cumstances: thus providing for sickness, mis-
fortune, educational expenses and other things
requiring extra funds, at the same time con-
serving the principal and making it accom-
plish the largest possible good for the bene-
ficiaries.
MAKING A WILL
Finally, every estate, irrespective of its size
or the age of its owner, should be properly
protected by a carefully drawn will. It is
nothing less than a tragedy when a man
spends his best years in building up an estate
so that the members of his family may have
some of the good things in life, then to have
that estate, once its owner's hand is released,
lost through inexperience and ignorance,
wasted in extravagant living, or become the
source of legal battles and family quarrels,
all because the owner failed to spend a few
hours in directing the proper disposition of
his estate through a carefully drawn and
properly executed will. Making a will is a
privilege conferred by law as well as a duty
and obligation which every owner of prop-
erty owes to his family. Of equal import-
ance to executing a will is the appointment
of a competent and experienced executor to
carry out its provisions. Settling an estate
is not a simple matter. Legal difficulties,
federal and state inheritance taxes, the prob-
lems of sale and investment of property — all
complicate the work of the executor, making
necessary the combined qualifications of ex-
perience, specialized knowledge, tact and pa-
tience. Our trust companies are offering just
such an executor. They not only assist their
customers in planning the disposition of their
estates either by will or trust agreement, but
also stand ready to carry out the provisions
of those documents to the best interest of all
concerned.
If an estate is small it needs the protection
of an experienced and reliable executor and
trustee so that it can be conserved and made
to produce the greatest possible good to those
for whom it is intended. If the estate is
large, then those who are to share in it need
to be protected from the potential evils of
sudden wealth. One of the greatest handi-
caps that can be placed ujwn a young man
or young woman is to have him or her come
into unrestricted possession of a substantial
estate without having acquired knowledge
of the value of money. Sometimes they
are able to weather the storm, but often they
fail, and the tragedy of the failure is that the
I&i
SOUTHERN MEDICINE AND SURGERY
November, 1020
responsibility for it rests upon the one who
thought he was amply providing for his fam-
ily. Through a will and a trust agreement
such a failure may be prevented, and when
more f)eople take advantage of this privilege
conferred by law there will be less suffering,
less misunderstanding, less wasting of estates
among families where the guiding hand and
leader has been removed.
Most of us are in the habit of thinking
that our greatest financial problem is earning
money, but from observation I am more and
more convinced that the greatest problem of
professional men is to conserve and invest
what they earn. Our banking institutions are
specialists in finance, just as you gentlemen
are specialists in medicine, and if you will
take your financial problems to the banker
whose confidence you have and whose integ-
rity and judgment you respect, you will re-
ceive assistance and counsel that will go a
long way toward solving those problems and
you will insure adequate and sympathetic pro-
tection for those whom you love should they
be deprived of your advice and guidance.
SCHOOL-CHILD TUBERCULOSIS. — Tuberculin
tests of school children of Philadelphia show
that 37.7 per cent are infected with tubercu-
losis at the age of 5 years and 90.2 per cent
at the age of 18 years. These figures indicate
that there has been no significant diminution
of incidence of tuberculous infection during
childhood to correspond with the diminution
of mortality from tuberculosis in recent years.
The intracutaneous tuberculin test is the
only accurate method of determining the inci-
dence of tuberculous infection in apparently
healthy children. Accurate information con-
cerning the frequency of infection at different
ages in children of different localities, prefer-
ably repeated at periodic intervals, would
give valuable information concerning the epi-
demiology of tuberculous infection.
Latent apical tuberculosis recognizable in
roentgenological films is often the precursor
of the adult type of pulmonary tuberculosis.
It is found in 1 per cent of adolescent chil-
dren (of high-school age) and is more fre-
quent in girls than in boys. Children with
this lesion should be under continuous obser-
vation and should pursue a modified high-
school regimen directed to prevent further
progress of the lesion.
Latent tuberculous foci in lungs and
tracheo-bronchial lymph nodes are found in
more than 10 per cent of the school children.
It may be the precursor of pulmonary tuber-
culosis. It varies from massive caseous le-
sions of serious import to firmly calcified foci,
which are evidently healed. Its significance
is determined by the size of the lesion, the
activity of tuberculin reaction, continued ex-
posure to open tuberculosis, 4ssociate4
changes in the lung substance, and the age
of the child.
Pulmonary tuberculosis by roentgenological
examination together with symptoms and
physical signs is found more than twice as
often in adolescent girls as in boys of the
same age. Our figures indicate that it is ap-
pro.ximately four times as frequent in colored
as in white children of high-school age.
The evidence we have obtained suggests
that tuberculous infection may spread within
schools but under the existing system of medi-
cal school inspection this seldom occurs. —
Opie, Landis, McPhedran and Hethering-
TON, Amcr. Rev. Tuberculosis, Oct., 1929.
Edema in Congestive Heart Failure. — Cardiac
edema can be relieved by digitalis in most instances.
In those patients in whom digitalis is ineffective,
diuresis may be produced frequently by other drugs.
01 the many diuretics at my disposal, theophylline
and merbephen, in combination with ammonium
chloride, have been most useful. In a series of 46
patients with congestive heart failure in whom
edema was not relieved by digitalis, diuretics were
successful in 25 cases, or about 54 per cent. The
greatest incidence of reaction was noted in the
rheumatic group. A striking incidence of reaction
was noted in the rheumatic group with persistent
cardiac activity. It may be that the cessation of
diuretic effect before edema is completely relieved
i:. due to a temporary depletion of blood chloride.
This appears to be borne out by two patients in the
present series. The failure of reaction to adequate
digitalization indicates a marked diminution of
cardiac reserve. Even when the patients subse-
quently reacted to a diuretic by complete relief from
edema, length of life exceeded six months in only
one instance. — William Goldrinc, Arch, oj Internal
Medicine, Oct., 1Q29.
November, 1920
SOUTHERN MEDICINE AND SURGERY
783
Arteriovenous Aneurysm*
\V. Lowndes Peple, M.D., Richmond, Va.
McGuire Clinic
Mr. C. W. C, aged 21, 5 feet 9 inches
tall, weighs 142 pounds. He is of a rather
athletic type, and is strong and wiry. There
is nothing in his own personal history nor
that of his family that has any bearing on
his present trouble.
Ten years ago he was accidentally shot
through the right thigh at close range with
a 22-calibre rifle, the bullet entering the in-
ner surface of the thigh near the apex of
Scarpa's triangle and passing out on the outer
and posterior surface at about the same level.
There was very little bleeding or swelling,
and the wounds healed quickly, confining him
to bed only four days. There was quite a
little stiffness in the thigh when he first began
to walk. When the bandages came off he
noted a peculiar thrill when his hand was
laid over the wound of entrance. It occupied
a space about the size of a dollar. When
the swelling and stiffness disappeared he re-
sumed his usual occupations and sports and
thought no more about it. He worked on
the farm, rode horseback, hunted and played
baseball without any inconvenience whatever,
ever.
He thinks there was no increase in the area
of the thrill until about a year before coming
to the hospital. He first noticed that the
area over which it could be felt was moving
upward and downward several inches, until
it was within a hand's breadth of the groin.
It was about this time that he noticed that
severe exertion would cause palpitation and
heavy beating of his heart, and that he would
be short of breadth. For the past six months
he has had occasional attacks of pain about
the apex of his heart, which he thought were
due to indigestion. None of his symptoms
stopped him from work or recreation. He
was teaching tobacco curing in Canada when
his first real trouble began. This was about
six weeks prior to admission, when he was
taken with a severe pain in the lower right
quadrant of the abdomen and upper portion
of the thigh. This lasted several days and
left him with the thrill well up in the groin
and a heavy bounding femoral pulse that
could be seen as well as felt.
After an interval of a month he had a sec-
ond spell of pain so severe that a physician
pronounced it appendicitis and advised his
going to the hospital. Instead he came home,
where the true nature of the condition was
recognized.
He was admitted to St. Luke's Hospital
October 24th, 1928, entirely free from pain
or tenderness. There was a pronounced vi-
brant thrill plainly felt along the femoral tract
from the knee to the groin. The common
femoral was very large and prominent. The
pulse was full, forceful and bounding. The
greatly enlarged vessel could be plainly seen
and felt above Poupart's ligament. At a
point just beneath the bullet wound of entry
the maximum thrill was felt and here the
bruit was also most audible. It was a very
loud whistling or whirring sound. It was
transmitted below to the popliteal region and
above to the external iliac. The character of
the pulse was shock-like. The right leg was
but slightly larger than the left, and there
were no varicose veins visible or palpable.
Though the femoral artery was large and
could be easily seen and felt, one did not see
or feel the dilated femoral vein that should
accompany it. The capillary circulation of
both legs and feet seemed equal. The dor-
salis pedis and the posterior tibial could be
easily and clearly felt in both feet and seemed
normal and equal.
Intradermal saline injections in both legs
showed wheals after SO min., indicating equal
and normal absorption.
The blood pressure in the right arm was
120/40, with a pulse rate of 75. If pressure
was made above the aneurysm there was an
immediate rise of the blood pressure to 135/
70, and a drop in the pulse to 60. This drop
in the pulse — Branham's bradycardia — was
constant and immediate. Blood pressure in
the right leg just above the popliteal space
was 300-plus /20. At the same level on the
left leg it was 150/80.
♦Presented to the Tri-State Medical Association of the Caroliaaf Md Virgini* metting »t
Greensboro, N. C, February 19-JJ, i929.
1&4
SOUTHERN MEDICINE AND SURGERY
November, 10^0
X-ray examination of the heart was re-
ported as follows: "The cardio-thoracic ratio
is 6K to 11^1 inches. Fluoroscopic exam-
ination shows a rather forceful heart beat.
The shadow of the aorta is normal, and the
action of the diaphragm is normal. Conclu-
sion: Patient has a rather marked enlarge-
ment of the heart, probably resulting from
an arteriovenous aneurysm."
Operation, October 29th, 1928.— A longi-
tudinal incision about 10 inches long a as
made, beginning a little below the base of
Scarpa's triangle and going well down
below its apex, its center being the wound
of entrance of the bullet and also the
wound of entrance of the bullet and also the
area of the loudest bruit. The muscles were
separated and the artery and vein quickly
exposed. The wound in the artery could
readily be located by a bulbous appearance
and a sudden marked narrowing of its lumen.
Above this point the artery was almost half
an inch in diameter, while below, it narrowed
to an eighth. The vein, while considerably
enlarged, was not as large as the artery.
When the artery was lifted the thrill was
intensified and the note of the bruit rose until
it could be plainly heard by the operators.
The vein was separated from the artery
and ligated high up, 21-2 inches. It was
noted that there was no communication be-
tween the artery and this vein. The artery
was then ligated above and below and the
femoral vein was then ligated below. After
this quadruple ligation, which was done with
linen, the two great trunks were divided
above and below and a dissection of the inter-
vening segment was begun. This brought
into view what had been readily felt but im-
perfectly seen before, another large vein and
a well defined eneurysm sac about the size
of a pigeon's egg. The vein, larger than the
femoral, and probably an anomalous femoral,
lay immediately beneath the artery and inti-
mately attached to it. Beneath this and a
little internal to it lay the sac. It was oppo-
site the hole in the artery and was as though
the force of the jet of arterial blood had
blown out the wall across the vein before it.
This anomalous femoral vein we also ligated
above and below with linen and then the sac
was easily dissected out. Several venous col-
laterals which opened into the sac were also
tied and divided. The six large stumps and
several little ones were examined, and as the
wound was quite dry, it was closed without
drainage.
It was noted that the pulse, which was
100 and of good volume and regularity just
before the artery was tied, dropped to 80
when the ligature was seated. In ten min-
utes it had dropped to 78, and was irregular
and rocky. It then went to 72 and was skip-
ping; in the next IS minutes it was 72 and
regular, and its volume good.
Though the whole leg was wrapped in cot-
ton and kept warm, at no time did the ca-
pillary circulation seem to differ from that of
the left foot. The pulse of the dorsalis pedis
which stopped when the artery was tied had
not returned when he left the hospital No-
vember 19th.
On December 10th he was seen again, and
at this time he was walking easily without
crutch or cane. There was no pain, soreness
or edema, and he asked to be allowed to go
to work on the 17th, just four weeks after
his d.scharge from the hospital. He has had
no discomfort about his heart, and the tumul-
tuous throbbing of his right femoral artery
has subsided.
He reported again on February 7th, 1929,
3 months after operation. His general health
was excellent. He was at his work and suf-
fering 1.0 inconvenience whatever. There
wai no edema of tlic foot or leg. The tied
femoral was much smaller and far less bound-
ing. The iliac, though still greatly enlarged,
was smaller and its pulse much d.mimshed
in intensity. His pulse was 74, and what is
very unusual, it had returned in both the
dorsal. s pedis and posterior tibial. H.s blood
pressure in the arm was 123 over 70 — a rise
of 30 points in systole, indicating a return
to normal function of the heart. A radio-
gram of his chest for comparison showed a
cardio: thoracic ratio of 5 '4 to 11'4- This
shrinkage of one-half inch in its transverse
measurement brings the heart back almost to
normal limits again.
The history and development of the ra-
tional treatment of this condition makes fas-
cinating reading, so much so that one is apt
to become ensnared in its many meshes that
extend so temptingly before one. No paper,
or even a report, seems proper unless one
pays homage to Halstead, Reid, Holman, Cal-
lender, Sir George Makins, Von Oppel, Korat-
November. 102Q
SOUTHERN MEDICINE AND SURGERY
78S
Fis. II
1 Fi-moral vein. 2. Ffiiiural arti-ry. 3. ?snonia-
I..U.S vein.
FiK. I
1. Femoral vein. 2. Femoral artery. 3. Femoral
nerve. 4. Ancmialous Femoral vein. 5. Musoulus
sartorius. 6. Musculus vastus medialis.
— ^eTno-reJl uei.'Yi
Fig. Ill
Fig. IV
SOUTHERN MEDICINE AND SURGER\
November, 1929
kow, and a number of other painstaking
gifted men, who have brought order out of
chaos in this condition. To bring the subject
to a practical basis it may be best to discuss
it under several headings:
First, Diagnosis. — With the symptoms and
signs of a bruit and a thrill, Bradford's
bradycardia, a dilated proximal vessel, and
an enlarged heart following a gunshot or stab
wound, there is little room for error, but even
in a picture less typical mistakes should occur
but seldom.
Second, Prognosis. — If there be an aneu-
rysmal sac, it carries with it all the dangers
of pressure changes, and finally of rupture
that an aneurysm does alone; but whether it
be just a simple fistula, or a fistula and a
sac combined, it carries with it another very
definite danger if left untreated over long
periods of time; and this is the dilatation of
the vessel proximal to the fistula and hyper-
trophy of the heart with serious structural
changes in both.
Third, Treatment. — This divides itself
into two practical questions. First, when
should one start? Second, how much should
one do? If the case is seen early, many ad-
vocate waiting until all local reaction has sub-
s'ded, so that dissection may be clean and
easy; and, also that collateral channels may
be developed to their maximum. If this de-
lay occasioned no risk, there could be no
question raised as to its advisability. How-
ever, as pointed out by Holman, in cases of
large fistulae, the proximal vessel and heart
changes are very rapid. And, again, the ex-
cellent result in traumas requiring immediate
ligation leads us to believe that we may have
over-estimated the importance of the devel-
opment of the collateral circulation in cases
of fistula. In regard to the second question,
how much should one do, the answer is
quadruple ligation certainly, and excision of
the intervening segment if it can be done
without undue hazard. Even with well seated
ligatures of linen or silk the condition is apt
to recur if excision is not done, by reason of
numerous branches that open into the sac it-
self.
The last question, should we tie and divide
the large normal healthy veins that drain
the part in order to equalize or balance or
stabilize the circulation? This is indeed a
trying question to decide, for when it first
firesents itself to us we have to reverse our
intellectual circulation and start our habit of
thought backward to take it in.
It is difficult at first to accept "in princi-
ple" as the diplomats say, but when one must
act upon it and accept all the attendant re-
sponsibilities, it is one of the hardest decisions
one ever has to make. One anxiously reads
Sir George Makins on "Gunshot Injuries to
the Blood Vessels." His array of fact and
argument that made it almost mandatory for
French and English surgeons in the World
War, when ligating an artery, to also occlude
the accompanying vein. He stated that liga-
tion of the artery alone was followed by gan-
grene in 40.27 per cent, whereas, simultane-
ous ligation of both artery and vein under
the same conditions gave but 24.5 per cent,
and "I speak only of gangrene from ischae
mia," he says.
One also reads of Von Oppel's remarkable
case of arteriovenous aneurysm involving the
axillary artery and vein in which three sepa-
rate operations were done in one day to ward
off an impending ischaemia of the hand.
At the first operation he ligated the axil-
lary artery just above the sac. At the sec-
ond, he ligated the axillary vein and a second
deep axillary vein and divided them. At the
third the sac was dissected out and the col-
laterals were tied and divided. After the
third operation, the pain which had been in-
tense, stopped and the hand which had be-
come blanched each time now remained pink
for the circulation had become stabilized.
All these make good comforting reading
the night before a contemplated op)eration.
There are many inviting fields to this fasci-
nating subject, for theorizing, discussion,
argument and even controversy. Time will
allow me to touch on only one of them. I
do this as a recorder only, and I call atten-
tion to it because of its practical bearing on
the outcome of these cases. I refer to the
enlargement of the proximal artery and the
heart, and will give the views of some of the
investigators as to just what brings about
these changes.
Hunter in 1762 regarded it as "due to th?
lessened work the artery had to do." Hodg-
son states that "it is due to that property by
which the size of arteries become adapted so
that of the parts which they supply." Broca
concludes that "the lessened pressure result-
ing from the deviation of blood through the
fistula call to the part a larger quantity of
Kovember, 1929
SOUTHERN MEDICINE AND SURGERY
blood and that the calibre of the vessel places
itself in harmony with the amount of blood
traversing it." Bourges thinks "the proximal
artery loses its tone through vasomotor
changes," etc. Debert thinks "it is a dilata-
tion due to a disuse atrophy, since the artery
needs no longer to contract against its cus-
tomary arterial pressure." Reid says "it
would be unusual if a simple handling of an
increased volume of blood by the pro.ximal
vessel did not lead to an hypertrophy and
strengthening of its walls."
Dr. Emile F. Holman, who has done an
immense amount of original work in this par-
ticular field of the subject, believes the en-
largement of the proximal artery and the
heart are directly due to the increased vol-
ume of blood they are required to handle
under the changed conditions. He also states
that the degree of these changes and the
time at which they appear are directly de-
pendent upon the size of the fistula. In a
large fistula we might expect marked changes
early. If the fistula is small they are less
pronounced and longer in manifesting their
presence. His statements are amply but-
tressed with the most clear-cut and convinc-
ing experimental proof.
In closing let me again pay homage to
these men who have done so much to quicken
the professional interest and to satisfy the
intellectual hunger of any who knock in ear-
nestness at this door.
DISCUSSION
Dr. G. p. LaRoque, Richmond:
Perhaps the most dramatic thing in medi-
cine is hemorrhage from a large artery or
vein. Ordinarily we expect to have disturb-
ances of circulation, and ordinarily we do
have them. Gangrene for some reason does
not happen. But arteriovenous fistula, in
addition to the damaging effect on the peri-
pheral circulation, is indicated by the im-
pending gangrene shown in some of the cases.
Perhaps the most dangerous result of arte-
riovenous fistula is dilatation of the heart.
This was discovered by __ _ It
had been overlooked by other men but is
now known to be caused by arteriovenous
fistula. Whether gangrene is impending can
be determined by the injection of salt solu-
tion. The normal disappearing time is IS
minutes, but in cases of impending gangrene
it will disappear in three minutes or even
more quickly.
My cases number ten, one of which was
congenital. Eight were due to injuries, all
of which were operated upon, and none pre-
sented any features of particular interest.
SLIDES
This shows a little girl who was sent to
an orthof)edic hospital for correction of a
deformity, one leg being longer than the
other. On examination it was found she had
an arteriovenous fistula, and the heart was
somewhat enlarged. VVe did not know the
location of the fistula, so no surgery was
done.
This case is a man forty years old shot in
the groin, forty-nine days before admission,
with a pistol bullet. He had a large hemor-
rhage at the time. He was sent to us for
the fistula. He had tremendously enlarged
veins. The injection of salt solution showed
impending gangrene. Operation was done
three days after admission, excision being
made of the whole lesion.
This is the first case I ever saw or had of
arteriovenous communication. It was oper-
ated on a half hour after it happened. The
man was shot in the groin and was bleeding
moderately. There were thrill, bruit, and
other signs of fistula. The fistula was iden-
tified here but not excised. Ordinary debride-
ment was done there. The vessels were re-
sected, but we did not do anything more than
complete debridement of the wound. I
though I had prepared his leg for a complete
amputation on account of gangrene, but the
man recovered without any gangrene. To be
sure I could follow up the case, I hired him
to work for me for two years, and at the end
of that time he had no disturbance of circu-
lation at all.
The fourth case was one of a pistol bullet
lodged in the femoral artery. He was going
downstairs late at night partially dressed,
and a man shot him in the back from above
as he was going down the stairs. The bul-
let entered the left portion of the back. We
did not know where it went. He complained
of pain in the left extremity. There was no
cord injury and no nerve injury we could
determine. The next morning we found no
injury to the nervous system to account for
the pain. The house man noted no [)ulse on
the left side. An x-ray was made, but they
could not find the bullet in the back. They
SOUTHERN MEDICINE AND SURGERY
November, 1929
then looked all over the body for it and
found it in the groin. Then we thought may-
be it had cut the artery. The blood disap-
peared from the chest in two weeks, and he
was ready to go home except for weakness in
the left extremity. Then I determined to
operate on h'm for bullet wound of the fe-
moral ve"n. The bullet had severed the thor-
acic aorta, traveled down the abdominal
aorta, and lodged in the femoral vein. The
vein, bullet and all were excised, and the
man recovered without incident.
There is one of the brachial arteries. You
have heard of considerable danger in ligating
the brachial artery on account of ischemia
and gangrene. An operation was done a num-
ber of years ago with no effect on the circula-
tion whatever.
That makes ten cases, and in summary we
can say either for recent or old injuries of
the blood vessels complete excision of the le-
s'on is called for.
Dr. J. BoLLiNG Jones, Petersburg:
I am very anxious to know the results of
this work. I had a chance to see this man.
He came in our hospital and, as the doctor
says, was diagnosed acute appendicitis. My
son was asked to operate for "appendicitis.
In going over him he readily recognized this
fistula, and I was asked to see him. I could
not make out any sac at the point of injury,
but that peculiar enlargement above the in-
jury extended away up into the belly. It
was very striking. I put the man back to
bed. He would not stay with us but left the
hospital, and the next I heard of him he was
over at St. Luke's, and I knew he was per-
fectly safe.
Years ago I was asked to see a man with
what I could not tell whether it was an arte-
rial aneurysm or an arteriovenous aneurysm
of the neck. When I saw him everybody
was waiting for him to die. The thing had
bur3t through to the skin and was hanging
over his clavicle and looked to be ready to
pop. The thing was so enormous you could
not tell anything about the character of it,
where the hole was. It was about to choke
h''m to death. I believed an interval would
occur before he was really dead, and I told
them I was going to split that thing open
and see what happened. I know now where
I lost out; it was by not having a donor. I
told an assistant when I ripped the thing
open to put his hand deep under the angle
of the jaw. I split that thing open and never
saw so much blood in my life. We started
artificial respiration, and he came back to
life. We gave him intravenous saline, and
he lived six hours. I believe if I had had a
donor we might have saved that man's life.
CORRESPONDENCE
Elizabeth City, X. C, Oct. 10, 1929.
Dr. L. B. McBrayer,
Sec. N. C. State Med. Society,
Southern Pines, N. C.
Dear Doctor:
.■\bout a week ago a Mr. Chas. Miller vis-
ited me posing as a representative of the
AMERICAN MEDICAL ASSOCI.VnON. I
am inclosing a receipt which he gave me, also
a letter from the AMERICAN MEDICAL
ASSOCL\TION which is self explanatory.
His description is as follows: about S feet
5 inches, slim, dark hair, not very neatly
dressed, of a rather nervous, highstrung and
familiar type, about 28 years old.
He also posed as a representative oi Col-
lier's and other magazines. I thought that
you might like to warn the other physicians
of the state and could if you thought it ad-
visable send this warning at some near fu-
ture time when you have occasion to write
to the Society members.
Very truly yours,
W. H. C. White, M.D.
535 North Dearborn St., Chicago,
Oct. 10, 1929.
Dr. W. H. C. White,
Medical Building,
Elizabeth City, N. C.
Dear Doctor White:
We have no authorized representative by
the names of Mr. Chas. Miller, and if you
can give us a description of the man who
called, we will appreciate it.
Accredited representatives of the .'\MERI-
CAN MEDICAL ASSOCLATION carry cre-
dentials signed by Dr. Olin West, Secretary
and General Manager. No such credentials
have been supplied to a Mr. Chas. Miller
and it is our belief that he is an imposter.
Yours very truly,
AMERICAN MEDICAL ASSOCIATION.
A. W. Stack.
November, 1929
SOUTHERN MEDICINE AND SURGERY
Some Principles in Bladder Therapy*
A. I. DoDSON, M.D., Richmond, Va.
From the Department of Urology, St. Elizabeth's Hospital
It may be truthfully said that the entire
urinary tract voices its complaints through
the bladder. Th's accounts for the fact that
when our patients apply for relief from the
bladder trouble, the causative lesion may be
found in any part of the urinary tract or
related organs.
In order that an individual may enjoy life,
the neuro-muscular mechanism of the blad-
der must receive and store urine and release
it at the desired time. It is well to review
briefly this mechanism that we may better
understand the means by which the normal
tenor of the bladder mechanism is upset in
diseases of the bladder, as well as in those
of its neighboring structures.
Young, in his Urology, gives a very concise
and satisfactory description of the anatomy
of the bladder and the mechanism of void-
ins. The anatomical division of the bladder
muscles being very indistinct. Young treats
them as one muscle, the detrusor of the blad-
der. The trigonal muscle is an entirely sep-
arate layer of muscle lying on the internal
surface of the detrusor (Fig. 1). Wesson has
shown that this muscle develops in the em-
bryo from the muscle layers surrounding the
lower end of the wolffian ducts and ureters
(Jounwl of Urology, 1920, Vol. 4, pages 279-
315). As the bladder expands, this muscle
comes to lie in the bladder. The bundles run
from the urethral orifices, being continuous
with the musculature of the ureter. As they
leave the ureter, certain bundles pass across
to meet and interlace with fibers of the oppo-
site side, forming the interureteric bar or
base of the trigone. Other bundles pass
downward converging toward the midline to
be inserted in the posterior urethra. The
internal bladder sphincter is formed from
longitudinal and transverse fibers of the de-
trusor muscle, while the striated muscle of
the urethra thickens at the level of the tri-
angular ligament to form the external sphinc-
ter. The nerve supply arises from the lum-
bar and sacral segments and is conducted to
the bladder through the hypogastric and
pudic nerves and the nervt crigcntcs. In
normal voiding the striated muscles are re-
laxed and the detrusor contracts. Young and
Wesson demonstrated that the trigonal mus-
cle, by pulling open the internal sphincter.
Fig. 1 — Successive stages in the dissection of the
trigone after maceration: V, Vesical orifice; TM,
trigonal muscle; Vr, ureteral orifice; CM, circular
muscle of the bladder; LM , longitudinal muscle of
the bladder; (/, ureter; A', opening from which ure-
ter has been removed. No. 1, normal trigone; No. 2,
the mucosa is incised behind the inter-ureteric bar
and the trigonal muscle raised from the circular
muscle, carrying the ureteral orilices with it; No. 3,
the trigonal muscle is completely separated from the
circular muscle and lifted, taking the ureter along
with it. Note the converging fibers of the trigonal
muscle entering the vesical orifice. After incising the
circular muscle it in its turn can be dissected away
from the longitudinal or outermost layer. (Redrawn
from Young.)
•Presented at the Fifth Annual Meeting of the Ex-Interns Association, St. Elizabeth's Hos-
pital, Richmond, Virginia, October 2, 1928.
790
SOUTHERN MEDICINE AND SURGERY
November, 1029
Tnuscle at vesical
orif Cce
veraTnori.
L urete
K.aTelCT
Fig. 2 — Diagrams to show the effect of contrac-
tion of the trigone in opening internal vesical
sphincter: A, trigonal muscles are shown passing
through lateral muscles of the sphincter and over
the uvual vesicae, B shows the effect of contraction
of the arc-shaped trigonal muscle, viz., to pull down
the uvula vesicae and open the sphincter. (Redrawn
from Young.)
A/
^
tt^H^ '-yW^SMf^^^f^m
^
^:
iBr
i^m
% l,\ Jl^-J
rl
L..
i '" ■
■ ^
1
^i^^^HDHSwsfl
n
y
M ■ '
Vf',
i.
Fig. 3 — Pronounced hypertrophy of the trigone
resulting from fibrous obstruction of the neck of the
bladder. In this case the hypertrophy of the trigone
added materially to the bladder obstruction.
plays a very important part in urination.
The muscle passing down into the fMsterior
urethra forms an arc, and the contraction
straightens the arc and opens the vesicle ori-
from the ureteral orifices, being continuous
with the musculature of the ureter. As they
free (Fig. 2). It will be noted that the trigone
is hypertrophied in cases of obstruction and
of inflammatory conditions of the bladder
which have existed for a long period of time
(F;g. 3). Occasionally this hypertrophy is
so pronounced that the thickened trisrone
muscle mu't be divided before the bladder
can completely empty itself. When it is nec-
Fig. 4 — Operation for relief of obstruction in hy-
pertrophy of the trigone and contraction of the neck
of the bladder. An incision is made down the mid-
dle length of the trigone, dividing the muscles and
extending through the internal sphincter area. In
this way a sufficient channel is produced permitting
the bladder to completely empty.
essary to operate upon the trigone, it should
be divided in the midline so that its function
will not be interfered with (Fig. 4). Young
has called attention to cases of difficulty of
urination following complete removal of the
muscle. Bearing these facts in mind, we can
better understand cases of pronounced blad-
der d'sturbance produced by apparently in-
significant lesions in the region of the trigone.
The continuation of this muscle with the
musculature of the ureters and its attachment
in the posterior urethra explains cases of fre-
quency of urination by lesions in the ureters
and posterior urethra without existing blad-
der pathology.
Pelouse (Journal oj Urology, June, 1925,
pages 679-687), in discussing a group of cases
which he classes as habit bladders, character-
izes the trigone as the flush button of the
bladder. In this group he described a class
of patients who, because of fear of a dis-
tended bladder, get in the habit of emptying
the organ at every possible opportunity. As
a result the trigone becomes irritable and the
bladder capacity is decreased. The treatment
nf thps" rases is quite tedious, it being first
pp^pccqrv to cecnro the absolute co-oneratinn
of the pitient and h's willingness to u^ider^o
a certain amount of discomfort while h's
November, 1P29
SOUTHERN MEDICINE AND SURGERY
bladder regains its normal size. A mild ap-
plication to the trigone and posterior urethra
in these cases is helpful. Congestion of the
urethra and trigone will also occur as a result
of excessive and perverted se.xual indulgence.
These cases are often quite difficult because
of the trouble in securing adequate history
and proper co-operation. The proper proce-
dure for treatment is evident.
Local inflammation of the bladder in the
absence of lesions in other parts of the uri-
nary tract is not of frequent occurrence.
Such lesions usually arise from traumatism,
direct extension and infection borne through
the blood stream. The most frequent causes
of bladder traumatism are pelvic operations
and parturition. I have been impressed by
the number of patients who date their trouble
from their hospital experience. Quite fre-
quently following operations and delivery, the
natient will be unable to empty the bladder.
There is no doubt that catheterization, even
under the most favorable conditions, often
produces cystitis, but it is less dangerous than
over-distention of the bladder. Marked dis-
tention may occur in the patient who partly
emnties the bladder. The distention increases
a little with each voiding and the voiding
becomes more frequent. Such bladders regain
their tone rather slowly and should be cathe-
terized and irrigated daily until the normal
tone has been re-established. It is good prac-
tice in all cases of long-standing infection to
determine if the bladder is capable of com-
pletely emptying itself.
In considering bacterial cystitis in the fe-
male, W. T. Briggs {Journal of Urology, Feb-
ruary, 1926, pages 209-218) gives a detailed
analysis of the cases of 250 patients com-
nlaining of bladder symptoms. Of this num-
ber only 86 were suffering with cystitis. In
67 cases the symptoms were the result of
kidney infection. The symptoms in 26 pa-
tients were cau=ed by stricture of the urethra,
while urethritis was the major lesion in 20
instances. I have found stricture and in-
flammation of the urethra a very frequent
r^use of bladder symptoms in the female.
Frequency and burning on urination, partic-
ularly when the urine is negative, or nearly
so, should lead one to investigate the urethra.
When the urethra is inflamed, the process
often extends to the trigone which has a
granular appearance with dilatation and tor-
tuosity of the blood vessels. The application
of a rather strong solution of silver nitrate
is most helpful in these cases. Foci of in-
fection should be suspected. I had a very
stubborn case that cleared up following the
extraction of teeth. The symptoms of 13 of
Briggs' patients were due to stones or stric-
ture in the ureter.
In the male diseases of the posterior
urethra and the prostate are frequent causes
of discomfort as well as sources of bladder
infection. I recall a number of patients who
have been entirely relieved by the destruc-
tion of urethral polyps, by the application
of silver nitrate to the posterior urethra, or
by the elimination of infection from the pros-
tate, after having suffered for months with
an irritable bladder. In the earlier stages of
prostatic hypertrophy, the symptoms are
solelv those of bladder irritability and. when
infection is added, cystitis persists until the
obstruction is removed. When cystitis per-
sists for a long time, deposits of fibrous tis-
sue are formed in the submvicosa and some-
times in the muscle of the bladder. These
deposits increase the irritabilitv of the blad-
der and greatly lessen its capacity. For this
reason freauency of urination mav persist
after all evidence of inflammatory disease has
disappeared.
Probably the most prevalent type of con-
tracted bladder is that caused by localized
panmural cystitis — Hunner's ulcer. This le-
sion occurs in the mobile portion of the blad-
der usually in the vertex, and causes constant
discomfort to the patient. The urine may
contain an occasional leucocyte and red blood
cell, but is frequently negative. Through the
cystoscope, the lesion appears as an erythe-
matous patch and stands out very clearly
when the bladder is distended (Fif^. 5). Near
the center of the area may appear one or
more superficial ulcerations. The inflamma-
tory process involves the submucosa and
often the entire thickness of the bladder wall.
The elasticity of the tissues is lost and when
the bladder is distended the mucous mem-
brane over the diseased area cracks and
bleeds. Drastic means are necessary to ob-
tain relief in these cases. The most accepted
method at the present time is desiccation
with high frequency current. The area is
?92
SOUTHERN MEDICINE AND SURGERY
November, 1929
usually not very large and is clearly outlined
but the desiccation should be carried well
outside the inflammatory area. Resection of
the diseased area should be done in those
cases that do not respond to desiccation.
m 7'
^c^
/■
^1e "
1_ =
Fig. 5 — Recurrent panmural cystitis (Hunner's
ulcer I. The saccule resulted from previous opera-
tion for resection of ulcer.
There are several problems that occupy
our attention when we undertake a study of
an inflammatory condition of the bladder. Is
it a primary or a secondary process? What
is the predisposing cause? What type of
medication will be best suited and how far
are we justified in carrying out instrumental
procedures whether for diagnosis or treat-
ment?
We designate those cases primary that are
not caused by infection in the kidneys, ure-
ters, prostate or urethra and are not respond-
ing to the persistent insults of tumor, stone,
foreign body or stagnation of urine due to
obstruction or paresis. Primary cystitis, as
previously mentioned, is most frequently due
to traumatism following injuries, pelvic sur-
gery and parturition; congestion due to ex-
posure to cold, dampness, irritating urine and
excessive venery; and to over-distention fol-
lowing operation, parturition, and failure to
respond to the normal impulse because of
timidity, as on long rides, picnics, etc. The
bacteria may enter through the urethra, on
instruments, or from contiguous structures.
.Xbsorpt'on from the bladder is very slight.
J. .\. H. MaGoun, jr., in a series of experi-
ments to determine the rate of absorption
from the urinary tract, concluded that bac-
teria did not enter the blood stream from the
normal or inflamed bladder. Phenolsulpho-
nephthalein and indigo carmine were ab-
sorbed to a very slight degree {Journal Urol-
ogy, July, 1923, pages 67-79). Therefore, in
cases showing a febrile reaction, we would not
expect the disease to be primary in the blad-
der. In elderly persons, obstruction and re-
tention should always be suspected; in men
contractures about the bladder neck and hy-
pertrophy of the prostate, while in women
cystocele and procidentia may cause the same
condition. Stones, tumors, diverticula and
strictures should be thought of in all cases
especially of long standing.
Probably the mc*;t important medicinal
procedures in all cases is a free intake of
fluids and the changing of th(. reaction of the
urine. No irrigation is better than a free
flow of urine, and no bacteria can flourish in
an environment the reaction of which is con-
stantly being changed. An identification of
the causative organism will aid in determin-
ing the reaction most to be desired. The
colon-typhoid group, the tubercle bacillus,
and the bacillus lactis-aerogenes are apt to
be found in cystitis with an acid urine, while
the cocci, the bacillus proteus group, and
the salmonella ammoniac are productive of
an alkaline cystitis. Acid cystitis is milder
and more responsive to treatment, — with the
exception of the tuberculous — than alkaline
cystitis. Alkaline cystitis is often severe and
the urine is very dirty. In long standing
cases calcium deposits are found in the blad-
der at times covering ulcerated areas and
again forming into stones of considerable size.
(Fig. 6).
Drugs are of doubtful value in the treat-
ment of urinary tract infections. In my own
experience, acriflavine is more helpful than
any other. Edwin G. Davis has shown ex-
perimentally that proflavine and acriflavine
administered by mouth in .05 gm. doses to
normal individuals is excreted in the urine
in sufficient concentration to render the latter
an unfit culture medium for colon bacillus
and staphylococcus. In acid urine the effect
is inconstant. ("Urinary Antisepsis — the
Secret'on of .Antisentic Urine by Man Fol-
lowing the Oral .Administration of Proflavine
and Acriflavine." Journal of Urology, March,
November, i^i^
§6tJttiEkN MEbtCiNt ANi> StiiGfefeV
i^i
1921, pages 215-223.)
In a series of experiments on rabbits,
Helmholz and Field tested the therapeutic
value of mercurochrome, hexamethylenamine
and hexylresorcinol in experimental urinary
infection in rabbits (Journal oj Urology,
April, 1926, pages 351-362). They found
hexamethylenamine to be superior to mercu-
rochrome and hexylresorcinol as a urinary
antiseptic in cases of infection produced by
staphylococcus albus and the colon bacillus.
Fig. 6 — Calcareous cystitis. Calcareous forma-
tions talvc place on ulcers of Ions standing associated
with alkaline urine and frequently with retention.
Hexamethylenamine must be administered
in sufficient dosage to produce a formalde-
hyde concentration of at least 1-20,000 to be
even inhibitive to the growth of bacteria.
Only about sixty per cent of urotropin is
eliminated by the kidneys, consequently the
fallacy of administering urotropin, cystogen,
etc., in doses of five to ten grains is evident.
Since acriflavine is more effective in an alka-
line medium and urotropin is effective only
when the urine is acid, I have adopted the
custom of using these two drugs according
to the reaction of the urine.
Local medication consists in drainage, ir-
rigations, instillations, and topical applica-
tions. Local treatment is rarely indicated in
acute cystitis when drainage is good. The
predisposing cause having been removed, the
disease will usually respond to changing the
reaction of the urine and to forcing fluids.
When there is retention of urine, bacteria
multiply and accumulate very rapidly and
drainage is of first importance. In cases of
acute retention from trauma or over-disten-
tion, frequent catheterization and irrigation
will usually suffice. When the bladder tone
is returning, it is well to catheterize following
voiding, so that the progress can be checked.
It will usually be found that there will be a
decrease in the residual from day to day. In
cases of long standing residual, an indwelling
catheter is more effectual. Irrigations should
be warm and should not contain drugs of
sufficient strength to cause the patient dis-
comfort. Exceptions may be made to this
in cases of long standing cystitis with thick-
ening of the mucous membrane and contrac-
tion of the bladder. In such cases, strong
solutions of silver nitrate are helpful. Instil-
lations should be used following irrigations
and consist of some soothing or antiseptic
solution as the case demands. Topical ap-
plications are useful in the treatment of ulcers
and localized inflammatory areas. In this
connection, the high frequency current may
be mentioned. Superficial desiccation of
such areas is very helpful both in the relief
of pain and in the ultimate cure of the dis-
ease. Instrumentation is indicated only in
acute inflammation of the urinary tract when
drainage is inadequate. When the disease is
of long standing or when the acute process
fails to respond to internal medication and
forced fluids, a thorough investigation is de-
sirable. I have previously called attention
to the frequency of bladder symptoms due
to diseases of other organs of the urinary sys-
tem, and to the large part diseases of those
organs play in the causation of bladder path-
ology. The accuracy of diagnosis possible
by present day urological methods makes em-
piricism unpardonable.
794
SOUTHERN MEDICINE AND SURGERY
November, 1029
Resume of Tuberculosis Work in North Carolina in 1929
L. B. McBrayer, M.D., Southern Pines, N. C.
The North Carolina Tuberculosis Associa-
tion headed up a committee from the several
service clubs, women's clubs, parent-teachers
associations, State Medical Society, and so
forth, and went before the Budget Commis-
sion and Appropriations Committee of the
last General Assembly of N. C, with a re-
quest to increase the appropriation to the
Extension Department of the State Sanato-
rium in the amount of $25,000 to the end
that the tuberculosis clinics for adults and
children could be continued and enlarged and
extended. We secured an increase of $10,000
annually, which, taking into consideration the
attitude of the General Assembly toward re-
ducing all appropriations as of previous
years, we considered quite an accomplish-
ment.
During the year Mecklenburg Sanatorium
has opened its Children's Division; Guilford
Sanatorium has done likewise. Forsyth coun-
ty is just opening a quarter million dollars
sanatorium that will take care of both adults
and children and the old sanatorium of about
sixty beds will be used for negroes pending
the erection of buildings for negroes. The
State Sanatorium has completed a splendid
new building which brings its capacity up
to five hundred, the Children's Division has
a capacity of sixty and they have treated
now about two hundred and fifty children.
Wayne county has an appropriation to build
a sanatorium at the County Home for indi-
gent citizens who have tuberculosis. Ca-
tawba county is just finishing a sanatorium
for children of about thirty beds; we believe
Catawba county has much larger plans in
the making. In different parts of the state
there are conversations in regard to district
sanatoriums composed of two or more coun-
ties, the latest being some five or eight coun-
ties surrounding Rowan. For the smaller
counties this is a wise procedure.
The Extension Department of the State
Sanatorium has continued during the sum-
mer with its adult clinics and since the open-
ing of school with its children's clinics. It
has now examined about 35,000 children and
finds that about 1.8 per cent of them have
tuberculosis sufficiently developed to need
treatment; that about 5 per cent more of
them are in need of very careful supervision
by physician and health officer or both, and
by the school offcials to the end that they
may be carefully treated for all intercurrent
diseases and defects and that their nutrition
may be kept at or above par. The remaining
18 per cent are infected with tubercle bacilli
but are not ill with tuberculosis at all, are
in a fair state of health and will probably
never have tuberculosis, provided the hygiene
of their lives is properly regulated, and that
means that they form proper health habits
and are properly nourished.
Some splendid work has been done in sum-
mer camps for children during the past sum-
mer, particularly at Lexington and Concord,
while the year before a splendid piece of
work of this kind was done in Rowan county.
About one hundred children were treated in
these three places.
The North Carolina Tuberculosis Associa-
tion, affiliated with the National Tuberculo-
sis Association, both of which are financed
through the Tuberculosis Christmas Seal
Sale, and 75 per cent of the sale left in the
local communities, continues to show the
splendid results which have characterized it
since its organization some eighteen years
ago.
It was the North Carolina Tuberculosis
Association which brought public health nurs-
ing to the fore in our state. It spent $52,000
in that work among the negroes of the state.
It employed the first State Director of Public
Health Nursing and popularized and set go-
ing in a proper way public health nursing in
our state.
It has backed up every progressive measure
and ofttimes brought to the ttention of the
people, frequently in a way that did not ap-
pear in the open. Perhaps the important
thing of all is the thing in which it is engaged
at this time, the matter of teaching the chil-
dren health habits and the proper nutrition
of the children of our state, and this too fits
in with both the finding and the treatment
of the cases before mentioned brought to
Kovember, \<ii^
SotTttfeRk MfebiCtNE ktib SURGEfeV
l^i
light by the Extension Department of the
State Sanatorium.
The State Board of Health and its county
and city health departments have always co-
operated effectively in the tuberculosis work.
This year and for many years they have de-
voted the November number of their Bulle-
tin to tuberculosis and this year, as hereto-
fore, have asked the Xorth Carolina Tuber-
culosis Association to furnish the copy.
The National Tuberculosis Association
continues to be the real leader of tuberculosis
thought and action in the world. During
the war and since, it has helped many of the
countries of Europe in the formulation of
plans and procedures in the fight against tu-
berculosis. It was called on to help the
United States Government in formulating es-
timates of the e.xtent of tuberculosis among
ex-service men following the war, and plans
for the handling of these patients. It has
organized State .Associations in every state,
which have become a component part of the
National .Association through representation
(m its Board of Directors. It has done much
valuable research, studying remedies claimed
to be useful in the treatment of tuberculosis,
working out the best treatment and the best
plans for a treatment in tuberculosis and in
the diagnosis, particularly the x-ray diagnosis
in adults and children. It is now conducting
perhaps the greatest piece of co-operative re-
search that has ever been organized — the lab-
oratories of thirteen universities in the I'nit-
ed States and Canada, two commercial
houses, and the United States Laboratory of
Hygiene. The work of the universities is
made possible by grants from the National
Tuberculosis Association. The workers have
been studying the tubercle bacillus for a pe-
riod of two years and the studies will con-
tinue for three years or longer, all this made
possible by the sale of Tuberculosis Christmas
Seals throughout the United States from
Thanksgiving to Christmas, a total of more
than five million dollars worth being sold last
year.
Perhaps the greatest accomplishment is the
development of a consciousness of the people
of our state that tuberculosis is a curable
and preventable disease and that we have
reached a point where we are sufficiently in-
formed to put into practice both of these,
which means, and such statisticians as Louis
Dublin agree, that those of us now living will
see the day when tuberculosis will be one of
the minor problems in disease and public
health; however, this will only obtain in case
the people lend wholehearted support to tnose
who are directing the way. While many or-
ganizations have had much to do in helping
to bring about this state of mind, the two
outstanding leaders are the North Carolina
Sanatorium and the North Carolina Tubercu-
losis .Association.
Treating Pyuria With Calcium Chloride
and Phenyl Salicylate
Coneiderinc that phenyl sahcylatc and calcium
chloride are used in somewhat constant proportions
in thi.s method of treatment, I communicated with
a pharmaceutical firm (Medicinaico, Ltd., Copen-
hagen) in regard to the possibility of preparing tab-
lets of 0.6 Gm. calcium chloride with a coating of
about OJ Gm. of phenyl salicylate, .'\fter some
experimentation, the manufacturers succeeded in
producing such tablets. I have treated a number of
patients with these tablets, using ,i three times daily
for standard doses. Within a few days, the urine
would give an acid reaction toward methyl red, just
as it did in the earlier treatment with calcium chlo-
ride and phenyl salicylate ; in a single instance the
urine was phenyl salicylate-colored Dyspeptic con-
ditions developed in no instance, not even on inges-
tion of l.S tablets a day. One of the patients suffered
from dyspepsia beforehand, and his condition was
not aggravated during the treatment. Thus the
same effect was attained with these tablets as when
calcium chloride and phenyl salicylate were given
separately; by this treatment, dyspepsia was avoided
altogether. The treatment with pyelol tablets is
therefore easy to carry through ; it is innoxious, and
it can eventually be given as ambulatory treatment.
In most of the cases in which it was employed, this
treatment resulted in recovery. It is shown experi-
mentally that the disinfecting power of phenyl salicy-
late against B. coli is increased by concurrent acidi-
fication of the urine. When calcium chloride and
phenyl salicylate were employed together in the
clinical treatment of twenty-four patients suffering
from pyuria, cures were obtained in 75 per cent
Calcium chloride alone caused the development of
gastric .symptoms in some patients, but this was
avoided by giving the calcium chloride in tablets
coated with phenyl salicylate which contained the
proper p<)rti<ins of both phenyl salicylate and cal-
cium chloride. — \. H. Joha.vsen, Arch. Internal
Med., Sept., 1929.
1%
SOUTHERN MEDICINE AND StmCERY
November, 10^9
PRESIDENT'S PAGE
Tri-State Medical Association
of the Carolinas and Virginia
—CYRUS THOMPSON
This world runs very much a streak of
lean and a streak of fat. "
I think it was Gibbon, a very genial un-
believer, who said that all religions are equal-
ly false and equally necessary — a statement
tantamount to a declaration that some form
of religion is necessary for the tolerable con-
duct of human life. Religion then is a very
helpful thing. Nevertheless, religion has been
the cause of much human suffering and
misery. Did you ever consider what propor-
tion of wars was carried on for the sake of
religion? A thing, therefore, that is useful
and good may also be bad and very destruc-
tive of happiness.
The sphygmomanometer is a very useful
instrument, and a knowledge of my patient's
vascular tension is desirable. But the sum
total of human happiness would have been
greater if the inventor of this instrument had
been shot dead just before he announced his
invention. I know of no more miserable ob-
session than a personal sense of high tension.
It incapacitates, it worries and increases, it
sits down by your patient's gateway day by
day and troubles his dreams by night. If
you want to destroy your patient's happiness,
take his blood-pressure, tell him his blood-
pressure is high, and watch the light of life
go out of him. He will go from you, meet
his friend, and tell him with gloom that the
Doctor says "I have high blood-pressure."
There are no golden afternoons for him after
that. The lion crouches at the poor devil's
gate.
But if your arteries are good, what differ-
ence does high tension make? Tension is
rather a matter of arteries than of mercurial
readings. A man with soft arteries is prac-
tically safe whatever his pressure, but a man
with degenerate arteries is in danger even
with what may be called a normal pressure.
What concerns me is not so much the force
of the engine's pumping as the integrity or
lack of integrity of the hose. As we grow
older and our tissues grow harder a higher
tension to nourish our cardiac and respiratory
centers is a necessity, and if our arteries are
" good a reasonably high tension is a bene-
faction.
Some years ago I had two patients with
apoplexy. They were unconscious, stertorous,
and distressful to the family. Both of them I
am sure would have succumbed without re-
covery from the attack. I bled both of them
and reduced they systolic pressure to 140 or
ISO. Their stertor ceased, they seemed much
less distressed, the family were comforted.
My patients were dead in a very few huim..
I knew then that, like a good host, I had
sped my parting guests. I have not since
bled for apoplexy. Dame Nature is wiser
it may be than we are. I am sure I hobbled
the old lady's feet, but I never told the
family so. Since then I have been inclined
to placebo, and wait for the salvation of the
Lord.
But with all the grim misery that comes in
the train of a patient's knowledge of personal
high tension, now and then a doctor comes
ufxjn something provocative of a smile. In
1918 I went for war purposes to a Piedmont
town to make a patriotic Fourth-of-July ad-
dress. I spent a day and night in the house
of a dear medical friend. I suggested to
him, when we were going to relieve our fa-
tigue with a glass of Scotch, that he call in
the Colonel, his father-in-law, to drink with
us. "No," said he, "the Colonel would enjoy
it, but he has high blood-pressure and is
afraid." A few years ago I learned that the
Colonel, a most genial gentleman, threw his
dreadful expectation of evil to the winds, and
took a glass when he wanted it. He died in
July, 1929, eleven years later, at the ripe
old age of eighty-four years.
Not long ago I went out to see a woman
some sixty-seven years old. She had been
married twice — first when she was fifty-four
ty and circumstance she was nurotic. She had
many pains and peculiar sensations, which she
was now a lonely childless widow. By heredi-
ty and circumstances she was neurotic. She
had many pains and peculiar sensations, which
she seriously recounted to me, to all which I
November, 1929
SOOTBERN MEDtCtNE AND SURGERY
W
listened with gravity. I examined her care-
fully and found her in fine physical condi-
tion. I was just about to assure her of my
conclusion when she said: "And, Doctor, I
am afraid I am suffering with high blood —
expression." "Ves, ]Miss Nan" said I, "I
was just going to see what your blood-ex-
pression is." With all her worry I found her
systolic pressure 150 and, therefore, assured
her that her h\ood-ex pirssion was not high.
She smiled thereat with ineffable comfort. I
had made her happy. Religion and the
sphygmo are both useful things, and both are
pregnant of human misery.
NOTES
By C. C. Hubbard, M.D. Farmer, N. C.
A saturated solution of boric acid in pe-
roxide of hydrogen has been found very use-
ful in sore mouth, tongue and throat, as well
as running ears and running surface sores.
As a gargle it should be used every 2 to 4
hours and as follows: Gargle a spoonful,
spit out. Wash out mouth with water, gargle
with the peroxide again, spit out, wash out.
In sore throat, from any cause, after gargling
twice wait a few minutes then swallow one-
half teaspoonful followed in a minute with
water. A gargle does not go very far down.
In tonsillitis I use the boric and peroxide
(twice each time), then in 2 hours use a
saturated solution of potassium chlorate in
hot water, as it does not dissolve readily in
cold water. Use it in same way as boric
solution, swallowing a little. In a real bad
condition it is well to use each wash closer
together. The peroxide-boric solution is
splendid to use after having teeth pulled. I
see many cases of infection following the
procaine method of tooth pulling and always
use the peroxide mixture. The peroxide boils
out pus and old decom[X)sing blood clots. The
boric heals the cavity.
R. .Acid Boric
Acetanilid, equal parts. M. et Sig: Dust
on wounds after thorough cleansing. It is
splendid treatment. It makes a firm, rather
hard shell which completed seals a wound.
Do not use on large surfaces as the acetanilid
may be absorbed, especially in children.
Sig. 1 capsule while flow is on. With, lately,
1 c.c. pituitrin hypodermically once a week.
The above is used in place of ergot. Ergot,
etc., in cases which will not or cannot be
operated. Most ergot as we get it is inert.
Ergot over one year old is practically inert.
R. Potass. Acet. oz. I
Potass. Brom. oz. yi io 1
Aquae g.s. ad oz. IV
M. et Sig. Teaspoonful before meals for
nervous, pale sluggish-kidneyed women, who
swell up and sleep poorly. Continue it for
a month or two.
Herpes Zoster should receive more atten-
tion than it gets by most of us. As four
cases in older people have shown me in the
last few months.
It is mighty good practice to read up on
the diseases you know all about. Maybe you
know too much about it or do not know the
right kind of enough.
Have used for years in uterine bleeding
from fibroid, and most other causes, cancer
excepted, R. Pulv. alum gr. 3 in capsule.
A RAPID BLOOD GROUPING METHOD
Apparatus
Capillary tubes, medium size, 6 inches
long. Capillary tubes, medium size, 5 inches
long. Stock sera. Group 2 and Group 3.
Suspensions of recipient's and donor's red
cells. Sera of donor and recipient, collected
in Wright's capsule tubes.
Procedure
The shorter capillary tube is dipped into
the Group 2 stock serum which is drawn by
capillary attraction to one-half the distance.
Immediately the tube is placed within the
recipient's cell suspension, care being taken
not to allow air bubbles to enter between
serum and cell suspension. The capillary
tube is then held at either end by the thumb
and index finger and inverted, allowing the
cells to gravitate into the serum. This pro-
cedure is repeated with the longer capillary
tube, using the type three stock serum.
Both tubes are placed under the low power
lens and by pro[>er focus one can readily note
within five minutes the final result. .Aggluti-
nation appears as fine cayenne pepper
clumps. The eyepiece itself may be used as
a direct focus upon the capillary tube.
Direct matching may be carried out in a
similar manner, dijiping the capillary tube
directly into the Wright capsules. — Nathan
GBOsor, Jour. Uib. & Clin. M^<i-t Oct., J929,
?08
(
SdttHERN ilEWClMt AND StfteEftV
PRESIDENT'S PAGE
Medical Societv oj the State of North Carolina
—L. A. CROW ELL.
November, 102^
There are some important problems facing
us as a State-wide Association primarily
established to safeguard the health of the
citizenship. I believe that we should face
and meet these problems fairly and squarely.
We have confined in the State's institu-
tions, including the prisons, institutions for
the insane, feeble-minded, deaf-and-dumb,
etc., 9,497 persons. These are State charges,
incapable of caring for themselves; therefore,
they should have accorded them the same
care and consideration that we, as individ-
uals, give our own immediate families.
The State should employ experienced and
skilled specialists in their particular field to
head all these institutions; men who would
devote their whole time and talent to the
work assigned them. In other words, no
part-time man should be employed to head
any State institution. No man can give his
best to a public position and a private prac-
tice at the same time. He will 'neglect one
or the other. It is impossible for a man to
serve two masters, for, "He will hate the one
and love the other."
The State's business is important enough
to demand the full time and attention of the
men employed to look after it, and our State
is able to pay for whole-time service.
Further, I believe that all the State's insti-
tutions should be headed by North Carolina
men. We have too long discouraged the
genius and ability of our native sons, and
this has tended to drive our brightest men
and women out of the State, not only to seek
their training but to give the advantage of
their skill and experience elsewhere in their
late years. As far back as the time when
Walter Hines Page — later to become our
great World War .Embassador to the Court
of St. James's, was editor of The Forum, the
cry went forth against our treatment of men
of Page's character and intellect in shunting
them into the background while we elevated
writers, teachers, preachers, and doctors from
other States into our highest positions of trust
and honor.
I beiieve in Carolina for Carolinians!
My opinion is that North Carolina should
establish an institution for the care and treat-
ment of drug addicts and whiskey inebriates.
The prevalence of these awful scourges is
sufficient to demand the attention of the
leaders of our State who are laboring for the
advancement of our people along every line.
I should like to suggest that the State pur-
chase a good farm of about five hundred
acres in a good farming section, and erect on
it buildings suitable for the care of these
people. They should be confined, under the
most patient and kindly restraint, of course,
for a sufficient length of time not only to in-
sure a cure, but until they are physically pro-
nounced able to work. They should be re-
leased only when it is positively known that
they are safe to the public and themselves
when on their own responsibility.
The State should care for such of its un-
fortunates, and thus relieve the medical pro-
fession generally of the responsibility and
annoyance now experienced in being beset
with requests for narcotics. Often, too often,
these unfortunates, by gaining sympathy of
the physician, cause him to over-run his cau-
tion and prescribe narcotics; thus, incurring
criminal liability upon himself, which some-
times results in punishment in prison.
If the State assumes charge of its insane
and its criminals, it is even more responsible
to society for its unfortunate drug and whis-
key addicts.
Should doctors accept contract work from
manufacturers and insurance companies? Is
such a step ethical? Personally, I answer
quite emphatically that I believe it is not.
I believe in the open shop method in medi-
cine as well as in labor and in the ministry
of Grace. I do not consider the method fair
to either the profession or the employee. To
lock the doors of medical opportunity against
employees of manufacturers and compel their
acceptance of the treatment of only such
contract doctors as may through any num-
ber of subterfuges or influence be appointed
sole custodians of their health is an injustice
to the employees, which we should frown
upon and heartily oppose.
November, 10^9
SOtTTHERN MEDICINE AND SURGERY
W
iO NVOHQ IVIOIJIQ
SOUTHERN MEDICINE AND SURGERY
j Tri-Stalc i\ledical Associalioii of llu' Carolinas and Virginia
I Medical Society of the Slate of North Carolina
James M. Northington, M.D., Editor
James K. Hall, M.D
Department Editors
Richmond, Va.
Frank Howard Richardson, M.O Black Mountain, N. C-
W. M. RoBEY, D.D.S Charlotte. N. C.
J. P. Matheson, M.D. \
H. L. Sloan, M.D . j
C. N. Peeler, M.D
Human Behavior
Pediatrics
Dentistry
F. E. Motley, M.D.
V. K. Hart. M.D.
F. C. Smith, M.D
The Barret Laboratories
O. L. Miller, M.D
Hamilton W. McKay, M.D .
Robert W. McKay, M. D...
J. D. M.\cR.4E, M.D.
J. D. M.acR.ae, jr., M.D
Joseph A. Elliott, M.D
Paul H. Ringer, M.D
Geo. H. Bunch, M.D
Federick R. Taylor. M.D
Henry J. Langston, M.D
Chas. R. Robins, M.D
Charlotte, N. C.
— Charlotte, N. C.^
— Gastonia, N. C. -.
I Charlotte, N. C...
*>►' Asheville, N. C._
Charlotte, N. C._
.\sheville, N. C.-_.
Columbia, S. C. .
Diseases of the
Eye, Ear, Nose and Throat
Laboratories
Orthopedic Surgery
Urology
Radiology
Dermatology
Internal Medicine
..Surgery
Oi.iN B. Chamberlain, M.D
Various Authors
James .^uams Hayne, M.D
.High Point, N. C _ Therapeutics
Danville, Va Obstetrics
Richmond, Va Gynecology
Charleston, S. C . Neurology
Historic Medicine
.. ^.-Columbia, S. C. .^..Public Health
Farm Relief, Better Food, Better
Health
From the earliest written records made by
man down to our own day there may be
found proof that a large and influential por-
tion, if not a majority, have held a fixed idea
that our natural cravings were for things in
their very nature hurtful to us. Doctors do
not need a bill of particulars to call to mind
a number of drugs, now known to be worth-
less, which were once held in high repute for
no other reason than because they were bitter
or otherwise nasty; many can remember
when orthodo.x treatment denied baths to
fever patients and gave them water to drink
only grudgingly and that tepid.
Right now the same line of reasoning
(rather unreasoning) causes our section to
import white flour from which to make in-
sipid bread, to the neglect of our own home
grown corn and p<jtatoes, which would meet
our needs far more satisfactorily from the
standpoints of both health and appetite.
The best of breakfast cakes is made of
corn meal; but it is doubtful if corn cakes can
be had in a half dozen restaurants in North
Carolina tomorrow morning. Plenty will
serve buckwheat cakes; and the buckwheat
crop of the state is so small that few of its
inhabitants would recognize buckwheat grow-
ing in the field. Thin, plain corn bread is
preferred by the great majority of those who
have had it plain, made up with milk or
water and a little salt, unspoiled by powders,
sugar or other fanciness, for eating with vege-
tables; and corn meal dumplings boiled in a
pot of turnip greens with ham hock make a
meal rarely to be equaled and never excelled.
Now about our potatoes. How many are
there, do you think, who would choose cold
sliced white bread ("wasp's-nest," as accu-
rately defined by our epicurean friend, Mr.
K. M. I5ell) if offered hot potatoes roasted
in their jackets? Until we lived some years
outside the South, we wondered why people
in other sections ate cold bread: living among
them explained it; they don't eat it; they
eat hot potatoes. But even there they order
bread. We all have a hard time getting away
from the idea that there must be "meat and
SOOTttEkk MfibtCtKfe ANt) StJftGEftY
Movember, 1034
bread" on the table. We are thus bound by
tradition, much to our detriment.
In Eastern North Carolina, according to
numerous newspaper accounts, more farmers
are unable to pay their taxes than in any
previous year in the history of the state. It
is reliably reported that last year first grade
potatoes, barreled by the roadside, were freely
offered for the cost of the empty barrel.
In the name of common sense, self help,
good health and pleased appetites, why don't
we eat our potatoes? Travelers in the poor-
est parts of Ireland, where the potato not
only takes the place of bread, but for days
at the time is the sole article of diet, find a
vigorous, ruddy race. With the accessories
which are to be had by even our poorest
people, a diet satisfactory in every way is in
easy reach.
The eastern counties of the Carolinas and
Virginia grow sweet potatoes in quantities for
the market. A paper in the past 10 days
carried an account of the growing of 248
bushels on one acre in the Piedmont section.
With care this vegetable can be cured so
that it will make a welcome addition to every
table several days in each week. It ought
to be generally known, too, that, as to pump-
kin pie, the more sweet potato and the less
pumpkin, the better the pie.
Recent investigation has shown that the
peach has dietary elements of the greatest
value, and frequently we see in a diet list
"orange juice or tomato juice"; why not rec-
ommend to our patients that they use tomato
juice, and bear it in mind that our section
grows many peaches and tomatoes and needs
to have their consumption increased, while
there's not an orange or banana grove in our
territory?
On a recent trip through Western Carolina
it was noted that there appeared to be an
unusually large crop of apples, but the fruit
was small and knotty. Inquiry of the wo-
man keeper of a drink stand elicited the ex-
planation. There came a hail storm when
the apples were small. The further informa
tion was vouchsafed, "Last year we had
plenty of apples and they didn't bring but
20 cents a bushel; this year they offer a
dollar, but we ain't got no apples." This
mountain woman had studied economics only
in the hard school of experience; but she
had come to the heart of the farmer's trou-
bles. Prices of farm products are always
high when there are no products to sell. The
winesaps and pippins of Virginia and the
Carolinas are superior in every way (except
in looks) to the much advertised apples of
Washington and Oregon. We have just as
handsome an apple as theirs, the "Ben Da-
vis"; but, as might be expected, it isn't fit to
eat.
In Southeastern North Carolina, centering
about Chadbourn, W^arsaw and a few other
points, is one of the largest strawberry-grow-
ing areas in the world. Year after year a
great part of the crop, and of the very best
berries, goes to waste because after a few
weeks of the season the price goes below the
cost of picking and crates. Is there a person
in the whole world who does not relish straw-
berry preserves? And where the perfect fruit
goes to waste annually by the thousands of
bushels, is there not a golden opportunity for
salvage?
North Carolina's herring fisheries are
among the greatest in the world, but entirely
tco much of the catch goes to making fer-
tilizer. Rueger's, in Richmond, one of the
most famous restaurants in the country, spe-
cializes in a breakfast of salt North Carolina
roe herring and corn cakes; try to find that
breakfast in Wilmington, Raleigh, Charlotte
or Asheville!
The Health Committee of the Medical So-
ciety of the State of Wisconsin gives out a
News Letter to the press of Wisconsin every
week or two. This journal has been kindly
placed on the mailing list, and it trusts that
nothing said here will be taken amiss; rather
that that state, and all others laboring under
the major affliction of goitre will derive bene-
fit. A recent news letter says:
"The lowly turnip and the onion were
given a rank in the food diet high above
the fancy cakes and salads by the Health
Committee of the State Medical Society.
Some old-fashioned vegetable dishes would
become popular if the medical profession had
its way.
'Don't despise the turnip and the onion
when picking your food,' declares the state-
ment in announcing a number of rules for
healthful eating. Fearing that suggestion
might not be sufficient the health committee
added:
'Adopt a cosmopolitan menu — become ac-
Kovember, 1020
SOtJTHERN MEDICINE AND SURGERY
801
quainted with goulash, Irish stew, pig's
knucliles and sauerkraut and a ragout with
vegetables.'
The statement declares that many people
eat continuously the same things with little
variation, and point out that some of the
symptoms of a lack of appetite come from
a 'monotonous diet.' It declares that so far
as health is concerned, 'the cheaper cuts of
meat cooked with vegetables are better than
a diet of steaks and chops.'
'One of the evils of the present-day eating
is to depend too much on quick cooking,'
continues the bulletin. "Good health will not
last with one minute meals.' "
The State of South Carolina has shown
that her vegetables have an unusually high
iodine content, and has made out a good case
for the contentiim that this is the explanation
of the astonishingly small number of cases
of eoiter among her population.^ This jour
nal has applauded, and applauds again, the
fine endeavor, headed by Dr. Wm. Weston,
of Columbia, which first formulated the con-
cept, then established the fact, then instituted
measures to turn the information to good
account in the interest of the health of the
country and of the agricultural industry of
South Carolina. It is said that milk produced
by cows that eat the grass and other vegeta-
tion produced in this favored state contains
much more iodine and iron than that pro-
duced by cows in the areas famed for dairy
products.
There is every reason to believe that inves-
tigations in North Carolina will disclose sub-
stantially the same conditions: and, if so,
there will soon ensue a demand for more
products than both states can supply.
The farmer has been the football of poli-
tics longer than any of us can remember.
During campaigning he is always promised
everything; once election results are an-
nounced he is given nothing except a lot of
silly advice about "diversification," to the
general effect that the cotton farmer should
plant tobacco, the tobacco farmer cotton, the
wheat farmer corn, the corn farmer wheat,
and so on. And on every possible occasion
the money he has paid into the treasury is
voted to irrigate or drain and bring land now
idle under cultivation to further glut the mar-
*"'?
1. Sec article by Dr. Hugh Smith, this issue.
ket with farm products.
We here reveal means by which our own
farmers can be helped; and by no exercise
of altruism, for we will be helping ourf^""s.
By eating potatoes and corn bread, not
along with, but instead oj, wheaten bread;
by eating our own fruits, vegetables and
dairy products; and by letting outlanders
know of the superiority or our products, we
can live on more appetizing food, produce a
hardier, healthier citizenry, and go far toward
assuring the farming and dairying industries
of our section returns commensurate with
their investments in labor and money.
Additions to Our Staff
We are gratified to have made notable ad-
ditions to our editorial staff.
Dr. Robert W. McKay, after several years
at the Brady Urological Institute, Baltimore,
and some two years association with his
brother. Dr. Hamilton W. McKay, in Char-
lotte, goes on with this brother as joint Edi-
tor of the Department of Urology.
Dr. J. Donald MacRae, jr., N. C.-Penn.,
internship Manhattan Maternity and Dispen
sary. New York, and Moses Taylor Hospital,
Scranton, Penn., 9 months Assistant Resident
in Radiology, Buffalo (N. Y.) City Hospital,
recently joined his father in the practice of
his sjiecialty in Asheville, and in the conduct
of the Department of Radiology.
Dr. James Adams Hayne, the efficient
State Health Officer of South Carolina, has
consented to take over the Department of
Public Health, the editorship of which was
made vacant by the sending of Passed As-
sistant Surgeon L. L. Williams from Rich-
mond to India on an assignment which will
occupy many months.
.Accidents to Hunters
Each year many lives are lost and many
others blasted through reckless disregard of
sensible precautions which in no way dimin-
ish the pleasure of the hunt for those who
take these precautions.
It is childish to aim a gun at any one even
if you know it is not loaded. There's always
a better way of getting a gun through a
fence, hedge, or brush than by dragging it
by the muzzle. Carrying a gun cocked adds
little to readiness to make a kill of game and
much to the likelihood of killing a hunting
SOUTHERN MEDICINE AND SURGERY
November, 1029
companion.
Slight punctured wounds should cause,
tetanus antitoxin to be given. Treatment is
rarely of avail once the disease develops. An
injury from a dog's tooth, even though appar-
ently accidental, should be considered as a
possible source of rabies.
Resolution
Mecklenburg County Medical Society, Octo-
ber 22nd, 1929.
Dr. Annie L. Alexander died at her home
in Charlotte, N. C, October ISth, 1929, after
a br'ef illness with oneumonia.
Resolved 1st: That the Society has lost
one of its most enthusiastic and loyal mem-
bers, the profession one of its highly honored
and resDected ohysicians.
Resolved 2nd: That the passing of this
unusual wonnn, removes from the community
<^rie of its most important influences, and
fmm the sick and suffering a symoathetic
friend and capable physician. Her presence
in the sickroom radiated love and kindliness
p"d inspired confidence. Having lived a life
of u'^efulness and piety, in her last hours she
could look back on the good 'she had done
with satisfaction and forward with assurance
and equanimity.
Resolved ,?rd; That a cony of these reso-
lutions be spread on the minutes of the So-
ciety, and given to each of the Charlotte daily
naner^. Southern Medicine and Surgery, and
the Presbyterian Standard, and a copy be sent
the family.
John R. Irwin, M.D.
George W. Pressly, M.D.
Otho B. Ross, M.D.
Commitee.
GoRGAS Institute Sponsors Second Essay
Contest
Hirh School Students in Junior and Senior
Classes to Participate in Health Contest
A second national essay contest on a health
topic is scheduled for iunior and senior stu-
dents of hiah schools throughout the country,
according to a recent announcement made
by the Gorras Memorial Institute, 1331 G
Street, X. W., Washington, D. C.
Chicago Man Donor of Prizes
Cash prizes for contest winners are again
available through the generosity and interest
of Mr. Charles R. Walgreen, of Chicago.
There will be three prizes for winners of the
national contest. First prize will consist of
$500 in cash with $250 travel allowance to
Washington, D. C, to receive the prize; sec-
ond prize winner will receive $250 in cash,
and the winner of third prize will receive
$100 in cash. State winners will receive $20
in cash and the winners of the high school
contest will receive a bronze Gorgas Medal-
lion. The subject selected for this year's
contest is "The Gorgas Memorial; Its Rela-
tion to Personal Health and the Periodic
Health Examination." The contest opens
September 16th and all high school papers
must be received at the headquarters of the
Institute by midnight, December 10th. High
school winners will be chosen by faculty
members. The winning paper will then be
sent to Washington to Institute headquarters
for entrance in the State Contest, the judges
of which will be the State Commissioners oT
Health, the State Superintendent of Schools,
and the Honorable Secretary of State. The
national winners will then be selected by the
U. S. Commissioner of Education, the Sur-
geon-General of the U. S. Public Health Ser-
vice, and the Director-General of the .Ameri-
can College of Surgeons.
As Christmas Presents for your
Doctor Friends, order 1930 Sub-
scriptions for SOUTHERN MEDI-
CINE & SURGERY.
1 Subscription . S 2.50
5 Subscriptions 10.00
Special Christmas card to each
address with name of Donor. In
cases where journal is ordered sent
to a doctor who is receiving: it
already, the doctor will be sent
card and the remittance returned
to sender.
November, 1929
SOUTHERN MEDICINE AND SURGERY
DEPARTMENTS
HUMAN BEHAVIOR
James K. Hall, M.D., Editor
Richmond, Va.
Psychiatry Outside the Walls
Although we are not all as happy as kings,
that sad fact does not nullify the belief that
the world is still full of a number of things,
and many of them are interesting things.
Otherwise human existence would be even
much more drab than it is thought by many
to be. So observant a citizen as the peri-
patetic theologian noted in ancient Athens
that the highly sophisticated citizenship of
that seat of culture were constantly on the
lookout for some new thing with which to
furnish themselves intellectual entertain-
ment.
The phenomenon which continues to cause
man most concern is the behavior of his fel-
low-man. The weather is a useful topic of
conversation because it does not beget con-
troversy, and absolute strangers may fall into
conversation about changes in atmospheric
temperature and relative humidity and pre"
cipitation without violating any of the laws
of propriety. In this respect the weather
ferves a most useful purpose. Talk about
extreme heat enables those who experience
its depressing effect to bear it with more
equanimity. For that reason the reaction to
it becomes a community affair, so that it
does not have to be borne by the solitary
individual. And intense cold is more intense
when one is alone. When two or three are
gathered together on a bitterly cold morning
waiting for the bus which never comes the
cold is endured with less suffering if all the
members of the little group are permitted to
stamp the ground, to prance around and to
slan their hands together, and to talk one
with another about the keen and nipping air.
In spite of the many sharp words siwken
one about another during our political cam-
paign now drawing to a close language re-
mains a useful institution and we could ill
afford to do without it. Verbalizations civil-
ize us, and enable us to know each other, or
pot to know each other, which is sometimes
the more advisable and the more comfortable
state. We read about the wonders of science
and the mysteries of theology and about eco-
nomics and finance and sociology and the
tariff and world [wlitics and agriculture and
relativity and the nature of the Milky Way
through a sense of duty, but we read history
and biography and fiction and poetry and
detective stories joyously because we are
reading about folks themselves — about our
own selves. .And, after all, we are little con-
cerned about anything else in the world ex-
cept each other, about how we ourselves, and
especially our neighbors, behave. Human
conduct has been, it is, and it will continue
to be the one thing in life in which all mortals
are most interested. And the unusual draws
attention to itself and away from the ordi-
nary and the everyday affair. The window-
dresser knows, whether he be a grocer or a
clothier, a fruiterer or a book-man, that the
d'splay of last year, yea, of last week, will
not arrest the eyes of the passer-by. We are
instinctively on the watchout for the new
thing — still, regardless of the personal flood
of years, we remain children, and we demand
change and novelty. Even the old method
of detaching and removing the appendix
vermiformis loses its appeal, and the surgeon
introduces a modified incision or a new stitch.
And the old drug must give way to the new,
or else assume a polysyllabic, unpronounce-
able name. It will ever be thus, inasmuch as
we remain human. For the same reason we
maintain our interest each in the other, in
those who are, in those who have been, and
in prophecies about those who are to be.
Even now there is si)eculation about the can-
didate for the presidency in the next election,
and in North Carolina about who will be
governor in the far-off years. And we fall
avidly upon the new "Life of" Henry viii, of
Napoleon, of John Paul Jones, of Andrew
Jackson, and of Andrew Johnson, and oi
George Washington, and upon the brief and
rascally sketches of those diabolical devils
who formulated and carried through the re-
construction policy in the old Confederated
States. We revel in debunking biogra|)hy.
The heroes become pedestalized only through
accident or chicanery, and we love to have
them lifted from their positions of eminence
and brought down amongst us where we know
they should always have been. .And that is
true. They are mortals, more like us, than
unlike us. And it is this tinge of democracy
804
SOUTHERN MEDICINE AND SURGERY
November, 1929
in the debunking process that appeals to us.
We love for our gods to be not human beings.
Deification carries with it the fear of the
necessity of eventual humanization. We
quietly ally ourselves with the hero either
because of his strength, — or his weakness.
Unless some quality in him be also in us we
know him not, and he remains non-e.\istent
to us.
But the unusual catches our eye and holds
our ear. My radio once astonished and mys-
tified me; now its noise has become an
abomination and it is kept silent. Even so
do we look upon human behavior. Last
February in Greensboro at the annual meet-
ing of the Tri-State Medical Association for
the first t'me in the history of that organiza-
tion a number of clinics were held. Thev
were all splend'd, and they appealed to all
the doctors who were there, .^nd the clinic
that excited not the least interest was that
at which a number of mental patients were
presented. .And again, a week or two ago,
at the annual meeting of the Virginia State
^ledical Society, held at the University of
Virginia, the program was opened by a
p^vchiatric clinic. Patients were presented
there from a State Hospital. One of the
patients, in the early stages of paresis, ad-
dressed the assemblage, and in the time
allotted to him he was unable to portrav fully
his conception of his wealth and his own
personal puissance, so great were his CTan-
d'ose ideas. He had become a b'llionaire, a
trillionaire, a sextillionaire; he had thousands
of wives, millions of children, and in an
ordinary day through the work of a million
men. each with a million hands, he had con-
structed a concrete bridge across the Atlan-
tic. And although an old specific infection
had brought him into the hospital he was
experiencing such a degree of happiness in
quality and in quantity as he had never be-
fore known and as none of us who heard him
could possibly comprehend. -And through
h'm was dramatically presented to the doc-
tors who packed the auditorium the relatively
unknown fact that a human being may be
terribly insane and yet altogether happy, and
contented. .And then a middle-aged man,
bowed under the weight of a profound degree
of melancholia, with wringing hands and
groaning voice, told of his terrible wretched-
ness— ^his ideas of self-sinfulness, and of his
unending suffering in that everlasting Hell
to which he would be sent. But another
man, also in the mid-years of life, fetchingly
gowned in the fashion of a present-day flap-
per, hesitated not a moment in telling that
although he was morphologically a man, yet
he was in reality a woman, the mother of the
human race, the crucifier of the Christ on
the cross, that he was ever-living and never-
dying, and that he had experienced existences
in all those regions from Heaven to Hell. No
one could possibly be more irrational in his
thinking, but aside from his dress scarcely
more sensible in behavior, and no one in the
Commonwealth of Virginia performs his daily
work more efficiently, loyally and dependably
than this man who for more than half his
life has been in the grip of paranoid dementia
praecox. And in this patient the assembled
doctors were enabled to understand what can
be done in the way of rehabilitation amongst
the so-called insane. This man. once mania-
cal and dangerously homicidal, is now useful,
productive, valuable to the state, and a com-
fort to himself — though still insane. In the
activities of a great state hospital he has at
last found his universe — and happiness.
Such case-presentations must have carried
imnressive information to many of the doc-
tors. Svphilis causes paresis, and paresis is
resnnnsible for more than twelve per cent of
all the 375.000 insane persons in hospitals
in the United States. Paresis is. therefore, a
preventable type of insanity. What prevents
svnhilis prevents iust so much insanitv. what
cures svphilis in the pre-paretic state wards
off iust so much insanity. .And early recog-
nition of oncoming melancholia, such as that
represented bv the middle-aged man, tends to
prevent suicide and to make it possible for
him to return home after two or three years
a well and a happy man.
Not all the insane suffer; some of them
experience a kind and a degree of happiness
thev had never known when well. But most
of them are unhappy, and many of them are
inconceivably miserable. Thev suffer not
alone because they are mentally sick; thev
suffer even more perhaps because they are
not understood. They can not make known
their feelings in language. Emotional experi-
ence are to a limited degree verbalizable. The
repression and the retardation and the pov-
erty of methods make it utterly impossible
November, 1929
SOUTHERN MEDICINE AND SURGERY
SOS
for the profoundly depressed human being
to convey to another any adequate impression
of his misery, and those who have not experi-
enced the anguish of melancholic misery can
scarcely understand its language — mute or
vocal. In consequence, the mental patient
becomes set aside, not understood, an object
of morbid curiosity, feared, a strange crea-
ture, not a human being suffering from a
form of sickness. Such a patient in the home
can not be easily visited, sympathetic neigh-
bors can hardly dare make inquiry or proffer
assistance. A social bowl becomes inverted
over the family; the neighbors are in whis-
pers. There is not sickness in the household;
no, it is something weird, strange, uncanny.
But a mild, brief physical illness may be not
undesirable. It gives opportunity for rest,
reading, ruminations, the ministrations of
loving hands and sympathetic and appreciated
services from neighbors. But mental illness
brings isolation and detachment and embar-
rassment and humiliation and unhappiness.
.Ml these unfortunate and mistaken and
hurtful and painful attitudes the psychiatric
clinic will tend to correct. There is no more
of the mysterious and the incomprehensible
in sickness of the mind than in sickness of
the body. In the unified human being it is
probably wrong to speak of the one to the
exclusion of the other. What is mind is also
body and what is body is also mind. In the
functioning cell wherever it may be at work
there is also mind; and mind, wherever at
work, displays itself through the medium of
matter. If the physicians and the lay people
of the United States came into daily associa-
tion with the hundreds of thousands of in-
sane in the country as intimately as they
come into contact with somatic sickness then
insanity would lose its awesomeness. Isola-
tion of the insane tends to increase wonder-
ment about insanity. Let the condition be
extra-muralized. Let there be mental clinics
here, there and yonder. Let knowledge of
this sort of sickness shine down upon all the
people.
Doctor — "H'm ! Severe headaches, bilious attacks,
pains in the neck — h'm. What is your age, madam?"
Patient (cooly) — "Twenty-four, doctor."
Doctor "H'm (continuing to write) — "Loss of
memory, too."
PEDIATRICS
For this issue, G. VV. Kutscher, jr., M.D.
Swannanoa, N. C.
Pyelitis
Pyelitis may result from a focus of infec-
tion, and then it becomes a new focus of
infection. Somewhat of a vicious circle to be
sure! •»
Many are the cases of so-called indigestion
in childhood that are in reality pyelitis.
\'omiting and fever are frequent symptoms of
pyelitis, thus accounting for the diagnosis of
indigestion. Since the systemic reaction of
pyelitis may last from one hour to several
days, it is easy to understand how a brief
attack of vomiting and fever can be diagnos-
ed indigestion. A thorough physical exami-
nation of the child may not elicit a single sign
to confirm the diagnosis of pyelitis. The
study (miscroscopic) of a specimen of urine
may be the only clue to the real nature of
the child's upset.
Pyelitis or pyelo-cystitis, which better de-
fines the pathology of the parts involved, is
an infection of the urinary tract, caused most
frequently by the colon bacillus. Because of
the anatomy of the external genitals, girls
are thought to be more frequently afflicted.
Internal sources of infection, though, no doubt
exist. Kerley states that his ratio is five to
one, girls predominating. The disease is
seldom met with after the fifth year, except
in pregnancy, where it has been suggested the
infection may have extended, unnoticed into
adult life.
The onset is usually sudden with a marked
elevation of temperature. It may also exist
without fever. The temperature elevation is
often sufficiently high to cause a chill. A
child may be playing, suddenly stop and
crawl up on the bed, and in a few moments
appear desperately ill. The mother tells that
the child came to her and crawled up on her
lap. The child's skin felt intensely hot. The
child is not so prostrated as the temperature
suggests. The temperature is septic in type
and when it soon subsides to normal the child
again feels well and often resumes his play.
This temperature variation from normal to
104 or 105 may last for days or may last
through but a single excursion.
Pain is seldom a prominent symptom but
at times is localized over the kidney region.
If cystitis is marked there is pain on urina-
tion. Vomiting is infrequent during initial
SOUTHERN MEDICINE AND SURGERY
November, 1929
attacks, but seems to become more pro-
nounced and severe with repetition of at-
tacks. Unless the disease is completely clear-
ed up, recurrent attacks are the rule.
Aside from headache, flushed cheeks, rest-
lessness, and discomfort, which go with the
fever, few physical signs are found on exami-
nation. The author has noticed a drooping
of the corners of the mouth as well as more
frequent tenderness over the kidney regions.
Tenderness is likewise frequently found at
the junction of the ureter and pelvic brim.
The urinary study is by far the most im-
portant phase of the diagnosis in pyelitis.
Frequently a specimen, especially early in
the disease, will show a marked bacilluria and
no pus cells. Later pyuria will develop. At
times it is difficult to find pus cells, but per-
sistence is often rewarded. Repeated daily
urinalyses is often required before a satisfac-
tory specimen is obtained.
Pyelitis is a disease which is frequently
better cured by Nature than by Art. Still
many cases seem to require medical interven-
tion. Sponging and packs are useful for the
febrile stage. Caprokol in liquid form has
been efficacious in many cases, but its ex-
pense is prohibitive in some cases. "The acid:
base treatment of years ago is as popular
today as it ever was. Sodium citrate in 5 to
10 grain doses is given every two hours until
the urine is decidedly alkaline, at which time
the dose can be decreased to a point where
the urine retains its alkalinity. This treat-
40 — jMedical
ment is kept up for ten days. Increased
amounts of citrus fruits are added to the diet
with a discontinuance of meat and eggs. The
following ten days urotropin and acid sodium
phosphate, 5 grains of each, is given every
two hours as above, and fruits removed from
the diet and meat and eggs added.
Repeated urinary studies will tell of the
progress of the case. So long as pus is pres-
ent in the urine, the acid: base treatment is
rotated. When drugs are discontinued, an
occasional urinalysis is indicated as a check-
up.
Given a female child with an unexplain-
able sudden onset of fever, no other sign or
symptom and a negative physical examina-
tion, pyel'tis is usually the cause.
EYE, EAR AND THROAT
For this issue, V. K, Hart, M.D.
Charlotte, N. C.
Obstructive Diphtheria
This title is used because it covers any
diphtheria of the larynx, trachea or bronchi.
When any one or more of these organs is
attacked, there results the symptoms of ob-
struction to respiration.
These are well known and constitute:
1. Inspiratory stridor.
2. Tracheal tug and marked epigastric
"dipping" as the accessory muscles of respira-
tion are brought into play.
3. Cyanosis.
4. Rapid heart.
5. Aphonia.
Such a symptom-complex may occur with
no previous membrane in the throat and a
negative pharyngeal culture. Then it is a
real primary laryngeal diphtheria. Such oc-
curs not infrequently. When the picture fol-
lows a pharyngeal diphtheria, the diagnosis
is obvious.
Whether primary or secondary, certain car-
dinal signs indicate immediate operative in-
terference. They are:
1. Excessive restlessness with persistent
loss of sleep.
2. A heart rate of 150 or over.
3. Obvious signs of fatigue.
4. .\ high grade toxemia with marked
temnerature reaction.
This picture may supervene despite a large
initial dose of antitoxin of not less than
70 noo units.
The nredilection of the toxin for heart
muscle is well recoenized clinicallv. Add to
this toxic mvncarditis the terrific strain ot
lone continued insufficient aeration, and a
myocardial collapse is imminent. In fact, the
deaths that occur after surgical interference
are usually cardiac deaths.
Given such a case, and if the child is not in
rollanse. direct laryneoscooic examination of
the larynx trachea is desirable with culture
and smears taken directly. . This gives an
exact idea of the pathology. (Occasional
staphylococcic and streptococcic infections
v'ill nrodure the same clinical picture necessi-
tatinT interference as a life-saving means.)
Aspiration of the larynx sometimes gives pro-
longed or permanent relief and makes intuba-
November, 1929
SOUTHERN MEDICINE AND SURGERY
tion safer.
If stridor continues, a test intubation
should be done. If this does not give imme-
diate relief, there is subglottic involvement
and an immediate tracheotomy must be done.
It is well to always be prepared for this be-
cause it is possible to shove a piece of mem-
brane ahead of the tube. Tracheotomy is
also indicated to put the larynx at rest if a
child cannot be extubated in four or five days
without dyspnea.
If obstruction returns after tracheotomy, it
is positive evidence of a tracheo-bronchial
diphtheria, the most malignant type. Usually
membranous casts or caked secretions can be
aspirated by suction through the tracheotomy
tube, though occasionally bronchoscopic re-
moval may be necessary. Welford recently
reported 24 such cases from the Chicago Mu-
nicipal Hospital for Contagious Diseases with
a mortality of 91 per cent.
The economic side is becoming a serious
one. These children are practically all from
verv fxior families.
There being no hospital for patients with
contagious diseases in Charlotte, they must
be isolated in private rooms with special night
and day nurses with consequent prohibitive
cost. There are no charity funds available.
Then, too, this is a preventable disease.
The profession should stress the administra-
tion of toxin-antitoxin in early life. Rarely
is diphtheria seen in a child who has had a
previous clean tonsillectomy. Education
should be carried particularly to the poorer
people. Certainly much in the future can be
accomplished by prophylaxis.
ORTHOPKDTr SURGERY
O. L. Mii.i.ER. M D.. Editor
Charlotte. N. C.
Ischemic Paralysis
Attention is again called to the very dis-
rouraeing and crippling condition of ischemic
disturbance ass<iciated with fractures or other
trauma. Writing in a recent issue of the
American Journal of Surf^ery, Dean Lewis
tells us that ischemic palsy (Volkmann's
ischemic contracture) is probably more com-
mon than is generally believed. He states
th.Tt if is primarily a myositis dependent upon
acute venous stasis following a trauma, most
frequently a supracondylar fracture of the
humerus. The tough antecubital fascia plays
an important role in confining the hematoma
nd preventing expansion. .Although tight
bandaging and circular casts have been look-
ed upon as the sole causes of the condition,
the statistics of Hildebrand and of Denuce
show that only about 60 per cent of the cases
have been treated with a cast.
In dealing with an injury likely to be fol-
lowed by ischemic contracture it is important
to be constantly on the lookout for signs of
developing venous stasis. Severe spontane-
ous pain radiating over the forearm, espe-
cially if it is associated with tenseness and
discoloration in the antecubital fossa, is a
danger signal. The muscles are swollen and
tense and the fingers rigid, swollen and cya-
notic. Motion is finally lost.
-After development of the palsy the hand
assumes a typical position, usually quite dis-
tinct from that seen in combined median and
ulnar nerve paralysis. The wrist is extended
or slightly flexed, the metacarpo-phalangeal
joints are extended, and the interphalangeal
joints are flexed. The thumb may be rigidly
adducted. Extension of the wrist leads to
flexion of the fingers, while extension of the
fingers leads to flexion of the wrist.
The condition is more easily prevented than
cured. In cases of supracondylar fracture
with marked displacement the use of a cast
or splint is contra-indicated and reduction in
acute flexion should not be attempted. Re-
duction can always be effected later. Poor
reduction with good function is preferable
to good reduction with ischemic contracture.
When ischemic contracture threatens, opera-
tive interference consisting in longitudinal
incision through the antecubital fascia for
relief of the tension is to be considered. The
author reports a case which was much bene-
fited by this procedure. When the contrac-
ture has developed the prognosis depends on
the amount of muscle tissue lost. The best
results are obtained by the use of elastic ten-
sion and gentle physical therapy with care
to avoid tearing through fibrotic muscle which
would lead to further contraction.
MISSIS LINBOIG TOO. MEBBY
The Spirit of St. Louis was making a few silver
circles before its reluctant descent upon Mitchell
Field.
"It's Linboi^!" shouted one of the spectators.
"Not LinboJK. Lindberch!" corrected a bystander.
"Well," said the shouting spectator, "he's flying
Linboig's plane!" — Philadelphia Public Ledger,
SOUTHERN MEDICINE AND SURGERY
November, 1929
UROLOGY
For this issue, William M. Coppridce,
M.D., F.A.C.S., Durham, N. C.
Urological Conditions in Infancy and
Childhood
Congenital malformations of the urinary
tract are possibly the most common of all
the errors of development. Many of these
anomalies never give rise to symptoms, and
a considerable number likely pass unrecog-
nized throughout the life of the individual.
The common occurrence of such lesions, some
of which cause serious kidney damage early
in life, emphasizes the imoortance of early
recognition and treatment. Dr. Charles Mayo,
in Surgery, Gynecology & Obstetrics of
March. 1929, published a most interesting
and comprehensive article dealing with the
contributing causes of these anomalies. Any-
one who may wish to refer to the embryologi-
cal side of the subject will do well to read
the article.
The most common and serious anomalies
which are amenable to treatment are those
affecting the drainage portion of the tract.
Obstructions about the neck of the bladder
are known to be fairly common and usually
lead to back pressure in the ureters 'and kid-
ney pelves which often causes destruction of
the kidneys by hydronephrosis. These ob-
structions have been described by many
urologists in recent years. They are usually
found to be due to congenital valves in the
posterior urethra. There is also a typ)e which
appears to be a hypertropic change about the
prostatic urethra resulting in narrowing of
the bladder orifice. I have seen one such
case that came to autopsy. The diagnosis
had been chronic nephritis in a boy of six.
The post mortem examination showed a
fibrotic change at the bladder neck with
considerable thickening of posterior urethra.
Both kidneys were completely destroyed by
back pressure of urine.
Most of these cases will show some symp-
toms or signs of urinary disturbance and in
their order of frequency they are as follows:
bed-wetting, dysuria, pyuria, hematuria, dis-
tended bladder or palpable kidneys. Those
who treat children should bear in mind that
these symptoms usually mean some pathology
and call for special investigation. In the
caseis of obstruction at the bladder neck
treatment is usually effective if diagnosis be
not too long delayed.
Tumors of the renal tract and of the ad-
renals in infancy and childhood are rarely
diagnosed early enough for successful treat-
ment to be instituted. Hematuria here is an
early sign of the pathology and should not
be ignored.
Progress in urological technique has car-
ried us a long way toward successful early
recognition of pathology in infants. Cysto-
scopy and urography is commonly practiced
in very young infants and with few unto-
ward results. When the child is very young
we usually do not resort to these measures
without an urgent indication but when indi-
cated they should be done.
We have probably treated in past years,
as chronic nephritis and lost our patients,
many children with congenital malformations
of the urinary tract, which if recognized could
have been successfully treated. Special uro-
logical examinations in children are not dan-
gerous and should be practiced whenever the
symptoms or signs in the case warrant them.
INTERNAL MEDTriNR
Paul H. Ringer. .\.B.. M.D., Editor
Abbeville. N. T.
Vaccines and Sera
All of us are so familiar with the more
time-tried products, such as antityphoid vac-
cine and diphtheria antitoxin that we are
apt to lose sight of the enormous number of
vaccines and sera that are at present on the
market for the prevention and treatment of
various infections. In the Annals of Internal
Medicine for October, 1929, Benjamin White,
Ph.D., of Boston, who is associated with the
Antitoxin and Vaccine Laboratory of the
Massachusetts Department of Public Health,
gives a long list of these substances, with
conclusions as to their prophylactic and ther-
apeutic value. The pharmaceutical houses
have put out so many preparations, with such
glowing descriptions of their efficacy, that it
is well to take stock and see just where we
stand with regard to this class of substances.
Acne. — A vaccine made from the acne ba-
cillus, either alone or combined with the
usual skin cocci, has been employed in the
treatment of this disease. It is recommended
that it be used in fairly large doses in con-
jiinctioii with appropriate treatment of the
November, 1929
SOUTHERN MEDtClNte ANt) StJfeGEftY
800
skin and with general hygienic and dietetic
measures. The curative effect is not partic-
ularly notable although some results have
been obtained.
Catarrh, common colds and influenza. —
We all remember what a bitter warfare was
waged during the various influenza epidemics
with regard to the efficacy of these vaccines;
even now many individuals, mainly laymen,
have faith in the "cold vaccine" as a preven-
tive of the common cold. There is little, if
any. evidence that vaccinated persons fare
better than the unvaccinated ones.
Asiatic cholera. — Bacterial vaccines made
from the cholera vibrio are antigenically po-
tent in producing a fairly high degree of re-
sistance to this disease. This immunity is
neither absolute nor enduring, yet, when kept'
at a proper level by semi-yearly or yearly
vaccination, it suffices to give excellent pro-
tection to troops and travelers, to physicians
and nurses, and to members of communities
where the disease is endemic.
Colon bacillus injections. — Bacilli of this
type have the peculiarity of inducing an im-
munity specific for the one strain injected,
and it seems unlikely that whatever immunity
might follow the injection of a stock vaccine
would cover the many strains encountered in
these varied conditions. One's chances of
success, therefore, would appear to be greater
with the use of autogenous vaccines, but even
here it may be questionable if any improve-
ment in the patient's condition may not be
due to some accompanying form of treatment.
Combined vaccines. — .■^ny vaccine conir
posed of B. coli, pneumococcus, I, II and
III, streptococcus (hemolyticus and viri-
dans), staphylococcus albus, staphylococcus
aureus, staphylococcus citreus, recommended
in cellulitis, phlegmon, septicemia, puerperal
sepsis, abscesses and other septic conditions
would .seem to be a decidedly hit-or-miss
form of treatment. Now that competent bac-
teriologic service can be so easily obtained,
there seems no need for neglecting the diag-
nosis or for injecting such a bacterial mixture
in the hr)pe that it might fit the case.
Diphtheria toxin jor the Schick test and
diphtheria toxin-antitoxin mixture are so
well known and in such common use that they
will not be dwelt upon in this abstract of
Dr. White's article.
Gonococcus vaccine. — Such vaccines have
been widely used in both acute and chronic
gonorrhea and its complications, but usually
with disappointing results. Like other Gram-
negative cocci, the gonococcus is capable of
stimulating only a low grade immunity, and
it is not to be expected that in a vaccine it
would arrest the acute process or influence
deep-seated lesions.
Pertussis. — Laboratory experiment has
shown that B. pertussis is a feeble immuniz-
ing agent and, therefore, one would antici-
pate that its injection would, at best, give
only a slight immunity, .so slight that infec-
tion would rarely be prevented, but perhaps
sufficient to strengthen somewhat the body's
natural resistance to the effects of the disease.
While there are many enthusiastic users of
pertussis vaccines, the whole evidence would
seem to indicate that such vaccines, whether
simple or combined, are of doubtful value,
and rank low in the list of biologic agents.
Plague. — Although one attack of plague
usually confers life-long protection upon the
suvivor, vaccines made from bacillus pestis
confer only an incomplete and transient im-
munity. McCoy and Chapin state that there
is no evidence that such vaccination has ever
controlled an epidemic. However, because
of the deadly nature of this disease the indi-
vidual who may be exposed to it might seek
such protection as these vaccines afford. The
best known of them is the Haffkine, although
those prepared by other methods are prob-
ably equally good.
Pneumococcus vaccines. — Experience with
pneumococcus vaccines for the prevention of
lobar pneumonia both in private and military
practice have not been encouraging.
Rabies. — Because of its universal use when
indicated, no comment is necessary. — (Ed.)
Rocky Mountain spotted jevcr. — The Fed-
eral Public Health Service has announced
that a vaccine against this disease may be
obtained free of charge by application to the
L^nited States Public Health Service Labora-
tory at Hamilton, Montana. Ranchmen,
prospectors and students investigating this
disease can now protect themselves against
this infection.
Scarlet fever streptococcus toxin. — For the
Dick test and also for active immunization —
is being used to such an extent that no com-
ment is necessary, and this same statement
applies in a far larger measure to the small-
810
SOUTHERN MEDICINE AND SURGERY
November, 1929
pox vaccine.
Staphylococci. — Ever since Wright's first
treatises on bacterial vaccines, those made
from staphylococci, particularly the albus
and aureus, have been considered as having
definite therapeutic worth for treating and
preventing the recurrence of local infections
due to these organisms. In the case of fur-
uncles, carbuncles, or other abscesses, vaccine
treatment seems to hasten maturation and
healing. In the indurated or burrowing in-
fections so typical of S. aureus, persistent
treatment preferably with an autogenous vac-
cine often checks the progress of the disease
and prevents relapse.
Streptococci. — The immunologist looks for
a definite but not marked immunologic re-
sponse on the part of a body injected with
killed streptococci, a response specific for the
biologic groups administered and sometimes
specific only for single strains. Streptococcal
infections of the sinuses, the middle ear, mas-
toid process, and endocardium have generally
been found to resist vaccine treatment.
Where it is desired to prevent secondary in-
fection from these cocci the use of a vaccine
of wide polyvalency might result in some
basic immunity. However, in using such a
vaccine, one should bear in mind these limi-
tations.
Tuberculins are touched on by Dr. White,
but will not be discussed here; neither will
vaccinations with typhoid and paratyphoid
bacilli.
Other vaccines. — The above list, while in-
complete, includes the preparations that are
most commonly used. Manufacturing labor-
atories in various countries supply vaccines
or similar products for the prevention and
treatment of asthma, erysipelas, ozena, pyor-
rhea, rheumatism, rhinoscleroma and other
conditions, infectious and otherwise. Since
to these products it is not fwssible to apply
our present standards of appraisal, they may
be left out of consideration.
Sera. — Stated in general terms, a patent se-
rum corresponding immunologically to the
infection to be treated, given in sufficient
dosage early in the disease should, if no se-
rious complicating factors e.\ist, be of the
greatest aid in bringing about recovery.
Antianthrax serum. — When such an infec-
tion has progressed, or when it exists in the
Jung or alimentary tract the use o( antianth-
rax serum will reduce the chances of a fatal
outcome. Fortunately such a serum is now
available and should be used according to
directions in all infections due to the anthrax
bacillus.
Anterior poliomyelitis. — The rationale for
the use of convalescent serum in this disease
appears to be sound. From the very nature
of this disease with the damage to the cells
of the brain and cord, one would expect that
this serum would be of value only in prevent-
ing further development of the infectious
process and would have little or no curative
action in remedying any cellular impairment
already present.
Antidyscntery serum. — Polyvalent sera
made by actively immunizing horses with the
Flexner, Shiga and other strains of the dys-
entery bacillus are useful in the treatment
of bacillary dysentery only, and their value
varies in inverse ratio to the length of time
that has elapsed since the onset of the at-
tack.
Anti-gas gangrene serum. — Such antitoxic
sera are obtainable from a few of the manu-
facturing laboratories, and along with appro-
priate surgical measures are indicated in
treatment.
Antigonococcic serum. — While sera are
available that contain specific agglutinins,
complement-fixing and other antibodies, their
immunologic reactions in vitro are not of a
high order, and their therapeutic action is
uncertain.
Antimeasles serum, antimeningococcic serum
and antipneumococcic serum are so promi-
nently featured in the medical literature that
there is no need to comment upon them, and
diphtheria, erysipelas and tetanus antitoxins
are so well grounded in their results that to
deal with them would be wearisome.
.{ntistaphylococcus scrum. — .Although Par-
ker and others have demonstrated toxin pro-
duction by staphylococci, the sera at hand
are essentially antibacterial in nature. One
would expect no more of them in the way of
curative action than from antigonococcic se-
rum.
.Antistreptococcic serum. — Postponing for
the moment any discussion of the streptococal
antitoxins, antibacterial sera specific for
streptococci may be considered. These are
made for treatment of infections due to strep-
tococcus hemolyticus and also S. viridans.
November, lOM
sotTttEftN MEbtctkfe ANt) stmeekv
Sll
From our knowledge of antistreptococcal im-
munity in general we would rate these serums
low 111 immunizing value. The occasional
favorable report from their users encourage
their continued manufacture.
Antivcnins. — Antisera specific for venoms
of the American rattlesnake, copperhead and
water moccasin are now manufactured in the
United States. Laboratory trials show that
such sera not only neutralize these venoms
in the test tube but protect animals injected
with kiUing amounts of venom. When in-
jected into human beings bitten by any one
of these three poisonous snakes, if given soon
alter the bite is received, they prevent or
modify the to,\ic symptoms. The shorter this
period the more useful is the antivenin.
'Ihe list which has been quoted is rather
staggering, and when- one goes through it, it
is rather disappointing to find that in such a
large army there should be so many poor
soldiers. The average man in practice does
not realize the enormous number of immun-
izing agents put forth, and it is for this rea-
son that the editor has thought it wise not to
call the attention of his readers to a host of
remedies of the same class in whose ranks
may be tound the most brilliant examples of
niouern medical discoveries and also, alas,
many examples of complete therapeutic fail-
ure and of pharmaceutical charlatanry.
RADIOLOGY
For this issue, J. Donald MacRae, jr.
Asheville, N. C.
A Principle in Radiotherapy
The fact that a cell is more vulnerable to
short wave radiation during the time when
it is undergoing mitosis is a principle in the
use of x-ray and radium, the recognition and
application of which has enabled us to get
some of the best results in these forms of
therapy. One of the criteria of high malig-
nancy in a tumor is the presence of many
mitotic figures. In a general way this is also
one of the criteria of high radiosensitiveness.
A tumor which is highly sensitive to radiation
is not necessarily one that offers a good prog-
nosis, for, while the primary growth may be
controlled or made to regress, the rapid
growth of the tumor has generally given rise
to distant metastases before the primary le-
sion has received its lethal dose.
Jladiologists interestecj in therapy have
sought for a means of taking advantage of
in.s cliaracteristic of tumor cells. Two
lueinous nave been evolved for keeping up
an almost constant bombardment ot these
ceub wiin radium or x-rays.
Kingery gave us the Deginning of the Sat-
uration lecnnique, wnicn I'lanaiar has re-
vised and put into a worKaoie lonn. js.iiig-
cry Dased his iiiought on me law ol mass
rcdCiioiis. AS applied to tne radiation euect
It could De stated as loUows; the rate ot loss
ol eilect vanes directly as the degree oi con-
centration. We make the hyjxjthetical as-
sumption that the concentration ol the eflect
IS a substance which can be lost. For a
high concentration of radiation effect there
will be a high rate of loss of effect and for a
low concentration a low rate of loss. Thus
if the concentration of the effect can be com-
puted as the percentage of complete satura-
tion the amount of etfect which would be
lost in a given time could also be computed.
These computations have been made in the
lorm ot tables and graphs to facilitate their
application. AlcKee used this principle and
louiid that when he had given a dose which
according to the computation then in use
should have given less than an erythema he
got a noticeable erythema. Evidently the
curve as plotted originally did not quite lit
the facts. Pfahaler and others have done
further work on this technique and have
plotted curves which more nearly lit the bi-
ological facts. As it stands today the tumor
mass is exposed to x-ray on successive days
and brought up to a point of saturation.
When this point has been reached the mass
is retained at saturation by a small dose,
say, three times a week. The proper dose
can be detei mined because we can compute
the loss which will have taken place between
doses. By using their technique the site to
be treated can be given an almost constant
bombardment with x-rays. This applies to
radium as well.
A few words here in favor of the use of
low milliamperage in the high-voltage x-ray
tube. Water-cooled deep-therapy tubes will
run on 25 ma. and thus shorten the time for
a given exposure to one-fifth of that for 5
ma. technique. If we are going to be con-
sistent in trying to approach the constant
bombardment effect, the longer exposure
SOUTHERN MEDICINE AND SURGERY
November, 192Q
should be the thing to strive for. True this
IS more tedious, but the chance of finding
the tumor cell in the vulnerable state is
greatly enhanced.
I realize that the direct effect of x-ray on
the tumor cell is not the only thing that
causes the regression and final death of the
tumor. There is the indirect effect through
a stimulation of the adjacent normal tissue.
As always the truth probably lies in the
means rather than the extremes, but the di-
rect effect is a real effect and must be con-
sidered.
The gamma ray of radium and the x-ray
are essentially the same except for a differ-
ence in wave length. Since, however, the
source of these two rays is different, we must
use the rays in a manner best adapted to
their peculiarities. One of the chief advan-
tages in radium is that the small quantity of
the element necessary in most cases, con-
tained in a proper capsule, can be placed in
body cavities or in the tissue and left in
place, without a great deal of discomfort to
the patient. A capsule can be left in the
uterus for 100 hours, with perhaps one or
two removals for douching. Radou seeds are
implanted in the tissue and allowed to remain
permanently. The same principle lies behind
it all — long-continued bombardment of the
cell to catch it in its most vulnerable stage.
When radium is left in a cancerous uterus
for 100 hours a comparatively small quantity
is used, 50 to 75 mgm. quite heavily filtered
by a capsule of gold or platinum. The heavy
filtration stops the beta and longer gamma
rays which have an escharotic effect. The
rays which pass through are highly penetrat-
ing and appear to have a more selective ef-
fect on the tumor cells. The filter has stop-
ped a large percentage of the total radiation
so the long duration of the treatment is feasi-
ble with less danger to the normal tissue.
Radon seeds are now made chiefly of gold
which also gives a heavy filtration effect.
Then the seeds are generally comparatively
weak, often one to five milicuries. (A mili-
curie has an immediate effect equivalent to a
milligram of radium element.) Since the ac-
tive life of a seed is only a few days, it may
be left in situ if desirable, even after it ceases
to emit gamma rays.
Jn small superficial lesions the dose re-
quired is generally so small that long treat-
ment is not necessary, but in larger and
deeper seated lesions the principles above
stated apply.
To sum up:
The best results on radiotherapy seem to
be attained by making haste slowly, by giving
the required dose over a comparatively long
period of time.
THERAPEUTICS
Frederick R. Taylor, B.S., M.D., Editor
High Point, N. C.
The Treatment of Constipation
After an absence of a year and a half in
an ertort to lurther the cause of periodic
nealin examinations by a campaign conduct-
ed under the auspices ol the Mate isoard oi
Health and the Rockefeller I'oundation, we
hnd ourselves once more in the field ol in-
ternal medicine. With this return to our
lormer activities, we are also discontinuing
the Department of Periodic E.xaminations,
and returning to the Department of Thera-
peutics.
We propose to take for our subject this
month a rather complex one — the treatment
of constipation.
Constipation is a complex group of condi-
tions, not a primary disease, but a condition
secondary to a great variety of environmen-
tal, functional, and structural causes. The
discovery of these causes and their correction
should be the prime objects in the treatment
of constipation.
It may be profitable to consider these
causes in 6 groups, viz.:
1. Nervous and psychic factors.
2. Improper habits, including dietary er-
rors. __ .jj
3. The abuse of drugs.
4. Reflex factors.
5. Partial intestinal obstruction.
6. Exhaustion states, atrophy, etc.
1 . We have put nervous and psychic factors
first because we believe them to be the most
frequent and important causes of constipa-
tion, though some would put improper habits
in the first place. Prof. W. B. Cannon has
shown the very important role played by
emotional disturbances in affecting the gastric
secretions. Dr. Walter C. Alvarez has dem-
November, 1929
SOUTHERN MEDICINE AND SURGERY
&U
onsiraied equally marked enects ol emotional
uibtuiUdULCa ua iiie muior luiicuoiis ui um
gabLiu-uiLcsiinai tract, un very rare occa-
bioiib, iiui nearly as otten as is Uie popular
uciiei, a suaden inght may produce an in-
voiuiiiary evacuation ol tne bowels. Un me
odier nand, an.xiety, worry, anger, and many
oLner mental states may oe associated witn,
and, we believe, cause, a spastic type of con-
stipation. In such cases, mental catharsis is
indicated ratner than physical. A careful,
detailed history, with the discovery of the
special factors producing nervous tension,
with the application of appropriate psycho-
therapy, is what is needed nere.
2. Almost everyone has been surfeited with
gratuitous misinlormation as to the role of
improper habits, especially dietary habits, by
the protagonists of this and that dietary fad.
Considerable real information of value has
also been circulated. Almost everyone knows
that a diet composed too exclusively of foods
which are almost completely digested and
absorbed tends to constipation in many per-
sons and that, for most of us, a certain
amount of roughage is desirable. What is
far less commonly recognized, even by phy-
sicians, is that many persons have a type of
gastro-intestinal tract that is irritated by such
roughage into a chronic spastic state, with
resultant digestive disturbances and spastic
constipation. Dr. Alvarez has done a great
service in showing that what he aptly terms
a smooth diet — a diet with a very low cellu-
lose content — is often indicated in spastic
conditions of the intestinal tract. He gives
a masterly exjx)sition of the principles under-
lying the use of the smooth diet in his chap-
ter on Diseases of the Stomach in the Ox-
jord Loose-lcaj Medicine. A properly bal-
anced diet, with due consideration of water
intake is important.
Dr. Edward Martin of the University of
Pennsylvania used to say that the normal
call to stool should be treated as an import-
ant order from a superior officer, to be obey-
ed at once. Repeated failure to give prompt
obedience to the normal stimulus is a potent
cause of constipation, as is failure to give
sufficient time to the act of defecation for it
to be complete. Such details as these are
all too often ignored in examining patients,
yet they are often of prime significance, Ir-
regular hours of eating should be avoided so
tar as practicable, insuiucient exercise is
often a cause of constipation that must be
corrected to cure the patient.
3. The abuse oj drugs with the establish-
ment of a purgative habit is still a factor of
importance, though of gradually lessening im-
portance. Few intelligent persons today hold
that a weekly dose of salts or castor oil
should be administered to the children. How-
ever, an amazing number of persons do abuse
laxative or purgative drugs, to their great
detriment. It is very ditticult to establish
normal intestinal function after a prolonged
purgative habit, and it is often imixissible to
completely break the habit at once.
4. Reflex Causes. Many of these are com-
monly recognized — especially those existing
in the gastro-intestinal tract, such as hem-
orrhoids, chronic appendicitis, etc. More re-
mote causies often go quite unrecognized.
One of the most important of these is eye-
strain. Spastic constipation associated with
eyestrain and relieved by proper glasses is a
frequent condition. A test type chart and
an astigmatic chart should, we think, be in-
cluded in the minimum equipment essential
for a general physical examination. These
rough tests of vision will not detect all re-
fractive errors by any means, but they will
in very many cases discover unsuspected vis-
ual defects, and referring the patients to the
ophthalmologist will secure more detailed in-
formation and also provide proper treatment.
5. Partial obstruction oj the intestinal tract
is by no means infrequent. Kinks, constrict-
ing bands, and fecal impactions must all be
considered. The first two often require the
x-ray for diagnosis. Fecal impactions are
usually in the rectum, and can be detected
by the palpating finger . Wc believe that the
digital rectal examination is more neglected
by doctors who arc in general highly compe-
tent and conscientious, than any other stand-
ard procedure of physical diagnosis. It does
not require elaborate equipment — f)nly a box
of finger cots, some lubricant, and the will to
work. Practice brings proficiency in this as
in other procedures. Often diagnosis and
treatment are combined, as the examining
finger may break up or remove impactions.
Treatment of other forms of partial obstruc-
tion, including kinks, constrictions, pressure
814
SOtJTHERN MEDICINE AND SURGERY
November, I0i9
on the bowel from without by an enlarged
prostate, a retroverted uterus, neoplasms, etc.,
IS, ot course, usually surgical.
6. Exhaustion States. Constipation may
occur in exhaustion states from any cause —
overwork, loss of sleep, prostrating illnesses,
extreme age. Herp as elsewhere the treat-
ment will depend on the cause. It is im-
portant in all cases of non-obstructive con-
stipation to try to determine whether we are
dealing with a spastic or an atonic type.
Ufug IHerapy. It is a platitude to say
that uiugs sliouid be avoided in constipa-
tion, especially constipation of the spastic
type, iiie iiy in ttie ointment is that tins
lb not always possible. A\. iimes rehei is
urgeiiiiy necdea. Vvnere the need is very
acuie, a Simple enema is ttie best thing lo
use. in less acute situations a smau oil
enema leit m tne rectum over night, mineral
oil inieriially, or some of the agar prepara-
tions, may oe tried. Laxative loods, such
as prunes, hgs, abundance of fruit of various
kinds, etc., oiten prove useful. When real
laxatives have to be used, we should select
those which are relatively free from consti-
pating alter-effects. Of these, cascara may
be taken as the type. We prefer the plain
bitter fluid extract to either the more pala-
table but weaker aromatic fluid extract, or
the various proprietary preparations of the
fluid extract reinforced with other less de-
sirable drugs. The bad taste has the ad-
vantage that the patient is not greatly tempt-
ed to take the drug over an excessively long
period. The aromatic preparation often has
little effect in obstinate cases other than,
perhaps, to upset the stomach. The liquid
form is usually preferable to pills for two
reasons — if the pills are not fresh they may
go through undissolved, and when using the
liquid, the patient can find and use more
exactly the minimum dose necessary to get
results. This should be found as soon as
possible and should be the dose used. There
are wide individual variations among patients
in the dose required.
In mild cases due to kinks, constrictions,
etc., mineral oil may be useful. It is often
worth while to try it for a while before re-
sorting to surgery. There seems to be some
difference in the lubricating properties of
vanous mineral oils marjieted (or internal
use. We look on Squibb's liquid petrolatum
as a very good preparation. At an events,
with the possible exception of mineral oil to
coiuroi cases uue to mud nou-progressive nie-
cnanical lactors, and to the use oi mud laxa-
tives 10 correct the atonic constipation oi
Old age, drugs muat always be looKed upon
as iiouuiig more tiiaii temporary aids in tne
ireainieiii oi constipation, and it siiouid De
the aim oi the physician to dispense with
them as soon as possible.
Physiotherapy plays a valuable part in
the treatment ol constipation. We have noted
already the value of exercise in some cases.
Massage has been lound useiul in some. Ihe
application ot the sinusoidal current is rec-
ommended by many authorities, sucu e. g.,
as the late Ur. t. a. Cjranger, who was Onei
Ol the JJepartmeiit ot Fnysical Inerapy in
the iioston City Uospital and a memocr oi
tne A. i\l. A. council on Physical inerapy.
\ve have as yet no personal experience with
tins method.
To conclude, the treatment of constipa-
tion involves the taking of a carelul history
and the making of a thorough physical ex-
amination, including a search for refractive
errors and a rectal examination, with the cor-
rection of all defects discovered, so far as
possible, including environmental, psychic,
habit, reflex, obstructive, and exhausting con-
ditions. Physiotherapy may be a valuable
adjunct in selected cases, when carried out
properly. Drugs should be used only when
unavoidable, and then, as a rule, only as tem-
porary expedients.
OBSTETRICS
Henry J. Langston, B.A., M.D., Editor
Danville, Va.
Preventing Puerperal Infection
The October issue of Southern Medicine &
Surgery calls attention to the large number
of deaths annually from puerperal infection.
We also mentioned the fact that there was
no method used at the present time to deter-
mine the large number of women with mor-
bid conditions resulting from puerperal in-
fections which were not fatal. We want to
consider puerperal infection further with
reference to prophylactic measures which are
sane, practical, workable.
The burden of this work and responsibility
November, 1929
SOUTHERN MEDICINE ANt) StJftGERY
$1$
falls upon the family physician. We have
trusted too much to nature and to luck in
these cases. We usually pass the responsi-
bility on to the patient or patient's family
saying that "she should have called me ear-
lier": when, had she called earlier, the prob-
abilities are that, with our indifferent atti-
tude, the outcome would have been the same.
Then, what should we do in order to specifi-
cally prevent puerperal infection?
First, we should inform our patients that
we want them to come to us for examination
and study up to the hour of labor. The only
way is to talk privately to our patients and,
as opportunities present themselves and speak
publicly of the necessity for proper study and
care during the period of pregnancy.
There are other things that we should do
specifically, conscientiously and systemati-
cally in each case.
Locate all foci of infection. Begin at the
nose. If there is sinus trouble or obstruction
this should be treated by the proper person
until cured. The teeth and gums should be
thoroughly examined and treated. If the
t(msils are found to be very decidedly dis-
eased, with pus in them, they should be re-
moved, provided it is not near the term of
pregnancy.
.■\ most careful history should be taken of
the urinary tract. Cystitis or pyelitis should
be faithfully treated until all symptoms dis-
app)ear.
Vaginal examination, any disease condi-
tions found treated. Much of our puerperal
infection comes from the patient contracting
gonorrhea from her husband, the disease is
allowed to go on untreated, then when she
goes in labor, as labor continues and after,
this infection passes up into the uterus and
tubes and frequently kills the patient.
The alimentary tract should be most care-
fully studied to determine if the patient is
having proper elimination. If the appendix
is diseased to such an extent that it may en-
danger the life of the patient, even though
the patient is pregnant, the best and wisest
thing to do is for the surgeon to remove the
appendix. The safest form of anesthesia to
be used in the removal of the appendix is
spinal anesthesia, in the hands of a person
who knows how to use it. The nausea and
vomiting of general anesthesia is avoided, the
removal of the appendix in a sense becomes
a very simple matter and the convalescence
of the patient is very much smoother and
nicer than where a general anesthetic is
used. The gall-bladder and the bile tract
must also be studied for possible infections.
No doubt many of our troubles connected
with puerperal infection are traceable to this
source. If the gall-bladder is found to be
very decidedly diseased or there are stones in
it, it should be treated and cured, if possible,
two or three months after the beginning of
pregnancy or two or three months before the
termination of pregnancy. In other words,
we have four or five months in which to cor-
rect the trouble of this organ.
With all of these conditions properly man-
aged, we believe we have advanced consider-
ably. Of course the big point in preventing
puerperal infection is to see that our patient's
entire body is functioning properly, and, as
we have emphasized before, this can only be
done by systematically studying the patient,
paying decided attention to the increases of
the weight of the patient, not allowing her to
get fat and flabby, requiring her to take con-
siderable exercise, keeping her weight very
close to normal. A patient who weighs 110
lbs. should not weigh much more than 120
or 125 lbs. at the time labor sets in. This
limited increase in weight will cause her to
feel considerably better than if her weight is
allowed to increase to 140-160 lbs., and she
to come to labor fat and flabby with an enor-
mous baby that is also fat and flabby. Also
see that the kidney output is right, that the
blood pressure is in the range of normal and
that elimination by the way of the bowels is
perfect or approaches perfection.
If we will as a group follow these princi-
ples in our prenatal care we will be able to
stamp out puerperal infections almost com-
pletely.
SURGERY
Geo. H. Bunch, M.D., Editor
Columbia. S. C.
Tumors of the Brkast
The location of the breast makes recogni-
tion easy of tumors in it. An intelligent
woman should and does become aware of
them early. She should be taught the poten-
tial danger of cancer in neglected breast le-
sions. She should know to consult her phy-
sician at once when any abnormality is found
816
SOUTHERN MEDICINE AND SURGERY
November, 1920
or suspected. If this were universally done
the mortality from cancer would become al-
most nothing. Lesions of the breast have
been the most effective field for educating
the public about the prevention and the cure
of cancer. Bloodgood repxjrts that in the
Surgical Pathological Laboratory of the
Johns Hopkins Hospital from 1899 to 1900
80 per cent of the breasts had cancer, 19 per
cent were benign, and benign lesions not oper-
ated upon were only 1 per cent. Today in
his clinic only 17 per cent of lumps in the
breast are cancer; 18 per cent are benign,
and the remaining 65 pier cent have benign
lesions for which operation is not indicated.
The contrast of conditions then and now
shows the striking improvement that has
come from education and co-operation of the
public.
The classical picture of advanced breast
cancer is now seldom seen. The fixed tumor
with adherent skin, retracted nipple, brawny
induration and extensive glandular involve-
ment is incurable. Multiple nodules under
the skin, fixation to the chest and hard palpa-
ble supraclavicular glands are positive contra-
indications to operation. Surgery in such
cases cannot remove the pathology; it only
stimulates the tumor and hastens the end.
Inflammatory lesions of the breast are ten-
der. They are likely to be of short duration.
Manipulation causes pain. The soreness is
worse during menstruation. There is apt to
be fever and leucocytosis. Pain is a late
symptom in cancer. It is the one symptom
that forces the ignorant patient to consult a
physician. She does not concern herself
about a tumor that does not give her distress
or trouble. It is only when the "weed" in
the breast begins to hurt that she becomes
alarmed.
In considering the nature of a discrete
lump in the breast the physician should re-
member the tendency of even obviously be-
nign growths to become malignant with age.
We think every non-inflammatory lump
should be removed. Whether the lump
should be simply incised or the whole breast
removed is a question that after frank dis-
cussion with her should be left to the choice
of the patient. The breast is not essential
to life and our practice has been in case of
reasonable doubt to play safe and remove the
breast. Although the operation is mutilating
there should be finally but little disfigure-
ment.
Theoretically the frozen section after local
excision, with complete operation at once if
cancer is reported, relieves the surgeon of the
responsibility of decision; but practically in
the average hospital this method of examina-
tion and diagnosis is inaccurate and uncer-
tain. If Bloodgood or Lynch were available
we could accept the diagnosis with assur-
ance, but most of us should not place too
much confidence in it otherwise.
In doing a complete operation on the breast
for malignancy there should be wide excision
of overlying skin with removal of both pec-
toral muscles and the cleaning out of all
gland-bearing tissue from the axilla. Surgery
for cancer, if effective, must be radical. After
operation we advise deep x-ray therapy, be-
lieving that it is helpful in preventing recur-
rence. It is given in inoperable cancer of
the breast as a routine to our patients. It
is not curative but it prolongs life. Its great-
est service to them is in controlling pain that
otherwise could be relieved only by mor-
phine.
In conclusion, a word about the stimulat-
ing effect of massage on cancer of the breast
may not be amiss. A tragedy that we shall
never forget was the death of an osteopathic
physician from inoperable cancer with great
masses of involved axillary glands and ex-
tensive edema of the arm. She had been
having daily massage by a sister physician
of a breast tumor which had been recognized
only about six months before death. An
equally lamentable tragedy in this city was
the recent death from hyperthyroidism of a
christian science healer without a physician
having been consulted. That this individual
had the absolute courage of her convictions
in no way saved her from the effects of the
disease.
NEUROLOGY
Olin B. Chambhrlain, M.D., Editor
Charleston, S. C.
Encephalitis and its Sequelae
The editor of this Department has several
times in the past called attention to the great
importance of bearing encephalitic sequelae
in mind when considering a case which pre-
sents vague symptoms referable to the nerv-
ous system. There can be little question of
November, 1929
SOUTHERN MEDICINE AND SURGERY
the fact that it is, next to syphilis, the most
frequently encountered infection of the cen-
tral nervous system. This statement, by the
way, takes issue with the assertion, which
has been made more than once in the past
few years, that multiple sclerosis ranks next
to syphilis in frequency. I have been utterly
unable to substantiate such a statement from
personal experience or to find data support-
ing it in literature. This question of the
comparative frequency of multiple sclerosis
in .America is an interesting one — and will
be discussed in an early report from this de-
partment. It is my wish to pwint out the
frequency with which the diagnosis of en-
cephalitis, of the epidemic type, must be
borne in mind. .A recent case, which may
be correctly labelled chronic encephalitis
lethargica, indicates the necessity of a care-
fully considered history.
.A young while man of 21 was brought for
diagnosis. A casual glance sufficed to make
it. The boy advanced into the consulting
room — with the slightly bent back, short
steps and blank facies of the Parkinsonian
syndrome. Examination confirmed the ten-
tative diagnosis. It then became necessary
to go back and find out when the acute in-
flammatory reaction, which injured cells in
the substantia nigra and pallida system arose.
To the surprise of the history taker no such
acute episode could be discovered. The step-
mother gave a very accurate and detailed
history. The boy had been considered bright
and entirely normal until the age of 12.
Then it was noticed that he was becoming
more of a behavior problem. Whereas before
he had been truthful and reliable, he became
slowly undependable. His school work fell
off in quality and he soon become unable to
keep up with his class. Closer questioning
of the mother, to see if any infection, how-
ever minor, had preceded this personality
change, failed to disclose it. The only phy-
sical abnormality noted during the period
was not considered important enough to be
told of spontaneously. A direct question,
however, brought out the significant fact that
during the year in which they first noted the
deterioration in the school work he showed
an unusual desire to sleep in the afternoon.
She states that she would sometimes find
the boy asleep in the barn when the other
children were playing. She was quite sure
that he had had no headaches or any sense
of malaise during this time.
The history of the subsequent years was
unfortunate. The condition was not recog-
nized. He underwent various treatments, all
apparently based on the vague diagnosis of
"nervousness" (one of the world's worst
terms). He was even in a school for feeble-
minded children for two years.
Besides the Parkinsonism, the boy pre-
sents another interesting by-product of en-
cephalitis— "oculo-gyric crises." Lately these
dramatic spasms affecting the eye muscles
have been reported rather frequently. During
the attacks, which come on often during em-
barrassment or excitement and last for min-
utes or even hours, the eyes are directed
either upward or to one side. They can be
brought down often by a strong conscious
effort, but soon return. The patient in ques-
tion had an attack at a subsequent visit. It
was interesting to watch the voluntary and
involuntary components of the direction of
gaze struggling with one another. In pass-
ing it may be said that the study of enceph-
alitis has thrown more light uix)n that queer
borderland between the organic and the func-
tional than perhaps any other disease.
SOUTHERN MEDICINE AND SURGERY
November, 1029
Our Medical Schools
Note. — It is intended to carry in each issue a col-
umn of news items of the medical schools of the
Carolinas and Virginia,
MEDICAL COLLEGE OF THE STATE
OF SOUTH CAROLINA
During the past summer Dr. Olin B.
Chamberlain, Lecturer on Medicine, held a
clinical clerkship in the National Hospital,
Queen's Square, London, England, where he
had the opportunity of working in the clinics
of Dr. James Collier, Dr. Gordon Holmes and
Dr. Kinnier Wilson.
Dr. Robert B. Taft, Lecturer on Physical
Therapy and Roentgenology, was given a
four months' leave of absence which he spent
partly in Vienna working under Dr. Holz-
knecht, and at .\x\n Arbor, Michigan, work-
ing under Dr. Hicky.
There have been several changes in the
Faculty this year. Mr. Edwin J. Farris,
from the Museum of Natural History, New
"\'ork, has been added to the Department of
Anatomy. Mr. Joseph L. Klotz, formerly of
the L^niversity of Nebraska, is acting .Assist-
ant Professor of Pharmacy, supplying the
place of Prof. W. A. Prout, who has been
granted a leave of absence for further study.
Dr. Francis W. Porro, formerly of Highland
Park, Illinois, and Mr. John H. Hoch, for-
merly of the Philadelphia College of Phar-
macy and Science, are occupying the posi-
tions of Instructor in Pharmacology, and
Lecturer in Botany and Pharmacognosy, re-
spectively. Dr. John M. van de Erve has
been added to the Department of Physiology.
Dr. J. D. McKennon, formerly of the Uni-
versity of Wisconsin, has been made Lecturer
on Clinical Pathology, succeeding Dr. T. H.
Byrnes, who has been transferred to the De-
partment of Pathology in place of Dr. H. H.
Plowden, who resigned to accept a position
elsewhere.
MEDICAL COLLEGE OF VIRGINIA
Dr. J. L. McElroy on July 1st became su-
perintendent of the college hospitals. Dr.
McElroy is an experienced executive, a grad-
uate of Indiana L^niversity School of Medi-
cine, former superintendent of the University
of Iowa Hospital and St. Luke's Hospital,
Chicago. Dr. McElroy had extended experi-
ence overseas both during and following the
Last year the college through hospitals and
clinics gave approximately 55,000 health ser-
vices to patients. Of these services, 34,609
were visits to the outpatient department;
7,906 were hospital patients who received a
total of 101,133 days' treatment; 3,064 were
emergency room treatments; 290 were home
obstetrical deliveries; and upwards of 10,000
were visits to the dental infirmary.
Miss Frances Helen Zeigler, R.N., former
educational director and assistant director of
nurses, school of nursing and health. Uni-
versity of Cincinnati, on September 1st be-
came dean of the school of nursing and direc-
tor of nursing .service of the college hospitals.
Miss Zeigler is an alumna of Virginia Inter-
mont College, Johns Hopkins Hospital school
of nursing, and Teachers' College, Columbia
L'niversity.
Faculty promotions effective July 1st for
the schools of medicine, dentistry, and phar- '.
macy are: Dr. Karl S. Blackwell, from as- *.
soctate professor to professor of otolaryngol-
ogy; Dr. W. R. Bond, from associate in to
assistant professor of physiology and phar-
macology; Dr. J. G. Carter, from instructor
in to associate in obstetrics and gyneco-
logy; Dr. George W'. Duncan, from assist-
ant in to instruct or in prosthetic denistry;
Dr. H. B. Haag, from associate in to
assistant professor of pharmacology and
physiology; Dr. W. Tyler Haynes, from as-
sistant in dental technics to instructor in
orthodontia and assistant in dental technics
and operative dentistry; Dr. Emory Hill,
from associate professor to professor of oph-
thalmology; Dr. A. O. James, from associate
professor of operative dentistry to professor
of operative dentistry and superintendent of
the infirmary; Dr. F. W. Shaw, from asso-
ciate professor to professor of bacteriology
and clinical pathology; Dr. H. Hudnall
Ware, jr., from instructor in to associate in
obstetrics; Dr. T. B. Washington, from as-
sistant in surgery to instructor in genito-uri-
nary surgery; Dr. J. M. Whitfield, jr., from
instructor in to associate in obstetrics.
New members added to the staff for the
current year are: Major James B. .Ander-
son, professor of military science and tactics;
Miss Mary Brockenbrough, associate in art;
Cliveden L. Cox, associate in pharmacy; Dr.
(page 820)
November, 1929
SOUTHERN MEDICINE AND SUIGERY
819
HISTORIC MEDICINE
For this issue. W. D. James, M.D., Hamlet, N. C.
Doctor D. IM. Prince, of Laurinburg
The late Dr. Daniel Malloy Prince, of
Laurinburg, N. C, was born at Ellerslie,
Marlborough County, South Carolina, on
July 14, 1848, a son of Laurence Benton and
Mary Rockdale (McEachin) Prince. Dr.
Prince's father, Laurence Benton Prince, was
a son of Laurence Prince of Cheraw, S. C,
who, in turn, was a son of Captain Charles
Prince of the British Navy. His grandfather,
Laurence Prince, married Charlotte Benton,
daughter of Colonel Lemuel Benton, and their
children thus became related to the famous
Thomas Hart Benton, United States Senator
from Missouri from 1820 to 1850, and one
of the great statesmen of the first half of the
nineteenth century.
.After excellent preliminary training Dr.
Prince entered the Medical College of South
Carolina at Charleston, from which school
he was graduated in 1870. Later he took
advanced work at Johns Hopkins. His life
from that time on was spent in the active
practice of his profession in all its branches.
His whole time and energy was devoted to
the medical profession. In a half century of
practice he gained an enviable standing
among his colleagues and the grateful devo-
tion of his patients. He was among the first
in the state to perform an abdominal opera-
tions. Dr. Prince, the late Dr. Kollock, of
Cheraw, S. C, and the late Dr. Will Steele,
of Rockingham, N. C, did all the rural sur-
gery within a radius of SO miles in his sec-
tion of the two Carolinas. He was often
called long distances on consultation. His
accuracy was remarkable in diagnosing sur-
gical conditions. His honesty and integrity
were above reproach. He was an honorary
member of the North Carolina and an honor-
ary member of the South Carolina Medical
Societies and was an active member of his
local County (Scotland) Society. He was
for many years a surgeon for the Seaboard
Air Line Railroad and a prominent member
of the Association of Seaboard Airline Sur-
geons.
(page 829)
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SOUTHERN MEDICINE AND SURGERY
November. 1929
Garrett Dalton, instructor in obstetrics; Dr.
J. B. Dalton, instructor in orthopedic sur-
gery: Dr. J. R. Ellison, assistant in surgery;
\V. M. Frayser, assistant in pharmacy; Dr.
J. Arthur Gallant, assistant in medicine; Dr.
Oscar L. Hite, assistant in nervous and men-
tal diseases; Dr. Paul W. Howie, associate
in surgery; Everett H. Ingersoll, associate
in anatomy; Miss Myrtle Krouse, assistant
in dispensing pharmacy; Dr. W. Grady
Mitchell, assistant in medicine; Dr. Kinloch
Nelson, assistant in medicine; Dr. W. A.
Peabody, associate in chemistry; Dr. John H.
Reed, jr., assistant in surgery; Dr. Earl L.
Shamblen, assistant in surgery; Dr. Merrill
G. Swenson, associate professor of prosthetic
dentistry; Millard K. Underwood, associate
in bacteriology and clinical pathology.
After seven years of service as dean of the
school of medicine. Dr. Manfred Call has
asked to be relieved of administrative work.
His resignation was most reluctantly accept-
ed. He will continue as professor of clinical
medicine.
Dr. Lee E. Sutton, jr., assistant dean, is
for the present acting as dean following Dr.
Call's retirement.
Dr. F. J. Wampler on July 1st returned
from a leave of absence to resume his duties
as director of the outpatient department and
professor of preventive medicine.
This session each school of the college has
a full enrollment: medicine, 371; dentistry,
128; pharmacy, 128; nursing, 170; techni-
cians, 9.
The Lewis Z. INIorris Memorial Fund, an
endowment of ;flO,000 to be used for student
loans, has been established by Seymour A.
Strauss of New York to perpetuate the mem-
ory of Mr. Morris, who gave many years to
the college as an able member of the board
of visitors.
'WAKE FOREST COLLEGE SCHOOL OF
MEDICINE
The Medical School of Wake Forest Col-
lege opened on September 17th, 1929, with a
full enrollment.
Under the auspices of the William Edgar
Marshal Medical Society, the officers of the
Society and Dr. Thurman D. Kitchin, Dean
of the Medical School, have arranged for a
number of distinguished doctors to lecture
at different times throughout the year. The
first regular meeting of the Society was held
on October 25, 1929, and at this meeting
Dr. Charles S. Mangum, acting Dean of the
Medical School of the L^niversity of N. C,
was the lecturer. Along with these lectures
some papers are read at each meeting by
some of our own students.
MEDICAL SCHOOL, THE UNIVERSITY
OF NORTH CAROLINA
Dr. I. H. Manning, dean of the Medical
School, is on leave of absence for the current
year on account of a recent illness.
Dr. C. S. Mangum, professor of -Anatomy,
is serving as acting dean of the school.
Dr. Reed Berryhill, of Charlotte, N. C, is
acting associate professor of Physiology.
Dr. James B. Bullitt, who during the past
year was on a Kenan leave of absence from
the medical school, spent the time in studies
at the Mayo Foundation and abroad. He
has now returned to his duties as professor
of Pathology.
Dr. O. A. McPherson, professor of Bac-
teriology in the medical school, spent the
summer in studies at the University of
Chicago. He received the Ph.D. degree in
Bacteriology at the recent convocation of this
University.
Disk May Give Cord Tumor Symptoms
Following slight (or repeated) trauma a fragment
of an intervertebral disk may become detached, and
eventually bulge into the spinal canal as a tumor.
The "tumor" is composed of the cartilage and fluid
formed by reaction to the foreign body. Two in-
stances of this lesion are reported, both being dis-
closed at operation. Both are in the midlumbar
region, and both occurred in men during the latter
half of life. The trauma at onset is relatively trivial
and perhaps repeated. The lesion is probably similar
to osteochondritis dissecans or traumatic joint-mice
of the elbow and knee joint. The early symptoms
are those of localized vetebral pain plus bilateral
sciatica — one side being affected more than the other.
Later, the symptoms arc rapidly increasing paralysis,
sensory and motor paralysis and loss of urinary and
vesical control and of reflexes — all due to compres-
sion of the Cauda equina. The signs and symptoms
suggest carcinoma of the vertebra. This preopera-
tive diagnosis was made in both cases. This lesion
offers a pathologic basis for cases of "so-called sci-
atica," especially bilateral sciatica. The lesion is
cured by operative removal of the cartilage. — W. E.
Dandy, Archives of Surgery, Oct., 1929.
November, 1929 SOUTHERN MEDICINE AND SURGERY
SPECIAL OCCASION: Soullicrii iMcdical A.s.sotia(ioii .Meeliiig,
.Miami, Florida, NovciiiIk-i- 191h-22iid, 1929.
TO THE MEMBERS OF THE SOUTHERN MEDICAL ASSOCIATIONS
Tlie SOUTHKR.\ RAILWAY SYSTIOI oilers pxcollonl service for the meiiibci's
of jour .\ssocia(ioii attcndiiin Hie nieetiiicj in Uliaini, Florida.
Tlu'oujih slecpiiifi ears witlioul eliaiifie will be operated from Greensboro, VVin-
slon-Saleni and Cbarlolle to Miami on Hie following Seliedule:
l.\'
(ireensboro
Sou. Rv.
Nov.
Nov.
iSov.
Nov.
Mov.
Nov.
Nov.
Nov.
Nov.
Nov.
Nov.
Nov.
Nov.
NIov.
181h
ISth
18th
18th
18th
18th
18th
18th
18th
18th
18th
19th
19th
191h
1:00 PM
I.v.
Iliqb Poinf
Sou. Rv.
1:30 PM
Lv
Lv
Salisbui'\ -,,
Coiieord
..Sou. Ry.
Sou. Rv.
2:35 P.M
3:13 PM
Lv
Lv.
Winston-Salem
Hiekorv
Sou. Rv.
Sou. Rv.
1:.55 PM
1-38 PM
lv
State.sville ...
Sou. Rv.
2 -40 P^I
Lv.
Lv.
Lv.
I, v.
.Moore.sville
Kings ^lounlain
(•asionia
Cbarlotte
Sou. Ry.
Sou. Ry.
Sou. Ry.
Sou. Rv.
4:00 PM
4:16 PM
4:43 I'M
5 05 p^i
Ar.
Lv.
Jaeksonville .. ...
.laeksonville
-. -Sou. Ry.
F.E.C. Rv.
7:30 AM
9-45 AM
Ai-.
^liann"
- F.E.C. Ry.
8:15 PM
Tliis servieo otfers dining ear sei-viee between QiarUrtte and Columbia and
.laeksonville and Miami, sei-ving all meals enroute.
The route is via Soiitbeni Railway llirougb Columbia and Savannah to Jack-
sonville thence the Florida East Coast Railway, paralleling the Atlantic Seacoast
lor the cntuc trip between .laeksonville and ^liami. pa.s.sing through .some of the
tanwius resort cities such as .Saint Augustine, Daytona, Titusville, Fort Pierce West
Palm Reach, Fort Lauderdale. Hollywood, etc.
The Florida East (kiasl Railway is double tracked Jaeksonville to Miami, usino
oil burning locomotives.
Reduced fares for Ibis occasion have been authorized on basis of one fare plus
on.-balf laic liria limit .November .{Olli, and one fare plus three-flfths of one fare,
linal limit .{() days in addition to date of sjile.
Tickets sold on presentation of identification certificates November I5tk-21st, 1929.
Round-trip fares from some of the important cities with sleeping ear rates are
(|Uoled below: ^^y ax<^
... ''':<'"' ^;.L^'"''' Lower Berth Upper Berth D Room
Cliarl<» te $42.48 $ 9.75 ,$7.80 $3l..50
(.iTcn.s boro 47.55 10.50 8.40 .37 .5(1
Higb I oirit 46.75 SEE RATES QUOTED FROM CHARLOTTE
Umst.Mi-halem 46.98 1()..50 S 'lO 37 V)
Co ,c .'.'.'.!' /tcr ?P^ "^'^'■^ QLOTEI) FROM CHARLOTTE
Vs . . /o{:) ^^^^ "^"^^ Ul OTEO FROM ClIXRLOiTE
sVnVes Ic //WT S S !')""^ ULOTEI) FROM CHARLOTTE
Ilickoi V /J«I S k'M''*^ UUOTEI) FROM CHARLOTTE
IlKkoi, 46.fii SEE RATES QUOIED FROM CHARLOTTE
Reduced i-ound-trip fares are on sale fr..m all stations on above basis and lim-
SelrSy'"''''" '''"■' "' "''"""'""<•" '••''iti.ates which may be secured Hon. the
lh..,ml,'i>' u!?'.'-'" ''""'' •'""'^'-'^"""•cin Railway olTers excellent service returnino-
l^vtZu^lZ^l!^^ '';•'"'■'■""";•'' '•■"•. '•••'•'-■" irip lifter the eo.yventi^m. "'
Railw'ly I'i^riri.^'pa;^.:;;:;' A;;en"''' •'"' '"■"'■'■•' '"^"'••"'"-" -» o- --y southern
R. H. GRAHAM,
Division Passenger Agent
SOUTHERN MEDICINE AND SURGERY
BOOK REVIEWS
November, 1929
DISEASES OF THE CHEST AND THE PRIN-
CIPLES OF PHYSICAL DIAGNOSIS, by George
W. NoRRis, M.D., Professor of Clinical Medicine in
the University of Pennsylvania, and Henry R. M.
Landis, M.D., Professor of Clinical Medicine, Uni-
versity of Pennsylvania ; Director of the Clinical
and Sociological Departments of the Henry Phipps
Institute of the University of Pennsylvania, with a
chapter on the Transmission of Sounds ThrouRh the
Chest, by Charles M. Montgomery, M.D., and a
chapter on the Electrocardiograph in Heart Disease,
by Edward Krumbhaar, Ph.D., M.D. Fourth Edi-
tion, Revised. 054 pages with 478 illustrations.
Philadelphia and London: W. B. Saunders Company,
1020. Cloth .ilJO.OO net.
This new edition has been prepared in full
knowledge of the desirability of replacing the
old with the new when the new has been
clearly shown to be better — and only when
this is true. It is a work for the clinician.
Throughout it keeps to the fore the thought
that laboratory aids in general are corrobor-
ative rather than diagnostic. "For the clini-
cians it would be well for them to remember
that the laboratory should be their partner
and not their master."
A book on diagnosis, conceive'd in this
spirit, and executed by men of the broad
training and experience of the authors, could
not fail of excellence. The style is particu-
larly appealing. As a means of spending
evenings profitably the book is heartily rec-
ommended, and we dare to say that the ma-
jority of doctors will enjoy evenings thus
spent far more than those spent at picture
shows.
RECENT ADVANCES IN TROPICAL MEDI-
CINE, by Sir Leonard Rogers, CLE., M.D., B.S.
(Lond.), FRCP., F.R.C.S., F.R.S., Major-General
Indian Medical Service, Ret. Medical .Adviser to the
Indian Office, Physician and Lecturer, London
School of Tropical Medicine; Lecturer on Tropical
Medicine, London School of Medicine for Women;
Late Professor of Pathology, Medical College, Cal-
cutta. Second Edition, with 16 illustrations. P.
B'akislon's Son & Co., Philadelphia, 1920. .$3.50.
This second edition in less than two years
is proof of a conscious need of information on
diseases v/hich we commonly think of as con-
fined to the tropics, many of which are by no
means curiosities in parts of our own coun-
try. There is a new chapter on Granuloma
Inguinale, a case of which was reported,
from Winston-Salem, in the issue of this
journal for October. Other subjects of spe-
cial interest to this section of the world are
Undulant Fever, Bacillary Dysentery, Hook-
worm Disease, Sprue, Pellagra.
THREE MINUTE MEDICINE: A Series of Brief
Essays on Popular Medicine, by Louis R. Effler,
A.M., M.D., Director of Education, The Toledo
.\cademy of Medicine, 1Q27-192S. Richard G. Bad-
ger, The Gorham Press, Boston, 1020.
The Toledo (Ohio) Academy of Medicine,
some two years ago, worked out a plan to
give the public, through the Toledo Times,
a series of essays of general medical interest.
Most of the essays making up this volume
appeared in 1927 and 8.
The subjects covered are varied. The first
is on "The Oath of Hippocrates"; then fol-
low an essay each on 31 of the greatest fig-
ures in Medicine from Hippocrates to Mur-
phy and his button. In the next section
striking subjects are "St. Luke, the Beloved
Physician," "Women in Medicine," "Dentis-
try," "Medicine and the Barber Pole," "The
Degree of Doctor."
In other sections: "The Chinese Wall,"
"The Training of the Sensus," "Reflexes,"
"Proud Flesh," "Catgut," "The Gospel of
Hope," "King Lear," "Medical Fads," "Med-
ical Jingoism," "Blood Transfusion," "Ani-
mal Experimentation," "Vaccination," "Mo-
tor Gas Poisoning," "Headache," "Epidem-
ics," "Birthmarks," "Phobias," and many
others.
It is perhaps too early to determine the
results of thus having the public supplied
with information on these important subject_s
by a medical society, but the reviewer is an
advocate of the idea and is eager to see such
a plan substituted for the so-called "health
columns" of all the daily newspapers. Here
we have a large number of the essays which
have been used by the society of what is as
near as any other to being a representative
city, and no doubt the Toledo Academy of
Medicine will be glad to supply suggestions
from its experience as to what modifications
are indicated.
November, 1929
SOUTHERN MEDICINE AND SURGERY
What happens
''SUGAR
in the body
^^9 Sugar is the most
prominent fuel burned
in the body
When sugar is digested, it is absorbed
from the intestines and carried to the
liver. From tlie liver it is converted into
glycogen, an animal starch. Later on
the glycogen is passed on and stored as
glycogen in the muscles. It is in the
muscles tliat sugar is burned to keep tlie
body warm. The muscles are the fire-
box of the body.
When the body has both sugar and fat
available at tlie same time, sugar is
burned by jireference. To use a military
analogy, sugar is the first line of troops in preference to fat, but fat is properly
and fats are the second line of troops. burned only when sugar is also being
Day in and day out, sugar is the most burned.
prominent fuel burned in the body, and For such reasons the public finds the
on a day of added exertion, the amount use of sugar of outstanding importance,
of sugar in the diet should be increased. The Sugar Institute, 129 Front Street,
Not only is sugar burned in the body New York City.
824
SOUTHERN MEDICINE AND SURGERY
November, 1920
DISEASES OF THE BLOOD, by Paul W.
Clovcii, M.D., Associate in Clinical Medicine, Johns
Hopkins University. Harper & Brothers, New York,
and London, 192Q. $2.50.
An excellent idea carried out all through
the book is that of explaining why such and
such a thing is so. This becomes evident in
the first few lines, in which we are told that
the blood, being, not a living tissue, but a
passive vehicle, abnormalities in the blood
must be regarded as symptoms of disease
elsewhere in the body. We know of no bet-
ter book for giving a comprehensive idea of
what we call Diseases of the Blood.
CLINICAL MEDICINE FOR NURSES, by
P.\UL H. Ringer, A.B., M.D., Formerly Chief of
Medical Service of the Ashoville Mission Hospital,
Asheville, N. C; and on staff of Biltmore Hospital,
Biltmore, N. C. Third Revised Edition, illustrated.
F. A. Davis Company, Philadelphia, 1P20. ,$3.00.
This new edition is published, not so much
because added knowledge has made great re-
vision necessary, as because the popularity
of the work has exhausted the former edi-
tion.
A controlling idea of the author is that
proper instruction of nurses in bedside medi-
cine does not mean giving a sketchy version
of a course appropriate to students of medi-
cine; rather that such instruction should aim
at imparting a grasp of the natural history
of disease processes sufficient to satisfy the
desire of intelligent persons to know about
phenomena which are their daily concern,
and sufficient to enable the nurse to observe
developments and carry out instructions with
understanding.
With this idea, and the manner of its car-
rying out, the reviewer is in hearty agree-
ment.
Drug therapy, dietetics, hydrotherapy, helio-
therapy, massage, electrotherapeutics, radio-
therapy, psychotherapy — all these are em-
braced.
Rest is given as the most effective thera-
peutice measure at our command. A sentence
full of sense is, "Four people out of five are
more in need of rest than exercise."
It is pointed out that the few really valua-
ble drugs should be known historically, bot-
anically, chemically and curatively. Enough
is given on prescription writing. The histori-
cal sketches are of great interest. Serum
therapy is covered from the viewpoint of the
doctor at the bedside. Little is taken for
granted. Procedures are described minutely.
The chapter on psychotherapy is far more
understandable — in that it is written in
words which have a meaning — than most we
have seen on the subject.
We know of no single book which has in
it more information which can be translated
into relief and cure of sick folks.
MODERN METHODS OF TREATMENT, by
Logan Clendeni.vg, M.D., Professor of Clinical
Medicine, Lecturer on Therapeutics, Medical De-
partment of the University of Kansas; AttcndinK
Physician, Kansas City General Hospital; Physician
to St. Luke's Hospital, Kansas City, Mo., with
chapters on special subjects by H. C. Anderson,
M.D.; J. B. Cowherd, M.D.; H. P. Kuhn, M.D.;
Carl O. Rickter, M.D.; F. C. Neff, M.D.; E. H.
Skinner, M.D.; and E. R. DeWeese, M.D. Third
Edition. C. V. Moshy Co., St. Louis, 1929. $10.00.
The editions have followed each other in
such rapid succession as to evidence worth,
THE HEALTH OF THE MIND, by J. R. Rees,
M..\.. M.D., Deputy Director of the Tavistock
Square Clinic, London. Washburn and Thomas,
Cambridpe, 1929. $2.50.
The author's effort is directed toward
meeting the needs of the average man who
wishes information on mental processes and
behavior problems, in other words, who
wishes to enlarge his understanding in the
most important of all fields — that of human
nature.
It is broadly conceived and free from fads.
Each subject is sympathetically approached
and discussed in plain, well chosen, smoothly
moving sentences.
The book is well suited for the purpose
intended and, ai reading for doctors, too, it
is both entertaini:^g and instructive.
Doctor — "l3 that a pitii.:it in the waiting room?"
Servant — ' Nc, s!r; he ccm;s once a month to read
the magazines."
"You done scid you could lick me."
"Uh-huh, I sho' did; want to see me demunstate?"
"Uh-uh, I'i jus' r^itfn' muh lis' made up."
"Daddy,'' cilled tin dcctT's small son, "I want a
drnk."
"Sorry," -^ -.-i ' 'i ; dad sleepily, "but I'm all
out of prescription bbn.;s." — Lije,
November, 1O20
SOUTHERN MEDlCtNfi AND StJftGEkV
8«
AN ANCIENT PREJUDICE
HAS BEEN REMOVED
Gone is that anaient prejudice against
cigarettes — Progress has been made.
We removed the prejudice against
cigarettes when we removed from the
tobaccos harmful corrosive ACRIDS
(pungent irritants) present in ciga-.
rettes mahiifactured in the old-fash-
ioned way. Thus "TOASTING" has
destroyed that ancient prejudice
against cigarette smoking by men
and by women.
It's toasted"
No Throat Irritation-No Cough.
nl
/:ij Iv aviii:ii h
UllVf •,TJV/<|< .i<l h.i'h
826
SOUTHERN MEDICINE AND SURGERY
November, 1929
NEWS
The Board of Medical Examiners of
N. C. reports on the June session. The ex-
amination was on 16 subjects, 70 questions
in all, percentage required for passing, 80
per cent. Total number examined, 102.
Passed, 94. Failed, 8. Licensed by endorse-
ment of credentials from other states, 24.
The Board membership is Drs. Walter W.
Dawson, Grifton; John K. Pepper, Winston-
Salem; John W. MacConnell, Davidson
(Secy.) ; William Houston Moore, Wilming-
ton; Paul H. Ringer, Asheville (Pres.); Foy
Roberson, Durham; Thomas W. M. Long,
Roanoke Rapids.
Dr. R. H. Long, Jefferson '16, a member
of the State (N. C.) Hospital staff at Mor-
ganton, for eight years, has been appointed
to fill a vacancy existing in the United States
Veterans' Bureau Hospital at Augusta, Ga.,
as neuro-psychiatrist.
Dr. John W. jMartin, of the medical staff
of the Roanoke Rapids Hospital, addressed
the 8th District Nurses Association, meeting
at Roanoke Rapids, Oct. 2Sth, on "Control
of Cancer."
Dr. a. J. Crowell, Charlotte, President
N. C. State Board of Health, has been elect-
ed a member of the Board of Governors of
the American College of Surgeons. The term
is 3 years.
Dr. Stephen W. Davis recently complet-
ed an internship in Philadelphia and has
opened offices in the Professional Building,
Charlotte, N. C.
Dr. W. C. Brann, graduate in medicine of
the University of Virginia, and a B.-'V. of
Richmond Medical College, is associated with
Dr. R. H. Fuller, South Boston, Va.
Drs. F. L. Knight and R. G. Sowers
have leased the Central Carolina Hospital at
Sanford, N. C, and will operate it in the
future. Dr. Knight has for the past four
years or more served as assistant with Dr.
John P. Monroe, who has operated the hos-
pital. Dr. Sowers, who is a native of Lex-
ington, has practiced medicine at Sanford for
a number of years.
Dr. O. L. McFadyen, of Fayetteville, was
elected president of the Fifth District Medi-
cal Society at the regular meeting held at the
Sanatorium, succeeding Dr. A. H. McLeod,
of Aberdeen. Dr. W. P. McKay, also of
Fayetteville, was elected secretary and treas-
urer, succeeding the new president in that
position.
It was decided to hold the next meeting in
Laurinburg.
Dr. Dean B. Cole announces the associa-
tion with him of Dr. Edgar C. Harper, Pro-
fessional Building, Richmond, Virginia. Prac-
tice limited to diseases of the chest.
Dr. Robert W. Smith, Maryland, '92,
died of apoplexy at his home at Hertford, N.
C, September 7th.
Dr. Joseph Eugene Burns, M. C. V.,
'23, and Miss Louise Morris, both of Con-
cord, N. C, were married September 7th in
New York City.
Dr. J. Donald MacRae, jr., .'\sheville,
has just spent a few weeks in Pittsburgh and
New York City.
The Eighth (N. C.) District Medical
Society held its annual meeting November
Sth, 1929, at Winston-Salem.
Aher a breakfast given by the President,
Dr. C. S. Lawrence, in honor of Invited
Guest, Dr. J. C. Bloodgood, the following
program was rendered:
Round Table Discussion of Present Day
Problems of Medical Practice:
"Private Hospital Problems" — Discussion
opened by L. A. Crowell, M.D., President of
the Medical Society of the State of North
Carolina; "Problems of the Specialist'' — Dis-
cussion opened by T. C. Redfern, M.D., Win-
ston-Salem; "Problems of the General Prac-
titioner"— Discussion opened by J. M. Mc-
Gehee, M.D., Reidsville.
Papers: Benign Tumors of the Small In-
testines, Dr. Brockton R. Lyon, Greensboro
Location of sore
area in wry neck
(Torticollis).
For Optimum Results
in the Management of
Spasmodic Torticollis ^^urofibrositis
Sciatica Lumbago SMyositis SMyalgia
and oAllied '^eumatic Conditions
in hot, thick layers over the affected area.
C Oelief from the painful symptoms comes more
■*• V. rapidly when Antiphlogistine is used: (1) be-
cause Antiphlogistine, properly applied, constitutes
an excellent means of securing arterial dilatation and
acceleration of circulation; (2) under the influence of
Antiphlogistine, the lymph circulation is markedly
increased, thereby washing out the tissues, stimulating
resorption, promoting cell nutrition and reduction
of infiltration.
Clinical and bedside observations of leading prac-
titioners the world over confirm the efficacy of
Antiphlogistine when used as a local adjuvant in
the management of those conditions associated with
infiltration, muscular rigidity and tenderness.
The Denver Chemical Mfg. Co.. 163 Varick Street, New York City. \
Dear Sirs: I would appreciate further information and sample of
Antiphlogistine for trial purposes.
Addr,
City..
jS
SOUTHERN MEDICINE AND SURGERY
November, 1929
—discussion opened by Dr. J. W. Tankers-
ley, Greensboro; Temporary Emotional Gly-
cosuria, with Case Repxirts, Dr. Wingate M.
Johnson, Winston-Salem; Anesthesia, Dr.
Arthur D. Ownbey, Greensboro; discussion
opened by Dr. E. A. Sumner, High Point;
Congenital Pyloric Stenosis, Dr. Marion Y.
Keith, Greensboro; discussion opened by Dr.
S. S. Saunders, High Point, N. C, and Dr.
Thomas D. Walker, Winston-Salem, N. C;
The Common Infections of the Nares ana
Nasal Sinuses, Dr. Kenan Casteen, Leaks-
ville; discussion opened by Dr. S. R. Taylor,
Greensboro; Some of the Uses of X-Ray
Therapy Not Commonly known in the Prac-
tice of Medicine, Dr. B. E. Rhudy, Greens-
boro; discussion opened by Dr. J. P. Rous-
seau, Winston-Salem; Prostatectomy, Dr. V.
M. Long, Winston-Salem. Discussion opened
by Dr. Wortham Wyatt, Winston-Salem.
The evening was set aside for an address
by Dr. Joseph Colt Bloodgood, of Baltimore,
on "What the Public Should Know About
Cancer."
Dr. p. p. McCain, superintendent of the
N. C. Tuberculosis Sanatorium, had the mis-
fortune to be in a collision on the night of
Nov. Sth, in which the driver of the other
car lost his life.
Dr. D. W. Holt, Greensboro, was recent-
ly e.xonerated of any blame in an action
brought against him alleging negligence.
The Pee Dee Medical Association held
its annual meeting at Florence, S. C, Nov.
12th.
Program as follows: Call to order by the
President, Dr. Douglas Jennings, Bennetts-
ville; Address by Dr. Charles R. May, Ben-
nettsvilie, President of the South Carolina
Medical Association; Address by Dr. M. R.
Mobley, Florence, Councilor Sixth District,
South Carolina Medical Association; "Cases
Presenting Problems in Tuberculosis Ther-
apy," Dr. W. A. Smith, Charleston; "Newer
Aspects of Infant Feeding," Dr. J. H. Price,
Florence; "The Management of Normal Ob-
stetrics," Dr. L. R. Kirkpatrick, Bennetts-
ville; "Syphilis of the Nervous System," Dr.
O. B. Chamberlain, Charleston; "The Mod-
ern Treatment of Syphilis," Dr. L. J. Rave-
nel, Florence; "Pellagra," Dr. R. L. Gardner,
Chesterfield; "The Management of Dia-
betes," Dr. W. R. Mead, Florence; "Diph-
theria Prophyla.xis with Toxoid or Antitoxin,"
Dr. Paul E. Sasser, Conway.
Richmond Doctor Leaves Million to
Charities
Dr. A. Spiers George, life-long resident of
Richmond, who died at his home, 5 North
Second street, on Nov. 1, left his entire es-
tate, estimated at $1,185,186, to be divided
equally between five Richmond charitable in-
stitutions: Virginia Home for Incurables,
Home for Needy Confederate Women, Shel-
tering .'^rms Hospital, the Sprin-Street Home
and the Memorial Home for Girls.
Dr. George was educated at the Virginia
Military Institute and the Medical College
of Virginia; in the latter school he was at one
time assistant professor of surgery. He had
been retired from practice for many years.
Dr. Harry Taylor Marshall, professor
of pathology and bacteriology at the Univer-
sity of Virginia for the past twenty years,
died Nov. 9th in the American Hospital, fol-
lowing an operation. He was 54 years old.
He was buried in Brussels. Dr. Marshall was
spending his vacation in France and Ger-
many, where he had studied in his youth,
when he was taken suddenly ill and rushed
to the American Hospital. The son of Col-
onel Charles Marshall, staff officer of Gen-
eral Robert E. Lee, Dr. Marshall was edu-
cated at Johns Hopkins University, where he
was president of the first graduating class.
November, 1929
SOUTHERN MEDICINE AND SURGERY
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Dr. Prince was married October 10, 1894,
to Irene Burwell Marshall, of Monclova,
Charlotte County, Virginia, daughter of Wil-
liam Morton and Virginia LaFayette Mar-
shall. The children of this marriage are:
Daniel Malloy Prince, jr., Laurence Benton
Prince, Irene Burwell Prince, William Mar-
shall Prince, Charles L'Empriere Prince and
Mary Rockdale Prince.
Dr. Prince was of English, French and
Scotch blood. The French blood came in
through the wife of Captain Charles Prince,
the English blood through the Bentons and
Princes and the Scotch-Irish blood through
his mother.
After a long illness, which he bore with
patience. Dr. Prince died at his home in Lau-
rinburg, on July IS, 1929. He was highly
esteemed, well loved and trusted by all. The
whole c(jmmunity lamented his loss. He was
a member of the Presljyterian Church and
contributed his share of labors for the ad-
vancement of his church as well as for the
progress of his community.
iid
SOUTIlEftN MeDtCI^f£ AND SURGERY November, 1929
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November, 102<3
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November, 1929
PROFESSION CARDS
PHYSICIANS' DIRECTORY
EYE, EAR, NOSE AND THROAT
AMZI J. KLLINGTON, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
PHONES: Office 992— Residence 761
Riirlington Nortli Carolina
J. SIDNEY HOOD, i«.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
PHONES: Office 1060— Residence 1230J
Si'd Nalioiial Bank BIdg., Gaslonia, N. C.
O. J. HOUSER, M.D.
Diseases of the
EYE, EAR. NOSE AND THROAT
Telephones — •
Office H.— 1672, Residence J.— 998-M
Hours — 9 to 5 and bv Apointment
219-23 Professional BIdg. Charlotte
HOUSER CLINIC
For Tonsils and Adenoids
415 North Tryon St. Phone Hemlock 4217
Consultation 219 Professional BIdg.
Phone Hemlock 1672
J. G. JOHNSTON, M.D
EYE, EAR, NOSE AND THROAT
Hours — 9 to 1 and by Appointment
Telephones —
Office H.— 18S3, Residence H.— 4303-W
G16-18 Trofessional Building, GiarloUe
H. C. NEBLETT, M.D.
Practice Limited to
DISEASES OF THE EYE
Telephone Hemlock 2361
Professional Building Charlotte
H. C. SHIRLEY, A.M.. M.D.
JOHN HILL TUCKER, M.D.
Practice Limited to
DISEASES OF THE EAR, NOSE
Diseases of the
EYE, EAR, NOSE AND THROAT
Hours — 10 to 1 and by Appointment
and THROAT
Professional Building Clrarlotte
Telephones —
Office H— 3884, Residence H.— 2513
309 Professional Building Charlotte
H. A WAKEFIELD, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
Telephones —
Office H— 727. Residence J.— 218-J
204 North Tryon Street Charlotte
INTERNAL MEDICINE
A. A. BARRON. M.D., F.A.C.P.
M. L. Slovens. M.D. Chas. C. Orr, M.D.
INTERNAL MEDICINE
NEUROLOGY
DBS. STEVENS AND ORR
INTERNAL MEDICINE
DISEASES OF THE LUNGS
Professional Building Charlotte
17 Chureh Street Asheville, N. C.
\V. O. NISBET, M.D , F.A.C.P.
Professional Biu'lding
INTERNAL MEDICINE
GASTROENTEROLOGY
D. H. NISBET, M.D.
Charlotte
M. A. SISKE, M.D.
W. C. ASHWOR TH. M.D.
IIAHIT DISEASES. NEUROLOGY
and PSYCH I. AT RY
Hours by Appointment
Piedmont Building Grccnshoro, N. C.
GRAYSON E. TARKINGTON,
M.D., F.A.C.P.
INTERNAL MEDICINE AND SYPHILIS
Ducan & Stuart Building Hours: 9-12, 3-5
Hot Si»rings National Park Arkansas
PROFESSION CARDS
November, 1929
JAMES CABELL MINOR, M.D.
PHYSICAL DIAGNOSIS
HYDROTHERAPY
lliii Springs National Park Arkansas
JAMES M. NORTHINGTON, M.D.
Diagnosis and Treatment
in
INTERNAL MEDICINE
Professional Building Charlotte
OBSTETRICS and GYNECOLOGY
ROBERT T. FERGUSON, M.D., F.A.C.S.
GYNECOLOGY
C. H. C. mLLS, M.D.
OBSTETRICS
Consultation by Appointment
l^rcfc.'sional Building Charlotte
By Appointment
Professional Building
Charlotte
W1LLIA3I FRANCIS MARTIN, M.D.
GYNECIC k GENERAL SURGERY
Professional Building Charlotte
RADIOLOGY
X-RAV AND RADIUM INSTITUTE
W. M. Sheridan, M.D., Director
X-RAY DIAGNOSIS SUPERFICIAL AND DEEP THERAPY X-RAY TREATMENTS
RADIUM THERAPY DIATHERMY
Sui(ps 208-209 Andrews Building Spartanburg, S. C.
ISdbl. H. Lafferty, M.D., F.A.C.R.
l'i'(\sl)ylcrian Hospilal
DRS. LAFFERTY and PHILLIPS
Charlotte
X-RAY and RADIUM
Fourth Floor Charlotte Sanatorium
Crowell Clinic
C. C. Phillips, M.D.
Mercy Hospital
\U\ J. Rush Shull Dr. L. M. Fetner
DOCTORS SHULL and FETNER
ROENTGENOLOGY
Roentgenologists to St. Peter's Hospital, Ashe-Faison Children's Clinic, Good Samaritan Hospital
IVofessional Building Charlotte
UROLOGY, DERMATOLOGY and PROCTOLOGY
THE CROWELL CLINIC OF UROLOGY AND DERMATOLOGY
Entire Seventh Floor Professional Building
Charlotte
Telephones— H.-A091 and //.-4092
Hours — Nine to Five
Urology:
/Indrew J. Crowell, M.D.
Raymond Thompson, M.D.
Claud B. Squires, M.D.
Clinical Pathology:
Lester C. Todd, M.D.
Dermatology:
Joseph A. Elliott, M.D.
Lester C. Todd, RLD.
Roentgenology
Robert H. Lafferty, M.D.
Clyde C. Phillips, M.D.
November, 1029
PROFESSION CARDS
Fred D. Austin. M.D. DeWitt R. Austin, M.D.
THE AUSTIN tXINIC
RECTAL DISEASES, UROLOGY, X-RAY and DERMATOLOGY
Hours 9 to 5— Phone Hemlock 3106
8th Floor Independence Bldg. Charlotte
Thos. Brotknian, .M.D., 25 Emma St., Greer, S. C
BUO(;ii.MA\'S RECTAL CLINIC
More Commodious Quarters in Colonial Apartments.
Improved Facilities.
X-Ray and Clinical Laboratories.
Recovery Beds for .Ambulant Patients.
Surgical Cases llospilalhed at Cluck Springs Samtarium
Dr. Hamilton McKay Dr. Robert McKay
DOCTORS McKAY and MeKAY
Practice Limited to UROLOGY and GENITO-URINARY SURGERY
Hours by Appointment
Professional Building Charlotte
Residence Phone 185S
221 East .Main Street
Dl{. W . B. LYLES
Practice limited to
UROLOGY and VROLOGICAL SURGERY
Hours 9-5. Sundays by .'\ppointment
Office Phone 1857
Spartanburg, S. V,.
W. W. CRAVEN, M.D.
GENITO-URINARY and RECTAL
DISEASES
9 a. m. to 1 p. m. — 3 p. m. to 6 p. m.
Professional Building Charlotte
R. H. McFADDEN. M.D.
UROLOGY
Hours 9 to S
514-16 Professional Bldg. Cliarlotle
L. D. McPHAIL, M.D
RECTAL DISEASES
405-408 Professional Bldg. Charlotte
WYETT F. SIMPSON, M.D.
GENITO-URINARY DISEASES
Phone 1234
Hot Springs National Park, Arkansas
DR. O. L. SIGGETT
UROLOGY
Castanea Building, .Xslicvillc, N. C.
Hours — 3 to 5 ; Phone — 2443
FOR SPACE RATES
Address
806 Professional Building
SURGERY
ADDISON G BRENIZER, M.D.
SURGERY and GYNECOLOGY
Consultation by Appointment
Professional Building Charlotte
RUSSELL O. LYDAY. .\LD.
GENERAL SURGERY and SURGICAL
DIAGNOSIS
Jefferson Sid. RIdg., Greensboro, N. C.
R. B. Mcknight, m.d.
SURGERY
and
SURGICAL DIAGNOSIS
Consultation by Appointment
Hours 2:30—5
Professional Building Charlotte
WM. MARVIN SCRUGGS, M.D., F.A.C.S.
SURGERY and GYNECOLOGY
Consultation by Appointment
Professional Building Clinrlodc
836 " PROFESSION CARDS
November, 1929
! ORTHOPEDICS
J. S. GAUL, M.D.
ALONZO MYERS, M.D.
ORTHOPEDIC SURGERY and
FRACTURES
ORTHOPEDIC SURGERY
FRACTURES
and
Professional BuiliUng. Charlotte
Professional Building
Charlott*
. HERBERT F. MINT, M.D.
FRACTURES
ACCIDENT SURGERY and ORTHOPEDICS
Wachovia Bank Building Winston-Salem, N. C.
() L. MILLER, M.D.
Practice Limited to
ORTHOPEDIC SURGERY and FRACTURES
Eiflecn West Seventh Street
Charlotte
GENERAL
THE STRONG CLINIC
Suite 2, Mediial Building
Charlotte
C. M. Strong, M.D., F.A.C.S. Oren Moore, M.D., F.A.C.S.
CHIEF of CLINIC, Emeritus ' Obstetrics and Gynecology
J. L. Ranson, M.D.
Genito-Urinary Diseases and Anesthesia
Miss Pattie V. Adaajs, Business Manager
Miss F.^nnie Austin, Nutse
HIGH POINT HOSPITAL
Hijih Point, N. C.
(Miss Gilbert Muse, R.N., Supt.)
General Surgery, Internal Medicine, Neurology, Ophthalmology, etc.. Diagnosis, Urology
X-Ray and Radium, Physiotherapy, Clinical Laboratories
Pediatrics,
STAFF
John T. Burrus, M.D., F.A.C.S., Chief 0. B. Bonner, M.D.
Harry L. Brockmann, M.D. Frederick R. Taylor, B.S., M.D.
Philip VV. Flagge, M.D. S. Stewart Saunuers, A.B., M.D.
DR. H. KING WADE CLINIC
Wade BiiildinK
Hot Springs, Arkansas
H. King Wade, M.D. Urologist
Charles S. Moss, M.D Surgeon
0. J. MacLaltgiilin, M.D.
Opthalmologist
Oto-Laryngoloisl
H. Clay Chenault, M.D.
Associate Uurologisl
Miss Etta Wade Pathologist
SOUTHERN MEDICINE and SURGERY
Vol. XCI
Charlotte, N. C, December, 1929
No 12
Cerebro-spinal Fever: Report of Three Cases
C. T. Smith, M.U., M. L. Stone, jM.D., and A. T. Thorpe, M.D.
Rocky Mount, N. C.
Park View Hospital
The three cases of acute cerebro-spinal
fever presented below did not progress be-
yond the second or pre-meningitic stage. In
case number one, the patient had two days
of extreme prostration when his life was de-
spaired of, then made a recovery. In cases
two and three the patients died after 10 and
2i hours of illness respectively, within 26
hours of each other. Definite contact had
been made by the last two with case one.
Bacteriologic diagnoses were made only
with the aid of the Hygienic Laboratory of
the U. S. P. H. S., as our cultures were per-
sistently negative.
Case 1. — White man, 21, ball-player, na-
tive of Florida, had been in Rocky Mount
for four days before onset of illness. He
was admitted to hospital April 17, 1929.
Family history and past medical history
were essentially negative.
History of present illness: Had not been
feeling well for the past two weeks. Nine
days ago went to a doctor in Macon, Ga.,
who told him his spleen was enlarged and
that he had chronic malaria. He was given
ten grains of quinine twice daily which he
had taken up till the day of admission. On
the morning of admission, beginning about
7 o'clock, patient had a chill which lasted
apparently four hours. Following this his
temperature went to 104; he became stupor-
ous and very restless; could be aroused to
answer questions; complained only of weak-
ness and sore throat. In the afternoon he
be-'an vomiting clear, later bile-stained
fluid. He was brought to Park View Hos-
pital by one of us (.1. T. T.) fourteen hours
after onset of violent symptoms.
Physical examination: The patient was
well nourished and well developed, stu[)orous,
with frequent quick movements of head and
extremities, greyish cyanosis about ears and
neck, pupils equal and reacted to light and
accommodation, pharynx red — no membrane;
about the shoulder-girdle and on the hips,
thighs and legs were a few small, irregular,
hemorrhagic spots from head of a pin to 1
cm. in diameter. Respirations were regular
and unembarrassed, resonance not impaired.
There were a few moist rales over both up-
per lobes. Fremitus was normally distrib-
uted. The heart was not enlarged to percus-
sion; the apex beat could be felt in the fifth
interspace inside the mid-clavicular line, rate
ISO. No murmurs. The pulse could not be
counted at the wrist. The blood pressure
could not be elicited. Abdomen soft, no
tenderness. The spleen, liver nor kidneys
could be palpated. Genitalia — negative,
small type. The tendon reflexes were not
exaggerated. No Babinski, no clonus.
Laboratory findings: Four different white
counts during the first three days of stay
were 38,600; 8,000; 22,800; 27,600— polys
around 85 per cent (staffs 40 to 55 per cent).
No malaria. One platelet count was 66,000.
Blood culture obtained on the second day,
grown on plate and glucose brain broth,
showed no growth. Blood Wassermann was
negative. The urine showed a faint trace to
a trace of albumin on five examinations. No
blood. The feces showed no parasites, no
ova.
Course of the disease: During first night
he complained of throat and back only and
took liquid nourishment well. Had six green
liquid st(3ols (no previous purge). His pulse
could not be counted during the night. On
the following morning he was cathetcrized
(had not voided in 12 hours), only one ounce
was obtained. The temperature, which was
105. S on admission, was normal on the morn-
SOUTHERN MEDICINE AND SURGERY
December, 1920
ing of second day. Patient coughed a great
deal during second day and complained a
great deal of sore throat. The temperature
went to 102.3 on evening of second day, but
the pulse could not be counted at the wrist.
Prostration e.xtreme, though respirations re-
mained around 24. The second night was a
restless but uneventful one. He did not void.
At 8 A. M. the third day his pulse could be
counted fairly accurately and an hour later
he voided ten ounces. The blood pressure
was 100-60. The spots about the extremities
were larger, more numerous, but at that, not
in any great number.
On the fourth day he began to complain
of pain in left ankle, knee and wrist. These
points became swollen, hot, and tender, but
not red. Cough still bothersome. On the
fifth day herpes appeared on lips, which be-
came extensive, involving the tongue. On
the sixth day he developed a right iritis and
his temperature went to 100. During the
rest of his stay in the hospital it did not go
as high. One of the spots on the right hand
attained the diameter of 2 cm. and later de-
veloped a bleb which dried in. He had sev-
eral other such blebs to develop on .the lower
extremities.
NameS^
Visited her father daily. On the night of
April 26th, did not seem to feel so well, so
was left at the rooming house while the
mother visited the father. At 6:30 on the fol-
lowing morning seemed sick and one of us
(.-1. T. T.) was called to see her and found
some purple spots about the face and extrem-
ities, temperature 104, patient stuporous
rather than restless, report of two loose bowel
actions during the night and vomiting once.
Three hours later he was called again and
found the spots much more numerous and
pronounced, and the baby in extremis.
Autopsy report (C. T. S.): Baby L. McR.,
age ly^ years. Apparently well nourished
and well developed.
Rigor mortis pronounced, skin has pink
spotted appearance. In addition there
are purple splotches, deeper hued about
face, arms, and legs mostly, but also on
trunk, varying in diameter from 2 mm. to 1
cm. Conjunctivae not injected. Pupils con-
tracted, equal. Mucous membrane shows no
hemorrhage.
Incision from suprasternal notch to the
symphysis pubis. Blood a very dark red.
Sternal flap removed. Thymus covered en-
tire base of heart.
Patient discharged from the hospital May
15th, with joint symptoms practically reliev-
ed and the iritis under control.
Case 2. — 2J/i-year-old daughter of patient
presenting Case 1. She had come up from
Florida to see her father and had been here
five days. Was apparently in good health.
Pericardium: No e.xcess free fluid. Sur-
face glistening. Heart not enlarged. No
s'gns of hemorrhage into muscular tissue.
Valves not diseased.
Left pleura: Fluid clear and not excessive.
Xo evidence of hemorrhage on pleural sur-
faces. Lung bright red in dependent portion.
December, 1929
SOUTHERN MEDICINE AND SURGERY
Cut surface exudes red bloody froth. No
pneumonia. Right pleura: Normal. Lung
as of the left.
.\bdomen: Liver enlarged. No hemor-
rhagic spots. Cut surface does not bulge.
No necrosis. Spleen about three times nor-
mal size, dark. Nodules stood out promi-
nently. No accessory spleen.
Left Kidney: Capsule strips with ease,
leaving a mottled red appearance. Cut sur-
face bulges and shows the mottling to extend
through the cortex. No pus or fat in pelvis.
Right Kidney: Same as left.
Stomach: No hemorrhages or ulcerations.
Jejunum and Ileum show some hemorrhagic
spots under peritoneum 5 cm. in diameter.
.Appendix small, not kinked, pointing to
pelvis.
Cecum and Ascending Colon: At ileo-
cecal valve an irregular mass resembling mul-
tiple polypi 8 cm X 2 cm. No ulceration.
Mesentery of colon contains numerous en-
larged lymph nodes 5 to 20 mm. in diameter.
Some hemorrhagic spots in mesentery.
Omentum shows no hemorrhage. Bladder
contracted.
Anatomical diagnosis: Tabes mesenteri-
cus. Polyposis of cecum and colon. Hem-
orrhage into peritoneum and kidneys.
Culture of blood obtained from the heart,
grown on plate and glucose brain broth
yields a Gram-positive coccus.
Microscopical report, Dr. McCoy, Hygie-
nic Laboratory:
"L — McR., age 2y2. autopsy, .■\pril 26th,
1929.
Liver: Moderate degenerative changes,
finely granular liver cells, hemolyzed red cells
in vessels. Post mortem autolysis.
Kidney: Patchy intracapillary congestion,
severe degeneration of convoluted tubules,
vacuolated, swollen, frayed, partly desqua-
mated epithelium with fairly normal or some-
what pyknotic nuclei, glomeruli contain little
IjlcHid. show no obvious lesions.
Thymus: More than the ordinary propor-
t'on of lymphocytes in the central reticular
area. Hassall's concentric corpuscles show
eleidin and central keratinization and often
ii-e.iking down so as to form small epider-
moid cysts.
Lymph nodes: Moderate swelling of
germinal centers, these loose-meshed with fair
amount of nuclear debris in the reticulum
cells. In pulp some reticulo-endothelial pro-
liferation. Pulp loose-meshed. No focal le-
sions.
Spleen: Follicles of moderate size with
peripheral fringe of lymphocytes centrally
swollen reticulum cells. Pulp moderately
filled with blood and much granular dark
greenish brown pigment, mostly free. Neu-
trophils are few. Number of concentrically
disposed nodules of endothelial cells enclos-
ing minute lumen. Pancreas: No lesions.
Skin: Dilated capillaries in corium, often
with pericapillary hemorrhage, usually with
no evident endothelial lesion, some with defi-
nite increase in large adventitial cells with
vesicular leptochromatic nuclei, some with
pericapillary polymorphonuclear leucocytes.
Considerable free greenish brown granular
pigment in cutix.
(Kidney 2 equals 1).
Lung: Congestion, patches of edema and
of alveolar hemorrhage, few large mononu-
clear cells in alveoli. Moderate amount of
brown granular pigment, largely in alveolar
epithelial cells.
In general: Fairly well marked post mor-
tem autolysis.
ciemsa stain
Spleen: No bacteria. Skin lesions: Groups
of rather large cocci lying in pairs for the
most part seen in several capillaries intra-
and extra-cellular. One hemorrhage shows to
one side an area of light neutrophil infiltra-
tion containing numerous similar cocci. These
cocci are Gram-negative. The individual
cocci measure about 0.56 to 0.8 micra — aver-
aging about 0.7 micra.
These cocci are regarded as morphologi-
cally consistent with the meningococcus.
Anatomic diagnosis: Purpura of skin. Fo-
cal hemorrhages in lung. Hyperplasia of
lymphoid type in glands and spleen. Septi-
cemia, meningococcus-like coccus."
(Signed) R. D. Lillie,
P. .'\. Surgeon.
Case 3. — Graduate nurse, 58, had relieved
in the room of Case 1 frequently for a few
minutes at the time, but had not been ex-
posed for three days. Was sent to the hos-
pital by one of us (M. L. S.), April 27, 1929,
with complaint of weakness, fever, stupor.
She was able to give the history of attending
a picnic dinner at noon of the day of ad-
mission. On the way home she felt weak
840
SOtJTttEfeN MEblClNfi AND StJfeGEfeV
December, 1929
and sick. Had to be taken home, vomited
frequently, first food and then bile-stained
fluid.
Family history and past medical history
practically negative save for vague "indiges-
tion" relieved by calomel and salts.
Physical examination: Stuporous on ad-
mission, color greyish, pupils equal and re-
acted to light and accommodation, tongue
heavily coated. Respirations were rapid and
short, but there was no impairment to pjer-
cussion; no rales on deep breathing. Fre-
mitus was normally distributed. The outline
of the heart could not be made out. There
were no murmurs or irregularities, blood
pressure 110/40, pulse 110. Abdomen soft,
no tenderness or masses, solid viscera palpa-
ble. The extremities had no marks or dis-
colorations. Tendon reflexes not exaggerated.
No Babinski, no clonus.
Laboratory findings: The urine contained
no pus, blood or albumin. The white cell
count was 6,800 — polys 66 per cent (staffs
54 per cent and segments 12 per cent), lym-
phocytes 26 per cent, large monos 7 per
cent, transitionals 1 per cent. The platelets
were apparently plentiful and the i-ed cells
normal in size and shape. No milaria. Blood
urea was 40 mg. per 100 c.c. Blood culture
on plate and glucose brain broth did not show
any growth.
Pul>
Resp.
130
50
120
45
110
40
100
35
90
30
80
25
70
20
60
1
15
m
ig
Course oj disease: The patient was ad-
mitted at 5 p. M., April 27, 1929, and was
examined promptly. The pulse was 110, tem-
perature 102, respirations SO.
At 7 p. M. purple spots, mostly 0.5 to 1
cm. in diameter, were seen on arms, shoul-
ders, hips, and thighs, and the pulse could
not be felt at the wrist. At 10 she was
sweaty, cold, restless, no pulse, and so re-
mained through the night. The following
morning she appeared the same though she
said she felt better. The spots had greatly
increased in number and size, some as long
as 8 cm. irregular and purple. At 11 a. m.
she died, not quite 24 hours from onset of
illness.
Autopsy (Dr. C. C. Carpenter, State Path-
ologist): Estimated weight 180 pounds,
length 150 cm., age 58 years.
Body that of a well developed and well
nourished adult female, showing numerous
hemorrhagic spots and blotches from 0.5 to
2 cm. in diameter, irregular, purplish, not
raised above the surface, the consistency of
the skin and subcutaneous tissue in these
areas apparently the same as the normal body
surface. Rigor mortis marked; livor mortis
marked.
Head: Scalp negative, pupils equal and
contracted, from two to five pin-point and
pin-head size hemorrhagic spots beneath the
conjunctivae. Buccal surfaces negative aside
from two pin-head size hemorrhagic spots
.beneath the mucosa of the lower lip. Teeth
show several cavities and fillings. Tongue
clinched between the teeth and covered with
a medium bluish frothy material exuding
from the mouth.
Brain: Meninges glistening, no hemor-
rhagic areas, no increase of cerebro-spinal
fluid, this fluid clear as compared to tap wa-
ter. Cut sections through the cerebrum and
cerebellum show no hemorrhagic areas. One
minute hemorrhage found in the medulla
oblongata but this out of the picture.
Peritoneal cavity contains no excess fluid,
peritoneal surfaces smooth and glisten-
ing, adhesions between the gall-bladder and
omentum. Diaphragm to fourth interspace
on the right and fifth rib on the left. Scat-
tered over the visceral and parietal perito-
neum a few pin-point and pin-head size hem^
orrhagic spots. Mesenteric lymph nodes not
palpable or visible. Retro-peritoneal area api
pears negative.
Beeemlier, ldi§
SotttttERN MEbtCIME AiflD SttfeGfikV
S4i
Pleural cavities: Left contains no excess
fluid. Pleural surfaces smooth and glistening
and free of adhesions. Scattered over the
visceral and parietal pleura pin-head size
hemorrhagic spots. Right free of excess fluid.
Scattered over the visceral and parietal pleura
pin-head size hemorrhagic spots.
Pericardial cavity: Pericardial surfaces
smooth and glistening. Cavity contains no
excess fluid. Scattered over the visceral and
parietal pericardium a few pin-point and pin-
head size hemorrhagic spots. Heart: Pul-
monary arteries opened in situ reveal no
thrombus or embolus. Estimated weight
within normal limits. Valves without evident
lesion. On the anterior wall of the left ven-
tricle is a diffuse hemorrhagic blotch about
1 cm. in diameter. Scattered over the re-
mainder of the myocardium pin-point and
pin-head size hemorrhagic spots.
Left lung dark reddish in the dependent
parts and slightly firmer in the lower lobe
than in the upper. On section a fairly large
quantity of greyish and reddish matter could
be expressed from the cut surface in the lower
lobe. Right lung dark reddish in the depend-
ent parts and slightly firmer in this area.
On section a reddish and greyish frothy ma-
terial could be expressed from the cut sur-
face.
Spleen: Estimated weight within normal
limits. Outer surface showed a few dark
bluish spots from O.S to 2 cm. in diameter.
On section these spots apparently correspond-
ed with the dark reddish spots of the cut
surface. The pulp was slightly softer than
usual. The splenic nodules stood out promi-
nently.
Liver: On external examination appar-
ently normal. Cut surface without definite
lesion. Estimated weight within normal lim-
its. Gall-bladder and ducts without evident
lesion.
Left kidney: On external examination a
few pin-point and pin-head size hemorrhagic
s{X)ts seen beneath the capsule. Capsule strips
with ease leaving a reddish surface. On sec-
tion of cut surface many reddish hemorrhagic
streaks and spots, especially marked in the
cortex. Right kidney: Several reddish hem-
orrhagic s[X)ts beneath the capsule on exter-
nal examination. The capsule strips easily,
the cut surface shows numerous reddish hem-
orrhagic streaks and spots, especially marked
in the cortex.
Adrenals and pancreas without evident le-
sion, i .^^
Gastro-intestinal tract: Scattered through-
out the wall of the stomach and intestines
are numerous reddish hemorrhagic spots and
blotches. Stomach contains a small quantity
of dark bluish tenacious material.
Pelvic organs without evident lesion as in
situ.
Anatomical diagnosis.
\. Purpuric spots of surface of body in
conjunctivae and mucosa of lower lip.
2. Edema and congestion of lungs.
3. Marked congestion of the kidneys.
4. Purpuric spots scattered throughout all
organs, especially the liver, pancreas, and
adrenals. Hemorrhagic sjxjts of the perito-
neum, pleura, and pericardium.
Microscopical report {Dr. McCoy, Hygie-
nic Laboratory) : Miss D., autopsy, May 3,
1929.
Spleen: The follicles are small, made up
of small lymphocytes. The red cells in the
pulp sinuses are laked. The pulp contains
numerous lymphocytes, neutrophil leucocytes
and some myelocytes.
Lungs: Moderate anthracosis only.
Stomach: Mucosa shows few patches of
lymphocytic infiltration and moderately ad-
vanced post mortem autolysis.
Cerebral cortex: No lesions of cells, ves-
sels or pia.
Heart muscle: Areas of quite marked
transverse fragmentation, a few of margina-
tion and emigration, some patches of intersti-
tial polymorphonuclear infiltration mingled
with lymphocytes and macrophages, but no
bacteria are demonstrated.
Medulla: Numerous pericapillary hemor-
rhages. Scattered small nodes of loosely ar-
ranged and various cells and few leucocytes,
one venule with perivascular hemorrhage and
group of lymphocytes in adventitia to one
side — a capillary also.
Adrenal: Small hemorrhages scattered in
cortex — one with necrobiosis of cortex cells
and much swollen coarsely vacuolated ceUs
at one margin. Considerable number of leu-
cocytes at border of one hemorrhage.
Liver: Marked fatty infiltration of centers
and intermediate zones of lobules, cjuite
marked lymphocytic infiltration in periix)rtal
connective tissue. Leucocytes apiwar rather
842
SOUTHERN MEDICINE AND SURGERY
December, 1929
numerous in capillaries.
Kidneys: Glomeruli well preserved. Cor-
tical tubules show thin epithelium with
ragged margin toward lumen and small
amount of debris within — autolysis. There
are a few patches of lymphocytic infiltration
near the cortico-medullary border. The ar-
terioles show very moderate intimal fibrosis.
Giemsa stain
Medulla: No bacteria in lesions. No cell
inclusions. Adrenals: Fair number of neu-
trophil leucocytes in hemorrhages and in ca-
pillaries.
Anatomical diagnosis: Acute interstitial
and fragmentary myocarditis. Acute hemor-
rhagic encephalitis. Acute splenic reaction
of septic type. Adrenal cortical hemorrhages.
Purpura (from history).
According to Councilman the high degree
of participation of the polymorphonuclear
leucocyte in the reaction in this case is evi-
dence against smalljxix."
(Signed) R. D. Lillie,
P. A. Surgeon.
Doctor Sara E. Branham, of the Hygienic
Laboratory, identified cultures from the naso-
pharynx of patient number 1 as the type 2
meningococcus; she also isolated a 'type 2
meningococcus from the father of this pa-
tient.
Doctor Branham also found in the cultures
frtm the blood of case number 3 an organ-
ism apparently bearing some close relation-
ship to the meningococcus, but not definitely
identified as yet.
COMMENTS
The microscopic tissue work was done by
the Hyggienic Laboratory of the U. S. Public
Health Service. And we wish to thank Dr.
G. W. JMcCoy, Director of the Laboratory,
for his visit, and the aid he and his staff gave
us in establishing definite diagnoses.
In Case number 1 a septicemia was recog-
nized clinically, and we were surprised to
find no growth on either the blood-agar plates
or in the glucose-brain-broth media.
The contagiousness of the disease was not
recognized until the occurrence of Case 2
The gross findings in the autopsy on this case
were also disappointing in helping to arrive
at a diagnosis. Fortunately one of the skin
lesions was excised, and Dr. Lillie of the
Hygienic Laboratory was able to demonstrate
intracellular Gram-negative organisms in the
tissue.
The immunity of many people to the men-
ingococcus infection was attested in that, of
a score or more of doctors, nurses, and lay
friends, who came in contact with these cases,
only two contracted the disease.
All three cases conformed closely to the
observations made by Herrick' at Camp
Jackson in 1918 on cerebro-spinal fever, ex-
cept that the recovery of the organisms was
not easily accomplished. No lumbar punc-
tures were done because of the absence of
meningeal symptoms.
REFERENCE
1. Herrick, W. W.: The Epidemic of Meningitis
at Camp Jackson, The Journal A. M. A., Jan. 29,
1018, p. 227. Meningococcus Infections Including
Cerebro-Spinal Fever, Oxford Medicine, Vol. V, pp.
71-106.
Benefits of National Maternal Aid Not Evi-
dent.— States that reject the Sheppard-Towner Act
would appear to have had better luck in the reduc-
tion of infant and maternal mortality than have
those states that submitted to this unfortunate meas-
ure. Although mortality rates have been on the
decrease over a period of years, yet only 12 out of
the entire 48 states had a lowered infant mortality
in 1028, and of these twelve states five did not work
under the Sheppard-Towner Act.
Illinois can congratulate itself with cold, hard
statistics that it refused to countenance the Shep-
pard-Towner Act. In Illinois, where there is no
Sheppard-Towner Act, the maternal mortality rate
for 1028 was only S.l per thousand. California is
the only state ranking anywhere near this figure
among those states working under the Sheppard-
Towner Act.
It is noted that the states accepted $4,607,2.!4.S6
of Federal funds, which means that the expenditure
was in excess of nine millions of dollars as most of
the Federal funds are matched dollar by dollar for
the states.
.'\pparently this vast expenditure was no factor
in lowering the death rate. Why ? Because the
Sheppard-Towner Act is not now, never was, nor
ever could be a medium for palliating maternal
mortality since the inherent nature of this legislation
makes it impossible to effect such functioning. —
Editorial, Illinois Med. Jour., Nov.
December, 10}^
SOtJtHERN MEDlClM; ANlD StTlGeftV
84J
Biographical Sketches*
Frank Hancock, M.D., Norfolk, V'a.
Mediaeval ^Medicine was solely concerned
with the collection and elaboration of ancient
tradition. Science had no relation to it. In-
vestigation was not a part of it. Long be-
fore Imperial Rome passed under the Goths
medicine had measurably declined in the
West. Intellectual interests and the dissemi-
nation of knowledge among the Arabs was
due to the fact that Greek literature was
early and freely translated into the language
of the Koran, the language of their govern-
ment and of their daily life.
Med'cine in the Christian West became
increasingly under the influence of the
Church. Priests and Ascetics became physi-
cians, and there followed a period of Monas-.
tic Medicine, what Cotton Mather called "an
angelical conjunction between medicine and
divinity." Reliance was upon supernatural
aid rather than medicine. It was here that
medicine and surgery became separated, be-
cause the Church would not allow her priests
to cut the human body nor to draw human
blood. Medicine soon became a fog of mys-
ticism and empiricism. However, it was the
Roman Church that preserved whatever there
was of medical knowledge and of literature
until later in the iMiddle Ages, when the
worst of the murderous wars were over —
wars between the Ostrogoths and Byzantines
and the invasion and occupation of Italy by
the undisciplined Lombards; and so it is said
the heritage of literature was preserved
through monkish industry. Thus we have our
own apostolic succession.
The sixth century abounded in plagues.
Sick people were carried into churches where
holy water was sprinkled over them and pray-
ers uttered for their relief. The more hope-
less medicine became, the more was salvation
looked for from supernatural agencies.
The rescue of mediaeval medical writings
and authors and their study was undertaken
by the order of St. Benedict under the direc-
tion of Cassiodorus, the last Roman who
sought to teach the value of ancient litera-
ture. This order was founded in the sixth
century, the century in which Justinian
closed forever the school of philosophy in
Athens. A study of the history of medicine
will teach you that we owe something to the
order. Its members used herbs with increas-
ing effectiveness; herbs they learned about
through the medical authors Cassiodorus had
advised them to study. By the eighth cen-
tury medicine was no longer entirely in
iMonkish hands, several Lombard lay physi-
cians being in practice in Lucca and Ravenna.
In Spain under the Visigoths, from the fifth
century, and in iMerovingian times in France
the conditions were quite the same. In
France culture declined to the profoundest
barbarism; the seventh century Merovingians
hardly knew how to attach their signatures
to documents. It was only in Carlovingian
times that the clergy improved, under a
sterner discipline. From the ninth century
onward cultural advance was unmistakable.
Charlemagne, in 813, forbade the priests
to employ consecrated oil for the purposes
of cure or magic. In this ninth century Al-
fred the Great sought to raise the educational
standards of the English, particularly the
clergy, and greatly succeeded.
The rise of medicine in the eleventh and
twelfth centuries coincides generally with the
rise in civilization. Quickening influences
came through the Crusades, the passing of
feudalism, the rise of the middle class. To
the town of Salerno on the Tyrrhenian Sea,
south of Naples, belongs the credit for shel-
tering the earliest medical school of the
Christian West in the eleventh century. Its
practices were not essentially different from
those of its ancient predecessor at Alexan-
dria, but it did serve as a connection, linking
the medicine of antiquity with that of the
mediaeval west. For 500 years all that the
physicians in Europe had known came
through the school at Alexandria. Salerno
was the mother of the Universities of the
middle ages, — Padua, Bologna, Paris, Oxford.
It is said to have been founded by an Ara-
b'an scholar, a Jewish rabbi, a Greek pontiff
and a Christian physician. Certainly eccles-
iasticisni of no sect had control here. One
♦{■resented to the Norfolk County Medical Society,
844
SOUTHERN MEDICINE AND SURGERY
December, 1929
of its most celebrated teachers was the wo-
man physician, Trotula. She wrote books
upon pathology and therapeutics and the dis-
eases of women. Her description of the pre-
vention of perineal tear, and her operation
when that rupture occurred, are as modern
as the most recent textbook.
Salernitan teaching generally, valuable
though it was, was crude besides contempo-
rary Byzantine and Arabic practices. These
two nations had never been completely
obfuscated. When a change did set in, to-
ward the last of the eleventh century, it was
due to the amazing fertility and resourceful-
ness of one man — Constantinus Africanus —
who more subtly conceived symptomatology,
and amplified therapeutics. There are few
more astonishingly erudite characters in our
history. He was born in Carthage, 1018,
but his precosity was such that he was sus-
pected of witchcraft and had to leave.
Strange, is it not, how the great genuises of
the world have been driven from place to
place by ignorant men! "The pain of a new
idea is one of the greatest pains in human
nature," said Walter Bogchat. John Locke
truth scarce ever yet carried it by vote
anywhere on its first appearance. Constan-
tinus settled in Salerno, and there accom-
plished his mission for the enfranchisement
of the human intellect. He extended the
range of occidental medical knowledge by
his translations into Latin of Hippocratic and
Galenic writings. All the subsequent Saler-
nitans were influenced by him and quoted
him in their books. One of these twelfth
century Salernitans mentions the use of the
soporific sponge in surgical operations. The
greatest accomplishment of this school of
Salerno was its revival of the art of surgery.
They used sutures in hemorrhage, silk in
particular. The students of this school now
carried its teachings to all parts of Europe.
It is easy to see that its influence was re-
sponsible for the awakening of the healing
art from its five centuries of lethargy in Eu-
rope. They developed no Hippocrates, but
this incomparable master of antiquity show-
ed them the way.
It was in this twelfth century that the
foundation was made for scientific medicine
that was to come after, just as the Moslems
once by way of Egypt, Persia and Syria, re-
ceived Greek knowledge, translated into their
own language, — so now the tide of culture
ebbed toward the West, and Arabic was freely
translated into Latin. It is a proof of the
insatiable thirst for knowledge and its pxjwer
to overcome all obstacles, because Christen-
dom and Islam along almost the whole Medi-
terranean littoral were in constant warfare.
The thirteenth century saw the end of the
Salernitan school. It had finished its work.
Bologna assumed the sceptre of authority. Its
surgical fame is linked with Hugo of Lucca
and his son Theoderic. It was they who
used the soporific sponge so effectually in
surgery, and treated wounds in a simple, non-
suppurative way. Their narcotic sfwnge con-
sisted of opium, hyoscyamus, mandragora and
lactuca. It was dried and put aside till need-
ed, when it was moistened with warm water
and put to its appropriate use. They also
used mercury and were familiar with the sali-
vation which follows its use.
William of Saliceto, and Jan Franchi the
Milanese, who practiced in Paris, are two of
the great names of this century. Arnold of
Vlllanova, the famous Catalonian, I must
pass over. He was one of the most fascinat-
ing characters of the middle ages. Cool,
brave, resourceful, not afraid of his beliefs,
even under arrest and threatened with death
by the Inquisitors. Three succeeding Popes,
whose favors he alternately won, saved him
repeatedly from the wrath of the terrible the-
ologians. He learned with what a watchful
eye the Inquisition marked the first stirrings
of intellectual freedom.
The dissection of human bodies was once
more practiced in the latter middle ages, after
1500 years of neglect — since the time of the
Ptolemies. This was due to the school of
Bologna. It was in this pre-renaissance era
that the poet Petrarch inveighed heavily
against the medical profession's continued
belief in astrology, alchemy and magic, its
willingness to rest its practices upon ancient
authority, its scholastic taint shown in its
fondness for rhetoric.
The fourteenth century will always be
celebrated for the epidemics of plague that
visited Europe — the most devastating that
the human race has experienced. Probably
25 million people died. Guy de Chauliac
and Henri de Mondeville were surgeons of
this period. Historians believe that the early
rise of French surgery is really due to the
December, 1029
SOOTHEllN MECtCINfi ANt) StftGEftV
ui
impetus given it by these men, particularly
the former, some of whose works are still
extant. Mondino was the great dissector of
this period, but he was not entirely free from
tradition, .\rabian influences were uppermost
now in all the universities, those that had
succeeded the e.xtinct Salerno. The medical
literature of the fifteenth century is saturated
with the spirit of .\vicenna and Rhazes.
"No rustling among dry leaves as yet her-
alded to the practiced ear the oncoming storm
of intellectual upheaval." Medicine of the
later middle ages was a mere replica of Ara-
bic medicine. At this time uroscopy was the
diagnostic method, and phlebotomy the sov-
ereign mode of treatment. Astrology still
ruled the intellect of mankind. It was at
this time that printing was introduced;
nothing significant could happen to medicine
until that occurred. Within thirty years af-
ter the discovery of movable type by Guten-
burg 800 medical books were printed.
Jewish physicians played an important
part throughout these middle ages, though
it was only in Italy that medical courses were
open to them. It was they who transplanted
Arabic medicine to the West, mostly by trans-
lations. The comparatively large number of
Jewish physicians in these days was due to
the fact that they were debarred all other
learned callings. They became physicians to
fKjpes and princes. The most celebrated of
them was Maimonides, born in Cordova in
1135. It was in this century that physicians
began to pay attention to obstetrics and
gynecology. Mortality in the former was
about SO per cent. Roslyn described the ad-
vantages of fwdalic version at this time.
Forty years later Pare popularized the pro-
cedure. In this sixteenth century Jacob
Nufer, the Swiss sow gelder, [performed on
his own wife the first cesarean operation of
which we have any knowledge. "Shackled
thought" had not yet been released, — a great
step forward had not been taken, but the
renaissance was near. The shadows that had
so long lain athwart the world were about to
disappear. The long battle was on between
the "vested doctrines of the past and the
aspiring truth." There was a slow and grad-
ual development of anatomy, reaching its
climax in Vesalius, Harvey and Malpighi.
Pathology based on scientific evidence was
ipore difficult. Paracelsus' chemical views
were largely hazy concepts of the -Arabians,
but he did give an impetus to the march for-
ward. He first used mercury internally.
Bartholin, the Dane, was among the first to
publish collections of pathological observa-
tions. H-s contemporary and close acquaint-
ance, Sylvius, at Leyden, sought to construct
a pathology out of the anatomy and physi-
ology knowledge and themes of his age.
Vesalius, Eustachius and Fallopius recast
anatomy. Pare brought surgery forward, and
ophthalmology was recreated. Up to the six-
teenth century there had been no such thing
as the science of human anatomy. The
pronunciamentos of Galen were relied upon.
Through Galenic glasses all things were seen.
Vesalius had to leave Padua when he showed
Galen's anatomy to be full of errors. It was
only a step from anatomy to physiology, the
study of form being close to the study of
function.
Peyer, Brunner, \'on Helmont and others
were working at pathology. The men of this
period were not sufficiently vivid to lend
color to their times, but they were the fore-
runners of greater ones to come. In the sev-
enteenth century chemistry separated from
alchemy. Robert Boyle demonstrated the de-
pendence of life upon o.xygen. Von Hel-
mont coined the word gas and demonstrated
the existence of C02. Sydenham was work-
ing in England trying to separate diseases
one from another, and to give them a scien-
tific nomenclature. Watching acute diseases
closely, he distinguished measles from scarlet
fever, rheumatism from gout.
Morello Malpighi, founder of histology and
greatest microscopist of the time, made nota-
ble contributions to embryology. It was he
who first studied red blood cells which had
been seen by Swammerdam seven years be-
fore. He established the histology of the
liver, spleen and kidneys. He discovered the
capillaries, and physiologists understood for
the first time how the blood passed from ar-
teries to veins.
In the seventeenth century there was a co-
lossal stimulus to the minds of medical men
with anatomists, clinicians, physiologists and
pathologists working. The brilliant young
Frenchman, Bichat, was working industrious-
ly for the dissociation of diseases. He be-
lieved that disease of connective tissue was
disease of connective tissue wherever found,
sotitHEkt* Mfebicifrt; AKb stjftcfekV
becemter, 19^9
without any respect to the organ it occupied;
that every tissue has everywhere a similar
disfKDsition and its disease must everywhere
be the same. It seems trite enough now, but
it was Bichat's mind that worked it out.
Laennec followed, one of those really great
men who broke new ground. His treatiese
on auscultation belongs among the epochal
works of medicine. A virtual revolution was
produced in nosography, that is in describing
and classing morbid phenomena. Laennec
tried hard to recognize in the living patient
anatomical changes found in the dead. It
was wh.le considering this question that he
conceived the idea of indirect auscultation,
and invented the stethoscope (1816). For
the first time was heard "the echo in human
lungs." At this time England and Francs
were at war. Laennec was captured and ta-
ken to England. All of his time there was
sf)ent in perfecting his stethoscope. He
called them his little trumpets. Before this
a physician's time was entirely spent in ob-
serving his patient, looking at his tongue and
urine. Now there was an objective exam-
ination at least of the thorax. The germs of
Pinel's and Bichats anatomical ideas had
sprung into life in clinical medicine. By
thus comparing the conditions present in the
course of d.sease and the lesions found
post mortem, he was able to create a series
of entirely new and classical pictures of dis-
ease. He first described emphysema, acute
and chronic edema of the lungs, bronchiecta-
sis, gangrene and pneumothorax. He distin-
guished pneumonia from bronchitis and pleu-
ritis. All of these diseases before his time
had been called peri-pneumonia. He anat-
omically and cl.nically described pneumonia
as it is known today. He separated pulmo-
nary tuberculosis from the other nineteen
forms of phthisis of the ancients. Laennec's
contemporary, Bayle, got so far in the sim-
plifying process as to describe only six kinds
of phthisis. He alone of all the men who
were working, or who had gone before, rec-
ognized that all of these varieties were but
different stages of the one disease, and he
taught the correlation of these signs and
symptoms. He discovered with his stethe-
scope that the disease begins in the apices.
He believed scrofula to be a tuberculous
manifestation. He died in 1821, aged forty-
f^ve years, leaving behind him a nosography
of hitherto unknown comprehension and ex-
actness.
G'ovanni Morgagni (1682-1771) founded
pathology. He published five volumes of his
observations and collections. He was never
to read it, however, as he was nearing ninety
and had gone blind.
After Laennec came Bretonneau, who de-
scribed diphtheria; Larres and Andral ty-
phoid; Bayle dementia paretia; Cruveillier
gastric ulcer, and Bouillaud mitral insuffi-
ciency and rheumatic endocarditis. Louis
continued Laennec's work on tuberculosis.
This great clinical movement of the eight-
eenth century spread rapidly and students
came from all parts of the world to learn
stethoscopy, anatomical diagnosis, and the
principles of research that actuated the Paris
school at that time. Medicine had come out
of its mediaeval thralldom, out of its long
miasma. A clinical school at this time arose
in Dublin. Robert Graves and William i
Stokes were its teachers; also there was
Cheyne, of the Cheyne-Stokes respiration;
Adams of the Adams-Stokes syndrome, and
Corrigan, whose pulse you know about.
To Guy's Hospital in London came Thom-
as Addison, Richard Bright and Hodgkin. In
1827 Richard Bright showed for the first time
the connection between anatomical changes
in the kidneys and dropsy and albuminuria,
creating that clinical picture of chronic in-
flammation of the kidneys that still bears his
name.
It was in 1694 that Frederick Bekkers de-
scribed the effect of heat and acetic acid on
certain types of urine. In 1764 the Italian
Cotugno described an acute nephritis with
anasarca and quantities of a heat-coagulable
substance in the urine. He was testing for
albumin in this urine because he had found
it in effusions of dropsical cadavers. This
was 62 years before Bright's classification of
the nephritides was written. Bekkers was a
pupil of Sylvius. Physiology, histology and
pathology were established in the seventeenth
century; Von Haller in physiology; Bichat
in histology; Morgagni in pathology. Casper
Frederick Wolff put the stamp of modern
science on embryology. His name is pre-
served in the eponym "Wolffian bodies."
Pinel about this time risked his reputation
and his safety by agitating for the insane, —
by insisting on treating them as sick rather
December, 10 JO
SOOTHfiftM MEbtClNt AND SUftGERY
84?
than as bewitched. In the eighteenth cen-
tury France was better represented in surgery
than in medicine. Jean Louis Petit invented
the screw tourniquet, and was the first to
open the mastoid cells. Littre described her-
nia of Meckel's diverticulum. Philipe Ric-
ard was the leading authority in venereal
disease, and dissociated syphilis and gonor-
rhea. In the eighteenth century England, for
the first time, began to develop that power-
ful grasp that was to characterize her after-
ward. Up to the eleventh century she was
under the barbarous Saxons. In the healing
art only herbs, incantations, magic, necro-
mancy, were used. It was only after the
N'orman conquest that rational medicine was
itttroduced. John of Gaddensden offered the
first formal introduction. In the thirteenth
century the Scotchman, de Gordon, gave the
first description of eye-glasses and trusses,
teaching at Montpellier.
In the course of a few decades clinical med-
icine had been completely transformed — one
of the most significant achievements in the
history of any science. The movement was
quickly felt in this country; \V. W. Gerhard,
a pupil of Louis, working at the University
of Pennsylvania with these new methods, de-
fined meningeal tuberculosis in children, and
differentiated typhoid and typhus. After
Auenbrugger developed percussion in Vienna
came the clinician Skoda, the pathologist
Rokitansky, who were to become leaders in
the new school. Schleiden introduced these
new methods in Berlin. The French physi-
ologist Magendie taught pathology as the
physiology of the diseased individual, — a
teaching which was followed by Muller,
Schwann, Traube, V'irchow, du Bois Rey-
mond, and others in Germany. This is in-
teresting as a manifestation of the shifts that
occur in history. Nothing has been heard
of Greece or Rome since the end of the mid-
dle ages, nor do we longer hear of Spain or
Italy as centers of medical learning. Central
Europe has come on as those southern coun-
tries relinquished their hold. The barren
period for medicine was over in Germany. It
was succeeded by scientific pursuits, far-
reaching results and brilliant leadership that
was maintained through most of the century
under V'irchow. The announcement of his
cellular pathology induced a thorough-going
fevision of microscopic pathology. The Ger-
mans pioneered in the effort to emancipate
physiology and pathology from clinical medi-
cine, and they went too far. They denied
the specificity in tuberculosis and diphtheria
established by Laennec and Bretonneau.
Even the great V'irchow said that croup and
diphtheria were distinguishable. They there-
upon denounced the whole doctrine of spe-
cificity, but they atoned for this in the con-
tributions they made to nosology and clinical
medicine.
Vierordt began blood counts in 1852, and
in 18SS employed a sphygmograph for inves-
tigating the pulse. Trommer and Heller in-
vented methods for examining the urine. In
1850 Helmholtz invented the ophthalmoscope.
The laryngoscope — by Garcia and Turck —
soon followed. In 1841 Andral of Paris ad-
vocated clinical thermometry. It was he who
really laid the foundation of hematology.
While clinical medicine swept on to great-
ness, surgery lurked behind, still performing
its operations without anesthetics or antisep-
tics. Claude Bernard followed Magendie in
his amazing researches. You will recall his
well-known experiments in glycosuria. They
said that to each specific cause the symptom
responds with characteristic specific phenom-
ena. Still they didn't know any more about
infection than Francastorius had known in
the fifteenth century. But the light was
about to break. Pasteur was at work. His
experiments revealed that microbes produced
a whole series of diseases, establishing sf)ecifi-
city for all time. His predecessors had been
right, — Sydenham, Bretonneau, Trousseau;
diseases were henceforth to be classed etiologi-
cally rather than pathologically. This man's
intelligence was wholly unaccountable. He
must have come from some more advanced
world.
Virchow's sun was setting. His cellular
pathology would remain, "but the jump from
him to Pasteur and Koch was too great a
hazard to be taken painlessly." Staining
methods were being develo[>ed by Gram,
Ehrlich, Koch. Imagine the relief to the
clinician to be able to say definitely that this
disease is tuberculosis, diphtheria, typhoid.
Then came the specific serum reaction in
typhoid and syphilis. The microbe of syph-
ilis was described by Schaudinn, a German
zoologist, in 1905. In 1876 Fournier stated
his belief that syphilis was the cause of
§6tJtttfeRW MEbtcl^ Aiib gttftefifeV
fiewmter, i^ii
tabes; — in 1875 Esmond and Jesser that gen-
eral paralysis was syphilitic in origin. This
was not believed until Xoguchi discovered
the spirochaeta pallida's relationship to gen-
eral paralysis. Vesalius and Pare believed
that aortic aneurism was associated with
syphilis. Thus centuries of acquisition were
required to add one fact to another. Bosch
published accounts of blood takings and
Ehrlich his experiments with leucocytes. iNIul-
ler and Magnus-Levy demonstrated basilar
metabolism in thyroid disease in 1893-95.
Thomas Addison, in 1855, described that dis-
ease of the suprarenal capsules which causes
the general bronzing of the skin and ac-
companying intractable anemia, whose origin
had previously remained unknown, even un-
suspected. This was the beginning of active
study of internal secretions.
Thus the profession has hurried on, for-
getting in one century what it had so slowly
learned in another, — making changes that are
witnesses to the vitality and vigor of the
minds that produced them, changes so pro-
found that you who have come after are
scarcely conscious of the sweep of them.
Amid this persistent search for truth there
has never been a time when somebody has
not lived right up to the ideals that the great
Greek instilled into the profession 2,500 years
ago; Galen, Erasistratus and Herophilus of
Alexandria; Alexander of Tralles; Paul of
Aegina, last of the Byzantine acholars; Avi-
cenna; Constantinus, in whose works are
found the great didactic poem, "Regimen
Sanitatus Salernitanum" — a collection of
medical rhapsodies that influenced the medi-
cal world for centuries; Roger, the surgeon
of the Salernitan school of the twelfth cen-
tury; Linacre; Sir Thomas Brown; Fabricius.
— Medical Arts Building.
Few Gland Products or V.^lue. — .\t the present
time it cannot be definitely stated which glands are
protagonistic and which antagonistic, each with the
other. Probably the thyroid works more in har-
mony than any of the other glands. It would seem
from careful investigation up to the present time
that only the thyroid gland can be given by mouth,
with definite proven clinical benefits, not only
in the severe case of cretinism but in the mild con-
ditions due to hypothyroidism.
The statement has been made by some that thy-
roid extract is of benefit in the Mongol, but such
has not been my experience unless the patient shows
hypothyroid symptoms in addition.
Parathyroid extract when injected raises the blood
calcium. Theoretically it should have a beneficial
effect, particularly in tetany. When given by mouth
it is inert.
There has been no active principle isolated from
the internal secretion of the thymus gland, and no
proven results either by injection or by mouth.
Adrenalin, or the extract from the adrenals, when
injected has definite chemical and physiological
action, and definite clinical use but perhaps more
as a drug than as an internal secretion. It is of
little or no benefit when given by mouth.
Extracts from the gonads in the male have no
proven clinical value either by injection or by
mouth. The so-called ovarian extract and corpus
luieum extracts have some clinical value when given
by injection. The feeding of either corpus luteum
or ovarian e.xtract has proven recently to be value-
less.
Insulin needs no discussion. Its value is proven.
In conclusion, leaving out the two internal secre-
tions definitely proven to be of value, which are
thyroxin and insulin, and the two internal secretions
which have great drug value, which are adrenalin
and pituitrin, one becomes almost a therapeutic
nihilist when he thinks and sees the large number
of cures ascribed to the extracts from the internal
;err-tions. Perhaps the greatest harm is not by
actually giving the drug, but by the false sense of
security engendered where important defects might
be remedied by mental training and other such use-
ful methods. — Mitchell, Jour. Tenn. State Med.
Assn., Nov.
IXTERFERENCE InCREA-SES MaTERNAL AND FETAt |
Mortality. — .\11 the reviewed statistics show that i
from OQ to 05 per cent of all labors terminate spon- ■
taneously and that the higher the incidence of oper-
ative intervention, whether done by the expert or
by the tyro, the greater the increase in both the
maternal and the fetal mortality. Therefore, it
may be deduced, first, that childbirth can be made
safer by intelligent appreciation of the physiologic
mechanism of labor and adherence to strict surgical
technic, and, secondly, that in the presence of com-
plicating disease the pregnancy in most instances
can be disregarded and attention given to the treat-
ment of the disease. — Polak & Clark, /. A. M. A.,
Nov. q.
becember, 1929
SOUtttEftN MEDICINE AND SURGERY
849
The Problems of a General Practitioner*
J. W. :\IcGehee, M.D., Reidsville, N. C.
I have been asked to lead at a round-table
discussion of the problems of a general prac-
titioner. This subject is broad and far-reach-
ing.
V'ice-President Tom Marshall's father, a
country doctor, wrote of his own experience:
"Mud everywhere; cracks in the house
everywhere; children waking in the
morning with their blankets covered
with snow; huge fireplaces where you
roasted on one side and froze on the
other; chills and fever; fever and chills;
day in and day out; night in and night
out, the country doctor went his rounds."
Under trying conditions the general practi-
tioner worked ; there were few specialists,
hospitals or laboratories from which he could
seek help or information. He laid the foun-
dation upon which our present practice of
medicine has been builded.
During the past 25 years there have sprung
up all over the country many things which
apparently have taken from the general prac-
titioner his work and his fees; we often hear
that his influence, prestige and practice is
on the wane and in a few years he will be
extinct. I can not think this is true, and
am not willing for one moment to admit any
part of it.
I am convinced that the present status of
medicine in all of its branches is laid on the
solid foundation of the work of the general
practitioner; he can be likened to the great
root and trunk of our mighty oak, sending
out stout branches in all directions; only so
long as the trunk and root are sound may
vigorous branches be put out. The general
practitioner must survive in vigor if the prog-
ress of medicine is to continue.
What are some of the problems of today
that we must meet? The Specialist; The
Free Clinic; Free Hospitals; Half-pay pa-
tients; the State Board of Health; the Ex-
tension Department of the Tuberculosis San-
atorium.
The Specialist. — Let it be said in the be-
ginning there is a real need for him, but we do
not think all doctors should be sjiecialists,
from any standpoint. There is a growing
tendency among the laity to seek the spe-
cialist without the knowledge or consent of
the family physician. The American people
want something special; they think if they
can get to this or that specialist all will be
well. The specialist has done much valuable
work, has made wonderful discoveries in
etiology, pathology, diagnosis and treatment
of diseases. He is my friend and I appreciate
his friendship and his help. But he should
be the general practitioner's helper, not a
substitute for the general practitioner. .\ pa-
tient can not be seen after piecemeal; the co-
ordinating must be done by the general prac-
tioner.
The Free Clinic. — In the larger cities free
clinics have sprung up and many patients go
from the rural sections to these clinics, be-
cause they can get something for nothing.
.After they get it, they do not appreciate the
motive of the giving or the service rendered.
Board of Health. — This state has had an
excellent Board of Health for many years
and each year this Board is sending out lit-
erature on health subjects, holding free clin-
ics, examining school children for tuberculo-
sis, vaccinating against diphtheria and small-
pox, examining and treating people for hook-
worm, removing tonsils and adenoids — all in
all, taking from the general practitioner and
forcing State medicine on us in a way hard
to distinguish from rank socialism. The past
summer Rockingham county had a free tu-
berculosis clinic and our city was placarded,
reading as follows:
"P'ree. Be examined by a specialist; find
out if you have tuberculosis. Tuberculosis
diagnosed early is curable." I have one of
these placards for your inspection, study and
comment. I want to say frankly, kindly and
emphatically that this is unprofessional, un-
kind and uncalled for, that it lowers the gen-
eral practitioner in the eyes of the public
and is calculated to do much harm and little
good. Do you gentlemen realize that some
♦Presented to the Eighth (N. <^.) District Mvdiul Sociclv, mcctiiii,' ut Winstoii-Sulcm, Ny-
vember 5, 1929.
SOUTHERN MEDICINE AND SURGERY
December, 1Q20
of your hard-earned money goes in taxes to
pay for th's kind of advertising? The phy-
sicians at the State Tuberculosis Sanatorium
are doing good work and they can be of
much help to us if they will limit their treat-
ment to patients at the sanatorium; they can
attend our County and State Medical Socie-
t'es and read valuable papers on the diagnosis
and treatment of tuberculosis; they can
continue to send us complete reports on cases
referred to them for examination. They can
further help the Sanatorium, the State, the
physician and the public by writing articles
for the newspapers, advising and requesting
people to see their family physicians when
they are not well, when they are losing
weight, running a little temperature, have a
persistent cough or a hemorrhage, however
slight. If they can get the public to consult
the family physician early, then we will fill
to overflowing the Sanatorium with patients
who have incipient tuberculosis. If it is right
that the State Sanatorium should send a spe-
cialist out to examine patients, or the Board of
Health should order a hookworm or adenoids
and tonsil clinic, vaccinate against smallpox,
diphtheria and typhoid fever sq the school
ch^dren will be free of d'sease, then why
should they not also have a free hospital
where patients can have their appendices and
gall-bladders removed free?
If these conditions continue, then our state
will be the father of socialistic medicine in
its worst form. I submit, Medicos, that no
County, State or Nation has ever prospered
under a socialistic government, and there isn't
any good that can come from this state en-
tering into the practice of medicine, in any
of its branches. Why pauperize a good citi-
zen? Why take a good thrifty producer and
make a dependent out of him?
The State Laboratory at Raleigh is doing
fine work, is doing much for us, and I want
to take this opportunity to thank Dr. Shore
and his men for their splendid service.
As you have followed me through this dis-
course you, no doubt, have become somewhat
bearish on the general practitioner's future;
and when we are bearish we are depressed,
despondent and rather blue.
Let us now take the optimistic side, and
sketch the future as we see it. We see on
all sides great changes in every phase of life.
We must get in line, in the front ranks and
lead instead of follow, remembering that all
change is not improvement. Most of our old
physicians are rapidly passing out and men
of my age are taking their places. We had
much better training in medical schools and
hospitals, and more equipment to do with
than our ancestors; consequently, have help-
ed in the advancement of medicine in all of
its branches. We attend our society meet-
ings, and occasionally are able to get away
to the big medical centres and see what is
going on. We have our journals that we can
read and may keep abreast of the times; we
are alert while on the go and are striving, in
every way possible, to take advantage of any-
th'ng new that will help us to be better diag-
nosticians and therapists.
I have spoken of the specialist; there is a
much-needed field for him; and we should
feel that we have in him a real friend, one
that we can refer our cases to and know he
will give our patients scientific treatment and
good advice. The general practitioner should
always refer any case to the specialist that
he does not feel capable of treating. The
snecialist should realize that the general prac-
tit'oner is caoable, and should also refer cases
to h'm for diagnosis and treatment; and, in
th's way, we can work together in mutual
reroect and confidence and at all times pro-
mote the best interest of patients.
Recruits to Our Ranks. — W^ith present re-
quirements men will come from college and
hospital better qualified and in every way
caoable of doing better work. They certainly
should be able to take a complete history,
mfike a thorough general examination, vacci-
nate against any disease, detect tuberculosis
in the incipient stage; in fact, do anything
the State Board of Health wants done.
General Practitioner's Office. — The reason
the specialist is able to do good work is be-
cause he has suitable offices, equipped with
necessary instruments, and he is able to stay
and work in his office. Every practicing
physician should have a comfortable, attrac-
tive office, a good library, and necessary in-
struments and equipment. He should have
either a practical nurse or a graduate nurse
to help him; he should devote half of his
hours to office work, and if he will do this he
will soon develop a good office practice that
will pay him well. He should expect SO per
cent of his work to be done at his office and
December, 1020
SOUTHERN MEDICINE AND SURGERY
851
should collect 50 per cent of his total fees
from office practice.
It has been said by other practicing phy-
sxians — internal medicine men, surgeons and
specalists in other branches — that the gen-
eral practitioner is capable of diagnosing 90
per cent of his cases, and that it will take
ten specialists to do the work of one practi-
tioner. If this be true, then from an eco-
nimic standpoint, how many years will it
take ten specialists to supplant one practi-
tioner and how can the people pay the ten
specialists. If you were ill and didn't know
what disease you had, what specialist would
you call first? We do our best work at our
offices; why not try to do more each day?
The problems of the general practitioner
are many and there is no sjjecific remedy.
We are burdened with charity patients and
professional dead-beats: the former we should
care for as much as our time and finances
will permit; for the latter, we should as a
body refuse to work. The practitioner should
not hesitate to take the responsibility of
treating any case which he knows he is com-
petent to treat. He should take more time
and be thorough in his examinations, and
charge his patients for services rendered. Ob-
stetrics is the hardest branch of medicine.
The general practitioner is often unexpect-
rd'y called upon to do major obstetrical sur-
g'cal work alone under the most adverse cir-
cumstances. In the day time we are busy
and at night we are tired. It is probable
th It obstetrical work causes more gray hairs
in his head than any other one thing, and,
w'thout a doubt, it is one of the primary causes
of so many of us going to an early grave.
We should require cash for these cases; this
beng one time the husband is forewarned
for nine months, he should be fore-armed
wilh the cash. I hope the day is not far dis-
tant when we will have an obstetrical hospital
in every county in North Carolina. This is
one branch of medicine that truly belongs to
the specialist, and I wish him God's blessing.
It has been well said that our patients are
most aopreciative when they are convalesc-
ing and th's is the psychological time to ren-
der your bill, certainly not later than the first
of each month.
There is a different relation existing be-
tween the specialist and his patients from that
between the general practitioner and his pa-
tients. The specialist sees most of his pa-
tients in his office and knows little of their
home life. The family physician must be
with his patient at all seasons, in sorrow and
joy, in death or recovery, from the dawn of
life to its sunset, at all life's entrances and
at all its exits, from the incoming wail to the
outgoing groan.
SUMMARY
We need our State Board of Health, State
Laboratory, Tuberculosis Sanatorium. We
should have a tuberculosis sanatorium in
every county. We need some specialists, but
not as many as we now have; and, last but
not least, we need our general practitioner
who should be in very truth a specialist in
reneral medicine and surgery.
In closing, I am reminded of this little
piece I copied from the Kansas Medical
Jcurnal, by H. W. Davis:
If you can set a fractured lemur with a piece of
strini; and a liatiron, and get as pood results as the
mechanical enKinccring staff of a city hospital, and
at 10 per cent of their fee:
If you can drive throuKh ten miles of mud to ease
the little child of a dead-beat:
If you can do a podalic version on the kitchen
table of a farm hou:e with husband holding legs and
grandma giving chloroform:
If you can diagnose tonsillitis from diphtheria,
w!th a laboratory forty-eight hours away:
If you can pull the thres-pronged fish-hook molar
of the 250-lb. hired man:
If you can maintain your equilibrium when the
lordly specialist snecringly refers to the general prac-
titioner:
If you can change tires at 4 below at 4:00 a. m.:
If you can hold the chap with lumbago from
taking back rubs for kidney trouble from the chiro-
practor:
Then my hoy, you arc ii Country Doctor.
HiNcKH Stkiki; Dkaiii in India. — .\ bun :er lUrike
for sixt\-two days is no joke. One cannot but
admire the young man of twenty-five, who for
more than two months resisted persuasion and cocr-
c!cn to satisfy hunger and embraced death for what
he believed to be the country's cause.
We arc, however, not concerned with the political
issue in the death of Jatindra Nath Das wh'i was
an undertrial prisoner in the Lahore jail; but we as
metiical m^n admire the power of endurance shown
by him. To die inch by inch from hunger in the
solitude of a pri.son cell is more difficult than death
of a .soldier in a battlel'ield. Such voluntary death-
help to solve the question how lung a min can live
without food. — Editorial, Indian Med. Record, Sept.
8S2
SOUTHERN MEDICINE AND SURGERY
December, 1929
Nephroptosis with Especial Reference to the Pathology
and Treatment*
C. O. UeLaney, :M.D., F.A.C.S., Winston-Salem, N. C.
Lawrence Clinic
Nephroptosis is the term applied to renal
mobility which exceeds the normal limits.
These limts according to Kelly, who has
probably made a more thorough investigation
of this condition than anyone else, are from
1.5 to 5 cm. in the female and about half
this in the male. When these limits are ex-
ceeded there is an accompanying laxity of
the perirenal fascia. The vessels become
elongated in long-standing cases and the ure-
ter has to adapt itself to the descent of the
kidney. As a rule the ureter retains its pa-
tency, but if pulled over a band of adhesions
or around an aberrant artery it may become
partially or completely occluded and thus
cause hydronephrosis.
Renal ptosis must be sharply distinguished
from ectopic k-'dney. The latter is a con-
genital fixed malposition with abnormal vas-
cular and fascial attachments. Moyable kid-
ney is usually attached in the normal way.
ETIOLOGY
Predisposinf^ causes. — Women are far more
frequently affected than men, according to
Dietl, 100:1; Glenard 100:12. Some more
recent writers refer to movable kidney in the
mile as very unusual. I have seen but very
few cases occurring in men and all of these
were slight to moderate in degree.
The most susceptible age is from 30 to 40.
Morris states that one-half of the cases occur
in the fourth decade. With development of
the sex characteristics in girls an outward
expans'on of the iliac crests takes place so
that the intercristal transverse diameter is
greater than the diameter of the inferior por-
tion of the thorax. These changes suggest
a possible factor in the greater incidence of
nephroptosis in women.
Southam's investigations showed that the
position of the kidneys in man at the present
is such that they are constantly exposed to
the action of gravity, continually inviting
prolapse.
Any condition which leads to weakness and
less of muscular tone in the abdominal wall
♦Presented to tbe Gaston County Medical and
may result in a general descensus of the ab-
dominal viscera as well as prolapse of the
kidney. Pregnancy plays the major role in
bringing about this condition. There is
no doubt that occupation is a contributing
factor in some cases. It is a reasonable pre-
sumption that women whose abdominal mus-
cles have already been weakened by pregnan-
cies and often by constitutional defects are
rendered more susceptible by work which
necessitates long hours of standing, lifting of
heavy weights and continual flexion of the
body.
Exciting causes. — Trauma is a very im-
portant factor. It is of interest more espe-
cially as it relates to industrial accidents and
the very general existence of compensation
laws. The part it plays in the development
of renal ptosis is no doubt often exaggerated;
still it must be recognized as a possible pri-
mary cause in some cases. Even though the
pre-existence of movable kidney is establish-
ed it is possible that accidents occurring in
industrial work may render the condition
more serious. This view is often taken by
juries. Nephroptosis per sc may reach an
advanced degree without producing obstruc-
tion; in other cases, because of the existence
of an aberrant artery or kinking and angula-
tion of the ureter, may give rise to an obstruc-
tive process where only moderate ptosis ex-
ists. This is sometimes observed in cases
where a previous kidney operation has been
performed. Only slight prolapse of the kid-
ney may drag the ureter down over a band
of adhesions producing obstruction.
SYMPTOMS
Often there are no definite symptoms.
Probably the most common symptom is a
constant aching pain or the recurrent spas-
motic pain which has long been referred to
as Dietl's crisis, the latter due to traction
upon or kinking of the ureter. Other symp-
toms are gastro-intestinal and referred to as
ir.d'gestion, flatulence, epigastric distress
after meals, belching, constipation and I055 |
Dental Society, July 3, 19J9,
December, 1029
SOUTHERN MEDICINE AND SURGERY
of appetite. Headache is not an uncommon
complaint in these cases and is probably of
toxic origin due to impaired elimination.
^Malnutrition is also in evidence in the ma-
jority of these patients. Not infrequently
nephroptosis occurs in neurotic individuals.
PATHOLOGY
The pathological changes both in the uri-
nary tract and those involving other organs
of the body vary within wide limits. We
know that in any acquired disease condition
there must be a beginning and it is obvious,
therefore, that the earlier one recognizes the
e.xistence of nephroptosis the less extensive
will be the pathology. The changes which
take place in the urinary tract are primarily
the result of obstruction of the ureter. As
result of kinking or prolapse over an aber-
rant artery or a band of adhesions which
gradually brings about increased back pres-
sure above the point of obstruction resulting
in dilatation and enlargement of upper por-
tion of the ureter and kidney pelvis. The
longer the duration of the disease as a rule
the more pronounced these changes will be-
come. In early hydronephrosis the damage
to the kidney may be slight, but in long-stand-
ing cases the pelvis and calices have expand-
ed at the expense of the kidney substance
with the result that the renal cortex has been
reduced to a narrow zone at the outer border
of the kidney. The extent of these structural
changes is reflected in impaired renal func-
tion. The degree of functional loss depends
upon the amount of obstruction present and
the duration of the process. Unfortunately,
pain is no index to the degree of obstruction
present. If the blockage of urine is contin-
uous pain diminishes as the process becomes
more chronic, and in advanced types of
hydronephrosis is often absent. Xot infre-
(|uently patients with long standing ureteral
obstruction and pronounced hydronephrosis
seek relief only for the gastro-intestinal symp-
toms. In cases characterized by intermittent
type of obstruction the pain is more severe
and the pathological changes are less pro-
nounced. This type of obstruction may ob-
tain over a period of ten to fifteen years with
only slight pathological changes in the kid-
i.ey. Obstruction in the urinary tract al-
ways invites infection and occasionally in
long-standing cases of nephroptosis we find
hydropyonephrosis. Infection is a serious
complication in these kidneys and occasion-
ally results in complete destruction of the
organ. Hunner reports ureteral stricture as
a frequent complication of nephroptosis and
stresses the importance of ureteral dilatation
as a necessary step in the management of
such cases. The stricture is usually found
in the infected cases. Renal calculus is an-
other complication which is occasionally met
with. Stone formation is favored by urinary
stasis and likewise infection when present.
An important pathological factor in movable
kidney is the effect it has upon other viscera.
Much has been written and said about the
effect of renal ptosis upon the ascending colon
and hepatic flexure. Severe constipation is
often a troublesome complication of renal
prolapse and a plausible explanation of this
is seen in the fact that movements of the
kidney may disturb the peritoneal support
of the colon so as to induce sagging which
in turn interferes with the circulation and
nutrition of the colon resulting in stasis of
its contents. In rarer cases of nephroptosis
which involves the left kidney, the spleen by
reason of its close association with the kidney
is very likely to share in its prolapse and
likewise partake of the pathologic conse-
quences. In extreme cases of prolapse of the
right kidney, where it descends into the pel-
vis, it may induce pressure upon the bladder
and in females upon the generative organs.
Billings reported a case in which he was able
to cure a persistent menorrhagia by anchor-
ing the right kidney. An important obser-
vation was made recently by Peacock who
reports several cases of orthostatic albumi-
nuria occurring in patients who had nephrop-
tosis. In every case the albumin disappeared
permanently from the urine when the kidney
was kept in its normal p>osition. This is a
point well worth keeping in mind when try-
ing to account for the presence of albumin
in the urine which is otherwise negative.
DIAGNOSIS
.•\ patient who gives a history including a
large part of the symptoms enumerated in
this paper together with loss of weight, weak-
ness and exhaustion upon slight exertion may
reasonably be suspected of having a movable
kidney. One thing 1 wish to emphasize at
this point is that the classic symptom Dietl's
8S4
SOUTHERN MEDICINE AND SURGERY
December, 1020
crisis is not a constant factor in the symp-
tomatology of nephroptosis. Probably in the
majority of cases it is absent from the his-
tory. In making a diagnosis it is important
to attempt to palpate the kidney with the
patient in the standing position because if
this is done only in the recumbent position
the kidney may return to its normal position
leading to error in the diagnosis.
Radiography, especially pyelography, is
invaluable in the diagnosis of movable kid-
ney. Since the introduction of sodium iodide
as an opaque medium there is but slight risk
in injecting the urinary tract. Pyelograms
taken in both the recumbent and standing
positions will demonstrate the exact extent
of kidney e.xcursion and the existence of
ureteral kinks, angulations, kidney rotations,
torsion, etc. In making pyelograms in the
standing position it is very necessary that the
catheter be withdrawn below the point where
the ureter receives the support of its perito-
neal and fascial coverings. This will leave the
upper end of the ureter free to assume the
position forced upon it by the descent of the
kidney.
Another diagnostic point, but one which I
believe has been over emphasized, is. that in-
jection of the renal pelvis will often cause
pain identical with that which the patient has
experienced before. This test is helpful only
when positive. In the majority of the cases
I have seen, the injection, even in advanced
hydronephrosis, does not cause pain. An-
other very important pxjint in the diagnosis
of abnormal mobility of the kidney and one
which to my mind determines the indication
for surgical relief in these cases is one that I
have not seen mentioned in the literature. I
refer to the estimation of the emptying time
of the kidney pelvis. This test is made by
injecting the opaque medium into the kidney
pelvis, removing the catheter and making
radiograms at intervals of from five to ten
minutes until the pelvis and ureter are empty.
The normal emptying time of the kidney is
variously estimated at from five to ten min-
utes. The prolapsed kidney will sometimes
retain the opaque medium for more than
sixty minutes. In such instances it is neces-
sary to reinstall the catheter and drain the
kidney. This information is of great help
in studying these cases, with the object in
determining the best plan of relief.
TREATMENT
Not many years ago medical students at a
certain well known college were taught that
whenever they made a diagnosis of movable
kidney not to tell the patient, for a person
so afflicted was beyond the reach of medical
skill. The modern urologist, however, main-
tains a more hopeful attitude toward these
patients and therefore is not reluctant in ap-
prising the patient of his true condition.
The treatment of nephroptosis may be
classified as palliative and curative. The
former is indicated in the aged and otherwise
poor surgical risks and advanced hydroneph-
rosis. It is also worthy of a trial in mild
cases in which the emptying time of the kid-
ney is not prolonged and the renal function
is unimpaired. On the other hand I am con-
fident that the average good results which
are obtained by the present methods of renal
suspension will convince even the most skepti-
cal that surgery should be employed much
more frequently in these cases. A few years
ago Young discouraged the too frequent prac-
tice of surgical suspension, but on the same
occasion gave a good account of the nephro-
pexies which had been done in his clinic.
I have never seen a recurrence fol-
lowing nephropexy. There are no doubt
countless thousands who are struggling
through life in almost continual pain unable
to earn a living or attend to their domestic
duties who could be restored to health and
usefulness by the surgical route.
In reviewing the literature on nephropexy
one must be impressed with the good results
which are generally reported. Lowsley of
Xew York in a large collection of cases re-
ports excellent results in more than ninety-
five per cent of his cases. Kelly and Hunner
report recurrences in less than five per cent,
and similar claims are made by other leading
authorities.
OPERATION
The methods employed for suspension of
the kidney vary considerably in the practice
of different operators. .Any type of operation
which permanently anchors the kidney in the
normal position and corrects the faulty drain-
age without injury to the organ is accept-
able. Some prefer to pass sutures through
the substance of the kidney while others ad-
vocate suturing the capsule alone. The ma-
December, 1929
SOUTHERN MEDICINE AND SURGERY
8SS
jority recommend partial decapsulation of the
posterior surface of the kidney to favor ad-
hesions between the kidney and the lumbar
muscles. In any type of operation it is of
prime importance that the fatty capsule be
stripped away cleanly from both poles of the
kidney and if any aberrant vessel is present
it should be ligated and incised.
author's method
In my own cases I deliver the kidney
through an oblique lumbar incision extending
from the costo-vertebral angle to a point about
one inch above the anterior superior iliac
spine. The fatty capsule is incised over the
outer border of the kidney and the kidney
freed from its attachments. The true cap-
sule is then incised along the outer border
of the corte.x to within one-half inch of each
pole. The capsule is then separated from
the kidney on each side for about one and
a half inches. A double chromic catgut su-
ture is then introduced into the reflected por-
tion of the capsule on the posterior surface
at the junction of the upper one-third and
lower two-thirds. The suture from this point
is whipped through the reflected capsule
downward along the posterior surface around
the lower pole to a point on a level with
its commencement on the anterior surface. A
large needle is then threaded on each end
of the suture and each needle carried through
the fascia above the 12th rib close to the spine.
The two ends are then drawn up until the
k'dney is brought into its normal position
and the two ends tied together. The false
capsule is then closed over the kidney and
anchored above the twelfth rib in like man-
ner. As an added precaution a catgut suture
is taken through the lowest portion of the
reflected capsule and anchored to the lumbar
fascia over it. Unless the kidney pelvis has
been opened for removal of a calculus or for
some other reason the incision is closed with-
out drainage.
The choice of an anesthetic is an import-
ant step in renal surgery. Recently I have
used spinal ane.ithesia routinely. It is pref-
erable to ether in this operation especially
because of the absence of vomiting and
rtriin'ng which nearly always follows the
administration of ether.
In connection with this pa[)er I wish to
report a group of twelve cases in which this
operation has been performed. All of this
series are female and all but one are married
women who have borne children. The aver-
age age is thirty-eight years, the oldest sixty-
five and the youngest twenty-six. The aver-
age duration of symptoms was six years, three
cases were complicated by renal calculi. Two
were removed by instruments before opera-
tion, one by pyelotomy. Two cases were
complicated by ureteral stricture. In all but
two cases the right kidney was involved.
Pyelotomy was performed in three cases. In
one case metastatic abscesses were opened and
drained.
The average number of hospital days after
operation was sixteen. The results in all of
these cases were good and up to the present
there has been no recurrence of symptoms in
any case. The first operation of this series
was performed four years ago and the last
patient was discharged from the hospital one
week ago.
I sincerely hope that I have not conveyed the
impression that I advocate surgical suspension
in every patient who has nephroptosis. On the
contrary, I reserve this procedure for select-
ed cases, only, in which after a thorough
study I am convinced that it offers a reason-
able promise of a permanent relief. The
earlier practice of performing surgical suspen-
sion, whenever a diagnosis of movable kidney
was made with no thought of the functional
capacity of the kidney or the degree of hy-
dronephrosis present, was no doubt responsi-
ble for the d'srepute in which this operation
was held a few years ago. With the aid of
better instruments and improved facilities
and technique which we have acquired in
recent years it is now nearly always possible
to determine in which cases the operation is
indicated and in which it is futile and dan-
gerous.
Occasionally in long standing cases of uni-
lateral nephroptosis in which hydronephrosis
has reached an extreme degree with marked
destruction of the kidney substance and low
renal function, if the opposite kidney is rea-
sonably sound, nephrectomy is advisable.
The point which I wish to emphasize in
closing is the necessity of a thorough examina-
tion of patients who give a history of long-
standing urinary symptoms. The success or
failure of the treatment in these cases depends
upon the degree of accuracy in reaching a
SOUTHERN MEDICINE AND SURGERY
December, 1929
correct diagnosis.
SUMMARY
In summarizing these remarks I wish to
emphasize the following points:
1. That nephroptosis is frequently the un-
derlying cause of the long train of gastro-
intestinal, neurological and other vague
symptoms.
2. That the history of these patients does
not necessarily include the classic symptom
Dietl's crisis.
3. That prolapse of the kidney because of
the gradual onset may reach an e.xtreme de-
gree without producing any definite urologi-
cal symptoms. For this reason a careful uro-
logical e.xamination should be more frequent-
ly employed when the diagnosis is not clear.
4. The estimation of the renal emptying
time is the best test of the degree of obstruc-
tion present and is especially helpful in neu-
rotic cases.
5. The employment of spinal anesthesia in
my judgment has reduced the danger in kid-
ney operations.
6. And lastly. The good results which are
generally obtained by kidney suspension
should recommend its more frequent employ-
ment in selected cases.
Acidosis and Disease*
H. H. Menzies, M.D., Hickory, X. C.
By acidosis is meant a condition in which
concentration of bicarbonate in the blood is
reduced below the normal level.' The deter-
mination of the plasma bicarbonate as a
criterion of the degree of acidosis usuajly met
with in disease was emphasized by Van
Slyke. The determination of the C02 ten-
sion in the alveolar air is a simpler method
and considered more accurate. By this
method I have reached the conclusions herein
stated. The basis of this e.xperiment is the
fact that the C02 tension in the blood leav-
ing the lungs and that of the alveolar air is
the same.
The simplest form of acidosis is seen where,
for various reasons, atmosphere containing
an excess of C02 is respired. This is cor-
rected by rapid respiration. Dyspnea is the
chief, and often the only symptom. Blood
changes here also take place and there is an
elimination by the kidneys of excess acids.
Thus acidosis is found in diseases of the lungs
such as pleurisy, pneumonia, emphysema and
asthma. All produce an increased C02 ten-
sion in the alveolar air and blood, and, be-
sides dyspnea, there is often cyanosis. ' In
lobar pneumonia there is a chlorine retention
with a decreased urinary output. In pneu-
monia there is also an abnormal production
of organic acid (lactic) and because of this
high acid content chlorine is retained. -
Uncompensated acidosis is produced when
the respiratory center for any reason fails to
respond to an increase of the molecular ratio
H2C03/NaHC03 and CH consequently be-
comes greater. The reverse is also true and,
if the CH is held constant, although there is
an actual increase of acid, there is compen-
sated acidosis.
The next form is the acidosis produced by
non-volatile acids. These may be the result
of changes in intestinal contents, may be
given as medicine, or produced by disease as
in diabetic ketosis and nephritis. The pres-
ence of the acids reduces the alkali reserve.
To this type belong those cases associated
with peptic ulcer, also those of pelvic infec-
tion. When the female organs are involved
there is, during the acute sta^e tympanitis,
and gastric distress and distention. These
may be the only symptoms for the relief of
which the patient seeks the advice of a phy-
sician. If allowed to continue, however, car-
diac embarrassment follows from pressure of
the d'stended stomach. The diseased parts
may give little or no pain. Coupled with
the above symptoms there is more or less
ac'dosis ranging from 15 to 30 degrees by
the alveolar air method. In chronic pelvic
infections there is found a low blood pressure
♦Presented to the Ninth (N. C.) District Medical Society, meeting at Hiclvory, September 26,
becember, 1020
SOUTHERN MEDICINE AND SURGERY
8S?
which is accompanied by one or all of the
above symptoms. In all of these cases alka-
line medication is indicated and because of
this a low CI content (hypochloremia) may
be produced and relief of this may be found
by intravenous administration of salt solu-
tion. When an alkali treatment has been
instituted there is a low chlorine intake — 2
gm. where 5 gm. is needed. Besides this
there is likely a depletion from vomiting or
diarrhea. While it may seem unwise to ad-
minister XaCl in these cases, this seems
actually to be the choice of action because
it insures an acid: base equilibrium. An over-
dose of salt solution is evidenced by burning
of the throat, chilly sensations, excessive
thirst and pyrexia. Where there is a low
plasma C02 concentration there is often
bypochloremia, but not always. This condi-
tion resembles a true alkalosis and is some-
times produced by over alkalinizing a patient
with acidosis.
This brings us to the consideration of alka-
losis, the symptoms of which are lassitude,
dizziness, distaste for food, irritability, nau-
sea and vomiting, aching in muscles, increase
of pulse rate, slow respiration, dry throat and
skin, mental stupor, even muscular twitching,
and tetany.'* One writer reports a case of
craving for salt. I have a similar case where,
from diet and aikalinization, chlorine became
depleted, and for the relief of gastric distress
and nausea the patient formed the habit of
taking salt. In this case HCl was absent
from the stomach contents, this not due to
vomiting. HCl administration soon relieved
her, raised the CI content and lowered the
C02 tension of the alveola air to 30 degrees.
Because of the action of calcium in prevent-
ing and relieving tetany, this element should
be included in alkaline treatment. But be-
cause an excess of sodium inhibits this action
sodium bicarbonate should not be included
in such medication. Calcium carbonate and
magnessium oxide should form a part of the
treatment, the former because of the pro-
longed neutralizing effect, the latter because
of this and also its laxative action. .Am-
monium chloride has been strongly advocated.
Yei the objection has been raised and justly
placed, that, granted the liver converts the
ammonia into neutral urea and allows the
chlorine to be freely absorbed, there being
a likelihood of a damaged liver in peptic ulcer
cases particularly, this extra burden on the
liver is not justified. However, this may be
obviated by allowing NaCI with ammonium
chloride. Thus ammonia and CaC12 may
be given judiciously either orally or intra-
venously, bearing in mind the likelihood of
a damaged liver.
Certain investigators'* have shown that
certain alkaline medications are soon con-
verted into acid, that, after the temporary
alkalinity, in 50 per cent of cases of sodium
bicarbonate administration the total and free
acid is increased. This is only true of so-
dium bicarbonate, however, and is another
reason for not using it as a neutralizer. It
is also true"* that calcium and ammonium
chloride tend to finally increase the HCl and
the total acid of the stomach. Granting this
and allowing for it in intensified alkaline
treatment with other medicaments, the chlo-
rine is lowered. Therefore, this retention of
chlorine is not harmful but advantageous,
not so, however, in pneumonia and a few
other respiratory conditions where the chlo-
rine content is high. These two considera-
tions remove the main objections to alkaline
medication. Therefore, bearing these in
mind, be free to use them as the indications
arise. In alkalosis, besides other symptoms,
there is that of "salt hunger" and another
almost as important is that of a tendency to
diarrhea and a tendency to elevation of blood
pressure. Frouin found lassitude, dullness,
muscular twitching, and weakness with pa-
ralysis of the posterior extremities and con-
vulsions in dogs kept on a salt-free diet.
Two brief cases may show this to satisfac-
tion. An old gentleman had been under alka-
line treatment for many years and he was on
a strict anti-acid diet. The chief complaint
was profuse, frequent watery stools. Finding
no gastric HCl I gave it and the diarrhea
stopped as from a huge dose of opium. No
ill effects were produced. The second was
a man who had for several months taken
alkaline treatment and subjected to a strict
salt-free diet. .-Ml at once the blood pressure
became dangerously high — 235 sys. I
changed his diet and gave him an acid pro-
ducer. In a few days the blood pressure was
down 50 [joints, and the pulse rate which had
been 140 drop[3ed to 70 — half of the original
rate. There was no other cause for the rapid
pulse or high blood pressure but alkalosis.
8S3
This was a pronounced alkalosis and was
increased by the salt-free diet.
REFERENCES
1. MacLeod, T., Physiology and Biochemistry.
SOUTHERN MEDICINE AND SURGERV December, 1920
. HoLTON, C, Arch. Int. Med., October, '26.
3. WiLDMAN, Arch. Int. Med., May, 1929.
1. Seegle, .irch. Int. Med., April, 1929.
Temporary Emotional Glycosuria*
WiNGATE M. Johnson, M.D., Winston-Salem, N. C.
Case 1. — White man, 64, entered Memo-
rial Hospital Nov. 11th, 1926, to have remov-
ed from his left shoulder a fatty tumor which
had become so large that it interfered with
wearing a coat. Aside from a moderate hy-
pertension of several years' standing, his past
history was uneventful. Repeated urinalyses
within the past ten years had shown an oc-
casional trace of albumin and a few hyaline
casts, but never sugar. Operating room ar-
rangements had been made for removal of
the tumor when the laboratory report on the
urine showed glucose present. There was
also a trace of albumin, but no acetone nor
diacetic acid. JNIost remarkable of all, the
specific gravity was 1002.
Although the operation was to have been
done under local anesthesia, the surgeon and
I deemed it advisable to postpone it until the
patient could be studied further. We found
that, although he seemed quite calm when he
entered the hospital, he had become greatly
agitated. His pulse was 160, his hands were
shaking and his speech tremulous. We as-
sured him that nothing would be done that
day, nor until he was in a satisfactory condi-
tion.
After a quiet day's rest, he presented an
entirely different picture. He was placid and
cheerful, his tremor was gone, and his pulse
had dropped to 76. His urinalysis showed
no sugar, and a sp. gr. of 1024. The tumor
was removed and he made an uneventful re-
covery. I have examined his urine several
times a year since then and no trace of sugar
has been found.
Case 2 was that of a boy eight years old
who was brought into Memorial Hospital on
Aug. 31st, 1929, for a tonsillectomy. The
admission specimen of urine was reported by
the interne to contain sugar 4 + . The spe-
cific gravity was 1020, there was no albumin,
and no acetone nor diacetic acid. Although
sugar had never been found before and al-
though there were no symptoms of diabetes,
it was decided to postpone operation. Ac-
cordingly they boy was sent home, and on
Sept. 2nd, 3rd and 4th I examined specimens
of urine which were absolutely negative. The
parents said that this boy — who was natur-
ally high-strung — had been very much ex-
cited over his operation for several days, and
had been almost hysterical on the morning
set for it.
Case 3 was that of a lady who had waited
until she was 67 years old to have an appen-
diceal abscess. On Sept. 15th, 1929, she was
sent into Memorial Hospital for operation.
She admitted an inexpressible dread of the
operation, though she realized its necessity.
The routine examination of the urine before
operation showed a considerable amount of
sugar, but in spite of this the appendix was
removed and the abscess drained, under
ethylene anesthesia. The postoperative spec-
imen twelve hours after operation was sugar-
free, and so were three more specimens on
successive days.
Case 4. — In examining a young lawyer for
life insurance, I found a moderate amount of
sugar in his urine, which was otherwise nega-
tive. There were no symptoms suggestive of
diabetes. Upon inquiry, I found that he was
just out of the court-room, where he had
been engaged in a hard-fought case which
had engrossed his attention for several days.
After the case had been decided and he had
resumed a more normal existence, no trace
of sugar could be found on repeated exam-
ination.
COMMENT
In each of these four cases, it is plain that
♦Presented to the Eighth (X. C.) District Medical Society, meeting at Winston-Salem, No-
vember S, 1929.
becember, 1929
SODtHEkl^ MEbtClKfe AMD StJftGEkY
m
strong emotion caused a tempwrary glycosu-
ria. In the first three cases, the emotion
was fright; in the fourth, the excitement of
keen competition.
This condition has been studied in detail
by Cannon, and described in his fascinating
book, "Bodily Changes in Pain, Fear, Hun-
ger and Rage." He found' that when cats
were excited by being bound, they invariably
eliminated sugar in the urine, but were sugar-
free next day. Four out of nine medical stu-
dents were found to have glycosuria after a
hard examinat'on, whereas only one of the
nine had it after an easier examination.'
Tigerstedt, of Helsingfors,- found glycosuria
in 10 of 13 students after a six-hour exam-
ination. Of 25 members of the Harvard foot-
ball squad examined immediately after the
final and most exciting contest of 1913, twelve
had sugar.' Five of these were substitutes
who did not play. The only spectator ex-
amined also had a marked glycosuria, which
was gone the next day.
In such strong emotions as fright and the
excitement of competition, it is well known
that the adrenal gland pours out an excess
of its secretion by way of preparing the body
for flight or fight. It is supposed by those
who know most about the ductless glands
that the internal secretions of the adrenals
and of the pancreas are antagonistic. Over-
activity of the adrenals may overcome the
inhibitory effect of the pancreatic secretion
upon the glycogen stored in the liver, and
thus liberate glucose m the blood as a readily
available fuel for conversion into bodily ac-
tivity. A large excess in the blood, of course,
will spill over through the kidneys into the
urine.
In distinguishing this temporary emotional
glycosuria from real diabetes, a blood sugar
reading would avail nothing, as it is the ex-
cess of sugar in the blood that causes its ap-
pearance in the urine. The differential diag-
nosis would have to rest upon both negative
and positive find.ngs; Negatively, upon the
absence of any history suggestive of diabetes,
the symptoms of which are too well known
to dwell upon; positively, upon the history
of a recent great emotion, such as fright,
anger, or the excitement of contest. The
specific gravity is apt to be lower in emo-
tional glycosuria than in true diabetes. The
final test is that of time; in emotional gly-
cosuria the sugar disapjjears within a few
hours after the crisis is passed.
While beside the mark, there are two pos-
sible sources of error in examining urine for
sugar which have given me trouble. One is
the use as a container of a bottle that has
held cough syrup or other sweetened sub-
stance, which was not thoroughly washed out.
The other, the careless preparation of Bene-
dict's solution.
Some months ago I found that, just after
getting a fresh bottle of Benedict's solution,
about a third of the specimens of urine ex-
amined gave the glucose reaction. Becom-
ing suspicious of this diabetic epidemic, I
tested at a hospital laboratory a specimen
that reacted positively to the office prepara-
tion of Benedict's solution, and found it neg-
ative. The original formula for Benedict's
solution called for:
Sodium (or potassium) citrate 17.3 gm.
Sodium carbonate (crystals) 200 gm.
Distilled water 700 c.c.
Dissolve with aid of heat — •
Copper sulphate crystals... 17.3 gm.
Distilled water _ 100 c.c.
_> '.:; t
This was later modified by substituting 100
gm. anhydrous sodium carbonate for the 200
gms. of the crystals. The clerk, however,
had made up the formula with 200 gms. of
the anhydrous carbonate. I am not chemist
enough to know what difference this made,
but I do know that it gave too high a per-
centage of positive glucose reactions.
REFERENCES
1. Cannon, W. B., "Bodily Changes in Pain, Hun-
Ker, Fear and Rape." D. Appleton. Second edition,
1920, pages 70-70.
2. Cannon, W. B., Personal Communication.
Knowledge of Syphilis in Infancy. — We are
still in the infancy of our knowledge concerning
syphiKs. We know the specific agent that deter-
mines the disease, but we have learned nothing of
its life cycle. We believe that the ultimate place of
any drug or agent in syphilotherapy will depend not
only on the results obtained in experimental rabbit
syphilis or, from the clinical standpoint, on the
rapidity of healing of a lesion and the disappearance
of spirochetes from an open sore, or on favorable
changes in the specific blood reactions and clinical
symptoms, but upon the fate of the patients, years
after ccs.salion of treatment and upon the ultimate
record; furnished by postmortem examinations. —
Coutt>, Am. J. oj Syplt., Oct.
i6b
SOtJtHERN MEMCINfi AND StftGEftV
December, lOiO
Post-Operative Distress
Harold Glascock, M.D., Raleigh, N. C.
Mary Elizabeth Clinic
I do not feel that post-operative distress
has received the study and investigation that
its importance deserves. The general im-
provement in operative methods has brought
some relief, but the literature does not show
that much scientific investigation has been
made along lines of postoperative distress.
The subject has failed to attract interest pos-
sibly because the amount of immediate dis-
tress does not always reflect the ultimate out-
come of the operation; however, if the first
five days after operation can be made univer-
sally more comfortable, surgery will be made
much more attractive as a therapeutic meas-
ure.
Most of the post-operative distress appears
to have its origin in the circulatory organs,
intestinal tract, liver and urinary tract. The
effect upon these organs is manifested by
shock, nausea and vomiting, gas distention,
increased flow of bile, albumin and casts, and
urinary retention.
Our attention was first attracted by the
fact that patients in labor take anesthetics
calmly as a rule with very slight ill after-
effects, as compared with the usual surgical
patient who takes the anesthetic with more
or less excitement and ill after-effects.
We have noticed for a long time that pa-
tients who were most excited and nervous,
and who ran a high pulse rate, seemed to
have more distress than the quiet resigned
patient with a slow pulse, and in checking
over the records we found the pulse rate in-
creased from 15 to 40 beats for several hours
previous to operation and concluded that this
mcrease in rate might be the source of cardiac
exhaustion. We then began to take blood
pressures immediately after operation, every
twenty minutes for three hours and then
every three hours for the next twelve hours,
and then at 9 a. m. and 4 p. m. the next four
days, and in checking over 50 cases of
laparotomy we found that in 45 there was a
drop in pressure after operation of from 5 to
30 points, indicating various degrees of shock,
the tendency being the higher the pre-oper-
ative pulse the greater the post-operative drop
in the blood pressure.
This drop in blood pressure was not ac-
companied by the recognized symptoms of
shock and thus we might speak of it as "sub-
shock" and did not seem to bear particularly
upon the ultimate outcome of the operation
as the blood pressure would return to its for-
mer height as a rule in from one to three or
four hours.
It was interesting to note that there was a
tendency for the patient to vomit at the point
of low blood pressure and of the SO cases
tabulated only 24 vomited, and 14 of the 24
did so at a fall in blood pressure of 20 mm.
and seven at the fall of 10-15 mm., and three
at a fall of 5 mm. There was also a tendency
for the blood pressure to remain stabilized
when there was a low pre-operative pulse.
This observation appears to indicate that
the fall in blood pressure has some relation
to nausea and vomiting. The drop in pres-
sure usually appears in the first six hours
after operation.
Of the seven patients given ether, all vom-
ited except two, while of 43 given novocain;
novocain and gas; or novocain, gas and a
very small quantity of ether, only nineteen
vomited. This would indicate quite conclu-
sively that novocain and gas given by an
experienced anesthetist markedly decreases
the post-operative distress.
We have attempted to support the circu-
lation in most of these cases by giving infu-
sion of digitalis in doses of one-half an ounce
to one ounce, sixteen and four hours before
operation. As yet this procedure has not
been worked out with any scientific data;
however, we think that it is a field of scien-
tific interest and that supportive treatment
might be based upon blood pressure, heart
rate, myocardial strength and circulatory re-
sponse to exercise, and if cardiac exhaustion
and a fall in blood pressure can be prevented,
nausea and vomiting may be lessened.
Of the 26 patients only 11 vomited as many
as four times and three of the 11 had aceto-
nuria.
The abdomen remained flat in 44 cases for
December, 10^9
SOtJtttEkN MfibtClMfi ANb strttGfikV
a five-day period, six were distended with gas
and all occurred in cases where the blood
pressure dropped from IS to 20 mm. Enemas
were given in 17 cases in the five-day period.
In 11 of these cases there was no distention
but an uncomfortable feeling in the abdomen.
Pituitrin was given in two cases.
We feel that a half-grain of calomel given
three and one-half hours before operation ac-
counts very much for the lack of distention,
in that it prevents fermentation, and the fact
that digitalis acts upon the non-striated mus-
cle keeps the intestinal muscle in a state of
normal tone and this has a tendency to pre-
vent distention.
Next, we find in analyzing the SO cases in
which the abdomen has been opened for va-
rious reasons, that the ages ran from 9 to SS
years, that 40 were acute and 10 were chronic
diseases, that ether alone was given seven
times and that novocain and gas were given
43 times. Thirty-six cases were of females
and 14 of males. The operating time ranged
from 18 to 83 minutes — average for the 50
cases iV/2 minutes. The point of highest
pulse during operation ranged from 80 to 140
and the highest temperatures following oper-
ation were 103 3/S in four cases and 103 in
two cases. The four highest blood pressures
on entrance were 140/9S; 140/7S; lSO/78
and 140/90. The four lowest pressures were
70/60; 90/64; 80/30 and 90/60.
It does not appear that age has any influ-
ence on vomiting; neither does the operating
time appear to have any particular influence.
In 24 cases there were changes in the urine
after operation, casts predominating as the
post-operative urinary effect; as a rule the
findings of albumin and casts were in cases
that showed a marked drop in blood pressure.
The average post-operative temperature was
101 3/5 and the average total days of fever
was eight.
The object of this study has been to dis-
cover the post-operative phenomena and find
a basis for further study rather than to arrive
at any definite conclusions.
Lessons From a Case in Which Ethylene Ex-
ploded, Killing Mother and Babe. — Ethylene 13
an exceedingly inflammable and e.xplosive gas when
mixed with oxygen or ether. Explosions may occur
in the use of this anesthetic through electrostatic
charges unless extraordinary precautions arc taken
to see that everything that has to do with anes-
thetic machine and surroundings is grounded. Even
then, there is a possibility of an explosion from
within the gas machine as it is at present built. It
would seem best for the present at least to return
to the use of nitrous oxide-oxygen gas and of ether
given by the drop method, no ether mixture being
allowed in the gas machines. A return to simpler
methods of anesthesia will enable the student to be
instructed better in general anesthesia and make it
possible for the surgeon to control anesthesia or at
least to keep in close touch with the anesthetist
during its administration. The open mask adminis-
tration of ether is best for analgesia and anesthesia
in the second stage of labor. In obstetrics compli-
cated methods of anesthesia should not be taught
to undergraduates or interns. The simple methods
will be more useful for deliveries in private homes
where about 60 per cent of deliveries still occur.-
Reuben Peterson, Am. J. Obs., Nov.
Factors in Reducing Maternal Mortalit\'.^
The maternal mortality rate of the United States is
not one of which we can be proud.
There are certain problems, not insurmountable,
which confront us for solution before this rate can
be materially reduced.
The most important factor is the provision of
suitable Institutions and of a well trained personnel
to provide proper care for mother.^ during preg-
nancy, labor and the puerperium.
It does not especially matter whether obstetric
care is urban or rural, at home or in the hospital,
as good care can be provided under all these con-
ditions.
It is also necessary for those now practicing ob-
stetrics to give a good account <if the "talent" en-
trusted to them.
It is most important to make proper and adequate
provision for the necessary and suitable training of
those who are to practice obstetrics in the future. —
Holmes et al, J A. M . A., Nov. 0.
862'
SOtJtHfekN MEDtCtt^fe AMD StJfeGfefeV
December, 1^2^
A Consideration of Infected Teeth*
Harry Bear, D.D.S., F.A.C.D., Richmond, Va.
Dean and Professor of Exodontia, Medical College of \'irginia, School of Dentistry
Any toolh may be found impacted, from a
central incisor to a third molar, in either
maxilla or in the mandible. This discussion
will deal with those impacted teeth most com-
monly met with — mandibular third molars,
maxillary third molars and maxillary cuspids.
ETIOLOGY
.A normal dentition is the usual expectancy
and any deviat on from this, whether of a
pre-natal or post-natal influence, may bring
about this anomaly. Advancing civilization
over centuries has brought an almost com-
plete change of our mode of living and diet
has played a large part. Likely there are
many other factors which cause impacted
teeth, but in the light of our present knowl-
edge we are not in a position to overcome
these sinister influences.
SYMPTOMS
There are various degrees and types of
impactions of the three teeth under considera-
tion, ranging from slight malalignment to
complete submergence by osseous and soft
tissues. Symptoms are local and general.
Local symptoms are those associated with
inflammation, pericoronal infection, involve-
ment of associated structures, pain, etc. A
few of the general symptoms may be the
result of foci of infection. Many other symp-
toms may be very indefinite and obscure.
Pain about the jaws and head may be traced
to impacted teeth; nervous disorders of one
form or another are often associated with
these impactions.
EXAMINATION
An examination of the patient should take
into cons. deration the general health as well
as other factors which may have a bearing
on the case. A careful clinical examination
should determine the relation of the impacted
tooth to adjacent teeth and the probable in-
volvement of associated structures. X-ray
examination is an indispensable aid. This
should be inclusive enough to localize the
impacted tooth, to observe the shape of the
crown and roots, relation to adjacent struc-
tures and the amount of osseous tissues in-
volved.
SURGICAL INTERFERENCE
It has often been said that a tooth should
be placed in normal alignment for usefulness
or it should be removed. This applies with
much force to the necessity for removal of
impacted teeth. It is true that we see many
patients of advanced age who have impacted
teeth from which they have never experienced
symptoms; but impacted teeth may be re-
sponsible for obscure symptoms. While it
may also be true that many of these patients
are operated upon without material benefit, it
does not follow that we can minimize the im-
portance of them without jeopardy in some
instances. There are also numerous cases
where good judgment would advise against
operation. These cases must be considered
individually and with all the facts in the
case at the disposal of the consultant.
Care must be exercised even in the proper
treatment of even simple types to prevent
complications which can so easily arise. The
removal of impacted teeth involves consider-
able application of the fundamental principles
of surgery. In acute cases where there is ex-
tensive involvement of the soft tissues it is
better to reduce the local inflammation be-
fore attempting surgical intervention.
The technic of removal is far from being
standardized, due partly to variation in the
types of impaction. There must be a mini-
mum of trauma and a minimum of disturb-
ance of adjacent tissues. It is presumed that
every facility for the observance of aseptic
surgery is employed.
CHOICE OF ANESTHETIC
The choice of the anesthetic to be em-
ployed should be determined by the exigen-
cies of the case and the selection should be
left to the operator in charge.
POST-OPERATIVE TREATMENT
Local treatment should consist of simple
♦Presented to the Fifth (N. C.) District Dental Society, meeting at Rocky ount, October 28, 1929,
December, 1929
SOWafeRN MEbtdl^rt: ANb SMGfiRV
non-traumatizing procedures. Advise the pa-
tient not to wash or rinse the mouth for at
least 12 hours. This may be more indehbly
impressed immediateh- after the operation has
been completed by not permitting the patient
to wash his mouth while in the office. E.x-
plain to him that the less the wound is dis-
turbed the less bleeding there will be, and
therefore the quicker and better the recovery.
In patients with a diminished flow of saliva
such wounds heal more readily, while it seems
that in cases of aptyalism the results are
even more favorable. As a rule, the external
application of ice compresses is ordered, not
only for the relief of pain, but also because
the cold tends to lessen edema and allays the
inflammation, thereby reducing the heat nec-
essary for the proliferation of bacteria.
The parts operated on should be rested as
far as practicable, while rest of the patient
is likewise conducive to hastening recovery.
Laxatives may be prescribed in order to fa-
cilitate proper elimination. A light diet, with
more than the normal amount of fluid intake,
is advised. For the relief of pain, sedatives
are prescribed. Milder remedies are, of
course, first used; if these do not suffice,
hypnotics may be necessary.
Regardless of the simplicity or gravity of
the operation, the patient should be seen on
the first, second or third day, if not for treat-
ment, at least for observation. If the wound
looks satisfactory, nothing is done to disturb
the healing process. The practice of contin-
ually disturbing a wound with instrumenta-
tion or with strong drugs cannot be too se-
verely condemned. Later, when satisfactory
healing is apparent, the patient may use a
mouthwash for its cleansing effect, and I
might add, for its psychic effect. As washes
are countless, there will be no difficulty in
appeasing the whims and fancies of the most
exacting dentist and fastidious patient.
Every case should receive the same atten-
tion in post-operative care as in the perform-
ance of the original operation itself — care
which is not to be relaxed until the operator
is satisfied and the patient discharged.
— 410 Professional Building.
Spinal Anesthesia
Jas. W. Davis, ALD., F.A.C.S., Statesville, N. C.
Davis Hospital
Fifteen years ago I considered spinal anes-
thesia dangerous. Now I know it to be one
of the safest and best anesthetics we have.
This change is due to great improvements in
the drugs and in the technic.
Practically all general anesthetics are use-
ful under certain conditions; but general an-
esthesia, no matter how well administered,
has certain disadvantages which spinal anes-
thesia does not have.
The great field for spinal anesthesia is in
operations below the diaphragm. For this
purpose .spinocain, administered by the Pitkin
technic, is a .safe anesthetic, controllable as to
effect, extent and duration. The anesthesia is
constant, the patient experiencing no pain
during the operation. Complications during
and after operation are few and usually of no
consequence.
For many years I have used local anesthe-
sia for many types of abdominal and other
operations. In appendicitis especially 1 have
found this exceedingly useful. It has, how-
ever, certain disadvantages in abdominal
operations. Pain and poor relaxation prevent
free exploration. There is often pain at the
time the appendix is lifted and adhesions
makes the appendix difficult to deliver pain-
lessly. With spinal anesthesia this pain is
eliminated entirely. Although, for certain
operations local anesthesia is the method of
choice, in nearly all operations below the dia-
phragm spinal anesthesia is the safest and
best we have. We get perfect relaxation
without difficulty and an operation with ex-
ploration can be done without delay and
without discomfort to the patient.
During the operation the intestines are
usually found contracted, instead of relaxed
and dilated with gas as is often the case
where a general anesthetic is used. This
contraction is a great help, as it often makes
§6btHERN IiiEbtCINE AM) StfeGfekV
fcecember, l92^
unnecessary the use of gauze packs to keep
the intestines out of the way. Gauze packs
tend to cause postoperative disturbance, espe-
cially gaseous distention of the intestines
from a paralytic ileus and intestinal adhe-
sions.
Among the many advantages of spinal an-
esthesia are:
1. It is the safest of all anesthetics.
2. There is complete anesthesia and abso-
lue freedom from pain. Only rarely is it nec-
essary to use an additional anesthetic to re-
inforce the spinal anesthetic.
3. Postoperative shock is almost entirely
eliminated.
4. There is no loss of consciousness and
the patient is relieved of the fear of going
to sleep.
5. Relaxation is usually perfect and this
eliminates the necessity of using gauze packs
in most abdominal operations. The intestines
are usually held out of the way of the opera-
tion without difficulty.
6. Spinal anesthesia is easily, quickly and
painlessly adminstered. Anesthesia is pro-
duced immediately and without delay.
7. There is no disturbance of the lungs,
liver, kidneys, heart or intestines. The cir-
culation is usually not affected. Any fall in
blood pressure is usually transitory and with-
out danger or harm to the patient provided
the head is kept lowered. By increasing the
Trendelenburg position cerebral anemia is
prevented and the blood pressure will usually
rise in a short wh le.
8. Postoperative disturbances and compli-
cations are lessened. There is usually little
if any nausea and vomiting. Tympanites and
ileus are almost entirely prevented, as is the
postoperative nausea, vomiting and gaseous
distention so common after ether anesthesia.
9. Spinal anesthesia may be given to indi-
viduals of almost any age. In this clinic we
have used it in patients whose ages ranged
from four to 88 years.
10. Nourishment may be taken earlier.
11. The anesthetic does not produce any
harmful changes in the body. There are no
after effects.
12. The anesthetic is controllable both as
to extent and duration.
13. Mortality is reduced.
The fact that this is the safest anesthetic
niay be impressed upon the patient's mind
and the patient can also be assured that there
will be freedom from pain and shock during
the operation. This will aid greatly in keep-
ing up the patient's spirits and avoiding that
great dread of an operation which is so de-
pressing and which sometimes has such a
profound influence toward preventing recov-
ery. There is no doubt but that a cheerful,
optimistic patient does better and is more
likely to recover than one who is frightened
and depressed and has forebodings of disas-
ter.
Xo anesthetic is without its dangers. Com-
plications may occur with any anesthetic,
however carefully administered. The risk is
least in spinal anesthesia. The administra-
tion of a spinal anesthetic demands a high
degree of skill and meticulous care as to every
detail. No one who is not qualified by train-
ing and experience should use this method.
There are certain conditions which demand
other anesthetics and there are contradindi-
cations to spinal anesthesia, but the contra-
indications are relatively few. .'\ny suppur-
ative condition in the region where the spinal
puncture is to be made, any inflammatory
disease of the spinal cord, or a brain or cord
tumor would be a contraindication to this
method. Recently I have operated upon a
man v\ho had, years ago, an injury of the
spinal cord in the region of the twelfth dorsal
vertebra producing almost a total paralysis
of the lower limbs. Since the accident the
patient has been unable to move about except
in a wheel chair. However, there was no loss
of sensation. Recently this patient had an
attack of appendicitis and a spinal anesthetic
worked beautifully in his case. There were
no after effects whatever.
We have used spinal anesthesia in this
clinic over a considerable period and in prac-
tically all types of operations below the dia-
phragm. Gall-bladder, stomach and kidney
operations, appendectomies, intestinal and
pelvic operations of all kinds, hysterectomies,
prostatectomies, hemorrhoidectomies and
operations upon the lower extremities includ-
ing the reduction of fractures and amputa-
tions are easily done under spinal anesthesia.
Pulmonary and respiratory infections and
tuberculosis are no longer necessarily contra-
indications to abdominal operations.
CONCLUSIONS
1. Spinal anesthesia properly given is the
December, 1020
SOUTHERN MEDICINE AND SURGERY
86S
safest and best anesthetic we have for oper-
ations below the diaphragm.
2. There are no general body or tissue dis-
turbances from the anesthetic itself.
3. It eliminates all pain from the opera-
tion.
4. Patients who are assured of these ad-
vantages go through an operation without the
fear and dread which is so common when a
general anesthetic is given.
5. Spinal anesthesia is a great factor in the
reduction of mortality in surgery.
REFERENCES
1. B.\BrotK, W. Wayne: Personal Communica-
tion.
2. LuNDY, John S.: Personal Communication.
i. Ev.ANS, Charles H.: Spinal .Anesthesia Prin-
ciples and Technic, N. Y.. Paul B. Hoeber. 1020.
4. Pitkin, G. P.: Journal of the Medical Society
of Neu' Jersey. July, 1027; British Journal of Anes-
thesia, October, 1028; Surgery, Gynecology and Ob-
stetrics, November. 1028; American Journal of Sur-
gcr\, December, 1028.
5. Matas, Rudolph: American Journal of Sur-
gery, December, 1028.
6. Russell, Thomas H.: American Journal of
Surgery, February, 1020.
7. Bunch, George H.: Southern Medicine and
Surgery, April, 1020.
S. BuscH, E.: Anesthesia of Lumbar Plexus.
venlralbl. f. Chir., 54:2701-2703, October 22, 1020.
0. Bii.r.ER, F.: Application in General and Uri-
nary Surfiery. Strasbourg-med., 85:333-338, Sep-
tember 5, 1027.
10. Paramore, R, H.: Eclampsia Treated with
Spinal Anesthesia, Case Report, Lancet 1:063, May
12, 1028.
11. AsTLEY, G. M.: Cesarean Section in Toxemias
of Pregnancy, Anesthesia &■ Analg., 7:125-128,
March-April. 1928.
12. Od.«;esco, S.: Cesarean Section, Rev. franc,
de gynec. et d'obst., 22:506-613. November, 1027.
13. SiSE, L. F.: Use of Ephedrin, 5. Clin. North
America, 8:105-200. February, 1028.
14. Pitkin, G. P., and McCormkk, F. C: Con-
trollable Spinal Anesthesia in Obstetrics, Surgery,
G\necolog\ & Obstetrics, 47:713-726, November,
lo'28,
15. SisE, L. F.: Spinal Anesthesia for Upper and
Liwer .Abdominal Operations. New England J.
Med., 100:50-66, July 12, 1028.
16. Davidson, A, H.: Spinal .Anesthesia in Ob-
stetrics and GvnecoloKV, Irish J. M. Sc, pp. 268-
272, June, 1Q28.
17. Studdiford, W. E.: Spinal .Anesthesia in
Treatment of Paralytic Ileus, Surg., Cynec. and Ob-
stetrics, 47:863-865,' December, 1028,
IS. Leveuf, J.: Spinal Influence on Intestinal
Peristalsis, Particularly in Intestinal Obstruction, 36:
1028-1020, August 12, 1Q2S.
10. IsENBERf.ER, R. M.: Investigation of Unto-
ward Reaction of Spinal Anesthesia, Proc. Staff
Meet., Mayo Clink. 2:204-207, October 10, 1028.
20. Sachs, E.: Practical Points on Spinal Anes-
thesia, Med. Welt., 1:530-542, May 14, 1027.
21. FoRr.UE, E., and Basset, .A.: Liege Med., 21:
1452-1481, October 21, 1029.
22. ScHATTENBURC, 0. L.: Safety Factors in Spi-
nal Anesthesia, California & West. Med., 29:397-401,
December, 1028.
23. \'iiLAViLLA, M.: Simple Method of Spinal
.Anesthesia, Rev. med. cubana. 30:1376-1370, No-
vember, 1028.
24. JuvARA, E.: Spinal .Anesthesia Technic, Bull,
et mem. Soc. nat . de chir., 54:624-631, May 5, 1028,
25. Holder. H. G.: Spinal .Anesthesia with Spe-
cial Reercncc to U.se of Ephedrine, California &
West. Med., 20:246-250. October, 1028.
26. MacNider, W. deB.: The Effect of General
.Anesthetics on Organism as a Whole, Surgery, Gyne-
co'ogy and Obstetrics, 40:403-405, 1025.
27. LuNDv, J. S.: Balanced .Anesthesia, Minn.
Med., 0:300-404, 1026.
28. LuNDY, J. S., and Osterberg, .A. E.: The
Chemical Basis of the Efficacy and Toxicity of the
Local .Anesthetics, Proc. Staff Meet., Mayo Clinic,
2:120-132, 1027.
20. McCuskev, C. F.: Untoward Reactions in
Regional and Local Anesthesia, Current Researches
in Anc'. and Anal., 7:248-252, 1028.
30. McKnight, R. B.: The Choice of an Anes-
thetic wHh Special Reference to Regional Anesthe-
sia, Jour. S. C. Med. A^sn., 24:00-05, 1028.
31. McKnight, R. B.: Studies in Spinal Anes-
thesia, Southern Medicine and Surgery, 00:745-749,
1028.
i2. Labat, Gaston: Regional Anesthesia, Phila-
delphia, W. B. Saunders Co., Vol. 1, 1022.
.M. KosTER, Harry, and Kasma.n, Louis P.:
Spinal .Anesthesia for the Head, Neck and Thorax;
its Relation to Respiratory Paralysis, Surgerv, Gy-
necology and Obstetrics, pp. 617-630, November,
1929.
Send Ciiiid to Family Doctor. — Children bav-
in'; any of the following symptoms should be sus-
pected of having bad tonsils and adenoids and
=hou!d be taken to the family doctor for an exam-
ination:
1. Repeated attacks of sore throat.
2. Stupid e.xprcssion and dullness.
3. Mouth hangs opon, chronic mouth bre.^ther.
4. Sleeps with mouth open.
5. Offensive breath.
6. Discharging nose.
7. Earache, discharging ear, deafness.
8. Takes cold easilv.
0. Has cnlarwd glands in the neck at lb':
cf the jaw.
10. Chrcnically underweight.
11. Poor chc-t development.
12. Joint and muscle jjains, commonly
"grcwing pains."
.All of these symptom; are not found in every
chid w!th diseased tonsils and adenoids, but several
of these symptoms indicate the need of an examina-
tion by the family physician. — Wisconsin State
Board of Health.
angle
ailed
Knew That
.A mudiial s'.udent was having a bard lime with a
written ex::m. One question was: "How would you
induce a copious perspiration?" He answered:
"Have the patient take a medical exam, in this col-
lege."
SOUTHERN MEDICINE AND SURGERY
December, 1929
Case Reports
Chronic Intestinal Obstruction of Four
Years' Duration, Due to Carcinoma
OF Transverse Colon — Resection
AND Anastomosis in Multiple
Stages — Recovery
James W. Gibbon, M.D., Charlotte, N. C.
A widow, 40, referred by Dr. J. M. Press-
ley, was admitted to the Presbyterian Hos-
pital June 17, 1929, complaining of recurrent
paroxysms of severe abdominal pain and
weakness. The first attack was four years
before admission. All attacks have been sim-
ilar, and during the four-year period she has
never been free from an attack longer than
three or four weeks. During the intervals
ihe feels fairly well. Recently she has been
growing steadily weaker, the attacks coming
at shorter intervals and being more severe.
M first, external heat in the form of hot
cloths, etc., relieved the pain but at present
morphine is necessary. The pain usually be-
rins in the pit of the epigastrium, extends
downward to a point around the umbilicus
ar.d then into the right side of the abdomen.
With the first attack four years ago, the pain
started in the right lower quadrant and ap-
pend c'tis was suspected. Onset of the pain
is sudden but sometimes gradual. The pain
is sharp and very severe during the paroxysm,
\ hc-n she walks the floor and groans. Pains
are definitely paroxysmal, each pain lasting
about five minutes, followed by a short pe-
riod of remission of five to ten minutes, and
then another pain, and so on. These recur-
ring pains may last six to twenty-four hours
before relief is obtained. After the attack
is over, she feels weak and there is soreness
all over the abdomen. Patient says pains are
1 ke labor pains. Attacks vary in severity
but otherwise are similar. When severe there
is nausea and occasionally vomits but vomit-
ing is unusual. With last attack vomited
once. With most of the attacks there is
much rumbling of gas in the abdomen. Ap-
pette has remained good. Weight 110 lbs.
Best weight ever 117 lbs. Bowels have been
costive for many years. Recently in habit
cf taking a dose of salts every other night.
There seems to her to be an association be-
tween the attacks of abdominal pain and con-
stipation. States that she must keep bowels
very loose, that is, moving three to four
times a day, or else continue to suffer at-
tacks of pain. Does not think that she has
had any diarrhea other than this. \o blood
o rmucus ever noticed in stools. Recently,
in spite of frequent purgatives, has not been
able to control the occurrence of pain as well
as formerly. In the past, a large movement
after a dose of salts gave lasting relief.
There is nothing of importance in the
medical history. In general, has always en-
ioyed comparatively good health. Marrisid,
husband dead, has three children living and
well and two dead.
On physical examination, there was noth-
ing of s'gnificance. She was pale and rather
devitalized-looking, but the nutrition was*
comparatively well preserved. There vvus no
evidence of much loss of weight. There was
some fever on admission which soon subsid-
ed. Blood pressure 100/^0. Abdomen show-
ed no distention, no palpable masses, no ten-
derness. !^ '
Laboratory findings: hgb. 60 per cent, r.
b. c. 3,610,000, leucocytes 13,400; urinalysis,
ncgat've; kidney functional test shows total
dye elimination in two hours, 65 per cent;
stool examination shows mucus, no blood, nn
parasites, no pus, no ova; barium enema and
x-ray picture give no information.
With a diagnosis of chronic intestinal ob-
struction probably in the small intestine, —
since the enema picture was negative for a
colonic lesion — operation was advised and
accepted.
Operation, June 24, 1929: .'\bdominal ex-
ploratory and cecostomy. Through a lower
m'dline incision, general abdominal exjjlora-
tion was made. Gall-bladder, both kidneys,
uterus, tubes and ovaries normal. The ap-
pendix was fibrosed and closely adherent to
the cecum. In the transverse colon just be-
low the pyloric portion of the stomach, there
was a hard contracting mass causing much
stenosis of the intestinal lumen. Xo gland-
ular enlargement could be felt in the mesen-
tery or along the spine, and no metastases
in the liver. Apparently, entirely a local
process. Having determined that the growth
December, 1020
SOUTHERN MEDICINE AND SURGERY
could be resected through an upper left ab-
dominal incision, the lower midline incision
was closed in layers and a cecostomy done
through a right McBurney incision. A rub-
ber tube was passed through the mesentery
to support the exteriorized cecum, the peri-
toneum sutured to the wall of the bowel, and
the rest of the incision closed in layers. Pa-
tient stood the operation well and reacted
cisions healed by first intention. After about
two weeks, it was impossible to keep the
tube in the intestine and drainage was then
allowed to take place into the dressings. This
had in the meantime changed from liquid to
solid and drainage was well cared for.
On July 14th patient given 700 c.c. whole
blood, preparatory to second stage of opera-
tion. Following this, blood showed hgb. 80
SPECIME.N REMOVED IN 1 HIS VASE
promptly.
A Mikulitz operation was not applicable
because of the clo.se pro.ximity of the growth
to the stomach.
On the third post-operative day the cecum
was opened, a Paul's tube inserted and fixed
with a purse-string suture. This took care
of drainage nicely for ten days and both in-
per cent, r. b. c. 4,.530,000, w. h. c. 8,900.
On July 21st patient given second !)lood
transfusion consisting of 620 c.c. whole blood.
Following this, blood picture showed hgb. 95
per cent, r. b. c. 5,560,000, w. b. c. 6,100.
.\t this time the patient seemed to be in splen-
did physical condition, having greatly im-
proved since the first operation, which was
SOUTHERN MEDICINE AND SURGERY
December, 1920
really just one of drainage.
Second Stage of Operation, July 2i, 1929:
Through an upper left rectus incision the
transverse colon containing the malignant
growth was delivered. Some changes had oc-
curred in the abdomen since the first op)era-
tion. There were omental adhesions on the
right side which made it a little difficult to
draw the mass in the colon through the left
incision. This incision was used in an effort
to get as far away as possible from the open
cccostomy. After these adhesions were sep-
arated, sufficient mobility of the transverse
colon was obtained to make resection and
anastomosis (end to end) easy. A ten-inch
segment of the intestine was resected with
a large part of the mesentery containing some
slightly enlarged glands. The abdomen was
closed without drainage.
The patient stood this operation much bet-
ter than the first one and reacted promptly.
Pathology: Scirrhus carcinoma of trans-
verse colon encircling entire lumen and caus-
ing marked degree of stenosis. The glands
in the mesentery showed no carcinomatous
infiltration but simply inflammatory changes
(H. P. Barret, Pathologist).
Th'rd Stage of Operation, August 17, 1929:
Patient made a nice convalescence following
the previous operation and today, under local
infiltration anesthesia and nitrous oxide, the
cecostomy was closed.
Prmary union followed and patient was
d scharged from the hospital on August 31st.
She was seen October 1st. The bowels were
regular, she has gained much weight and is
in good physical condition.
Remarks: One of the first interesting fea-
tures in this patient was the long history
(four years) of paro.xysmal attacks of ab-
dominal pain due to chronic intestinal ob-
struction from a scirrhus carcinoma of the
transverse colon. Next was the absence of
metastases or the extension of the growth
beyond the original site, even after a possible
duration of four years. The enlarged glands
found in the excised section of the mesen-
tery proved microscopically to be inflamma-
tory. The record of this patient is reported
because it presents so perfectly most of the
clnical and pathologic characteristics which
experience has taught us to associate with
carcinoma of the large intestine.
To summarize these briefly:
1. Carcinoma of the colon is of slow
growth.
2. Metastases occur unusually late, if at
all, in the course of the disease. Many fatal
cases coming to autopsy have conclusively
shown that death was due to infection, sep-
sis, abscess and perforation of the bowel wall,
all directly the result of chronic obstruction,
the malignant process being still local. It is
to the striking scantiness of the lymphatics
of the colon that the slow rate of growth
and late metastases in carcinoma of the colon
are due.
3. Chronic obstruction, upon which acute
obstruction is sometimes superimposed, is
universally present. This results invariably
in stas's and chronic infection in the bowel
wall above the growth. Edema, round cell
infiltration, sepsis in the bowel wall above
the growth, are commonly encountered. It
is this secondary infection which so frequent-
ly causes the neighboring lymphatic glands
to become enlarged and not necessarily an
extension of the malignant process.
4. It was largely to overcome this situa-
tion which, as can be readily seen, makes
primary resection and an anastomosis at one
sitf'n^ a very dangerous op)eration, that the
multiple stage operation was first devised.
Increasing experience has fully justified the
safety and usefulness of the multiple stage
operation in malignant disease of the colon.
The one stage resections carried a mortality
of 42 per cent, while the multiple stage has
reduced this to 12.5 per cent.
— 623 Professional Bldg.
Ciiii.undOD Diseases Frequently Overlooked. —
Of all the diseases of childhood, those most com-
monly overlooked are: acute and subacute otitis
media, acute pyelitis, empyema following pneumonia
in the infant, diphtheria, rickets, scurvy, tuberculosis
and cercbro-spinal meningitis, infantile paralysis,
endocarditis, intussusception, intestinal obstruction
and pylorospasm or pyloric stenosis. — McKibben, in
Jour. Florida Med. Assn., Nov.
Righteous Wrath
The doctor took one glance at his new patient.
"You'll have to call in another physician," said he.
".^m I as sick as all that?" gasped the patient.
"No, but you're the lawyer who cross-examined
me last March when I was called to give expert tes-
timony in a certain case. Now, my conscience won't
permit me to kill you, but I'm hanged if I want to
cure you, so goodby."
December, 192>
SOUTHERN MEDICINE AND SURGERY
SPECIAL
Idealism*
H. S. LoTT. M,D., Winston-Salcm, N. C.
Gentlemen, will you forgive me for pre-
senting to you this thought tonight? It is
the motive, you know, that counts in all that
we do, and the motive is my love for the high
ideals in professional service, and the thought
a product of a recent occurrence in our midst.
Having been the first Councillor for the
Eighth District, this district including ten
counties, none of which, at the time of this
appointment, were organized, working bodies
as local socieies; and having had the honor,
and the privilege of creating into organized
and working bodies eight of these counties,
all of which have been living ,and growing
throughout (he intervening years, and con-
tributing their quotas to the scientific and
financial life of the State organization; can
you wonder at the feeling of resentment
aroused at seeing our district meeting con-
verted into a commercial advertising agency?
Unfortunately, there are men in the profes-
sion who advertise; and, "it pays" (Johnny
Pool told us that, years ago), but the ques-
tion is, are these the best men, and the most
safe in their service to the patient? The
experience and observation of a life-time tells
us that they are not; the reason being a lack
of the quickened conscience in their service,
the most vital and essential feature of it all.
Again, it is unfortunate that the people
don't know; and the man who gives out a
wonderful account of glaring symptoms in
any feature of pathology gets the attention
of the people; in their innocent ignorance,
they feel that he is their best friend, because
he tells them all about it. That the public
should be warned of the dangers and the rav-
ages of tuberculosis, and of cancer and taught
that in early recognition lies their greatest
safety goes without the saying: and this is
fa'thfuUy done by all honest, intelligent phy-
sicians. And, herein lies the greatest ad-
vances in the service of today, made possible
by the present day perfection of surgical
toilet and technique; recognition, and re-
moval, of suspicious pathologic foci; and,
oftt'mes, this also means cure. But the glar-
in'; publicity, and the advertising by pic-
tures of people who "have been cured," when
we know that these patients may, or may
•Presented at the December meeting of the For-
syth County Medical Society, Winston-Salem, N. C.
not, have had in these foci, the distorted can-
cer cell of malignancy, savors only of com-
mercialism, and is beneath the dignity of
ideal professional men. Also, that the "day
of clinical diagnosis, is past;" is both untrue,
and disastrously misleading to the young men
of today; who are taught truly by the master
minds in teaching, that the clinical diagnosis,
carefully made, is the most important and
valuable one; making of each man a close
clinical observer; with always at his com-
mand the laboratory findings as an adjunct,
and of undoubted value as either confirma-
tory, or corrective evidence.
Lawson Tate, with the master mind that
has made his name immortal, told us long
ago, that the distorted, and suspicious cancer
cell is not always to be trusted as a diagnostic
criterion; he having, in many cases where it
was found, known the patient to go on in
years to the fullfillment of a long and whole-
some life; whereas, in other cases, in which
no distorted cell was found, the life was
spent in a very few years, depleted by the
ravages of progressive malignancy. That sus-
picious foci should be removed goes without
the saying; and, with present day toilet and
technique, is safe, and far better than the
doubt, but the patient should always be given
a frank and truthful opinion about it.
Unfortunately, today, there are many me-
chanical workmen, who always accept with-
out dispute the accounts of the cases they
see; whereas, the man with skill, wisdom and
conscience — the three vital essentials, goes
always into the clinical life and history of
the patient, before foriming a final opinion.
Shall we sacrifice the historic and sacred
prestige and dignity of our professional life,
with all of its uncertainties, to politics and
commercialism?
My thoughts, to night, are in idealism.
Is there a "Visionary Life?" Most assuredly
there is. What is life without a vision?
Thoughts are the soul of it,
Making the whole of it,
Blend into unison
Visions Divine,
("omel beck's the best of us.
Leaving the rest of us.
On! to the goal of this vision
Of thine.
—321 Nissen Building, . ,
870
♦ ■-
SOUTHERN MEDICINE AND SURGERY December, 1020
SOUTHERN MEDICINE AND SURGERY
Official Organ OF .( T'^'-S'^"' -^X-'li-al As.soein.ion of Iho Carolinas an.l Virc.inia
I Jlcdical Society of the State of North Carolina
James M. Northington, M.D., Editor
Department Editors
James K. Hall, M.D Richmond, Va. ._
Frank Howard Richardson, M.l) Black Mountain N C
W. M. RoBEY, D.D.S Charlotte. N. C -1_1
J. P. Matheson, M.D. V
H. L. Sloan, M.D i
C. N. Peeler, M.D
F. E. Motley, M.D
V. K. Hart. M.D. \
F. C. Smith, M.D )
The Barret Laboratories Charlotte N C
O. L. Miller, M.D
Human Behavior
- Pediatrics
Dentistry
> Charlotte, N. C.
Eye,
Hamilton W. McKay. M.D
Robert VV. McKay, M. D
J. D. MacR.m, M.D
J. D. M.AcR.^E, JR., M.D
Joseph A. Elliott, M.D
Paul H. Ringer, M.D
Geo. H. Bunch, M.D „__
Federick R. Taylor. M.D
Henry J. Langston, M.D
Chas. R. Robins, M.D
Olin B. Chamberlain, M.D
Various Authors
James .^dams Hayne, M.D
Gastonia, N. C
I Charlotte, N. C
\ .■Ksheville, N. C
Charlotte, N. C
.^sheville, N. C
— Columbia, S. C.
High Point, X. C
Danville, Va
-Richmond, Va. .
Diseases of the
Ear, Nose and Thr
Laboratories
..Orthopedic Surgery
Urology
Charleston, S. C...
Columbia, S. C. ..
Radiology
Dermat ology
.Internal Medicine
Surgery
Therapeutics
Obstetrics
Gynecology
Neuro'ogy
..Historic Medicine
Public Health
The Family Doctor
We are not persuaded that it is impossible at once
to bring the family doctor into much closer touch
with hospital work. If the salt of the profession is
losing its savour, we do not believe it is beyond the
wit of man to re-salt it. — Editorial, The Lancet,
London, Nov. 2, 1920.
Upon the shoulders of the family doctor ulti-
mately rests the hope of the prevention of diabetes
and of diabetic coma. Every opportunity therefore
must be afforded him to familiarize himself with
the modern treatment of diabetes. No diabetic
should be di.scharged from a hospital without dili-
gent effort made to return him to his own physician
or to insist, if he has none, that he find one near his
home. That clinic which seeks to treat its diabetics
exclusively without the assistance of the family phy-
sician will not only fail to get the best results with
its own patients, but we believe is derelict in its
duty to the broader aspects of medicine. The infor-
mation which accompanies a patient when discharged
from a hospital should not only protect that patient
from coma for life, but should be of such educational
value to the doctor that he can utilize it in the
treatment of other diabetics whom he does not feel
it necessary to send to a hospital. For every diabetic
day spent in a hospital, we suspect there must be a
hundred diabetic days lived in the home, and the
shepherds who watch these diabetic sheep as they
wander and stray through life are the doctors who
practice alone unaided by hospital facilities. — Edi-
torial. Ncii' England Medical Journal. Nov., 1020.
It was with no slight gratification it was
noted that, in a recent issue of one of the
oldest, best edited and most influential medi-
cal journals, the leading editorial bore the
caption. "The Renaissance of General Prac-
tice." Immediately there comes to mind The
Great Renaissance (rebirth) following on
The Dark .\ges. It is evident that The Lan-
cet regards our own age as rather dark for
the family doctor; but the very title chosen
shov/s a belief in a rebirth to better things,
wh'ch is at hand.
We have never feared for the family doc-
tor in the long run. Whatever fears we may
have had have been for sick folks, in case
the ascendency of the specialist brought mat-
ters to such a point that self-respecting gen-
eral practitioners, refusing longer to function
as mere emergency aids and distributing
agents, would tell patients who called them
at midnight to choose their own specialists
December, 1P20
SOUTHERN MEDICINE AND SURGERY
and apply to them for aid just as they would
if it were midday. Should this come to pass,
it would result in greater appreciation of the
family doctor and more considerate treatment
of him in every way; for it is impossible for
a patient to know what specialist to call, very
few specialists are good general doctors, and
besides, neither the great inconveniences nor
the small and uncertain fees appertaining to
such cases would fit in well with the ideas
of those little used to being discommoded
and much used to substantial rewards. The
family doctor may here well share a thought
with George Herbert:
"If goodness leade him not, yet wearinesse
May tosse him to my breast."
As Dr. ^NIcGehee so well points out in an-
other section of this issue, the family doctor
must be ever alert to protest and have his
patients protest against unwise and unjust
extension of activities of governmental agen-
c es in the practice of Medicine.
The same editorial in The Lancet uses
other words of a kind to which the readers
of this journal have grown familiar. "If the
f.nnily doctor is to look after nothing but
minor complaints, if he is to surrender his
patient during every illness, if he is to be
kept out of the activities of the public health
service .... then he stands little chance
of being a good doctor." But these things
will not be allowed. They can not come to
pass unless the family doctor surrenders.
But the family doctor can not practice the
IMedicine of his grandfather and have the
influence and income of his grandfather. He
must have a clean, comfortable office. He
h s senses in his investigations, and he must
examine his patients, record his findings,
work out his diagnoses and apply the best
that is known in treatment.
A few months ago we happened into a
drug-store in a distant town and noted on
entering that it was dirty to the point of
filthine.'^s. To the side of the entrance hung
I sign carrying the name of a well educated
doctor wh') has had a good hospital service
ard who has not been in practice five years.
The stairs leading to the offices evidently
h".d not been swept in weeks. When a doc-
tor moves into such surroundings he either
raises their tone to his or he sinks to theirs —
soon all are on one plane.
The status of the family doctor of the next
decade is assured; it is only for the next few
years that he is threatened with being caught
in the pinchers between a failure on the part
of the laity to realize that a good family
doctor is their best health dependence, on
the one hand, and an over magnification of
the importance of the specialist on the other.
Our objective is to take whatever steps may
be necessary to make it plain to society that
so long as there are families there must be
family doctors, and to see that the rewards
of the family doctor, in honors and in mate-
rial things, are commensurate with his labors
and his knowledge.
The Tri-State's Coming Meeting
Plans for the meeting of the Tri-State
Medical .Association of the Carolinas and
\Mrginia to be held in Charleston February
18-19, have been brought to the point where
it remains only for them to jell. We are
assured of an excellent meeting made up of
clinics and essays and addresses, about a
50:50 division.
Every effort has been made and will be
made to have subjects of wide and genuine
interest prepared and presented with the
greatest care. The time limit will be rigidly
adhered to. One essayist can not be given
more time than is his without taking unjustly
from another. Every writer who goes over
his manuscripts carefully with a view to de-
tecting superfluous words, phrases, clauses,
sentences and paragraphs, finds it possible to
cut down his first draft at least one-third
without hurting its meaning and with great
improvement of style and consequent appeal
to hearers and readers. The editor of the
f'riinsylvaii/a Medical Journal some months
ago reminded his readers that the man who
made t'cvo blades of grass grow where one had
grown before is honored, but that it is the
writer who makes one word serve where two
had been intended, who is awarded the palm.
.Sir Clifford .Allbutt, whose style is, to our
mind, even more charming than that of Sir
William Osier, always made seven drafts of
an article before submitting it for publica-
tion— and he was Regius Professor of Medi-
cine at Cambridge.
It is planned to hold the sessions in the
large assembly room of the Francis Marion
Hotel and — by the kind permission of the
872
SOUTHERN MEDICINE AND SURGERY
December, 1920
College — in an amphitheater of the Medical
College of the State of South Carolina.
A few distinguished medical personages
from outside our territory and many of our
own Fellowship will present a program which
all of us will enjoy and from which all of us
will profit.
The City of Charleston has a unique
charm. It will be peculiarly fitting that doc-
tors come attended by their ladies. No offi-
cial "entertainment" will be provided, but
then, we have been long convinced that nine-
tenths of us would hail with joy a Mussolini
who would abolish "entertaining."
In due time the Secretary will send out
copies of a preliminary program so that the
fellowship can know just how imperative it
is that they not miss the meeting, and just
what compelling reasons they can offer a good
medical friend why he can not afford to re-
main outside.
Dr. Victor C. Vaughan
On November the twenty-first, in the death
of Dr. Victor C. Vaughan, a blow was dealt
the medical world comparable, in our times
and in our minds, only to that given by the
death of Osier and a few others.
Dr. Vaughan's contributions to our knowl-
edge of the chemistry of vital processes have
been so great as to have given him the name,
Father of Bio-chemistry. .\nd since it may
well be that the word biochemistry is tauto-
logical, in that life is only a series of chemical
processes, only a brief pondering will disclose
how near to the gods was this man.
We Southerners like to claim our worthy
kin. The first three American generations
of this family of Vaughans lived in Hanover
County, Virginia; Dr. Vaughan's father lived
in Durham, North Carolina, removing while
a young man to Mt. Airy, Missouri, where
he married and brought up his family.
At jNIount Pleasant College, in Missouri,
student Victor Vaughan made a brilliant
record in the classics, but contact with chem-
icals and test-tubes awakened interests which
decided him on his life work. He went to
Ann .Arbor, because the University of Michi-
gan had the largest and best equipped chemi-
cal laboratory in the country — the second
best in the world. An interesting and aston-
ishing feature of his education is that he
learned microscopy from the engineer who
ran the accommodation train from Jackson
to Detroit.
He lost an opportunity to become profes-
sor of histology at the University of Michi-
gan by declining to make a profession of
religious faith, replying, "The position con-
cerns the teaching of science and has no re-
lation to religious belief." Later he was dean
of the department of medicine for thirty
years, and in these years the school became
a leader in the medical education of the coun-
try. He served in the Spanish-.*\merican
War and was a member of the Typhoid Com-
mission which applied the lessons learned by
the most disastrous experience of that war.
He promptly entered the World War and was
placed in charge of the Department of Com-
municable Diseases. We have a very lively
recollection of sitting on a stage with Dr.
Vaughan at the awarding of diplomas to a
class of medical graduates. He and many
others of us were in uniform. He spoke
briefly to the graduates about how to be good
doctors and how to be good patriots, and
warned against possible disillusionment, when
we came marching home. But there was a
genial smile on his face when he told us in
gentle tones that doctors should volunteer
their services, despite the fact that when they
come back and put in applications for loans
to buy Fords to resume practice, the men
who staid at home and absorbed the vacated
practices, would come to the meetings of the
Boards of Directors in Packards and Cadil-
lacs and likely vote that the loans be denied.
Dr. Vaughan had been president of the
.'\merican Medical Association, of the Ameri-
can .Association of Physicians, and of scores
of bodies in the fundamental sciences. He
wrote voluminously on subjects pertaining
particularly to chemistry and to medical ed-
ucation, and considerably on things in gen-
eral. He touched nothing that he did not
adorn. His ".A Doctor's Memories" is a
charming bit of autobiography. We recall a
passage dealing with his seeing a sign on the
front of a bank in a strange town giving the
name of a Vaughan as president. Being in
no hurry he decided to go in and speak with
this [xissible cousin. But the Doctor said "he
was no cousin: he was rich, he was hand-
some, and he didn't invite me to dinner."
When Dr. Vaughan began his scientific ca-
reer thousands of surgeons still regarded anti-'
December, 1929
SOtJtHERN MEDlClNfi AND StJftGERY
873
septic surgery as a fad (aseptic surgery was
not to be heard of for some time), spontane-
ous generation still had many adherents in
high places, and the acceptance of micro-
organisms as even possible causes of disease
was by no means general. His fundamental
equipment, his sound broad training, his
greatness of heart, and his craving to know
made it inevitable that he would promptly
range himself on the side of demonstrable
fact and that he would joyously follow in
this path to the end.
Few there be to whom Medicine in Amer-
ica owes as much as to Dr. Victor Vaughan.
The Cost of Medical Care
Few subjects are being more agitated now
than that of the cost of being sick. There
is a Committee on The Cost of Medical Care
with headquarters in Washington, its chair-
man a member of The President's Cabinet,
and with a membership made up of men of
the k ind of Barker of Baltimore, Horsley of
Richmond, Wilson of Charleston, and Ran-
kin of Charlotte, to speak for the profession;
and economists, bankers, philanthropists, la-
bor officials, ct al. We have a report of "The
First Two Years' Work" of this Committee.
That two years has been taken for laying
the groundwork and outlining procedure in
a job of such magnitude likely should not be
wondered at.
This agitation .somehow failed to infect us.
We have never known of a case in wh.ch a
sick man, woman or child lost life or limb
because of lack of funds. Some 20 or 25
years ago somebody said that millionaires and
paupers were the only ones who could obtain
com[)etent medical care in this country; and
parrots have been repeating it ever since.
Circumspicc — look around. How many cases
did you ever know of in which any one suf-
fered for lack of medical care because he or
she could not pay for it? The kind of con-
sultants and sijecialists with whom we have
been surrounded have always been entirely
willing to give their best services and accept
any payment recommended by family physi-
cians, and in probably a fifth of the cases
received nothing at all. Of course the vast
majority of our population can not pay at the
rate of the highest fees of which there is any
record. Neither can the average man who
must go into court pay an attorney such a
fee as that which Rufus Choate collected
from the New York Central Railroad and
on which he retired — $800,000. But the
point is they are not e.xpected to pay the
highest fees, and provision is made by doctors
themselves by which capable services are ren-
dered, with fewer exceptions than can be
found as to any other necessity.
There is much confusion of terms in this
discussion. All the expenses of an illness are
commonly designated "doctors' bills,'' where-
as commonly hospital bills and nurses' bills
generally make up from 50 to 90 per cent
of the total. Moreover, in a great proportion
of the cases all other bills incurred during an
illness are paid, but the doctor never gets a
cent. And some of the most vigorous and
vociferous protesters that doctors' fees are
outrageously high never pay a doctor in any-
thing but abuse. It is well known that the
last man we forgive is the man we have in-
jured most.
Of course there are some doctors who
charge outrageous fees. There was one Ju-
das among The Twelve. Only recently we
learned of a surgeon, not a thousand miles
away, of a very mediocre mental ecjuipment
and no exceptional training, charging $1,800
for services for which $180 would have been
ample remuneration, and, in another case,
charging $1,000 for a very trifling service
over a very short time. In our opinion a
thug who hides behind a tree with a section
of lead pipe in his hand and strikes down the
lirst passer-by and robs him of his wallet is
a gentleman by comparison; for he violates
no confidence and he runs considerable risk
of having to atone for his robber}'. Such
doctors, tew though they be, reflect hurtfully
on the whole profession and most particular-
ly on the honest men in the same city. Fam-
ily doctors should advise their patients to
refuse to pay outrageous charges for si>ecial
services and denounce the would-be robber
to his medical society and in the newspai:)ers.
In an interview carried by The Baltimore
News, November 15th, Dr. Robert L. Keyser
speaks his mind entertainingly and truth-
fully.
"For every man in Baltimore who holds
out for a high fee, there are ten men just as
reliable who will reduce their fee to an
amount the i)atient can afford.
"And yet there is complaining every day
874
SOUTHERN MEDICINE AND SURGERY
December, 1929
on the part of patients. Do you want to
know why?
"A man comes to me with an ill wife. I
tell him she must have an operation. He
wants the best surgeon. I get him the best.
He tells me he has a small salary, and I tell
the surgeon.
"But what does the man do but go to the
hospital and put on airs like a French mon-
key, put his wife in a great big room, order
two special nurses by night and two by day,
fill the room with flowers and keep the lady
there till she feels inclined to move.
"I tell him his wife would have the same
chance of recovery in a ward, or in a small
room with one nurse, and that she doesn't
need to stay more than a week or two at the
outside. He hits the ceiling. 'Oh Doctor,'
he says, 'you forget my wife must have the
best. Look at Mrs. Smith, she wouldn't
think of having one nurse,' and so on ad
infinitum.
"Finally the bills come in. The hospital
bills are enormous of course — he has been
getting millionair eservice. The more im-
portant surgeon's bill is far smaller in pro-
portion, and conies later.
"When it arrives you can hear him holler
a block away. 'Outragel The last strawl'
"If there is any wholesale friction between
the man of average means and skilled medi-
cine, I have seen enough of both to know
where the fault lies. And in 90 per cent of
the cases, I will wager it doesn't lie with the
doctors."
A great deal of this outcry about doctors'
fees comes from men who have grown enor-
mously wealthy by questionably means and
who would make atonement — by giving it
back? Not much; but by putting up one
dollar and squeezing five out of doctors, they
would promote another enterprise at the ex-
pense of others and get their names in the
papers and on marble as philanthropists. One
might reasonably ask why not pay out more
money in honest wages and let the wage-
earner pay the doctor of his choice and the
hospital of his choice, rather than accumu-
late vast sums and then give a small portion
back as a charity?
Do hospitals charge too much? A good
hotel charges as much for a room without
meals as a good hospital does for a room and
meals; the hospital gives attention night and
day by educated nurses free, while all the
attention to be had in a hotel is from a negro
boy and that at considerable expense. And
who knows of any hospitals making money?
The way to keep your patients from paying
out large sums to hospitals is to keep them
out of hospitals unless there is a real, plainly-
discernible-to-the-naked-eye reason for put-
ting them in, and then getting them out just
as soon as you safely can.
Xo, we cannot get worked up over the
amount of suffering and the number of deaths
due to the inability of the average man to
get competent medical care. The lack is too
small. We know of no other great necessity
which is supplied the average man in such
abundance. To our way of seeing things there
is far more reason to appoint a Committee
to investigate and report on: why the pota-
toes a farmer has to sell for SO cents a bushel
cost the man who eats them 75 cents a peck;
why when wheat goes back to the price at
which it sold when a loaf of bread sold for
a nickel, for a smaller and poorer loaf a dime
is exacted; why bananas and apples are five
cents each on the fruit stands no matter what
the variation in production; why our courts
are allowed to be run by the lawyers for the
lawyers.
The gap between the feeding, the housing,
the clothing and the education, available to
the rich on the one hand, and the average
man on the other, is 75 per cent in excess of
the saine as applies to competent medical ser-
vice available.
Even salvation, which has been said to be
free, is today not so readily available to the
average man as competent Medical Care.
For Simplicity and Decency
One of our fixed ideas is that many of our
joys and most of our sorrows are to be shared
only with those enclosed by a small circle.
In this spirit we are glad of the opportunity
to pass on to our readers a fine thought of
Halifax Jones, of the Chapel Hill Weekly:
Simplicity in funerals ought to be universal,
but it is so unusual that the simplicity of
Clcmenceau's was played up as the main news
element in the reports of the great man's death
It seems to me that the display in connection
with marriages and funerals constitutes the
world's most serious affront to decency and
good taste. I admire many things about Clem-
December. 1020
SOUTHERN MEDICINE AND SURGERY
87S
enceau, but nothing more than the directions he
t;ave for his burial. Particularly was I pleased
by what 1 read of the exclusion of the news
photoeriiphers from the scene. For once this
impudent tribe seems to have been successfully
thwarted. The despatches say they were kept
away from the burial by the police. Consider-
in? their customary insensitiveness and ferocity,
it surprise? me that anything less than a ma-
chine 'jun battalion was able to hold them in
check.
Added words could only mar this perfect
picture.
We would only remind doctors that i( is
within their power, more than in that of mem-
jjers of any other group, to prevent this form
of vulgar display, which oftentimes leaves
surviving dependents destitute.
The wise use of our influence with our
wealthy patients would induce many of them
to do as Clemenceau did, set the poor a whole-
some example of dignity and simplicity,
which would be helpful esthetically and eco-
nomically to everyone except the undertaker
— and he has demonstrated his ability and
willingness to look out for himself.
of the mistake is evident. x'Vmerican inventive
genius has failed to produce a leakless suit-
case.— Halifax Jones, in Chapel Hill Weekly.
Smokers all over the world pay the tobacco
(axes that are collected in Xorth Carolina.
These taxes are so colossal that this state
ranks second — or is it third? — in internal
revenue payments to the national govern-
ment. Kvery now and then some idiot pre-
sents this fact as evidence of the state's
v.e:dlh. Xow I read of a proposal to reduce
the lax on cigarettes and other forms of
minufactured tobacco. I am heartily in fa-
\-or of the reduction if for no other reason
thin lh;it it will put an end to the asinine
assunijitions growing out of the sale of m'l-
lious of di)llars of tobacco tax stamps in
Dili ham, Winstun-.Salem and Reidsvilie. —
Halifax Jones, in Chapel Hill Wrrkly.
\ dispatch from Washington say.; that a
leaking suit-case, discovered in the railway
ilation, led to the indictment of Representa-
tive Dciiison of Illinois for violation of the
[)rohii)ition law. IJenison is described as a
"consistent dry, who voted for the eighteenth
amendment, the X'olstead act, and the Jones
l.iw." .Asked for a statement about the in-
dictmeiii, the unlucky congressman says that
it "resulted from a mistake." The nature
As Christinas Presents for your
Doctor Friends, order 1930 Sub-
scriptions for SOUTHERN MEDI-
CINE & SURGERY.
1 Subscription $ 2.50
5 Subscriptions 10.00
Special Christmas card to each
address with name of Donor. In
cases where journal is ordered sent
to a doctor who is receiving it
already, the doctor will be sent
card and the remittance returned
lo sender.
What could be as appropriate for
an old college chum, a retired
doctor friend, a new doctor in your
community?
\ir\MI\ \ MA i:s OF MAW FOODS
i'i5i;si;\ii:n i\ m:\v pi ijlicatio.n
riie KiMTaii of Home Fcoiioniies of llie
I'. S. I>e|i:ir'lineiil of \(|[-iculliirr lia.s i.s.su('il
a new |)iil)llciiliori on vilanilii.s, Circiihir S'l-
C. "XKaniliiN in Food Mii(er'ial.s." I'hr circii-
hir- ina.\ he ohlalncd free from (he Olfice of
Iriforiiiiidoii, Deparlment of .Vjiriciilliire,
\\aslilii(|(iiii. I>. C, a.s loii(| a.s (here i.s a siip-
|)l.\- iiMillahle for free (lis(rihii(ioii. A (ahle
Ml (he circular (|ive.s (he occurrence of vi(a-
mlii.>s A. i:. and V. In Kill fooil.sdin's. which
(he hiireaii helieves is (he iiiosi coiii|ireheii-
.sivi' ever compilpil. \o( only i.s (he vKamlii
coiiten( of (he raw fresh fooil O'ven, hii( in
many ea.ses AKamiii values are repord'd for
juice, |iiil|i. (|''cen leaves, hieaehed leaxfs,
iMid odici' sepaialc pads of (he same food.
The clfecl of cookiiiji. camiiiiji, (leh.Mlradoii,
sloraije. and oilier processes on (he slahilKy
of vKamiiis is al.so iiiilicaled in some meas-
ure hy (he data prcseiit<Ml.
Ill aiidldoii lo the iiiformadoii i|i\('ii In
lliis (ahiilar s(:i(ciiieii(. (he circular ileiiiics
llic \ilamiiis lliiis far Kiiowii and slalcs (he
fuiicdoii of each In (he did. For (he hcnclK
of diiise \vjsliiii(| (o coiisiiK orijiiiial sources
nil \i(amiii occurrence and on research (ecli-
iiie, die circular jiixcs 'i(i() references lo sei-
eiidlic lilcradire, dadiiji hack lo (he lime
\ilaniiiis were discovered 211 years a||o.
8?6
souTHEkN Medicine and stRGERY
December, 19i9
DEPARTMENTS
HUMAN BEHAVIOR
James K. Hall, M.D., Editor
Richmond. Va.
The Great Psychiatric Light House
The most impressive and significant event
in the Mental Hygiene movement in the
world took place in New York City on De-
cember the third and fourth when the New
York State Psychiatric Institute and Hospital
was dedicated. The building, magnificent in
its location on the bank of the great Hudson
River, stands at the end of West 168th
Street, near to the new Neurological Institute,
and hard by the great Presbyterian Hospital,
and it constitutes an integral and a large part
of the Medical Department of Columbia
University. The structure illustrates in inde-
structibility, in spaciousness, in equipment,
and in purpose the last word in effort to pro-
vide all those facilities required in making a
thorough study of mental diseases, in the
treatment of mental disorders, in making pos-
sible researches, individual and social, physi-
cal and psychical, into every conceivable
cause that could underlie mental maladjust-
ment. Situated on the steeply sloping bank
of the river, the front door of the building is
on the tenth floor at the end of 168th Street,
and ten floors below on the opposite side, is
another entrance from Riverside Drive. One
of the speakers referred to the structure, out-
topping in height all the other buildings in
the medical center, as symbolizing the posi-
tion that psychiatry has so recently attained
in the domain of medicine.
The exercises were carried out under the
auspices of the New York State Department
of Mental Hygiene, the able and alert com-
missioner of which is Dr. Frederick W. Par-
sons, once the superintendent of an up-state
State Hospital. The Director of the Insti-
tute is Dr. George H. Kirby, who is likewise
Professor of Psychiatry in Columbia Univer-
sity. On the third of December addresses,
brief, concise, each with a definite and sjie-
cific message, were made by Dr. Kirby, who
presided; by Commissioner Parsons; by Dr.
William Darrach, the Dean of Columbia's
Medical School; by Dr. Walter W. Palmer,
of the Chair of Medicine; by Dr. Frederick
Tilney, of the Neurological Institute; by Dr.
Nicholas M. Butler, President of Columbia,
and by the Lieutenant-Governor of the State
of New York, Herbert H. Lehman. In the
afternoon of that day greetings and congrat-
ulations were spoken by Dr. Adolph Meyer,
a director of the Psychiatric Institute in the
old days when it was a part of the State
Hospital on Ward's Island; by Professor
Eugen Bleuler, of the University of Zurich,
who is so well known to us through his text-
book on Psychiatry. He is no longer a young
man, but there was quickness in his move-
ment and in his speech — all in English — that
carried no suggestion of age. Professor Ed-
ward A. Strecker, of the Chair of Psychiatry
in the Jefferson Medical College, is exceed-
ingly pleasing in appearance, in manner and
in speech. Professor Henri Claude came all
the way from Paris to pay his tribute — so
gracefully in French that I could almost un-
derstand him.
On the second day messages were deliver-
ed by Professor Ernst Kretschmer, of the
University of Marburg; by Dr. Ernest Jones,
the psychoanalyst, of London; by Dr. Wil-
liam F. Lorenz, of the University of Wiscon-
sin, and by Dr. David K. Henderson, of the
University of Glasgow. Dr. William A.
White was kept away by a court involvement
in California, to the great regret of all of us.
No other speaks more lucidly and engagingly.
Kretschmer is the perfect morphological rep-
resentative of our war-time conception of the
typical young Teuton — the embodiment of
physical health, good training, and absolute
self-assurance. I could scarcely follow his
thesis in German but those who fully com-
prehended what he had to say assured me
that the dogmatism of his views was in keep-
ing with his appearance of self-satisfaction.
Most of us know Ernest Jones through his
writings on psychoanalysis. He spoke per-
suasively about the contributions of that phil-
osophy to psychiatry. Lorenz spoke in detail
of some recent therapeutic measure adopted
by him in an effort to arouse stuporous cata-
tonic patients. Henderson, of Glasgow, pre-
sented an exceedingly interesting paper deal-
ing with the relationship betwixt mental ab
normality and criminal behavior. The con-
cluding addresses in the last afternoon were
by Dr. Macfie Campbell, of the Harvard
Medical School; by Professor Wajther SpieJ-
December, 1929
SOtJTHERN MEDICINE AND StRGEftV
m
meyer, of the University of Munich: by Pro-
fessor Franklin G. Ebaugh, of the University
of Colorado, and by Professor Constantin
Von Economo, of the Chair of Neurology and
Psychiatry in the University of Vienna. I
had to tell Dr. Macfie Campbell, who talked
about psychiatry and the medical student,
that previously I had been unable to decide
whether he simply had more sense than any
one else or whether he was only better gifted
in verbalizing and phrasing what he knew,
but that I had come to the conclusion that
in both respects he stood rather alone. He
and Henderson, of Glasgow, are certainly
twin brothers in such ability. They both
illustrate very well the fact that the Scotch-
man uses his head to think with, and not for
purposes of evasion. Professor Spielmeyer
said that he had not previously spoken in
English, but his language was easily under-
stood, and he presented his thesis without
apparent difficulty. Dr. Ebaugh occupies the
Chair of Psychiatry in the University of Col-
orado, and his paper constituted a review of
the recognition of the increasing importance
of phychiatry as a branch of medicine as
manifested by college curricula. Dr. Von
Economo is a captivating-looking Italian. He
made use only of the English language but
I was told that he could verbalize just as
easily and as gracefully in Italian, French,
and German. It is easy to believe that he is
as intimately acquainted with the anatomy
of the nervous system, gross and microscopic,
as the average man is with the pockets in
his clothes. He it was who identified sleep-
ing sickness along about 1916 or 1917 as a
specific disease entity, and not a sequel of
influenza.
Dr. Adolph Meyer, of the Department of
Psychiatry in Johns Hopkins University, was
constantly referred to as the dean of Ameri-
can psychiatry. He was the Director of the
Psychiatric Institute in the old days and his
address was largely a review of the progress
that had been made in the conception and
the treatment of mental diseases in this coun-
try since he began his work with us in 1890-
odd. He still occupies leadership in accurate
ipientific knowledge of neurology and psych-
iatry, and the inlluence of his work can
scarcely be estimated. He has created his
own jisychiatric immortality.
Within the present generation North Caro-
lina has made no mean contribution to the
advancement of medical knowledge. At the
moment I am impressed by William de B.
MacNider's enlargement of the knowledge of
the function of the kidney; by James B. Mur-
phy's work in malignant disease; by Watson
S. Rankin's activities in the domain of public
health work; by the quiet and resourceful
helpfulness of Clarence A. Shore in the lab-
oratory of the North Carolina State Board
of Health to all the doctors in that state; by
John A. Ferrell's genius in the International
Health Board, and by the patient, long-con-
tinuing, accurate, and fundamental researches
of George H. Kirby in the structural and
other factors underlying nervous and mental
diseases. Year after year in the quietness of
a small laboratory he has led the way to a
deeper and a more philosophic understanding
of the meaning of disorders of the mind, and
today, in the new splendid Institute in which
he presides as director, he occupies the most
exalted and the most influential position in
psychiatry in America, and perhaps in the
entire world.
The new Institute is supplied with all the
facilities for research into the condition of
the physical situation of the mentally sick
patient as well as with all those agencies for
psychiatric, psychologic, and sociologic inves-
tigation. Mental maladjustment may arise
as easily out of an unwholesome situation
which surrounds the individual as out of a
bad condition within the patient. In the
Institute every phase of the individual's life
will be studied. And in the building there
are beds for 200 patients, and a large out-
patient service will be as attentively attended
to as the patients within the walls. In the
Institute there are also auditoriums and class
rooms, and the medical students of Columbia
will be taught psychiatry in dignified, im-
pressive, and thoroughgoing fashion; There
is certainly no such other institution in .Amer-
ica, nor perhaps in the world. A great light
has been set upon the hill, and that George
H. Kirby will keep it burning bright none of
us who knows him doubts at all.
The Curse of Hopelessness
Worse even, it seems to me, than a grave
medical condition is a bad state of mind
with reference to the situation. The patient
who gives way to despair often dies; perhaps
SOUTHERN MEDICINE AND SURGERY
December, 102Q
such a state of mind deserves death because
it inv'.tes death. And restoration to good
health often comes as a reward for the con-
tinued courage displayed. "Fight on" must
be the motto of every one who hopes to be
able to continue to buffet the waves of exist-
ence. .And if it be important for the indi-
v'dual to maintain an attitude of courage
with reference to h!s own sickness it is per-
haps even as consequential for the medical
man to live in an atmosphere of hope both
with reference to the patient's condition and
with reference to his own resources and ef-
forts.
I am not yet an old man, yet I remember
well when tuberculosis was regarded as a fatal
disease. And a generation ago consumption
was usually fatal. The infection terminated
in the death of the individual for reasons
m')rc thin one. The diagnosis could not
eas ly and accurately be made early, the fa-
cilit es for the proper care of such a condition
were not so complete as they are today, and
when the diagnosis had been made death was
invited because of the attitude of the doctor,
the patent, and the community. There was
a folding of the hands and calm resignation —
and often ante-mortem infection of the other
members of the fam'ly, and of the neighbor-
hood. Much the same state of mind formerly
existed with reference to malignancy. The
cancerous patient was doomed to die. But
now a change has come about. No one ex-
pects tuberculosis, if apprehended early, to
eventuate in death, And no one looks upon
many forms of malignancy as necessarily fa-
tal. "
Why the change? Because of the tireless
efforts of a few individuals to bring hope out
of despair. Because some patients and some
doctors refused to surrender. Koch worked
and hoped and worked on until he had un-
covered the cause of tuberculosis and some
day some quiet, ceaseless, courageous inves-
tigator will wake up the world with a few
words about cancer, and then what is known
about it will be encompassed definitely in a
few lines rather than in tomes and tomes.
Dr. V'ictor C. Vaughan has just died in this
city, an old man, but he left behind an im-
perishable record of an achievement. When
he was no longer a young man, when his
fam ly was rather large and dependent upon
him, he went out to see if he could not find
out where the blue horizon really begins.
And down in the tropics he lent his brave
help to others in trying to find out certain
definite things about certain fevers, and those
things were found out. Patience and unre-
mitting effort and courage brought their re-
ward.
The opportunity of the day lies in the do-
main of the so-called chronic states. There
is probably no such condition as incipient tu-
berculosis or cancer in the acute form. When
the diagnosis is made the condition is already
chronic. But no alert and resourceful medical
man thinks of adopting an attitude of help-
less despair even in the presence of advanced
chronic disease. The very term should be
abandoned. Its use has a depressing effect
upon those who speak and write it as well as
upon those who hear it and who read it. The
use of the word tends to beget hopelessness
and despair and an attitude of unjustified in-
act-vity in the medical man. This statement
is not so true in any other domain of medicine
perhaps as in mental medicine. If there are
300,000 patients in the various hospitals of
the United States I have no doubt that at
least 200,000 of these individuals who are
mentally sick are looked upon by those medi-
cal men who have charge of them as hope-
lessly diseased. Such an attitude dooms most
of tiiese patients to a situation of life-long
mental incapacity. They are relegated to
back wards in which efforts to fetch them
out of a vegetative existence cease, I have
not the least doubt that the recovery percent-
ages in our state hospitals could be doubled.
1 have in emphatic fashion the feeling that
as many patients could be restored to useful-
ness in society from the chronic wards of
state hospitals as from the acute service if
intelligent and unremitting and courageous
efforts were made with the so-called chronic
patients. But the number of doctors in at-
tendance upon these patients would have to
be increased enormously and an infinite num-
ber of nurses would be necessary, and hope
of be.ng able to do the impossible would have
to be alive in the hearts of all of them. I
should like to see an asylum for chronic men-
tal patients taken over by an enthusiastic
psychiatrist who had as much sense as en-
ergy, and as much money as he could spend.
I have not the slightest doubt that such an
adventure would startle the world, and that
Deccmlier, \020
SOUTHERN MEDICINE AND SURGERY
870
it wduld ultimately do as much good as the
discovery of the causative organism of ty-
phoid fever. Pinel did his great pioneering
with the chronically insane.
PEDIATRICS
pR.'iNK HowARu Richardson, M.D., Editor
Black Mountain, N. C.
Diphtheria Not Conquered
It is not at all uncommon to find among
physicians, even the better informed of us,
the impression that diphtheria, like yellow
fever, can be named among the diseases that
have been mastered by man. It would indeed
be subject for congratulation if this were
true; but an editorial in a recent number of
the Joiinuil of the A. M. A. points out that
this cannot be trul\- said. Especially are we
reminded that the improvement that we do
see has been due not nearly so much to the
discovery and use of antito.xin as we should
have been inclined to believe. It happens,
rather interestingly, that the occurrence of
diphtheria had already been declining for a
number of years just preceding the discovery
of antito.xin. A similar situation exists with
regard to the lessening of tuberculosis during
the past several decades, which has been gen-
erally conceded to be due to the wholesale
propaganda directed against the great white
plague all over the civilized world. A more
careful reading of the story told by the mor-
tality and morbidity tables, however, shows
us that this reduction was due to take place
anyway, judging by the trend of the disease
taken over many years, — which is of course
the only fair and sensible way in which to
interpret vital statistics. If more care were
exercised in this regard, there would be less
enthusiasm over some of our health drives
and anti-this-that-and-the-other movements.
The Journal editorial points out that since
the discovery of antitoxin near the end of the
last century, the incidence of diphtheria has
remained practically stationary in most coun-
tries, although in the past two years it has
evinced a tendency to rise again, it is inter-
esting to see that the slight rise in some
countries has been counterbalanced by the
drop in others; and that its severity is the
same in the East as in the West and in hot
as in cold countries. The mortality from the
disease, however, has diminished considerably
since the discovery of antitoxin ( 1895-1 cS96).
An intriguing fact, which has yet to be
accounted for in some satisfactory way, is
that the sharp rise in the number of cases
that occurs in most countries from October
to January is not due to the cold weather
that we ordinarily associate with these
months; for the reason that it occurs quite
as regularly in those countries in which there
is little difference in temperature between
summer and winter months. Just why is
there this increase with the onset of fall?
It has been possible to study the question
of natural immunity against diphtheria, for
the reason that the Schick test is such a de-
pendable criterion. While we have been ac-
customed to say that the newborn baby .^
immune to diphtheria, and that he remains
so for about the first ten months of his life,
we have forgotten that this is probably not
the case with infants whose mothers have
failed to develop an immunity. It is not to
be supposed that such mothers can transmit
something that they do not themselves pos-
sess! Of course this constitutes a serious
break in our frontal attack upon diphtheria;
fur we have been accustomed to delay the
protective inoculations until around the end
of the first year, which is early enough in the
case of those infants whose mothers have ren-
dered them immune by transmitting their
own immunity to them.
In the past quarter century, two new con-
ceptions have entered into the picture of
diphtheria prevention. (Jne is the carriei
theory, — the editorial pointing out that the
number of carriers has been observed to vary
between 7 and 37 per cent, after the occur-
rence of diphtheria among the groups studied.
It gives the proportion of carriers to total
population as 4.6 per cent. This means of
course that quarantine and isolation can
never control the disease effectually; only the
conferring of immunity can do this.
The other new conception is that of devel-
oping natural immunity, — sometimes by re-
peated exposure to small doses of infection,
and sometimes (cause not well understood)
among tropical peoples, where the known
epidemics would hardly be sufficient to ac-
count for such a high percentage (80 per cent,
for instance, found in a group studied in the
Philippines.)
It would be init useless repetition to refer
here to the well known method of jireventive
inoculation against diphtheria by the now
generally adopted lu.xin-antiloxin inoculations,
*86 SfttJtttEkN MEMClKfi AM) StJRGEftY
checked up by Schick testing six, nine, or
twelve months later in order to make sure
that none escape getting the complete immun-
ity. The Drs. Dick, in their article recently
published in the Journal oj the A. M. A.,
remind us that there are two other agencies
which may be used in place of toxin-antitoxin,
whose efficacy was demonstrated by von Beh-
ring in 1913, and put into use on a wholesale
scale first by Park and his associates of the
New York City Department of Health, —
notably by the indefatigable Zingher, whose
death occurred but a comparatively short
time ago.
These two agencies are anatoxin, a "non-
toxic but antigenic modilication of diphtheria
antitoxin," distributed under the more read-
ily remembered name "toxoid;" and anti-
microbic vaccine. The Dicks prefer the use
of diphtheria toxoid in three doses to even
the five doses of toxin-antitoxin sometimes
recommended. While it may be wise for the
rest of us to remember this in case we are
called upon to protect adults, it will probably
be wiser for a long time to continue to advo-
cate and to use generally the well understood
and widely applied toxin-antitoxin .technique
of three injections, a week apart, followed in
nine months by a confirming or non-confirm-
ing Schick test. In the latter instance, two
more inoculations should be given. When a
health measure has been as widely adopted
and so universally satisfactory as toxin-anti-
toxin has been, it seems hardly wise to at-
tempt to substitute another technique, unless
it is overwhelmingly superior, — as does not
seem to be the case with toxoid.
Meanwhile, let us all remember our ob-
vious duty, — which is to bring to the parents
of all children under our care the desirability
of diphtheria protection; and to place square-
ly up to such parents as decline to give it,
their resf)onsibility for the development of
diphtheria that may occur at any time in
their children.
EYE, EAR AND THROAT
Henrv L. Si.oan, M.n.. Charlotte, \. C.
(Report of a member in attendance im the Congress)
The Thirteenth International Con-
gress OF Ophthalmology
The Thirteenth International Congress of
Ophthalmology was opened by Her Majesty
the Queen iMother of the Netherlands on
September 5, 1929, in the Conccertgebouw,
Amsterdam. The Queen Mother declared
December, 1920
the Congress open in the following words:
"It is a great pleasure to see the oculists
of the world joined together here, and I greet
you as the noble representatives of ophthal-
mology, a science which deserves one of the
highest places. You have prepared your-
selves to undertake an arduous task and to
do a great work in the interest and for the
well-being of humanity."
"Let me assure you that I and the people
of the Netherlands will follow your discus-
sions and debates with the greatest sympathy
and the most vivid interest. In expressing
our most fervent wishes for the success of
your efforts and for a favorable result of
your conferences, I declare open the Thir-
teenth International Congress of Ophthalmol-
ogy-"'
Professor Doctor Van der Hoeve, in his
presidential address, extended a cordial wel-
come to the representatives of all nationali-
ties who were to take part in the Congress.
It was very interesting to hear Professor Van
der Hoeve addressing the Congress fluently
and with the greatest ease in the French,
German, English and Dutch languages.
The Congress was held in part in .-Amster-
dam September 5-10, and in part in Scheven-
ingen, September 11-13.
In Amsterdam the scientific sessions were
held in the Aula of the Colonial Institute.
There were many communications read. I
can only refer to a few in this short report.
.At 2:30 p. m. of the first day a symposium
was held on "The Etiology and Xon-operative
Treatment of Glaucoma," by Messrs. Duke-
Elder (London). Hagen (Oslo), Magitot
(Paris), and Wessely (Miinchen).
Duke-Elder reviewed the recent knowledge
of glaucoma and concluded that at the pres-
ent time medical treatment, although it can
do much, cannot by any means replace sur-
gery.
Dr. Magitot attached great weight to an
accurate examination of the general condition
for cardio-vascular derangements, hereditary
and acquired lues. He emphasized the im-
portance of a diet jxior in salt and water.
Dr. Wessely stated that in the treatment
of glaucoma it is dangerous to subordinate
the approved local treatment to general meas-
ures, and the right moment for operative in-
terference must not be allowed to pass un-
utilized.
December, 1020
SOUTHERN MEDICINE AND SURGERY
Monday, September 9th: — Papers were
read on the "Geographical Distribution and
the International Social Campaign against
Trachoma." Drs. Gronholm (Helsingfors) ,
von Grosz (Budapest), Maggiore (Sassari),
Mijashita (Tokio), Sohby Bey (Cairo), Soria
(Barcelona), and Wibaut (Amsterdam) de-
scr'bed the distribution of trachoma in their
resiective countries, and the methods em-
ployed for its prevention and treatment.
.\ number of interesting and very useful
inventions were demonstrated. A new elec-
tric ophthalmoscope was exhibited. With
this apparatus eight can observe distinctly
and with ease the same ocular fundus, or any
g'ven point of the fundus. This will prove
a great help to teachers of ophthalmology.
.\n improved method of ocular fundus pho-
toTraphy was also demonstrated, whereby an
cycground can be photographed clearly with-
out any light reflex. An essay on "The Pho-
tography of the Ocular Fundus in Colors"
v,a. read by Xida (Paris).
Other interesting papers were read on the
cause and the treatment of detachment of the
retina. Dr. H. Arruga (Barcelona) dealt
with the treatment of detachment of the re-
tina. He confirmed the findings of Professor
Gonin (Lausanne) that in most cases of re-
t'na! detachment there are tears. If these
tears close spontaneously, or through treat-
me-it, reattachment of the retina takes place,
but otherwise this does not take place.
The tears must be carefully traced and
locilized, which is done with considerable
d'ff'culty. When the detachment is recent.
Dr. Arruga says, 50 per cent are cured by
thermocautery, provided there has been no
previous treatment, and that the tear is small
and s'tuated near the equator of the eyeball.
In longer standing and more unfavorable
cases, 10 per cent are cured.
Dr. Gonin (Lausanne) spoke very inter-
estin^'ly on his methods of local treatment
of detachment of the retina. He laid stre'^s,
too, (in fmding a hole in the retina and the
closing of the hole by means of a thermo-
cautery puncture of the retina through the
sclera, and some time after this is done the
choroid and retina become adherent at the
point of the puncture. He says that an early
operation should be done and that time
should not be wasted in other forms of treat-
ment.
Dr. Gonin has revived a world-wide inter-
est in the treatment of retinal detachment,
a cond'tion which has been for some time
considered hopelessly incurable.
This was one of the most enthusiastically
discussed subjects of the Congress.
At the afternoon session of Thursday, Sep-
tember 12th, Dr. Harvey Gushing (Boston)
opened the proceedings with a very good pa-
per on the " 'Chiasmal Syndrome' — Primary
Optic .Atrophy and Bitemporal Field Defects
in .Adult Patients with a Relatively Normal
Sella Turcica." He described the chiasma
as the cross roads where the oculist, the neu-
rolog'st, the rhinologist and the neuro-sur-
p-eon met, but said that in his opinion the
onhthalm'c surgeon should have the rieht of
way. "Sunrasellar Tumors" was the title of
an interesting paoer by Dr. Gordon Holmes.
Members of the Conqress discussed th's sub-
ject very profitably for their audience.
These and many other interesting paoers
should find their place in every ocul'st's li-
brarv. A bound volume of the Transactions
can be had by writing Dr. W. P. Zeeman,
Secretary of the Congress (the cost of the
volume will be $10 to $15, probably).
There were many social diversions for the
members of the Congress. There were teas,
receptions by local medical soc'eties, notably
one at the palace by the Prince Consort,
s'"ht-seeing excursions, etc. The entire Con-
srress was splendidly organized. All in all, I
feel sure that the members of the Congress
left .Amsterdam and Scheveningen with most
cordial feelincs toward their medical breth-
ren of Holland, not only because of the bene-
fit received from attendance upon the scien-
tific sessions of the Congress, but also be-
cause of the hospitable treatment they re-
ce'ved at the hands of their Dutch confreres.
Tonsillectomy and Diphtheria Immunity
V. K. Hart. M.D rhar'.oitc, N. C.
It is an interestinsT, but unquestionably ac-
curate, observation that any type of diphthe-
ria is extremely rare in a child who has had
a previous tonsillectomy and adenoidectomv.
The writer has seen only two such cases, both
very m'ld. and local pediatricians report a
very slight incidence in children with pre-
viously clean operations.
What is the rationale of this observation?
Schick and Topper {American Journal of
SOUTHERN MEDICINE AND SURGERY
December, 1Q20
Diseases oj CItUdren, November, 1929) in an
interesting article on this acquired immunity
g've the following explanations: "1. During
the six months after tonsillectomy, a certain
percentage of the patients would have devel-
oped immunity, even without the tonsillec-
tomy; but this increase in the number of neg-
ative tests would have been only relatively
fm^Il, from S to 10 per cent, and would not
have resulted in more than 80 per cent of
the cases showing a negative test. 2. A cer-
tain percentage of our children may have
been carriers of diphtheria bacilli. .According
to Zingher, there is an average of about 4
lo 5 per cent of diphtheria bacilli carriers in
New \ork City. After the tonsillectomy,
s'me of the children may have developed a
nvld unrecognized autoinfection and a conse-
oucnt immunity. This occurrence can ex-
pla'n only a small increase in the negative
tests. 3. The children on whom we have
reported here, living in congested districts,
may have been exposed to an infection with
d'ohtheria bacilli, and so some may have ac-
qu'red. immediately after tonsillectomy, a
m'ld infection with diphtheria which stimu-
lated the production of diphtheria 'antitoxin.
4. We must cons'der the fact that the minute
dnse of toxin which was injected with the
testing may have stimulated the cells to pro-
du'-e antitoxin. Opitz mentioned such a po-3-
'^'b'lity. -S. .According to Hirszfeld, infections
other than diphtheria not only produce their
SDJcific antibodies but also increase the pro-
duction of other antibodies. It is possible
that infections established as the immediate
consequences of the operation raise the small
amount of antibodies against diphtheria, an
rmount too small to be detected by testing
before tonsillectomy, to a higher level."
In this same article they reported observa-
fors in children, aged 2 to 12, all of whom
bad positive Schick tests prior to operations.
S'x months after operation these children
v,'ere again given the Schick test. In the
group of six years or younger 82 per cent
were negative. Eighty-two per cent of the
second group, more than 6 years of age, were
also negative. Comparing these with pre-
v'ously accepted figures, it is a decrease,
roughly, in the positives of 53 per cent in the
fir.n group and 18 per cent in the second
group. The situation is even more clearly
shown in that 82 per cent of both groups and
also of the group as a whole became negative
after tonsillectomy and adenoidectomy.
They state that the practical applications
are: "1. the recommendation of tonsillectomy
in place of immunization with toxin-antitoxin
for children with diseased tonsils who are
sensitive to horse serum; 2. the recommen-
dation of testing children who have been
tonsillectomized six months or more previous-
ly before immunizing with toxin-antitoxin."
Of course, with the use of goat serum toxin-
antitoxin the first is negligible. The second
application is, however, one that may well be
kept in mind in everyday practice.
ORTHOPEDIC SURGERY
0. L. Miller, M.D., Editor
Ch.irlotte, N. C.
E.ARLY Recognition and Treatment of
Congenital Dislocation of the Hip
The incidence of congenital dislocation of
the hip is rather low in this part of the
world. The condition is met with far more
frequently in France, Italy and some other
foreign countries. Because the incidence is
low here does not make each dislocated h'p
any the less crippling, but this scarcity makes
it necessary for the doctor to be more on the
alerL to d'scover its presence.
Probably sufficient emphasis has not yet
been given to the fact that if the congenitally
d'slocated h'p is recognized early and thor-
oughly reduced, when reduction is not so
difficult, a very normal hip may result. Late
reductions are not so encouraging.
Prof. V. Putti, Bologna, Italy, who has
probably had more experience with this de-
form'ty than any man now working, states
that the technique in use for the closed re-
duction of congenital dislocations of the hip
has attained such a degree of perfection that
very little can be done to improve it. Those
v/ho are dissatisfied with closed reduction
propose to apply on a much wider scale re-
duction by open operation. He does not
believe that this represents the best solution
of the problem. The road to be followed is
a different one, that is the lowering oj that
age limit, which is still commonly considered
the youngest suitable for beginning treat-
ment.
The idea that treatment ought to be begun
early is agreed to by everyone. The age
which at present is considered most suitable
is two years, that is the age at which atten-
December, 1020
SOUTHERN MEDICINE AND SURGERY
tion is called to the deformity by the char-
acteristic limp. Futti contends that there is
no reason, either theoretical or practical,
which forbids commencing treatment before
that age. It is a fundamental principle of
orthopedics that congenital deformities should
be treated from the moment of birth. Why
on earth should not this principle, which is
so rigorously applied in the treatment of
club-foot and which, with more la.xity, is
adipted in the treatment of wry-neck, cleft
palate, and scoliosis, hold good also for that
of congenital dislocation of the hip? The
actual reasons against it are the following:
1. Because it is very difficult, and often
impos^ble, to recognize the dislocation until
the child has begun to walk.
2. Because it is said that at one or two
years of age the condition of the joint is
mechanically more favorable for reduction.
3. Because it is technically difficult to
keep immobilized for many months an infant
who has not yet gained control of his bodily
functions.
it is undeniable that it Js not easy to dis-
cover the dislocation before the child has
begun to walk. Yet there are a number of
signs which may make us suspect it, and
ihe suspicion can easily be confirmed by .x-
rays. In Italy there are regions where these
dislocations are so common, and where what
one may call the "orthopedic education" of
the doctors and of the people themselves is
fo advanced, that the mothers spontaneously,
or on the advice of the family doctor, bring
up children a few months old in order to
have their fear of the deformity cleared up.
The loving eye of a mother does not m'ss
even slight evidence of asymmetry or abnor-
mality: and the doctor, who knows that the
dislocation is frequently hereditary or fa-
milial, will not fail to warn the parents, who
have dislocations amongst their forebears, or
have it themselves, or who.se first ch^ld was
treated for dislocation.
Furthermore, is it really very difficult to
diagnose the dislocation before one vear? If
a mother often succeeds in doing it, why
should not a doctor always succeed? One
limb seems to her shorter than the other:
one of the feet turns outward: in separating
the lower limbs she saw, or felt, that one
went less ea.sily than the other: she observed
that one limb was held in a certain degree
of flexion: or that, if she tried to correct this
flexion, the child cried. It is just such small
s'gns that make one suspect a dislocation,
and which should induce one to have an
x-ray examination.
Prof. Putti's opinion is that to improve the
results of the treatment of congenital dis-
location, one must lou<cr the age limit for
beginning treatment. But to render this
possible, it is neces-^ary for parents to learn
to bring their children for medical examina-
tion early, and that the doctors shall be able
to m:ike the diagnosis in time. That will
ccrta'nly occur more constantly in the future
with suitable publicity and with better orth-
opedic training for the medical profession.
UROLOGY
.\ Practical Routine Management for
Gonorrheal Urethritis and Usual
Complications
for this issue. M.ARiox H. VVvman, M,D.
The Wyman Urological Clinit
Columbia, S. C.
(Thi^ outline of treatment i? an attempt to briefly
.'Summarize cur routine treatment for jjonnrrhea in
Ihe male.)
No new drugs have been instituted in the
management of gonorrheal urethritis in the
last 20 or 30 years. However, we have gain-
ed much valuable information which may be
summarized as follows:
Weaker solutions of drugs are used, and
a given case is treated less frequently than
formerly. Be.ginning treatment in an early
(new) gonorrheal urethritis, some silver
preparation, preferably argyrol as weak as 5
per cent, is used in the anterior urethra, be-
ing injected once and never more than twice
daily, with an ord.nary blunt-pointed .-Xsept
bulb syringe. Of prime and utmost im )ort-
ance in the early stages is free drainage from
the urethra through the external meatus, and
free incision of the meatus is indicated if it
is not sufficiently large to easily permit the
passage of a No. 28 V. sound. .\s in other
infections, if the pus and infected material
cannot easily escape from the external meat-
us, it will naturally dam back into the pos-
terior urethra and cause complications of
prostatitis and epididymitis. Sounds may
be (and probably should be) used very gent-
ly in the anterior urethra as early as the end
of the first week even in the face of acute
.symptoms. In other words, after a few days
of injection treatment, an acutely inflamed
SOUTHERN MEDICINE AND SURGERY
December, 1929
and edematous urethral mucous membrane
is an indication, rather than a contraindica-
tion, for the use of sounds. This may be a
radical departure from the accepted text-book
treatment, but in our experience the gentle
use of sounds early (in the anterior urethra
only) insures free drainage and prevents com-
plications of periurethral infections as well
as prostatitis and epididymitis. These pa-
tients should drink laige quantities of water
and before any treatment is given urination
should take place. Before the passage of a
sound, the anterior urethra should be injected
with some silver preparation, or should be
irrigated as will be described later. After
seven or ten days, or at most two weeks,
treatment with injections, irrespective of the
amount of shreds or discharge in the urine,
the patient should be put on hot permanga-
nate of potassium irrigations (by the gravity
method only) through the entire urethra.
Wc feel confident that the postponement,
neglect, or delay in irrigating the posterior
urethra, rather than the too early treatment,
is the cause oj complications such as pros-
tatitis and epididymitis.
In all complications of gonorrheal ureth-
rlt's, all local treatment of the urethra should
be dscontinued immediately and not reinsti-
tuted until all symptoms of complications
have subsided and free urethral discharge has
reappeared. It is well known, of course, that
during an acute complication period of pros-
tatitis or epididymitis, and even in gonor-
rheal rheumatism, the urethral discharge be-
comes scant.
The best treatment for the complication
of acute epididmymitis is a free incision into
the epididymis followed by support of the
scrotum and rest in bed for 48 hours. If
for any reason an epididymotomy cannot be
performed, elevation of the scrotum, possibly
strapping with adhesive plaster, rest in bed
and appl'cations of ice is the best alternate
treatment.
Poulticing the prostate for acute prostatitis
with hot sitz baths, hot rectal douches, and
rest in bed with the symptomatic treatment
for the pain and fever is all that can be
done. Under this treatment the inflammation
usually subs'des within a few days. Should
acute retention of urine occur during this
complication, a soft rubber catheter will have
to be i4se(} to empty the bladder. The ca-
theter may be reinserted as often as neces-
sary to keep the bladder empty, but we pre-
fer a small indwelling catheter fastened in
with adhesive plaster and allowed to remain
in 24 to 48 hours. The presence of the ca-
theter not only keeps the bladder empty (the
patient pulling the stopper as he desires), but
the reaction of the urethral mucous mem-
brane to the presence of the catheter seems
to be beneficial, the pus escapes satisfacto-
rily at the meatus, the catheter seeming to
act as a wick drainage.
Vaccines should be used for gonorrheal
arthritis, the stock mixed Ne'sserian vaccines
being satisfactory. The only complication of
gonorrhea in which we have any confidence
in the use of vaccines is in the treatment of
gonorrheal arthritis.
There is one other factor of great practi-
cal benefit in handling infections in the
urethra: that is, a rest period during the ac-
tive treatment. It is almost impossible to
convince a patient, but we are certain that
a rest day once a week without any local
treatment whatever, even in the acute stages
of gonorrheal urethritis, is extremely benefi-
cial. Gonorrheal patients, as other patients,
ins's^ upon fighting infections very vigorous-
ly with drugs, but if we insist upon our pa-
tients resting, say, every Sunday, without
any local treatment whatever, an immunity
will be established sooner and a cure will be
effected much earlier and with fewer compli-
cations. We have all observed how quickly
a profuse urethral discharge subsides when
treatment is reinstituted after a rest period
incident to some complication.
To summarize; emphasizing drainage:
First, and of paramount importance, in-
sure free drainage from the urethra, by a
meatotomy when indicated.
Second, the early passage of sounds into
the anterior urethra is not contraindicated, —
it insures free drainage and thus helps to
prevent complications. (Do not allow the
use of cotton at the meatus, for it prevents
free drainage.)
Third, weaker solutions of drugs as injec-
tions and irrigations are used and used not
more than twice daily, preferably once daily.
We feel sure, beyond a shadow of a doubt,
after extensive experimentation, including
our army experience, that the patient will
have a much more decided recovery much
December, 1929
SOUTHERN MEDICINE AND SURGERY
sooner and without complications and se-
quelae if weaker solutions are used and used
not too frequently. Were we limited to the
use of just one drug for the local treatment
of gonorrhea, we would unquestionably use
a weak, hot permanganate of [xitassium solu-
tion as an irrigation. The early irrigation
of the posterior urethra by the gravity method
is of prime importance. We wish to restate
and to emphasize that it is the neglect of the
posterior urethra, rather than the too early
treatment, that is the most frequent cause
of the complications of prostatitis and epi-
didymitis.
Drugs by mouth are indicated only to re-
lieve painful and frequent urination and ter-
minal hematuria which sometimes compli-
cates posterior urethritis. We insist upon the
use of large quantities of water by mouth
during the whole treatment. We prescribe
a bland diet, advise the avoidance of all alco-
holic and carbonated drinks and urge avoid-
ance of sexual excitement. We alkalinize the
urine or give santal oil for frequent and pain-
ful urination. We discontinue all local treat-
ment of the urethra during any of the com-
plications of gonorrhea.
It might be advisable to add the follow-up
treatment with massages of the prostate and
the use of sounds and to say when it is safe
to declare a patient cured. Caution: Do
not massage the prostate nor pass sounds into
the posterior urethra too early! Of course,
the personal equation comes into play with
each individual patient, but as a routine,
after a patient has been allowed to remain
off treatment for a few days and no acute
urethral discharge reappears, we institute
prostatic massage at five-day intervals, cov-
ering varying periods of time according to the
amount of pus in the massaged prostatic se-
cretion. This massage period covers a week
or two and sometimes several months. If
a patient has a definitely infected prostate
with shreds in his voided urine that infec-
tion and that symptom will probably be pres-
ent as long as the patient lives; the gonococci
disappearing from the prostate, but some
other germ, usually the colon bacillus, pro-
lunging the infection indefinitely. I have
shown in a former paper' that shreds in the
voided urine from a male patient always
prove the presence of an infection in the pros-
tate. Sounds are passed at weekly or bi-.
weekly intervals if the patient has any stric-
ture or tightness in the urethra. If there is
no tightness whatever to the passage of a
No. 28 or Xo. 29 F. sound, the sound need
only be passed on one or two occasions.
Never pass sounds unless the bladder is filled
with permanganate solution. Use woven
sounds below No. 23 F. and steel ones of the
larger sizes. Over treatment, or too prolong-
ed local treatment of the urethra with injec-
tions or irrigations in the late stages of ureth-
ritis will undoubtedly cause a urethral dis-
charge to continue which is purely a medici-
nal irritation of the urethral mucous mem-
brane.
Gonorrhea in the male is always curable
and many men who have gonorrheal ureth-
ritis and receive proper treatment do not
ever have an infected prostate or stricture.
With this optimistic possibility in mind, let
our treatment be directed to prevent pros-
tatitis and urethral strictures, for we have
learned from sad experiences that curing is
very difficult.
1. Interesting FindinRs in the Examination of
Gcnito-Urinan,' System of Ex-Scr\ice Men.
SURGERY
Geo. H. Bunch, M.D., Editor
Columbia, S. C.
The Danger of Auto-Digestion in Pan-
creatic Injury — An Experience
In the operating room the life of the pa-
tient depends upo nthe skill and the judg-
ment of the surgeon. Clear thinking and
prompt action are imperative. His informa-
tion must be in his head. Unexpected con-
ditions are often found that make complete
change of procedure necessary if the best re-
sult possible for the patient is to be attained.
There is little time for deliberation. There
is no opportunity for consultation. Knowl-
edge of surgical literature is helpful: wide
experience is essential. Even with these
when the final outcome is disapp<iinting one
wonders what might have been done to make
the result more favorable. The endeavor of
the surgeon is to give the patient the benefit
of the best that surgery has to offer. The
responsibility is great; the obligation is ob-
vious.
A woman of middle age comes to operation
with a fairly typical history of ulcer. The
X-ray findings are those of chronic gastric
SOUTHERN MEDICINE AND SURGERY
December, 1929
ulcer near the pylorus. The general condi-
tion is good. Under spinal anesthesia the
abdomen is opened and an indurated ulcer
found. Partial gastric resection is decided
upon. The dissection is tedious. The pos-
terior wall of the stomach is adherent to the
pancreas: separation without undue difficulty
leaves a small irregular area on the anterior
surface of the body of the pancreas denuded
of peritoneum. The injury is superficial and
is of the peritoneal covering rather than of
the pancreas itself. After resection of the
pylorus (with the ulcer) the end of the duode-
num is closed and the end of the stomach is
closed. Omentum is sutured over the de-
nuded area of the pancreas before posterior
no-loop. Gastro-enterostomy is done to re-
establish intestinal continuity by the Bill-
roth No. 2 method. There is no gross soiling
and the wound is closed without drainage.
The operation has lasted something over an
hour and the patient leaves the table in good
condition.
She apparently does well after operation
for three days: there is no fever, no disten-
tion, no nausea. The pulse is of good qual-
ity. She is considered convalescent. Then
some time after midnight she is reported by
the nurse as not doing well. She is found
almost in extremis with weak pulse and in a
cold sweat. She does not respond to stimu-
lants. A donor is secured and a transfusion
of 600 c.c. of unmi.xed blood is given. In a
few hours she dies,
Necropsy done next morning by the hos-
pital pathologist does not show any internal
hemorrhage. The anastomosis has not
leaked. There is no general peritonitis. But
a large portion of the posterior wall of the
stomach and much of the omentum is necrotic
from pancreatic digestion. Pancreatic juice
from the denuded area on the body of the
pancreas has evidently escaped into the les-
ser peritoneal cavity in sufficient volume to
digest the tissues coming in contact with it
and to cause death. Post-mortem examina-
tion has revealed the cause of death which
would never otherwise have been understood.
An imperfect study of the literature avail-
able gives but little emphasis to the danger
of injury to the pancreas in surgery of the
upper abdomen. Balfour says a denuded
surface should be seared with the cautery.
Moynihan says when the pancreas is injured
the wound should be drained.
We knew that shot-gun wounds and stab
wound that might sever the pancreatic ducts
demand drainage, but have never before real-
ized the necessity for drainage in small su-
perficial injuries. In this case the denuded
surface was larger than a quarter and smaller
than a lifty-cent piece. Yet from it suffi-
cient pancreatic juice escaped to cause death.
A small drain to the pancreas might have
saved her.
We make this report in the hope that it
may prove of practical benefit to the readers
of Southern Medicine and Surgery.
THERAPEUTICS
Frederick R. Taylor, B.S., M.D., Editor
High Point, N. C.
Some Features of the Southern Medical
Association Meeting
This is not primarily a therapeutic editorial.
The editor took a few days off and went to
the Southern Medical Association meeting at
Miami, and is now taking a while off and
writing in a field largely distinct from thera-
peutics. Those who were at the meeting and
those who know Florida better than the writ-
er, please turn to something more interesting
than this.
We missed the early part of the meeting,
arrived in Miami Wednesday night after a
very pleasant trip down in a special car with
doctors from all along the main line of the
Southern in N. C, found the general meeting
going on in the open air, heard a long and
uninteresting talk by Dr. W'm. Gerry Mor-
gan of Washington, president-elect of the A.
M. A., then a good talk by Dr. Fernandez,
secretary of Public Health and Charities of
the Republic of Cuba, on The Present Status
of the Practice of Medicine and Sanitation
in Cuba. (Dr. Fernandez is also president
of the Pan-American Medical Association.)
Being specially interested in pellagra at
this time, we attended sections having that
on the program. Especially noteworthy were
a paper by Dr. Wheeler of the U. S. P. H. S.
in the Section on Public Health, with the
usual warmth of discussion on the subject of
etiology and one on the treatment of 100
cases of pellagra with arsphenamin by Dr.
Wilson of Jacksonville, reporting improve-
ment in 78 per cent of cases. A boat ride
down Biscayne Bay with this section offered
December, 1020
SOUTHERN MEDICINE AND SURGEftY
a unique and delightful recreation, though
the water was too clouded to let down the
glass and see the great drama of marine life.
;\Iiami might well be called the dustless
city. It is marvelous how, after two days
of a brisk wind, practically no dust could be
found. Even in the business district, down
near the magnificent City Hall, which towers
as the chief and most beautiful landmark of
southern Florida, where the wind blows al-
most constantly, there seems to be no dust.
The ground being made largely of coral, and
the fact that little or no coal is burned in
the city, are reasons given for this. The trop-
ical vegetation, while perhaps not yet at its
height, was beautiful. The poinsettias, Turk's
caps, hibiscus, bougainvilleas, palms of many
sorts, live oaks, etc., made a scene never to
be forgotten, especially in the park fronting
on Biscayne Bay.
At a later general meeting, Dr. Hugh S.
Gumming, Surgeon-General of the U. S. P.
H. S., gave an excellent address on "Some
Public Health Problems of Special Interest to
the South," and Dr. Heuer of Cincinnati gave
a splendid Oration on Surgery: ''The Train-
ing and Qualifications of the Surgeon." Dr.
Cumming was elected President of the South-
ern Medical Association for the coming year,
a choice which honored the Association as
well as Dr. Cumming.
On our return we explored the won-
derful historic town of St. Augustine, saw
the oldest house in the U. S., went through
the historic old Fort ^Marion including the
terrible secret dungeon adjoining the torture
chamber in which it is said no one ever lived
over 12 hours, drank from the spring that
Ponce de Leon thought was the Fountain of
Youth (the water was not so very good!),
saw the magnificent public buildings and
hotels, and the famous million dollar Bridge
of Lions, guarded by sculptured lions present-
ed to the city by a wealthy physician. Dr.
.Anderson. Then by bus to Jacksonville,
where we were driven over the city by Dr.
Kirby-Smith, and shown the new million dol-
lar St. Vincent's Hospital. The trip was a
notable one for us, for we had never been
in Florida before. The scientific and tech-
ncal exhibits were very fine indeed, and
many hours of study could be spent profit-
ably with them. The .Section on Dermatol-
ogy and Syphilology had a magnificent dis-
play of photographs of a great variety of
skin conditions, and there was the usual in-
comparable display of photographs of leprosy
put on by the V. S. P. H. S., in charge of
Dr. O. E. Denney of the Leprosarium at
Carrville, La. Splendid ophthalmologic ex-
hibits, electrocardiographic records, patholo-
gic exhibits, radiologic and urologic demon-
strations, were all to be seen. Many forms
of entertainment were provided from dog rac-
ing to open air concerts, so that the meeting
was from every standpoint one of the most
delightful we ever attended.
Baggage inspection at St. Augustine and
elsewhere may have caused some qualms to
some persons, as it was conducted by a fed-
eral soldier, but he was merely searching for
the possibility of fruit fly transmission, en-
forcing the quarantine under the authority
of the U. S. and Florida State Departments
of Agriculture.
FOOD .■XND CRIME
("Wrong food causes crime," says Salvation Army.)
When Jesse James held up a train
Or blew a safe or till.
It wasn't due to twisted brain
Or urge to rob and kill ;
His depredations many and
The speed with which he shot
Were due to this: he couldn't stand
The awful food he got.
When Gerald Chapman made us quake
With deeds the statutes ban,
He lacked the vitamins that make
.\ normal, honest man.
His life of dire crimes, you see,
Was due to this, they say —
He had the vitamins called "B,"
But lacked the ones called "A."
And so it's been throughout all time
Where good and bad both meet:
If you'd avoid a life of crime
Be careful what you cat.
All sorts of food can take a kid
.^nd wreck him in his teens —
But nothing makes him hellward skid
Like unwashed spinach greens!
— From H. I. Phillips' column in the New York
livening Sun.
SOtJtHERN MEDICINE AND SURGERY
December, 1929
OBSTETRICS
Henry J. Langston, B.A., M.D., Editor
Danville, Va.
The Use of Piper Forceps in Breech and
Version Deliveries for the After-
Coming Head
In the July, 1928, issue of this journal we
discussed somewhat at length the manage-
ment of breech delivery. We covered the
conduct of the first stage of labor and sug-
gested the use of the Voorhees bag as a val-
uable asset in bringing to the proper termi-
nation in the shortest physiological time the
first stage of labor; then we recommended
that the patient be anesthetized to complete
relaxation in the management of the second
stage of labor; that the cervix be completely
dilated or dilatable and that the vagina be
ironed out thoroughly so as to prevent lacer-
ations; then, by getting hold of the feet,
making it a frank feet presentation and from
this point on gently manipulating the baby
until it was delivered.
Most physicians dread a breech presenta-
tion, or they dread having to do a podalic
version because of the risk to the baby's life.
This fear is groundless, provided the
physician has done what we have frequently
suggested; namely, measured the pelvis of
the mother so as to be certain that it is of
ample size; also that the baby is not abnor-
mally large. Besides this the physician
should acquaint himself with the Piper for-
ceps. Dr. Piper, who is Professor of Obstet-
rics of the University of Pennsylvania, stated
this to us in a letter of recent date:
"A good many years ago, I had felt that
the extraction of the after-coming head — ■
both in breech presentation and in podalic
version — with the high element of mortality
and morbidity, was due to the necessity of
traction of the after-coming head directly
from the shoulders. I am sure that you and
many other practitioners have felt that most
uncomfortable sensation of a snap in the neck.
At about this time I began to use whatever
forceps were at hand and found that the
average run were too difficult to put on when
the patient was delivered in the semi-Walcher
position; that except with the Tarnier axis-
traction, the cephalic curves were not flat
enou?h but that on the other hand in the
Tarnier with the power that they had, there
was too much danger of crushing the skull.
"So I bought a very light pair of Tarnier
forceps and modelled the blades therefrom,
changing the shanks to make them longer
and thinner than any other forceps; the han-
dle is of very little importance. The present
forceps is the fourth model — as a matter of
fact, the fifth, because the first model was
changed and used after the original manufac-
ture. The present model is practically iden-
tical with the one preceding it except that it
is manufactured in bulk and is a shade
lighter."
Also Piper, in a paper by himself and Dr.
Carl Bachman, published in the Jour, oj the
A. M. A., January, 1929, speaks of his forceps
in this manner:
"The advocacy of the routine use of for-
ceps on the after-coming head is not new,
and the plan has many points in its favor.
To render the maneuver easier, however, the
senior author has devised and used in the
past five j'ears a specially designed instru-
ment embodying the following features: (1)
a blade having a somewhat flattened pelvic
curve for high applications, as in the Tarnier
forceps; (2) a lengthened shank, which per-
mits an unusual degree of 'Spring' between
the blades and thus prevents compression of
the head, and (3) depressed handles, for
greater ease of application and manipulation
in the presence of the delivered fetal body.
The technic of application requires aiming
the blades directly at their intended positions
on the sides of the head, without rotation,
and from below. An assistant meanwhile
holds the child's arms and legs
maintaining the trunk at not too great an
angle of extension on the neck. Whether ab-
solutely required for extraction of the head
or applied as an elective maneuver, the chief
function of the instrument is that of flexion
and not traction; in addition, it serves to
control the exit of the brow across the peri-
neal edge, protecting the latter from the lac-
erations that sometimes occur as the head
'jumps' out in this final act of the birth."
We have used this forceps many times for
approximately two years, and with one ex-
ception we have found it most valuable in
easy delivery of the after-coming head; also
we have been better able to protect the pelvic
floor. In our judgment every physician who
is doing much obstetrics should have it and
should learn to use it. If it is applied prop-
erly and abundance of time is taken we can
sav^ tjie babies that we have formerly lost;
1020
SOUTHERN MEDtCtNE AND SURGERY
889
we can prevent injuries we have formerly had
and we will feel very much more comfortable
about the fact that we have done the best
work with the best instruments procurable.
It is our opinion that if a baby can be deliv-
ered alive at all, if a person knows how to
manage extraction of breach or extraction of
baby in podalic version, if he uses the amount
of time that is advised by Dr. Potter, if the
baby can be delivered at all by any method
through the birth canal it can be done with
this forceps. At any rate we call the atten-
tion of the profession to it and urge that
members acquaint themselves with this
forceps because we feel that after each person
has become acquainted with it he will cer-
tainly have one of them in his bag for use
in the future.
To observe the principles above set forth
with the proper use of Piper forceps, we be-
lieve that breech deliveries and podalic ver-
sions can be brought down to the point where
we will have probably less than 4 per cent
stillbirths; whereas, in the past, stillbirths
have been very high as result of our inability
to deliver properly the after-coming head.
For Enemas Wider Use
Many persons appear to suffer from flatulence
and indigestion simply because there is always a
plug of fecal material blocking the outlet of the
intestinal tube. If they could only clear out the last
ten inches of the bowel without upsetting the first
20 feet or more they would be well. When they
fill the bowel with rough food or when they take
laxatives every night the treatment is often worse
than the disease. I say to them: "But why do you
not use enemas? They empty the lower bowel
without disturbing any other part of the tract."
The answer is generally either that several physicians
wave warned them of the horrible results of taking
enemas, or else that enemas give distress or fail to
bring results.
The commonly expressed fear of enemas is not
based on facts, so far as I have been able to learn.
I have never seen anyone injured by them, nor
have I ever seen such a case demonstrated. Some
of the men who cry out most loudly about this
danger do not object to giving enemas in the office
for a consideration.
Many of the persons complaining of indigestion
have such a sensitive colonic mucosa that ['"■'^
water or soap-suds irritates it a great deal and the
patient continues to pass mucus at frequent intervals
for two or three hours afterwards. If these per.^ons
are taught to add a rounded tablespoonful of salt
to the bag full of water they will rarely experience
distress afterwards and many will then find enemas
very helpful.
Sometimes they fear and hate the procedure be-
cause some physician has told them that they must
lie down and must hold the water for ten minutes
after it is put in. When they learn that an enema
can be taken in a few minutes while seated on the
toilet bowl much of their dread of the procedure
will disappear.
It is important also, when treating these patients,
to relieve their minds about the largely mythical
dangers of auto-intoxication. Often these persons
can be greatly helped if they can be taught to be
satisfied with three good bowel movements a week.
Nature never intended many women to have a
movement once a day; some do not eat enough to
make a stool every twenty-four hours.
I never use strychnin, pepsin, pancreatin, or
bismuth. Patients who cannot be helped by rest,
proper dieting, and better hygiene are generally suf-
fering from some organic trouble such as gall-blad-
der disease which can best be relieved by surgical
treatment. — Alvarez, in Jour. hid. Slide Med. Assn.,
Nov.
We give you a picture of this forceps so
that you can get some idea of it before you
purchase it.
"Why didn't you answer my letter?"
"I didn't get it."
"V'ou didn't get it?"
"No, and besides, I didn't like some of the things
you said in it." — Ex,
SOUTHERN MEDICINE AND SURGERY
December, 1929
NEUROLOGY
Olin B. Chamberlain, M.D., Editor
Charleston, S. C.
Tumors of the Spinal Cord
The current issue of the Archives oj Neu-
rology and Psychiatry contains an extremely
worth-while paper by Elsberg on Tumors of
the Spinal Cord. The paper is made up of
two distinct parts, namely, diagnosis of the
spinal cord neoplasms and procedures relat-
ing to operation. It is with the diagnostic
criteria that this department is concerned.
There are few men who have had a wider
acquaintance with spinal cord surgery than
Charles Elsberg. As head of the Depart-
ment of Neurological Surgery at Columbia
University his experience has been tremen-
dous. In a very informative paper he com-
ments upon certain points of diagnosis well
worth knowing and remembering. I shall
make no attempt to present an abstract, but
rather simply allude to particularly interest-
ing points brought out by Elsberg.
In about 25 per cent of tumors of the cerv-
ical part of the cord, there was found a well-
marked dissociation of tactile from pain and
temperature sensibility over the body below
the lesion. That is, the classical phenomena
usually associated with syringomyelia, in
which touch is retained, but pain and tem-
perature sense lost, was noted. This is well
worth bearing in mind. All of us are so
familiar with this sign as pathognomic of
syringomyelia that we would be apt to be
prejudiced in favor of that diagnosis did we
not bear in mind Elsberg's finding.
Another point of considerable importance
in estimating the level of the tumor is the
realization of the considerable discrepancy
which may exist between the skin level at
which the changed sensations are detected,
and the actual segment or segments affected.
He shows with diagrams how, because of the
lamellization of the spino-thalamic tracts in
the lateral columns, early pressure will affect
fibers coming from lower skin segments —
whereas later and more marked pressure will
involve fibers relaying sensation from a high-
er level.
Elsberg insists upon the usefulness of the
protein estimation of the spinal fluid. He
uses the method perfected clinically by Ayer
— and Fremont-Smith — and originally de-
scribed by Denis. The normal protein con-
tent following this methocj is 40 mg. It is
pointed out that it is almost always increas-
ed in spinal tumor. In only one out of 200
cases was the reading 40 or less. In tumors
situated outside the dura the protein content
was not as excessive as in intradural tumors.
This difference is so marked that it serves as
a useful diagnostic point.
Elsberg feels that the spinal manometric
procedure — as outlined by Stooky in the Ar-
chives oj Neurology and Psychiatry of July,
1929 — is highly worth while. These are, in
brief, developments and modification of the
familiar Queckenstedt procedure, whereby
spinal block is indicated by pressure on the
juglar veins.
He is not enthusiastic over the use of
iodized oil. He has seen several cases of
inflamed meninges resulting from its use —
and he points out that the oil probably re-
mains in the sub-arachnoid space for a long
time after its introduction. In fact, Elsberg
states that one should be able to make a sat-
isfactory diagnosis in the vast majority of
cases without the use of the oil. This is, of
course, a controversial point, and there are
many clinics which use the method. The
editor of this department agrees very heart-
ily with Elsberg in his conservatism. After
all it is decidedly unfair to the patient to
make use of a dangerous or probably dan-
gerous procedure when the same informa-
tion may be acquired by other means, even
though more patience and exactness is nec-
essary. Thorough and painstaking sensory
tests, aided by harmless manometric methods
will localize the tumor in the majority of
cases. In doubtfully localized tumors the
use of a further method, such as the iodized
oil, may be occasionally called for. But we
should all be willing to use our senses and
clinical acumen to their fullest before we call
for a laboratory procedure of dubious harm-
lessness.
As Usual
Little Ned had returned from his first day at
school. "And what did you learn at school today?"
asked his father.
"I learned to say 'Yes, sir,' and 'No, sir,' and
'Yes, ma'am' and 'No, ma'am.'
"You did!"
"Yeah!"
The other day we got an invitation to a stag
party. It read: "The party will be gin at 9:00
o'clock. — Colorado Medicine,
December, l9i9
SOtJtHEftN MEWClMfi ANt> StJRGERY
S91
MISCELLANY
A Letter to Dr. F. R. Taylor from
His Brother
Because of your deep devotion to the scien-
tific objective study of disease, I wish you
were with us now. The Marquesan race is
mortally sick. One of the finest physical
types in the world is already in the throes of
death.
We were anchored in Hana V^ava Bay,
Fater Hiva, a couple of days ago, and I ac-
companied Dr. Mathewson, our physician, to
the adjoining harbor of Amoa to tend the
sick.
The motor boat was met by two hand-
some Greek gods, alasl in undershirts and
pants, and we were landed in an outrigger
canoe as only Polynesians can do it through
the heavy surf. One of the gods spoke French
fluently, and he and I were soon chatting
haltingly as we walked among the cocoanut
palms to the village.
I was all eyes for the gigantic scenery
which combines so powerfully tropical luxuri-
ance with rugged mountains. About a large
banyan trunk were clustered some women and
children and as we approached I realized that
the popular conception of romantic beauty
in the South Sea women was not so much of
a myth as I had supposed. But all the time,
this handsome brute beside me kept saying,
"Beaucoup des malades ici" (a lot of sick
people here) and other mundane things. He
seemed remarkably intelligent and very sin-
cerely anxious to make our visit both pleas-
ant and a help to his miserable countrymen.
The chief was in Hana Vava, and I do not
think our escort had any official capacity
whatever.
Our first case was a combination of the
two familiar venereal diseases. He gave the
doc a stone copy he had made of one of the
native gods, and a handsomely carved rose-
wood cane.
The next were two cases of elephantiasis,
man and wife. The man's case was new and
very painful. We could do practically noth-
ing, but they literally forced two chickens
upon us. There were more venereal cases
in their later stages, a sprained shoulder, and
some hints of tuberculosis.
Our escort told me it was three, six, eight
months, often, sometimes more than a year,
between the government physician's visits to
the town.
We came upon a little consumptive dwarf
of a Spaniard from Guam with cataracts. He
was a runaway steward from a whaler in
1904 and had lived here ever since. Yes, he
would like to go to the states again, but how
would he leave these, his native wife and
seven kids? Truly a model South Sea sailor,
this Joe.
A half-dozen children had joined the pro-
cession now, joking and scampering about us.
One in a yellow flowered dress was gloriously
healthy and handsome. A couple in the old-
fashioned "pareu" (?) were charmingly pic-
turesque. One was surprisingly active on a
pair of bilateral club feet. So we frolicked
along, teaching them to say "At-a-boy!" until
we came to a house built according to the
archaic cannibal Marquesan plan. It was
made of upright poles woven close together
with bark or something, and thatched with
cocoanut leaves. At one end of its cobble-
stone veranda was an open shed, consisting
of only a roof and the posts that supported
it. This was the family kitchen, and here
on some palm logs sat an old man with bad
elephantiasis, and a peculiarly miserable
looking man, his son. We gave the custom-
ary "ca-a-o-a" of greeting, and sat down with
them. The old gentleman talked for some
time about his legs, which he had the grace-
ful humor to laugh at, and then his wife
came with a similar set to exhibit. A few
sentences take a long time, when they must
be interpreted each way from English to
Marquesan via my French, but in time they
showed us the real patient. The young man
opened his shirt collar and exhibited on
either side of his neck open running sores
over two inches long. The doc was plainly
puzzled, as I could tell by the amount of
fool questions I had to ask for him. "How
old is he?", "Who are his parents?", "Was
m
SOtJtfiERN MEDICINE AND SURGERV
December, 1929
he born here?", etc. You know how to stall
for time. Doc's pink young face beneath a
Mexican straw sombrero registered nothing,
but I knew he was searching all the forgotten
corners of his medical education. Two or
three times his lengthy figure folded up as
he squatted down to look, and again he arose
to consider. "Do you notice anything funny
about his left hand, Larry?" "Now that you
mention it, yes." "Ask him if he ever feels
cold in his hands." "Est-ce-qu'il a froid dans
les mains?" Our grave escort engaged in a
few new combinations of vowels without con-
sonants with the patient and replied, "Pas
dans les mains, mais souvent dans les pieds"
(not in the hands, but often in the feet).
The doc moved back a step and I began to
chuck a little girl under the chin and tickle
her. A pretty young woman came forward
and sat down to nurse a little baby. I asked
who was its father. "Le malade." Somehow
the little girl and I became positively hilari-
ous in a tickling contest — it would not do to
show how I felt. Doc presented the patient
with all the dressings in his bag, and much
advice, but touch him again he did not do.
The baby had impetigo, and the httle bag
was lightened of what was left of zinc oxid.
We went scampering down to the stream
with the kids and washed carefully. Doc
told me to explain to our guide, "II dit que
c'est bien mauvais. C'est le leprosie." (He
says that it is very bad. It is leprosy.) The
man bowed his head a little, gulped, straight-
ened up with a far-away look in his eyes.
Then he looked at me quite intimately as if
to say, "I can see your sympathy with my
people." What he did say was a slow "Ah,
oui." (Oh, yes.)
As we walked down I was impressed with
the one most obvious feature of the place.
The path was lined with stone terraces which
had formerly been the foundations of houses.
Almost all of them were either altogether va-
cant or supported only a ruin of rotting poles
— "II y a beaucoup des malades ici, mon-
sieur." (There are a lot of sick people here,
sir.) "C'est domage" (It's too bad), I re-
plied. "It's a damn disgrace to the French,"
I added to Doc.
He told me there were less than two hun-
dred in the town. It seemed as though we
had seen more patients than that. What re-
mains of the population is mostly near the
beach along the broad avenue there. It is
nothing but a wide stone path, but its dimen-
sions and the ancient breadfruit trees evenly
planted down the sides bespoke a greater
town in the old days. It is good to think of
the dances that took place before they fell
from grace, and of the merry idle cannibals
who were still free a half century ago.
A little girl with flowers in her glossy black
hair met us in front of one of our earlier
patient's houses. They still know the use of
flowers and cocoanut oil. She carried a co-
coanut shell with five fresh eggs in it. Her
husky brother followed her with four bunches
of bananas on a pole. We had learned now
to accept presents, although we felt like rob-
bers. Self respect requires them to give the
stranger more than he has given, and it was
touching to see their faith in Doc's hurried
and often hopeless efforts. It took an extra
trip for the surf boat to bring our fees from
shore to the launch.
Barring the leper, Hana Vava seems to be
worse than Amoa. Doc could scarcely walk
through the town to take a bath in the stream
without being called in to see tuberculosis
cases. This year there have been four births
to fourteen deaths. The poor old French
cure, eighty-five years old, and with elephan-
tiasis, seems resigned to saving their souls
and letting them die. The French system
provides for two doctors in the whole archi-
pelago. As a matter of fact, there is only
one here, and in the absence of an adminis-
tration, most of his time is taken up with
government. He is, so far as we can see,
both wise and anxious to help, but what can
one man do?
Last night most of the sixty inhabitants of
Hana Vava came on board for a dance. With
a tin can for a drum they did a wonderful
job. I never knew how thrilled I could be
watching dancing before, or how thoroughly
congenial and human a bright bunch of sav-
ages can be.
The South Sea Islander is by no means
dead yet, but without help, this most charm-
ing of races cannot last long. If help is de-
nied, the crime of murder shall be written
again against white civilization.
It is a long time since I have been so
much stirred by a social situation.
December, 192>
SOUTHERN MEDICINE AND SURGERV
)ii)i
Resolutions
(Rec'd for Publication Nov. 25)
The Guiltord County ^Medical Society, in
regular session, resolves:
WHEREAS: the members of the Medical
Profession of the State of North Carolina are
rendering through the practice of their pro-
fession a vital and necessary service to hu-
manity with the paramount thought of ren-
dering service and aid and not that of pe-
cuniary reward, yet realizing that a certain
amount of compensation for their services is
essential, as is the case for the services of
members of various other professions and
occupations,
THEREFORE, since the Medical Tracti-
tioner heeds the calls of suffering mankind
night and day, summer and winter, with the
relief of the unfortunate human being upper-
most in his mind, and giving his attention
to the pecuniary remuneration last, it can be
readily seen that he is often called upon to
see the sick and afflicted indigent of his com-
munity who are unable to pay even the small-
est fees. This, of course, means that he gives
his services freely and without hesitancy, not
weighing the cost of his medical education
which has been increased by the recent re-
quirements of two years of academic work,
four years for an M.D. degree and one to
two years in a hospital, serving without com-
pensation. The State has also added the
requirements of health and birth certificates,
quarantine cards and venereal disease re-
ports, all of which require time to fill out.
By giving this service directly to the sick,
the state and county are thereby relieved of
a large burden, both directly and indirectly,
because no sick man can produce and a citi-
zen who is not an asset is a liability.
The equipment necessary for the practice
of modern medicine is considerably greater
than formerly, due to the new diagnostic
methods which require elaborate and expen-
sive instruments.
Because of the above mentioned conditions,
the time of the medical practitioner is large-
ly taken up in treating the indigent sick of
his community, for which he received no rec-
ompense. This then places uix)n the doctors
of the state a greater financial burden than
that carried by any other profession.
fHEREEORE, in consideration of this
uncompensated service that the medical pro-
fession is called upon to render mankind di-
rectly, and the city, county and state indi-
rectly, the Guilford County Medical Society
resolves to go on record as upholding and
supporting the recent step taken by the Ire-
dell-Alexander County Medical Society, in
an effort to prevail upon the State of North
Carolina to abolish the Twenty-five Dollar
Annual Tax on all medical practitioners,
which will relieve a certain amount of the
financial burden now carried by this profes-
sion.
FURTHER, to aid in this matter by re-
questing each County Medical Society to ap-
point a committee to confer with their local
representatives and senators, in an effort to
induce them to see he justice of the above
request.
BE IT FURTHER RESOLVED that a
copy of this resolution be spread upon the
minutes of this Society and a copy sent to
the following named persons: The Governor
of North Carolina, The Speaker of the House
of Representatives, The President of the
Senate of North Carolina, The President of
the North Carolina State Medical Society,
and to each Senator and local Representa-
tive, to be presented to the House of Dele-
gates at the next annual meeting, to each
member of the State Medicalt Legislation
Committee, to the Secretary of each Medical
Society in each county, to the Editor of
Soul hern Medicine and Surgery and to the
Associated Press.
Iodine Research Program
Since January 1, 1928, Mellon Institute of
Industrial Research, Pittsburgh, Pa., has had
in operation a Multiple Industrial Fellowship
founded for the purpose of investigating the
pro|iert!es and uses of iodine. All results of
the Fellowship studies will be published. Re-
cently, through an additional appr()|)riation
from the Fellowship donor, Mellon Institute,
acting for the Iodine Fellowship, has made
arrangements for the study of certain iodine
proiilems in other institutions that have spe-
cial facilities for such types of work. On
October 7, 1929, a scholarship was founded
at the Philadelphia College of Pharmacy and
Science by a research grant from the Insti-
tute. This scholarshi[) — which, for the col-
lege year 1929-30, will be held by Mr. U f,
§otJttJ£kM Mfebtcmfe ANb StJkGtftV
becember, 1920
Tice — will have for its aim a broad investi-
gation of vehicles and solvents for iodine,
especially for external use m medicine. A
large number of new organic chemicals will
be studied as solvents with the object of
evolving, if possible, a more satisfactory
preparation than the alcoholic tincture now
in use.
Another phase of the research program in-
cludes a grant made on September 26, 1929,
to the Pennsylvania State College for a com-
prehensive investigation — under the direction
of Professor E. B. Forbes of the Institute of
Animal Nutrition — of the nutritional place
and value of iodine in the feeding of live
stock. Dr. Karns and his co-workers on the
Iodine Fellowship of Mellon Institute are co-
operating closely with Dr. Forbes and his
staff, mainly by preparing standardized feeds.
The findings of this research also will be
made available to the public, in accordance
with the Iodine Educational Bureau's policy
of disseminating to every one interested the
result of all investigations made under its
aegis.
Mellon Institute is giving consideration to
the founding of a research scholarship in a
medical school for the purpose of aiding in
the solution of incompletely answered ques-
tions respecting the utility of iodine in inter-
nal medicine. A number of pharmacologists
are aiding the Institute in determining a pro-
gram for such pharmacodynamic inquiry.
The N. C. State Board of Medical
Examiners
Meeting at the Washington Duke Hotel,
Durham, November 2 7th, the Board licensed
19 physicians upon endorsement of their cre-
dentials from other states. Several members
of the Duke iMedical Faculty were among the
group licensed.
The list is as follows, with new locations
as far as has been determined:
Dr. David Asbill, of South Carolina, will locate
at the Davis Hospital, Statesville, N. C.
Dr. Harold .^moss, of Johns Hopkins and Harvard
Universities will be Professor of Medicine at Duke.
Dr. William Bastian, of Williamsport, Pa. (unde-
termined).
Dr. Lucien Achard, of University of Naples, will
be at the State Hospital, at Morganton.
Dr. John Bradficld, of LaCrosse, Wisconsin, will
locate at Tryon, N. C.
Pr. F. Bert Brown, of Georgia, goes to the Orth-
opedic Hospital at Gastonia, N. C.
Dr. Clyde Crane, of Marion, Ohio (undetermin-
ed).
Dr. Vartan Donidian, of Scranton, Pa. (undeter-
mined).
Dr. Fath Fairlield-Gordon, of Boston, is at the
N. C. C. W. as Psychiatrist.
Dr. Julian D. Hart, of Johns Hopkins, will be a
member of the Duke Medical Faculty.
Dr. Clem Ham, of South Carolina, is the new
health officer for Pitt County.
Dr. William L. Kirby, of Nashville, Tenn., will
locate in Winston-Salem, N. C.
Dr. William Miller (colored), of Charleston, S. C.
(undetermined).
Dr. George P. Nowlin, of Virginia, will be with
the Nallc Clinic, of Charlotte.
Dr. Leora Perry, of South Carolina, may locate
in Charlotte.
Dr. Alfred Shands, of Washington, D. C, will be
Professor of Orthopedics at Duke Medical School.
Dr. John E. Taylor, of West Virginia, has located
in Morganton.
Dr. Porter P. Vinson, formerly of Davidson, N. C,
and now a member of the Mayo Clinic, was also
licensed in North Carolina.
Dr. Wiley D. Forbus, of Johns Hopkins Hospital,
will be Professor of Pathology at Duke.
Several men were before the Board for dis-
cipline for violation of the Medical Practice
Act.
The personnel of the Medical Board which
;s ;;ow in its third year of office, having been
elected for a term of six years, is:
Dr. Paul Ringer, Asheville, President.
Dr. John W. MacConnell, Davidson, Secretary-
Treasurer.
Dr. Foy Roberson, Durham.
Dr. W. W. Dawson, Griffon.
Dr. W. H. Moore, Wilmington.
Dr. J. K. Pepper, Winston-Salem.
Dr. T. W. M. Long, Roanoke Rapids.
Fancy vs. Fact
It was late in the evening and several callers were
chatting in the parlor when a patter of little feet was
heard at the head of the stairs. The hostess raised
her hand for silence.
"Hush, the children are going to deliver their good
night message," she said softly. "It always gives me
a feeling of reverence to hear them. They are so
much nearer the Cre?.tcr than we are, and they
speak the love that is in their little hearts never so
fully as when the dark has come."
There was a moment of dense silence — Then
"Mama," came the message in a shrill whisper,
"Willie's found a bedbug."
December, 1920
SOUTttekN MEWCINE ANt) SWkCfefeV
m
NEWS
Southern Orthopedic Hospital,
Richmond
Dr. Thomas F. Wheeldon, orthopedic sur-
geon of Richmond, will head the staff of the
new Southern Orthopedic Hospital, which has
grown out of an orthopedic institution oper-
ated for eight years in Barton Heights, Rich-
mond. The new institution will have
thirty-five beds and latest equipment for
orthopedic work, specially equipf)ed therapy
baths, x-ray equipment and other facilities
for major operations. The hospital will han-
dle other cases, as well as specialize in orth-
opedic surgery.
The original valuation of the property was
$165,000. The new corporation will expend
$15,000 in improvements. These improve-
ments will include the building of a ramp for
the moving of patients and installation of
equipment.
Gambles to Have Clinic
Drs. J. R. and J. F. Gamble have purchas-
ed a lot on Main street, Lincolnton, on which
it is their plan to erect a General Clinic build-
ing next spring.
The plans include an x-ray room, operating
room, office and consultation rooms on the
first floor, while the second story would be
devoted entirely to rooms for patients.
Both Dr. J. F. and Dr. J. R. Gamble are
graduates of the University of Tenn. Medical
School, and both have been long well estab-
lished in practice at Lincolnton.
New Martha Jefferson Hospital,
Charlottesville
The new $100,000 building, the gift of a
friend who wishes to be anonymous, was
opened December 1st.
The hospital will be operated in the future
on a non-profit basis. The doctors who
owned all of the common stock and many of
the preferred stockholders, have donated their
holdings to the organization with the idea of
making it a community hospital.
Dr. J. K. HoBGOOD, of Thomasville, has
joined the medical staff of the State Hospital
at Morganton.
.■\MERICAN L.\RVNX.OLOGIC.AL, RHINOLOGI-
CAL & OTOLOGICAL SOCIETY
A MEETING OF THE SOUTHERN SECTION WILL BE
HELD yANUARY ISTH, 1Q.50, AT ROANOKE, VIRGINIA.
Beginning promptly at o a. m., the following pro-
gram will be rendered:
1. "What Do We Know .'\bout the Cause and
Prevention of the Common Cold," Dr. C. M. Mil-
ler, Richmond. Va. Discussion, Dr. H. B. Stone,
Roanoke, Va. (By invitation.)
2. "What Can Otolaryngology Do to Develop the
Physical and Mental Potentialities of the Rising
Generation?", Dr. J. A. Stucky, Lexington, Ky.
Discussion, Dr. H. H. Briggs, .^sheville, N. C.
3. "Difficulties of Differentiating Certain Types of
Mastoiditis from Furunculosis," Dr. C. D. Blassin-
GAME, Memphis, Tenn. Discussion, Dr. Mortimer
H. Williams, Roanoke, Va. (By invitation.)
4. "A Report of Two Intranasal Angiomas," Dr.
J. J. Shea, Memphis, Tenn. Discussion, Dr. Thom-
as E. HiiciiES, Richmond, Va. (By invitation.)
5. "Brain Tumor, Cured by Ojiening and Draining
a Sphenoidal Sinus," Dr. T. W. Moore, Huntington,
West. Va. Discussion, Dr. J. A. White, Richmond,
Va.
6. "Differential Diagnosis of Laryngeal Carcinoma,"
Dr. Fielding O. Lewis, Philadelphia, Pa. (By in-
vitation.)
7. "Laryngeal Tuberculosis with Report of Case,"
Drs. E. E. Watson and Churchill Robertson,
Mount Regis Sanatorium, Salem, Va. (By invita-
tion.) Discussion, Dr. J. W. White, Norfolk, Va.
8. "Diagnosis and Treatment of Lateral Sinus
Thrombosis," Dr. Fletcher D. Woodward, Char-
lottesville, Va. Discussion, Dr. C. D. Noftsinger,
Roanoke, Va. (By invitation.)
Q. "Some Aspects of Laryngeal Tuberculosis," Dr.
J. B. Greene, .^sheville, N. C. Discussion, Dr. J. B.
NicHOLLS, Catawba Sanatorium, Va. (By invita-
tion.)
10. Remarks by Oiir President, Dr. Ross Hall
Skillern, Philadelphia, Pa.
11. "Presentation of Cases: (a) .Atelectasis of
Lower Left Lobe, Due to Impacted Wisdom Tooth;
Recovery; (b) Massive Collapse of Entire Left
Lung, Due to Impacted .22 Cartridge Shell; Recov-
ery," Dr. M. S. Equen, Atlanta, Ga. Discussion,
Db. E. T. Gatewood, Richmond, Va. (By invita-
tion.)
12. "Cerebrospinal Rhinorrhca," Dr. J. W. Jer-
VEY, Greenville, S. C. Discussion, Dr. Grant Pres-
ton, Harrisonburg, Va. (By invitation.)
13. "Tuberculous Otitis Media With Report of
Case," Dr. M. R, Modlev, Florence, S. C. (By in-
vitation.) Discussion, Dr. P. V. Mikell, Columbia,
S. C.
m
SOUtttfekK MEbtCltjfe Ato StRGfifeV
fiecemter, i9ii
LUNCHEON 1:30 P. M.
Visiting members of the Society and guests will
be entertained at luncheon by the Chairman.
MOTORCADE 3:00 P. M.
4:30 P. M. Members and guests will be enter-
tained at the home of the Chairman.
The semi-annual meeting of the Tenth
District Medical Society was held at Bre-
vard, October 23rd, afternoon and evening,
and in addition to the valuable program, ad-
dresses were delivered by Dr. L. A. Crowell,
and Dr. L. B. McBrayer, President and Sec-
retary-Treasurer, respectively, of the ]\Iedical
Society of the State of North Carolina. On
report of Dr. Frank H. Richardson of the
work of the Ninth District Medical Society
in conducting a clinic last summer on the
diseases of children, the Tenth District Medi-
cal Society decided to hold a clinic for the
doctors of their district during the year and
appointed a committee of which Dr. Richard-
son is chairman, to work out the details and
put the clinic into effect. The new officers
are Dr. J. G. Anderson, of Asheville, Presi-
dent; Dr. D. M. Mcintosh, of Old Fort,
Secretary, re-elected. The next meeting will
be held at Marion.
The Fourth District (N. C.) Medical
SocuTY met at Wilson, November 12th, un-
der the presidency of Dr. T. W. M. Long,
of Roanoke Rapids.
Dr. .J D. Willis, of Roanoke, Va., present-
ed a valuable paper on "The Use of Liver
E.xtracts in the Treatment of High Blood
Pressure." Other papers on the evening's
program were by Dr. A. G. Woodard, of
Goldsboro, and Dr. N. M. Saliba, of Wilson.
All papers elicited prolonged round table dis-
cussion.
Dr. Thel Hooks, of Smithfield, was elected
president. Dr. G. E. Bell, of Wilson, vice-
president, and Dr. W. B. Kinlaw, of Rocky
Mount, secretary-treasurer. The ne.xt meet-
ing will be held in Rocky Mount on the sec-
ond Tuesday in February.
The Iredell-Alexander Counties Med-
ical Society's officers for 1930 are: Presi-
dent, Dr. L. M. Little, Statesville; Vice-
President, Dr. J. S. Talley, Troutman; Secre-
tary-Treasurer, Dr. Roy C. Tatum, States-
ville; Delegate to State Society, Dr. M. A.
Atjams, Statesville.
The Cabarrus County Medical Society
at its December meeting elected new officers
for the ensuing year as follows: Dr. I. A.
Yow, president; Dr. J. R. Howard, vice-presi-
dent; Dr. D. G. Caldwell, secretary and
treasurer.
Dr. N. E. Lubchenko, of Harrisburg, was
elected delegate to the State Medical Society
meeting next April. Dr. P. R. McFadyen
was named as alternate.
The Scotland County Medical Society
held a meeting on November 27th, at Lau-
rinburg.
Papers were read at this meeting by Dr.
Jennings of Bennettsville, Dr. J. M. Gardner
and Dr. Jno. S. Gibson, and Dr. E. A. Liv-
ingston of Gibson. Dr. L. T. Buchanan,
president of the society, presided.
The Mecklenburg County Medical So-
ciety, on Dec. 3rd, heard papers by Dr. V.
K. Hart and Dr. R. F. Ferguson and elected
officers for 1930. Dr. L. G. Gage was chosen
president. Or. R. T. Ferguson vice-president,
and Dr. R. B. McKnight secretary — all with-
out opposition. .Appreciation was expressed
of the work of the retiring secretary. Dr. L.
C. Todd, who refused to stand for re-elec-
tion.
Delegates to the State Medical Society
were chosen as follows: Drs. J. E. S. David-
son, John Q. Myers, R. H. Lafferty, J. P.
Kennedy, J. M. Northington; Alternates,
Drs. J. R. Irwin, R. M. Gallant, Wm. Allan.
R. H. Lafferty and J. H. Tucker.
The Cumberland County Medical So-
ciety held its monthly meeting December
6th. Subjects discussed: "Some Phases of
Diphtheria and Scarlet Fever," Dr. A. S.
Root, Raleigh; "The State Laboratory of Hy-
giene," Dr. C. A. Shore, Raleigh; "Surgical
Treatment of Gastric and Duodenal Ulcer,"
Dr. E. S. Bulluck, Wilmington. After a four
reel motion picture demonstration, officers
were elected.
The Union County Medical Society
held its last meeting for the year at the Hotel
Joffre, Monroe, Dec. 12th. Dr. J. H. Can-
non, of Charleston, S. C, the special guest of
the occasion, addressed the society on Irreg-
December, 1929
SOUTHERN MEDICINE AND SURGERY
ularities of the Heart.
Ur. Cannon's excellent address came di-
rectly after a sumptuous dinner and was illus-
trated by electrocardiographic records. Ur.
L. A. Crowell, president of the State Society,
spoke briefly, as did Drs. J. H. Tucker, R. F.
Leinbach, T. C. Bost and J. :M. Xorthington,
of Charlotte.
Dr. John Q. Myers, Charlotte, has asso-
ciated with him Dr. D. C. Jones, who re-
cently completed an internship at the Uni-
versity of Pennsylvania Hospital.
Dr. Julian A. Moore has opened offices
at 301 Flatiron Building, Asheville, N. C,
for the practice of general and thoracic sur-
gery.
Dr. Annie .Ale.xander, recently deceased.
Dr. Walter P. Craven, 84— College of
Physicians and Surgeons, Balto., 83 — died at
his home in ^Mecklenburg County, December
5th. He had not been in practice for a num-
ber of years.
Dr. Craven was born in Randolph county,
but had practiced medicine in Mecklenburg
for SO years. He was an elder of Hopewell
church, a member of the Mecklenburg Camp
of Confederate Veterans and a member of
the Mecklenburg Medical Society.
Among the survivors are two doctor sons,
Dr. William Wilhelm Craven, of Charlotte,
and Dr. Thomas Craven, of Huntersville.
Dr. Preston Nowlin, Univ. of Va. '24,
has become a member of The Nalle Clinic,
Charlotte. Other members are Drs. B. C.
Nalle, E. R. Hipp, L. G. Gage, G. D. Mc-
Gregor, L. W. Kelly.
Dr. Beverley R. Tucker, of Richmond,
spoke to the Ginter Park Woman's Club on
November 20th in appraisement of the char-
acter and the public services of John Ran-
dolph, of Roanoke. Dr. Tucker has just pub-
1 shed for private distribution "The Lost Le-
nore," a one-act play dealing with the life of
Edgar Allan Poe.
Dr. Percy G. Hamlin, late of the staff of
the Eastern State Hospital, Williamsburg,
Virginia, is now a member of the staff of the
Slate Hospital at Harrisburg, Pennsylvania.
Dr. Thomas M. Jordan has resigned his
position at the State Hospital, Raleigh, and
has been succeeded by Dr. I. W. Lamm, of
Lucama.
Dr. W. W. D.awson, prominent Pitt coun-
ty physician and member of the State Board
of Medical Examiners of N. C, suffered pain-
ful and possibly serious injuries in an auto-
mobile accident near Grifton Dec. 4th.
The Tuomy Hospital, Sumter, S. C, is
to have a $100,000 addition. Work is to
commence in January.
Dr. Eugene Kahn, of Munich, Germany,
has been made Professor of Psychiatry and
Mental Hygiene in the Yale School of Medi-
cine. The Rockefeller Foundation pledged
$100,000 a year for ten years to develop the
psychiatry program and in addition provided
the funds for the Institute of Human Rela-
tions building, now under construction, in
which the department will be housed.
Dr. L. V. Cloninger, of Statesville, was
shot to death in a Charlotte boarding house
November 2nd. He was 5S years old.
Dr. R. H. Gary, of Murfreesboro, died
October 26th. He was stricken with paraly-
sis while testifying in a civil case at Winton.
Dr. Ernest E. Hadley has resigned from
the psychiatric staff of Saint Elizabeth's Hos-
pital, to devote his entire time to the practice
of Psychiatry and Psychoanalytic Therajiy.
His office is removed from the Rochambeau,
to the Columbia Medical Building, 1835 Eye
Street N. W., Washington, D. C.
Dr. Leora Perry, Medical College of the
State of South Carolina '26, has removed
from Ridgeland, S. C, to Charlotte, N. C,
and will use the offices formerly occupied by
Dr. W. G. Bvrd, of Goldsboro, died of a
sudden heart attack, October 25th.
On Dr. .Andrew Johnson Crowell,
Charlotte, has recently been conferred the
honor of election to the International Urolog-
ical Society. The next meeting wil be held
in ^Madrid.
Dr. .\nnie L. .Xlexander, of Charlotte,
died October 15 th, Dr. Alexander was the
SOtJtHERN MEWClNfi AND SURGERY
December, 1929
first practicing woman physician south of the
Potomac River.
A man claiming to be Mr. Chas. Miller,
about 5 feet 5 inches tall, slim, dark hair, not
very neatly dressed, rather nervous and fa-
miliar type, about 28 years old, was calling
on doctors in Elizabeth City recently purport-
ing to be representing the American Medical
Association. Advices from the A. M. A. are
to the effect that they do not employ any
such jjerson.
Dr. L. a. Crowell, President of the Med-
ical Society of the State of North Carolina,
addressed the meeting of the First District
Medical Society at Edenton, September 28th.
Dr. J. M. Peterson and his family, of
Spruce Pine, N. C, have moved to Johnson
City, Tenn., which means Spruce Pine will
suffer a distinct loss. He has accepted a po-
s tion on the medical and surgical staff of the
National Soldiers" Home in Johnson City.
Dr. a. F. Toole, 52, of Asheville, died
recently after a lingering illness.
At the special term of Superior Court the
case of O. E. Smith, administrator, vs. Dr.
C. R. Wharton, for alleged neglect, which it
was claimed, caused the death of plaintiff's
wife, was non-suited.
Dr. Connie Guion, a native of Lincoln-
ton, has been made Chief of the Department
of Medicine of the Cornell Clinic, New York
City.
Simple Enough
Plain Talk writes from Why Not to ask if Shucks
and Nubbins knows why a Randolph catfish bites
the hook on the left side of his mouth. That's easy:
the Randolph catfish is right-handed. All right-
handers assault plug tobacco and play a chicken leg
from left to right. — 0. J., in Greensboro News.
The judge admonished the prisoner: "I cannot
conceive a meaner, more cowardly act than yours.
You have left your wife. Do you realize that you
are a deserter?"
"Well, judge, if you knowed dat 'oman lak I does,
\ ou woulden call me no deserter. Judge, I'se uh
refugee, dat's what I is. Yes, suh, uh refugee."
Our Medical Schools
medical college of the state of south
carolina
At the Miami meeting of the Southern
Medical Association the Food Research
Laboratory presented an exhibit showing the
results of survey work on the iodine content
of foods. The maps and charts displayed
under the supervision of Mr. F. Bartow Culp,
of the Laboratory, created a great deal of
interest.
A paper entitled "The Potato as an Index
of Iodine Distribution," by Roe E. Reming-
ton, F. Bartow Culp and Harry von Kolnitz,
of the Food Research Laboratory, was pub-
lished in the October number of the Journal
of the American Chemical Society.
Dr. Roe E. Remington, of the Department
of Nutrition and Food Research, delivered
an address at the annual banquet of Gamma
Sigma Epsilon Chemical Fraternity, at Co-
lumbia on November 29th.
Dr. Kenneth M. Lynch was elected
pres'dent of the American Society of Tropical
Medicine at the Miami meeting.
Dr. Robert Wilson was elected chairman
and Dr. Kenneth M. Lynch secretary of
the section on medical education of the
Southern Medical Association, at the Miami
meeting.
medical college of VIRGINIA
The number of visits to the outpatient de-
partment of the Medical College of Virginia
has increased fifty per cent in the last four
years and the service is still growing. Last
year there were 34,609 visits. The records
for the first five months, July to November,
of the current year show an increase of 2,043
over the corresponding period last year.
There is also a substantial increase in de-
mands for dental service on the part of clinic
patients. At present there are approximately
fifteen hundred visits per month to the dental
infirmary or an average of around sixty per
day.
The grant from the Chemical Foundation
for research in chemistry in relation to medi-
cine and dentistry has made it possible to
add another member to the department of
chemistry this year. Six special research
December, 1929
SOUTHERN MEDICINE AND SURGERY
899
rooms have been provided and equipped to
take care of the increased activities of this
department.
Dr. Page Northington, class '17, is as-
sociated with Dr. C. G. Coakley, of New
York, after two-and-a-half years of work in
diseases of the eye, ear and throat at the
New York Post-Graduate and at Bellevue.
Dr. Northington has also been appointed in-
structor in oto-laryngology in the College of
Physicians and Surgeons, Columbia Univer-
sity, and attending surgeon at the Presby-
terian Hospital. He will do special work
in vestibular testing, under a research grant,
at the New York Neurological Institute, un-
der the direction of Professors Tilney and
Pike.
W.AKE FOREST COLLEGE
The doctors of the State are extended a
most cordial invitation to hear Dr. W. G.
Morgan, President of the A. M. A., who will
lecture to the Wake Forest students in Jan-
uary. This lecture is under the auspices of
the \Villiam Edgar INIarshal Medical Society
and is also a lyceum number of the college.
Dr. and Mrs. Morgan will be the guests of
President and Mrs. Gaines while here, and
everyone is looking forward to his lecture.
We will be glad to let you know the exact
date and should hear this week. I am sure
all N. C. doctors will enjoy meeting him.
On December 5th Dr. W. C. Davison, of
Duke University, spoke to our medical stu-
dents and friends on the "Evolution of Medi-
cine." In tracing the history of medicme
Dr. Davison showed us some very rare, old,
original medical books which he had collect-
ed in North Carolina.
The next meeting of the William Edgar
^Marshal Medical Society will consist entirely
of papers prepared by the students on re-
search work, and should be very valuable to
all the members.
Junior Physician — $2200 and cottage;
married; splendid opportunities; at Eastern
Shore State Hospital, Cambridge, Maryland.
(Apply State Employment Commission,
22 Light Street,
Baltimore, Md.)
No Ice-Collar, No Bleeding. — Two years ago I
was struck with a peculiar fact relative to my ton-
sillectomies. The cases operated on at the various
hospitals were subject to post-operative blecdinR,
while such bleeding was much less prominent or
practically absent in the cases operated on in the
office and sent to their respective homes. This
held good in tonsillectomies done under both local
and general anesthesia. The patients operated on
at the hospitals would have their necks immediately
enclosed in an ice container, whereas the office cases
received no such medication. I gave orders that
none of my tonsillectomy cases was to have an ice
pack applied to the throat following operation, and
this rule has been adhered to in the last 250 ton-
sillectomies. In this number there has been one
post-operative hemorrhage of minor consequence.
I am firmly convinced, in spite of all teaching to
the contrary from the time the first tonsillectomy
was ever performed, that the ice pack is not only
of no value, but is a positive menace. I have hesi-
tated for some time to publish such a view, realizin';
that it is contrary to universal conception. I am
making no pretense at analyzing the physiological
princip'es underlying it. I believe it is generally
recognized that the application of cold causes a
primary contraction of the arterioles, and this is
followed by secondary paralysis and rela.xation. This
may or may not be an important factor. On the
other hand, from a purely theoretical standpoint, it
is possible that the contraction of the superficial
arterioles of the skin induces a compensatory dilata-
tion of the deeper vessels with wh'ch we are pri-
mirily concerned. If this method of treatment is
sufficiently followed by our oto-Iaryngologists, the
truth of these deductions will be readily proven
and the ice collar will be relegated to the realms of
antic]uity. — Reese, in Southwestern Medicine, Nov.
The Seesaw as a Therapeutic Agent
1. The head is lowered 10 to 15 degrees for about
two minutes.
2. The body is on a level for two or three min-
utes.
3. The head is elevated 10 to 15 degrees for two
or three minutes. By these treatments the brichial
blood pressure is raised 10 to IS mm. of mercury
when the head is down, and lowered 10 to 15 mm.
when the head is up.
Shortly after each of the treatments there is fre-
quently an improvement in the cerebral circulation.
One patient who was so confused mentally that
he was not able to recite a simple ditty, was so
improved by these exercises that he could recite the
entire poem without hesitation; al.so, whereas he
had previously been unable to attend to his business
affairs and unable to sign checks, he was able to
resume these tasks. — A. H. Terry, jr., New York
Stale Jour, nj Med., Dec, 1020.
900
SOUTHERN MEDICINE AND SURGERY
December, 1Q29
BOOK REVIEWS
THE NUTRITION OF HEALTHY AND SICK
INFANTS AND CHILDREN, for Physicians and
Students, by £. Noble. Professor of the University
and First Assistant; C. Pirguet, Late Professor of
the University and Director of the CUnic; and R.
Wagner, Assoc. Professor and Second Assistant — AH
of Children's Hospital of the University of Vienna.
Authorized translation by Benjamin M. Gasul, B.S.,
M.D. Second edition, revised, illustrated. F. A.
Davis Company, Philadelphia, 1Q20. S3. 50.
The book represents a decision to make
Professor Pirquet's "Nem'' system available
to the English-speaking physician. The pure-
ly clinical dealing with nutritional disturb-
ances recommends it strongly to the practi-
t'oner. A definite quantity of milk replaces
the calorie as the unit of feeding, hence
"Nem" — nutrition — equivalent — wilk.
The sitting height, instead of the standing
height or the weight, is used as a basis for
calculations of food requirements. !Many
simplified terms are used which can be read-
ily learned, and which will greatly simplify
the nomenclature of feeding. The instruction
is concise, often to the point almost of blunt-
ness; but it gives the impression of knowl-
edge of the subject which would be expected
of authors of such enormous clinical experi-
ence.
MRS. EDDY: The Biography of a Virginia Mind,
by Edwin Franden Dakin. Charles Scribner's Sons,
New York and London, 1929. $5.00.
This biographer approaches his subject
with a remarkably open mind and deals with
it dispassionately throughout. Naturally, the
product will not please either blind followers
or rabid enemies. It would seem that there
is a great willingness to gloss over ^Irs.
Eddy's many deliberate departures from the
truth.
Careful notes on the early life of ]Mary
Baker reveal an every-day picture in a fam-
ily doctor's practice — that of a child not as
robust as its brothers and sisters dominating
the family by tantrums, breath-holdings, "fits
of catalepsy" and "spells of unconscious-
ness." To the credit of the family doctor,
he sa'd that Mary had hysteria mingled with
bad temper. Her father prided himself on
paying every penny be owed but paid the
scantiest wages in his community. Mary,
after reading carefully how Samuel was called
by the Lord, naively re-enacts the scene with
herself in the role of Samuel; and she replies
to the questionings of the elders when she
applies for admission to the church — she says
at 12; church record shows 17 — with the
same vague impressiveness and lack of can-
dor which characterized her later life. Of
her many husbands, perhaps, the item of
most interest is that the first, "Wash" Glover,
died of yellow fever in Wilmington, N. C,
and was there buried. Thereafter she re-
sumed her selfish tyranny over her father and
s'sters, was given morphine to control her
hysterical outbursts, and later subjected to
mesmerism, to which she was unusually sus-
ceptible. The soon began to fall into mar-
velous trances and receive messages from the
dead. Soon afterward she gave her child —
which had never nursed — to its foster-
mother.
Dentist Patterson, whom she married in
1853, was an understanding man. When a
nei':;hbor who had driven 30 miles through
snow-drifts to tell him his wife was dying,
told his news breathlessly, the doctor calmly
remarked "She'll probably hold over until I
finish this job," and went on with his work.
As soon as the Civil War broke out he man-
aged to get himself captured at Bull Run,
and spent the next few years in Libby Pris-
on. iHis wife wrote a poem on his capture
entitled "To a Bird Flying Southward!"
She visited one, Quinby in 1862, from
whom she purloined most of the stuff which
goes to make up Christian Science.
Her later life and writings, how she be-
came a deity and entered into the secret place
of The iMost High, and the concluding chap-
ters under the title "The Twilight of a God,"
— all these make most fascinating reading.
And an amazing amount of work has been
done to make it factful as well as fascinating.
.APPLIED ELECTROCARDIOGRAPHY: .\n In-
troduction to Electrocardiography for Physicians
and Students, by Aaron E. Parsonnelt, M.D.,
F.A.C.P.. .Attending Physician and Cardiologist,
Beth Israel Hospital, Newark, N. J., and Albert S.
Hyman, A.B., F.A.C.P., .Associate Physician and
Cardiologist, Beth David Hospital; with a foreword
December, 1029
SOUTHERN MEDICINE AND SURGERY
by Harlow Brooks, M.D., F.A.C.P., Professor of
Clinical Medicine, New York University. 120 illus-
trations. The MacMillan Co., New York, 1929.
$4.00.
The authors express the hope that this vol-
ume may "dispel that inferiority complex
that surrounds the doctor when he contem-
plates the use of the electrocardiograph."
The care taken to make every statement
plainly understandable and to give reasons
should go far toward accomplishing this ob-
ject. Electrocardiograms, indicating healthy
hearts, and those representing various disease
conditions are analyzed and contrasted.
BLOOD GROUPING IN RELATION TO CLIN-
IC.\L AND LEGAL MEDICINE, by Laurence H.
Snyder, Sc.D., Associate Professor of Zoology, North
Carolina State College, Raleigh ; Committee on Blood
Grouping, National Research Council. Willmms &
Wilkins Co., Baltimore, 1929. JS.OO,
The blood group problem is important to
doctors mainly because of its relationship to
transfusion and the determination of parent-
age. A technic of transfusion is translated
from Librarius of Halle, as early as 1615.
The first successful transfusion in animals of
which we have knowledge was done at Ox-
ford in 1666; in man, my Major, at Kiel, in
1667, or by Denys at Montpellier, in 1667.
Crile's work in 1907 gave a great impetus to
the procedure. Agote of Beunos Aires first
transfused citrated blood in 1914.
Chapter heads are: Indications for Blood
Transfusion, Choosing a Donor, Technic, He-
redity of Blood Groups, Blood Groups and
Pathology and Racial Distribution.
BODILY CHANGES IN PAIN, HUNGER,
FEAR AND RAGE: An Account of Recent Re-
searches Into the Function of Emotional Excite-
ment, by H'alter B. Cannon, M.D., S.D., LL.D.,
George Higginson Professor of Physiology in Har-
vard University. Second edition. D. App'.eton &
Co., New York and London, 1929. $3.00.
Like the Bible and the Constitution, Dr.
Cannon's writings on his researches have been
much quoted and little read. Here may be
had knowledge of matters of such importance
as the bodily changes ensuing on pain, hun-
ger and strong emotions, and which are so
intimately concerned with the individual's
welfare and preservation.
The description of the wonderful arrange-
ment by which a hotter flame and more fuel is
automatically and promptly supplied for giv-
ing greater strength to the arm or fleetness to
the legs, and the clotting time is shortened
against the chance of death from hemorrhage
is well worthy of careful study and profound
reflection.
THE CARE OF THE SKJN AND HAIR, by
Wm. Allen Pusey, A.M., M.D., LL.D., Professor of
Dermatology emeritus. University of Illinois; For-
mer President of the American Dermatological Asso-
ciation and of the American Medical Association.
D. Appleton & Co., New York and London, 1929.
$1.50.
The structure, functions and nutrition of
the skin are described. General health con-
siderations are included. There are chapters
on bathing, soaps and powders, creams and
ointments. Of special interest is that on
chapping, chafing, sunburn, poison ivy,
herpes. What to do about bad complexions,
greasiness, red noses, wrinkles, warts, moles
and freckles will interest many; while the
care of the hair and more or less vain efforts
to retain it concern us all.
R.\CIAL HYGIENE: A Practical Discussion of
Eugenics and Race Culture, by Thurman B. Rice,
A.M., M.D., Associate Professor of Bacteriology and
Public Health, Indiana University School of Medi-
cine; E.xtension Lecturer in Eugenics, Indiana Uni-
versity; Chairman, Indiana Eugenics Committee.
The MacMillan Company, New York, 1929. $4.50.
This is a book for the general reader on
the fundamentals of human heredity. The
welfare of the race is its aim. One of the
important questions asked and answer at-
tempted, is "Are the Colored races menacing
White civilization?"
The author concedes that the cause of eu-
genics has suffered from the activities of its
own over zealous friends. He shows a
thoughtful consideration for the sensibilities
of all races, peoples and classes.
The Jew is said to represent the most suc-
cessful experiment in race culture. Heredity,
environment and training make "The Trian-
gle of Life," and to each much importance
is attached.
Mendel's Law, Good and Bad Stock, In-
herited Diseases and Defects, Inbreeding
SOUTHERN MEDICINE AND SURGERY
December, 1929
Economic Problems, Marriage Selection, The
Defective as a Social Menace, and The Prac-
tical Application of Racial Hygiene, are im-
portant chapter heads.
The facts are carefully authenticated, the
reasoning cogent and the narrative in an en-
tertaining style which loses nothing for being
expressed in words understandable to intelli-
gent general readers.
THE VOLUME OF THE BLOOD AND PLAS-
MA IN HEALTH AND DISEASE, by Leonard G.
RowNTREE, M.D., and George E. Brown, M.D.,
Division of Medicine, The Mayo Clinic and The
Mayo Foundation, Rochester, Minnesota, with the
Technical Assistance of Grace M. Roth. 12mo,
219 pages, illustrated. Philadelphia and London:
W. B. Saunders Company, 1929. Cloth, ?3.00 net.
The authors believe we have reached a
point, from which forward, information on to-
tal quantities of blood and its plasma will in
many cases appear as needful. By the dye
method this knowledge is easily available.
Their observations lead them to conclude that
plasma content is remarkably constant, vary-
ing only in very narrow limits, exxept under
most e.xtraordinary circumstances. , They are
convinced that blood plasma and volume are
deserving of much intensive study.
HEALTHFUL LIVING: The Why and How, by
S. E. BiLiK, M.D. Charles Scribner's Sons, New
York and London, 1929. $2.50.
A screed written in a vigorous, go-getter
style by an apostle of the idea that we need
to exercise our muscles regularly whether we
use them or not.
The chapter on Our Body will give the
average exerciser a better idea of what goes
into his make-up; those on Exercise, Diet,
Girth Control ,etc., will appeal to those who
■ are entertained by the ways of radio-announc-
ers.
MEDICAL LEADERS From Hippocrates to Os-
ier, by Samuel W. Lambert, M.D., and George M.
Goodwin, M.D. Illustrated. The Bobbs-Merrill
Company, Indianapolis, 1929. $5.00.
The authors attempt to trace the order of
progress of knowledge of disease and its mas-
tery; paying homage to individuals is inci^
dental, or at least secondary. The majority
•pf the human race, they recognize to be "in
the nursery of medical progress," and the au-
thors would contribute toward closing up the
gap between keen leaders and dull followers.
A handsome, well illustrated book, full of
information and stimulation from Hippxjcrates
and Aristotle to Gorgas and Osier.
NEW AND NON-OFFICI.'VL REMEDIES, 1929,
Containing Descriptions of the .\rticles which Stand
Accepted by the Council on Pharmacy and Chem-
istry of the .American Medical Association on Jan-
uary 1, 1929. American Medical Association, 535
North Dearborn Street, Chicago. ,
"In this edition appears for the first time
a list of 'exempted articles,' which the Coun-
cil has decided to publish. These comprise
( 1 ) medicinal products which have been ex-
amined by the Council, and which are mar-
keted under descriptive, non-proprietary
names with well established therapeutic
claims, and (2) non-medicinal articles which
are not advertised as therapeutic agents, the
composition of which is sufficiently disclosed
to permit judgment as to their harmlessrieSs
or safety, and the use of which under ordi-
nary circumstances is, in the opinion of the
Council, not contrary to public welfare."
MEDICINE MONOGR.\PHS, VOL. XVI: COR-
ONARY THROMBOSIS: ITS VARIOUS CLINI-
CAL FE.-\TURES, by Samuel A. Levine, Senior
Associate in Medicine Peter Bent Brigham Hos-
pital, Boston, Mass. The Williams & Wilkins Com-
pany, Baltimore, 1929. $3.00.
The author would emphasize that cor-
onary thrombosis is a condition which can
in most instances be readily recognized,
can in most instances be readily recognized,
and that the knowledge which has brought us
to this point has come through the observa-
tions of practitioners on their patients ante
and post mortem, rather than through ex-
perimental investigation.
There is discussion of the relationship of
coronary thrombosis to angina, to diabetes, to
hypertension and sclerosis, to syphilis, to he-
redity, to age and sex and to other diseases.
A typical attack is described — a most dra-
matic event, coming on usually when the vic-
tim is at rest, and promptly recognized by
him as a perilous state. Complications and
electrocardiographic findings are shown. Treat-
ment is given at length but with the qualifi-
ption that further experience with the dig-
December, 1929
SOUTHERN MEDICINE AND SURGERY
AN ANCIENT PREJUDICE
HAS BEEN REMOVED
I^m79. The American Tobacco Co.. Mfrs.
Cone is that ancient prejudice against cigarettes
—Progress has been made. Weremoved the prej-
udice against cigarettes when we removed from
the tobaccos harmful corrosive A CRIDS (pun-
gent irritants) present in cigarettes manufac-
tured in the old- fashioned way. Thus " TOAST-
ING" has destroyed that ancient prejudice
against smoking by men and by women.
It's toasted'
No Throat Irritation-No Cough.
SOUTHERN MEWCINE AND SURGERY
December, 1029
ease will bring improvement.
One hundred and forty-five condensed case
reports complete a monograph of the very
first order on a subject of the very first im-
portance.
SCIENCE AND THOUGHT IN THE FIF-
TEENTH CENTURY: Studies in the History of
Medicine and SurRery Natural and Mathematical
Science, Philosophy and Politics, by Lynn Thorn-
dike. Columbia University Press, New Y'ork, 1Q20.
$4.75.
This work is the fruit of an effort to sup-
ply information on a neglected period, that
between 1250 or 1300 and the early years
of the 15th century. Derogatory notions
concerning medieval medicine and surgery are
called old-fashioned; systematic dissection of
the human body for purposes of instruction,
the discovery of the contagiousness of many
diseases previously regarded as non-contagi-
ous, the practical disappearance of leprosy,
the use of mercury against syphilis, the em-
ployment of narcotics by inhalation, the pio-
neer work of Hugh of Lucca, Theoderic, and
Henry of Mondeville in aseptic surgery — all
these and many more are recounted as
achievements of that age, and equally as im-
portant advances were made in other lines,
as mathematics, astronomy and philosophy.
"The 13th century knew China better than
we knew it in the middle of the 19th cen-
tury."
The relative importance of Medicine and
Law was earnestly and ingeniously argued in
Florence. Jealousy among medical men is
ascribed to the fact that the practice of med-
icine is under the rule of Mars and Scorpion,
which sign and planet are "insidious, mal-
evolent, plotting against and hating all oth-
ers."
Many ancient treatises are abstracted and
described; a ISth century autopsy is minutely
described; mathematical, astronomical and
philosophical advances are cited. The whole
work is compiled from researches into origi-
nal sources. It is an illuminating volume
which will not only give valuable informa-
tion, but correct much misinformation, and
give us a more wholesome respect for our
ancestors of the period.
DISEASES OF THE STOMACH: A Text-Book
for Practitioners and Students, by Max Einhorn,
M'D., Emeritus Professor oi Medicine at tbs New
York Post-Graduate Medical School and Hospital;
Consulting Physician to the Lenox Hill Hospital,
New York. Seventh Edition, Revised. William
Wood & Co., New Y'ork, 1929. $6.00.
The author is of the opinion that func-
tional disturbances frequently lead to organic
lesions, and that eradication of the func-
tional ailment will frequently prevent the
development of the organic lesions.
Earlier editions are followed in the general
arrangement. It is cleverly and appropri-
ately said that, for the pleasant and proper
taking of food, there must be previous work,
and subsequent rest. [Our own King James
Version says that our Edenic ancestors were
condemned to eat bread in the sweat of the
"face," not "brow," as Dr. Einhorn and so
many others quote at it.]
We would prefer that the term, catarrh,
be omitted from medical literature and vo-
cabularies; certainly we would never think
of Gastric Catarrh as a diagnosis to explain
a sudden fever of 103 or 104 and other symp-
toms suggesting typhoid.
The treatment of peptic ulcer is given in
no very great detail and follows the usual
tendency of a medical man to place most
emphasis on the value of medical treatment.
• Dr.SIEGERTS ^
(Elix. Ang. Amari Sgt.)
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unpleasant drugs — tones appetite
and metabolism. Elix. Ang. Amari
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Send jor Sample
\ J. W. Wuppermann Angostura
Bitters Agency, Inc.
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I the pain
\^ of the
initial pleurisy in
the pneumonia:; —
is unrivaled. To the Medical Pro-
fession the world over, the name
Antiplilogistine means far more
than a poultice. From its very
inception, in fact, Antiphlogistinc
has always been universally recog-
nized as synonymous with the
prompt suppression of pain — both
supcrfirial and deep-seated.
/^ 1 PREAD at the onset — not as a last
V — y straiv — but at the very onset of
a suspected pneumonia, Antiphlogis-
tine has in countless numbers of cases
shortened the period of the attack and
erased much of the suffering and pain.
Many leading medical authorities ac-
claim this topical measure as the sine
qua non for the successful management
of pleurisy and the pneumonias.
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906
SOUTHERN MEDICINE AND SURGERY
CHUCKLES
December, 1929
No Expense Account
To a Jewish ex-service man an acquaintance re-
marked: "So you were in the army, Ikey?"
"Oh, I vas in the army," was the proud response.
"Did you get a commission?"
"No, only my vages!"
Evidently
Boy (reading epitaph) — "Here lies a lawyer and
an honest man." What does that mean, dad?
Father — Two men in one grave.
Never Happened: No Such Dentist
Dentist — That's all right, sir; I don't expect pay-
ment in advance.
Angus — Dinna fret, mon. I was just counting ma
silver afore I took the gas.
Never
"Gentlemen," said the surgeon as he entered the
lobby of the Good Egg Club, "I have a patient
hovering between life and death. One thing will
save him. Is there a gentleman here who will vol-
unteer to give me a quart of — "
"That's enough, doc, I'll do it!" cried out an
athletic youth.
"But it must be good, you know. It must be
pure. I shall have to make a careful examination."
"Sure thing. Step right in here."
They entered an adjoining anteroom and the
sturdy man started to remove his coat.
"Here, here — what's the idea?" demanded the
doctor.
"Don't you want to examine me?"
"Certainly not. Just let me see the whiskey?"
"Whiskey? Well, of all the nerve? Think I'd
give up a quart of good whiskey for a guy I never
saw in my life? I thought you only wanted blood.
Counter Salesman: "Yes, sir, and what is your
pleasure?"
Misfit: "Drinking and necking, sir, but just now
I'd like to buy a shirt." — Williams Purple Cow.
"Good heavens, Max, what are you doing with
the vacuum cleaner?"
"Why, mother, the baby swallowed my nickel."
"That's a funny sort of hump on your chest, sir,"
said the tailor, "but we'll make the suit so that it
won't be noticeable."
"I'm afraid you will," said the man, "that my
wallet."
Hostess (at children's party): "Won't you have
another piece of cake, Alice?"
Alice (who had promised mother not to answer
"yes"): "Well, the idea is not repugnant to me."
"When'll ye be getting marrit, Donald?"
"Och, I dinna ken, Sarah has some printed station-
ery she must use up first, and she dinna write much
on account the postage."
Nurse: "Come and see what the doctor brought
your mother."
Tommy (gazing with displeasure on the new ar-
rival): "I bet she blames me. He wouldn't have
known where we lived if I hadn't got the flu." —
Sidney Bulletin - — - — —
"Say, Jack, are you still engaged to that awfully
homely girl you took me to see a year ago?"
"Well, I should say not."
"Good for you. To tell you the truth, old man,
you certainly had my sympathy. She was the most
awful mess I've ever seen any place. How in the
world did you get out of it?"
"Married her."
Boy That Passed Coached Him
"Dad, you are a lucky man."
"How's that, son?"
"You won't have to buy me any school books
this year. I've been left in the same class." — Stock-
holm Kasper.
"See here!" said the zealous traffic cop. "Keep
on the proper side of the white line."
"What line?" inquired the motorist. "I can't see
any white line."
"Well, ain't ye got any imagination?" — Sta Nebr.
Owner of Dude Ranch: "Yes, I can fix you up
with a horse to ride. Do you want a flat English
saddle or a saddle with a horn?"
Drug Store Cowboy: "Give me the English sad-
dle. I don't believe there is enough traffic out here
so I'll need a horn." — Colorado Medicine.
"What is the meaning of the word 'hence'?"
"It's vot you hold wit your girl ven you is in
love."
Mrs. Jones had bought a perambulator on the
installment plan. Month after month she faithfully
visited the shop, handing over her meager payments.
The cashier grew fond of her. Finally came the past
payments, and the clerk bade her a touching fare-
well.
"I shall miss you, Mrs. Jones," he said. "You've
been such a regular customer. Er — and how is the
baby by now?"
Mrs. Jones smiled triumphantly.
"Wonderfully. He's getting married next week."
December, 1929 SOUTHERN MEDICINE AND StJRGERY
A NEW BACTERICIDAL DYE
BISMUTH-VIOLET
IHexamelhyl-lriamin-tiiphenyl-carbinol . . . bismuth]
A triphenylmethane dve which is very destructive to the common pathogenic
bacteria. It is' KOX-IRRITATIXG AND NON-TOXIC. It contains no mercury,
and may be applied to large denuded areas of the body such as burns and lacerations
without danger of toxic absorption by the patient. It has also been long known that
many of the aniline dyes stimulate epithelialization in wounds.
BISMUTH-VIOLET
Is of value in the treatment of:
Infected Wottnds
Infections of the Soft Tissues
Impetigo Contagiosa — after all crusts and scabs are removed
Tinea (Ringworm) — after an ointment of salicylic has been applied and allowed to remain
from 12-24 hours
Infected Leg Ulcers
c0njuncti\^tis
Sinusitis
ANY INFECTION to which the dye may be applied directly
USE IT AS YOU WOULD TINCTURE OF IODINE OR OINTMENT OF
AMMONIATED MERCURY
Tlie following pathonenic oioanism.s are killed by BISMLITH-VIOLET in the
fulluwing diliilioiLs:
Staphylococcus albus, aureus and citreus-
Streptococcus pyogenes
B. Typhosus
B. Paratvphosus A and B
B. Coll ' ■
B. Tetani and spores
B. Welchii and spores
B. Anthracis and spores
1,000,000,000
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Manufactured solely by
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PftOFESSlON CARDS
December, 1920
PHYSICIANS' DIRECTORY
EYE, EAR, NOSE AND THROAT
AMZI S. ELLINGTON, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
PHONES: Office 992— Residence 761
Burlington North Carolina
J. SIDNEY HOOD, M.D.
Diseases of the
EVE, EAR, NOSE AND THROAT
PHONES: Office 1060— Residence 1230J
3rd National Bank BIdg., Gastonia, N. C.
O. J. HOUSER, M D.
Diseases of the
EYE, EAR, NOSE AND THROAT
Telephones —
415 North Tryon St. Phone 2-0841
Hours — 9 to 5 and by Apointment
219-23 Professionai BIdg. Charlotte
HOUSER CLINIC
For Tonsils and Adenoids
Office 7457, Residence 7011
Consultation 219 Professional BIdg.
Phone 7457
J. G. JOHNSTON, M.D-
EYE, EAR, NOSE AND THROAT
Hours — 9 to 1 and by Appointment
Telephones —
Office 7824, Residence 7657
616-18 Professional Building, Charlotte
H. C. NEBLETT, M.D.
Practice Limited to
DISEASES OF THE EYE
Phone 3-5852
Professional Building Charlotte
H. C. SHIRLEY, A.M.. M.D.
JOHN HILL TUCKER, M.D.
Practice Limited to
DISEASES OF THE EAR. NOSE
Diseases of the
EYE, EAR, NOSE AND THROAT
Hours — 10 to 1 and by Appointment
and THROAT
Professional Building Charlotte
Telephones —
Office 2-3034. Residence 7918
309 Professional Buildmg Charlotte
H. A WAKEFIELD, M.D.
Diseases of the
EYE, EAR, NOSE AND THROAT
Telephones —
Office 2-3510, Residence 7360
204 North Tryon Street Charlotte
INTERNAL MEDICINE
A. A. BARRON. M.D., F.A.C.P.
INTERNAL MEDICINE
NEUROLOGY
Professional Building
Charlotte
M. L. Stevens, M.D. Chas. C. Orr, M.D.
DRS. STEVENS AND ORR
INTERNAL MEDICINE
DISEASES OF THE LUNGS
17 Church Street
Asheville, N. C.
W. O. NISBET, M.D , F.A.C.P.
Professional Building
INTERNAL MEDICINE
GASTROENTEROLOGY
D. H. NISBET, M.D.
Charlotte
W. C. ASHIVORTH, M.D.
M. A. SISKE, M.D.
HABIT DISEASES, NEUROLOGY
and PSYCHIATRY
Hours by Appointment
Piedmont Building Greensboro, N. C.
GRAYSON E. TARKINGTON,
M.D., F.A.C.P.
INTERNAL MEDICINE AND SYPHILIS
Dugan & Stuart Building Hours: 9-12, 3-5
Hot Springs National Park Arkansas
December, 1920
PROFESStGN CARDS
JAMES CABELL MINOR. M.D.
PHYSICAL DIAGNOSIS
HYDROTHERAPY
Hot Springs National Park Arkansas
JAJIES M. NORTHINGTON, M.D.
Diagnosis and Treatment
in
INTERNAL MEDICINE
Professional Building Cliarlollc
OBSTETRICS and GYNECOLOGY
C. H. C. JIILLS, M.D.
OBSTETRICS
Consultation by Appointment
Professional Building Charlotte
ROBERT T. FERGUSON, M.D., F.A.C.S.
GYNECOLOGY
By Appointment
Professional Building Charlotte
RADIOLOGY
X-RAY AND RADIUM INSTITUTE
W. M. Sheridan, M.D., Director
RADIIM LOANED TO PHYSICIANS AT MODERATE COST
Suites 208-209 Andrews Building Spartanburg, S. C.
Robt. H. Lafferty, M.D., F.A.C.R.
DRS. LAFFERTY and PHILLIPS
Charlotte
X-RAY and RADIUM
Fourth Floor Chaiiottc Sanatorium
Presbyterian Hus])ital
Croivell Clinic
C. C. Phillips, M.D.
Merey Hospital
Dr. i. Rush Shull Dr. L. M. Fetner
DOCTORS SHULL and FETNER
ROENTGENOLOGY
RDi-iilgciiologisIs to St. Pcler's Hospital, Aslu'-Faison ('.hiidi-cirs (Illiiic. (iood
Saniarilaii Hospital
Professional Building Charlotte
UROLOGY, DERMATOLOGY and PROCTOLOGY
THE CROVVELL CLINIC OF UROLOGY AND DERMATOLOGY
Entire Seventh Floor Professional Building
Charlotte
Hours— Nine la Five Telvphonr—.\-'W\
Urology: Dermatology:
Andrew J. Crowell, M.D.
Raymond Thompson, M.D.
Claud B. Squires, M.D.
(Clinical Pathology:
Lester C. Todd, M.D.
Joseph h.. Elliott, M.D.
Lester C. Todd, M.D.
R(M>nlgenology
Robert H. Lafferty, M.D.
Clyde C. Phillips, M.D.
910
PROFESSION CARDS
December, 1929
I'led p. Austin. M.D. DeWitt R. Austin, M.D.
THE AUSTIN CLINIC
RECTAL DISEASES, UROLOGY, X-RAY and DERMATOLOGY
Hours 9 to S — Phone Hemlock 3106
Sill Floor Independence BIdg. Charlotte
Tlios. Bi'ockman, M.D.. >ii*s*Mf^y«f' - 25 Emma St., Greer, S. C
BROGKMANS RECTAL CLINIC
More Commodious Quarters in Colonial Apartments.
Improved Facilities.
X-Ray and Clinical Laboratories.
Recovery Beds for Ambulant Patients.
Surgical Cases Hospitalized at Chick Springs Sanitarium
Dr. Hiiniillon McKay Dr. Robert McKay
DOCTORS McKAY and MeKAY
Practice Limited to UROLOGY and GENITO-URINARY SURGERY
Hours by Appointment
Professional Building Charlotte
Residence Phone 1858
221 Ea.st .Main Street
DR. W. B. LYLES
Practice limited to
UROLOGY and UROLOGICAL SURGERY
Hours 9-5. Sundays by Appointment
Office Phone 1857
Spartanburg, S. C.
W. VV. CRAVEN. M.D.
GENITOURINARY and RECTAL
DISEASES
<) a. m. to 1 p. m. — 3 p. m. to 6 p. m.
Professional Building Charlotte
R. H. MeFADDEN. M.D.
UROLOGY
Hours 9 to S
514-16 Professional Bldg. Charlotte
L. D. MePHAIL, M.D
RECTAL DISEASES
405-408 Professional Bldg. Charlotte
DR. O. L. SIGGETT
UROLOGY
Caslanea Building, .\slieville, N. C.
Hours — 3 to 5; Phone — 2443
WYETT F. SIMPSON, M.D.
GENITO-URINARY DISEASES
Phone 1234
Hot Springs National Park, Arkansas
FOR SPACE RATES
Address
806 Professional Building
SURGERY
ADDISON G BRENIZER, M.D.
SURGERY and GYNECOLOGY
Consultation by Appointment
Professional Building Charlotte
RUSSELL O. LYDAY, M.D.
GENERAL SURGERY and SURGICAL
DIAGNOSIS
Jefferson Std. Bldg., Greensboro, N. C.
R. B. Mcknight, mj).
SURGERY
and
SURGICAL DIAGNOSIS
Consultation by Appointment
Hours 2:30 — 5
Professional Building Charlotte
WM. MARVIN SCRUGGS, M.D., F.A.C.S.
SUkGERY and GYNECOLOGY
Consultation by Appointment
Professional Building Charlotte
December, 1929
PROFESSION CARDS Oil
WILLIAM FRANCIS »L\RTIN, M.D.
GENERAL SURGERY
GYNECOLOGY
Professional Building CaiarloUe
ORTHOPEDICS
J. S. GAUL, M.D. ALONZO MYERS. M.D.
ORTHOPEDIC SURGERY and ORTHOPEDIC SURGERY and
FRACTURES i FRACTURES
Professional Building Cliarlotte Professional Building Charlotte
HERBERT F. IVRNT, M.D.
FRACTURES
ACCIDENT SURGERY and ORTHOPEDICS
Wachovia Banii Building Winslon-Salem, N. €.
O L. MILLER, M.D.
Practice Limited to
ORTHOPEDIC SURGERY and FRACTURES
Fifteen West Seventh Street Charlotte
GENERAL
THE STRONG CLINIC
Suilc 2. Medical Building Charlolte
C. M. Strong, M.D., F.A.C.S. Orf.n Moore, M.D., F.A.C.S.
CHIEF oj CLINIC, Emeritus Obstetrics and Gvnecology
J. L. Ranson, M.D.
Genito -Urinary Diseases and Anesthesia
Miss Pattie V. Adams, Business Manager
Miss Fannie Austin, Ntitse
Bl BRIS CLIMC \ HIGH POINT HOSPITAL High Poin(. N. C.
(Miss Gilbert Muse, R.N., Supt.)
General Surgery, Internal Medicine, Proctology, Ophthalmology, etc., Diagnosis,
Urology, Pediatrics, X-Ray and Radium, Physiotherapy, Clinical Laboratories
STAFF
John T. Burrus, M.D., F.A.C.S., Chief Everett F. Long, M.D.
Harry L. Brockmann, M.D., F.A.C.S. O. B. Bonner, M.D., F.A.C.S.
Phillip W. Flagge, M.D., F.A.C.P. E. A. Sumner, B.S., M.D.
DR. H. KING WADE CLINIC
Wade Building
Hot Springs, Arkansas
H King Wade, M.D. Urologist
CiiARiEs S. Moss, M.D Surgeon
0. J. MacLaik.iilin, M.D.
Opthiilmologist
Olo-Laryngoloist
H. Clay Ciienault, M.D.
Associate Uurologist
Miss Etta Wade Pathologist
LaDT»n* 1 'WW fff
$li SOtJtttfeftN M6btCI^J6 AMt) StrtlGEkV Becember, 19^9
INDEX 1929
ORIGINAL ARTICLES
Abortion, The Psychiatric Consideration of, R. F. Gayle . 2S1
Achlorhydria, Gastric— Its Significance and Treatment, R. O. Lyday 79
Acidosi; and Disease, H. H. Menzies -— 856
Agranulocytic Angina, 0. 0. Ashworlh and E. A. Mines, jr. 22
Amebiasis,' The Therapy of (Report of Cases), A. B. Hodges S
Amebiasis, Chronic Intestinal, L. G. Cage 30
Anesthesia, Spinal, J. W . Davis - 863
Apotheosis of the Individual, The, /. A'. Hall 133
Appendicitis, Chronic, as a Cause of Indigestion, M. 0. Burke 391
Arterial Vascular Diseases of the Extremities, Surgical Indications in Certain, R. B. McKnight 699
Arteriovenous Aneurysm, If. L. Peple — - — '83
P'ographical Sketches, Frank Hancock ,__ 843
Bismuth-Violet in the Prevention of Wound Infection, /. S. Barksdale 597
Bladder Therapy, Some Principles in, .4. /. Dodson 789
Brain Tumor, Differential Diagnosis of, From Vascular Disease, C. C. Coleman and J. G.
Lverlv - 536
Broken Back, /. 5. Gatd 557
Carcinoma of the Large Intestine, J. W. Gibbon - — ~ — - 300
Cardio-Vascular-Renal Disease, Combined Drug Therapy in Some Problems of, /. G. Murray 69
Cerebro-spinal Fever, C. T. Smith. M. L. Slone and .4. T. Thorpe - 837
Cellulitis, Acute, of the Orbit, H. C. Neblelt ._ . 381
Catarrh of the Head, ,4. J. Ellington 548
Childbirth, Pain in, and Care of Birth Canal, H. J. Langston 695
Clinical Laboratory, The, in Diagnosis and Treatment of Disease, /. A. Kolmer. — _ — 292
Chronic Intestinal Obstruction, Due to Carcinoma of Colon (Case Report), J. W. Gibbon - 866
Clinic and Group Practice, Harold Glascock _ : 27
Constipation, Functional, R. D. Metz _ , 685
Cysts, Mucous Membrane, of the Maxillary Sinus, /. P. Matheson 9
Coronary Occlusion, Dewey Davis and Douglas VanderHooj _ 456
Dentistry and Medicine, The Mutual Dependency of, J. M. Northington 480
Descensus Uteri, C. S. Lawrence . . 769
Diabetes, Management of the Complications of, W. J. Mallory 1
Diabetes Mellitus, H. C. Slillwell 396
Doctor and Citizenship, The, T. D. Kitchin 283
Drug Addicts, Institutional Care and After Treatment of, W. C. Ashworth _ 603
Duodenal Ulcer, Ruptured, With Symptoms Simulating Ruptured Tubal Pregnancy, R. B.
McKnight _ _.'. 21
Effort Syndrome, The Importance of Diagnosing, W. B. Kinlaw 682
Enamel, Hypoplasia of, Result of Treatment, P. L. Chevalier 625
Encephalocele, G. H. Bunch 255
Enterostomy — Its Surgical Importance, T. C. Bost _ 96
I-.pilcpsy in Children, The Ketogenic Diet in the Treatment of, T. D. Walker, jr — - 155
Extra-Abdominal Lesions, Abdominal Symptoms of, DeWitt Kluttz 333
Fibroids, Uterine, How the Pathology Affects Treatment, Ivan Procter 318
Foreign Bodies in the Air and Food Passages, E. G. Gill 315
Fractures, Instructive, and Other Orthopedic Cases, /. 5. Gaul 13
Frozen Section in Surgery, The Importance of, B. C. Willis _... 459
Gavel, Presentation of. Made from Wood from "Belroi," /. A. Hodges — Acceptance, Stuart
McGuire 2 1 8
Gas Gangrene, R. B. Davis 541
Gastric Ulcer, S. O. Black _ . 461
General Practitioner. The Problems of a, /. W. McGehee 849
Glvcosuria, Temporary Emotional, W. M. Johnson _ 858
Goiter, J. W. Davis '- _ _ __ 152
Goitre, Endemic, in Its Relation to North Carolina, L. M. Ingersoll 689
Gongylonema — With Case Report in a Woman, H. W. Lewis 330
Granuloma Inguinale, D. C. Eskew and S. D. Craig 679
Hallus Valgus, R. L .Anderson 74
Harelip and Cleft Palate, J. W. Davis _ 554
Health Examinations, An Analytic Research Based Upon 436, in 51 Counties, F. R. Taylor.... 464
Hospital Management, Some Neglected Factors in, Malcolm Thompson 26
Hypertension, Essential, Dewey Davis _ 7S7
Idealism, H. S. Lott 869
Incipient Pulmonary Tuberculosis, Active, The Diagnosis of, O. E. Finch _ Ri
Investment Program for the Professional Man, W. H. Neal 779
Influenza, Conference on. Report of the, C. O'H. Laughinghouse 71
Insterstitial Pregnancy, Douglas Jennings 558
Iodine Content of South Carolina Foodstuffs, The, Hugh Smith 762
Lacerations of the Cervix and Vagina, Repair of Fresh and Old, H. J. Langston 224
Larj-ngoscope and Bronchoscope, Some Applications o/, G. C. Cook 158
Medicine, Lay control of, T. D. Kitchin _ _ 103
Mastoiditis as a Cause of Diarrhea in Infants, W. L. Harris _ _... 764
Meckel's Diverticulum, Acute Obstruction Due to, J. W. Davis 478
Meckel's Diverticulum (Case Report), F. C. Hubbard 6J9
becember, 102g SOUtHERN MEDICINE AND SURGERY
Medical History, Has It Any Value?, /. L. Miller 143
Medical Problems, Some, T. D. Kitchin 220
Medical Problems — Present and Future, W. B. Robertson 307
Minor's, Dr., Position in the Medical World, National and International, C. H. Cocke 98
Minor, Dr. Charles L., H. H. Briggs ■ — 1°°
Nephroptosis, C. O. DeLanev - 852
Optochin, Pncumococcic Meningitis Treated With, With Complete Recovery, M. A. Lackey.- 477
Otitis Media, Chronic, Conservative Treatment, D. S. Asbill _ 706
ParoxNsmal Tachycardia, /. M. Hutcheson 615
Periodontia, If. D. Gibbs _ - — 545
Peripheral Circulation, Disturbances of the, F. L. Knight 383
Pneumonia, Lobar, The Treatment of, G. W. Black 778
Pneumonia, Post-Operative, and Its Relation to Atelectasis, W. E. Lee 369
Post-Operative Distress, Harold Glascock - — - 860
President of The Tri-State Medical Association, Address of the, /. K. Hall - — . 133
President of the Medical Society of the State of North Carolina, T. D. Kitckin _ 283
Prostate Gland and Bladder, Surgery of the, J. D. Highsmith — — 606
Prostate Gland Obstructions, Resection of, 7". M. Davis — — 773
Pulmonary Tuberculosis, Rest and Compression Therapy in, /. W. Dickie 600
Purulent Pericarditis, Early Pericardotomy in, .4. G. Brenizer 468
Psychiatrist in Court, The, Winfred Overholser _. _ _ 137
Rectum, The, With Special Reference to Carcinoma and Hemorrhoids, C. M. Van Poole 771
RoentRenography of the Chest, Remarks on the Importance of, E. W. Schoenheit — 87
Roentpen-Ray Plates, Examination of, G. F. Walsh _ — _ 550
Rural Medical Service, Rural Hospitals as a Means of Properly Distributing, Wm. C. Tate... ill
Serum Sickness, R M. Pollilzer _._ — -. — 311
Squint, Early Treatment of, H. C. Neblett 709
Sterilitv, R. T. Ferguson _ _ _ . 326
Stricture of the Female Urethra, H. W. and R. W. McKay 227
Syphilis, Recognition and Treatment of Early, A. B. Cannon 211
Teeth, impacted, .^ Consideration of, Harry Bear _ 862
Thrombo-Angiitis Obliterans, Douglas Jennings 625
Thymus Gland and Convulsions, C. P. Mangum 547
Thyroidectomy, On the Technique of, H. A. Royster ._ 472
Tuberculosis, Primary, of the Penis, William Frontz and R. W. McKay _ 92
Tuberculosis Work in North Carolina in 1929, Resume of, L. B. McBrayer 794
Tuberculous Infection in the Infant, Primary, E. A. Park _ _.„ 449
Lndulant Fever, P. W. Flagge _. _ 81
Uremia, Treatment of, A. B. Holmes 612
Urology, A Better Perspective in, C. 0. DeLaney 385
Urology Day by Day, /. P. Kennedy 703
Venereal Menace, The, W. W. Craven 622
Vaginal Speculum, The History of, R. E. Seibels 669
Veast Metabolism, Urine Tests for Some of the Products of, /. A. Buchanan _ 390
CLINICS
Allergy, W. T. Vaughan 241
Diseases of Children, E. A. Park __ 231
General Medicine, Garnell Nelson, J. M. Hutcheson, W. B. Porter _ _ 245
Nervous and Mental Diseases, M. P. Lonergan, J. S. DeJarnette 52'
EDITORIALS
(Unsigned Editorials are by the Editor)
Accidents to Hunters . gOi
Additions to our Staff gOi
Advertising, One Kind of 44
Anderson, Dr., Exonerated 436
Appreciation, J. K. Hall l^j
.Authors, To _ 43
Basic Science Laws
107
Bathing Customs and Manners of 500 Years Ago '_ 409
Brawley, Dr. Robert Vance, / .E. Stokes ^ __ 37
'■Charities," So-Called, As Menaces to Medicine _ J _ _ I 718
Cleveland Horror Need Not Be Repeated, The 405
Crane, Dr., Dissents ' 4gg
Cravings, Our Own, as Reliable Guides Z Z _ Z_l_ _ 41
District Meetings, Recent (Privilege Tax) Z _ _ 720
Epilepsy, A New Simple and Promising Treatment for 1 !__"L " 566
Family Doctor. The .. .. _ "__ __'"" ~ 870
Family Doctors, A Means of Initiating Into A Mystery Z_I '.'. 400
Farm Relief, Better Food, Better Health __ " _1J__ 799
Fee Splitting— Unnecessary Operations. Richard Cabot 1 '"_ _ J 3 " 631
Garnishment Laws and News Items, Interest in
Garrett, Dr. Franklin Jefferson, //. /. Ledbetter I
Gorgas Institute Sponsors Second Essay Contest
Greensboro Meeting, The
341
39
802
341
Home Doctors, On Appreciating and Applauding Original Work of ~ !„.„" .Z Z..~..... 617
SOUTHERN MEDICINE AND SURGERY December, 1929
Kitchin, Ex-President; Crowell, President 340
Lav Control of Medicine — - _ 162
Maternal Death Rate, What Gave Us Our Disgraceful? Meddlesomeness: What Keeps It
From Being Lowered? Complacency 562
Meeting, The Greensboro 341
McNeil, Dr. James William, 0. L. MacFadyen 38
Medical Care, The Cost of - 873
Medical Licensure, Basic Science Laws as to 107
Medical Societv of Mrginia's Program '20
finor. Dr. Charles L., P. H. Ringer 34
linor. Dr. Charles L., Hayn'ood Parker 3S
linor. Dr., In Memoriam, Vestry Trinity Church 36
linor. Dr., In Memory, Buncombe County Medical Society ■ 36
"Minor" Medicine and Surgery, The Importance of 342
Ninth District Clinics - 489
Pellagra Situation and Its Management, The 406
Pneumonia, Potassium Permanganate, Treatment in 407
Portland. Echoes From 569
Poft-Graduate Instruction Close to Home 111
Post-Graduate Course, Third, at Charleston 343
President of the Tri-State — Cyrus Thompson 2S9
Private Practice Must Prevail — 488
Propriety, Our Idea of 167
Quackerv Squelched, More 167
Resolutions 802
Robertson, Dr. W. B., Thinks and Speaks Out 342
Sanocrysin, P. P. McCain 569
Secretan.- of Health at Washington, A . 261
Simplicity and Decenc\-, For 874
South Carolina Vegetables Superior 489
Subscribers Who Will Not Pay 408
Syphilis, How Curable Is? : 564
Tayloe, Dr. Joshua 41
Tri-State Meeting, The Coming 44
Tri-State Meeting, The Coming 871
Tri-State Meeting, The Thirt\-flrst 163
Tri-State, The, The President of 259
I.;ndulant Fever, Is it Carried by Milk? ; 630
U!tra-\'iolet Rays to Complement Wi;iter Sunshine 167
\.'ughan. Dr. X'ictor C. 872
Wakefield, Dr. William, /. R. Irwin _... 629
War of the Lambs, The 343
Way to Serve the Journal, A , 344
What a Doctor Should Carry Regularly 165
Wh\- Not Do Th's in Your Town? 409
When You Read a Paper [Penn. Med. Journal) 721
Will President Hoover Tell Us How? 260
W'lMams. Dr. Louis L. 4S9
Willis, Achille Murat 40
Workmen's Compensation Act, North Carolina 565
DEPARTMENT EDITORIALS
(Unsigned Department Editorials are by the Editor of that Department)
HUMAN BEHAVIOR
.Anderson, Dr. .Albert, Governor McLean's Opinion of 171
Book. The Right, At Last _ 47
Capital Offenders in North Carolina, A Study of 634
Conclusion of an Outrageous Attack, The 400
Devotion, Undivided 571
Diagnostic Effort, An Honest 4go
Emotional Lips and Downs 723
Fear Enthroned 724
Graduation Ruminations 4jl
Grim Business 570
Hopelessness, The Curse of 577
Human Behavior, A Study of ^45
International Congress. The First, on Mental Hygiene 402
Lawlessness, Our, Will Be Explained 4II
Liquor and Lawlessness in Virginia ]70
Prognostic .. . _ 4^
Prosecution or Persecution ~ Ij2
Psychologist Enters Politics, The . ----j~ 4gQ
Psychiatric Light House, The Great „______ " g^g
December, 1929 300 East Twenty-first Street, New York City
Psychiatry Outside the Walls - 803
RebeUion in Prisons — 570
Tobacco, The Eccjesiastization of _ - 170
W'illebrandting in Raleigh Fails _ — ^b-t
Department Editor — /. A'. Hall
PEDIATRICS
Course in Pediatrics, Ninth District Society Arranges 414
Croup 276
Diphtheria Not Conquered - _ _ 879
Impetigo Contagiosa, G. W. Kulscher, jr. _ 725
Infants, Post-Natal Care of, G. W. Kutscher, jr. . - 571
Lactation, Human - 4S
Milli, Unmodified Dried, G. W. Kulscher, jr. 113
Post-Graduate Education and Organized Medicine, F. H. Richardson and G. W. Kutscher, jr. 401
pyelitis, G. W . Kulscher, jr .-_ _ ...._ _ _ __ 805
Schick Test — .- - 172
Southern Parenthood Institute, Initial Session _ 637
Tonsils and Heart Disease - 360
Department Editor — R. H . Richdrdscii
DENTISTRY
Debt _- _. _ _ 416
Vincent's Infection : 357
Pyorrhea . . „ _. 572
Department Editor — W. M. Rohey
DISEASES OF THE EYE, EAR, NOSE AND THROAT
Diphtheria, Obstructive, V. K. Hart _ _ _ _„ 806
Eye Strain at Different Ages, F. C. Smith 405
Gradcnigo's Syndrome, V. K. Hart _ 573
Lnryngoscopy, Direct, As a Method for Cultural Studies in Infants and Children, C. N. Peeler 630
Meniere's Disease, T'. A'. Hart _ 416
Obscure Oral Bleeding, V. K. Hart _ 725
Cphthalmology, The Thirteenth International Congress of, H. L. Sloan 880
Peroral Endoscopy — Its General Medical Value, V. K. Hart 358
Refraction .After Sixty, H. L. Sloan _ 270
Tonsillectomy and Diphtheria Immunity, V. K. Hart 881
Vertigo, V. K. Hart _ 40
Vertigo As a Warning in Middle Ear Disease, V. K. Hart 173
Department Editors — The Matheson Clinic
LABORATORIES
Eosinophilia in Diabetics Treated With Insulin, A^. M. Smith 417
Purpura, The Blood in. N. M. Smith _ _ _ 174
Sickle Cell .Anemia, N. M. Smith 50
Department Editors — The Barret Laboratories
ORTHOPEDIC SURGERY
Congenital Dislocation of the Hip 882
Foot .Ailments, Common in Children _ 51
Foot .Ailments in Women and the Major Cause 114
Foot .Ailments, Further Comments On 175
Hip Tuberculosis — Operative Treatment 574
Infantile Paralysis: Early Diagnosis and Treatment, Edward King 418
Ischemic Paralysis 807
Nachlas', Dr., Letter " "^ '_ 726
Orthopedic Surgery, Progress in . _ ""_ 54O
Ossification in Both Scaphoids, Abnormalities of, B. H. Kyle Z_.- "1 496
Poliomyelitis, B. H. Kyle _1 J 496
Prolonged Immobilization, The Use and Abuse of, A. T. Moore J'''"Z _ _ 355
Unreduced Elbow ,^q
Department Editor — 0. L. Miller
UROLOGY
.Albuminuria, Significance of, C. O. DeLaney _ 574
Cohabitation Pyelitis, R. F. Finney J _ J J 5^
Gonorrheal Urethritis and Usual Complications, M. H. Wytnan 1 ZI 88^
Lesions of the External Genitalia in the Male, H. W. McKay _ _ ^ 640
Malformation of the Kidnev, O. T. Finklea lift
Prostatic Abscess. R. W. McKay _ 'Z_ 7,7
Pyuria, The Significance of .. _1 "^ J_ """ "" "Z " 177
Sexual "Xourasthenia," L. T. Price _ Z ~ Z __ Z Z 265
Testicular Tumor in Infancy, Raymond Thompson arid L C Todd Z J U7
Ureteral Stone, Reporting a Ca.se of, /. P. Kennedy ^ _ '"""Z '" "" 420
\ esical Calculus, Unusual Nucleus for, /. W Visher _____ " 497
SOUTHERN MEDICINE AND SURGERY December, 1929
UroloRical Conditions in Infancy and Childhood, W. M. Coppridge — SOS
Department Editor — H. W. McKay
RADIOLOGY
Cancer of the Uterine Cervix, J. D. MacRae 421
Cancer, Group Handling of, J. D. MacRae, jr. ; — 576
Hodgkin's Disease, J. D. MacRae 643
Pelv.metry with X-Rays, /. D. MacRae 117
Radiothcrap.w A Principle in, J. D. MacRae, jr 811
X-Ravs, Routine, in Public Health Work, J. D. MacRae .__ 54
X-Ray Films, J. D. MacRae 498
Department Editors — /. D. MacRae and /. Donald MacRae
DERMATOLOGY
Dermatitis Venenata _ 422
Ringworm of Hands and Feet _ — _ 644
Department Editor — /. D. Elliott
INTERNAL MEDICINE
Aging of the Heart Muscle, The 423
Cancer, Why is Age More Prone to? .' 353
"Cardiac Pain" Rather Than "Angina Pectoris" 354
Fungi in Medicine 499
Hospital of 1567, A _ 178
Lobar Pneumonia, Treatment of, With Anti-Pneumococcus Serum 118
Nephrosis 730
Rheumatic Fever 645
Tuberculosis, Early Diagnosis of 272
Vaccines and Sera 808
Department Editor — P. H. Ringer
SURGERY
Blood Transfusion . 346
Brain Injuries 180
Broken Instruments, Pieces of, As Foreign Bodies 646
CkeM Injuries _ 120
Hand, Wounds and Infections of .„_ 425
Hemorrhoids _ „ 500
Infectious Gangrenous Dermatitis, George Benet 55
Pnncreatic Injury, Danger of Auto-Digestion in 885
Pa ncrcatitis. Acute 733
Snake Bite 577
Spinal Anesthesia , 1 264
Tumors of the Breast 815
Department Editor — G. H. Bunch
HEALTH MAINTENANCE
Abdominal and Rectal Conditions in 271 Health Examinations 181
Eye, Ear, Nose, Throat, Mouth and Sinus in 271 Health Examinations 56
THERAPEUTICS
Constipation, Treatment of _ _ _. 812
Southern Medical Association Meeting __ 886
Department Editor — Frederick R. Taylor
Health Examinations of Physicians , 647
In General _. .]_ 273
Private Practice, Some Serious Drawbacks to the Present System of 501
Respiratory and Circulatory Diseases in 271 Health Examinations 121
What May We Learn From These Examinations? _ 353
Department Editor — F. R. Taylor
OBSTETRICS
A Challenge and a Criticism 57g
Are We Practicing Obstetrics? ~ 122
Long Labor — Its Dangers I 268
Long Labor — Its Dangers II 352
Long Labor — Its Dangers III 427
Looking Backward and Forward _ _ 57
Piper Forceps, in Breech and Version Deliveries Jl.~ 888
Placenta Previa „ _ "' jq^
Postpartum Hemorrhage ~_ ^ (,49
Pregnancy Complicated With Appendicitis 182
Puerperal Infection ' ,1_„.''.. 731
Puerperal Infection, Preventing gl4
Department Editor — H. J. Langston
NEUROLOGY
Case for Diagnosis, A _. _ 533
Concussion .. , _ ' 271
Encephalitis and Its Sequelae _ _ J "" Z 816
Impressions From National Hospital, London _ _ 734
Neurology Set On Its Feet „ ------- -— ^ ^^^
Spinal Cord, Tumors of the _ _ ~ _Z!1 890
Tumors gf tbe Temporal Lob? .„. „ . 124
Department Editor— 0, 5. Qhambtrlm
December, 1929
SOUTHERN MEDICINE AND SURGERY
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_ , HISTORIC MEDICINE
Kratton, J. Rufus (Autobiographical Sketch) I
Bratton, J. Rufus, II . _ _ Zl""
Bratton, J. Rufus, III J' ^'^^
Brevard, Ephraim, R. W. McKay 11_ Z
Dale, Dr. Thomas, of Charleston.' R. E. Seibels Jl Il~~~\
Firn Medical Article Printed in the Colonies 1__Z_
Hancock. Dr. Phillip Spencer, /. B Fisher ! " "
McClurg. Dr. James. O. F. Northington, jr 1 1_
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Ut. W. L. Dunn, M. L. Stevens '
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Dr. A. M. Willis. C. C. Coleman Jl\
Dr. C. L. Summers. J. L Hanes
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Dr. H. M. Stuckev. C. B Epps
Jeffenon Medical College Au.xilian,- to 'the Tri-Statl.X
W. Holt
193, 197
198, 202
198
..... 199
199
200
202
202
197
Anderson, R. L
Asbill, D. S
Ashworth, O. O.
Ashworth, W. C
Barksdale, I. S.
Bear, Harry
Black, G. W
Black, S. O.
Bost, T. C.
Brenizer, A. G.
Briggs, H. H.
AUTHORS
Buchanan, J. A.
Bunch, G. H.
Burke, M. O. .
Cannon, A. B.
Chevalier, P. L
Cocke, C. H. _
Coleman, C. C.
Cooke, G. C. _
Craig, S. D.
Craven, W. W.
Davis, Dewey 456, 757
fei.'^zr-zzzz:^^'^^*'"^'?^^
Davis, T. M.
Dejarnette, J. S.
DeLanev, C. O _
Dickie, J. W.
Dodson, A. I.
773
525
-.385, 852
600
789
Ellington, A .1. c,a
Eskew, D. C Z
679
Ferguson, R. T. _
Finch, 0. E.
Flagge, P. W. Z
Frontz, William __
Gage. L. G.
Gaul, J. S.
Gayle, R. F.
Gibbon. J. W.
Gibbs, W. D.
326
84
81
92
30
13, 557
251
299, 866
545
Gill, E. G. 315
Glascock, Harold 27 860
Hall, J. K.
Hancock. Frank
Harris. W. L.
Highsmith, J. D. .
Hines, E. A., jr.
Hodges, A. B.
Hodges, J. A.
Holmes, A. B.
Hubbard, F. C. ...
Hutcheson, J. M.
Ingersoll, L. M. _
133
- 843
764
606
22
S
218
612
619
245, 61S
689
Jennings, Douglas
Johnson, W. M.
Kennedy, J. P.
Kinlaw, W. B.
Kitchin, T. D. '__
Kluttz, DeWitt
Knight, F. L.
Kolmer, J. A.
-558, 62S
_ 858
703
682
.103, 220, 283
333
383
292
Lackey, M. A.
Langston, H. J. ._
Laughinghouse, C. O'H.
Lawrence, C. S.
Lee, W, E. "_
Lewis, H. W.
Lonergan, M. P.
Lott, H. S.
Lydav, R. 0.
Lyerly, J. G.
McBrayer, L. B.
McGeh'ee, J. W.
McGuire. Stuart
477
-224, 69S
—71, 369
769
369
330
525
869
79
536
794
849^
218
McKay, H. W. _ _ _ 227
McKay. R. W. "_ ZZ 92 227
McKnight. R. B. "" '21' ftoo
Mallory, W. J -~-.-_-_-.ii, ovy
Mangum, C. P. II_Z_ZZ__ 547
Matheson, J. P. . ~_ ~
SOUTHERN MEDICINE AND SURGERY
December, 1929
Menzies, H. H.
Metz, R. D.
Miller, J. L.
Murray, J. G.
Neal, W. H.
Neblett, H, C.
Nelson, Garnett
Northington, J. M.
Overholser, Winfred
Parks, E. A.
Peple, W. L
Pollitzer, R. M.
Porter, W. B.
Procter, Ivan
856
685
143
_381, 709
245
480
231, 449
783
311
245
318
Robertson, W. B,
Royster, H. A. ...
307
472
Schoenheit, E. W.
Seibels, R. E.
Smith, Hugh
Smith, C. T
Stillwell, H. C.
Stone, M. L.
Tate, Wm. C.
Taylor, F. R.
Thompson, Malcolm _
Thorpe, A. T.
VanderHoof, Douglas
Van Poole, C. M.
Vaughan, W. T.
Walker, T. D., jr.
Walsh, G. F.
87
669
762
837
396
-^ ill
464
26
837
456
771
241
155
550
Willis, B. C. 459
•*<~M"5'*"j»<'-><.«M~:..X":-H":":";'>:'<' ■:••>•>•!••:•*•$
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NEW INTERNATIONAL
WEBSTER'S
DICTIONARY
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Flatulence. — Intestinal flatulence ranks third
among the ten most common complaints of private
patients suffering from digestive disorders. In gen-
eral, flatulence may be caused by e.xcessive gas
intake or production, by deficient gas expulsion, or
by deficient gas absorption. Atmospheric air plays
a definite but not necessarily a major role in the
etiology of flatulence. The chronic stomach bubble
is a rare but striking cause of flatulence. The diet
may cause flatulence, but this factor can be readily
controlled in most cases. An abnormal intestinal
flora plays the leading role in the flatulence of in-
testinal infections. Gas may be secreted from the
blood under certain circumstances. At times, this
may be an important cause. Evidence is presented
for the belief that the greater part of the gas so
secreted is nitrogen. Flatulence from deficient gas
expulsion arises in complete obstruction and in re-
dundant colon. Constipation is not a frequent
cause. Deficient gas absorption is an important
cause. It may result from interference with mu-
cosal blood supply, destruction of mucosal integrity,
or depression of muscular tone. Interference with
mucosal blood supply occurs in volvulus, portal
obstruction, mesenteric vascular occlusion or sclero-
sis, and general circulatory failure. The incidence
of flatulence in hypertension was strikingly high (46
per cent) in our cases. Interference with mucosal
integrity is best illustrated in colitis. Almost one-
half of our colitis cases showed flatulence. Interfer-
ence with muscular tone is probably a very import-
ant cause of flatulence. Atony may result from
various neurogenic or myotoxic causes and thus
retard gas absorption and favor gas excretion from
the blood. In our opinion, a theory of flatulence
which would assume a sudden development of intes-
tinal atony with rapid filling of the bowel by blood
gases, chiefly nitrogen, would best account for many
of the sudden baffling distentions encountered clini-
cally. Such a theory would explain the flatulence
of neurologic ileus; of toxemias associated with
severe pneumonia, sepsis and typhoid fever; of va-
rious hysterical states; as well as that encountered
post-operatively. — Kantor & Marks, Annals of In-
ternal Medicine, Nov.
December, 1929
3UL1ULK.\ ilLlJlLl.Nh A.NU bLKUl.KV
Tri-State Medical Association of the Carolinas and Virginia
Thirty-second Annual Meeting, Charleston, S. C, February 18-19, 1930
Official Journal
Southern Medicine and Surgery
OFFICERS FOR 1930 SESSION
PRESIDENT
OR. CYRUS THOMPSON '
JACKSONVILLE, N. C.
VICE-PRESIDENTS
OR. J. M. BAKER
TARBORO. N. C.
OR. W. R. WALLACE
CHESTER, ■. C.
RICHMOND, VA.
SECRETARY-TREASURER
OR. J. M. NORTHINGTON
CHARLOTTE, N. C.
EXECUTIVE COUNCIL
ONE YEAR TERM
DR. R. L. PAYNE,
NORFOLK, VA.
DR. F. B. JOHNSON
CHARLESTON. S. C.
DR. E. S. BOICE
ROCKY MOUNT, N. C.
TWO YEAR TERM
DR. W. P. TIMMERMAN
BATESBURG. S. C.
DR. D. A. GARRISON
OASTONIA. N. C.
DR. J. BOLLING JONES
PETERSBURG, VA.
THREE YEAR TERM
DR. R. E. SEIBELS
COLUMBIA, S. C.
DR. DEAN B. COLE
RICHMOND, VA.
DR. C. C. ORR
ASHEVILLE, N. C.
Medical Society of the State of North Carolina
1929-1930
Meets at Pinehurst April 28-29-,i0, 10.?0
rresident Seventh District
Dr. L. A. Crowell Lincolnton Dr. T. C. Bost ._ Charlotte
J^irsl Vice-President Eighth District
Dr. W. B. Murphy Snow Hill Dr. R. B. Davis Greensboro
Second Vice-President Ninth District
Dr. W. E. Warren Williamston Dr. M. R. Adams Statesville
—.,..,, „ ... Tenth District
rh.rdV,ce-Pres,dent ^^ j P ^^^, Waynesville
Dr. N. B. Adams . Murphy chairman Committee on Arrangements
Secretarv-Treasurer Dr. C. A. Julian.._-_ . Greensboro
_ Dr. L. B. McBrayer Southern Pines *Deceased
_. , n- , • , COUNCILORS CHAIRMEN OF SECTIONS
rirstUislrM ^ ^ ^. Public Health and Education
Dr. H. D. Walker Elizabeth City q, j^ p r gunner Morehead City
Second District Suri;er\
TL-^'r.^^^'^^ ^ ^'^°" ■ ^^'^^" Dr. Robert W. James Monroe
Third District £^, £„^ ffg^f. ^nd Throat
Dr. J. B. Cranmer Wilmington ' Dr. V. M. Hicks Raleigh
Fourth District G\necolcgv and Obstetrics
Dr. W. H. Smith Goldsboro Dr. R. A. Ross Durham
Fijth District Pediatrics
Dr. E. A. Livingston Gibson Dr. Thos. M. Wati^on _ WilminRton
Sixth District Practice of Medicine
Dr. V. M. Hicks Raleigh Dr. W B. Kinliiw Rockv Mount
SOUTHERN MEDICINE AND SURGERY
December, 1929
Tuberculosis Kills
1 out of 5
of all who die between 15 and 45
It is the enemy of steady employe
meat, high wages and prosperity
For tuberculosis strikes during the
most productive years of life.
Help us to rout tuberculosis,
BUY
CHRISTMAS
SEALS
The National, State and Local Tuberciilosis
Associations of the United States
i