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UNC-CH  HEALTH  SCIENCES  LIBRARY 


H00380519Q 


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http://www.archive.org/details/southernmedicine911929char 


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. 


SURGEON'S  NEEDLE 

Cutting  Edpe 

Regular  Eve 

Per  Doz.  $1.50 


Stainless  Anchor 

Surgical  Needles 

To  those  vigilant  men  of  science — the 
surgeon,  the  doctor,  the  dentist — comes 
stainless  steel,  the  incorruptible,  the  steel 
of  immaculate  cleanliness,  devoting  its 
lingular  qualities  to  the  enrichment  of  Human 
Happiness  For  Surgeons  and  Doctor,  and 
Dentists  arc  the  unselfish  guardians  of  Public 
Health,  and  that  which  best  serves  their  pur- 
po;e  best  serves  the  interests  of  Humanity  at 
large.  Stainless  Anchor  suturing  needles  arc 
forever  inviolate  to  the  contamination  of  rust, 
coirosion,  tarnish,  stain:  No  more  the  dangers 
of  infection  which  lurks  in  the  small  and 
inacessible  eye  of  a  surgeon's  needle.  The 
presence  of  these  silvery  bright  Stainless 
.Anchor  Surgical  Needles  in  the  operating  room 
cr  the  doctor's  of  lice  is  more  than  a  badge 
of  progressiveness ;  it  is  a  pledge  of  super- 
caution  in  the  public  good.  .Anchor  Surgical 
Needles  are  made  from  genuine  Stainless  Steel. 
An  effective  aid  in  the  ever-ending  fight 
against  infection. 

Vou    cannot    go    wrong    when    you    ask    for 
.Anchor  Brand. 


Srl/ing  Agents 

Winchester  Surgical  Supply  Company 

0  !•:.  7th  St.,  Charlotte,  X.  C. 


y^ 


6 


ROUND   POINT 

For  Catgut 

Regular  Eve 

/'(■;•  Doz.  $1.50 


FOR  A  WHILE  ONLY 

"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 

Hovis,  L.  W.  Charlotte 

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 

Myers,  Alonzo  Charlotte 

Myers,  J.  Q.  .....Charlotte 

Munroe,  H.  Stokes  Charlotte 

Munroe,  J.  P.  (Hon.)  Charlotte 

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 

Nisbet,  D.  H.  Charlotte 

Nisbet,  W.  O. Charlotte 

Northington,  J.  M. ...Charlotte 

Orr,  Chas.  C Asheville 

Parker,  J.  R.  Burlington 

Parker,  O.  L.  Clinton 

Peeler,  C.  N.  Charlotte 

Peery,  Vance  P.  .....Kinston 

Perry,   H.   G.  Louisburg 

Petteway,  G.  H. Charlotte 

Phillips,  C.  C.  Charlotte 


March,  IQ.'o 


SOUTHERN  MEDICINE  AND  SURGERY 


Pittman,  R.  L.  Fayetteville 

Procter,  Ivan  M. Raleigh 

Pugh,  Chas.  H Gastonia 

Rankin.  W.  S.  -.-- ..rharlotte 

Ranson,  J.  L. Charlotte 

Roberson,  Foy  Durham 

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 

Shuford,  J.  H.  Hickory 

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 

Thompson,  S.  Raymond  Charlotte 

Todd.  L.  C Charlotte 

Tucker.  John  Hill  Charlotte 

V'ann,  J.  R.  Spring  Hope 

Verdery,  W.  C Fayetteville 

V'ernon,  J.  W. Morganton 

Walters,  Chas.  M Burlington 

Warren,  Wm.  E Williamston 

Weathers,  Bahnson  Rosemary 

West,  Thos.  M.  Fayetteville 

Whisnant,  A.  M Charlotte 

\\'h!taker.   F.   S.   Kinston 

Whitaker.  Paul  F. Kinston 

Willis.  B.  C.  -. Rocky  Mount 

Wooten,  W.  I.  Greenville 

Wooten,  F.  P.  Kinston 

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  _.... 

H.  F.  Starr  

H.  C.  Henry 

E.   G.   Gill   


Reccmmendrd   by 

VV.  C.  Ashworth 

W.  C.  Ashworth 

W.  C.  Ashworth 

McG.  Anders 

Vm.  Allan 

Robt.  C.  Brvan 

R.  B.  Davis 

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 
.__J 
„._J 

_....;, 

—J 

—J 

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—J 

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-J 

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-J 


-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 
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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 


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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 


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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. 


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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) 


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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, 


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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 


^  °       =  o 


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a  :i  y  =  o 
o.  _  2.  o  g 
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— •  ^    O     r 

3-5    =    C    ; 

J5  "    c  5' , 


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5  S 


2:  ?  •^  3  ?- 


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 

MERCK  &  CO*  iNc: 

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- 
perature and  pulse  rate  and  acts  favorably  on  the  toxemias 
of  sepsis  in  such  conditions  as  Pneumonia,  Puerperal  Fever, 
Post-operative  Sepsis,  etc. 


Oral  Administration 
American  Bio-Chemical  Laboratories,  Inc. 

27  Cleveland  Place,  New  York  City 
■■■'     II    ill  il|lgW^BBi*g^WBipWiiTBiHllllriri<    III 


American  Bio-Chem.  Lab.,  Inc.      A 
27  Cleveland  Place,  New  York  City. 
Please  send  sample  and  literature. 
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 


•H'4'^4-4~H-'H~»^»^-H-'M'^^<-'f-H'^~H'  ■!■  <■ »  » •!■  »H 


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. 

StmpUs  are  at  your  disposal 


RIEDEL  &  CO. 


BERRY  AND  SO.  5TH  STS. 


BROOKLYN,  N.  Y. 

1  ti  I  ttn** 


Marp Black  Clinic  &  PriVateHospital 

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  ani  Abdominal  Surgery 
H.  E.  Mason,  M.D.,  General  Medicine 

Russell  F.  Wilson,  M.D.,  Genito-Urinary  Diseases  and  X-ray 
Paul  Black,  Hydro-  and  Electro -Therapeutist 
Especially  equipped  for: 


Surgical, 


Hydrotherapeutio,    Dietetic,    Metabolic, 
Laboratory,   X-ray  and    Radium 


Olaano*!* 

and 

Tr»atm«nt 


Rate*  per  week  (payable  weekly  in  advance):  Wards — $17.50;  Two  and  Three  Bed*  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  $50.00. 

Addrtss  communications  to:  MISS  HELEN  LANCASTER,  Business  Manager 


\ 


Support  the  Journall    Buy  from  its  advertisers. 


I 


June,  1929 


SOUTHERN  MEDICINE  AND  SURGERY 


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       | 

(1  1-3)  FARES  for  the  round  trip  between  all  points  within  a 

i-adius  of  150 

miles. 

SIX-DAY  LIMIT  round  trip  tickets  on  sale  daily  at  ONE  and  ONE-HALF       1 

(1  1-2)  FARES  for 

the  round  trip  between  all  points  within 

a  radius  of 

150  miles. 

FARES  FROM 

CHARLOTTE 

NORTH    CAROLINA 

Round 

Round 

One                       Trip 

Trip 

Way              "Two-Day 

"Six-Day 

To 

Fare                    Limit" 

Limit" 

BARBER.  N.  C 

$1.56                     $2.10 

$2.35 

BLACKSBURG,  S.  C.  .. 

1.67                       2.25 

2.55 

CHESTER,  S.  C 

1.60                       2.15 

2.40 

COLl  \IBIA,  S.  C 

3.96                       5.20 

5.85 

UAMILLE,  VA 

5.12                       6.85 

7.70 
1.20 

GASTOMA,  N.  C 

78                       1.05 

GREENVILLE,  S.  C 

3.84                       5.15 

5.80 

GREENSBORO,  N.  C 

3.38                       4.55 

5.10 

HIGH  POLNT,  N.  C 

2.84                        3.80 

4.30 

HICKORY.  N.  C 

2.74                        3.70 

4.15 

MOORESVILLE,  N.  C. 

1.02                       1.40 

1.55 

ROCK  HILL,  S.  C 

90                       1.20 

1.35 

SALISBURY,  N.  C 

1.59                       2.15 

2.40 

SENECA,  S.  C 

5.22                       7.00 

7.85 

SHELBY,  N.  C 

1.91                       2.55 

2.90 

SPARTWBLRG,  S.  C. 

2.70                       3.60 

4.05 

SPARTANBURG,  S.  C. 

2.70                       3.60 

4.05 

\VINSTON-SALE.M,  N. 

C 3.00                        4.00 

4.50 

Tu  all  other  stations  within  150  miles  from  Oiarlotte,  on  the  same  hasis. 

Also  10-trip,  20-trip 

and  30-trip  low  fare  tickets,  between 

stations  200 

miles  apart,  good  for  6  months. 

ASK  AGENTS  FOR  PARTICULARS 

CITY  TICKET  OFFICE 

237  West  Trade  St.,  Qiarlolte  Hotel 

Phone  Hemlock  20 

SOUTHERN 

RAILWAY  SYSTEM 

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 
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  Mirrorless  Ophthalmnscope  is  easy  to  use 
For  Direct  or  Indirect  Methods 

POWERS  &  ANDERSON 


503   Cranby    St. 
Norfolk.    Va. 


603   Main   St. 
Richmond,   Va 


Smsical  hislriimcnts.  Hospital  Supplies,  Etc. 


During    1928   it    was    my   privilege   to 

make  Supporters  jor  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. 

Liberal  discounts 
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. 


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.] 

wanted     for     150    bed    tuberculosis    hospital, 

young  single  assistant  physician   who  has  com- 

pi  eted   hospital    internship   and   has   special   in- 

tfrest    in    tuberculosis.      .fl'io.oo    a   month    and 

maintenance     .  address superintendent    meck- 

LKNBURG    COUNTY     TUBERCULOSIS    S.-VNA- 
TORIUM,  Huntersville,  N.  C. 


June,  1020 


SOUTHERN  MEDICINE  AND  SURGERY 


44S 


THE  STANDARD 


LQESER*S  INTRAVENOUS  SOLUTIONS 

— — ^—     CERTIFIED      — ^^— 
T  0  F  S  F  R '  S  I 

INTRAVENOUS   SOLUTION 

OF 

IRON  AND  ARSENIC 

A  standardized  sterile  solution,  5  cc.  contain  64  mg..  (1  grain)  of  Iron  Cacodylate. 
In  hermetically  sealed  Jena  glass  ampoules. 

In  12  years,  steadily  increasing  numbers  of  physicians  have 
demonstrated  the  safety  and  practicability  of  its  intravenous; 
injection  and  therapeutic  value  in  the  treatment  of  all  Secondary 
Anaemias  following  Malaria,  Pellagra,  Influenza  and  other  infec- 
tions as  well  as  Surgical  Procedure. 

Clinical  Data  sent  on  request. 


LOESER  LABORATORY 


22  West  26th  Street 


New  York  City 


;„j.^„;..;„;..j,.j,.j.^.j..;..;..;..;.^..«..;..j..;.^..;..;..;..;..j..}..5..j..5..5..;..;..5..;..;-.;..5";";-. 


The  Better  Acid  Medium  Urinary  Antiseptic 

HEXALET 

(Sulphosalicylic  hexamethylenamine) 


Allays  severe  burning  and  has 
a  soothins:  effect  in  kidney  and 
bladder  conditions  without  causin,!' 
hematuria  when  take  for  a  long 
period  of  time. 

To  clear  shreds  and  pus  in  chronic 
and  non-specific  cases. 

No  eructations,  gastric  or  stomach 
disturbance. 

Full  literature  upon  request 


RIEDEL  &  CO.,  Inc.,  Berry  &  So.  5th  Sts.,  Brooklyn,  N.  Y. 


HEXALET 


RIEDEL 


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 


ADV. 

RATES 


EACH   ISSUE 


Whole   Page,  $20.00 
Halt  '■  12.50 

Quarter    "  7.50 


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 


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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 


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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 


South  Carolina 

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 
Especially  equipped  for: 

Surgical,    Hydrotherapeutic.    Dietetic,    Metabolic,  Diagno»l» 

Laboratory,   X-ray  and    Radium  and 

Treatment 

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 
Way 
Fare 

$1.56 

1.67 

1.60 

3.90 

5.12 

78 

Rotmd 

Trip 

Two-Day 

Limit" 

$2.10 

2.25 

2.15 

5.20 

6.85 

1.05 

5.15 

4.55 

3.80 

3.70 

1.40 

1.20 

2.15 

7.00 

2.55 

3.60 

3.60 

4.00 

Round 
Trip 
"Six-Day 
Limit" 
$2.35 
2.55 
2.40 
5.85 
7.70 
1.20 
5.80 
5.10 
4.30 
4.15 
1.55 
1.35 
2.40 
7.85 
2.90 
4.05 
4.05 
4.50 

(iREEWILLE,  S.  C. 
GREENSBORO.  N.  C.  . 

HKJH  POIM ,  \.  t; 

HICKORY.  V   C 

MOORESVILLE,  N.  C. 
ROCK  HILL,  S.  C. 

3.84 

3.38 

: 2.84 

2.74 

1.02 

.90 

SALISBI  RY,  N.  C 

SE\EC\,  S    C. 

1.59 

5.22 

SHELBY,  N.  C. 

1.91 

SPARTA.XBl  RO,  S.  C 
SPARTANBURG,  S.  C 
WINSION-SALEM,  N. 

2.70 

2  70 

C 3.00 

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. 

Liberal  discount': 
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. 


[adv.] 


W.^NTED  FOR  150  BED  TUBERCfLOSI.S  HOSPITAI,, 
VOUNO  SINGLE  ASSISTANT  PHYSICIAN  WHO  HAS  COM- 
PIETED  HOSPITAL  INTERNSHIP  AND  HAS  SPECIAL  IN- 
TrREST  IN  TUBERCULOSIS.  SI  50.00  A  MONTH  AND 
MAINTENANCE  .  ADDRESS SUPERINTENDENT  MECK- 
LENBURG COUNTY  TUBERCULOSIS  S.ANA- 
TORIUM,  Huntersville,  N.  C. 


bUL'TUIiK.N  MEDICINE  AND  SURGERY 


July,  1929 


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July,  1929 


SOUTHERN  MEDICINE  AND  SURGERY 


in  amebic  dysentery 

ST0VARSOL 

REG.  IN  U.  S.  PATENT  OFFICE 
ACETYLAMINO-OXYPHENYLARSONIC  ACID 

Accepted  by  the  Council  on  Pharmacy  and  Chemistry 
of  the  American  Medical  Association 

Manufactured  by 

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SUCCESSORS  TO 

POWERS-WEIGHTMAN-ROSENGARTEN  CO. 

Literature  on  request  to  Philadelphia  Office  916  Parrish  St. 


DisuLPimMifi 

Orto-OKihenzoyl-sulphon-  nucleino  •  formoi  -  sodium' 
tetradimethyUtmino  -antipyrin  -  bicamphoraitit 


should  be  given  AT  ONCE  when  a  rise  in 
temperature  indicates  Sepsis  in  such  conditions 
as  Cold,  Influenza,  Pneumonia,  Post  Abortum, 
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Please  send  sample  and  literature. 
Dr. 


524  SOUTHERN  MEDICINE  AND  SURGERY  July,  1929 


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Half  "         12.50 

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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 


Insured 
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 

(^ontatner,  hermetically  sealed  by  an  easily  removable  metal  cap 
and  ring,  the  physician  is  assured  of  a  highly  efficient  container,  on  the  one 
hand,  maintaining  the  hygroscopic  potency  of  its  active  ingredients  and 
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. 


During    1928   it   was   my   privilege   to 

7iiake  Supporters  jar  doctors  in   every 

State  and  in  many  distant  countries.— 

Katherine  I..  Storm,  M.  D. 


'  tmm:  \" 

Every    Belt 


^"  STORM" 

SUPPORTERS 

for  all  condi- 
tions. Three 
distinct 
"Types"  with 
many  varia- 
tions. Prices 
?S.OO  up. 

Liberal  discounts 
to  Hospitals  and 
to  all  Social  Ser- 
vice Departments 


Ask  for  literature 

KATHERINE  L.  STORM,  M.D. 

Originator,    Sole   Owner   and    Maker 
1701     DIAMOND    ST.  PHILADELPHIA 


DISULPIMMIN 


J."--mi.,".'h„;uV'«i»J»" 


Clinical  evidence  is  being  daily  received  in  con- 
firmation of  the  Laboratory  claims  for 

DISULPI129MIN 


If  you  wish  to  control  Febrile  Diseases  of  Sepsis 
send  for  literature  and  samples. 


Orally 

Admmhtrrcd 

American  Bio-Chemical  Laboratories,  Inc. 

27  Cleveland   Placs,  New  York  City 


American  Bio-Chem.  Lab.,  Inc.       A 
27  Cleveland  Place,  New  York  City. 
Please  send  sample  and  literature. 
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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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. 


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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 


Mead  Cycle  Co.,  Chicago,  U.  S.  A. 


On  Any 
MEAD 
Bicycle 

whether  you  buy  from 
your  Local  Dealer  or 
from  us  direct. 

On  Your  Bicycio 

Prices  From  «21'<>  Up 

Get  full  particulars 
by  mail  today.  Use 
coupon  below. 

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You  are  allowed  30 
days'  actual  riding 
test  before  sale  is 
binding. 

Write  Today  Premium  Offer  and 
name  of  nearest  Mead  Dealer. 

CUT  on  THIS  LIME 


I       Please  send  full  information  and  name  of  near- 

I  est  dealer. 

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wheels,  equipment. 
Low  prices.  Send  no 
money  .Use  the  coupon. 


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 

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For  Tonsils  and  Adenoids 

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Telephones — 

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H.  C.  NEBLETT,  M.D. 

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H.  C.  SHIRLEY,  A.M..  M.D. 

Practice  Limited  to 

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and  THROAT 

Professional  Building                 Charlotte 

JOHN  HILL  TUCKER,   M.D. 

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Telephones — 

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A.  A.  BARRON.  M.D.,  F.A.C.P.                    .VI.  L.  Stevens.  VI.I).      Chas.  C.  Orr,  MI). 

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CRAVStJN  E.  TARKIN(;T(»N, 
\l.l)..  F.A.C.P. 

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in 
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.Andrew  J.  Crowell,  M.D. 
Raymond  Thompson,  M.D. 
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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. 
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September,  102Q 


PROFESSION  CARDS 


667 


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Improved  Facilities. 

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Geo.  W.  Presslv,  M.D.,  F.A.C.S. 

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CharloUe 


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and 

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Hours  2:30 — 5 

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Wachovia  Hank  ISiiildiiiji 


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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 
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Charlode 


Oren  Moore,  M.D.,  F.A.C.S. 
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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 


ni 


Wkure  jDiqaJEcK.  is  noco  ntac^e 


D      D      a      a 


Thjt  cetdral  admirxisfraiion  buildiwo  of 
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 
the  point  that  makes  and  holds  users  of  Digalen. 

A  trial  villi  for  your  bag  on  request 

Hqffmann-La  Roche,  Inc. 

Makers  of  Medicines  of  Rare  Huality 
NUTLEY,  NEW  JERSEY 


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^ 


•Saturdny  niehl 


?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. 


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>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^ 

A  NEW  BACTERICIDAL  DYE 

BISMUTH-VIOLET 

[Hexamethyl-triamin-triphenyl-carbinol  .   .  .  bismuth] 

A  triphenylmethane  dye  which  is  very  destructive  to  the  common  pathogenic 
bacteria.  It  is' XOX-IRRITATING  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  ti-eatnient  of: 

Infected  Wounds 
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 

Conjunctivitis 

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  pathogenic  organism.s  are  killed  by  BISMLITH-VIOLET  in  the 
folluwiiig  dilutioiiis: 


Staphylococcus  alhus,  aureus  and  citreus.. 

Streptococcus  pyogenes 

B.  Typhosus  

B.  Paratvphosus  A  and  B  -. 

B.  Colt  '....... 

B.  Tetani  and  spores  

B.  Welchii  and  spores     - — .. 

B.  Anthracis  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  bottles,  Physician's  office  size.     One-half  ounce  bottles  for  the  trade. 
Samples  and  literal ure  will  be  sent  on  request 

Manufactured  solely  by 

TABLE  ROCK  LABORATORIES,  INC. 

Greenville,  South  Carolina,  U.  S.  A. 


744 


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 

DlSULPIinMIM 


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  York  City 


American  Bio-Chem.  Lab.,  Inc.       A 
27  Cleveland  Place,  New  York  City. 
Please  send  sample  and  literature. 
Dr.    _ 


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SOUTHERN  MEDICINE  AND  SURGERY 


October,   1929 


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 


On  Any 
MEAD 
Bicycle 

whether  you  buy  from 
your  Local  Dealer  or 
from  us  direct. 

On  Youp  BIcyolm 

Prices  From  «2I'<>  Up 

Get  full  particulars 
by  mail  today.  Use 
coupon  below. 

Sold  On  Approval 

You  are  allowed  30 
days'  actual  riding 
test  before  sale  is 
binding. 

W.>^f-A  TaJ»»  for  Catalog,  Free 
write  lOday  Premium  Offer  and 
name  of  nearest  Mead  Dealer. 

CUT  OH  THIS  UHE 


r  Free  Trial 


I   Town_ 
I 

!    Special 
Offer 


j  Mead  Cyole  Co.,  Chicago,  U.  S.  A. 

I       Please  send  full  information  and  name  of  near- 

I  est  dealer. 

I 

I  NamK 

!  Street  or 

I  P.O.Box 


1735 


Stale_ 


Tires  »iM 

Guaranteed. —  Lamps, 
wheels,  equipment. 
Low  prices.  Send  no 
money  .Use  the  coupon. 

\ta:kA  ^y^l'  Company 


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 


THE  AMERICAN  RED  CROSS 


November,  1929  SOUTHERN  MEDICINE  AND  SURGERY  8M 


A  NEW  BACTERICIDAL  DYE 

BISMUTH-VIOLET 

[Hexamethyl-triamin-triphenyl-carbinol  .  .   .  bismuth] 

A  triphenylmethane  dye  which  is  very  destructive  to  the  common  pathogenic 
bacteria.  It  is  NON-IRRITATING  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 

I.S  of  value  in  the  treatment  of: 

Infected  Wounds 
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 

Conjunctivitis 

Sinusitis  i  ■ 

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  palliogonie  organLsms  are  killed  by  BISMLITH-VIOLET  in  the 
following  dilulioiLs: 


Staphylococcus  albus,  aureus  and  citreus.. 

Streptococcus  pyogenes  

B.  Typhosus  -„ ..._ 

B.  Paratyphosus  A  and  B  

B.  Colt    

B.  Tetani  and  spores 

B.  Welchii  and  spores  

B.  Anthracis  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  bottles,  Physician's  office  size.     One-half  ounce  bottles  for  the  trade. 

Samples  and  literature  will  be  sent  on  request 

Manufactured  solely  by 

TABLE  ROCK  LABORATORIES,  INC. 

Greenville,  South  Carolina,  U.  S.  A. 


SOUTHERN  MEDICINE  AND  SURGERY 


November,  102<3 


Tuberculosis   Kills 

1  out  of  5 

of  all  tvho  die  bcticeen  15  and  45 

It  is   the   enemy  of  steady   employ- 
ment,   high    wages    and    prosperity 
For  tuberculosis   strikes  during  the 
most  productive  years  of  life. 
Help  us  to  rout  tuberculosis. 

BUY 

CHRISTMAS 

SEALS 

1  MtoWV    .''. 


The  National,  State  and  Local  Tuberculosis 
'  A^ociations  of  the  United  States 

mAJ  /I  )0>i  'Ami 


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 

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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 


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Doctor  Friends,  order  1930  Sub- 
scriptions for  SOUTHERN  MEDI- 
CINE &  SURGERY. 

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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.) 


The  familiar  flavor  powerfully  masks 
unpleasant  drugs  —  tones  appetite 
and  metabolism.  Elix.  Ang.  Amari 
Sgt. — q.s. 

Send  jor  Sample 


\     J.  W.  Wuppermann  Angostura 
Bitters  Agency,  Inc. 

14  East  i6t^  Street,  New  York,  N.  Y. 


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. 


TnE  Hewih  CntMn :*i  Mfg.  Co..  163  Viirick  Si..  N<-w  York. 

You   mav   «pn(l   Die.   free    of  all  chorpea,  yonr  illustratei] 

hrochure,  "The  Pnruniomc  Lung",  tugelljer  *ilh  .ample  of 

Aiitipblogiittine  for  elit  '     ' 

jif.n. 

Addrna 

Ciry Sutu 


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 

1,000,000,000 

1,000,000 

100,000 

1,000,000 

100,000 

100,000 

100,000 


Six  ounce  bottles,  Physician's  office  size.     One-half  ounce  bottles  for  the  trade. 
Samples  and  literature  will  be  sent  on  request 

Manufactured  solely  by 

TABLE  ROCK  LABORATORIES,  INC. 

Greenville,  South  Carolina,  U.  S.  A. 


m 


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 


917 


PUBLIC  HEALTH 

Health  Education,  Department  of,  G.  M.  Cooper 

Influenza.  £.   G.   Williams  

Keeping  the  Gate,  £,  A.  Branch "_ ^ 

Newton  Bill,  The,  £.  G.   Williams 


278 

59 

359 

125 


Department  Editor— i.  L.  Williams 


_  ,  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_  

Pr.nce,  Dr.  D.  M..   W.  D.  James    "ZT"!  

Renaudot.  Theophrastus.  R.   E.  Seibels        Z Z.Z^_ 

"'"''MEETfx^'^'''^-^''    ASSOCIATION,    PRo"CEEDING¥~¥iirRTY:FfF[iF"ANNUAL 

Ut.   W.  L.  Dunn,  M.  L.  Stevens ' 


SOS 
581 
650 
184 
61 
428 
348 
735 
819 
267 


-     _.  ^.,  veils 

Dr.  G.  F.  Mclnnes,  F.  B.  Johnson 
Dr.  A.  M.  Willis.  C.  C.  Coleman  Jl\ 
Dr.  C.  L.  Summers.  J.  L    Hanes 
Dr.  J.  H.  Miller.  R.  E.  Hughes 
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":":";'>:'<' ■:••>•>•!••:•*•$ 


"SUPREME  AUTHORITY" 


NEW  INTERNATIONAL 
WEBSTER'S 
DICTIONARY 

—THE  MERRIAM  WEBSTER 
Because 

Hundreds  of  Supreme  Court 
Judges  concur  in  highest  praise 
of  the  work  as  their  Authority. 
The  Presidents  of  all  leading  Uni- 
versities, Colleges,  and  Normal 
Schools  give  their  hearty  indorse- 
ment. 

All  States  that  have  adopted  a 
large  dictionary  as  standard  have 
selected  Webster's  New  Interna- 
tional. 

The  Schoolbooks  of  the  Countr\' 
adhere  to  the  Merriam-Webster 
system  of  diacritical  marks. 
The  Government  Printing  Office 
at  Washington  uses  it  as  author- 
ity. 

WRITE  for  a  sample  page  of  the 
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and  India  Papers   FREE 


%  G.  &  C. 

5.  Merriam 
4  Co, 


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