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UNC-CH HEALTH SCIENCES LIBRARY 



H00380519Q 



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Tri-State Medical Association Meets February, 19-20-21 



U.N. C 




Volume 9i1 
Number 1 



JANUARY, .1929 



Single Copies SOe 
$2.50 Per ABB«m 



CONTENTS 



Original Articles 

Management of the Complications of Diabetes, W. J. Mallory 1 

The Therapy of Amebiasis (Report of Cases), A. B. Hodges 5 

Mucous Membrane Cysts of the Maxillary Sinus, J. P. Matheson 

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. 




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L X D O :V. 
Primal (or T. C X :•: the i.i>»/' i- 






'^ / -V / J- 




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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 

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Address Meriwether Hospital, 37 Watauga St., Asheville, N. C. 
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SOUTHERN MF.niCINE AND SURGERY 



January, 1929 



NEWS 



The jMarlboro County ^Medical Society 
held its annual New Year's meeting and ban- 
quet January 10th, at the jNIasonic Temple, 
Bennettsville, S. C. 

Program: "Achlorhydria, " Dr. Walter R. 
Mead, Florence, S. C; "Arsenicals and the 
Optic Nerve," Dr. J. Wilkinson Jervey, 
Greenville, S. C. — Discussion opened by Dr. 
Simons R. Lucas, Florence, S. C; "Restora- 
tion of Function by Silk Inserts in Injured 
or Destroyed Tendons," Dr. William Tate 
Graham, Richmond, Va. — Discussion opened 
by Dr. O. L. Miller, Charlotte. X. C; "Ob- 
servations on the Treatment of Puerperal 
Sepsis," Dr. Oren INIoore, Charlotte, N. C. — 
Discussion opened by Dr. Lester A. Wilson, 
Charleston, S. C; "Carcinoma of the Cervix 
Uteri," Dr. Kenneth JNI. Lynch, Charleston, 
S. C. — Discussion opened by Dr. A. Johnson 
Buist, Charlestion, S. C; "A Large Gluteal 
Aneurism Simulating a Sarcoma of the But- 
tock," Dr. Hubert A. Royster, Raleigh, N. C. 
^Discussion opened by Dr. AddiSon G. Bre- 
nizer, Charlotte, N. C. 

Between the afternoon and evening sessions 
dinner was served in the banquet hall. Dr. 
D. D. Strauss, Sec, Bennettsville. 



The Sampson County Medical Society 
met at Clinton, N. C, December 3, 1928. 

Program: Business meeting and annual 
election of officers; dinner at the Rufus King 
Hotel; papers and discussions: "Some Re- 
marks on the Ethical and Economic Sides of 
Practice," Dr. J. S. Brewer, Roseboro; "Early 
Diagnosis of Cardio-nephritic Disease," Dr. 
Ernest S. Bulluck, Wilmington; "Anesthesia 
in Obstetrics," Dr. V. R. Small, Clinton; 
"Tubal Pregnancy," Dr. David Rose, Golds- 
boro; "Perforating LHcer of the Duodenum," 
Dr. R. L. Pittman, Fayetteville. Dr. Paul 
Grumpier, Sec. 

The Robeson County Medical Society 
held its regular monthly meeting at the Lor- 
raine Hotel, Llecember 6th. 

The following officers were elected for the 
new year: Dr. H. T. Pope, of Lumberton, 
president; Dr. H. M. Baker, of Lumberton, 
vice-president; Dr. E. L. Bowman, of Lum- 
berton, secretary-treasurer. Dr. A. B. Holmes, 



of Fairmont, was chosen delegate to the State 
Medical Society, with Dr. J. F. Nash, of St. 
Pauls, as alternate. Drs. R. S. Beam, of 
Lumberton, J. McN. Smith, of Rowland, and 
A. B. Holmes were named censors for a period 
of three vears. 



Richmond .Academy of Medicine 
Dr. Wyndham B. Blanton was installed as 
president of the Richmond .Academy of Medi- 
cine at the regular meeting on January 8. 

."^n interesting paper on hysterosalpingogra- 
phy, illustrated by lantern slides, was pre- 
sented by Dr. M. P. Rucker and Dr. L. J. 
Whitehead. 

Dr. Lee S. Huizunga, of New Haven, Conn., 
gave an exceedingly interesting talk on lep- 
rosy. Dr. Huizunga has devoted many years 
to the study of the disease in various parts 
of the world, and the malady remains almost 
as much of a mystery as it was in ancient 
davs. 



Two Hospitals at Danville (Va.) Merged 
.Announcement has been made of the con- 
solidation of Memorial Hospital and Ed- 
munds Hospital after several weeks of nego- 
tiating. Under the merger terms Dr. T. W^. 
Edmunds, owner of one hospital, received 
S23,000 on the agreement that he will not 
sell the building for hospital purposes within 
ten years. 

Arrangements have been made to transfer 
the 42 pupil nurses at Edmunds Hospital to 
Richmond and Charlottesville. 



Marion Hospital Opened January 14th 

The formal opening and dedication of the 
Marion General Hospital was held January 
1 4th, when it was opened to the public. The 
hospital was sponsored by the Kiwanis Club 
and was made possible by the donation of 
$35,000 from the citizens of Marion and Mc- 
Dowell county and by $25,000 from the 
Duke endowment fund. 

Dr. ^^'. S. Rankin, of the Duke endow- 
ment, and Dr. C. O'H. Laughinghouse, head 
of the State Health Department, attended. 



For the University of Virginia, the year 
1928 has been one of greater expansion thcui 



Januaiy, 1929 



SOUTHERN MEDICINE AND SURGERY 



6S 



any previous twelve-month period within the 
105 sessions of continuous academic history. 

Nearly $6,000,000 has been added to the 
productive endowment of the University, and 
other gifts received during the year have 
reached a total of almost $300,000. Con- 
struction has been started, or has been in 
progress, on new buildings that are to cost 
well above $2,000,000. 

President Edwin A. Alderman announced 
last June that an alumnus, whose name has 
been withheld, had created a trust fund of 
between §5,000,000 and $6,000,000 for the 
benefit of the University, half of which 
would be used for scholarships and fellow- 
ships. 

This fund has been found to total almost 
§6,000,000, which gives the University a total 
endowment of §10,000,000. The universities 
of only two states, Texas and California, now 
have larger productive endowments than the 
University of \'irginia. 



Dr. Paul Earl Sasser, Conway, S. C, and 
Miss Sarah Ellen Freeman, Bennettsville, 
S. C, were married December 20th at the 
Little Church Around the Corner, Xew York. 

Dr. Sasser was graduated from the Univer- 
sity of South Carolina and the Medical Col- 
lege of the State of South Carolina. After 
serving his internship at Roper Hospital in 
Charleston, he began his practice of medicine 
in association with his brother. Dr. Arch Sas- 
ser, in Conway. He is at present taking spe- 
cial work in New York, where the young 
couple will remain until March 1, after which 
time they will make their home in Conway. 



Dr. J. A. Marshall, 73, county super- 
visor, former county treasurer and former 
mayor of Greenwood, S. C, died at a Green- 
wood hospital December 20th. 

Dr. Marshall was completing his first term 
as supervisor, having been elected in 1924. 
He was (he county's first treasurer, having 
served for ten years from 1897 and was may- 
or of the city for one term, several years ago. 
He was a graduate of the University of Geor- 
gia Medical College and practiced his pro- 
fession at Greenwood a number of years, 
and later at Brooksville, Fla., before entering 
politics. 



sian and school teacher of Guilford county, 
died at his home at .Guilford C. H. Decem- 
ber 16th, after an illness of several months. 
Dr. Millis spent most of his life in the 
southern part of the county and in northern 
Randolph, where he served the community 
usefully. Since his retirement in 1890, the 
physician had lived at Guilford C. H. 



Dr. Robert Armistead Deane, negro phy- 
sician, was laid to rest December 15th in St. 
Paul's Memorial chapel cemetery, Lawrence- 
ville, Va. He died December 13th at the Pe- 
tersburg Hospital. 

Dr. Deane was a native of Richmond, 'Va. 
He was a graduate of Union University and 
the Howard University Medical School. 
.^bout twelve years ago he located at Law- 
renceville and at the time of his death he 
had built up a county-wide practice and was 
regarded a skill practitioner. 



Dr. J. A. Shaw, Fayetteville, while riding 
on the running board of a county officers' 
cab in an effort to overtake a driver who 
had struck his automobile, had his leg frac- 
tured. 

The accident occurred when a truck swerv- 
ed slightly to one side and crushed the doc- 
tor's leg against the car. The driver he was 
seeking to apprehend made his escape. 

Dr. Shaw was taken to the Highsmith Hos- 
pital, where he is a member (if the medical 
staff. 



Dr. .Adrian T. Millis, 80, prominent phy- 



Dr. John Sawyer Hitchcock, 59, one 
time personal physician to Calvin Coolidge 
at Northampton, Mass., died December 14th, 
at his residence, "Fall Field," Albemarle 
county, Va., after an e.xtended illness. He 
was a graduate of Amherst College and the 
I'niversity of Virginia. During the Spanish- 
American war he served in the medical corps. 
For many years he was the head of the health 
department of the State of Massachusetts. 

Dr. William Williams Keen, Philadel- 
phia, December ISth received the gold medal 
of the Pennsylvania Society at the organiza- 
titon's thirtieth anniversary dinner. 

Dr. Keen is 91 years old. He served' as a 
surgeon in the Union Army during the War 
Between the States, and soon afterward was 
largely in.^trumental in introducing antiseptic 



66 



SOtrrttEftN MEbtCtKE AND StTRGERY 



January, 1930 



surgery into this country. 



Dr. Clara E. Jones, Goldsboro, one of the 
most beloved women of North Carolina, is 
suffering from the effects of the fall that she 
sustained seven weeks ago in Ardmore, a resi- 
dential section of Philadelphia. 

Dr. Jones was crossing a street when sud- 
denly a car driven by a woman whirled around 
a corner, striking Dr. Jones, knocking her 
down and breaking a leg below the knee. 
She was taken to the home of her daughter. 
Dr. Margaret Castex Jones Sturgis, in Ard- 



nf medicine at the old Columbia University, 
as dean of the staff of Garfield Memorial 
Hospital, and as attendant and consulting 
physician at a number of other hospitals. 

It was through his efforts that the medical 
department of National University was 
founded in 1883, and he received an honorary 
LL.D. degree from that college in 1890. 

Dr. Cook served with the Seventh Virginia 
Cavalry in the Civil War, was a surgeon in 
the Spanish-American War, and served on 
the draft board in the World War. His son, 
Dr. Richard L. Cook, Sunmount, N. Y., sur- 



Dr. George E. Kornegay has established 
himself at Davis, Carteret county, N. C, for 
the practice of his profession. Davis has 
been known for some time as "the town with- 
out a doctor." 



Dr. Levi A. Walker, 55, University Col- 
lege of Medicine, Richmond, '98, prominent 
for many years in the professional life of 
Burlington and Alamance county, died De- 
cember 28th, at his home on West Davis 
street, following a brief critical illness. He 
had been in declining health the past three 
years. 

At the time of his passing, Dr. Walker 
was city health officer, and had been for 
many years, and was associated with Dr. P. 
C. Brittle in medical practice. 



Dr. J. Lewis Clinton and Miss Katie 
Rose Crews, both of ^Martinsville, Va., were 
married December 24th. 



Dr. Vernon Clark Lassiter and Miss 
Mary Dorothea Pfohl, both of Winston- 
Salem, were married December 22nd. 

Dr. Lassiter is a graduate of Emory Uni- 
versity in Atlanta. After graduating, he 
served as interne at Grady Hospital, Atlanta, 
for two years, and for the past three years 
has been resident physician at Memorial Hos- 
pital, Winston-Salem. 



Dr. George Wythe Cook, 82, L^niversity 
of Maryland, '69, native of Front Royal, Va., 
died in Washington, D. C, December 26th. 
He had been prominent in Washington medi- 
cal and social circles for many years. 

Dr. Cook had served as clinical professor 



Dr. George W. Black announces the re- 
moval of his office from Pineville, N. C, to 
ISIS South Boulevard, Charlotte, N. C. 

Dr. Wm. Francis Martin, Charlotte, has 
been made a member of the Executive Com- 
mittee of the American Medical Association 
of Vienna. Dr. ^Martin studied at Vienna for 
several months of last year. 



Dr. Henry V. Long, Statesville, has been 
appointed a member of the State Board of 
Charities and Welfare by Governor IMcLean. 
He succeeds Rev. C. H. Durham, of Lumber- 
ton, resigned. 



Dr. Benjamin HeRxMan Bailey, Sandston, 
Va., and Z\Iiss Frances Adcock were mar- 
ried December 28th at Orlando. Among the 
guests were Dr. and Mrs. J. B. Bailey and 
Dr. and Mrs. J. R. Bailey, of Keysville, Va. 



Fifty or more of Dr. W. J. Newbill's 
(Univ. of ^Maryland, "68) relatives and con- 
nections greeted him with words of love and 
congratulations on New Year's Day at the 
Beach Hotel, Irvington, Va., in honor of his 
82nd birthday, R. H. Fleet acting as toast- 
master. There were many responses in elo- 
quent toasts from Dr. Loverick P. Law, the 
Rev. S. .\. Donahue, Dr. W. H. Street and 
Arthur James. Doctors present from a dis- 
tance were: Dr. Henry Street, Richmond, 
and Dr. F. W. Stiff, Harmony. 



Dr. J. D. Blair and Miss Nan Brasing- 
ton, both of Bennettsville, S. C, were mar- 
ried Januar\- 4th. 



Dr. \\. A. \\'ooDRUFF, Woodruff, S. C, was 



Januah-, 19f0 



SOOTttERN MEDICtNE AN15 StTRGERY 



It 



recently made a trustee of the Medical Col- 
lege of the State of South Carolina. 



Dr. Charles E. Barker, of Grand Rap- 
ids, Mich., physician to President Taft, spoke 
at Gaffney, S. C, Sunday, January 13th, un- 
der the auspices of the Gaffney Rotary Club. 



Dr. Harry Walker, Courtland, \'a., and 
Miss Pamela .Ann Gary, Richmond, were 
married December 8th in the Little Church 
.Around the Corner, Xevv York Citv. 



Dr. James Robert Anderson, 67, Tulane, 
'82, died at his home at Morganton, N. C, 
December 1 2th. 



Drs. Albert D. and Mercer Parrott lost 
their father, and Drs. James M. and W. T. 
Parrott, a brother, when Mr. George F. Par- 
rott, of Lenoir county, died on December 
10th. 



Dr. J. W. Tankersley, Greensboro, and 
Miss Nellie Gray Ozment, Guilford Col- 
lege, were married in Raleigh, November 3rd. 




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"Poor Mary, that was her third husband who 
committed suicide." 

"Yes, it must have completelv unmanned her." — 
C. C. A'. }•. Mercurv. 



Irate Father: "What is that stuff on mv mvj car? 
Where have you been?" 

Calm Son: "Thais only Iraffu jam."- ,1/(i7i/j;ijh 
Gargoyle. 



Ciillector: "Do you believe in a hereafter?" 

Woman at Door: "Certainly I do!" 

Collector: "Well, this bill from Dr. Blank is over 
two years old; go get the money— that's what I'm 
here after!" — Colorado Medicine. 



"(live, for any one year, the number of bales of 
illon e\portetl from the United States." 
"1401; none."— /';>/)'j Magazine. 



«8 



-^ 



SOUTHERN MEDICINE AND SURGERY 



January, 1929 



REVIEW OF RECENT BOOKS 



THE TREATMENT OF DIABETES MELLITUS, 
by Ellioll P. JosUn. AID. (Harvard), MA. (Yale), 
Clinical Professor of Medicine, Harvard Medical 
School; consulting Physician, Boston City Hospital; 
Physician to New England Deaconess Hospital. 
Fourth Edition, enlarged, revised and rewritten. 
Illustrated. Lea & Febiger, Philadelphia. ?Q.OO. 

"Diabetics and especially diabetic children 
are here to stay," says Dr. Joslin. It is only 
in the last few years that more than a very 
few of these unfortunates could stay here 
long, and those stays were far from happy 
ones. It is only because of the discoveries 
of Banting, and their application by Joslin 
and others, that diabetics may stay and stay 
in comfort. 

The book represent the results of painstak- 
ing study of many thousands of the author's 
own patients, with the addition of anything 
from other sources which "on second or third 
perusal seemed worth while." 

Section heads are: The Diabetes of To- 
day; Insulin; Theory, Incidence, Etiology 
and Curability; Physiology and Patholog\'; 
Urine, Blood and Respiration in Diabetes; 
Diet in Health and Diabetes; Onset, Preven- 
tion, Classification, Prognosis, Symptoms; 
Treatment; Treatment of Acid Intoxication 
and Diabetic Coma; Arteriosclerosis and 
Heart Disease; Treatment of Complications; 
Surgery and Diabetes; Diabetes in Child- 
hood; Diabetes in Pregnancy; Glands of In- 
ternal Secretion; Diabetes in the Old; Renal 
Glycosuria; Management of the Diabetic in 
Office and Hospital; Foods and Their Com- 
position; Harris and Benedict Prediction Ta- 
bles. 

Here may be found, clearly set forth, what 
is known today on this very common disease. 
Every family doctor and every specialist is 
vitally concerned with diabetes. Every doc- 
tor practicing medicine should have — and 
study — this book. 



of the .American Dermatological .\ssociation. Eighth 
Edition, revised and enlarged. 126 illustrations. P. 
Blakifton's Son & Co., Philadelphia. :>2.00. 

The text has been thoroughly revised where 
revision was needed. The illustrations have 
been improved. A review of treatment of 
syphilis of the nervous system has been add- 
ed. Despite numerous typographical errors, 
it would be difficult to think of a text on skin 
diseases which a' family doctor could use with 
as great profit to himself and his patients. 



A COMPEND OF DISEASES OF THE SKIN, 
by Jay Frank Schamberg. A.B., M.D., Professor of 
Dermatology and Syphilology Graduate School of 
Medicine, University of Pennsylvania; Ex-President 



THE PRACTICAL MEDICINE SERIES, com- 
prising eight volumes on the year's progress in Medi- 
cine and Surgery. 

Gf.ner.\i. Surgerv, by Evarts A. Graham, A.B., 
M.D.. Professor of Surgery, Washington University 
School of Medicine; Surgeon-in-Chief of the Barnes 
Hospital and of the Children's Hospital, St. Louis. 
Series 102S. The Year Book Publishers, Chicago. 
.S^.OO. 

The author considers the work which dem- 
onstrates the control of paralytic ileus by 
splanchnic anesthesia to be an important de- 
velopment of the year. The lack of uniform- 
ity in the results of treatment of erysipelas 
by serum does not deprive the subject of in- 
terest. Bell's colloidal lead treatment of can- 
cer is discussed; as are the new injection 
methods for varicose veins. The test for pan- 
creatic disease worked out by Elman and JMc- 
Caughan of Washington University is describ- 
ed and praised. 

The Eve, E.\r, Nose and Thro.\t, Edited IkV 
Charles P. Small, M.D., Albert H. Andrews, M.D., 
and Grprge E. Shambaugh, M.D. Series 1928. The 
Year Book Publishers, Chicago. S2. 50. 

This volume follows more the general plan 
of a condensed textbook, with special empha- 
sis on recent advances, than that of abstract 
and comment; although the latter plan is 
made use of to a considerable degree. 

The constant keeping in mind of the inter- 
dej^endence of the head specialists and family 
doctors makes the method of procedure of 
especial value. 



SOUTHERN MEDICINE and SURGERY 



VOL. XCI CHARLOTTE, N. C, FEBRUARY. 1929 NO. 2 



Combined Drug Therapy in some Problems of Cardio-Vascular- 
Renal Disease* 

T. G. Murray, M.D., Greenville, S. C. 



It is the purpose of this paper to crystallize 
our thoughts regarding the relative value of 
certain drugs in the treatment of two import- 
ant problems of cardio-vascular-renal disease, 
namely, edema and high blood pressure. We 
meet with these complications frequently, 
especially in one particular type of cardio- 
rcr:al disease. 1 have in mind the edematous, 
dyspneic, hypertensive type with a decompen- 
sating heart and a small grey, granular kid- 
ney of the so-called chronic interstitial ne- 
phritis and arteriosclerosis. In other words 
the typical old cardio-renal patient of the 
cliarity ward. 

During the past summer I treated on the 
cliarity ward of the Greenville City Hospital 
::bout 14 of these cases, and during this time 
made an effort with this limited series to 
dcterni ne in some degree the relative value 
of a number of drugs, separately and in com- 
bination, in the management of edema and 
high blood pressure. The drugs with which 
we worked particularly were digitalis, citrin 
(containing the glucoside, cucurbocitrin), 
novasurol (merbaphen), and ammonium chlo- 
ride. ?.Iy use of these drugs over a period of 
three months brought about in my own mind 
some rather defmite, though not dogmatic, 
conclusions concerning their use. 

Tirst. we observed a group of these pa- 
tients v,'ith edema and hypertension which 
were given alone the usual text-book dose of 
the tincluie of digitalis, that is, 15-20 minims 
(not drops) three times a day. The diet v/ps 
restricted as usual and they were put at rest 
in bed. The blood pressure reading, urine 
output and fluid intake were measured and 
cherkrd • :!ch day. This group was com- 
r-ared with a group receiving no digitalis or 
I •i.cr medxation. The group receiving digi- 

*P»esente(i to the Greenville Countv Medical So- 
ciety, Kovembet o, 1928. 



talis was so slowly digitalized that there was 
absolutely no difference apparent in the 
progress of the two groups for many days. 
We then selected another group to the mem- 
bers of which we administered a dram of the 
tincture of digitalis every four hours until the 
to.xic symptoms began to appear. In this 
group v/e noted rapid improvement as com- 
pared with the two previous groups. There 
was a larger output of urine, the edema 
cleared up much more rapidly, and the vas- 
cular tension steadily, and in some cases rap- 
idly, declined. In the case of a negro woman 
v.ilh a blood pressure reading of 225 160 who 
was edematous and laboring for breath, with 
a blood creatinine reading of seven and non- 
protein nitrogen of 80, whose urine showed a 
heavy 4-plus albumin with granular and hyla- 
line casts, — and withal it seemed impossible 
that she could live more than a few hours — 
v.e administered one-half oimce of the 
freshly prepared tincture of digitalis and di- 
rected that a dram be given every 4 hours 
following. The next day she was fairly com- 
fortable, the edema was greatly lessened and 
she was breathing with comparative ease. 
Improvement continued and she is still living. 
This, of course, is not a safe procedure in 
every case. This small series of cases con- 
vinced me that digitalis is more valuable in 
the treatment of edema and hypertension of 
c.udio-renal disease than 1 had previously be- 
lieved. I am also convinced that large doses 
are abL'.olutely essential to oht.iin the iiest and 
(luii-kest results. 

Next citrin (cucurbocitrin) was tried. The 
: cti(!n of this drug is thought to be a selective 
o)ie, by its mild and gradual depression of 
the vaso-constrictor center, or of the sympa- 
thetic ganglia themselves. It is also possible 
for the drug to stimulate the depressor fibres 
in the blofid vessels owing to the presence 
of the drug in the blnod stream. Morsover, 



70 



SOUTHERN MEDICINE AND SURGERY 



February, IM* 



citrin miy have a selective action on the 
sympathetic vascular iunction, or upon the 
vascular wall itself. There is no depression 
of the cardiac musculature. In repeated ex- 
periments this has never been observed. 
The fa-lure of citrin to dilate the blood ves- 
sels may be due to a vaso-constrictor cause 
too powerful for this drug to overcome. 

Bordley and Baker- from their recent 
studies are led to believe that arterial hyper- 
tension is a compensatory phenomenon de- 
pendent on arteriosclerosis in the brain stem; 
that the rise in the arterial pressure is due 
to cerebral anemia induced by the sclerotic 
changes in the finer vessels of the medulla. 
Moreover, they state that their findings are 
in accord with respect to the association of 
arterioscleorsis in the retinal vessels and the 
vessels in the base of the brain. In Wilkin- 
son's series^ of 68 cases in which this drug 
was used, tv.'elve cases showed no response 
to the drug. It was observed in these 12 
cases that the retinal vessels were markedly 
sclerosed. 

Likewise, our use of citrin in these ad- 
vanced and complicated cardio-renals was not 
as satisf-ctory as in earlier cases of hyperten- 
sion without failing compensation and with- 
out retinal chants. Our findings here coin- 
cide with the findings of Wilkinson and 
Barksdale^ that citrin has its best therapeutic 
value in early, uncomplicated cases of arterial 
hypertension. We were pleased to discover, 
however, to cur own satisfaction at least, that 
citrin, in covibinatlcn ■with digitalis and one 
of the diuretics — e'ther novasttrol or ammo- 
nium chloride — hns a real place in the treat- 
ment of these edematous and hypertensive 
victims of cardio-renal disease. Of this com- 
bination, I shall have more to say later. 

Let us now paj^s io the use of novasurol as 
a diuretic. We uicd this drug on seven very 
edematous patients, first alone, then in com- 
bination with other drugs. We administered 
novasurol intravenously to avoid sloughing of 
tissue. Beginning with a dose of O.S c.c, we 
increased the dose every three days up to 2 
c.c. The water intake was measured, also 
the urire output for 24 hours. It was ob- 
served that 4 of the 7 responded in a very 
remarkabl: way. At times the urinary output 
in 24 hours increasing from 600 to 1400 c.c, 
following the .idminislration of novasurol. In 
two casee there was a sli^t increase in urin« 



output, while one was absolutely uninfluenced 
by the drug. Toxic effects were encountered 
in only one of the 7 cases. This man devel- 
ijped a mild d'arrhea and a rather distressing 
stomatitis, which cleared up quickly. Five 
of the seven cases had renal involvements 
when novasurol was administered, but after 
close obser\'ation, we felt positive that no 
further reiial damage was done by the admin- 
istration of this drug. We believe that the 
chances of kidney damage are much smaller 
than is commonly believed; however, we are 
mindful of the fact that our series was a 
very small one and we should always be on 
our guard for toxic side actions of this mer- 
curial preparation. 

Ammonium chloride was used as a diuretic 
alone and in combination. It v/as adminis- 
tered in enteric capsules to avoid gastric irri- 
tation. It was used alone in 5 cases and 
produced a satisfactory, but not a spectacular, 
diuresis in all of them. It appeared that 
;;mmonium chloride was a less spectacular, 
but a more consistent and dependable diure- 
tic than novasurol. That is, it never pro- 
duced so enormously increased an output as 
did novasurol, but it increased the output to 
a considerable degree in a larger percentage 
of cases. It was interesting to note that, in 
some casv°s novasurol hid a remarkable diu- 
retic effect and in the same cases ammonium 
chloride was ineffective, and likewise, when 
ammonium chloride did its best work on some 
edematous patients novasurol seemed entirely 
ineffective. The fact remains that both drugs 
pre good diuretics, but neither is effective in 
every case. 

Having spent some time observing the ac- 
tion of these drugs separately v.e now studied 
another series of cases in an effort to deter- 
mine the best combination of these drugs to 
use. Of course, we cannot apniy the same 
rules or the same treatment to all of these 
edematous hypertensive, cardio-renal patients; 
but we were able to come to some concrete 
conclusions applicable to a majority of cases. 

CONCLUSIONS 

First, we observed that digitalis in large 
doses in combination with citrin (cucurbo- 
citrin) was more effective than either drug 
alone, digitalis improving the force of the 
heart action, and citrin lowering the vascular 
tension. 

SeccHid, it was evident that novasurol ^id 



February. !*?♦ 



SOUTHERN MEDICINE AND SURGERY 



Biiwrionium chloride produced more effective 
diuresis in combination than did either drug 
separately. 

Finally, the combination of di-ugs giving 
the most convincing and most consistent re- 
sults in these decompensated cardio-renal- 
vascular cases were found to be: digitalis 
;t-ctiiig on the heart, citrin relieving vascular 
tension, and novasurol and ammonium chlo- 
ride, one or |>referably both, increasing the 
urinary output. Thus by the use of these 
four drugs in combination, we get direct ac- 
tion together on heart, artery and kidney. 



Further studies are in progress and will be 
reported in future papers. 

BIBLIOGRAPHY 

1. Wilkinson, Ciuorgc R.: "Further Studies on 
the Blood Pressure Lowerintr Effect of Cucurbocitrin 
in Man." South Carolina Medical Association Joiir- 
nn!, 1Q27. \'ol. xxiii. No. S. 

2. Kordley, Jas., and Baker. B. M.. jr.: "A Con- 
sideration of .Arteriosclerosis of the Cereliral Vessels 
and the Pathoaenesis of Hypertension." Johns Hop- 
kins Hospital Bulletin, 1026, Vol. xxxi.\, p. 220. 

i. Bark'dalc, Irvini; S.: "Studies on the Blood 
Pressure LowcrinK Principle in the Seed of the Wa- 
termelon (Cucurbita Citrullus), Am. Jour, of the 
.\fcdical Sciences, Jan., 1026, No. 1, Vol clxxi, p. 
111. 



Report on the Conference on Influenza* 

C. O'H. I.AUGHiNGHorsE, M.U., Raleigh, X. C. 

Hrkl at the Office of the Surjjeon (knieral U. S. P. H. S., Washington, January 10th, 1Q20 



The .Surgeon General being ill, the con- 
ference was opened by Assistant Secretary 
of the Treasury Shumann. .Assistant Sur- 
aeon General W. F. Draper presided. .\ 
written message from the Surgeon General 
was presented on the status of the present 
epidemic and purpose of the conference and 
a definite program submitted, although no 
government funds are available for this pur- 
\V-<<e. .\ rcjll-call was made of the State 
Health Officers and, while all states were not 
represented, all sections were. 

Pruf. Edwin O. Jnrdon reviewed the pres- 
ent kiiMwledge of the pathology, bacteriology 
and epidemiology of influenza. He was able 
to give us nothing new. The outstanding 
feature of his address was the emphasis put 
ufwn the fact that in epidemics of influenza 
all suspicious colds were of necessity classi- 
fied as influenza : therefore many thousands 
'■■f cases so reported were really coryza, rhin- 
itis, phtryngitis and bronchitis. Its rapid 
spread from the Pacific coast during a period 
of ihrci' months proved to his mind, however, 
th.nt we were dealing with a definitely epi- 
demic influenza. The disea.se is no respecter 
of pf-rsons, age. sex or race, and the people 
most su.'^crptible who suffer th,- highest death 
riilc lire those between 18 and 29. He felt 
thai thildan, becau.se of tlieir isolated lives 



;-.;ty, Jacoiry 14, VAi 



U:i-J\ 



were probably more or less protected, and 
that elderly people were not less susceptible, 
but furnished fewer victims because of coming 
into contact with fewer persons. The nutri- 
tional condition had little or nothing to do 
with their resistance. He stated positively 
that he did not know the cause of influenza 
JMit felt that in this epidemic it was causing 
deaths only by making fallow fields for 
streptococcic, staphylococcic, pneumococcic, 
and other respiratory bacterial infections. 

Dr. Frost, of the I'. S. P. H. S., and Mr. 
Edgar Snidenstr'cker. statistician, emphasized 
the fact that the epidemic of ten years ago 
laid the beginning of a scientific foundation 
for the study of influenza and the knowledge 
iibtained from that epidemic would be used 
advantageously in the handling of the pres- 
ent one. In 1918 the pandemic of inlluenza 
evidenced everywhere a leucopenia in a large 
proportion of the cases; the anticipated im- 
munity because of previous attacks has not 
materialized; moreover, a study of inlluenza 
in 1918 and of the disease during the past 
iliree months showed marked difference in se- 
\crit\- ;i;(I in percentage of population at- 
tacked. He thought tfie age incidence 
in young adults to be highest; thai children 
from five to nine showed .some decline: that 
I rum ten to eleven the incidence of infection 
gradiislly increased, the \<t:nk bein^ rricbed 
!!6« ttve.".'.; ■iciU'j tc ihu'.y. [Isjc.nsr : labora- 
tory I'lrustrat'ed th'e fitttttrtocentesis but this 



SOUTHERN MEDICINE AND SURGERY 



February, 1929 



bacterium needs further study before its sig- 
nificance can be stated, as is true of the Pfeif- 
fer bacillus. The hemolytic streptococci 
are found so constantly in normal res- 
piratory tracts that we were as yet not in 
position to even bring charges against it much 
less to convict it. Doctor Frost, after much 
d'Fcussion, committed himself to the droplet 
as a mode of infection. He warns against 
transmission by means of eating utensils. 
Such methods as public health authorities 
suggest for control are singularly futile. Doc- 
tor Frost concluded by making a broad state- 
ment that if influenza is to be conquered it 
will by systematic labors of research v^orkers 
— that experimental research, clinical research 
and epidem-ological research are the blessed 
trinity from which research workers are to 
obtain the information necessary for the 
throttling of this disease. 

Assistant Surgeon General A. M. Stimson 
gave an outline of studies on influenza con- 
templated by the Public Health Service. I 
will not go into this further than to say that 
the U. S. P. H. S. was insistent upon urging 
the assistance of state health officers and 
physicians in procuring sufficient funds. He 
also begged that the Rockefeller Commission 
compensate those undertaking original stud- 
ies in this disease. Various physicians from 
all over the country — Anders, Bloodgood, 
\Velch, Christian, Haven Emerson, Rosenau, 
Rosenow and other men of national import- 
ance discussed the manifestations of the pres- 
ent outbreak and compared it with other out- 
breaks of influenzT and other infections of 
the respiratory tract. These discussions re- 
volved around, first, preventive measures; 
second, therapeutic measures v.hich may re- 
duce mortality. Noth'Rg was advised in the 
way of prevention that we are not already 
practicing. The consensus of opinion seemed 
to be that school children were perhaps safer 
at school under school regime than they were 
at home. There was a most interesting dis- 
cussion of the immunization power of Rose- 
row's serum which is put out by Park Davis 
Company both to immunize and treat. There 
\:z^ 3 t'emendous difference of opinion. For 
CAnrnple, Rosenow of Rochester showed sta- 
tistics which seemed to prove it had wonder- 
ful immurii.'ing influence, while Rosenau of 
Harvard, stated that he had used it with no 
effect. There was general agreement that, as 



a therapeutic measure, serums were of no 
avail. 

Advice the public health service or authori- 
ties were in position to give was taken up, 
but nothing new was presented. Lastly, sug 
gestions were offered as to the most pronounc- 
ed lines of research and what agencies should 
undertake this research, whereupon Assistant 
Surgeon General Draper appointed three com- 
mittees, one on epidemiology, one on preven- 
tion, and one on research, to report as soon 
as their conclusions were reached. The out- 
standing men in the country were put upon 
these committees. 

Col. Siler, of the U. S. Army, presented 
graphs and gave his opinions on the control- 
ability of influenza as practiced in the Army. 
The Army of th? U. S. is divided topographi- 
cally into nine districts: The Southren dis- 
trict, the Northern district, East, West and 
Central districts, and certain sub-divisions of 
these districts. Col. Siler obtains weekly re- 
ports from all of these districts. He took the 
position that in the Army certain things had 
been done in this particular ep"dsmic to de- 
crease the number of cases and to pronounc- 
edly decrease the death rate, but his report 
could h;lp us little since in civil life we have 
not the control of our patients that belongs 
to Army service. He believes that confine- 
ment to bed of all suspicious respiratory dis- 
eases immediately upon their appearance, is 
the one peg upon which is hung the safety 
of the people of this country during the pres- 
ent epidemic. After much discussion he ad- 
mitted that in the beginning it was impossible 
to differentiate influenza from other respira- 
tory infections. He puts sick soldiers to bed 
early, advises cheerful rooms with tempera- 
ture of 60, windows open, and sodium bicar- 
bonate. He was pronounced in the opinion 
that ordinary respiratory infections are un- 
commonly preceded by influenza; that influ- 
enza paves the way for pneumonia, pleurisy 
and the like by lowering resistance. He said 
nothing about abdominal influenza, that there 
\v;;5 little influenza, if any, in the North At- 
lantic Army jxists, and not a great deal in 
tiie Southern posts, but his reports vv^ere daily 
increasing; that on the West coast the epi- 
('vniic ii.'d been severe and in the Middle 
\\'fsl it had beer, territic but had reached its 
peak and was subsiding; that in. Chicagoj for 
example, the peak w'as reached;, from J"ort. 



i'ebruiry, 1929 



SOOTHERN MEDICINE AND SURGERY 



1i 



Sam Houston his reports were very few but 
he was anticipating more reports from that 
section. The epidemic was quite pronounced 
in Panama and very Hght in Hawaii. The 
most interesting facts that I got from Col. 
Siler's tallc were that in the Army where men 
can be controlled the epidemic of influenza 
of 1928 and 9 was not lasting longer than 
two or three weeks, and that he was trying 
to instruct Army officers as to what is a com- 
mon cold ar.d what is influenza but he was 
meeting with no success. 

It was almost the unanimous opinion that 
there were no secondary waves. It was 
thought best not to send out specific instruc- 
tions as to diagnosis because there were not 
enough instructions to present in a concise 
manner. It was generally agreed that the 
mortality rate in this epidemic would be low, 
that schools, as a rule, should be kept open. 
It was also unanimous that the death rates 
through the country had practically doubled 
from all causes during the past week. 

Interesting points brought out were that 
the mortality rate was higher in the rural 
districts than in cities, and that the Chicago 
epidemic began early in November, reached 
its peak December 15th, and that pneumonia 
cases increased materially two weeks after 
December ISth. It seemed to be the consen- 
sus of opinion that there was a much smaller 
percentags of pneumonia in this particular 
epidemic than that of 1918. Chicago under- 
took to control her epidemic by distributing 
literature concerning colds by press, radio and 
publ c addresses. Theatre owners were urged 
to ventilate their theatres. 

Then came the report made by Dr. Simon 
Fle.xner from the committee on research. 
Doctor Flexner asked for group activities in 
the study of influenza clinically and epidem- 
iologically. The bacteriology and pathology 
side of it should be left to research. He dis- 
cussed bacteria pneumoncentes as it has oc- 
curred since 1918. He does not believe it 
to be the cause of influenza. 

Dr. L. C. Hogan stated that he had treated 
a great many cases with intravenous injec- 
tions of sodium salicylate in a sodium bicar- 
bonate solution. It relieves pain, accelerates 
convalescence and reduces complications. 
Fruit juices were discussed with some enthu- 
siasm by men from Florida and California. 

Rosenow of Rochester stated that careful 



study revealed that 41 out of every thousand 
who had been vaccinated had the disease; 
that 700 out of every thousand who had not 
been vaccinated had it; that .64 per thou- 
sand vaccinated died, while 4 out of every 
thousand unvaccinated died; that of 8,306 
persons vaccinated against influenza 31 con- 
tracted it, while of 800 unvaccinated .-.07 con- 
tracted it. But, in the face of this, another 
man of outstanding prominence stated that 
vaccination was practically valueless. Dr. 
Arthur McCormick, State Health Officer of 
Kentucky, stated that the State Board of 
Health of Kentucky was preparing and dis- 
seminating immunizing influenza serum and 
that he had every reason to believe it had 
done much to protect his state against influ- 
enza. The conference did not go on record 
approving vaccination. 

It was generally agreed that all institutions, 
orphan asylums and the like should be quar- 
antined. 

It was brought out in the conference from 
all sections of the United States that those 
were panic-stricken, while those having func- 
localities which had no health departments 
tioning health departments were going about 
their work, accepting the epidemic in a phi- 
losophical manner, and using such precau- 
tions as the public press and health bulletins 
sent out. This is particularly impressive be- 
cause it was unanimously agreed that every 
county in every state should have a function- 
ing health department in order to take care 
of such calamities as influenza just as every 
municipality has its fire department. 

Advices were given to hospitals and to 
schools to avoid contact between influenza 
patients to protect against cross infection. It 
was also advised that hospital herdings in in- 
fluenza should be avoided, that hospital cases 
should be limited to severe cases only. 

Dr. Welch made an illuminating talk, giv- 
ing it as his opinion that influenza was caused 
by some toxic virus as yet unknown; that 
the disease itself did not amount to so much, 
but that the toxic virus causing it had the 
peculiar power of lessening resistance of the 
body to such an extent that it became a fal- 
low field for implantation of extraneous in- 
fections. He had no fear of a second wave. 

Dr. Bloodgood stated that all surgery at 
Johns Hopkins other than acute emergency 
surgery had been discontinued for the duration 



H 



soirrHEiN MEDicmi jkHb aaxussk^ 



PAav»,tr, Isif 



of the epidemic. This decision, I think, was 
based upon the opinion of Dr. Welch as to 
the lessened resistance to other infections. 
He was strong in recommending paper hand- 
kerchiefs so that they could be burned. He 
urged education against spitting, the practic- 
ing of personal hygiene, the dissemination of 
information that respiratory diseases were in- 
fectious, and the avoidance of crowds. He 
felt, however, that schools and colleges should 
not be closed, but insisted that the assem- 
bling of all classes and all groups in one hall 
should not be permitted under any circum- 



stances. He advised the exclusion of visitors 
from institutions and hospitals. Frequent 
hand-washing, particularly before meals, re- 
fraining from exposure and fatigue, and hold- 
ing in abeyance anything like fear, were em- 
phasized; also 8 to 10 hours sleep with 
plenty of cover, a well-balanced diet, clothing 
to suit the environment. Plenty of water, 
and cathartics only to meet the usual indica- 
ion. Alcohol as an influenza remedy did not 
excite the interest that prohibition did in the 
last campaign. 



Hallus Valgus 

Report of End Results 
R. L. Anderson, B.S., M.D., Richmond, Va. 



In a period of five years in the orthopedic 
service at the ^Massachusetts General Hos- 
pital, a total of 145 feet were operated upon. 

An end result study on 49 out of the 85 
patients and on 89 out of the 145 feet of)er- 
ated upon was made. This paper is based 
on an end result study of these cases. It was 
thought projjer to include in that part of the 
paper not directly concerned with the end 
results other facts related to these patients 
on some of whom end results could not be 
obtained. 

Sixty of these patients were women and 25 
men. Undoubtedly the narrow-toed fashion- 
able shoes worn by women is a causative fac- 
tor. The youngest patient was 15 and the 
oldest 81; 12 were between IS and 20; of 
those 20 to 60 the number was fifteen to sev- 
enteen for each decade. Of the 12 cases 
under 20 years, 10 were girls and two boys, 
which may be attributed either to girls' shoes, 
or to the greater attention paid to their feet, 
causing them to consult physicians earlier. 

In the other decades the proportion was 
fairly parallel to the total number of cases. 
(Occupations seemed to have no important 
bearing. The housewife was the most fre- 
quently affected. Two telephone operators 
and one policeni.in were among the number. 
Of the men, salesmen, factory workers and 
laborers were tl.c' most common occupations. 

The average duration of symptoms was 10 



years; the shortest one year, the longest (one 
F>atient) "from childhood." It was not infre- 
quent to find patients who had suffered 20 
years or more. 

What finally brings these patients to the 
hospital? The history was definite in 129 
of the 145. Pain alone in and around the 
first metatarso-phalangeal joint was the most 
common presenting symptom. This was 
present in 47 cases. The next most common 
complaint was pain and deformity — 28 cases. 
Nineteen cases complained of pain and the 
bunions. The deformity alone bothered 19. 
Bunions were responsible for 1 1 cases appear- 
ing; 14 came in for treatment of discharging 
bunions. 

Out of the 145 patients operated upon, only 
17 gave a history of previous treatment. Of 
these, six were treated with arch supports 
bought from a shoe store, two with special 
shoes, two with bunion plasters and in one 
case the patient opened an infected bursa. 
Only five had been treated by a chiropodist, 
it is thought that these figures do not truly 
represent the number actually receiving treat- 
ment, but it does give a fair picture of the 
measures attempted to give relief. 

It is well known that hallus valgus is asso- 
ciated frequently with various degrees of foot 
strain or at least with potentially weak feet. 
Eighty-two were found to have feet which 
showed evidence of wvaknws, 12 bad prona- 



Fabnwry, 1«J« 



SOUTHERN MBOICINE AND SOROBRY 



tion alone, 31 showed a pronation and a flat- 
tening of the anterior arch, with varying de- 
grees of callus formation. Thirty-four show- 
ed a flattening of the anterior arch alone as- 
sociated with hallus valgus. In five the tight- 
ness of the tendo Achillis was the only abnor- 
mal finding. Hammer toes were associated 
in six of the cases; two showed rigid flat feet; 
in five there was an ankylosis of the first 
metatarso-phalangeal joint; in 12 the bunions 
had become infected. 

How seveie was the hallus valgus operated 
upon? We have used the same classification 
that Cleveland uses: slight, deformity 20 de- 
grees or less; moderate, 20 to 35 degrees; 
severe, 35 degrees or more. Unfortunately 
the records did not always state just the 
degree of deformity present. We found defi- 
nite data on 92 cases of the series. Sixty- 
five were severe, 26 moderate, and only one 
showed slight deformity. That is what one 
would expect with an average duration of 
symptoms of ten years. We shall consider 
later the degree of improvement shown in 
these cases. 

Arthritis is found frequently associated 
with hallus valgus. Frequently, the subjec- 
tive symptoms are probably due to this asso- 
ciated ailliritis. Often it is difficult to decide 
how much of the patient's trouble is due to 
the one a.^.d how much to the other. Roent- 
gen ray e.xamination was made in 93 cases: 
17 showed evidence of arthritis with spur for- 
mation; 30 symptoms such as swelling, red- 
ness and heat which were attributed to arth- 
ritis. Of these, ten cases had positive roent- 
gen ray findings, thirteen had negative find- 
ings and ten had not been rayed. So it may 
seem that arthritis is a factor in the condi- 
tions, which should be kept in mind. Pre- 
operative and post-operative roentgen raying 
should be made a routine, as this gives more 
definite evidence than clinical examination 
alone. 

We shall describe briefly several of the 
operative procedures most commonly used. 

A plastic operation devised by Dr. Nathaniel AUi- 
ton was periormed in a large number of cases. A 
sraight incision is made on the dorsal surface over the 
first matatarso-phalangeal joint. The capsule is in- 
cised exposing the metatarsal head with its exostosis. 
The head is disarticulated. The exostosis is removed 
with an Oitcotome and sufficient of the head removed 
to allow this joint to be overcorrccted in adduction. 
The rough edges of the metatarsal head are smooth- 
id With a rasp and the scar surface carbolized fol- 



lowed by alcohol. The capsule is resutured with the 
toe overcorrected and in marked plantar flexion. 
Subcutaneous tissue and sliin are sutured in layers, 
rather heavy dressing applied with pad separating 
the great toe from the second toe and holding the 
toe well over in overcorrection. Perkins has report- 
ed a series of 50 cases following this line of proce- 
dure, with sati.-factory results in all but two, and a 
disappearance of severe valgus deformity in every 
case. 

The Keller operation was frequently p-'r; rmed in 
(lur series. A straight incision is made dori.iily, be- 
•jinning proximal to the interphalangcal joint of the 
great toe e.xtending to about one inch on the first 
metatarsus. Then the first phalanx of the great toe 
and the di-tal end of the lir.-t metatarsal are ex- 
posed. The joint capsule is iiKised with an osteo- 
tome, the exostosis is removed from tlie first meta- 
tarsal and carbolic used as in the .Allison operation. 
In addition, one-third of the proximal phalanx of 
the great toe is removed either with an osteotome 
or with a Gigli saw. The rout;h end is smoothed 
and carbolized. A purse string suture of the capsule 
is then made between the cut surface of the phalanx 
and the metatarsal. The remainder of the capsule 
and the periosteum are sutured with silk. Subcu- 
taneous and skin sutures are made in layers with 
silk. A soft dressing holding the toe overcorrected 
is now applied as in the Allison operation. 

Silver has devised an operation which is logical 
and fulfills all theoretical requirements for success- 
ful correction of the deformity. A curved incision 
is made with the convexity downward over the 
joint. The fibrous capsule is exposed and the bursa 
is removed. A V incision is made through the cap- 
sule forming three flaps — one distal, one dorsal and 
one plantar. The distal flap, as broad at its base as 
the diameter of the phalanx, is carefully freed and 
reflected to serve for the construction of the internal 
lateral ligament of the capsule later. The dorsal 
and plantar flaps are dissected back until the meta- 
t.ir-al head is sufficiently e:vpo:ed. A thin layer of 
cortex together with the exostosis is removed, the 
articular surface being left intact as far as possible. 
The capsulotomy is now performed, with the toe 
held in strong dorsoflexion, a tenotome is inserted 
betweL'n the capsule and head making first a longi- 
tudinal inci-ion dorsally. Then with the toe in 
strong plantar flexion, a longitudinal incision is made 
here al-o exposing the plantar ed^e of the outside of 
the capsule. Then adducting the toe strongly these 
two incisions are united by a vertical incision so that 
one has on the outer side of the joint a capsular 
flap with proximal base. Correction of the meta- 
t::ro-phalangcal joint is now possible. The toe is 
overcorrected to 45 decrees and in this position the 
d'Stal flap made on the medial side of the joint is 
pulled strongly bacl.ward and sutured to the periso- 
tcum of the metatarsal holding the toe in position 
of overcorrection. The proximal, plantar and dorsal 
flaps are then closed over the distal flap and finally 
the wound is closed in layers. In 49 cases he reports 
n. partial relapse of one toe in two cases both bilat- 
eral. This operation was performed in five cases in 
our series. 

In this series of cases the Keller operation 
was performed in 85 cases, the Allison opera- 
tion in 38 cases, and the plastic operation 
with removal of bursa in six. In two cases, 
in addition to this latter procedure, the ex- 
tensor hallucis longus tendon was divided. 



u 



SOUTHERN MEDICINE AND SURGERY 



ITebruary, 1929 



In five the Silver opeiation was performed. 
Two formal arthroplasties were done. Once 
the second toe was amputated in a patient 
81 years old. These operations were by ten 
different surgeons of the visiting staff and 
twenty of the house staff. The visiting sur- 
geons operated in 85 cases and the house staff 
in 60. 

Ordinarily these operations may be done 
quickly. A unilateral operation took an aver- 
age of 32 minutes, and a bilateral 55. It is 
interesting to both the patient and the hos- 
pital to know approximately the length of 
time necessary for the patient to remain in 
the hospital. The average stay after the Al- 
lision operation was ten days, after the Kel- 
ler twelve, and after the Silver fifteen. 

In 123 cases the wounds healed by primary 
intention without drainage; in 15 there was a 
sero-sanguinous drainage; in sLx, a frank in- 
fection with purulent discharge. One gave a 
positive culture of the streptoccocus hemolyt- 
icus. The patients whose wounds were clean 
remained in the hospital an average of nine 
days, those with serous drainage twelve, those 
in which the infection occurred 23. The 
treatment of the wound is only a part of the 
post-operative treatment. As is well known, 
hallus valgus has frequently a concomitant 
condition of faulty weightbearing. 

Sixty -seven out of the 89 cases in which 
end results were obtained gave symptoms and 
showed signs of needing foot supports. Of 
these, 51 received foot plates, 18 were given 
shoe plates and exercises, 28 were given neith- 
er shoe plates nor exercises. 

The patients who had shoe plates wore 
them on the average of nine months — shortest 
period two months, longest two years. The 
usual course in patients who have weak feet 
is about as follows: Impressions for plates 
are taken pre-operatively, operation is 
done, in seven to ten days the sutures are 
removed and a small dressing applied, the 
Ijatient is encouraged to move the great toe 
frequently — actively and passively — especial- 
ly in plantar llexion. In addition, he is given 
exercises to strengthen the long and anterior 
arches of the foot. In fourteen days, the 
patient is enc iraged to walk about a little 
with ordinary .-a k-s on with the leather cut 
over the greai toe. .After 21 days, he is 
given his shoe j-lates and is sent to buy new 
shoes along orihopedic line.?. In his new 



broad shoes and foot plates he walks about 
and, after seven to 14 days more, he is about 
ready to resume his ordinary life. .After a 
convalescence of approximately four weeks, 
the patient is encouraged to resume his regu- 
lar life. 

We now come to the real rasion d'etre of 
this paper, namely, the end results. These 
were studied from both the view of the pa- 
tient and the surgeon. The cases were ana- 
lyzed with reference to resultant, 1st, pain; 
2nd, deformity; 3rd, motions in the first 
metatarso-phalangeal joint. Pain is always 
naturally a difficult symptom to analyze. If 
there was pain in and around the great toe 
joint, an effort was made to find out if it was 
slight, moderate or severe. This of course 
could not be done mathematically. 

Motions in the metatarsophalangeal joint 
were considered excellent when active exten- 
sion was 30 degrees or more, and active flexion 
20 or more; good when extension was from 
20 to 30 degrees and flexion ten to twenty; 
fair with extension ten to 20 degrees and 
flexion five to ten; poor when extension was 
less than ten degrees and flexion absent or 
less than five degrees. 

We made an effort to find out the effect on 
pain, deformity and motion in the great to« 
joint of certain variables. .Analyses were 
made with regard to: types of operations per- 
formed; pre-operative condition of the feet; 
post-operative care of the feet; arthritis; 
healing of the wounds; and degree of im- 
provement in deformity. 

First, let us discuss briefly the results ob- 
tained with the various operative procedures. 
Following the plastic operation devised by 
Allison 10 per cent of the patients had 
slight pain, 15 per cent had moderate 
pain, none had severe pain. So, a total of 
25 per cent of the cases had some pain in the 
first metatarso-phalangeal joint after opera- 
tion. -After the Keller operation, none of the 
patients had slight or moderate pain, but one 
patient (2 per cent) had severe pain. In the 
five patients having the Silver operation, one 
patient (20 per cent) had moderate pain af- 
terwards. Out of a total of 90 cases, nine 
or 10 per cent of the patients had more or 
less pain. 

It is important to trj- to fairly estimate 
the degree of correction of deformity. 
IJefinite data as to the exact deformity pr«6- 



F.fcrMr>-. 1929 



SOUTHERN MEDICQfS AtOt SU11CISR¥ 



a 



put before and after operation could not be 
obtained in every case. Seventeen cases (65 
per cent) undergoing the Allison operation 
showed severe deformity in the beginning and 
nine (35 per cent) had a moderate deformity, 
in the end results, 19 per cent had no de- 
formity, 61 per cent had slight deformity and 
19 per cent had moderate deformity. 

With cases undergoing the Keller opera- 
tion, eighteen or 60 per cent had a severe 
deformity and twelve or 40 per cent a moder- 
ate deformity. In the end results 6 per cent 
had no deformity, 66 per cent had a slight 
deformity, 22 per cent a moderate deformity 
and none a severe deformity. With the Sil- 
ver operation, in the three cases with definite 
data all had severe deformity in the begin- 
ning and in the end results, two or 66 per 
cent had no deformity and one had slight 
deformity. 

Out of a total of 59 cases, nine (16 per 
cent) v^ere entirely freed of deformity, 62 
per cent had slight, 20 per cent a moderate, 
and none a severe deformity. The resultant 
slight or moderate deformity was present in 
about the same proportion with these types 
of operations — 40 per cent with the plastic, 
47 per cent with the Keller and 40 per cent 
with the Silver operation. 

Motion in the first metatarso-phalangeal 
joint ran about the same, no matter what 
type of operation. Excellent motion occurred 
in 15-20 per cent, good 40-50 per cent, fair 
30-40 per cent, and poor in about 4 per cent 
except in cases v/ith the Silver operation, 
which had no cases with poor motion result- 
ing. 

Let us nov/ consider the effect of pre-oper- 
ative pathology on the end results in this 
series. Of the 38 cases, with pronated feet 
and flattened anterior arches, 55 had some 
pain following the operation, of which num- 
ber 80 per cent had slight pain and 14 per 
cent had moderate and 4 per cent severe 
pain. As regards deformity with this type 
foot, 39 per cent had persistent deformity — 

24 per cent slight, 15 per cent moderate. In 
feet with the anterior arches alone affected, 

25 per cent had persistent pain — 13 per cent 
slight, 12 per cent moderate. The percent- 
age of deformity ran parallel with those hav- 
ing both flattened arches and pronated feet. 

In feet with the arches apparently normal, 
•■ly 15 per cent had pwiin after operation. 



Deformity was present in 40 per cent, about 
the same as with feet having poor anterior 
and longitudinal arches. Motion was about 
the same regardless of the condition of the 
feet. 

The ix)st-operative treatment of these cases 
following operation it is of importance 
to appraise. Thirty-three patients were 
cent had slight to moderate pain after oper- 
ation, 42 per cent had slight to moderate de- 
formity, 15 per cent had excellent motion, 66 
per cent good motion, 19 per cent fair mo- 
tion. 

In cases given shoe plates and exercises, 
33 per cent had pain after operation, 44 per 
cent had slight to moderate deformity, 83 
per cent had good motion and 5 per cent fair 
motion. Patients given exercises alone show- 
ed only 10 per cent with pain, 60 per cent 
had deformity, 20 per cent excellent, 70 per 
cent good and 10 per cent fair motion. 

In cases given neither shoe plates nor ex- 
ercises, only 14 per cent had pain afterwards, 
33 per cent had deformity with two or 6 per 
cent having severe deformity. Motions were 
about the same as in other classes of cases. 
It must be borne in mind that cases in which 
neither exercises nor plates were given were 
probably the most favorable types of cases. 
This should not be interpreted to mean that 
the post-operative treatment is not necessary 
in certain type of cases. 

End results were obtained in 16 cases, 
showing evidence of arthritis before opera- 
tion. Four or 25 per cent of these had pain 
post-operatively. Two or 12 per cent had 
severe pain. Five or 31 per cent had more 
or less deformity after operation. In 25 per 
cent motion was excellent, in 25 per cent 
good, and in 33 per cent fair and in 12 per 
cent poor. 

Out of 145 feet operated upon, 12 wounds 
showed infection of some kind. Of these, 
16 per cent had slight to moderate pain. Ten 
or 83 per cent had deformity from slight to 
severe, none had excellent motion, 33 per cent 
good, 37 per cent fair, and 16 per cent poor 
motion. The type of operation gave slight 
differences, only in end results. 

CONCLUSIONS 

Pain. — Pain is relieved in about 90 per 
ctBt •! cases with tht opieratioTi for hallu* 



SOtJTHERN MEDICINE AND StmOERV 



'ffliK<mt, W* 



valgus. The Keller operation in our series 
relieved this symptom more effectively. The 
more normal the foot before the operation, 
the less apt the patient is to have pain after 
the operation. 

Post-operative treatment has little influ- 
ence on the persistence of pain. 

Arthritis pre-operatively pred.sposes to 
greater pain afterwards than in cases of non- 
anhritic feet. 

The healing of wounds has little apparent 
effect on the persistence of pain after opera- 
tion. 

Dejormity. — Severe deformity is always 
relieved by operation. In about 20 per cent 
of cases moderate deformity will recur. 

Deformity may be well corrected with any 
type of of>eration, which is well executed. 
Pre-operative condition of the arches of the 
feet has no effect on resultant deformity. 
Post-operative treatment does not relieve de- 
formity if the operation has not removed it. 
It does probably prevent recurrence of the 
hallus valgus with its train of symptoms. 
Some patients need plates, and those needing 
exercises should have them independently of 
the hallus valgus. This occurs in a large per- 
centage of cases. Arthritis pre-existent has 
no effect on resultant deformity. Cases in 



which infection sets in have much {r«at«r 
percentage of deformity than those in whi«k 
the wounds remain clean. 

Motion. — Motion remains adequate in tko 
vast majority of cases no matter what type 
operat.on is performed. The condition of tho 
aiches of the feet has no effect on the mo- 
L on of the metatarso-phalangeal joint. Post- 
operat.ve treatment has little effect on motion 
e.'-xept that exercises with plates result in bet- 
ter motion than when plates alone are used. 
Closes Wxth arthritis do not get as good mo- 
tion as cases without arthritis. Infection 
predisposes to some limitation of mobility. 

BIBLIOGRAPHY 

1. Cleveland, M.: Hallus Valgus, Final Results m 
two hundred operations. Arch. Sitrg., Vol. 14, No. *, 
page 1126. 

2. Payr, E.: Ab. J. A. M. A., Vol. 65, page 1681, 
Ncv. 2, 192S. 

3. Perl;;ns, G.: Lancet, Vol. 1, page 540-544, 
M:irch 12, 1927. 

4. Sliver: Jottr. Bone and Joint Surg., Vol. S, 
1923, page 225-232. 

5. St.';nd'er: Textbook of Operative Orlhoptdics. 
(D. .A.ppAtcn & Co., 1925.) 

■Note: The materia! for this paper was •btal>*4 
from Dr. Nathaniel .\l!is n's Orthopedic Service at 
the Massachu^eLts General Hospital. It was throujli 
W.% courlriy in allowing me to work up the material 
that I am ab'.e to write this paper. Also, I am a^- 
precinlive ot his co-operation in the preparation af 
the paper. 



if^umty, 1929 



sotrrHERN kxDfaMU nth iMgkiiv 



Gastric Achlorhydria — Its Significance and Treatment 

R. O. Lyday, M.D., M.S., Greensboro, N. C. 



The fact that gastric juice contained hydro- 
chloric acid was first demonstrated by 
Schmidt. By free hydrochloric acid is meant 
the acid existing in solution. This is easily 
dissociated with the production of a corre- 
sponding number of hydrogen ions. The com- 
bined acid is that combined in some way with 
protein material. 

According to Howell, the parietal cells 
which furnish the hydrochloric acid are 
massed in the glands of the middle and pre- 
pyloric regions, scantily in the fundus, and 
absent in the pyloric end. More recently, 
however, it has been shown that these parie- 
tal cells are present even in the cardia. This 
observation has an important bearing con- 
cerning the advisability of radical surgical 
procedures in the treatment of gastric and 
duodenal lesions. 

The compound hydrochloric acid is formed 
from sodium chloride of the blood, the sodium 
being replaced in some unknown way by 
hydrogen and the substance is secreted upon 
the free surface of the stomach as hydrochlo- 
ric acid. Cannon says: "Hydrochloric acid 
in the stomach seems to favor or produce a 
relaxation of the pyloric sphincter, while in 
the duodenum, on the contrary, it causes a 
contraction of the sphincter. Hydrochloric 
»cid in the stomach aids pepsin in the diges- 
tion of proteins and is considered valuable 
«s a bactericidal agent, preventing fermenta- 
tion, etc."' 

The absence of free hydrochloric acid from 
the gastric contents may be a clinical entity, 
which may be of a congenital or acquired 
■ature; or it may be secondary to other path- 
ological conditions in the human organism. 
Under the group first mentioned the condi- 
tions are commonly called achlorhydria and 
•chylia gastrica. In differentiating between 
these two conditions, which are so similar 
from a clinical as well as from a laboratory 
point of view, some clinicians consider those 
cases of absence of hydrochloric acid in which 
the total acidity amounts to more than 20 
ilegrees as being achlorhydria, and those with 
« total acidity below this point as belonging 
f the class of achylia gastrica. Physiolo- 
fhti, en the other hand, consider the een- 



dition achlorhydria when only the free acid 
is absent and achylia gastrica when both acid 
and ferments are absent. C. S. McVicar be- 
lieves that clinicians should restrict it to those 
cases which show an absence of both free 
hydrochloric acid and pepsin. 

The presence or absence of free hydrochlo- 
ric acid cannot always be determined by a 
single fractional test, for on many occasions 
subsequent examination has shown a moder- 
ate amount of the acid present, or even the 
normal amount in some instances, where not 
even a trace could be detected on the first 
examination which extended over a period of 
two hours. Therefore, more than one frac- 
tional test is necessary to prove its absence 
from the gastric contents. When the first 
test fails to show a trace of free acid it usual- 
ly indicates that it is absent or nearly so. 

This abnormal gastric secretion is found in 
a. cerUin percentage of persons in whom no 
history of gastric trouble is obtainable and is 
only discovered in a routine gastric analysis. 
In many of these its presence cannot be ac- 
counted for. It is of no significance from 
the point of view of therapy. 

Diarrhea is fairly frequent and does not 
seem to be related to any certain etiological 
factor lying behind the condition we are con- 
sidering, but definitely related to the absence 
of the acid. As is well known, this form of 
diarrhea is usually characterized by several 
watery movements coming on immediately 
after the ingestion of food. Lack of tonus 
of the pyloric sphincter is considered an im- 
portant factor in the causation of this symp- 
tom. Cannon's views on the control of the 
pylorus have recently been called into ques- 
tion. McClure, Reynolds and Swartz, on a 
basis of radiographic experiments, conclude 
tkat acid is not the principal factor controll- 
ing the opening and closure of the pyloric 
sphincter in man. Bland, Campbell and 
Hern, witk simulUneous intubations of the 
stomach and duodenum, showed that acid in 
tie duodenum does not necessarily close the 
pylorus, for the most rapid emptying took 
place at the time when the duodenal contents 
were unusually acid. 

kiurwc that padntB who have 



Id 



SOUTHERN MEDICINE AND SURGERY 



I'ebruary, l9id 



this type of diarrhea associated with the con- 
dition here described are often relieved by 
t!ie free use of dilute hydrochloric acid by 
mouth. Ryle says that this may relieve by 
increasing the output of pancreatic secretion 
enhancing digestion in the small bowel, or 
by increasing pyloric tonus without any di- 
rect digestive or bactericidal action. 

During the latter part of the last century 
two cases were reported in which the secre- 
tion of hydrochloric acid was said to have 
resulted from the oral administration of the 
acid. Recently H. V. Dobson, of the IMayo 
clmic, by using the same patient for a series 
of 19 experiments, made a very thorough in- 
vestigation of this condition. Three frac- 
tional studies which were made during a pe- 
riod of five weeks demonstrated the absence 
of free hydrochloric acid from the stomach 
contents. A low peptic content was also ob- 
tained. To make doubly sure that a true 
achlorhj'dria was present the patient was 
given h.stamine. Still he continued to show 
an abseixe of free acid. 

The patient was placed on dilute hydro- 
chloric acid in gastron, which is a glycerine 
extract of the gastric mucosa of the pig con- 
taining much pepsin. At a later date free 
acidity was discovered during the early part 
of the second hour of digestion. At this time 
another histamine test was given and it pro- 
duced a free ac.dlty of 23. Improvement in 
the patient's condition was shown by an in- 
crease in appetite, weight, etc. 

Pepsin was present in the gastric contents 
in relatively good concentration in all in- 
stances when adequate free acidity was ob- 
tained whether or not gastron was adminis- 
tered. Therefore, it seems that acid is the 
more important of the two in the treatment. 
His conclusions concerning the action of hy- 
drochloric acid in the stomach are as follows: 
"The first action of acid in the stomach 
seems to be to saturate proteins, then stim- 
ulate the production of pepsin, and finally to 
provide an acid medium for the action of 
pepsin. It also has an antiseptic effect, and 
after evacuation into the duodenum, stimu- 
lates pancreatic secretion. It is possible that 
free acid may have a stimulating effect on 
the acid-secreting mechanism resulting in the 



production of more acid. For this reason it 
is not necessarily true that, in cases of ach- 
lorhydria, small doses of acid will suffice as 
well as larger doses, since it has been shown 
that large doses are necessary to produce free 
acidity." 

At this point w^e might refer briefly to the 
treatment of the clinical condition known as 
achlorhydria. 

Metkcd of Administration. Hydrochloric 
acd should be given in as large amounts as 
possible, depending on the individual toler- 
ance. As much as two and one-half drams 
or more may be given during the digestive 
period. Thirty minims in two ounces of 
fluid as a vehicle may be given at the middle 
of the meal and the same quantity repeated 
at 15-minute interval for an hour or more 
(Dobson). 

I have seen good results follow the admin- 
istration of from twenty to thirty minims of 
hydrochloric acid to the dram of gastron. 
This is added to milk or water and sipped 
v.'ith the meals. 

In a review of a large series of cases, in 
which fractional gastric analyses were made 
and checked at a later date, the commonest 
condaions found associated with this absence 
of free hydrochloric acid in the gastric con- 
tents, in the order of their frequency, were: 

1. Pernicious anemia in 15 per cent. 

2. Chronic cholecystitis in 14.7 per cent. 

3. Carcinoma of the stomach in 12.3 per 
cent. 

4. Achylia gastrica in 11.7 per cent. 

5. Achlorhydria as a clinical entity in 11.2 
per cent. 

In many instances, as previously mention- 
ed, the cause for the absence of free hydro- 
chloric acid cannot be dstermined, nor is it 
of any special significance in many of those 
cases wh3re there are no gastro-intestinal 
symptoms; yet its absence, particularly if 
th:; patient be a middle-aged individual who is 
anemic or who gives a history of recent 
weight loss, makes it imperative that the phy- 
sician rule out those two serious diseases 
v/hich are so frequently preceded and asso- 
ciated with this condition; namely, pernicious 
anemia and carcinoma of the stomach. 



February, 1929 SOUTHERN MEDICINE AND SURGERY 

Undulant Fever* 

p. W. Flagge, M.D., High Point, N. C. 
From the Medical Service of the High Point Hospital 



Undulant fever has many synonyms, the 
more common of which are Malta fever, 
Bruce"s septicemia, slow fever (Texas), 
Mediterranean phthisis, etc. We find it de- 
scribed as a "specific fever, due to the mic- 
rococcus melitensis, Bruce (1893) character- 
ized by its long undulatory course, early 
arthritic symptoms, sweats, increasing debil- 
ity and anemia." 

For U-, it vould present little more than 
passing interest but for the fact that it is 
present in our country and spreading v.'ith 
undetermined rapidity. It v/as probably rec- 
ognized as an entity as early as 400 B. C. 
However, it was not until the end of the 
eighteenth century that attention was drawn 
to the fact that many cases were in and 
around Malta, at which time it acquired the 
name of Malta fever. Marston, in 1859, suf- 
fered with it ar.d was the first to clearly de- 
fine and differentiate it from typhus and ty- 
phoid fevers. In 1S97, Wright and Douglass 
ur;dertcok to jirove by experiment that the 
disease could be d'agnosed by agglutination 
tests. In 19C4, the British Admiralty and 
War Office, in collaboration with the Civil 
Goven.ment of the island of Malta, under- 
took an exhaustive study of the disease as it 
exists on the island and to this report we are 
indebted for much of our present knowledge. 
Available information relative to its dis- 
tribution in the United States by reported 
cases is as follov.s: California 2; Connecti- 
cut 1; Illinois 4; Maryland 2; Michigan 7; 
New York 9; Ohio 1; Pennsylvania 1; South 
Dakota 1; Utah 3; Virginia 3; Washington 
1; Ontario, Canada, 1. This does not include 
the Southwestern states where it is known to 
have been prevalent for 35 years. Nor does 
this mean the extent of the spread of the in- 
fection, for iii the state of Iowa alone inves- 
tigation by the U. S. P. H. S. in collaboration 
with the State Board of Health has estab- 
lished its existence in 83 cases unreported. 

Thus we see there is already a fair sprin- 
kling of recofnizcd cases over a vide area 
with a demo .-.irable concentration in at least 
one stole. And, since there is every reason 

Tre-cnttd to the GuUi'ord Cpunty. ilcoicaL So 



to believe that the average physician is not 
on the lookout for its appearance in his own 
practice, it is certain that these figures fall 
far short of representing the actual existence 
of this infection. 

Tlie causative agents, the micrococcus 
melitensis and the bacillus abortus, are found 
in the spleen, liver, kidneys, lymphatic sys- 
tem, salivary glands, blood, bile, urine and 
miilk. The goat is the natural host; horses, 
sheep, cows and ho'rs may be and are infect- 
ed. The usual mode of entrance is by the 
alimentary tract, but it is possible to be in- 
fected through the respiratory tract, the cu- 
taneous system, and the generative organs. 
It v.ould seem that the greater number of 
infections are from the use of milk from goats 
and cows and it is clinically proven that the 
infection from the goat is by far the more 
severe. Laboratory infection by the micro- 
coccus melitensis is said to be common. 

Of pathology and morbid anatomy it is in- 
teresting to note that the disease belongs to 
the septicemia group. The infection enters 
the blood from the intestines. Here it pro- 
duces hemolysins, agglutinins and a .specific 
immune body. The question of a permanent 
immunity is, however, under dispute, some 
authors holding there is "unlimited recur- 
re.ice.'' 

Undulant fever may be said to be protean 
in its symptomatology. To look for pathog- 
Tiomonic signs and symptoms is certain to 
court disaster in diagnosis. Whether the in- 
fect'on be of the melitensis or abortus variety 
the symptomatology is the same with the ex- 
ception that the melitensis infection is usual- 
ly the more severe and prolonged. There is 
a period of incubation of ten to fifteen days 
in man, but, since practxally all who con- 
tract the infection may have prolonged ex- 
posure, the period of incubation has little sig- 
nificance. Kearns states that "what is need- 
ed is a widespread clinical consciousness of 
the disease, and a h'gh index of clinical sus- 
l^'cion that will lead physicians to routinely 
lisk for the abortus agglutination test in all 
c;ai'.cs of undiagnosed fever." 

Commonest of . all. symptoms is the con- 

vaouauass of the patieat tiiat he has fevwv 



12 



POlTTHltW ytWDKaMB AND SURGERY 



February, 1*2* 



Along with this there will be "lymptoms of 
general'zed infection — irregular chills, back- 
ache, headache, and more or less copious 
night sweats. Less common may be gastro- 
intestinal symptoms: vomiting, epigastric 
pain, or diarrhea. Of nervous symptoms we 
may look for headache, insomnia, dizziness, 
drowsiness, etc. 

N^aturally, in the case of continued fever 
we turn to th? blood for information and 
here afaln, omitting one test, we have little 
positive information. Leucocytosis is not the 
rule and leucopenia is not uncommon. A low 
neutro' h'e and a high lymphocyte count, 
with a leucopenia is suggestive. A secondary 
anemia may be expected if the disease has 
existed for a time. A blood culture may be 
positive if taken at the height of the fever. 
A positive agglutination with either the 
abortus bacillus or the micrococcus meliten- 
s;.. will be conclusive. 

The course of the disease is uncertain and 
msKy cases are treated for some of our more 
c; nimon infections as pulmonary tuberculosis, 
malaria, typhoid and some of the more com- 
mon arthritic infections. The diagnosis will 
re-t uoon the elimination of other infections 
ad the fii.ding of a positive agglutination 
t: -t with the above mentioned organisms. 

Piophylacf c measures available are the 
cl minat on of milk from the diet, or boiling 
it if it is thought to be infected. Since milk 
i-~ one of our most useful and widely used 
rtcles of det, it would seem that the time 
is ripe for our national and state health au- 
thor, t'.s to take active measures to place in 
operation some plan to prevent this most u.«e- 
fu! and wholesome food from suffering gen- 
eral contamination, rather than depending 
upon th; elimination of milk from the diet, 
or instituting the expensive procedure of 
pa-teurization or steriliz.-ttion. 

To date we have no therapeutic measures 
that couid be classed as curative, or uniform- 
ly affecting the course of the disease. Mer- 
cuiochiome in 1 per cent solution in varying 
doses has seemed occasionally to have an 
abortive effect. The arsphenamines have 
hzen tried with some benefit at times and 
quinine has also been helpful. When these 
measures fail we have little to fall back on 
other than symptomatic treatment with jjood 
nursing and dietetic measures tbtt «<« mim- 
lated to buUd up vesistmtdt. 



CONCLUSIONS 

Undulant fever exists in the United States 
today as an endemic disease. 

The rapidity of its spread is so far unde- 
termined. Its spread will convert one of our 
most wholesome and valuable foods into a 
hazard to the health of millions of adults and 
children. 

This infection should be carried in mind 
constantly by the profession, and agglutina- 
tion tests demanded of the laboratories of 
our Slate Boards of Health. 

.\11 cases should be reported early so as to 
give our state and national health authorities 
a proper persrjective for preventive measures. 

CASE REPORT 

.Married man, aged 3:3, sales pnimoter. ad- 
promoter, admitted July 23, 1928. 

Family History. — Not significant. 

Previous Personal History. — The usual 
diseases of childhood. Tonsillitis frequently. ■ 
Tonsillectomy in 1920. Muscular rheumatism 
frequently. Malaria in childhood. Appendi- 
citis, 1916, with operation. Sick headache 
occasionally all h's life. For the past three 
months more fre.-|iient and persistent. Thinks 
that eating to cu - :: '1 nf acid food will 
induce he sdacho. S r>i '; , for the past five 
or six years, with r:iti]ei severe "cold in the 
head" at times during this period. Na.sal 
polyp removed in 1927, and again in Febru- 
ary, 1928. Smokes from six to ten cigars 
[>er day. Eats to excess frequently when well. 
Rarely uses alcoholic liquors, but will take 
a fecial drink. 

Present Illness. — During the month of 
.Time spent three weeks in New Jersey and 
ii;i? week in New York State. At some in- 
definite period during the latter part of June 
he began to feel below par and was unable 
to a.ssign a reasonable cause. He continued 
to work and some-time in July, before the 
fourth, went to Grand Rapids, Michigan. On 
tlie fourth, he had a sick headache. Took 
a rather free purge at this time; a few days 
later left for Toronto. En route he suffered 
an attack of what he thought to be indiges- 
tion due to indiscretion in diet while in 
Grand Rapids. In Toronto, was seen by a 
physician who diagnosed la grippe and put 
him on alkaline treatment. He was very sick 
and hud a severe headLache for two days. He 
rjSBumtd " oik, but was av/are that he b^d 
fWe'r an'd wus itr^ii^ strength. 'Aitei U 'tiw 



Fftbnuii?', 192» 



SOUTHERN MEDICINE AND SURGERY 



•lays, he began to have secere, drenching 
Hight-sweats; was extremely nervous and do- 
ing his work under great handicap. At times 
there would be a distinct chill at night. 
There was much general aching, some swell- 
ing of the lymph nodes in the neck, but no 
joint pams. Outside the spell of acute indi- 
gestion, he had no further intestinal symp- 
toms other than loss of appetite. He found 
tkat he had lost ten pounds in weight during 
thf first week of his illness. Becoming un- 
able to carry on his work, he returned to his 
hotae in Greensboro and with his family went 
t© the mountains for a few days, but con- 
tiMued to grow worse and was brought home 
before the end of the week. He sought the 
advice of his physician, who placed him on 
l«rge doses of quinine at frequent intervals. 
Net improving in his home, he entered a lo- 
c«l kotpital and was under observation for 
•« unknov-n period. Continuing unimproved, 
he entered our institution shortly afterv.ard. 

Phi-s-c.il Examination. — A markedly over- 
we ght man of age given. Looks anemic and 
has rather "knocked out" appearance. Temp. 
99.5, pulse 76. 

Head— scmsv.hat bald, otherwise normal. 

Mouth — one defective posterior molar on 
left s:de. Some dentistry in good condition. 

Throat — no tonsils, normal. 

Neck — short, thick, negative. 

Chest— thick walls, respiratory excurs'on 
normal and even. The right apex gave a 
markedly prolonged expiratory murmur over 
tfce supraclavicular region. In this area, oc- 
casional inconstant rales. 

Abdomen— fat walls, appendiceal scar in 
good condition, negative. 

Extremities- skin a trifle flabby, normal. 

Reflexes — noimal. 

Rectum — normal. 

Diagnosis (Tentative).— Sinusitis, obesity. 



dental decay and infected posterior molar. 

Laboratory Findings. — Urine — straw color- 
ed, acid. sp. gr. 1012, no albumin, no sugar, 
in'croscop'cal normal. 

r.lood— July 23, 1928— Hb. 77 per cent; 
r.b.c. 3. 850 COO; w.b.c. 5760— p. 79 per cent 
!. :0 per cent, e. 1 per cent; August 6, 1928 
- -v/.b.c. 5050 — p. 66 per cent, 1,30 per cent, 
'\ 2 per cent, t. 2 per cent. 

Til lee examinations for malarial plasmodia 
^'.cre nen;ative. 

W d:il was negative for typhoid, paraty- 
phoid (A) and (B) on two occasions. Was- 
;e;m.ann negative. Blood culture negative 
tv.ice. 

X-xray.— July 23, 1928, sinuses show dis- 
tinct Laziness of the left antrum. 

August 24, 1928, chest, negative x-ray. 

On August 2, there having been some sus- 
p'c on as to the possibility of the case being 
;: dubnt fever, a culture of the bacillus abor- 
;-'.2 v,as procured and an agglutination test 
i:rde v.'hich was found positive in dilution 
of 1/130. Th's test was repeated on August 
n a; d found positive in dilution of 1/200. 
Th's same serum was forwarded to the U. S. 
P. H. Lab. Hygiene, which found it positive 
i' d'lution of 1/320. 

F.' m d te of entry up the 21st day he suf- 
fered irre-rular chilly sensations and ch lis at 
• ■■'ht followed by drenching sweats. On the 
1 t diy the temperature fell to normal and 
ema'r.ed so while he stayed in the institu- 
linn. The range of temperature was 98,6 to 
102 (once only), the usual diily maximum 
beng 101. On the 24th day he seemed quite 
veil, except for general weakness, and was 
dismissed. Reports after dismissal indicated 
that he had no further fever. He resumed 
his work about the third week after and has 
continued in good health. 



^^OUTHSMJ MKBI6IMI AND SUKUERY 



Frbruarv, 1«2* 



The Diagnosis of Active Incipient Pulmonary Tuberculosis 

O. E. Finch, M.D., Raleigh, N. C. 

Mary Elizabeth Clinic 



By this is meant the earliest form of pul- 
monary tuberculosis which can be recognized 
by the usual methods at our command. The 
importance of early recognizing this condi- 
tion is admirably emphasized by Dr. P. P. 
McCain, superintendent of the North Caro- 
lina State Sanatorium, who wrote: "A recent 
survey of the after-results of treatment of 
the 3,C00 patients discharged from the North 
Carolina Sanatorium during my service over 
the past ten years shows the following: 

Of the incipient cases 89 per cent are liv- 
ing ar.d 80 per cent are working. Of the 
moderately advanced cases 59 per cent are 
1 v'ng and 13 per cent are working. How 
picquent are these figures of the need of an 
c.irly diagnosis." 

In presenting this subject it is intended 
cnl}' to review for mutual benefit some of the 
i.iore commonly accepted methods used in 
!;:e diagnosis of this disease. Our interest 
in this condition can not be too frequently 
; I'rred, for only by an early diagnosis can 
•. 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 

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 Henry Hotel not 
later than 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 














Cornflakes 


10 


8 

1 
4 



o.s 

2.5 
1.0 
2.0 



8 

7.5 
12.0 


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 





2.4 


1.5 


23.1 


Vegetables 5% — 


60 


2.0 


1.0 





12.0 


Cream 40%- 


______ 30 


1.0 


1.0 


12.0 


116.0 


Fruit 10% 


„.._ 30 


2.0 


1.0 





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 12.0 diet makes the method more practical. 

Cream 40% 60 2.0 ^" ^'" '"" ^ 



Unecda Biscuits 2 10. 






12.0 


24.0 


232.0 


2.7 


24.3 


13.3 


110.7 


1.0 


53.0 



Cheese 7^ 2^0 2^7 24.3 VII. The ketogenic diet will cure many 

Butter 16 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 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 

—J 

—J 

_T. 

-J 

-J 

-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 
ngton 
ngton 
ngton 
ngton 
ngton 
ngton 
ngton 
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ngton 
ngton 
ngton 
ngton 
ngton 
ngton 
ngton 
ngton 
ngton 
ngton 
ngton 
ngton 
ngton 
ngton 
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ngton 



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,