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American Medicine
H. EDWIN LEWIS, M. D.
Editor
IRA S. WILE, M. D.
Attociste Editor
Volume XXV, Complete Series
Volume XIV, New Series
JANUARY-DECEMBER
1919
f^
ME
EDI
AMERICAN
MEDICINEi
AN
NE
American Medical Publishing Company
Burlington, Vt., and New York, N. Y.
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Copyright 1919
American Medical Publishing Company
niqitiypdh^/ VjOOQi.g .
WWCfltTMEDlCIN
PUBU8HED MONTHLY
BdHmiml OfH«««t 18 Bmmt 41«« St., Ifew York CHy. Pnbltcation OIHc^a i 189 CoU^i^ St«, BnrMnjton, Vi
Coaglite S«riei, ToL XXY. No. 1
Hew BeriM, VoL XIY. No. 1
JANUARY, 1919
$2.00
TEABLTl
In AdyancN
CONTENTS
BDITORIAI* €XmMSaST 1
MBlf AKD THIMG8 !•
ORIGHf AX ABTICIiES ^7
liONDON liBTTBB ■•*
PHT8ICAI4 THE&AFY ■*«
THB AWNCKTATOB 4»
AMONe fTHB BOOKS 88
BTIOI«OGT ANP DIAGNOSIS 54
TBBlATBODlfT - • , M
(Continued on page 6)
CONTRIBUTORS
ROBBRT MORRIS, M. D., New York City.
ARNOLD STURMDORF, M. D.* F, A. O. S.» ete.*
New York City.
OHARIiBS IPir. BURR* M. D., Philadelphia, Pa.
HBNRY Ii. SHIYBIjY, M. D., New York City.
H. GBRAIiD OHAPIN, IX. D., New York City.
B. SHBRTITOOD-DUNN, M. D., Paris, France.
M eeooDd-elMS matter Juauy 38, 1008, at ibe PosI Office at BiiTliii«ton, Vt, under Ad of Congress, March 8, 1879.
In the Treatment of
RHEUMATIC and
NEURALGIC ILLS
yon will obtain Bnbstantial aid from the thorough use of
K-Y ANALGESIC
This non-greasy, water-soluble local anodyne will enable you
to ease your patient's pain and discomfort, while your internal or
83r8temic medication is combating the cause of his condition.
The advantages, moreover, of relieying the pain of a facial
neuralgia, an inflamed joint, or aching lumbar muscles without re-
course to coal tar derivatiyes cannot fail to appeal to medical men.
K-Y ANALGESIC is a safe and effective adjunct that will daily
grow more useful to the practitioner as the many opportunities for
its effective use are realized.
VAN HORN ft SAWTELL DEPARTMENT
18 * 17 E. 40TH STRBET. NEW YORK. U.S.A.
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The Itifltietiza
Menace
INFLUENZA (with its aequela of pneumonia) is said to
have caused more deadis than occurred in the American
army in France. It is still widely prevalent Fresh out-
breaks are reported in many places where the epidemic was
thought to have subsided. Danger lurks everywhere.
The situation demands that every possible precaution be
ob^rved.
Prophylactic vaccination is the rational procedure.
In one locality, where several thousand persons were
vaccinated before the appearance of symptoms, not a
single death occurred.
Influenza-Pneumonia Vaccine
(Prophylactic)
This vaccine* the formula of which was suggested by
Dr. Rosenow, is offered to die medical profession with con-
fidence in its efficacy as an immunizing agent It is composed
of cultures newly isolated from cases occurring during the
prevailing epidemic. £ach mil (€x.) contains five bilKon
bacteria* in these proportions:
Diploeoccot pneamonue, type I
Diplocoocua pneumoniie, tirpe U
Diplocoocua pneumoniie, type III
DiplooocctM pneomonue. type IV
Streptococcus hemobrticua . . .
Bttcterium influenza (Pfettfer)
StaphsrlococciM pyogenes aureiu
. 500 1
. 750 miUioiM
. 500 millioDS
. 1250mUlioiie
. 1000 millions
. 500inillions
. 500 1
Used only •• * propliylftetie of iiifhieiixa
•nd the ppenmonie tnat aoBMtiBiee followa.
Initial doee, H nuls second doee, 1 mil; third dose. \\i mile-et intenrels of eeveo days*
Parke, Davis & Company
Home Offices and Laboraloriea,
Detroit, Michigan.
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COiNTRIBUTORS
ANDERSON, H. B., M. D.,
Toronto, Canada.
BAKER, HON. NEWTON
D., SeCy of War, Wash-
ington, D. C.
BARR. LIBUT.-COL. SIR
JAMES, M. D., IX..D., F.
R. C. P., F. R. S. B., Liver-
pool, England
BIZOT, A. R., M. D., Louia-
TlUe, Ky.
BLUMER, GEORGE, M. D.,
New HaTen, Conn.
BOWMAN, R. G., Red Cross,
New York aty.
BRAISTBD, W. C, M. D.,
Surgeon-General of the
Navy, Washington, D. C.
BRAM, ISRAEL, M. D., Phila-
delphia. Pa.
BULKLEY, L. DUNCAN, A.
M., M. D., New York City.
BURR, CHARLES W., M. D.,
Philadelphia, Pa.
CARLBTON, CLARA L.,
Bradford, Mass.
CHAPIN, H. GERALD, LL.D.,
New York City.
COPBLAND, ROYAL S., M.
D., New York City.
DANIELS, HON. JOSE-
PHUS, Sec'y of Navy,
Washington, D. C.
DAVIN, JOHN P.. M. D.,
New York City.
DAVIS, EDWARD P., Col. M.
C, U. S. A., Philadelphia,
Pa.
FISHER, LEWIS, M. D.,
Major M. C, U. S. A.,
Philadelphia, Pa.
FORBES, HENRY HALL,
M. D., Capt. M. C, U. S. A.,
New York City.
PITLD, JOS. E., M. D., New
York City.
GALLOWAY, D. H., Ph. G.,
M. D., Roswell, New
Mexico.
GEYSER, ALBERT C, M. D.,
New York City.
GOLDSTEIN, HYMAN I., M.
D., Camden, N. J.
GOODHUE, E. S., M. D.,
LLD., Pukoo-Molokai, Ha-
waii.
GORGAS, WM. C, M. D..
Surgeon-General (Ret), U.
S. Army, Washington, D. C.
GOULD, GEORGE M., M. D.,
Atlantic City. N. J.
GRAEF, CHARLES, M. D.,
New York City.
HARTING. JOANNA WAL-
TON, New York City.
HAYS, HAROLD M., M. D.,
Major M. C, U. S. A., New
York City.
HILL, H. W., M. D., Capt. C.
A. M. C, St. Panl, Minn.
HILTON, DAVID C, A. M.,
M. D., F. A. C. S., Lincoln,
T^ehr&ska
HOGNER, RICHARD, M. D..
Boston, Mass.
HURST, ARTHUR F., M. A.,
M. D., Oxon.. F. R. C. P..
Newton Ahbott, Devonshire,
E^ngland.
IRELAND, M. W., M. D..
Surg.-Gen. U. S. Army,
Washington, D. C
JISR, J. G., M. D., Cairo,
Egypt.
JOHNSON, MAJ. J. PRATT,
M. C, D. A. D. M. S., S. A.
M. C, Johannesburg, South
Africa.
KAHN, MORRIS H., M. D.,
New York City.
KAPLAN, DAVID M., M. D.,
New York City.
KEITH, D. Y., M. D., Louis-
ville, Ky.
KEITH, J. P., M. D., Louis-
ville, Ky.
KNAPP, MARK I., M. D.,
LL.B., LL.M., New York
City.
KNOPF, S. ADOLPHUS, M.
D., New York City.
KONKLE, W. B., M. D., Mon-
toursville. Pa.
LAASE, -CHRISTIAN F. J.,
M. D., New York City.
LATIMER, M. J., M. D.,
Chicago, 111.
LAVESON H., M. D., New
York City.
LINDENBERGER, I., M. D..
Louisville, Ky.
LLOYD, L. I., M. D., Lieut. R.
A. M. (T.). Hempstead,
England.
LYDSTON, G. FRANK, M. D.,
Chicago, 111.
LYMAN, H. W., M. D., Capt.
M. C, U. S. A.. St. Louis,
Mo.
MARCO, B. BARRYMORE.
D. D. S.. New York
City.
MARCY, HENRY 0., A. M.,
M. D., LL.D., Boston, Mass.
MARSHALL, PERRY, M. D.,
New Salem, Mass.
MARTIN. FRANKLIN L., M.
D., Col. M. C, U. S. A.,
Chicago, 111.
MARTIN, WILLIAM. M. D.,
Atlantic City, N. J.
MAYER, LEO., A. M., M. D.,
New York City.
McCOY, G. W., M. D., Di-
rector, Hygienic Labora-
tory, U. S. Public Health
Service. Washington, D. C.
McILROY, A. LOUISE, M. D.,
D. Sc, Surgeon-in-charge,
Salonica, Greece.
McKENZIB, R. TAIT, M. D..
Major M. C, R. A., Phila-
delphia, Pa.
McMURTRIE, DOUGLAS C,
Director, Red Cross Insti-
tute for Crippled and Dis-
abled Men, New York City.
MEAD, J. E., M. D., Major
M. C, U. S. A., Detroit,
Mich.
MEYER, LEO B., A. M., M. D.,
Major M. R. C. U. S. A.,
New York City.
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CONTRIBUTORS
MINER, DONALD, M. D.,
Major M. C, U. S. A., Jer-
sey City, N. J.
MONOGHAN, W. J., M. D.,
Lleut.-Col. M. C, U. S. A.,
New York City.
MORRIS, M. FORD, JR., M.
D., Atlanta, Ga.
MORRIS, ROBERT T., M. D.,
New York City.
N
EUSTAEDTER, M., M. D..
Ph. D., New York City.
OGINZ, PHILIP, M. D.,
Brooklyn, N. Y.
OTIS, EDWARD O., M. D.,
Boston, Mass.
PELLE, HENRY E., M. D.,
Louisville, Ky.
PERKINS, ROGER G., M. D.,
Prizren, Serbia.
PERSHING, GEN. JOHN J.,
Gen. Commanding Ameri-
can Expeditionary Force,
Chaumont, France.
R
AND, W. H.. M. D., Wash-
ington, D. C.
REDFIELD, CASPER L.,
Chicago, 111.
REUTERDAHL, HENRY,
Lieut-Commander, U. S. N.,
R. F.
ROBINSON, BEVERLEY,
M. D., New York City.
ROOSEVELT, LIEUT.-COL.
THEODORE, New York
City.
SANGER, MARGARET,
New York City.
SCHAPIRA, S. WILLIAM,
M. D., New York City.
SCHEFFEL, CARL, Ph. B.,
M. D., Boston, Mass.
SCOTT, GEORGE DOW, A.
B., B. S., M. D., New York
City.
SHERWOOI>DUNN, B., M.
D., Paris, France.
SHIVELY, HENRY L.. M. D.,
New York City.
SIMPSON, VIRGIL E., M. D.,
Louisville, Ky.
SOUCHON, EDMOND, M. D.,
F. A. C. S., New Orleans,
La.
STEVENS, GEO. T., M. D.,
Ph. D., F. A. C. S., New
York City.
STRAGNELL. GREGORY, M:.
D., Late Surgeon, * Paris,
Harmon-on-Hudson, N. Y.
STURMDORF, ARNOLD, M:.
D., F. A. C. S., New York:
City.
TALMEY, B. S., M. D.. New
York City.
TAYLOR, J. MADISON, A.
B., M. D., Philadelphia, Pa.
TRAVIS. EUGENE M., ESQ.,
State Comptroller, Albany,
N. Y.
VIPOND, A. E., M. D..
Montreal. P. Q.
VOORHEES, IRVING WIL-
SON, M. S.. M. D., New
York City.
WILSON, D. S., M. D.,
Louisville, Ky.
WITTENBERG, JOSEPH, M.
IX. Brooklyn, N. Y.
WOOD, MAJ.-GEN. LEON-
ARD. Chicago, 111.
ZUEBLIN, ERNEST, M. D..
F. A. C. O. P., Cincin-
nati, Ohio.
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INDEX, 1919
JANUARY— Pages 1 to 56, in-
clusive.
FEBRUARY— Pages 57 to
112, inclusive.
MARCH— Pages 113 to 176,
inclusive.
APRII^-Pages 177 to 240, in-
clusive.
MAY— Pages 241 to 304, in-
clusive.
JUNE— Pages 305 to 440, in-
clusive.
JULY— Pages 441 to 498, in-
clusive.
AUGUST— Pages 499 to 556,
inclusive.
SEPTEMBER— Pages 557 to
618, inclusive.
OCTOBER— Pages 619 to 682,
inclusive.
NOVEMBER— Pages 683 to
742, inclusive.
DECEMBER— Pages 743 to
802 inclusive.
A ccidents, automobile, 446.
motor, and speed laws, 609.
and defective laws, 757.
Acidosis, diagnosis, 552.
theory of, 66.
Acne vulgaris, 238.
Addiction, drug, narcotic,
seeking to control, 255.
Addicts, drug, care and treat-
ment of, 682.
drug, in Louisiana, 742.
Adenoids, tonsils and, re-
moval of, 496.
Adrenalin test, 791.
Air, poisoned, of industrial
sections, 741.
Alcohol, prescription of, 609.
science and, 251.
Alcoholic drinks, government
regulates dispensing of,
498.
Almanacs, health, 250.
Amebic dysentery, 739.
dysentery, treatment of, oil
of chenopodium in the,
56.
Americanization and health,
183.
America's defective manhood,
440.
Among the books, 52, 235, 303,
611.
Anderson, H. B., 602.
Animal powers in health and
disease — Redfleld, 542.
Anthrax, treatment of, neo-
salvarsan in the, 496.
Antiscorbutic value of raw
juices of root vegetables,
174.
Antithyroid treatment of
menorrhagia, 732,
Aphasia, some remarks on —
Laveaon, 715.
Appeal, Dr. Lorenz*s, 094.
Appendectomy^ new incision
for, 238.
Appendicitis, chronic, 236.
chronic, sign in, Rovsing's,
737.
etiology of, 675.
in children, 298.
Appendix, removal of the,
thru the vagina — Oallo-
way, 729.
Arachidic bronchitis, 5G1.
Armenia, starving, and the
world's duty, 755.
Armies, disease in, insect-
borne— LZoyd, 329.
Army Med. Corps keep army
effective, 802.
Arsphenamine, administra-
tion of— McCoy, 296.
Arterial tension, high: treat-
ment of high blood press-
ure— Lindenherger, 98.
Arteriosclerosis, 674.
high blood pressure and —
Bizot, 100.
Arthritis, gonorrheal, 738.
multiple, of obscure origin
— Simpson, 789.
rheumatoid, 793.
Artificial limbs, 751.
Aspirin, incompatibility of
quinine and, 556.
Asthma, bronchial. 552.
hay fever and, 299.
treatment of, 294.
treatment of — Knapp, 642.
Astigmatism, observation on,
296.
Atrophy, muscular, treatment
of, 796.
Attendance, free medical, as
a public utility — Good-
hue, 720.
Attendants, trained, dearth
of, 566.
Automobile accidents, 446.
Aviation, problems of, med-
ical— Fisher <6 Lyman,
400.
B
ables, hogs, and bees, 511.
Bacillus, gas. infection in
wounds, 614.
Bacon, digestibility of, 615.
Baker, Secretary of War, 316a.
Barleycorn, John, and Lady
Nicotine, 186.
Barr, Sir James, 183.
Basedow's disease, hyperthy-
roid theory of, 793.
Bedbugs, destruction of, 802.
*'Beer or bedlam," 66.
Bees, hogs, and babies, 511.
Biologic food tests, 181.
studies, practical results
of, 182.
Birth control and birth pre-
vention, 122.
control opinions, 114.
control, why not, clinics in
America — Sanger, 164.
prevention, birth control
and, 122.
rate, infant mortality and,
445, 750.
Births of a nation, 749.
Bites, treatment of, 799.
Bizot, A. R., 100.
Bladder, wounds affecting the,
616.
Blindness of the new-born,
3.
Blood lust, 491.
pressure, high, treatment
of — Lindenberger, 98.
regeneration and bone mar-
row activity, 550.
Blumer, George, 457.
Bones, development of duct-
less glands, and, 228.
Bowman, R. G., 726.
Brain cases, interesting—
Ch-aef, 89.
Braisted, Surg.-Gen., U. S.
Navy, 316c.
Bram, Israel, 216.
Bronchial asthma, 552.
Bronchitis, 504.
arachidic, 561.
prevalence of, 505.
Bronchopneumonia, influen-
zal, use of vaccines in
acute influenza and, 111.
camphor in, 798.
Bulkley, L. Duncan, 129.
Burr, Charles W., 27.
Camphor in influenzal bron-
chitis and bronchopneu-
monia, 798.
Cancer, cutaneous, 738.
gastric, pancreatic extract
in, 733.
of occupational origin, Is?
— Rand,. 469.
of the uterus, deductions
concerning, 668.
problem, present status of
the— Bulkley, 129.
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INDEX, 1919
radium treatment of, 794.
what we know about, 742.
Carcinoma of the gall-bladder,
552.
Cardiac lesion, high blood
pressure without — Simp-
son, 99.
Cardiovascular diseases dur-
ing the war period —
Kahn, 473.
Carleton, Clara Louise, 736.
Cartilages, floating, in the
knee Joint— Jisr, 101.
Catarrhal deafness, physio-
logic treatment of, 230.
Catheterization, simple and
practical method of, 801.
Centers, state health, 68%.
Chapin, H. Gerald, 37.
Chenopodium, oil of, in the
treatment of amebic dys-
entery, 56.
Chest, physics of the, and
their relation to diseases
and injuries of the thor-
acic organs— Barr, 193.
Childbirth, pregnancy and,
among Siberian Aborig-
ines, 480.
Children, appendicitis in,
298.
nuts and fruits in feeding
of, 492.
weak feet in, as an etiologic
factor in the production
of rickets, 173.
Chocolate in the war, 495.
ChoresL— Stevens, 207.
treatment of, 239.
Christmas in the hospitals,
758.
Chronic appendicitis, 236.
Circulatory disorders, obser-
vations on — Martin, 466.
Cirrhosis of liver, diet in, 301.
Clinics, birth control, why not
in America — Margaret
Sanger, 164.
mental, necessity for, 623.
Cockroach : its destruction,
495.
Communicable diseases, 311.
Constipation, management of,
among school girls. 553.
Copeland, Royal S., 175.
Corpus luteum in nervous dis-
eases, 488.
in vomiting of pregnancy,
793.
Coryza, vaccine treatment of,
56.
Cough, chronic treatment of
— Voorhees, 635.
Country, rural districts of
the, 628.
Critics, president's, 125.
D
angers, moral, fatigue
and its, 632.
of European travel, 71.
Diarrhea, acute, in infancy,
496.
chronic, 237.
Diathermia in the post paraly-
tic stage of poliomyelitis,
607.
Diet in cirrhosis of liver, 301.
Dietetic treatment of liver
diseases, 55.
Diphtheria control, 61.
Disabled soldiers, rehabilita-
tion of, influence of pen-
sion or compensation ad-
ministration on the — Mc-
Murtrie, 355.
Disease, a crowd, 505.
and returning soldiers, 7.
and wounds in the war, 440.
carriers, methods for deter-
mining. 748.
causation of, insect trans-
mission or, 676.
Daniels, Secretary of the
Navy, 316b.
Davin, John P., 104 and 614.
Davis, E>lward P., 410.
Deafness, catarrhal, physio-
logic treatment of, 230.
Death of Dr. C. F. Taylor, 693.
Debt, nation's, to the doctors,
315.
Defectives, mental, 449.
Deflciencies in medical edu-
cation, 177.
Degeneration, reaction of,
107 and 170.
Dental infection, importance
of, etiologic— Ifarco, 286.
Depopulation and illegitimacy,
631.
Diabetes insipidus, pituitary I
in, 731.
mellitus, milk diet in, 677.
treatment of — Allen, 173.
Diagnosis and treatment:
malaria — Robinson, 91.
causes, and treatment of I
chronic cough — Voorhees, '
635.
clinical, and physiologic
dietetics, 546.
doubtful, of pulmonary tu-
berculosis with remarks
on treatment — Robinson,
661.
group, development of, 689.
of acidosis, 552.
of cerebrospinal meningitis,
297.
of early pulmonary tubercu-
losis— Morris, 527.
of hyperthyroidism by
basal metabolism, 791.
of peptic ulcer, 54.
of pulmonary tuberculosis,
early, 54.
of smallpox, 296.
tuberculin in, 552.
Diagnostic value of dulness in
traumatic intraabdominal
extravasations, 172.
gall-stone, complicating
pregnancy, 236.
health and, animal powers
in—RedfleJd, 542.
heart, left scapular pain
and hyperalgesia in, 297.
insect-borne, in armies —
Lloyd, 329.
occupational, 150 cases of —
Hand, 718.
treatment of, modern, py-
retotherapy in, 497.
Diseases and injuries of the
thoracic organs — Barr,
193.
cardiovascular, during the
war period — Kahn, 473.
communicable, 311.
infectious, in hospitals, 4.
nervous, corpus luteum in,
488.
preventable, losses from,
242.
skin, 295.
systemic, failure to cure,
by spectacles — Oould, 539.
venereal, eradication of, in
localities — Souchon, 224.
venereal, flght against, in-
ternationalizing the, 629.
Divorce, problem of, 126.
Doctor's equipment for leader-
ship, 314.
office, state may provide,
510.
sphere, widening the, 630.
Doctors, nation's debt to the,
315.
vs. legislators, 695.
women, conference of, 571.
Doctors' duelemma, 454.
unions, 572.
"Don't Quit"!, 302.
Door-knob, hygiene of the —
Rand, 600.
Dream-interpretation, uncon-
scious and modern, psy-
chology of the — Talmey,
257.
Drink, an effect or a cause,
of CTim^'i— Marshall, 121.
Drug addiction, 738.
government survey of, 240.
narcotic, great fundamental
need in connection with
the problem of, 191.
narcotic, in the new-born —
Laase, 283.
narcotic problem of, 189.
narcotic seeking to control,
255.
Drug campaign, 240.
danger, prohibition and the,
49.
narcotic, legislation, false
economy and, 127.
situation, 128.
Drugs, good and bad, 187.
Ductless gland therapy, 295.
Ductless glands and develop-
ment of bones, 228.
Digitized by
Google
INDEX, 1919
in chronic tuberculosis, 673.
Inter-relation of, 105.
thyroid hormone and its
relation to other, 229.
Dysfunction, endocrine, 671.
Dysentery, amebic, 739.
Economy, false, and pro-
posed narcotic drug leg-
islation, 127.
JEklucatlon, intelligence and,
12.
mass, 569.
medical, deficiencies in, 177.
municipal, experiment in,
503.
Educational forces, hospitals
as, 243.
Educator, soldier as, 434.
Embryologic material, hu-
man, appeal for, 675.
Empyema, treatment of, 799.
Encephalitis lethargica —
Copeland, 175.
Endocrine dysfunction, 671.
tropisms — Kaplan, 586.
Enuresis, treatment of, etiol-
ogy and, 736.
Epilepsy, belladonna treat-
ment of — Vipond, 707.
pituitary gland in, 550.
Epithelioma, treatment of, by
radium, 740.
Etiology, remarks on, and
treatment of tuberculosis
—Geyser, 80.
Eugenics, marriage laws and,
800.
Evolution, speeding up, 512.
Examinations, physical, of
recruits, 623.
Experiences of a medical re-
serve officer with the A.
E. F.— Meyer, 759.
Extract, leucocyte, for the
treatment of undeter-
mined infections, 674.
Extracts, organic, subcutane-
ous administration of the,
673.
Eyestrain, an artists, tragedy
ot—Oould, 725.
Fatigue and its moral dan-
gers, 632.
at the front, 608.
Feeding, rectal, 174.
Fees, question of, 573.
Feet, weak, in children, as an
etiologic factor in the
production of rickets, 173.
Female, gonorrhea in the,
56.
economy, human, relations
of the ovarian secretion
to, and practical ovarian
organother apeusis —
Oginz, 595.
venereal infection in the,
549.
Fetal growth, thyroid and,
489.
Fever, trench, 248.
Fisher, Lewis, 400.
Flatfoot, 56.
Fletcherism, 70.
F6od tests, biologic, 181.
value, of meat, 680.
Forbes, Henry Hall, 385.
Ford, Henry, case of, 455.
Foreigner, the, 184.
Forests, health, and health
towns, 574.
Franco-American medical en-
tente, 498.
Fruits, nuts and, in feeding
children. 492.
Fuld, Jos. E., 536.
Gall-bladder, carcinoma of
the, 552.
Galloway, D. H., 729.
Gall-stone disease complicat-
ing pregnancy, 236.
Garage sanitation, 2.
Gas bacillus infection in
wounds, 614.
Gastric cancer, extract in,
pancreatic, 733.
secretion, stimulation and
inhibition of, and the
subcutaneous administra-
tion of certain organic
extracts, 673.
GastrorentetritiB, yeast in,
553.
Genesis of speech — Talmeyi
575.
Geyser, Albert C, 80 and 278.
Gift, a promising, 685.
Girls, school, constipation
among, 553.
Gland, ductless, therapy, 295.
extracts, effect of, on bile
secretions, 229.
Glands, ductless, and develop-
ment of bones, 228.
In chronic tuberculosis, 673.
inter-relation of, 105.
thyroid, functions of the,
427.
thyroid hormone and its re-
lation to, 229.
Gloves, rubber, things to re-
member about, 555.
"God give us men!", 303.
Goitre, exophthalmic, treat-
ment ot—Geyser, 278.
intrathoracic, showing a
thyrotoxicosis, 608.
prevention of — Bram, 216.
Goldstein, Hyman I., 665.
Gonococcemia and metastatic
gonorrhea — Goldstein,
665.
Gonorrhea, acute anterior,
management of, 678.
in the female, 56 and 799.
metastatic, gonococcemia
and — Goldstein, 655.
Gonorrheal, arthritis, 738.
Goodhue, E. S., 720.
Gorgas, Surg.-Gen., 316h.
Gould, George M., 88, 539 and
725.
Graef, Charles, 89.
Gunshot wounds, treatment
of, 497.
Gynecology, medical versus
meddlesome — Sturmdorf,
23.
Hallux valgus, treatment of,
surgical— Fi^I(2, 536.
Handshaking, 179.
Harting, Joanna Walton, 420.
Hay fever and asthma, 299.
Hays, Harold M., 388.
Hazards of cloth sponging, 64.
Headache — Neustaedter, 143.
Health almanacs, 250.
Americanization and, 183.
and hygienic standards of
industrial workers —
Scheffel, 276.
animal powers in, and dis-
ease— Redfleld, 542.
to Serbia, bringing — Per-
kins, 522.
conservation, why not,
among medical special-
ties?—Taylor, 92.
courses in public schools,
513.
creed, student's, 740.
forests and health towns,
574.
industrial, 309.
insurance, compulsory —
Davin, 104.
insurance, organization
against, 742.
insurance, some favor, 448.
ministry of, 684.
program, labor, 5.
public, administration of,
115.
public, and telephones, 697.
public, obligation of the
physician to the, 680.
rural, administration, 627.
rural, organization, 565.
secretary of, in the cabinet,
7.
Heart block, so-called: brief
review of recent litera-
ture—PcHe, 73.
disease, left scapular pain
and hyperalgesia in, 297,
treatment of, 799.
irritable, 551.
of a pregnant woman, 174.
Hematuria, clinical aspects
of, 298.
Hill, H. W., 663.
Digitized by
Google
INDEX, 1919
Hilton, David C, 772.
Hoarseness, 299.
Hogner, Richard, 599.
Hogs, bees and babies, 511.
Home nurses, 502.
Hormone control of renal
function, 489.
Hormones and the vegetative
nervous system, 428.
Hospitals as educational
forces, 243.
Christmas in, 758.
special establishment of, 11.
Human element, failure of
the, 50.
Hurst, Arthur P., 340.
Hygiene board, federal social,
247.
mental, and school progress,
568.
mental, program of, 622.
of the door-knob— Rand,
600.
Hygienic standards of indus-
trial workers, health and
^Scheffel 276.
Hyperalgesia, left scapular
pain and, in heart dis-
ease, 297.
Hyperemia, therapeutic effect
of, 483.
Hyperopia, myopic specta-
cles for— GfouZd. 88.
Hyperthyroid theory of Base-
dow's disease, 793.
Hyperthyroidism, 229.
differential diagnosis of,
791,
myxedema and, thyroid ex-
tract in, 427.
tuberculosis from, differ-
entiation of, 488.
Hysteria and the surgical
specialties in war and
peace — Hurst, 840.
Ignorance and a low death
rate, 610.
Illegitimacy, depopulation
and, 631.
Immigrants, type of, 443.
Immigration, restricted, 442.
Impulse conduction thru po-
larization, 46.
Indemnity and prevention,
447.
Index, a sanitary, 745.
Industrial medicine and its
remuneration, 507.
specialists, 505.
Infant, abnormal, nutrition
of the, periods in the —
Scott 581.
mortality, 444.
mortality and birth rate,
445.
Infantile paralysis, treatment
of, operative improve-
ments in the — Mayer, 133.
Infection, dental, etiologlc
importance of — Marco,
286.
Infectious diseases in hos-
pitals, 4.
Inflammation, ' radiotherapy
in, 795.
Influenza and the ostrich, 13.
epidemic, recent, clinical
aspects of the, 554.
is lethargic encephalitis
due to, 114.
prevention of, 691.
treatment of, 796.
Influenzal pneumonia, pre-
vention of, 552.
Injuries, diseases and, of the
thoracic organs, physics
of the chest and their
relation to — Barr, 193.
Insect-borne disease in ar-
mies— Lloyd, 329.
Insect transmission or causa-
tion of disease, 67G.
Institutional care, 450.
Institutions, non-liability of
charitable, for the negli-
gence of physician or
nurse — Chapin, 37.
Instructions, reasonable med-
ical, 119.
Insurance, health, compulsory
— Davin, 104.
health, compulsory, inevit-
able, 674.
health, some favor, 448.
Intelligence and education,
12.
Internal secretions, 673.
Intrathoracic goitre, showing
a thyrotoxicosis, 608.
Ireland, Surg.-Gen., U. S.
Army. 316b and 317.
Iritis, treatment of, 301.
"It can be done!". 303.
It's what you think — poem,
15.
Jacobi, Abraham, M. D.,
LJLD., In memorlam —
Knopf, 515.
Dr., death of, 451.
Jisr, J. G., 101 and 480.
Johnson, Major J. Pratt, 149.
July and August, 446.
**Ju8t whistle a bit" — poem,
514.
1^ ahn, Morris H., 473.
Kaplan, David M., 58G.
Keith, D. Y., 272.
Keith, J. P., 272.
Kidney, action of, pituitary
extract on» 1^^-
Knapp, Mai-ir I., 642.
Knee Joint ^/^ating cartilages
*° theLf/f^r. 101.
Konkle. W. B.. 733.
Knopf, S. Adolphus, 515.
I aase, Christian F. J.. 2S3.
Latimer, M. J., 699.
Laveson, H., 715.
Law, obedience to, 499.
Laws, motor speed, accidents
and, 609.
Legislation, drastic. 500.
narcotic drug, false econ-
omy and proposed, 127.
Legislators, doctors, vs., 695.
Lethargic encephalitis, 113.
encephalitis, is, due to in-
fluenza? 114.
Lethargica, encephalitis —
Copeland, 175.
Leucocyte extract for the
treatment of undeter-
mined Infections, 074.
Liberty loan, victory, profes-
sion and the, 192.
Limbs, artificial, 751.
Lindenberger, I.. 98.
Lipovacclnes, 562.
Liver, cirrhosis of, diet In,
301.
diseases, dietetic treatment
of. 55.
Living, cost of, wages and,
449.
Lloyd, L. I., 329.
London Letter, 44. 102, 226,
287, 481.
Lydston, G. Frank, 699.
Lyman, H. W., 400.
Makeshift, an American —
Bowman, 726.
Malaria, carrier of, 493.
endemic, as a military prob-
lem, 439.
in the United States. 302.
its diagnosis and treat-
ment— Robinson, 91.
treatment of, 677.
treatment of, with quinine
hydrochlorld, 239.
Mammary extract In the treat-
ment of uterine fibromy-
omata, G72.
Manhood, defective, Ameri-
ca's. 440.
Marco, B. Barrymore, 2SC.
Marcy, Henry O., 477.
Marriage laws and eugenics.
800.
Marshall. Perry, 727.
Martin, Col., 316e.
ivlartln, William, 4G6.
Maternity, motherhood and.
G9G.
Mayer, Leo. 133.
McCoy, G. W., 296.
Mcllroy, A Louise. 34G.
Digitized by
Google
INDEX, 1919
MeKenzle, R. Tait, 366.
McMurtrle, Douglas C, 355.
Mead, J. E.. 372.
Measles, malignant, 798.
prevention of. 56.
Meat, value of, 680.
Mechano-therapy, place of,
in the re-education of
impaired movements —
McKenzie, 365.
Medical activities of U. S.
Navy under Admiral
Sims' command — Renter-
ilahl, 417.
and surgical developments
of the war, 435.
and surgical work as a pris-
oner of war, 438.
Association, American, rem-
iniscences of the founder
of— ifarci/, 477.
capital, New York as a,
453.
care of troops in billeted
areas in Bordeaux Area,
France— Hays, 388.
cooperation, 121.
department of the United
States Army, activities of
the, during the war— /re-
land, 317.
Editors* Association, Amer-
ican, golden jubilee- vic-
tory meeting, 176.
education, deficiencies in,
177.
instructions, reasonable,
119.
journalist's splendid record
in the army medical serv-
ice, 67.
national licensure, 659.
problems of aviation— Fi«7i-
er d Lyman, 400.
profession, reconstruction
and the— Blunter, 457.
regimental, work — Miner,
398.
reserve corps, commissions
in, 240.
teaching, reforming, 743.
versus meddlesome gyne-
cology— Sturmdorfy 23.
service corps, volunteer, —
DavU, 410.
Medicine and surgery— 3for-
Hs, 17.
as a vocation, GO.
fifth year in, 244.
industrial, and ItB remu-
neration, 507.
infiuence of the war on,
555.
politics and, 756.
sociologic aspects of, 686.
Men, salvage of— Mead, 372.
Meningitis, cerebrospinal,
diagnosis of, 297.
Menorrhagia, antithyroid
treatment of, 732.
Mental defectives, 449.
diseases, war increases, 176.
Metric system, 746.
Meyer, Leo B., 759.
Migraine, etiology of, 675.
Milk diet in diabetes mel-
litus, 677.
Miner, Donald, 398.
Ministry of health, 684.
Mission, home, 509.
Monoghan, Lieut.-Col., 316g
and 412.
Morality and the nude, 633.
Morris, M. Ford, Jr., 527 and
785.
Morris, Robert T., 17.
Mortality, infant and the
social status, 689.
of negroes, 500.
Motherhood and maternity,
696.
wombless, 254.
Motor accidents and speed
laws, 609.
Mouth, 621.
trench, 676.
Mumps, cerebral complica-
tions of, 737.
Muses, the doctor — poem —
Carleton, 736.
Myopic spectacles for hyper-
opia—GowZd, 88.
Myxedema and hypothyroid-
ism, thyroid extract In,
427.
Narcotic control, regula-
tions for. 176.
drug addiction in the new-
born— Laase, 283.
drug addiction, problem of,
189.
drug addiction, seeking to
control, 255.
drug legislation, proposed,
false economy and, 127.
drug question, 456.
Nation's debt to the doctors.
315.
Nation, births of, 749.
Navy, U. S., medical activities
of, under Admiral Sims'
Command — Reuterdahl,
417.
Necropsies, pathology and,
567.
Negroes, mortality of, 500.
population of the United
States today, 502.
Neosalvarsan in the treat-
ment of anthrax, 496.
Nervous diseases, corpus
luteum in, 488.
vegetative, system, hor-
mones and the, 428.
Neuralgia, trigeminal, etiol-
ogy of, 237.
Neurasthenia, strychnine In,
and anxiety neuroses,
678.
Neuritis, war, and shell shock,
439.
Neustaedter, M., 143.
New-born, blindness of the,
3.
New Year, 1.
New York as a medical cap-
ital, 453.
Nicotine, Lady, John Barley-
corn and, 186.
Nitrite of soda in treatment
of high blood pressure —
Wilson, 100.
Nude, morality and the, 633.
Nurses, home. 502.
Nutrition, periods In the, of
the abnormal Infant —
Scott, 581.
Nuts and fruits in feeding
children, 492.
Obstetrics, pituitary extract
in, 672.
Oglnz, Philip, 595.
Oil of chenopodium In the
treatment of amebic dys-
entery, 56.
Opium, shall, be proscribed?
617.
Opportunities, new, 184.
post-war, 314.
splendid, 509.
Oral sepsis, result of, tonsil-
litis and pharyngitis as a
— Anderson, 602.
Organisms, two new, 683.
Organized medical leadership,
57.
Organotherapy in manage-
ment of wounds, 229.
Orthopedic, work of an, cen-
ter In Macedonia — Mc-
Ilroy, 346.
Osteoma, multiple, of the
nasal accessory sinuses,
etiology of, 55.
Otis, Edward O., 140.
Oto-laryngologist, experiences
of an, in the advance sec-
tor—P'orfte^, 385.
Ovarian secretion— its rela-
tions to the human fe-
male economy and the
practical ovarian organo-
therapeusis — Oginz, 595.
Ovaries, relation of the, to
metabolism, 490.
secretion of the, effects of
under and over, 106.
Pancreatic extract in gastric
cancer, 733.
Papilloma, warts, verruca,
233.
Paraffin, treatment of wounds
by, 740.
Digitized by
Google
10
INDEX, 1919
Paraglandular organs, 488.
Paragraphic reflection s —
Konkle, 733.
Paresis, treatment of, intra-
cranial, 299.
Pathology and necropsies,
567.
Pelle, Henry E., 73.
Pension, or compensation ad-
ministration, influence on
the rehabilitation of dis-
abled soldiers — McMur-
trie, 355.
Perkins, Roger G., 522.
Pershing, General Command-
ing American Expedition-
ary Force, 316d.
Pharyngitis and tonsillitis as
a result of oral sepsis,
— Anderson, 602.
Physician and the New York
State Income Tax Law —
Travis, 782.
under prohibition, 616.
Physicians, list of decorated,
429.
list of, who died in action
or of wounds, 432.
Physics of the chest and their
relation to diseases and
injuries of the thoracic
organs — Barr, 193.
Physiologic dietetics and
clinical diagnosis, 546.
treatment of catarrhal
deafness, 230.
Pituitary extract, action of,
on kidney, 106.
extract in diabetes insipi-
dus, 731.
extract in incontinence of
urine, 608.
extract in obstetrics, 672.
gland in epilepsy, 550.
Plagues, venereal, fighting,
120.
Pluriglaridular syndrome, 428.
Pneumo-catarrhal diathesis,
prevention and treatment
of pneumonia and other
respiratory infections by
mixed vaccines — Johnson,
149.
Pneumonia, influenzal, pre-
vention of, 552.
pneumo-catarrhal diathesis,
and other respiratory in-
fections, treatment of by
mixe<l vaccines — Johnson,
149.
principles in the manage-
ment of— Otis, 140.
treatment ot— Morris, 785.
Poisoning, TNT, prevention
of, 508.
Poliomyelitis, acute anterior,
with some remarks about
momenclature — Burr, 27.
post paralytic stage of,
diathermia in the, 607.
Politics and medicine, 756.
Polyneuritis, experimental,
59.
Postage stamps, are they
dangerous? 620.
Post-influenzal examinations,
8.
Practice, the major and minor
in, 698.
Pregnancy and childbirth
among Siberian Aborig-
ines, 680.
complicating, gall-stone dis-
ease, 236.
supervised, 744.
vomiting of, corpus luteum
in. 793.
Pregnant woman, heart of a,
174.
President, soldier, surgeon,
754.
President's critics, 125.
Prevention, indemnity, 447.
Prisoner of war, medical and
surgical work of, 438.
Prize fight, 441.
Profession and the Victory
liberty loan, 192.
Prohibition, 14.
and the drug danger, 49.
and individual rights, 66.
and the alarming drug
figures, 512.
enforcement law — Davin,
614.
physicians under, 616.
Prostate, hypertrophied, etiol-
ogy of — Lydston and
Latimer, 699.
Pruritus ani, etiology of, 173.
Psora, how to recognize, when
not a specialist — 8her-
woodrDunn, 40.
Psychoanalysis and the
Kaiser, 185.
Psychology of the uncon-
scious and modern dream-
interpretation — Talmey,
257.
strange, of the people in
Germany, 188.
Puerperium, diet during the,
739.
Pulmonary tuberculosis cases
treated with ultraviolet
light — Zueblin, 210.
Pyretotherapy, a new thought
in the modern treatment
of disease, 497.
Quinin hydrochlorid. treat-
ment of malaria with,
239.
Quinine, incompatibility of,
and aspirin, 556.
Radiotherapy: indications
and resuKs obtained
when properly used —
Keith d ^eith, 272.
in inflammation, 795.
Radium, treatment of epithe-
lioma by, 740.
Rand, W. H., 469, 600 and 718.
Rate of conduction speed, 47.
Reconstruction and the med-
ical profession — Blumer,
457.
Recreation as a moral force
in army life — Shertoood-
Dunn, 418.
Rectal feeding, 174.
Red Cross, aid of the, 629.
international, activities,
307.
Redfield, Casper L., 542.
Re-education in impaired
movements, m e c h a n o-
therapy in— McKenzie,
365.
vocational, 687.
Reflections, paragraphic —
Konkle, 733.
Registration, birth, 690.
Rehabilitating the maimed,
10.
Research, nutritional, 801.
Reuterdahl, Henry, 417.
Rickets as an etiologic factor
in the production of weak
feet in children, 173.
Robinson, Beverley, 91 and
661.
Roosevelt, Theodore, Jr..
Lieut-Col. 316h.
Theodore, the late, 16.
Salaries, teachers', 752.
Saline solution with organ
extracts in shock, 672.
Saloon, saving the, 252.
Salt solution, normal, use of,
physiologic, 288.
Sanger, Margaret, 164.
Sanitary cordon to check the
spread of typhus in Po-
land, 729.
index, 745.
Sanitation, garage, 2.
sleeping car, 69.
Scapular, left, pain and hy-
peralgesia in heart dis-
ease, 297.
Scarlatina, cure of. rapid
554.
Schapira, William, 406.
Scheffel, Carl, 276.
Schools, public, health courses
in, 513.
systems, 570.
Science and alcohol, 251.
Scott, George Dow, 581.
Serbia, bringing health to—
Perkins, 522.
Serious state of affairs, 62.
Serum treatment of typhoid
fever, 677.
Service facts, selective. 117.
Digitized by
Google
INDEX, 1919
11
Shell sbock, neuritis and. 1
war, 439.
Sherwood-Dnnn. B., 40 and
418.
Shively. Henry L... 29.
Sbock. extracts in, organ,
saline solution with, 672.
Sick and wounded, care of,
from overseas, at U. S.
Army Debarkation Hos-
pital No. 3 (Greenhufs)
— Monoghan, 412.
Silver service stripe, 1.
Simpson. V. E.. 99 and 789.
Skin diseases. 295.
eruptions, 620.
Sleeping car sanitation, 69.
Smallpox, diagnosis of, 296.
Soda, nitrite of, in treatment
of high blood pressure-
Wilson, 100.
Soldier as educator. 434.
Soldiers, disabled, a message
to. 11.
disabled, rehabilitation of,
influence of pension or
compensation administra-
tion on the — McMurtrie,
355.
Souchon. Edmond, 224.
Specialists, industrial, 505.
Speech defects, correcJtion of,
national society for the
study and, 302.
genesis of— ToZmcy, 576.
Statistical method, knowledge
of, 564.
method, end and aim of the,
564.
Statistics, vital, 563.
Status, social. Infant mortal-
ity and, 689.
Stevens, George T., 207.
Stragnell, Gregory, 378.
Strychnine, action of, upon
the output of epinephrine
from the adrenals. 731.
in neurasthenia and anxiety
neuroses. 678.
Sturmdorf, Arnold, 23.
Sunlight and sense, 433.
Suprarenal insufficiency, 732.
Surgeon, soldier-president,
754.
Surgery, medicine and — Mor-
rU, 17.
war, experiences in — Strag-
nelh 378.
Surgical, medical and. devel-
opments of the war, 435.
medical and. work as apris-
oner of war, 438.
non-treatment of gastric
ulcer. 604.
specialties, hysteria and
the, in war and peace —
Hurst, 340.
treatment of hallux valgus
and its complications —
Fttld, 536.
Syndrome, pluriglandular,
428.
ibyphilis, congenital, 619.
Systemic diseases, failure to
cure, by spectacles, over-
looked causes of — Oould,
539.
T almey, B. S.. 257. 575.
Taylor. Dr. C. F.. death of,
693.
Taylor. J. Madison, 92.
Teacheis* salaries, 752.
Telephones, public health
and, 697.
Tendency of the past few
years, 568.
Tetanus, treatment of. 239.
Thoracic organs, diseases and
injuries of the, physics
of the chest and their re-
lation to— Borr. 193.
Thymus, enlargement of the.
treatment of, 106.
Thyroid and fetal growth,
489.
extract In myxedema and
hypothyroidism, 427.
glands, functions of the,
427.
hormone, identification of
the. clinical, 607.
hormone and its relation to
other ductless glands. 229.
intoxication, treatment of,
733.
Thyrotoxicosis, and Intra-
thoracic goitre. 608.
TNT poisoning, prevention of,
508.
Tonsillectomy during child-
hood, 63.
Tonsillitis and pharyngitis
as a result of oral sepsis
— Anderson, 602.
Tonsils and adenoids, re-
moval of. 496.
removal of. 678.
Towns, health, health forests
and, 574.
Traumatic Intraabdominal
extravasations, dulness
In, diagnostic value of,
172.
Travis, Eugene M., 782.
Treatment, Allen, of diabetes,
173.
ambulatory, of varicose ul-
cers, 739.
antithyroid, of menor-
rhagla, 732.
belladonna, of epilepsy and
other spasmodic diseases
—Vipond, 707.
care and, of drug addicts,
682.
causes, diagnosis and, of
chronic cough — Voorhees,
635.
diagnosis and, of malaria —
Robinson, 91.
dietetic, of liver diseases,
55.
etiology and, of enuresis,
736.
Intracranial, of paresis,
299.
modern, of disease, pyreto-
therapy a new thought In
the, 497.
neosalvarsan In the, of
anthrax, 496.
nitrite of soda in, of high
blood pressure — Wilson,
100.
non-surgical, of gastric
ulcer, 604.
of asthma, 294.
of asthma — Knapp, 642.
of bites, 799.
of cancer with radium, 794.
of chorea, 239.
of empyema, 799.
of enlargement of the thy-
mus, 106.
of epithelioma by radium.
740.
of exophthalmic goitre —
Qeyser, 278.
of extensive septic wounds,.
015.
of gonorrhea In women, 79 &.
of gunshot wounds. 497.
of heart disease, 799.
of Infantile paralysis, oper-
ative improvements In
the— Mayer, 133.
of Influenza, 796.
of Iritis, 301.
of malaria, 677.
of malaria with qulnln hy-
drochlorld, 239.
of muscular atrophy, 796.
of pneumonia — Morris, 785.
of rheumatoid arthritis.
793.
of tetanus, 239.
of thyroid intoxication, 733.
of uncinariasis, 56.
of undetermined infections.
leucocyte extract for the.
674.
of vaginitis, position In.
upside-down — Hogner,.
599.
of vertigo. 55.
of whooping cough. 678.
of wounds by paraflln. 740.
oil of chenopodium In the,.
of amebic dysentery, 56.
physiologic, of catarrhal
deafness, 230.
remarks on etiology on,
tuberculosis — Qeyser, 80.
serum, of typhoid fever,
677.
surgical, of hallux valgus
and Its complications —
Fuld, 536.
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12
INDEX, 1919
tuberculin, In chronic pul-
monary tuberculosis—-
Shively, 29.
vaccine, of coryza, 56.
Trench fever, 248.
mouth. 676.
Tribute, words of, to Med-
ical Profession — Baker,
Daniels, Ireland, Brai-
sted, Pershing, Wood,
Martin, Monoghan, Gor-
gas and Roosevelt, 316a-
316h.
Tuberculin in diagnosis, 552.
treatment in chronic pul-
monary tuberculosis, the
end results of — Shively^
29.
Tuberculosis, chronic, duct-
less glands in, 673.
chronic pulmonary, end re-
sults of tuberculin treat-
ment in — Shively, 29.
early, difterentiation of,
from hyperthyroidism,
488.
of the anus and rectum,
675.
pulmonary, cases treated
with ultraviolet light —
Zuehlin, 210.
pulmonary, diagnosis of,
with remarks on treat-
ment— Robinson, 661.
pulmonary, . diagnosis of
early — Morris, 527.
pulmonary, early diagnosis
of, 54.
remarks on etiology on
treatment — Oeyser, 80.
respect to. medical officer
of health with, attitude
ot—mil, 663.
Typhoid carriers, controlling,
importance of, 626.
control, 625.
fever, treatment of, serum,
677.
Typhus, aid checks, Ameri-
can, in Roumania, 495.
spread of, check the, sani-
tary cordon to, in Poland,
729.
Ulcer, gastric, treatment of,
non-surgical, 604.
peptic, diagnosis of, 54.
Ulcers, tropical — Jisr, 480.
varicose, treatment of, am-
bulatory. 739.
Ultraviolet light, cases treated
with, pulmonary tubercu-
losis— Zveblin, 210.
Uncinariasis, treatment of,
56.
Urine, incontinence of, ex-
tract in, pituitary, 608.
I Uterine flbromyomata, treat-
I ment of, mammary ex-
I tract in the, 672.
I Uterus, cancer of the, deduc-
tions concerning, 668.
Vaccine treatment of coryza,
56.
Vaccines, mixed, prevention
and treatment of pneu-
monia and other respir-
atory infections by pneu-
mo-catarrhal diathesis,
— Johnson, 149.
use of, in acute influenza
and influenzal broncho-
pneumonia, 111.
use of, inefficient, 300.
Vagina, appendix thru the,
removal of the— Oallo-
way, 729.
Vaginal, treatment of, dis-
charge, 740.
Vaginitis, treatment of, posi-
tion in, upside-down —
Hogncr, 599.
Vegetables, root, value of raw
juices of, antiscorbutic,
174.
Veins, resting the, a simple
expedient. 238.
Venereal cases in camp:
rendering infected sol-
diers non-contagious —
^chapira and Wittenberg,
400.
diseases, eradication of. in
localities — Souchon, 224.
diseases, flght against, in-
ternationalizing the, 629.
infection in the female, 549.
peril, 253.
plagues, fighting, 120.
suspects, 747.
Verruca, papilloma, warts,
233.
Vertigo, treatment of, 55.
Vipond, A. R. 707.
Vivisection, anti-, fallacy, 452.
Vomiting of pregnancy, cor-
pus luteum in, 793.
Voorhees, Irving Wilson, 635.
Wages and cost of living,
449.
War casualties. 306.
chocolate in the, 495.
demonstration hospital of
the Rockefeller institute
246.
developments ot the. med-
if'al and ^iirgical' 435.
^^\fo^^ anci pounds in the,
influence of the, on med-
icine, 555.
making, unprofitable, 72.
neuritis and shell shock,
439.
period, diseases during the.
cardiovascular — Kahn,
473.
prisoner of, work as a,
medical and surgical, 438.
service, one piece, 245.
surgery, experiences in—
Stragnell, 378.
surgical specialties in,
hysteria and the. and
peace — Hurst, 340.
wounds of the, 695.
Warrior, effeminate, 498.
Warts. 737.
Warts, verruca, papilloma,
233.
Water, how to make, safe,
679.
Well done and farewell, 451.
Whooping cough, treatment
of, 678.
Wilson, D. S.. 100.
Wittenberg, Joseph, 406.
Wombless motherhood, 254.
Wood, Major-Gen., 316d.
Workers, industrial, stand-
ards of, health and hy-
gienic—Sc^ie/feZ, 276.
Workmen's compensation law,
302.
Wounded, clearing the —
Harting, 420.
sick and, care of. from over-
seas, at U. S. Army De-
barkation HospiUl No. 3
(Greenhut's) — Monoghan,
412.
Wounds affecting the bladder,
616.
contaminated and infected,
principles of treatment—
Hilton, 772.
disease and, in the war,
440.
gunshot, treatment of, 497.
infection in, gas bacillus,
614.
many, to heal, 755.
of the war, 695.
organotherapy in, 229.
septic, extensive, treatment
of, 615.
treatment of, by paraffin.
740.
Y
east, value of in gastro-
enteritis, 553.
^ueblin, Ernest, 210.
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American Medicine
H. EDWIN LEWIS, M. D., Maumzing Editor
IRA 8. WILE, Associate Editor
PUBUSHID MOHTHLT BT THB AUBRICAM MlDICAL PUBUSHDIG COMPAMT
Covyriffhted by the Amerieui Medical Pablishinff Co., 1919
Complete Series, Vol. XXV, No. 1
Nev Series, Vol. XIV. No. 1
JANUARY, 1919
to no YEARLY
#^.UU In Advance
THE NEW YEAR
Have you heard the voice of the New Year
faintly calling
For earnest support and cordial assistance,
sadly needed ?
Oh, World of Men, will you lift up hu-
manity, bleeding?
Resolve while the gates of Janus, slowly,
are closing.
Will you strive for the happiness of unnum-
bered souls,
Suffering anguish or quavering in hopeless-
ness, dumbly aspiring?
Will you work for the wealth of cooperat-
ing nations and peoples.
Struggling, famished, scourged, or op-
pressed ?
Will you serve mankind that health may
revivify bodies.
Prostrate, with life quietly ebbing?
Will you heal wounds that only time can
efface ?
Will you teach mankind to live well and to
be well?
Will you awaken to the value of a single
human life ?
Create vital assets instead of penalized lia-
bilities.
You have talked in terms of men and gold.
Of instruments of destruction,
Of armaments, mighty navies, and death
dealing war.
Think now of manhood, womanhood, child-
hood,
Powerful, vigorous, resolute, majestic in
harmonious action.
Contemplate the potentials of peace, long
enduring.
The world cries for a stronger race.
Put physical health before gross strength.
The world clamors for intelligence.
Esteem mental capacity and attainment be-
yond freakish genius.
The world pleads for nobility of character.
Cultivate a conscience for militant justice.
Rather than the passive realization of moral
truths.
I bid you hold fast to the promises of 1918,
For truth' and justice, democracy and the
social weal.
Help make life worth living.
Aid the world to develop a more capable and
more spiritual species of man.
Free man from every enemy that would
beat or press him down.
May 1919 bring to all a rich measure of
peace, prosperity and health.
— Ira S. Wile.
The Silver Service Stripe. — ^The De-
partment of War has seen fit to decree that
silver chevrons are to be worn by those of
the military forces who have not had the
opportunity of serving overseas. It is patent
that obvious distinctions are created be-
tween the wearers of the gold service
stripes and the wearers of the silver serv-
ice stripes. It is undoubtedly true that after
a short period of time the only outstand-
ing differences between men will be be-
tween those without stripes, and those with
them. For the time being, there is apparent-
ly a discrimination as to the value of serv-
ices or the importance of the place of serv-
ice between men who should and do possess
the same standing in the eyes of the general
public insofar as their patriotism or willing-
ness to serve is concerned.
Whether as volunteer or as draftee, all
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January, 1919
EDITORIAL COMMENT
American Medicine
men have performed their duties and lived
up to their obligations in the places to which
they were ordered and for the period of
time the Government demanded their pres-
ence. Many men whose enviable good for-
tune made them a part of the expeditionary
forces had served the colors for briefer
periods of time than brothers in arms who
were retained for necessary and important
duties on this side of the Atlantic. Similarly,
a large group of soldiers who succeeded
in crossing the broad mine-sown sea had
no greater active participation in the rag-
ing conflict than colleagues who were serv-
ing in camps or cantonments, in the quar-
termaster's department, the ordnance de-
partment, or in the medical department in
the United States. Nevertheless, gold and
silver stripes are awarded as badges of dis-
tinction to differentiate these two bodies of
men on the basis of the fact that one has
and one has not been transported three
thousand miles from the United States.
The work of the medical department of
the army wherever established was largely
uniform, with the exception of that portion
engaged in services at base hospitals,
casualty clearance stations and first aid sta-
tions within the zones of advance or evacua-
tion. The diseases and accidents among sol-
diers were practically identical at home and
abroad. The character of the medical serv-
ices performed was of the same high grade
and the results were not dissimilar on either
side of the ocean. The splendid manifesta-
tions of spirit, loyalty and cooperation were
in no wise dissimilar and scarcely warrant
any line of demarcation being drawn by the
character or the color of the service stripe
as determined by official mandate.
It is possibly a trifling matter around
which to build up discussion and argument,
but it would appear to have been a finer
tribute to all the forces if no belittling dis-
tinctions had been created, based upon dif-
ferences of location which were beyond con-
trol of the individuals concerned. In truth,
men served when, where, and how they
were directed. The gold stripe is not to be
regarded as an index of merit but of luck.
It is not an evidence of greater valor, in-
telligence, capability, or achievement, but a
symbol of chance overseas duty. This is
scarcely a basis for separating a group of
soldiers and sailors from their equally valor-
ous and willing companions in arms.
The fewer distinctions between indi-
viduals that are created in a democracy, the
more democratic is its character. The glory
of the war is sufficient to cover all men
with honor, and under the draft system,
which levels all plans of social or economic
status, it appears to be particularly unwise
to create a differentiation which unhappily
merely stresses the importance of what the
gold stripe really represents — sl trip in a
transport.
Garage Sanitation. — From time to time
instances are reported of individuals who
have been suddenly overcome by fumes in
private or public garages. It has generally
been assumed that the symptoms develop-
ing are due to poisoning by carbon mon-
oxide. A preliminary study of the health of
workers in garages by Louis I. Harris,
Monthly Bulletin of ihe Department of
Health of the City of New York (Novem-
ber, 1918), presents the facts and figures re-
lating to 43 garages covered during the in-
vestigation. While evidences of marked oc-
cupational disease were not definitely as-
certained, various shortcomings in hygiene
and sanitation were noted.
Occasional records were secured of mod-
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EDITORIAL! COMMENT
January, 1919
erately severe' manifestations of illness, pre-
sumably attributable to carbon monoxide.
The principal symptoms complained of in-
cluded nausea, vomiting, headache, weak-
ness, pallor and a subjective feeling of in-
toxication. While this symptom-complex
may be due to the inhalation of fumes of
combustion, it is not at all unlikely that a
certain measure of chronic intoxication is
developed as the result of the slow and in-
sidious action of carbon monoxide inspired
for varying periods of. time during an in-
definite number of days. The study of gar-
ages was made during a season of the year
when open window ventilation was prac-
ticed and there was little opportunity to de-
termine with scientific accuracy the exist-
ence of either acute or chronic monoxide
poisoning.
It is not at all unlikely that garages may
eflFect or condition some physical debility,
especially during the winter months when
their underheating causes the air in the
C}'Hnders of the engines to become cold, and
starting difficulties result, so that prolonged
running of the engine is required for warm-
ing up. With a large number of motors
operating within a few hours in a mod-
erately sized garage, it is not improbable
that carbon monoxide, carbon dioxide and
other gases of combustion are present in un-
due volume in the garage atmosphere. Ade-
quate ventilation and proper heating of
garages constitute the natural prophylactic
defenses for preventing the accumulation of
the harmful products of combustion. Even
during the months of May and June, when
the air of the garages was tested, fumes and
gases were found present in 43 out of the 43
garages, suggestive of the greater possi-
bility of danger during the winter season.
Among other evidences of the lack of
health protection of garage workers, there
might be mentioned the frequency of un-
guarded machinery, the lack of cuspidors to
partially localize the constantly pro-
miscuous expectorations, the occasional
presence of the common towel and common
drinking cup, and the absence of lockers
for the protection of street clothing. The
fact that 127 causes for complaint were
noted in the 43 garages is indicative of the
value of inspections of this character, as
well as the all too frequent neglect of the
sanitary aspects of an occupation which in-
volves a moderate degree of hazard to the
respiratory and nervous systems.
The facts which were ascertained for large
public garages merely serve to call atten-
tion to the importance of the entire subject.
Private garages, even those utilized for a
single motor car, may be equally danger-
ous to the chauffeur or jowner-operator if
due and proper precautions are not taken to
insure adequate ventilation and proper con-
ditions of heating during the winter months.
The dangers of carbon monoxide poison-
ing are not to be overlooked even tho the
number of fatalities due to poisoning of this
character may not be large. The effects of
exposure over a considerable period of
time are varied in character and depend
largely upon the location of the effects in
the attack upon the nervous system.
Further investigations of this character
are necessary in order to arrive at definite
conclusions as to the relative hazards to
garage workers. A more complete study is
necessary before definite regulative ord-
nances or laws can be formulated to protect
those who earn their livelihood in garages.
Blindness of the New-Bom. — ^The ef-
forts which have been made to aid the pre-
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January, 1919
EDITORIAL COMMENT
American Mediginx
vention of blindness are of as great im-
portance as the splendid attempts now being
made to re-educate soldiers and sailors who
have been blinded in war. It is difficult at
times to estimate the accomplishments of
those who are working thru voluntarily es-
tablished organizations in behalf of the
physical welfare of communities. The De-
cember number of The News Letter (pub-
lished by the National Committee for the
Prevention of Blindness, Inc.) presents
some statistical material which is stimulat-
ing and encouraging. The fact that progress
has been made in controlling ophthalmia
neonatorum is manifest. The figures in-
clude statistics from 41 schools in
cities having day school classes for
the blind during 1917 and 1918, and
40 schools in. cities having day classes
reporting their new admissions in 1917
and 1918. In 1907-1908, 26.6 per cent,
of the children admitted into classes for
the blind in schools were handicapped
because of ophthalmia neonatorum. In 1912
and 1913 this percentage had fallen to 22.8
per cent, while in 1917 and 1918 it had
reached the low level of 14.7 per cent.
Recognizing the greater interest that has
been taken in this condition and the more
general attention that is being given to the
education of blind children under public
auspices, it is very suggestive that the per-
cental decrease pf new admissions of chil-
dren blind from this single cause is due to*
the continued eflforts to prevent the occur-
rence of infected eyes among the new-bom.
The higher standards of obstetric practice
on the part of hospitals, private physicians
and midwives are admitted. State laws de-
manding the use of silver solutions imme-
diately after birth may be regarded as the
most significant factor in reducing this most
calamitous infection. The finest form of
conservation of vision is to be found, not in
the institution of classes for the blind and
the partially sighted but in the elimination
of ophthalmia neonatorum, a disease readily
preventable, and the existence of which is
a constant challenge to the thoroness of ob-
stetrical attention.
Infectious Diseases in Hospitak. — ^The
control of infectious diseases of children de-
pends largely upon administrative problems
involving the securing of adequate isola-
tion and quarantine. Hospitalization has
proved difficult for many years, particularly
in smaller communities where it seemed in-
advisable to erect an isolation plant. With
the old idea that infection is air borne, it
appeared to be necessary to establish en-
tirely separate buildings or to create a hos-
pital plan whereby ward isolation might be
made complete. Recent experience war-
rants a new opinion in regard to the man-
agement of contagious diseases treated in
hospitals, insofar as methods of prevention
of cross infections are concerned. Public
Health Bulletin Number 95 is based upon a
study of 6,078 cases of infectious diseases
of children among immigrants treated by
officers of the Public Health Service at the
hospital on Ellis Island. The statistical
analysis of their results indicate that cross
infection in hospitals is avoidable in direct
proportion to the increase of the number
of isolation units. The isolation units, how-
ever, may be within the ward.
The practical recommendations for hos-
pital construction provide for the abolition
of the common admission room, and the
abandonment of the common bathroom for
newly admitted patients. Convalescent
wards should be small and no unit should
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American MkdiCinb
EDITORIAL COMMENT
January, 1919
accommodate more than five patients and
most of them should contain but one bed. It
should be possible, however, by the use of
glass in the partitions, for convalescent chil-
dren to see each other without the possi-
bility of direct contact. The partitions may
be of the cheapest material so that the cost
of construction need not be high.
Patients suffering from contagious dis-
eases should have considerable individual
attention and nurses should be employed
for only eight hour shifts. Each nurse
should be called upon to care for no more
than six acutely ill or twelve convalescent
patients. This is, of course, a marked varia-
tion from the present custom in most hos-
pitals.
The details of hospital organization and
management for the treatment of contagious
diseases represent the summation of a large
experience, and merit thoro study, par-
ticularly by health officers in small cities or
by county officials. For this purpose, the
bulletin above referred to, prepared by J. G.
Wilson, Past Assistant Surgeon of the Uni-
ted States Public Health Service, affords
excellent material, clearly stated and ra-
tionally organized and presented.
The conclusion of Dr. Wilson is of the
utmost social and medical significance. He
asserts the "practicability of treating con-
tagious and non-contagious diseases in the
same hospital and with the same nursing
forces." He demonstrates that while it is
not advisable to use the same open wards
for both classes of cases, it is nevertheless
practical to eliminate the danger of cross
infection if these wards are cut open into
small cubicles and the proper nursing tech-
nic enforced. "As a natural corollary to this
method, it would follow that all general hos-
pitals should have provisions for treating
cases by the cubicle system and thus be pre-
pared to receive contagious cases in emer-
gency. It would also follow that small
communities which cannot afford both a
general and an isolation hospital should
plan their general hospital and its manage-
ment so that contagious diseases might be
received as freely as non-contagious."
If it be possible to utilize general hos-
pitalization with slight modifications for the
treatment of contagious and non-contagious
diseases, a tremendous saving can be ef-
fected in the cost of hospital construction
and administration, with a corresponding
gain in the efficiency of control of the in-
fectious diseases of childhood. Of greater
importance is the fact that by this method
of cubicle management of contagious dis-
eases, cross infections may be eliminated
and thus the danger of the disease con-
tracted in the hospital may be decreased.
The theory of infection thru the direct
contact of patients as opposed to air borne
contagion is responsible for a recognition
of our earlier timidity in the hospital treat-
ment of infectious diseases. If the experi-
ence at the Ellis Island Hospital is cor-
roborated, a distinct step in advance will
have been taken in the handling of the types
of diseases under discussion. Similarly, as
a result of such future proof, there will be
greater freedom in the hospitalization of in-
fectious diseases with corresponding assist-
ance in limiting their spread.
A Labor Health Progranu — Coordi-
nated public interest is essential for prac-
tical and effective public health administra-
tion. The harmonious interaction of all
branches of organized society is of para-
mount importance. Health is not a matter
of capital or of labor, of Caucasian or of
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January, 1919
EDITORIAIi COMMENT
American Mbdicinx
Negro, of rich or poor, of Catholic, Protes-
tant, or Jew. It is preeminently a potential
attribute of human beings, and may be se-
cured only thru the willingness of the gen-
eral public to work out a definite policy
which includes the willingness to pay for
it.
Numerous programs have been suggested
for increasing national vitality. Many have
had to deal purely with problems relating
to contagious diseases and civic sanitation.
In an address before the Sociological Sec-
tion of the American Public Health Asso-
ciation, Arthur E. Holder, a representative
of labor and a member of the Federal Board
for Vocational Education, offered for con-
sideration The Labor Program for Health
and Safety {American Journal of Public
Health, December, 1918). The most strik-
ing feature evident in the proposed scheme
is the stress placed upon matters ordinarily
regarded as of economic importance. There
has been, of course, a more or less academic
interest of health officials in economic and
social affairs, owing to continued reports
of the intimate relations between standards
of income and standards of familial health.
It is patent that increased stress must be
placed upon the so-called economic program
as a factor in raising the health conditions
of the country.
The labor program proposed includes a
demand for a shorter work day, with a
maximum eight hours for all manual toilers ;
a release from work at least one full day
in seven; the establishment of a higher
minimum wage; the elimination of the
sweatshop system; the abolition of night
work by women and minors; the cessation
of child labor; equal pay for equal work
regardless of sex; the Saturday half holi-
day fifty-two weeks in the year. The eco-
nomic value of these propositions is ap-
parent, and their health values are no less
clear to those appreciating the relation be-
tween fatigue, disease and accidents,
and higher wages as related to improved
conditions of nutrition, clothing, and shelter.
Labor believes in fresh air and urges the
establishment of playgrounds for children,
adjacent to all public schools, the creation
of large open breathing spaces or parks in
some sense of nearness to congested cen-
ters of living.
Educational impetus is suggested for the
encouragement of out-door exercise, the
formation of fresh air clubs, the inaugura-
tion of efforts to emphasize the need for
better rooms and fresh air ventilation in
all houses and living apartments.
Labor does not demand prohibition, but
recommends the cultivation of temperate
habits, including the diminution of the use
of intoxicants. More valuable is the re-
quest for conferences between employers*
workers and physicians, and the develop-
ment of community forums where health
conditions can be openly discussed by
parents and physicians. There is the custom-
ary demand for rigid inspection and en-
forcement of laws in mines, mills, factories
and workshops, and the demand for suit-
able ventilation, sanitation and safety de-
vices under every condition where a lack
of these will work to the disadvantage of
those employed.
Labor appreciates the value of medical
and dental inspection in public schools at
public expense and desires their continuance
and extension. It advocates the establish-
ment of a modernized scheme of physical
education at public expense with a further
provision for the free examination of adults
by the medical forces employed to secure
the optimum health conditions in the school.
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Amxbican Mkdicinb
BDITORIAIi COMMENT
Jaj^xjary, 1919
A Secretary of Health in the Cabinet—
The most significant suggestion, tho by
no means a new one, is the demand that all
Federal health agencies be concentrated in
one department with a cabinet member
serving as secretary. This resume indicates
the economic and social scope of labor's
program for health, tho it obviously does
not represent the full program designed to
consider every phase of the subject. Insofar
as it goes, it merits careful consideration
of health officers and all persons, medical
men or laymen, who possess a social con-
science and a practical interest in the im-
provement of public health.
For political and other reasons, there has
been no effort made on the part of municipal,
county, or state health officers to participate
actively in the promulgation of laws, ordi-
nances, or enactments that have had for
their purpose the alleviation of conditions
admittedly due to economic maladjustments.
In the fulfilment of obligations, there is
every reason to believe that the point of
view of health officials will be of pronounced
importance in the future in securing the
passage of bills which seek to provide for
more reasonable opportunities for correct
living.
If poverty is accepted as a most serious
factor in the causation of disease or in the
creation of susceptibility to disease, it is
manifestly proper for public health officials
to align themselves with those social forces
seeking to reduce conditions militating
against the general physical and social wel-
fare of their communities. The accumula-
tion of evidence demonstrates the necessity
for attacking economic conditions as a basis
of improving the health standards of the
country. The cases tried before the United
States Supreme Q)urt dealing with the ten-
hour law, the regulation of night work for
women, and minimum wage law were fought
largely upon facts indicating the anti-social
effects of long hours, low wages, fatigue,
industrial strain, illiteracy and similar ele-
ments as manifest thru increased diseases,
disability and racial deterioration. If the
highest court of the nation is ready to take
cognizance of health conditions as a basis
of judgment in determining the justice of
legislation, it is about time for physicians
to recognize the interdependence of health
and economic status.
It is impossible to divorce the physical
welfare of a country from its economic
regulations. The program of labor, there-
fore, demands recognition and understand-
ing, cooperation and support insofar as is
possible under existent systems of public
health administration.
Diseases and Returning Soldiers. — ^The
return of soldiers and sailors to civilian life
will test the efficacy of our quarantine reg-
ulations. While the American expeditionary
forces have not suffered seriously from
exotic epidemic diseases, most careful over-
sight is required to prevent an introduction
of such diseases as cholera, typhus and
plague by a small group of returning men
and women who may possibly be carriers of
these diseases, ordinarily rarely found in
this country. This fact has already been
recognized by the Public Health Service and
attention is called to the methods of control
in the Public Health Report, December 6,
1918. Explicit instructions have been issued
to all quarantine officers, "urging the most
careful examination, including laboratory
tests, of all units liable to be carriers of
these diseases." Officers of the Public
Health Service familiar with quarantine
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January, 1919
EDITORIAL COMMENT
American Medicinb
procedure have been sent to various ports
of Europe where they will supervise the en-
forcement of the United States quarantine
regulations applicable at foreign ports
against passengers and ships destined for
ports of the United States. The United
States military authorities will cooperate in
every way to provide for the examination,
debusing, and disinfection, when neces-
sary, of all troops prior to embarkation.
Supplementing the eflforts in foreign
ports, all soldiers will be subjected to the
United States quarantine regulations at the
port of entry, and this will include the hold-
ing of all suspicious cases for a period of
observation and examination, the delousing
of clothing and other infested materials so
as to insure a clean bill of health for all
those about to return to civil life in the
communities whence they came.
The dangers of infection from those re-
turning from foreign shores is probably no
greater than the likelihood of communal in-
fection by soldiers discharged from train-
ing camps. Conditions have changed so
much since the period of the Civil War that
there is little probability of any serious in-
fluence upon the state of public health in-
cident to the release of the million and a half
men who were remaining in cantonments
and camps at the time of the signing of the
armistice.
It is of paramount importance, however,
to recognize the possibility of an increased
dissemination of disease from these mili-
tary and naval sources, altho it may be ac-
cepted as a fact that the activities of public
health officials will be prompt and thoro in
investigating and supervising all diseases oc-
curring in the person or the family of a
discharged soldier, sailor or marine. Health
authorities should demand a special report
upon all forms of disease occurring within
three months after discharge from any
branch of national service. In this pro-
cedure they would undoubtedly have a full
measure of support on the part of the medi-
cal profession as well as the appreciative
cooperation of the general public in whose
interests such regulations would be made.
From the public health standpoint this is a
regulation worthy of consideration and
action.
Post-influenzal Examinations. — ^While
the epidemic of influenza has apparently re-
turned in many sections of the country, the
seriousness of the infection appears to have
moderated. In thoro accord with the his-
tory of epidemics, the infecting virus ap-
pears to have lost some measure of its viru-
lence. In all probability there will be a con-
tinued incidence of the infection for many
months and, possibly, the last of its appear-
ance in epidemic form is not within hailing
distance.
Thus far the total results of study and in •
vestigation in the fields of pathology and
therapeutics have revealed very little that is
new. There appears for the present a cer-
tain uniformity of opinion that the bacillus
of influenza is not the primary etiolog^c
organism and that the actual cause is not
known. Apparently the pneumonias incident
to the infection following closely upon the
influenza may be due to one of the four
types of pneumococcus, streptococcus, pos-
sibly hemolyticus, Friedlander's bacillus, or
some other organisms or viruses thus far
undetermined. The frequent reporting of
these infective agencies is suggestive of
some relationship to the complicating pneu-
monias, tho the exact relation is thus far
conjectural.
In prophylaxis there is a certain weight
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American Mbdicinb
EDITORIAL COMMENT
January, 1919
of information in favor of the use of the
gauze mask as a reasonable preventive de-
vice, provided it is properly, worn, fre-
quently washed, and continuously utilized
by those still free from evidences of the
disease. There is a serious question, how-
ever, as to the efficacy of universal mask-
wearing in communities as a prophylactic,
because of the difficulty in establishing com-
plete control over its use by the general
population. It possesses merits which com-
mend themselves despite the practical diffi-
culties involved.
The use of vaccines still remains a moot
point, with the general impression that while
this treatment has proven of value in many
cases, it still requires considerable more in-
vestigation before a definite conclusion can
be reached. At the present time there is
naturally much doubt in the adequacy
of endeavors to prevent a disease due to
an undiscovered organism by the injection
of microorganisms not proven to possess
direct etiologic relations.
Theoretically, isolation and quarantine
command attention and consideration. It is
doubtful, however, whether in the face of
an epidemic attacking thirty to forty per
cent, of the population such a procedure is
practicable. This is emphasized in view of
the difficulty of determining who are the
carriers or, indeed, of securing sufficient
control of groups of persons bent upon
pleasure, worship, or occupation during the
time that they are in the incubation period
of the disease. In all probability, contact in-
fection is the main means of distribution
tho, possibly, mouth infection may play
a small part. The control of these two
items in the presence of an epidemic of
large proportions appears to be beyond the
possibilities of health organization as at
present administered.
A consideration of the history of influenza
epidemics indicates that the high rate of re-
spiratory fatality and morbidity manifest
during the epidemic is wont to continue for
a brief period of years following the sub-
sidence of the original epidemic. The in-
crease in bronchitis and pneumonia is par-
ticularly marked for four or five years fol-
lowing an epidemic of this character. Vic-
tims of tuberculosis are more prone to ex-
acerbations of their conditions, and prob-
ably no small share of the pneumonia death
rate following influenza is due to pneu-
monias developed among those whose vi-
tality has been impaired by tuberculous in-
fection.
It is of paramount importance in the fol-
low-up work after influenza to urge fre-
quent re-examinations of those who have
been unfortunate enough to contract in-
fluenza and more particularly those who
have undergone a siege of complicating
pneumonia. The decrease in the number of
cases of influenza reported should not be
regarded as an excuse for the relaxation of
eflforts toward the control of respiratory
.diseases which today present the greatest
problem in public health. Omitting the con-
tinued oversight given the tuberculous pa-
tients, no set of conditions merits more
thoro and continuous investigation, super-
vision and control than infections of the
respiratory tract. Physical examination and
re-examination are prerequisites of attack-
ing this phase of the health problem. It is
to be hoped that the present-day experience
will not be without some benefits to those
who have escaped with their lives. . Every
individual who has had influenza should
undergo a careful physical re-examination
within three months after recovery.
If it is possible to take advantage of the
present state of mind toward respiratory
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EDITORIAL COMMENT
AMKRIOJlN Mbdicinb
diseases so as to secure a state of public
opinion favorable to the annual examina-
tion of all persons irrespective of their
health, a tremendous step in advance will
have been taken. The preventing of serious
morbidity may be aided only by repeated
examinations during a state of alleged good
health. The results of the examination of
large numbers of persons believing them-
selves fit physically have demonstrated the
large variety of defects which are fre-
quently present and which, unremedied, may
lead to serious impairments of vitality.
Rehabilitating the Maimed. — ^With the
dawn of peace coloring the horizon, the
question as to what the new day is to bring
looms large. The country has been altered
so that the focus of all things has been the
winning of the war. The focus need hardly
be changed, because a war for human suc-
cess and justice will continue. The char-
acter of the problems, to engage the inter-
ests and enthusiasms of the public will be
altered in form, tho the end is the old de-
sire for "life, liberty and the pursuit of
happiness."
Restoration to normal function is not al-
ways a rapid process. Compensatory hyper-
trophies have characterized the industrial
sphere. The manpower of the nation has
been diverted in various and unusual di-
rections, and the reversion to normal func-
tion will be a slow and trying period of
time. For normal men, readjustment will be
made without difficulty. Those who have
been handicapped by reason of disease or
casualty represent a definite problem whose
solution is academically simple, but practic-
ally will require continued thought and most
careful supervision.
Douglas McMurtrie, discussing "Social
Responsibilities in the Rehabilitation of
Disabled Soldiers and Sailors," (Medical
Record, October 26, 1918) points out the
necessity of establishing a new public con-
science towards disability. Industry has had
comparatively little use for the handicapped
individuals. The fact that many thousand
men will be potentially less fit to compete
for a livelihood, as a result of national serv-
ice, places a serious obligation upon the na-
tion. Injuries, themselves, are far less seri-
ous to individuals than the attitude of the
public towards those who are disabled.
Judging b oa<st performance there has been
a large mc^.^ure of injustice in the attitude
of the wudd towards those who thru acci-
dent have become less capable. Discourage-
ment, trials, and the struggles of cripples
are a sad commentary upon the degree of
understanding of the conditions confront-
ing the disabled. The assumption of useless-
ness is unfounded in fact. Almsgiving is
neither the antidote nor the stimulus essen-
tial for physical and psychical rehabilitation.
Fortunately, the general public prejudice is
being offset by a new campaign of public
education, having as its end an intelligent
conception of our duty towards those who
have been disabled in public service. The
re-establishment of self-respect and self-
support becomes the keynote of the new
regime that is being fostered under national
auspices. Not lionization, but opportunity,
not free food, but industrial training, not
charitable relief, but opportunity in the in-
dustrial world, represent the paramount is-
sues that must be met.
Those who are taken from fields of suc-
cessful effort deserve to be returned, capable
of realizing success once more. The word
"cripple" deserves to be scrapped, save in
its technical meaning. There must be no hint
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American Medicinb
BDITORIAIi COMMENT
January, 1919
11
or suggestion of inferiority or gross in-
capability. The physical disability must not
carry with it a connotation of helplessness.
The disabled, maimed and handicapped
cannot rise to a position of self-support
without the full backing of an interested
and helpful public. Practically all the co-
belligerent nations have appreciated the im-
portance of saving the handicapped from
the blighting eflFects of unenlightened public
opinion. Campaigns of education have
sought, and with marked success, to dis-
seminate information concerning the mod-
em principles and methods of dealing with
the disabled.
The estaUishment of special hostMtals
by the Medical Department of the Army is
being supplemented by the practical work
of the Federal Board for Vocational Educa-
tion. The government is prepared to assist
those disabled by the war to become more
efficient in their previous calling, or to train
the disabled to take up a new vocation. The
United States Government practically guar-
antees to every man disabled in the war,
under circumstances entitling him to benefits
of the War Risk Insurance Acts, the bene-
fits of such of the following services as he
may require : "Vocational advice and assist-
ance in selecting a suitable occupation ; help
in returning to the old occupation again if
advisable; support while in training for a
new occupation or for greater proficiency
in an old occupation ; a course of prelimin-
ary employment ; permanent employment in
a desirable position; and follow-up work
to protect him from mistakes and exploita-
tions." (Monograph No, I, Vocational Re-
habilitation Series No. 1,)
This program is the starting point of a
new phase of public education. It is a nat-
ural step in advance along the line of the
conservation of human resources. It is to
be regarded not merely in its vocational or
commercial aspects, but as a distinct step
along public health lines. The re-establish-
ment of family life under normal conditions
is most certainly a vital factor in health
protection. Earning capacity represents a
hygienic asset in direct ratio to its ability
to secure rational living under conditions
that build up health. The pernicious prac-
tices of the past which have resulted from
indiflFerence or ignorance must be discarded.
Casual labor, dependence, lack of adequate
food, shelter and clothing, dependence upon
philanthropy, are evidences of wastefulness
of human life and welfare. Self-respect,
self-support and at least a modicum of hap-
piness, are contributory to health.
Ability is to become the corrective of dis-
ability. Power is to strengthen weakness.
Public support and encouragement is to off-
set almsgiving and discouragement. Optim-
ism, based upon potential effectiveness, is
to supplant the pessimism born of in-'
capacity. Reeducation and rehabilitation are
truly phases of public health work.
A Message to Disabled Soldiers. —
Surgeon-General Gorgas, in his message
to disabled soldiers, has voiced what must
be the sentiment of the nation, and the
inspiration of his words should carry on,
not merely to the disabled soldier but to
every disabled individual regardless of the
origin of the handicap.
"More than chevrons, bars, or insignia,
the marks of battle which you bear, sacred
symbols of your service to a high cause,
have given you a rank among your fellows.
That rank makes you forever one of those
to whom the nation shall always look for
future sacrifices as noble as those you have
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12
January, 1919
EDITORIAL. COMMENT
American Medicine
already made and for future achievements
worthy of your past.
"No matter what has befallen you, you
are still a soldier. Altho you have returned
from the front you have to fight foes more
worthy of your steel than the Germans-
discouragement, loss of ambition, readmess
to accept the easiest way, reluctance to play
your part in the peace world. We know
you will conquer these enemies.
"Your country needs you yet to fight the
battles of peace.
"You are still one of the world s workers.
In spite of your handicap you can produce
with hand or with brain just as much as
the next man. Your country needs soldiers
in the great army of workers.
"You will not have to go it alone. The
Government and the Red Cross will see
you thru. The Government will restore to
you the use of injured members, it will
teach you a trade, it will give you an op-
portunity to earn your living as beforr
How many a doctor has seen the brightest
pupils of his class sink into obscurity and
failure in professional life, and the so-
called dullards rise to distinction and serv-
ice; an experience which only confirmed
his suspicion that there was something rot-
ten in the state of education. To such doc-
tors the new system of entrance examina-
tions to be introduced in Columbia College —
a system that will test the intelligence,
ingenuity and resourcefulness of the stu-
dent rather than his memory — will come as
refreshing news.
For a long time leading educators have
been dissatisfied with both educational
methods and test methods as they were con-
ducted in the schools of the nation. Some
years 'ago, a radical professor astounded
perhaps better than you did before. And both his pupils and his colleagues by per-
all along the line the Red Cross will be ^[^^^^^ ^^e students to take their textbooks
"VeTv"e^kdgedTur'faith in you. We with tKem into the examination room and
are for you and with you always." to use them freely. The professor, m estab-
lishing this practice, did so on the ground
that a test was successful only in the meas-
ure that it approximated the sort of test a
student would meet in real life. The tests
in real life were not of how well a man
could remember what was recorded in cer-
tain books, but how well and intelligently
he could apply the information thus
recorded. To this information he would al-
ways have access. The doctor, except in
rare circumstances, can refer to his text-
books at will in the study of a baffling case.
It is a waste of effort to have to carry in
one's mind an array of facts which one can
always obtain with less effort, leaving the
mind free for more useful tasks. The tests
which the radical professor submitted were
extremely successful. They were tests not
of the student's memory, but of his ability.
He was given a difficult problem, and was
permitted to employ all the facts at his com-
Intelligence and Education* — No one
realizes better than the doctor, who recalls
his college days vividly, how often memory
was made to serve in place of real knowl-
edge ; how frequently burning of midnight
oil for a few days before examinations and
cramming his aching head with figures,
facts and vague formulae carried him to
triumph thru tests which he could never
pass again only a week later. And in later
years, reflecting on the defects of a sys-
tem that places so great a premium on
memory and so little on intelligence, how
many a doctor has regretted this diversion
of the trend of education from the real
purposes for which it was designed, knowl-
edge that remains with the years and intel-
ligence fortified to meet the tests of life.
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EDITORIAL COMMENT
January, 1919
13
mand in the solution of the problem. So
successful was this step that it was pres-
ently imitated by other educators.
The system to be introduced at Columbia
is another advance in the right direction.
It has been the experience of those in charge
of the entrance examinations that many ap-
plicants have been able to gain admission
merely by cramming up in advance, tho
it was found later that they were utterly
lacking in the intelligence that made them
fit subjects for the higher education. The
examinations in future will be along the
line of the famous Binet tests, establishing
the applicant's claims to intelligence and
promise rather than his capacity for re-
membering. These tests will demonstrate
the real quality of mind which the student
presents, his alertness, his ingenuity, his
capacity for intelligent use of knowledge.
They will determine whether it is worth
while spending four laborious years in try-
ing to train him for an intellectual life, for
which he may not be fitted. The test of his
actual knowledge will merely be his record
in the school from which he comes. And
above all, these tests will indicate the special
fitness of the applicant for a particular
career — whether his mental disposition fits
him the better for a future as an engineer,
a teacher, a doctor, a lawyer, or one of
the other professions. They will eliminate
the haphazard choice of a career, the bur-
dening of the brilliant pupil with the drag
of an unintelligent one with whom the for-
mer must keep pace. It is a change that
promises the most gratifying results.
Influenza and the Ostrich* — ^The ostrich
is an extraordinary bird. It is a most naive
creature. By a singular trait of character, it
chooses the moment of greatest danger to
do the most absurd thing. When pursued
by a hunter or an enemy and when it sees
no possible exit or escape, it buries its
head in the sand and assumes the delight-
fully philosophic attitude that ignorance is
bliss. Unquestionably such an attitude is
conducive of a most comfortable and com-
forting state of mind, but it would be rash
to recommend it as a salutary state of body.
One is reminded of the learned rabbi of old
who was confronted with the problem of a
growling dog and was reproved for his
nervousness. *T know that barking dogs
never bite," said the rabbi calmly, "but
does the dog know it ?" And the huntsman,
with leveled gun, unaware of the beauties of
the ostrich philosophy, pulls the trigger and
the ostrich pays the price of his unworldli-
ness.
The Board of Health of the City of New
York, searching the zoological gardens for
a model after which to pattern itself, has
unfortunately selected the ostrich as a type
most worthy of imitation. In view of the
wide range of choice at these gardens, the
selection is inexplicable. Many men and in-
stitutions have gone there for inspiration
and guidance, and the worst that has be-
fallen them has been the acceptance of the
monkey as the most fitting model. It re-
mained for the Board of Health to demon-
strate its originality by honoring the long
neglected ostrich. And, having selected this
worthy bird as its pattern and guide, it has
succeeded in emulating the original with
such fidelity as to arouse wonder and awe
in all who have followed its course. Thus,
one morning recently there were reported
over five hundred cases of influenza and
one hundred odd deaths from pneumonia.
This was by no means an exceptional day,
the figures of late adhering closely to this
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January, 1919
BDITORIAIi COMMENT
American Medicins
total daily. In the minds of most un-
prejudiced men this would constitute a seri-
ous situation, and the one word that would
characterize the situation adequately would
be "epidemic." But the Board, singularly un-
mindful of the facts and their most obvious
interpretation, has dropped that one word
from its vocabulary. Imitating the ma-
neuver of its favorite bird, it buries its head
in the sand and assumes the ingenuous phil-
osophic attitude that ignorance is bliss.
"Danger? Nonsense; I don't see a thing!"
And the huntsman goes on with his deadly
rifle practice.
Now, such strategy would be admirable
and commendable only on one condition : if
the Board means to encourage in the pub-
lic a state of ignorance which it does not
share itself, and if, aware of a danger which
it prefers to keep to itself, it pursues a
severe policy of eradication. But unfor-
tunately it would appear that the Board en-
courages ignorance not only in the public
but actually in itself, and goes blithely along
unaware of the many danger signs along
the path it has taken. It buries its head in
the sand and breathes a sigh of relief. One
can only regret that the Board, in its wan-
derings in the zoological gardens, never
discovered the lion. Certainly that king of
the jungle would serve as a better model.
It has, in moments of greatest danger, a
tendency quite the opposite of the more
spiritual ostrich — it turns and fights, and it
fights well. Hardly a philosophic or lofty
attitude, one must admit, but one often con-
ducive to safety. It is perhaps rash to try
to predict what the spirit of the lion, in-
spiring the conduct of the Board, might ef-
fect, but one may divine that its course
would be something after this manner: it
would divide the city into about five hun-
dred districts. At the head of each of
these districts it would place a competent
inspector, fully instructed and trained in
his duties. This inspector, ever vigilant
for signs of danger, would report all
cases of influenza, and promptly bring
into play all the machinery of the Board
in an eflFort to isolate this source of
danger to the community, protecting the
population and helping the individual at the
same time. Rather blunt and uncomplicated
as plans go, but the mind of the lion is blunt
and uncomplicated. Perhaps a more careful
search would reveal a model even more sat-
isfactory than the lion; but, in any case,
one must conclude that the ostrich has
proved thus far a distinct failure. A rather
regrettable conclusion, for the ostrich is
a really nice bird — when he helps to beautify
a lady's hat.
Prohibition. — ^Among the indirect re-
sults of the World War has been the "con-
quest" of John Barleycorn. After a due and
prolonged struggle, the legislatures of 40
States have ratified the Federal Amendment
and practically only one year more of dis-
tilled and spirituous liquors remains for the
people of the United States. In eflFect, pro-
hibition begins July 1st, unless, perchance.
President Wilson should declare demobiliza-
tion to have been accomplished before that
period, as a result of which, a brief Oasis
would spring forth.
In view of the accomplished fact, dis-
cussion as to the advisability of prohibition
sinks into a subsidiary position. It is proper
to dwell upon the achievement of what
ought to give promise of being a decided
social advance.
The results of the prohibition movement
cannot be judged for a long period of time.
At least a generation that has developed
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American Medicinb
EDITORIAL COMMENT
January, 1919
15
and grown up in a non-alcoholic environ-
ment is necessary before any judgment can
be drawn or scientific opinion held with
reference to the effects of prohibition upon
the general health and welfare of the race.
Will poverty be decreased; will crime be
lessened ; will disease be diminished ? Theo-
retically speaking, one should hope for evi-
dences in positive affirmation of these de-
sired ends. It will take many years to se-
cure the reflection of the improved social
condition, hoped for, in terms of morbidity
and mortality rates. Whether arteriosclero-
sis, nephritis, epilepsy, insanity, malnutri-
tion are to be less common as a result of
soft drinks remains to be demonstrated.
Doubtless there will be manifest some ef-
fects indirectly related to alcoholism upon
conditions such as homicide, venereal dis-
eases, lowered standards of living, and con-
sequent inferior familial development, and
possibly, a favorable decrease in the inci-
dence of accidents in industry. From a
priori conjectures one would expect to find
marked improvement in social welfare, with
consequent benefits to the public health.
Whether this goal will be attained or not is
a matter for future determination.
It is not improbable that complete prohi-
bition will not exist for many years, as long
as the appetite of men for alcohol remains
unassuaged. A new generation growing up,
free from the temptations, and lacking the
opportunity for the satisfaction of a craving
such as their forebearers possessed or, in-
deed, lacking such a craving, will serve as
the best example of the real effects upon
public health and welfare.
So much harm has been attributed to the
consumption of alcoholic beverages that it
will be a matter of unusual interest to com-
pare the statistical material of a non-drink-
ing generation with that relating to past
generations for whom alcoholic drinks have
not been denied. So many factors enter into
the causation of disease, it is difficult to
judge of their relative importance. By the
elimination of one factor hitherto regarded
as quite dominating, it will become possible
to appreciate in a comparative study the real
part it may have played in the production
of misery, sickness, accidents and general
unhappiness in the world.
For the time being, the "drys" have won
the day. Whether their efforts in bringing
about the passage of the national amend-
ment will prove to be the advance desired
is merely a problem whose actual determina-
tion will depend upon the character of the
laws promulgated to insure the enforcement
of the new enactment. It will also deter-
mine whether John Barleycorn is really
dead, or has reverted to a state of sus-
pended animation. The world should be bet-
ter, because of the non-usage of alcohol.
Present-day opinion strongly supports the
view that a social improvement has been
made. The actual basis for this judgment,
its soundness or incorrectness, can only be
determined after the lapse of years during
which careful analyses of social and health
factors will be required.
If 8 What Ton Think!
If you think you are outclassed, you are;
You've got to think height to rise,
You've got to be sure of yourself before
You can ever win a prize.
Life's battle don't always go
To the stronger or faster man.
But soon or late the man who wins
Is the fellow who thinks he can.
— aiinical Medicine.
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MEN AND THINGS
American Medicine
'i^^i=^
EN AND
The Late Theodore Roosevdt* — ^An at-
tempt to classify men on 'broad lines of
character leads to a recognition of two
types : The Hamlet type, given to much re-
flection and little action; and the Macbeth
type, given to much action and little re-
flection. It was the distinction of the late
Colonel Roosevelt that he achieved a vinion
of the two types in a single personality
which is rare in the extreme. He was at
once a doer and a thinker, and each element
in him was developed to an extraordinary
degree. When it was a question of action
there were few men that could anticipate
him, fewer that could bring the same
amount of energy and vigor to bear upon
a task once undertaken. To his intellectual
tasks he brought a quality of mind and a
lucidity of reflective power which was ad-
mirable. Of course, the mistake of the Ham-
let type is that it often does too little, and
the mistake of the Macbeth type is that it
often does too much. The Hamlet in Roose-
velt was not so pronounced as to lead him
into frequent errors of thought, but the
Macbeth in him was dominant enough to
lead him occasionally into 'the mistakes of
that type. "The man who never makes a mis-
take," said Stephen Girard, "never does any-
thing." Roosevelt did a great deal, and he
made mistakes. His meeting with the Kaiser
and his enthusiasm over that pathetic
paranoiac was a mistake. His impulsive at-
tempt to tell the rulers of England how best
to manage their colonial affairs was a mis-
take which brought down the resentment
of the whole British press upon his head.
His bolting of the Republican party in 1912
is considered a mistake by many, a mistake
which was chiefly responsible for the sur-
render of power to the rival party. All this
is true, but on the credit side of his sheet
there is a balance of good work well done
which cannot be denied by even his enemies.
And of enemies Roosevelt had more
than is the average man's allotment. You
can tell a man by his friends, but you can
tell a man equally well by his enemies ; and,
on the side of his foes, political and intel-
lectual, were ranged some of the best minds
in the country. On the other hand he num-
bered among his stanchest admirers and sup-
porters individuals of the highest rank in
every quarter of the republic. He was a born
leader of men, and, as often happens in the
case of a man of such immense personal
magnetism, the enthusiasm he aroused in
some was as warm as the opprobrium in
others was bitter. Few men were ever so
frequent and so heated a subject of con-
troversy as Roosevelt, and that perhaps is
the highest testimonial to the vigor and ful-
ness of his career. No one was ever indif-
ferent to him. They either loved him or
hated him, and that was no doubt precisely
as he wanted it to be. He himself was never
guilty of the offense of indifference. He
either loved people intensely or he hated
them intensely, and he rarely disguised his
feelings out of consideration of tactfulness.
In his eyes the one unpardonable sin, in
action or in thought, was timidity.
It is perhaps too early to presume to
give a just estimate of the man. Time alone
can give the perspective needed for such
a judgment. But it would hardly be rash to
anticipate the judgment of the future and
predict that he will find a conspicuous place
in history, a place that has been occupied
by but few men in the development of our
country. In time the partisan spirit that em-
bittered many men against him will disap-
pear, and the permanent qualities of heart
and mind which the man possessed in so
rich a measure will alone be remembered.
That these have even now come to outweigh
the qualities which have so often been the
subject of dispute may be judged by the
wholehearted grief of the entire nation at
his death. In Roosevelt the country has lost
a great stimulator of thought, its greatest
disciple of action.
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ORiaiNAL ARTICLES
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17
ORIGINAL
RTI C LE S
ADDRESS ON MEDICINE AND
SURGERY.^
BY
ROBERT T. MORRIS, M. D.,
New York City.
Mr, President and Members of the Eastern
Medical Society:
I have been asked to review the subject
of Medicine and Surgery, particularly with
reference to modern methods. In study-
ing anatomy we get at our subject a little
more clearly and interestingly if we begin
with comparative anatomy; consequently
before taking up the subject of the Medi-
cine of Today let us dwell for a moment on
the medicine of the past. You know what
the ancient Egyptians did in the way of
surgery and medicine. You know that even
in South America some excellent surgical
work was done among the ancient Peru-
vians. There is a mystery about their
trephining. No one knows why some of it
was done, because skulls that were appar-
ently perfectly normal have been found
that were trephined. In hunting with the
Indians I have learned that when they kill
a bear they often make an opening in the
skull to let out the bad spirit, tho one would
imagine that it had already been let out by
the bullet; but this may be a tradition that
dates back for centuries, and it is possible
that this idea may account for some of the
'Before the Eastern Medical Society, Decem-
ber 13. 1918.
trephining done in ancient times. That,
however, is pure speculation. However,
away back in the days of. Hammurabi some
surgery was done, for the ancient records
show that Hammurabi supports my claim
that a short incision is desirable in surgery.
He also advises surgeons to have their in-
struments clean. That is very good ad-
vice, dating back 2000 years B. C, and ig-
nored by many after him, for in the days of
my old preceptor, not so very many years
ago, I remember that he washed his hands
after an operation instead of before. We
have forgotten a good deal in the long in-
terval since Hammurabi, for knowledge
comes and goes ; we adopt the part adapted
to our needs and then it goes out of our
minds because of newer and perhaps more
rational methods. Democritus who was
born 460 B. C. believed that disease was
due to minute living particles. Democritus
is said to have blinded himself in order to
have time to think and develop his philoso-
phy and not be disturbed by external im-
pressions that were confusing. At the
present time, while we are again interested
in the subject of disease being caused by
small organisms, I do not know of any
doctors who have blinded themselves in
order to have time to stop and think. It
may be that some part of ancient history,
in point of application, would be desirable
today when we are all in such a hurry to do
everything at once and to do all the work
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in sight. That becomes a very serious
matter for some of us. I find many men
hurrying eagerly and earnestly, not having
time to enjoy life and I sympathize with
them for I find myself in the same position.
Not long ago while walking around on the
farm I found myself looking at a guinea
hen's nest. She had laid so many eggs
that she could not cover and hatch them all,
so she simply sat on all that she could and
let the rest go. I took a lesson from that
guinea hen, and in the crowding demands
of medicine and surgery let us all follow the
same methods — sit on our nest and do what
we can comfortably and let the rest go.
We have passed the stage in medicine
when men were killed for advancing new
theories in science. Why were they killed ?
In those days superstition often took the
place of knowledge as it does today ; but in
those days superstition was more closely
connected with theology and with the
anthropocentric point of view, consequently
anyone who made startling advances was
disturbing some tenet in theology and en-
dangering the souls of the people. It was
on highly moral grounds that the scientists
who made advances were tortured or put
to death.
Next, medicine arrived at the stage where
men were simply, persecuted for making
new advances. Why were they persecuted?
The human mind has wonderful resources
for resisting the introduction of knowledge
into itself. Men arrive at comfortable
conclusions, they agree upon comfortable
conclusions and then proceed about their
daily sins and their daily occupations with
ease; but when some new theory is ad-
vanced which obliges men to rise and Hft
themselves above the conventions, they fear
a certain discomfort and for that reason
they exhibit a certain amount of intoler-
ance at what obliges them to leave their
comfortable* seats of convention upon which
men were agreed. By the time when men
have finally agreed upon any subject, it is
often quite out of date.
Now-a-days a change is taking place,
men are really so eager for new knowledge
that they do not resent the introduction of
a fresh idea, but in their speed are more
inclined to grasp it by one edge and to run
away with it before gathering in the loose
ends, and consequently we have the specta-
cle of men advancing rapidly with quite
incomplete knowledge of a subject; advanc-
ing rapidly, I would say, in gaining the atr
tention of the public and the profession
rather than in classifying data well.
I have just read the introduction in the
very valuable book of Dr. Charles Geiger on
Bone Surgery — osteoplastic work. Dr.
Geiger says that the wonderful advances
that have been made in bone surgery place
it in advance of other branches of surgery
today. I suppose that almost every man
who is engaged in special work of other
kinds would question this point of view;
and yet, don't you see there is something
really very wholesome in it after all ; some-
thing stimulating, something encouraging;
when k man believes that his subject is the
most important one in medicine today, he
is obliged to do such very hard work in
order to justify his belief that he accom-
plishes a great deal more than if he had any
doubts about his position.
The matter of focal infections is one of
the very new subjects of the day which
men are taking up with a great deal of in-
terest but are going ahead perhaps with in-
complete knowledge and not comprehend-
ing the range and scope of the entire sub-
ject ; consequently this subject is falling into
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ORIGINAL ARTICLES
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19
disrepute in certain fields because of the
over-enthusiasm of some of the advocates
of focal infection- theory in relation to dis-
tant demonstration — endocarditis, rheuma-
tism, gastric ulcer, cholecystitis, various
forms of neuritis, etc. The philosopher,
taking all the evidence judicially, will event-
ually give the medical profession the basic
facts and what is valuable in the subject.
Right now one might utter a warning to the
general medical profession against taking
too active an interest in this subject. Hardly
a day passes that I do not see a group of
strong men like a pack of wolves "tearing
away at the tonsils, one on one side of the
question and another on the other side,
and the poor tonsil is torn to pieces. We
do not know where we stand on the subject.
That is not right. The patient has to bear
the consequences of the differences of
opinion. It seems to me that we ought to
have some sort of court to pass judgment
on the findings of the men who are working
so actively in new work. Facts should be
classifiable so that you and I may know
what to say when the tonsils really do ap-
pear to be the cause of infection — as witH
gastric ulcers and endocarditis, for exam-
ple. When we make cultures and find
streptococcus viridans or bacteria that are
known to be dangerous under certain cir-
cumstances, it does not necessarily follow
that the toxins from these bacteria are
causing the distant demonstration in a given
case. It does not even follow that the anti-
bodies called out by the presence of these
toxins for protection are themselves produc-
ing an autolysis which gives us the symp-
toms of the disease. This is certainly true
in some of the cases — in a certain percent-
age of the cases. It is our duty then to say
that a focal infection of the tonsil may per-
haps cause endocarditis, may cause rheu-
matism of the joints, may perhaps cause gas-
tric ulcer by way of selective afl&nity, which
Rosenow has described to us. It is our
duty to find out in what proportion of cases
the toxins are producing such distant
effects and that we must do, not by taking
out all infected tonsils, not by having all
infected teeth pulled out to satisfy our
curiosity in the case but by so far as pos-
sible eliminating one by one aU other factors
and by exclusion getting down to the fair
presumption that any one focus of infection
is producing any one given demonstration.
At the present time the matter of infected
tooth roots is not receiving attention enough,
for the reason that when Rosenow first
directed attention to the subject and Bil-
lings made his excellent clinical observa-
tions to corroborate these findings, other
less careful observers jumped to conclusions
and played havoc with teeth and with ton-
sils which should not have come out. The
focus of infection bringing teeth and tonsils
under suspicion is often in the colon, when
the matter of excluding the colon definitely
has not been taken into consideration.
In our newer work in this field, the
peripheral irritations have been taken up
with enthusiasm and the subject carried be-
yond its natural limits by those who did not
exercise judicial faculties in weighing or
producing evidence. We know that eye
strain will produce distant effects — peri-
toneal adhesions, loose kidney. These are all
peripheral disturbers of autonomic and sym-
pathetic nerves. They register impulses up-
on ganglia and upon brain and cord centers
with demonstration at a distance in many
cases, but we are to very carefully exclude
the cases in which such peripheral objective
signs are present but are not producing the
subjective symptoms of which the patient
complains. A great deal of work has been
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ORIGINAL. ARTICLES
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done wrongly, hurriedly, thus bringing mod-
ern medicine, the medicine of today, into
disrepute because men sometimes place too
much stress on the value of the objective
signs relating to organs or structures which
may or may not produce peripheral irrita-
tion in a given case. The results may be
secondary or in the third role. Peripheral
irritation may produce effects in such a way
that the sympathetic control of the diges-
tive function is disturbed, general metabolic
change is disturbed, and then follows a
series of toxic manifestations which stand
really in the third role — the peripheral irri-
tation having merely allowed incomplete
digestion to occur, causing disturbance of
the alimentary tract, followed by a series
of affections, no one effect being a diag-
nostic entity, everything being in close co-
ordination, every demonstration being in
one category, to be separated analytically
by the really good physician.
With our many specialists today a patient
will have great difficulty in getting into the
hands of the right authority. If I send a
patient to a physician who is a heart spe-
cialist, with a question of heart trouble and
that patient comes back without heart
trouble it is because the doptor was not in.
None of us is ideal ; we all have something
wrong, and almost any specialist will find
something which will occupy his entire at-
tention if any one of us happens to drop
into his office.
Consequently, in our modern medicine,
we need some one guiding hand; we need
the old time physician who was guide, coun-
selor and friend, who would weigh the evi-
dence of all the specialists and reach his
own conclusions and give the patient the
benefit of his wise decision. The medicine
of today, the most of our modern medicine,
is falling into disrepute in the minds of the
laity, for the laity is inclined to go to spe-
cialists without first getting the advice of
the good old family physician — but such a
man is very hard to find today, tho I believe
he is the man of the future when we have
completed one of the customary spiral cy-
cles marking upward social movement.
The subject of endocrine disturbance is
one of the very newest today. Endocrine
disturbance sounds very nice and knowing.
We sometimes feel that in this subject we
shall find a panacea for all ills; yet all
bodily activities are carried on under endo-
crine stimulation. When we have per-
verted function of any of the endocrine
glands, a doctor is prone to come to the
conclusion that he may decapitate the
demon of all the patient's ills by simply
caring for the endocrine gland that is in
evidence. The thyroid gland has received
an undue portion of attention for the reason
that it is in sight. Men forget its connec-
tion with the adrenals, the spleen and
various other organs of the endocrine chain,
because the thyroid is in sight. It is some-
thing like a skull bump.
The older phrenologists ascribed all
human faculties to certain bumps on that
part of the skull which they could feel ; only
those that could be thus determined having
any significance, human faculties, the
phrenologists forgetting that on the base of
the brain there are just as many bumps un-
accounted for. I do not know what they
would say about these, unless to say that
they represent the dual personality.
The study of endocrine disturbance per-
haps takes us into the really largest new
field of today. Under the conditions of
civilization men are reaching cultural
limitations just as other animals and plants
reach cultural limitations under conditions
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ORIGINAIi ARTICLES
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21
of a high degree of cultivation; and when
cultural limitations are reached we then
have arrested development in greater or
less degree; breeding comes to a pause,
various perversions occur and down goes
that variet}' of man which was represented
in the history of nations. We now know
how the ancient civilizations really passed
away — how Rome feU, Egypt, Peru. We
know how France is going today. We
know that in all civilizations the time comes
when cultural limitations are approached as
they are with animals and plants. The New-
foimdland dog, the Morgan horse, the Wil-
son strawberry are passing away. They
reached cultural limitations and are pass-
ing out. The same thing is occurring in
our civilization here. Cultural limitations
are being approached, arrested development
is appearing in larger and larger numbers
of people and with this arrested develop-
ment apparent in physical defects we
find that physiologic responses, functional
in character, are so closely aUied to struc-
ture that when anjrthing is wrong with
structure, function responds; consequently,
in our civilization today we have a larger
and larger niunber of people with arrested
development of certain organs and with a
higher degree of disturbance of function
of the endocrine glands. We may, there-
fore, expect to make more and more mis-
takes along with the recording of new
truths. When taking up the therapy of
the internal secretions, while making ad-
vances, collecting more facts, we come
again to the point where a well balanced
judicial mind is needed in medicine today in
the matter of these endocrine functions and
the matter of endocrine therapy.
What has the war been doing for our
new surgery? Apparently no great new
principles have been brought out in war
surgery. The field of battle is not the
place for developing theories. Theories
come out of philosophy, they come out of
metaphysics applied to data carefully col-
lected by the philosopher, so that perhaps
we should not look for anything revolution-
ary in the way of new work to come out of
this war. But there has been a splendid
opportunity for the application of princi-
ples and out of this war has come a knowl-
edge and perfection of detail in technic and
improvement in methods of procedure
which will be of lasting benefit to the entire
world. We did not know really or appre-
ciate the fact that the Dakin-Carrel method
was enormously valuable, until there was a
violent controversy upon both sides and the
men who believed in the Dakin-Carrel
method had to prove their position by re-
cording facts of such consequence that no
one could dispute the evidence. A large
amount of constructive work has been done,
giving our orthopedists, with osteoplastic
work, an enormous opportunity. I should
not take up the subject of war surgery this
evening, for one thing leads on to another
and a speaker might devote an hour, a week,
or a month to the subject, preferably a
month.
Who is to stand back of the medical pro-
fession when there is need for so much
laboratory work, so much expensive special
work in making up a brief relating to any
one case ? The public must do that. How
is the public to do it? I hope that what I
am about to say now will not lead me to be
shot — hold your revolver until I am thru —
but the cold fact is that a paternal govern-
ment like that of Germany gave us the most
remarkable efficiency in advancing medicine
that has been demonstrated in the history
of the world. The method the(t German
scientists applied to medicine led to magnifi-
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ORIOINAL. ARTICL.es
AMERICAN Medicine
cent advances in medicine and in surgery,
altho the German mind is not intrinsically
superior to the EngHsh, French or Italian
mind. Progress was made by Germany
because of the paternal, autocratic form of
government which had value until it was
taken in charge by an imperial neurotic who
could sign away his people's prosperity. Can
we have anything to take the place of
paternal government? There is the need.
There is the need over the entire world for
the sort of backing, the support, which
paternal Germany gave to its scientific in-
stitutions. In this country we are depend-
ing very largely upon private endowment,
private funds; but no matter how gen-
erously they are given, the public cannot
understand the needs of the medical pro-
fession in science. The generous gift of
the late Captain De Lamar would have to be
repeated many times over, for we need
many times ten millions of dollars for en-
abling our doctors to do for the public what
we wish to do for the public betterment
impersonally, not for ourselves personally.
How about the medical colleges of to-
day? I find that in many of our medical
colleges there is a certain loss of morale, a
certain lack of character, which belongs to
our hurried methods of today. Students
are taught to pass examinations quickly
and well, without regard for - the moral
character involved in the question of their
duty toward the public, which is to follow,
and consequently there is a great deal of
complaint about cheating in examinations
and other evidence of grasping the main
chance, instead of students developing the
point of view toward the profession and the
public which should be given to every young
man in our medical colleges. It is
not the passing of examinations which is
important, but the large idea, the point of
view given by the teachers to the entire
subject of medicine idealistically, which
must be developed in our medical colleges
unless there is to be a still greater
loss of morale and still greater slump
toward commercial thought. This matter
appeals to me very deeply. In looking over
the different medical colleges I find
among the teachers men of the highest de-
gree of scientific attainment, men who are
competent as teachers in their scientific
studies, but they do not set standards or
give the point of view, the outlook on life
which leads the student to become the true,
the great physician, who is to minister to
the wants of the people ; and it is the human
side of the subject rather than the material
side which in the end gives character and
the stamp of high caste.
Recently a father said to me, "I had
hoped to send my son to my medical Alma
Mater, but on looking over the catalog it
seemed to have a dearth of great teachers or
leaders* of thought and to be suggestive of
medical politics."
As a corrective it seems to me that any
medical college teaching faculty belongs
under close supervision of the president of
a university and that medical colleges so far
as possible should be a part of the univer-
sity. The reason for this is because the
university represents our entire social sys-
tem in miniature and the president of the
university is supposed to have in mind the
making of the best citizens out of each one
of his students. His approval or disap-
proval of teachers would have reference to
this point and he would exclude from the
teaching staff some of the men who are ex-
perienced at placing themselves, at the ex-
pense of others belonging to a certain
scholarly group respected by the public for
intrinsic worth but so busily engaged in
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ORIGINAL. ARTICLES
January, 1919
23
their work that they are not experienced in
maintaining position.
All young men are idealists. All young
men look to their teachers for the setting of
such high examples that students may go
forth into the world equipped as physicians
who will do their best toward the public
and toward each other. Unless this matter
is taken into serious consideration in all of
the medical colleges today in this country
we shall not maintain our status as we
should in the estimation of the public, which
has a way of arriving at right conclusions.
In closing, I would say this : All present
day physicians — all of the younger men and
the older men — see before them such an
enormous amount of work which should be
done if they are to stand abreast of the
times that the tendency is for them to take
their work too seriously. They are very
apt to lose the finer side of human nature
which goes with broad interest in many
things. No one physician here can com-
prehend the entire subject of medicine; no
one can do the very best that can be done
for all of his patients. It is well for a
doctor to have human interests in many
things outside of his profession — art, litera-
ture, music and the beautiful things in life
— because we are here only once ; we are not
here for a long time, and if we do not lead
a delightful life here I do not know when
the next chance will come. I have a clergy-
man friend who tells me not to worry about
this, but those of us who are practical men
I believe should make an effort, while be-
coming high caste physicians, to try to lead
an ideal life ; and every doctor should stop
and ask himself from time to time: Am I
leading an ideal life, the sort of life which
I wish my son to lead ?
616 Madison Avenue.
MEDICAL VERSUS MEDDLESOME
GYNECOLOGY/
BY
ARNOLD STURMDORP. M. D.. P. A. C. S.. etc.
New York.
Medical gynecology, or more specifically,
medicinal gynecology, is a relic of the days
when "Obstetrics and the Diseases of
Women and Children" constituted a single
department in the medical curriculum of
our colleges.
The operative furor, initiated by the
Listerian epoch, with its multifarious sins
of commission, was naturally superseded
by a reactionary conservatism, which, tend-
ing to the opposite extreme, rehabilitated
and perpetuated certain therapeutic meas-
ures in gynecology, embodying sins of
omission, that cannot be defended on any
established physiologic, pathologic or clin-
ical basis.
There is an undeniable but very limited
field for legitimate medical gynecology be-
yond which, any drug treatment, whether
local or systemic, constitutes meddlesome
tinkering.
Every rational therapeutic attempt must
be based, as far as possible, upon a clear
conception of its aim and scope; empiri-
cism has lost its place in the treatment of
gynecopathic manifestations.
As an example, let us choose the most
frequent and familiar symptom of gynecic
disorders, namely, leucorrhea, and analyze
the utility of routine treatment by medicated
douches, tampons, caustics, dilatation,
curettement, etc., in fulfilling established
pathologic indications.
The acute irritative phases of this mani-
festation may and should be successfully
* Read before the New York Physicians' Asso-
ciation, Oct. 27, 1918.
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January, 1919
ORIGINAL ARTICLES
AMBftlCAN MB>ICINB
palliated by topical medication, but no
method of topical medication can perma-
nently cure a chronic leucorrhea because
every chronic leucorrhea presents the out-
ward expression of chronic endoccrvicitis
resulting from an infection of the deeply
imbedded racemose muciparous tufts in the
endocervical mucosa.
Chronic endoccrvicitis is the most prev-
alent and its manifestations comprise the
most familiar symptom-complex among
gynecologic disorders. It constitutes a
concrete clinical entity of pathogenic poten-
tialities which may menace the integrity of
the entire gynecic system; nevertheless, it
is accorded no special consideration as such
in the current text-books, where its de-
scription is scattered among various chap-
ters as an incidental feature, under captions
such as "cervical catarrh," "simple fol-
licular or papillary erosion," *'eversion,'*
"hypertrophy," etc., all of which depict only
different phases of the same pathologic
process, the course and nature of which are
obscured by perpetuated misconceptions
that dominate a most ineffectual therapy.
In structure and in function a sharp line
of demarcation differentiates the cervical
mucosa from the corporeal endometrium.
Physiologically, the cervical canal pre-
sents nothing more than a passive com-
municating channel between the vagina and
the uterine cavity proper. The cervical
mucosa, composed of deeply penetrating
racemose glands, simply secretes mucus;
it does not participate in the cyclic meta-
morphoses of the corporeal endometrium
essential to menstruation and deciduation;
but more significant than this structural
and functional contrast is the striking dis-
parity in pathologic manifestations dis-
played below and above the internal os.
The cervical mucosa evinces a marked
susceptibility to infection, while the cor-
poreal endometrium, contrary to orthodox
conception, is practically immune ; in short,
the cervical mucosa might be aptly termed
the uterine tonsil.
Omitting the detail of laboratory evi-
dences, it will serve all practical purposes
to state that at present most pathologists
interpret the histopathic features of "chronic
endometritis" as normal endometrium, in
the transudative phase of its menstrual
cycle, and while the existence or non-exist-
ence of chronic corporeal endometritis is
still a matter of academic controversy, clin-
ically at least, the condition may be safely
discarded.
Nevertheless, the cardinal symptoms of
chronic endoccrvicitis, namely, the abnor-
malities in menstruation and deciduation,
point so directly to involvement of the cor-
poreal endomertium that their occurrence
in the absence of endometritis demands
elucidation.
To correlate the pathology and symp-
tomatology of chronic endoccrvicitis, we
must revise some current conceptions of
the myometrial structure and its dynamics.
The specific functions of the uterus in
menstruation aiid gestation demand a wide
range in the control of its blood supply and,
like the heart, the uterus automatically re-
sponds to its fluctuating circulatory neces-
sities by rhythmic contractions and dilata-
tions, not only during pregnancy but, thru-
out its functional existence.
The myometrium is composed of smooth
muscle fibers which, like all non-striated
muscle, exhibits the intrinsic phenomenon
of rhythmic contraction, independent of any
neurogenic stimuli. Not only are these
contractions necessary in maintaining the
nutritional and functional integrity of the
uterus as a whole, but they also serve the
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25
equally essential purpose of drainage; the
cervical secretions must find free egress
from the normal and more especially from
the diseased conditions of its mucosa.
Under normal conditions, such drainage
is effected, not merely by a passive out-
flow thru a patent os but, by the active
rhythmic expression resulting from uterine
contraction.
To comprehend this mechanism, it is
necessary to dispel the anatomic myth of a
cervical sphincter; such a sphincter would
imply the existence of a concentrically con-
tracting muscular ring; the structural de-
sign of the cervical musculature precludes
any concentric closure of its outlet which
dilates with every uterine contraction, be-
cause its fibers, directly continuous with
those of the corpus uteri, do not at any
point completely encircle the cervix, but are
disposed in a serried succession of oblique
circle segments which, by .contracting
spirally upward, necessarily shorten every
diameter of the uterus, and by their un-
coiling in th^ cervix widen the os like an
iris diaphragm in a microscope.
In the cervix, as elsewhere, every infec-
tion incites the greatest reaction in its
lymphatic system.
The cervical lymphatics may be traced
from their lacunar origin in the mucosa,
thru minute funnel shaped ostia, directly
to the muscular coat, where they expand
into an extensive capillary net which,
spreading along the perimysium, enmeshes
every fascicle and bundle of the uterine
musculature to the peritoneal surface,
whence they drain into their collecting
channels at the base and top of the broad
ligament.
Thus the normal course of the lymphatics
conveys an infection from the cervical
mucosa, not to the corporeal endometrium
but, along the intramuscular planes of the
uterus as an ascending lymphangitis, which
impairs uterine contractions by infiltrating
the muscle sheaths ; then progressing to the
periadnexal ramifications, it inhibits tubal
peristalsis and agglutinates the fimbrial
ostia by the production of velamentous
bands; finally reaching the ovaries, it in-
filtrates their tunica albuginea, impeding
the normal rupture of graafian follicles.
It is this ascending intramuscular lymph-
angitis and periadnexitis, with its resultant
impairment of uterine, tubal and ovarian
functions, not an endometritis, that links
the pathology and symptomatology of
chronic endocervicitis.
The dominating pathologic factor that
determines the morbidity of a cervical
laceration is not the extent of the tear but
the incidence of its infection. Such an in-
fection does not remain limited to the
lacerated area, but sooner or later involves
the entire endocervical mucosa from the
external to the internal os.
In the treatment of chronic endocervi-
citis, the failure of prevailing therapeutic
methods offers the most convincing evidence
of inadequate fundamental concepts. ,
Chronic endocervicitis is primarily and
essentially an infection of the deeply
situated terminal tufts of the endocervical
muciparous glands. These glandular sac-
cules harbor the infecting organisms for
years or a lifetime. Their distention from
duct occlusion produces the familiar Na-
bothian cysts, which may honeycomb the
cervical structures or, becoming purulent,
riddle it with miliary abscesses.
It is an axiomatic surgical principle, in
the control of alt infectious processes, to
direct our therapeutic aim at the primary
focus of infection. In general and special-
istic practice, the escharotic, the dilator and
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the curette still hold sway as established
routine measures, especially for the chronic
endocervicitis in the nullipara. Mild
escharotics and discriminate dilatation, by
promoting drainage, may prove of some
benefit in very superficial infections, but
curettage cannot be too emphatically con-
demned in any case.
The curette does not and cannot reach
the deeply situated infected racemose tufts
of the muciparous glands in the cervical tis-
sues, and it should not injure the utricular
tubules of the corporeal endometrium,
which is rarely, if ever, involved in the dis-
ease, and whose specific functions in men-
struation and gestation have been perma-
nently vitiated by the lacerations and in-
oculations incidental to this time-honored
traumatism.
The only positive evidence of chronic
corporeal endometritis that I have ever
seen, came from uteri that had been
cauterized and scraped from one to several
times.
To cure endocervicitis, we must remove
the entire infected endocervical mucosa.
While endocervicitis persists, its symptoms
must j)ersist.
The operation of trachelorrhaphy was
originally based on the conception that the
local and general manifestations of torn
cervices resulted solely from gaping flaps,
and that a cure of the condition demanded
nothing more than a plastic closure of the
gap.
The operation reproduces the original
area of laceration and unites its edges by
suture. It is obvious that the curative
scope of this procedure is thus limited to
the cases in which the infection has not ex-
tended beyond the lines of the original
tear — ^a rare condition, for we know today
that the functional disturbances following
cervical lesions which demand surgical in-
tervention signalize the infectious invasion
of the entire breadth and depth of the
cervical mucosa, and that the conservation
of the invaded areas, within the cervical
canal beyond the lacerated edges, is pro-
ductive of surgical failures.
On the same lines, a partial or low am-
putation of the cervix eliminates only a part
of the diseased cervical mucosa, while a
complete or high ablation of the entire cer-
vix for chronic endocervicitis is an unwar-
ranted mutilation of its muscular mecha-
nism.
When a cervix splits during labor, the
rent runs practically in the direction of its
muscle fibers. When the cervix is ampu-
tated, its muscle fibers are severed trans-
versely. The spontaneous tear, unless in-
fected, exercises but little influence on the
muscular mechanism, while the transverse
ablation destroys it completely.
To summarize briefly, the cure of a
chronic endocervicitis productive of local
and general manifestations, whether in the
nulliparous or multiparous cervix, demands
a complete enucleation of the entire endo-
cervical mucosa, the preservation of . its
muscular structure and the accurate re-
lining of its denuded canal.
In a previous article on "Tracheloplastic
Methods and Results," I have submitted an
operative procedure which fulfills the patho-
logic indications and technical demands as
enumerated. Four years of added ex-
perience, in my own service and that of
others, have tended only to justify its
claims and substantiate the validity of its
fundamental principles.
Tuberculous Adenopathies. — Radio-
therapy properly applied invariably exerts
a most favorable eflFect in tuberculous adeno-
pathies in the various stages of the disease.
— Med, Times.
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27
RAPID RECOVERY IN A CASE OF
ACUTE ANTERIOR POLIOMYE-
LITIS (LANDRY'S TYPE) WITH
SOME REMARKS ABOUT NOMEN-
CLATURE.
BY
CHARLES W. BURR, M. D.,
Professor of Mental Diseases, University of
Pennsylvania, Philadeiphia, Pa.
It is impossible to make, during the acute
stage of infantile spinal palsy, save as a
guess, a prognosis as to life or as to the ex-
tent and severity of the palsy which will re-
main thruout life. High fever does not in-
crease, nor slight fever decrease the chance
of severe and lasting palsy, and even the
severity of the other acute general symptoms
is of little value in forming a judgment as
to what the result will be. More than a
few children go to bed only a little sick,
with slight headache, backache and muscle
ache, or indeed no pain, and a little fever,
and next day are found to have a total palsy
of both legs or more rarely of legs and
arms, and often are left with one extremity
atrophied and more or less paUied for life,
while other children, seemingly more seri-
ously ill, have but little palsy. In other
cases the palsy comes on only after days
of severe illness with quite high fever. A
high cell count in the spinal fluid is of prog-
nostic import, increasing- greatly the serious-
ness of the outlook. Diagnosis, and conse-
quently prognosis, is made more difficult
because the disease may run its course
without palsy, indeed, without any cerebro-
spinal symptoms. During an epidemic,
spinal puncture should always be made and
the fluid be microscopically examined in the
case of every child acutely ill. Thruout the
illness the extremities should be examined
repeatedly to discover if palsy be present.
Too often, physicians in treating sick chil-
dren are so absorbed by thinking about the
fever, the bowel conditions and the like,
that they do not notice a paraplegia or even
the entire loss of the use of the arms. Also
the parents should be warned at the first
visit what may occur. It is better need-
lessly, as it may turn out, to worry the
parents than to have them suddenly dis-
cover that a child whom they did not think
seriously ill is palsied.
Our conception of infantile palsy has
widened greatly. Only recently has Lan-
dry's paralysis been included in the concep-
tion of the disease, and some authorities
still claim it to be a distinct and separate
disease entity. Since, however, in the 1916
epidemic cases occurred here and there pre-
senting the clinical picture of Landry's
paralysis, namely, a purely motor palsy be-
ginning at the feet and ascending, without
anesthesia, with only slight pain, with ab-
sent knee jerks, without muscular atrophy
and with death following involvement of
the respiratory centers, it is safe to conclude
that Landry's paralysis may be identical in
causation with anterior poliomyelitis, even
if other poisons may also act to produce a
similar picture. In other words, Landry's
palsy may have one or several causes, but
one is surely the same as that causing acute
anterior poliomyelitis. What was the caus-
ative factor in Landry's own case we shall
never know. We only know that there was
no gross disease of the spinal cord, no
myelitis. Whether there were cellular
changes in the spinal cord such as can now
be seen, because methods of examination
have been improved since Landry's day, or
whether there was a peripheral multiple
neuritis, it is impossible to tell.
I give my patient's history briefly. A
male mulatto fairly intelligent, 27 years old,
of good constitution, not alcoholic and free
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from active syphilitic taint at the present
time, as is confirmed by a negative Wasser-
mann test of both blood and spinal fluid, tho
he gives a history of chancre six months
ago. His family history is negligible ex-
cept that both parents had white blood
which is of some interest because anterior
poliomyelitis seems to be infrequent in the
negro.
After having had headache, cough, hot
and cold flashes, without any definite chill,
and a feeling of malaise for about two
weeks (he had no medical attention and
does not know if he had fever, tho his de-
scription indicates he had a little rise in
temperature) he was seized on 1-1 5-' 18
with fever and quite severe pain in the
right knee joint which sent him to bed but
lasted only a few hours. Next day, how-
ever, his legs became so weak, the palsy be-
ginning in the ankles and ascending, he
could not stand and on the third day his
hands, and later in the day his arms, became
so paralyzed he could not move them. He
suffered slight and transitory pains in the
arms and legs for a few hours at the outset
of his illness. Thruout the course of his
illness he had no difficulty in controlling the
bladder and rectum and no paresthesia or
anesthesia.
He was brought to the Philadelphia Gen-
eral Hospital, where I first examined him,
on 1-23-18. There was then a flaccid
palsy, complete in extent and total in sever-
ity, of the arms and legs, of the parietal ab-
dominal, and thoracic muscles. Breathing
was diaphragmatic but there was no dis-
order of speech or difficulty in swallowing.
The neck muscles were a little weak. The
cranial nerves all performed their functions
well. Sensibility to touch, pain and tem-
perature were normal over the entire body.
The knee, biceps, Achilles, and abdominal
jerks were all absent but the cremasteric
was present on both sides. The plantar jerk
was also absent but that is not significant,
because it is often not present in healthy
people. There was of course no ankle
clonus. The temperature was normal.
There was no pain on pressure over the
nerve trunks. There was some slight en-
largement of the lymph glands thruout the
palpable portions of the body. The heart
and lungs were normal save that both apices
gave signs of a possible incipient tuberculo-
sis. The urine was normal. Three days
later (1-25-48) he began to be able to flex
and extend the left thumb a little. By
l-30-'18 he could raise his right hand to the
mouth but was too weak to hold anything.
On 2-1 -'18 he could raise both arms and
weakly use the hands. He then, only after
function had been quite a little regained in
the arms, began to regain power in the legs
and on 2-19-'18 could manage to get out of
bed and into a chair. On 2-28-'18 he had
largely recovered motor power, or rather
extent of movement in all extremities, but
was easily tired on using his hands, and
could not walk without fatigue for more
than five minutes. He was discharged
shortly after, entirely well. He had no
fever during his stay in the hospital, and
tho for a time his muscles grew more and
more soft, there was at no time any local
atrophy. His reflexes were still absent at
the time of his discharge and probably will
never return.
I am strongly inclined to the pathologic
diagnosis of multiple neuritis rather than
acute anterior poliomyelitis, in the etymo-
logic meaning of the word, because of the
complete restoration of function. It is
hypothetically possible that the anterior
horns may be poisoned without any inflam-
matory destruction of cells, but with a palsy
as widespread and complete as in this case,
one would expect a destructive lesion and
destroyed cells are not recreated; greatly
inflamed nerves often are. Pain along the
nerve trunks is also of diagnostic impor-
tance. When I first saw him I gave (to
myself) a very bad prognosis. I diagnosed
an ascending anterior poliomyelitis and ex-
pected it to reach the respiratory centers
rapidly and to cause death.
The interesting point in the case is the
quick recovery with complete restoration of
function, only forty- four days elapsing be-
tween the beginning of palsy and complete
recovery — recovery so complete that he
could labor. A point of scientific interest
is the continuance of the absence of the
deep reflexes. This often occurs in in-
fectious neuritis, e. g,, in diphtheria the
knee jerk may continue absent many years
after the acute illness, in fact for life; even
in cases without palsy of the legs, and long
after recovery from arsenical and alcoholic
neuritis it may be impossible to elicit any
of the deep reflexes.
The lesson my case teaches is, never to
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give an absolutely bad prognosis no matter
how widespread the palsy, barring of course
respiratory involvement from invasion of
the respiratory centers. It should also be
remembered diat the improvement of the
palsy may continue for many months even
without treatment. I am beginning to
doubt whether electric stimulation plays a
large, or even a small, part save as it exer-
cises the muscles, in this late improvement,
but local massage and passive exercise of
the individual muscles does help a great
deal. Furthermore the patient should be
encouraged to try voluntarily to contract
the muscles in which even . only a little
power remains.
Our recently acquired knowledge has
changed and widened our conception of
the disease and a new name is needed for it.
To speak of acute anterior poliomyelitis,
when the lesion may be in the peripheral
nerves, the spinal cord, the medulla, or the
brain, and to speak of infantile palsy when
the patient may be a middle-aged man, is
confusing to students and inaccurate. To
call a disease palsy when there may be no
palsy is absurd. The earlier conception
of the disease was based on the post mortem
findings in patients who died of other dis-
eases years after the attack and in whom
there had been residual palsies needing the
attention of orthopedists and neurologists.
Further the patients all had had the acute
attack in childhood. The lesion found at
autopsy, a mere scar one might say, was an
atrophy of the cells of the anterior horns
of the spinal cord; hence the pathologic
designation, acute anterior poliomyelitis and
the clinical name, acute infantile palsy.
Since it has been discovered that the acute
lesion may involve the gray matter of the
medulla and of the cerebrum as well as the
spinal cord and that adults, tho less fre-
quently than children, are affected, and
since it has been proven that multiple neu-
ritis may present a similar clinical picture,
and finally, since it has been established
that the poison may not attack the nervous
system at all, but causes only general symp-
toms, we certainly need a more accurate
name. If it should finally be proven that one
specific organism causes the disease, the
naming would be easy ; give the bacterium a
name connoting nothing and call the disease
after it, but there is still doubt in the minds
of some investigators whether only one or-
ganism is guilty. One of the things which
creates doubt is the fact that in the present
epidemic of influenza, so called, there have
been occasional cases of palsy clinically in-
distinguishable from acute anterior polio-
myelitis, which indicates either that more
than one microorganism may cause identical
lesions and therefore similar symptoms, or
that, mixed with several other, and there
are several, organisms sweeping the country
today is the microorganism of infantile
spinal palsy. In any event we need some
other designation for the disease than those
in use at present.
THE END RESULTS OF TUBERCU-
LIN TREATMENT IN CHRONIC
PULMONARY TUBERCULOSIS.'
BY
HENRY L. SHIVELY, M. D.,
Professor of Clinical Medicine, Fordham Univer-
sity; Consulting Physician to Loomis and
Stony Wold Sanatoria; Visiting Physi-
cian to St. Joseph's Hospital for
Consumptives, New York City.
It is now twenty-eight years since the an-
nouncement of the discovery of tuberculin
by Robert Koch in 1890, and out of the
mass of conflicting evidence as to the status
of this much debated therapeutic agent
there has crystalHzed an opinion favorable,
on the whole, to its value in selected cases,
based upon the experience of many observ-
ers in widely different fields of clinical med-
icine. If we dismiss the extravagant hopes
that were entertained soon after the an-
nouncement of its discovery, its reckless ad-
ministration in large doses, and its careless
use in incompetent hands, it is apparent
that from the beginning we possessed in
tuberculin a remedy potent alike for good
or evil. But is not this equally true of
digitalis, strychnia, arsenic and other power-
ful drugs of demonstrated value?
^ Presented at a stated meeting of the Medical
Association of the Greater City of New York,
November 18, 1918.
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Tuberculin is today in general use in all
well conducted sanatoria, and there is a
substantial agreement among sanatorium
physicians that patients who have received
tuberculin treatment are less likely to re-
lapse after arrest of their disease, that they
more readily regain working efficiency, they
more frequently lose their bacilli, and their
restoration to health is more permanent
after a period of years than that of pa-
tients under similar conditions and in simi-
lar stages of the disease who do not receive
specific treatment. The fact that surgical
tuberculosis involving bones and joints,
tuberculosis of the eye, lesions of the skin,
as lupus, favorable changes in which are
more readily appreciable than in tuberculo-
sis of internal organs, very generally show
striking improvement under tuberculin,
would cause us to consider it not improbable
d priori that similar favorable results might
be expected in the lungs. In reviewing
the recent literature of tuberculin one is
struck by the favorable testimony of the
ophthalmologist, the orthopedic surgeon,
and the dermatologist who have an oppor-
tunity to actually see, in local tuberculous
lesions of their special fields, the striking
effects of tuberculin treatment. The laryn-
gologist is more skeptical as to the good ef-
fects of tuberculin, and this I attribute to the
fact that the secondary tuberculous lesions
he sees in the larynx are so often terminal
complications of advanced disease in the
lungs. These cases are wholly unsuited
for tuberculin treatment. In cases of tu-
berculous adenitis of the cervica and axil-
lary glands, often causing disfiguring de-
formity, the effects of tuberculin adminis-
tration are also often brilliant and plainly
evident.
It should be remembered that tuberculin,
which in itself has no direct curative prop-
erties, is in no respect like diphtheria anti-
toxin or therapeutic vaccines, but is an ac-
tive immunizing agent dependent for its
useful effects upon its power to stimulate
the production of antibodies, protective sub-
stances produced within the body itself,
which render its tissues unfavorable to the
growth of tubercle bacilli or perhaps di-
rectly inhibit their pathologic effects.
It is apparent then, that for the produc-
tion of good results from the administra-
tion of tuberculin it is necessary that there
should be not too great a depression of the
normal physiologic functions, a limitation
which at once removes from the scope of
possible tuberculin treatment a large class
of cases. Patients with severe mixed infec-
tion or with grave complications, such as
nephritis or diabetes, cases of acute miliary
tuberculosis, rapidly advancing cases of pul-
monary tuberculosis with areas of softening
and recent cavities, and advanced laryngeal
cases, patients with organic heart disease
with broken compensation, and cases com-
plicated by suppurating sinuses with amy-
loid visceral changes, cannot be expected to
react favorably to tuberculin. On the other
hand, many incipient and early favorable
cases do sufficiently well with the ordinary
dietetic and hygienic treatment under the
strict medical supervision of their mode of
life, which can usually be best obtained in a
well conducted sanatorium. Whenever it is
possible I send my tuberculosis patients to a
sanatorium with the expectation, not of a
definite cure in many cases, but that the
patient will become familiar with, and learn
by precept and example the principles to be
followed in the long, hard fight he is to
make in order to get well and keep well.
The patient who has been to a sanatorium
is always a better patient, he is more amen-
able to discipline, realizes the formidable
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31
nature of his disease, and is better equipped
to cooperate with his physician in overcom-
ing it. Relatively few patients, however,
can remain at the sanatorium long enough
to obtain a definite arrest or cure, and it is
for these discharged sanatorium patients,
who have been educated and trained in
the anti-tuberculous life, that the tubercu-
lin treatment is often especially indicated to
maintain the improvement they have made,
and in some cases complete their cure.
In general the special field for tuberculin
administration is in that class of cases hav-
ing good resistance without fever, who have
attained a fair degree of improvement with
the ordinary dietetic and hygienic treatment
at home or in the sanatorium, but who have
failed to go "over the top" and attain an
arrest or cure of their disease. It is in these
cases that we often see results which can be
regarded as brilliant by the most conserva-
tive clinician. A cautiously increased course
of tuberculin therapy will often impart the
necessary impetus to cause the patient to
lose his bacilli and attain a definite arrest.
Twelve years ago at the Presbyterian
Hospital and in my private practice I began
to select cases for tuberculin administration,
chiefly among patients who had received
previously the advantage of sanatorium
treatment, but who had failed to obtain a
cure. It is evident that this class of cases
offers a severer and fairer test of the value
of tuberculin than patients who, coinci-
dently with removal to the country, in an
adequate sanatorium environment, receive
the tuberculin together with rest, a proper
diet, freedom from care and change of
climate. It seems reasonable to assume
that after patients have had, for periods of
time varying from one to two years, the
usual dietetic and hygienic treatment and
then, with everything going on as before
except the addition of tuberculin, show a
quick response and a definite favorable
change, that the improvement is attributable
to the tuberculin and the tuberculin alone.
I first used Koch's old tuberculin, but
for seven years have employed exclusively
Bazillen emulsion, which I believe to be
the best therapeutic preparation, as it con-
tains not only the extractives of Koch's old
tuberculin, but also all the substance of the
bacillary bodies, and is to be preferred in
every case to those tuberculins from which
the alleged injurious substances are claimed
to have been removed. We are not suffici-
ently familiar with the chemistry of the
tubercle bacillus and its derivatives to be
able to remove the reaction-producing sub-
stances without impairing its therapeutic
value. The whole subject of tuberculin ad-
ministration has been invested with a too
elaborate technic, and has discouraged
the general profession from the trial of a
simple method of treatment which is full of
potential benefit for many patients. Sahli,
Weicker, and Koch himself urged that tu-
berculin should not be limited exclusively
to sanatoria and the practice of specialists,
.but should be used more extensively by gen-
eral practitioners of medicine. The time
has certainly arrived when every tubercu-
losis clinic at least should have its tuber-
culin class. The well established principles
of treatment now generally followed, the
proper selection of cases, the not too rapid
increase in dose, and the sedulous avoid-
ance of reactions surely are not difficult to
achieve, and I can see no reason why any
well trained physician, who is capable of
administering vaccines or diphtheria anti-
toxin, is not also competent, with the exer-
cise of good judgment and the necessary
patience, to give the tuberculin treatment.
While care should be taken to avoid too
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large or too rapidly increased dosage, much
time may be lost by beginning with or con-
tinuing too long excessively minute and
meticulous doses. It is quite probable that
doses of 1/10,000,000 or even 1/1,000,000
of a gramme, as sometimes employed, are
practically as inert as water. With an adult
I have usually employed a beginning dose
of 1/10,000 to 1/5,000 c.c. of Bazillen emul-
sion as it comes from the laboratory, and I
have never seen a reaction or unfavorable
symptom of any kind with this beginning
dose. The proper dilutions are made with
sterile normal salt solution with one-half
per cent, phenol as a preservative.
Beside the regular routine effects, which
in favorable cases are gradually obtained
from tuberculin over a long period of time
and which are perhaps not very striking,
but are after all of great importance for
the patient who may thereby attain an
arrest of his disease, there are the occa-
sional spectacular results, all too few in
number but which every one who has much
to do with tuberculin sees at times. I have
selected a number of such cases for brief
citation from my case records.
Case I — Jennie M., aged seventeen years/
came under my care May 1, 1908. Her mother,
two maternal aunts, and an uncle had died of
consumption and another uncle was ill with the
same disease. She had typhoid fever seven
years previously and had coughed for several
years with purulent sputum, hemoptj^is, chills,
fever, profuse night sweats, loss of flesh and
strength, dyspnea, poor appetite and amenor-
rhea for two months. She was pale, ill nour-
ished and stoop shouldered. There was marked
dulness and diminished hreath sounds over
hoth upper lobes. Afternoon temperature 99.4''
to 100.8** F., pulse 100, respirations 22, weight
103 1^ pounds. No tubercle bacilli in sputum.
By October, she had made, under dietetic and
hygienic treatment, a gain of eight and one-
half pounds in weight, but numerous rftles were
present over the right apex. In December, she
had a small hemorrhage, and in February
bacilli were detected in her sputum. From
March to October she was at the Adirondack
Cottage Sanatorium, where she improved con-
siderably in spite of one large hemorrhage.
During the winter of 1909-10 she did badly and
was kept in bed for several weeks, during which
time her temperature ranged between 101'' and
102" F. After her fever had subsided, altho
she was not considered a very favorable case
for the treatment, she was given injections of
old tuberculin and made a surprising improve-
ment She received thirty-one injections in
all; her cough and expectoration gradually dis-
appeared, her temperature became quite normal
and her hemoptysis ceased. The summer she
spent in the country and on her return in No-
vember she stated that for four months she
had not coughed at all and it was impossible
to obtain a specimen of sputum for examination.
Dulness persisted over both upper lobes, but
she had no rftles. In December, 1911, her im-
provement had been maintained, she was free
from symptoms and for the past four years she
had had good health and has been regularly
employed as a bookkeeper.
Case II — Amelia M., aged twenty-two. Family
history negative as to tuberculosis. She had
measles as a child, no important illness since.
She first came under observation June 12,
1908, with a history of cough of six months
duration, purulent sputa, hemoptysis, loss of
flesh and strength, fever afternoons, night
sweats for three months, pains in the chest;
fair appetite, but poor digestion, menstrual
function regular.
On physical examination, pale, poorly nour-
ished, marked dulness and broncho-vesicular
breathing, increased whisper over both upper
lobes; over the left behind, pleuritic friction
sounds. Temperature 101" F., pulse 126, respi-
rations 22. Weight S7% lbs. Six months pre-
viously she weighed 100 lbs. Tubercle bacilli
present in the sputum. She was put on dietetic
and hygienic treatment and improved consid-
erably as regards cough, expectoration and
temperature. On December 8, 1909, her gen-
eral condition, however, was not very satis-
factory. Temperature 98.4" F., weight 99 lbs.
Tuberculin injections beginning with V,t mgrm.
were begun March 9, 1910, were continued
twice a week and increased up to 9^ mgrm.
as a maximum dose. She had 66 injections in
all. Tubercle bacilli disappeared from the
sputum. November 15, 1910, on physical exam-
ination there were dulness and broncho-vesicular
breathing over both upper lobes, more marked
over the right. No cough or expectoration and
she feels much stronger. Temperature 98° F.,
pulse 72, weight 105. Under date of December
30th, her marked improvement has continued
and she considers herself well.
Case III— An inspector in the park depart-
ment, aged thirty-flve years, had a cough for
eight months with purulent sputum, loss of
flesh and strength, chills, fever, night sweats,
dyspnea on exertion, and one week befere com-
ing for examination on March 22, 1910, he spat
up a small quantity of blood for the first time.
He had lost twenty pounds in weight and bacilli
were present in his sputum. There were dul-
ness, broncho-vesicular breathing, whispering
bronchophony and fine rales at his right apex.
His afternoon temperature was 99" F., pulse
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ORIGINAL. ARTICLES
Januaby, 1919
33
102. He was unwilling to leave his work to
take sanatorium treatment and, on March 31st,
tuberculin treatment was started with an in-
jection of V»*, gm. of Bazillen emulsion. Injec-
tions, twenty-three in all, were continued twice
a week, the dose being gradually Increased up
to a thirtieth gm. June 14th, the date of his
last injection, he had gained twenty-five and
one-half pounds, his rftles had disappeared, tem-
perature was normal, he had lost his cough and
expectoration and he considered himself per-
fectly well. He was examined again In Novem-
ber and frequently since; he has had no recur-
rence of his former symptoms and all that re-
mains of his morbid physical signs is a slight
residual dulness at his right apex. His cure
has been maintained for more than eight years,
during all of which time he has been at work.
Case /y— In October, 1911, a daughter of this
man, aged fifteen years, came to me on account
of small hemoptyses which she had had for
five days, slight cough and morning sputum
which had lasted for several months. When
six years old, she had an abscess in the neck.
She had slight dulness and increased breath
sounds over the right apex and posteriorly over
both apices fine rftles were heard. Evening
temperature 99" F., pulse 120, weight 106
pounds; no bacilli in sputum. She received
tuberculin treatment twice a week from October
2l8t to February Ist. She had then lost her
cough and expectoration, gained seven and one-
half pounds, had normal afternoon tempera-
ture, rftles cleared up and she felt very well.
She was examined again in March when her
condition was unchanged and she has reported
to me at intervals since. For more than five
years she remained in good health, until in
July. 1917, she was killed in an automobile
accident
Case y—November 21, 1910. Julia O'B., age
38; married. Father and a sister died of con-
sumption. Has always been well except for
present illness. Two years and a half ago had
a profuse hemorrhage and two years before had
a suppurating gland in the left side of the neck.
For more than two years she has had a slight
cough, with scanty mucopurulent sputa. No
loss of flesh or strength; no chills or fever; no
night sweats. Is somewhat short of breath on
exertion. Appetite good; digestion excellent;
menstruation regular. Was at a tuberculosis
sanatorium in Sweden for two months a year
ago. Was at Stony Wold for six months and
was discharged last August.
P. E. Fairly nourished; good color; dulness,
broncho-vesicular breathing, increased whisper,
exaggerated vocal fremitus, subcrepitant rftles
over both upper and right middle lobes. Signs
extend lower over the left. Temperature 98.6* ;
pulse 90; weight 136%. Has been sleeping out
of doors in Morrlstown, N. J., since leaving the
sanatorium. T. B. present in sputum.
On February 22, 1911, tuberculin treatment
was begun with Vimm c. c and was continued
twice a week until June, 1911. when she had
lost her cough and expectoration and had at-
tained a weight of 140%. She said she could
not feel better.
December 29, 1911. Spent the summer living
out of doors in Morrlstown, N. J., and has done
extremely well..
P. E. Well nourished and good color. Slight
residual dulness over right apex. No rftles.
Temperature 98.2; weight 141.
June 13, 1912. Has been living in the East
River Homes under favorable conditions for
past six months. Had no cough or sputa all
last winter. After a somewhat fatiguing trip
to Morrlstown, N. J., had a small hemoptysis
night before last P. E. Cervical glands a
little enlarged; moderate dulness, increased
hreathing over both apices; over the left, breath
sounds a little sticky. Temperature at 11 a. m.
98.6; pulse 96; respirations 18; weight 136^^;
tubercle bacilli present in the sputum, which is
tinged with blood.
June 12, 1913. She has been entirely free
from cough and expectoration and has h&d no
hemoptysis. Considers herself perfectly well.
Appetite and digestion good. P. E. Moderate
dulness over right apex; high-pitched percus-
sion note over the left No rftles. Tempera-
ture at 6 p. m. 98.8; weight 141^.
She has remained in good health since the
date of the last examination and has been able
to work as a nurse in the Home Hospital. She
has had no pulmonary symptoms for five years.
Case yZ—April 6, 1910. Helen K., age 21;
single. Stenographer. Father died of consump-
tion. Measles and whooping cough as a child.
No serious illnesses since. For past 15 months
has been losing flesh and strength. Slight
hacking cough; mucopurulent sputa. No chilly
feelings or fever. No dyspnea. Has had a
number of profuse night sweats. Pains between
the shoulders. Appetite fair. Suffers from oc-
casional attacks of indigestion and sick head-
aches. Menstruation regular. P. E. Sallow,
pale and rather poorly nourished; cervical
glands somewhat enlarged. Percussion note
high-pitched over right apex. Temperature
99.6; pulse 84; weight 107— a year ago 113.
No T. B. present in sputum. Von Pirquet tuber-
culin test positive.
On April 12th. she was put on tuberculin treat-
ment and received two injections per week up
to June 11th. when she had lost her cough and
expectoration, the night sweats had disap-
peared, was feeling stronger, and her weight
had increased to 115 pounds.
The summer and fall of 1910 she spent In
Denver. Since her return to New York in
December, she has been working steadily as a
stenographer, has felt very well and has had
no cough or expectoration.
She was not examined again until March 31,
1916, when for ten days she had had a feeling
of oppression in the chest, but no cough or
sputum. Appetite had been good. Fine rftles
were detected at the right apex and behind
there was moderate dulness and wavy modified
breath sounds, with an occasional subcrepitant
rftle. The breath sounds over the left apex
behind were of the **cog wheel" type. Her
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ORIGINAL. ARTICLES
American Medicine
weight was 103^. Temperature at ^.00 p. m.
98.6; pulse 84; respirations 18.
October 7, 1917. Slight dulness persisted at
the right apex, but there were no r&les present.
Weight 107. Has no cough or expectoration.
October 27, 1918. Slight residual dulness at
right apex. Weight 112%. No pulmonary
symptoms.
Case y//— February 6, 1911. Marvin B., age
43. Accountant. A paternal aunt died of
hasty consumption, family history otherwise
negative as to tuberculosis. Has had no im-
portant previous illnesses. In 1902 spat upi a
little blood and at infrequent intervals since.
Morning cough since last November, purulent
sputa. Had an attack of "grippe" two weeks
ago, since then has had chilly sensations and
several night sweats, has felt feverish after-
noons. Has been losing flesh and strength
since last May, appetite has been poor and
suffers from indigestion — pains in epigastrium
and distension after eating, nausea, eructations.
P. E. Poorly nourished, pale. Moderate dul-
ness over right apex, behind over right upper
lobe breath sounds and whispered voice are
increased and rubbing, pleuritic friction sounds
are heard. Temperature 6 p. m. 99. Pulse 92.
Weight 130%, a year ago 146. Nares-septum
deflected to left Cervical glands slightly en-
larged. No tubercle bacilli present in the
sputum, Von Pirquet's tuberculin test positive.
February 6th, tuberculin treatment was begun
with VioMo c. c. and continued twice a week in
graduated doses until April 23rd his maximum
dose attained being Vm c c. He gained 15%
pounds in weight, appetite and digestion were
normal and the neck glands were no longer
palpable. Rftles disappeared, the only remain-
ing morbid pulmonary sign was moderate dul-
ness over right upper lobe. He continued to
gain in weight after cessation of the tuber-
culin treatment and May 20, 1912, weighed
156%. He has continued in good health for
past six years but has at times spit a little
blood. February 1, 1918, was again examined
after an attack of "bronchitis" lasting two
weeks — cough, mucopurulent sputa, one slight
hemoptysis. P. E. Dulness, modified breath
sounds — interrupted wavy inspirations over
right upper lobe. Over left apex high-pitched
percussion note, soft amphoric breathing, a
few fine rftles. Temperature 6 p. m. 98.2*.
Weight 144. No T. B. present in sputum.
Case y///— May 20, 1912. Thomas F. W., age
46; broker. A brother, a sister and several
cousins died of pulmonary tuberculosis. Measles
as a child. Four years ago had typhoid fever.
Last January had an attack of "bronchopneu-
monia," after which he took a short sea trip,
by which he was much improved, but a per-
sistent morning cough has continued with
copious purulent sputa which contained tuber-
cle bacilli. Has had occasional slight hemop-
tysis, no pain but a feeling of oppression in the
chest. Has had several night sweats recently.
Appetite and digestion are good. No alcoholic
habit. Smokes two cigars and one or two
pipes a day.
P. E. Tall-r-6 feet 5 inches. Poorly nour-
ished; chest is fiattened, shoulders stoop. Dul-
ness, exaggerated vocal fremitus, increased
breath sounds and whisper over right upper
and middle lobes. Behind, inspiration clicks
and inconstant subcrepitant r&les are elicited.
Temperature at 6 p. m. 100**; pulse 120; respira-
tions 18; weight 171, a year ago 177.
On May 22nd, tuberculin treatment was insti-
tuted with Vmm c c. of B. E. and was continued
twice a week up to June 16th, when he was ad-
mitted to Loomis Sanatorium, where the tuber-
culin treatment was continued.
December 24, 1912, there was dulness, in-
creased breath sounds and whisper over right
upper lobe; no r&les were demonstrable; he
weighed 187%; the sputum still contained
numerous tubercle bacilli.
April 2, 1913, he was discharged from Loomis
Sanatorium as an arrested case. A few bacilli
persisted in the expectoration. There had been
a notable improvement in his physical sig^s.
The percussion note was a little high-pitched
over the right upper lobe and the breath sounds
were somewhat exaggerated. Temperature at
5 p. m. 100*; pulse 96; weight 199. At Loomis
he attained a maximum dose of Vit c. c. tuber-
culin.
He returned to business and reported regu-
larly for examination at intervals of two or
three weeks to a month. He continued to gain
weight and on October 25t)i weighed 202%
pounds. He had passed three negative sputum
examinations, tho at the last, September 15,
1913, a few bacilli were found.
January 19, 1918. He has been free from
cough and expectoration for the past five years.
His weight has remained between 212 and 216.
Occasionally when he has had a cold, a sputum
examination has been made at intervals of
three or four months, but has always been nega-
tive for bacilli. He has no rftles, no demon-
strable morbid pulmonary signs. He has been
able to carry on a large and important busi-
ness and has led an active out-of-door life,
playing golf, and states that he has had better
health in the past five years than for ten years
before he was ill.
Case IX — December 24, 1915. Oliver G., age
30; single. Mother, a younger sister and a
maternal aunt died of consumption. Measles,
whooping cough and diphtheria in childhood.
Malaria at 12. Frequent attacks of sore throat
and "catarrh." Pleurisy six years ago, at
which time he was in bed for six weeks. Has
had a hacking cough since, which has been
worse in winter. Purulent sputa, no hemop-
tysis. Has lost fiesh and strength. Quit work
as a wire drawer one month ago. Dyspnea on
exertion. Pains in chest, which are worse on
the left side, also in shoulder. Chilly sensa-
tions; feverish afternoons. Profuse night
sweats. Appetite poor; indigestion and diar-
rhea for the past month. Has had marked
hoarseness and dysphagia for two months. For
three weeks both knees have been swollen and
painful. Was formerly an excessive beer
drinker — 25 glasses a day — and had also an ex-
cessive cigarette habit — 20 to 25 a day. Has
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JANL'AKY, 1919
35
Stopped his beer and tobacco for three weeks.
P. E. Fairly nourished; cervical glands en-
larged; dulness; broncho-yesicular breathing;
increased whisper over both upper and right
middle lobes. Numerous subcrepitant rftles
over left upper lobe and a few are also heard
at right apex. Temperature at 12.00 p. m.
99.5*"; pulse 108; respirations 18; weight 113%,
normal weight a few years ago, 175. The
larynx shows a considerable thickening of both
arytenoids and a small ulceration of the right
cord. Tubercle bacilli present in sputum.
He was put to bed and was kept under ob-
servation for several weeks, during which time
his temperature ranged between 97.8'' and 102*".
The lesions in his throat and lungs were pro-
gressive and he lost weight. On February 4,
1916, there were definite signs of a small cavity
below the left clavicle. Weight 132%; his
temperature having fallen and not exceeding
99 to 99.5 in the afternoon.
He was put on tuberculin treatment February
26th, with an initial dose of Vtsm c. c. B. E., which
was continued until July 19, 1916, when he re-
ceived a maximum dose of % c c This patient
showed a most extraordinary improvement in
his throat lesions and in his general condition,
having attained at the end of his treatment a
weight of 152% pounds. The arytenoids were
infiltrated, but the vocal cords approximated
very well, altho grayish and discolored, the
right especially. The hoarseness and pain on
swallowing had practically disappeared, the
small ulceration on the right cord had appar-
ently healed. Bacilli weife still present in the
sputum. His temperature ranged between 97.2''
and 98.6^
I arranged for his admission to Loomis Sana-
torium Annex on August 18th, where he re-
mained as a patient until May 1, 1917, and made
a further substantial gain in weight His max-
imum weight on February 22nd was 167 pounds.
He was able to do some work and has since
been employed in the institution. He was ex-
amined by me again in the summer, when there
was a further recession in his physical signs
and his constitutional condition was regarded
as very satisfactory.
Case X— January 20, 1916. Raoul H., age 32.
Married; architect A paternal aunt died of
tuberculosis of the lungs. Scarlet fever at 4;
acute articular rheumatism at 10; a severe at-
tack of enteritis at 18. Tonsils and adenoids
removed at 5. Had laryngitis at 20. Was told
he had endocarditis at 21 and was disqualified
for military service in France. Was treated
for hay fever and asthma three years ago; 18
months ago had cough and purulent sputa; six
months later, a considerable hemorrhage was
followed by a dry pleurisy on the left side. Has
lost fiesh and strength and has had chills, fever,
night sweats and pains in left chest. Appetite
is generally good; digestion fair. Dyspnea on
exertion; occasional feeling of palpitation and
faintness; sleeps poorly. Does not use alcohol
or tobacco. Received sanatorium treatment
from April t6 July, 1916. Temperature at no
time exceeded 100''.
P. E. Fairly nourished; good color; cervical
glands slightly enlarged. Dulness,. increased
vocal fremitus, exaggerated breath sounds and
whispered voice over right upper lobe; behind
an occasional fine rftle is heard. Over left
upper lobe and extending lower than over right
more marked dulness, broncho-vesicular and
"cog wheel" breathing, whispering bronchoph-
ony. Temperature at 7 p. m. 98.6*; pulse 84;
respirations 18; weight 152. Between Jan-
uary 10th and 20th the temperature ranged
from 97.1 to 99.4. Sputum contained tubercle
bacilli last summer.
February 9th. No bacilli present in sputum.
Al apex of cardiac al*ea there is distinct rough-
ening of the first heart sound. Under dietetic
and hygienic treatment and residence at the
East River Homes, he did fairly well, but there
was a progressive loss of weight and at times a
slight afternoon temperature as high as 99.6".
On June 21st tubercle bacilli were present
in the sputum. Weight 139^.
Tuberculin treatment was begun on June
26th, when he received an initial dose of 'Am*
c. c This was continued up to June 8, 1917,
when a maximum dose of Vw c. c was given.
Bacilli disappeared from his sputum. He lost
his cough and expectoration, rftles were no
longer demonstrable and his temperature has
ranged from 97'' to 98.6". He gained in fiesh
and strength, and thruout his treatment has
continued his work as an architectural de-
signer. He has remained well to the present
time with slight residual inactive signs at
apices; has a good appetite and digestion; is
living in the country at Pelham, N. Y. and his
weight was 146^^ on June 26, 1918.
Case X/— October 5, 1917. Catherine F. B.,
age 25; married. Father died of consumption
22 years ago, also a paternal uncle. Has had
"bronchitis" every spring and fall for ten years.
Had an attack of grippe eight years ago. Has
had cough for three weeks, mucopurulent
sputa; hemoptysis two weeks ago and also at
times before, when she has had "colds." Has
lost fiesh and strength in the past six months.
Pains in region of sternum and back; chilly
sensations; feverish afternoons; dyspnea on
exertion; no night sweats. Appetite very poor;
indigestion; nausea; eructations.
P. E. Fairly nourished; good color; cervical
glands not enlarged; dulness; increased breath
bounds and whisper over right upper and mid-
dle lobes, no r&les demonstrable. Percussion
note over left apex high-pitched and short.
Breath sounds are modified — above the nipple
and in the axilla fine crepitant rftles are heard.
There is a small spur projecting from the
septum in left nostril. Oropharynx and
larynx normal. Temperature at 5 p. m. 99.8*;
pulse 96; respirations 24; weight 134, three
months ago, 153. No tubercle bacilli in sputum.
Under hygienic and dietetic treatment for a
month she gained 10 pounds in weight but fine
rftles were present over both upper lobes and
slight hemoptysis continued.
November 30th. Tuberculin treatment was
begun with V«m>oo c. c. of B. E. which was con-
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January, 1919
ORIGINAL. ARTICLES
American Medicinb
tinued up to June 9th. with graduated weekly
doses, attaining a maximum of Vw c. c* when
she had gained 19 pounds, had lost her cough
and expectoration, felt strong and well and has
remained In good health since.
Case X//— October 2, 1913. Charles A. Q.,
age 23; stenographer; single. Family history
negative as to tuberculosis or other significant
diseases, except that a paternal uncle died of
consumption. Measles in childhood; had catarrh
of the bowels when 6 years old. Denies venereal
disease. Has been in ill health for past four
years. Has been treated for malaria aQd
rheumatism. Had occasional hemoptyses seven
years ago. Has lost flesh and strength, fever-
ish afternoons, dyspnea on exertion, appetite
fair, digestion poor. Complains of pains In
back and legs. Denies cough, but has a morn-
ing expectoration of purulent sputum.
P. E. Pale; poorly nourished; dulness,
broncho-vesicular breathing and increased
whisper over boUi upper lobes. Cervical glands
enlarged; temperature at 7.00 p. m. 100°; pulse
90; respirations 24; weight 111%, four years
ago, 123. Has a psoriasis eruption over the
shoulders, extensor surfaces of the arms and
legs. Tubercle bacilli present in the sputum.
Tuberculin treatment was begun on October
10, 1913, with an initial dose of Vimmo c. c, and
was continued until March 28, 1914. He did
extremely well and at this date had only a
little moderate dulness over the right upper
lobe; no cough or expectoration. Weight 123%.
Has lost his bacilli.
On July 30, 1916, weighed 130%, with no
positive morbid pulmonary signs except a little
high-pitched percussion note over the right
apex. No tubercle bacilli in sputum.
In the spring of 1918 he was accepted by an
army board for service and was sent for train-
ing to Camp Upton. He is now in France and
in good health.
I do not cite these cases as illustrations
of what will often be seen in the adminis-
tration of tuberculin, but if the treatment
were more extensively used in suitable
cases, I have no doubt that more of these
exceptionally favorable results would be ob-
tained, for it is impossible without trial to
say what patients will respond well to the
stimulus of the injections, just as it is
equally impossible to say why tuberculosis
in some cases runs a rapid and fatally pro-
gressive course, terminating in a few
months and in others continues over a long
period of years with relatively slight im-
pairment of the health. In administering
tuberculin we are dealing with an unknown
reaction which cannot be predicted in ad-
vance, but which must be gradually de-
termined by cautious and careful study for
each individual patient. The mysterious
factors of what, for want of a better term,
we call the patient's resistance are an im-
portant element, and it is certainly true
that in many cases this can be developed
and strengthened by immunizing doses of
tuberculin.
In the past ten years I have treated
with tuberculin 57 cases which have con-
tinued under observation for periods vary-
ing from one to eight years after the con-
clusion of their treatment. Of these, 28
were markedly benefited, 15 having made
a definite arrest of their disease. Nineteen
others received benefit to a less extent, in
six no effect, whatever could be attributed
to the treatment. Twelve cases have died,
nine from the ordinary progress of their
disease, one from intercurrent lobar
pneumonia, and two from spontaneous
pneumothorax. In perhaps half of the
cases that subsequently died there had been
improvement in symptoms which could be
fairly attributed to the tuberculin adminis-
tration, and it is believed their lives were
prolonged and made more comfortable. In
no case could the treatment be considered
to have had an influence in determining the
fatal issue. Of the 57 cases reported on,
38 had positive sputum, 19 at no time had
bacilli present. Of the complications to be
noted, there were six cases who had well
marked tuberculous laryngitis; there was
one case of tuberculous peritonitis in whom
the ascites disappeared without recurrence ;
one case of tuberculosis of the wrist joint,
which made a perfect recovery without de-
formity or impairment of joint function ; in
six patients the cervical glands were con-
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January, 1919
37
spicuously enlarged, sufficiently so to con-
stitute a disfiguring deformity. In all of
these glandular cases the influence of tuber-
culin treatment was favorable in effecting a
marked reduction in the size of the glands.
There was one case who had been previously
treated for a tuberculous iritis, and in one
patient bacilli were found in an excised
tonsil. In only one of the throat cases
could any good effects be seen from the
tuberculin — in this case a tuberculous ulcer
healed and the patient gained 39j4 pounds.
Twenty-four of the cases here reported had
received sanatorium treatment.
THE NON-LIABILITY OF CHARIT-
ABLE INSTITUTIONS FOR THE
NEGLIGENCE OF PHYSiaAN
OR NURSE.
BY
H. GERALD CHAPIN, LL. D.,
of the New York Bar, New York City.
It was Irvin Cobb who commented upon
the cheerful frame of mind induced in the
average patient when, prior to an operation,
he is presented with a general release of
all liability and requested to affix his signa-
ture on the dotted line.
To what extent the courts will recognize
such a document is a question which we
need not consider here. This short article
deals with cases where an institution or-
ganized for charitable purposes has failed
to adopt this prelhninary measure of pre-
caution and the operation has gone agley.
Under the doctrine which may now be
regarded as thoroly established, a chari-
table institution will not be responsible for
injuries resulting thru the negligence or
want of skill of the physician or nurse. The
reason is generally stated to be found in
public policy, for if the rule were otherwise.
the trust fund might be entirely destroyed
and diverted from its proper purposes. Put
in plain language, it is better .for the one to
suffer than the many.
Thus the Supreme Court of Michigan in
a leading case (Downs v. Harper Hospital,
101 Mich, 555) where an insane patient
while unwatched, had committed suicide
by leaping from a window, observed that if
a trustee or employee is guilty of negligence
he may be held responsible individually, but
the law jealously guards the charitable trust
fund and does not permit it to be frittered
away by the negligent acts of those em-
ployed in its execution. The trustees could
not by their own direct act divert it from
the purposes for which it was given. It
certainly follows therefore, that the fund
cannot be indirectly diverted by the tortious
or negligent acts of the managers of the
fund or their employees tho such acts result
in damage to the innocent beneficiary.
Those voluntarily accepting the benefit of
the charity, accept it upon this condition.
At one time, Rhode Island adopted a con-
trary view denying any immunity to chari-
table institutions as such (Glavin v. Rhode
Island Hospital, 12 R, L 411) y but this was
subsequently changed by legislative enact-
ment. {Laws of 1909, Ch. 213, § 38.)
It is somewhat curious, however, that
the non-liability doctrine should be said
to apply only provided due care has been
exercised by the hospital in the selection
of the guilty individual. (See Hearns
v. Waterbury Hospital, 66 Conn, 98;
McDonald v. Mass. Gen. Hospital, 120
Mass. 432; Corbett v. St. Vincent's Indus-
trial School, 79 App. Div, 334, affmd. 177
N. Y, 16.) This limitation, it is submitted,
is utterly illogical if public policy is to
dictate that under no circumstances should
there be any diversion of the funds.
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ORIGINAL. ARTICLES
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Nor will the hospital be responsible
merely because it accepts payment from pa-
tients able to afford it. Incidental revenue
does not change its standing as a charitable
institution.
What is probably the leading case in New
York is Schloendorff v. N. Y. Hospital
{211 N. F. 125) decided in 1914. The
latter institution does not charge either for
board or for treatment if the patient is un-
able to pay, but if well-to-do, a charge of
$7.00 per week is made for board. Mrs.
Schloendorff was suffering from a stomach
disorder and came in the $7.00 per week
class. After some weeks of treatment, the
house physician discovered a lump which
proved to be a fibroid tumor. He consulted
the visiting physician who advised an opera-
tion. The patient testified that she was in-
formed that the character of the lump
could not be determined without an ether
examination, to which she consented but
notified the house physician that there must
be no operation. She was taken at night
from the medical to the surgical ward and
prepared for an operation by a nurse. On
the following day, ether was administered
and while she was unconscious a tumor was
removed. Her testimony was that it was
done without her knowledge or consent,
tho in this she was contradicted by the
house physician, the visiting surgeon and
by several attendant nurses. Following
the operation, and according to the testi-
mony of her witnesses, because of it, gan-
grene developed in her left arm; some of
her fingers had to be amputated and her
sufferings were intense.
Judge Cardozo pointed out in his opinion,
that it is now a well settled rule that a
charitable institution, such as the New York
Hospital, it not liable for the negligence
of its physicians and nurses in the treatment
of patients. In New York, this exemption
has been placed upon two grounds. The
first is that of implied waiver, since one
who accepts the benefit of a charity enters
into a relation which exempts one's bene-
factor from liability for the negligence of
his servants in administering the charity.
The hospital remains exempt tho the pa-
tient makes some payment to help defray
the cost of board, since such pa)mient is to
be regarded as a contribution to the income
of the hospital to be devoted, like its other
funds, to the maintenance of the charity.
The second ground of the exemption is the
relation subsisting between a hospital and
the physicians who serve it. This relation
is not one. of master and servant. The
physician occupies the position, so to speak,
of an independent contractor, following a
separate calling, liable of course for his own
wrongs to the patient whom he undertakes
to serve, but involving the hospital in no
liability if due care has been taken in his
selection. The same argument applies to
nurses. The superintendent is a servant
of the hospital. The assistant superin-
tendents, the orderlies and the other mem-
bers of the administrative staff are servants
of the hospital. But nurses are employed
to carry out the orders of the physician to
whose authority they are subject. The
hospital undertakes to procure for the pa-
tient the services of a nurse. It does not
undertake thru the agency of nurses to
render those services itself. He concludes
with the following words:
"A ruling would indeed be an unfor-
tunate one that might constrain charitable
institutions as a measure of self-protection,
to limit their activities. A hospital opens
its doors without discrimination to all who
seek its aid. It gathers in its wards a com-
pany of skilled physicians and trained
nurses and places their services at the call
of the afflicted, without scrutiny of the
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ORIGINAL ARTICLES
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39
character or the worth of those who appeal
to it, looking at nothing and caring for
nothing beyond the fact of their affliction.
In this bendicent work it does not subject
itself to liability for damages, tho the min-
isters of healing whom it has selected have
proved unfaithful to their trust."
In Ward v. St. Vincent's Hospital {39
App, Div, 624) the subject was viewed
from a dififerent angle. This case was
based upon an alleged contract by which a
charity hospital, which was in the habit of
furnishing private rooms and nurses, for
full price, undertook to furnish the patient
with a skilful, trained and competent nurse
for a stipulated sum per week, but failed to
do so and on the contrary furnished one un-
skilful and inexperienced who placed an
unprotected hot water bag against the pa-
tient's leg while she was under the influence
of ether, whereby she was severely burned.
The decision was to the eflfect that assum-
ing such a contract had been made and that
it had not been fulfilled, the hospital was re-
sponsible. This goes to show that the non-
liability rule does not rest on the ground of
a diversion of trust funds but rather on the
theory of waiver which may be implied,
either where the patient is treated wholly or
where he is treated partly without pay.
That this is the true reason is shown by^a
line of cases where the party injured was
not a patient at all. Thus in Hordern v.
Salvation Army {199 N, Y. 233) the action
was brought to recover for personal in-
juries received by a mechanic who had been
engaged in making repairs on a boiler, the
accident occurring thru the defective con-
dition of a runway or staging. After point-
ing out that in New York the immunity of
charitable corporations for the wrongs of
their servants has been made dependent on
the relation which the injured party bore
to the corporation and not upon the sacred
character of the trust funds themselves,
the court observed that if a charitable cor-
poration in dealing with its property pur-
sues a line of conduct which results in in-
jury to outsiders, there is no reason why
it should not be responsible since the purity
of its general purposes will not justify its
wrong.
A similar doctrine was announced in a
later case where an outsider had been in-
jured by collision with an ambulance and
it was there stated that "it must now be
regarded as settled that a charitable cor-
poration is not exempt from liability for a
tort against a stranger because of the fact
that it holds its property in trust to be ap-
plied to purposes of charity." (Kellogg v.
Church Foundation, 203 N. Y. 191, 194.)
As illustrative of the point that the phy-
sician is to be treated not in any respect as
' a servant of the hospital, but rather as an
independent contractor, are cases holding
that a steamship company is not responsible
for the negligence of the ship's surgeon
provided that due care has been exercised
in his selection. (Allen v. State Steamship
Co., 132 N, K. 91; Laubheim v. De Koning-
lyke N. S. Co., 107 N. Y, 228.) A doctrine
applied to hospital and medical departments
maintained by railroad companies (Eighmy
V. Union Pac. Ry. Co., 93 Iowa 538) or
supported by the contributions of the em-
ployer and employees (Harden v. Atl.
Coast Line Ry. Co., 152 N. C. 318; Richard-
son V. Carbon Hill Coal Co., 10 Wash. 648).
Such cases diflfer, however, from those of
charitable hospitals in that there cannot be
spelled out the waiver already mentioned,
being more analogous to instances where
the patient has paid a full fee in which there
would seem to be no absolute liability but
rather only a duty of reasonable care in
selection. • 55 Liberty Street.
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40
January, 1919
ORIGINAL ARTICLES
American Medicine
HOW TO RECOGNIZE PSORA WHEN
NOT A SPECIALIST.
BY
B. SHERWOODDUNN, M. D., .
Paris, France.
Officier d'Acad^mie; Membre oorrespondant,
Soci6t6 Obst^trique et Qsmdcologique de
Paris; Surgeon (Colonel) Service de
Sant6 Militalre de Paris; Physician
to Cochin Hospital.
During the hours of consultation from
nine to twelve, four times per week, in our
venereal service at Cochin Hospital, out of
sixty to one hundred patients seen daily,
ten per cent, will be afflicted with psora.
For some unaccountable reason, there
seems to be an epidemic of this disease.
Recently, while in the private office of a
banker, he asked me to look at an eruption
upon his arms and I had to tell him he had
the itch. One of the leading cloth mer-
chants of Paris came to consult me with the
same disease, and passing the evening at
the house of some friends in the most aris-
tocratic quarter of Paris, the occasional un-
easiness of my hostess, whom I know very
well, caused me to question and finally ex-
amine her, and she also was suffering from
the same malady.
Psora is called a venereal disease. Just
why, I cannot tell, it can be contracted in
many ways, besides sexual contact, and is
in no wise localized to the sexual organs.
It is a contagious eruption of very minute
pimples; pustular, vesicular, papular, in-
termixed and alternating, and terminating
in scabs. It is caused by the insect of the
Genus Acarus, seu Sarcoptes seu Phthirium
sen Cheyletes Scabiei.
From time immemorial it has been looked
upon as a shameful disease, and the practi-
tioner wants to feel confident of no error
when diagnosing it; it is because of this
that I have thought it might be worth while
to renew our acquaintance with its symj>-
tomatology, and particularly at the moment
when so many of our doctors are coming to
France with the troops, where they are
bound to see more or less of it. Many first-
class practitioners have never seen a case in
their whole practice.
The reason for the present extension of
psora to the better classes in Paris is doubt-
less found in the promiscuity of social rela-
tions since the outbreak of war. Refugees
from the destroyed districts and other
countries have flocked to Paris, giving rise
to many stations for the distribution of
partly worn clothing, bedding, etc. Many
buildings not originally intended for habita-
tion have been used to house them, where
the lack of bathing conveniences and proper
care of the person, tends to breed the dis-
ease. The widespread want and misery
have called all classes into service of some
sort of relief, and ladies and men of refine-
ment come into daily contact with the un-
kempt and unclean.
The classic points taught, by which to
diagnose psora, can be summarized as fol-
lows:
1. It is a venereal disease;
•2. Its contagion will often solve a
doubtful diagnosis;
3. It is found exhibited on the feet,
hands, wrists, arms, axilla and
nates in both sexes.
These are the rules imposed upon the
practitioner, and, while good as an index,
form only a rudimentary basis for his ex-
amination as he progresses in knowledge of
the disease.
Let us analyze them in their order.
1. It is a venereal disease,
I do not see the reason for this classifica-
tion, except that it is communicated by
sleeping in the same bed with one affected
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ORIGINAL. ARTICLES
January, 1919
41
and the reason is simple. The acarus is
noctambulant; it is only at night that it
becomes animated and active. It is at night
that the one afflicted feels the intolerable
itching and will scratch even while asleep,
whereas he is hardly at all aflfected during
the day.
It is said that one cannot contract the
contagion by shaking hands, or coming into
contact in the workshop, office, or school-
room ; but one of the hospital attendants at
Cochin, who habitually carried the garments
of patients coming for the treatment, to the
sterilizing room upon his left shoulder, con-
tracted the disease, the first papules appear-
ing at the base of the neck and upon the
left shoulder; cases of this kind, however,
are exceptional; the disease is caught by
sleeping with one affected, or in a bed that
has been occupied by one aflfected. It
should be noted that it is not in the least
necessary for the intervention of the sexual
act to aflfect the contagion, the simple
sleeping in the bed with one afflicted is
sufficient. Soldiers and refugees, sleeping
side by. side, are as surely contaminated as
a man and woman who retire for another
purpose than sleeping. Nevertheless, the
latter is the most frequent cause, and be-
cause of this the disease is more frequent
among the young, altho the old are not ex-
empt; they catch it if exposed, but it is
seen less frequently among them, for the
reason that they more often sleep alone.
2. To solve a doubtful diagnosis, —
Nothing could be easier of diagnosis than
a case of psora six weeks or two months
old, which creates a host of typical lesions
in its course; but nothing is more difficult
to recognize in the first few days of inva-
sion, when the lesions are few and wanting
in the marked characteristics which appear
only with a certain age. It is in these cases
that one has to follow a varied and detailed
inquisition to arrive at a differential diag-
nosis.
Do you sleep alone? Does the one you
sleep with have a rash? Do they scratch
themselves during the night? Have you
any strangers visiting you? Do they
scratch themselves? Have you slept with
any strange person recently?
The contagious, pruriginous skin dis-
eases are few and confined to the pedicu-
loses and psora.
The phthirius pubis and its eggs are con-
fined almost exclusively to the hairy por-
tions of the pubis.
The pediculus corporis gives rise to ex-
coriated lesions of marked character,
usually in extended lines formed by the
finger nails in scratching and almost con-
stantly behind the shoulder and axilla.
The pediculus capitis is confined to the
head and easily recognized.
The pediculus tdbascentium occurring in
phthiriasis is said to differ from the or-
dinary body louse, but the signs are prac-
tically the same.
Evidence of the existence of these para-
sites differs from that of psora, in that the
latter commences as a rule with pinhead red
points gradually creating a circumscribed
erythema as a roseola, then fading to a
yellow, brownish spot with from three to
six weeks' age, at which time careful inspec-
tion will discover the parasite in these spots.
Sometimes groups of these lesions are pus-
tular, or infectious. The difficulty some-
times is to differentiate these spots, when
widely distributed over the whole body,
from the roseola of syphilis.
A patient having a communicable disease
who comes complaining of itching and
scratching, in the absence of pediculoses,
has psora, and by the process of exclusion
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January, 1919
ORIGINAL. ARTICLES
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a doubtful case can always be determined.
The busy practitioner has no time to
make the microscopic examination of a
sarcoptus extracted from a pimple, and
must therefore arrive at a diagnosis from
the fact that psora is caught by sleeping
with one so afflicted or in an unchanged
bed that has been previously occupied by
one, and when the lesions are not suffi-
ciently advanced to present their charac-
teristic signs, it is by the close questioning
of the patient that one can arrive at the
diagnosis. Sometimes this is not easy, for
if the patient has slept clandestinely with
one of the opposite sex and wishes to con-
ceal the fact, an admission cannot be
secured ; then we must recur to other fixed
signs.
Psora is always found in certain loca-
tions,— One of these locations may be free
from lesions, but the others will not. If
irritations and signs of scratching appear
upon the face and neck, some other disease
can be suspected, as psora does not appear
on these surfaces.
In order to closely examine the ordinary
locations of this disease, the patient should
present the upper part of the body nude;
one of the almost constant seats of lesions
is in front of the axilla.
When a person is standing erect with the
arm falling by the side, there is found, or-
dinarily, two or three wrinkles in rays ex-
tending from the point of the axilla up-
ward and outward; when this region is in-
vaded by the sarcoptus, these rays are in-
creased to a half dozen, with slightly raised,
reddened points extending along the long
axis of the wrinkles, and are extremely
characteristic.
The deep fold at the base of the nates is
another favorite seat of the lesions and
equally characteristic. They are not as a
rule as great in number as found in the ax-
illary region, but are more prominent and
pronounced in character.
The wrinkles formed by the flexion of
the hand at the wrist are another situation
where the lesions will be found, following
the lines of the wrinkles.
The text-books make particular mention
of lesions to be foimd upon the posterior
surface between the fingers at the base;
specialists do not count so much upon these,
because they are so little characteristic.
In the male as well as in the female, the
generative organs should always be exam-
ined, as they are the most frequent seat of
primary lesions ; male genitalia in particular
is abnost invariably attacked. The integu-
ment covering the penis, the prepuce and
sometimes the glandes will present small,
red pinpoints at rare intervals, slightly ele-
vated, rather hard, and the patient will com-
plain that they at times embarrass him be-
cause of the intolerable itching. When found
in this situation they neither resemble nor
can they be confounded with any other
dermatoses.
In women the breast is frequently the
seat of lesions ; the irritation from scratch-
ing may resemble eczema; if it be eczema,
it lends presumption to psora as the cause.
If it is not eczema, and even with, there will
be found the traces of scratching, with from
two to ten, seldom more, small red points
distributed over the gland, the areola and
nipple, then look for the lesions in the other
characteristic regions.
If a nursing baby is attacked, look at the
plantar of the feet for elevated, inflamed
pustules and examine the mother or wet
nurse as the source of contagion.
I now come to the much-talked-of
"scabies burrow."
In the specialist's clinic, crowded daily
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ORIGINAL ARTICLES
January, 1919
43
>yith all varieties of dermatoses and genito-
urinary cases, the whole morning of exam-
ination will pass without the dermatologist
once thinking of this much-talked-of sign.
He will make his diagnosis of scabies by
rapid localization and elicited history, and
only thinks of looking for the famous
scabies burrow in cases of quite recent date
or feeble signs, which the histories fail to
enlighten.
What is the scabies burrow ? How does
it look ? Have you ever seen the burrow of
a mole trailing its sinuous course along the
top of the ground? The burrow of the
sarcoptus is the same on the human skin.
One sees it best on those of unclean habits
and unkempt skin ; coal heavers and work-
ers in dark liquids, which penetrate the
skin pores and darken it ; when the burrow
is recent and uncolored, it is difficult to
recognize, but to bring out its character you
have only to impregnate the surface of the
raised portions with a drop of iodine, at
once wiping it off — a simple precaution and
often useful.
The white burrow is still more difficult
to describe than to recognize. If you were
to pass a needle along thru a part of the
epidermis at the end of a finger without
causing any bleeding, then withdraw the
needle, you would see its track left, slightly
raised, of a mat white appearance; substi-
tute a sinuous track for the straight one
made by the needle and the aspect is iden-
tical with the fresh burrow of scabies. It
is difficult to distinguish and will often pass
unnoticed.
The more ordinary lesions are the pimply
eruption, forming papules and vesicles,
often decapitated by the finger nails in
scratching, and in certain situations, where
most constantly found, following the apex
of the folds of the skin of the wrinkles.
It is unnecessary to go further into the
minutiae of detail ; this article is not written
for specialists in skin diseases, but for those
who, by reason of this world-war and who
enter the service, will be called upon to
recognize diseases they are little accustomed
to see.
The scabies burrow in which is found the
sarcoptus, its eggs and its excretions, con-
stitutes, it is true, the elemental lesion of
psora; but where one does not find it, re-
member that psora is a regional disease — its
lesions may be distributed all over the body,
exclusive of the neck, face and head, but
exists with localization in front of the ax-
illa, the flexor wrinkles of the wrists in both
sex; the breast of the female and prepuce
or glandes of the male and plantar surface
of the feet in the nursing child. In these lo-
cations one makes the diagnosis. If in doubt,
question the patient as to his surroundings
and habits, and especially if he sleeps with
anyone from whom he could have caught it,
or someone to whom he may have com-
municated it; the single fact of contagion,
outside of a case of pediculosis easy to
eliminate, marks the disease as psora.
146 Avenue des Champs Ely sees.
Treatment of Bronchitis in Oiildre
Potassium bichromate in small doses tritu-
rated with sugar of milk, (Southern Clinic,
Aug., 1918) will give excellent results in
treatment of bronchitis in children, and in
bronchial irritations.
For Sudden Cardiac Dropsy.— Good
remedy is citrate of caffein, adult 2 to 5
grains 3 times a day. It is easily taken by
feeble persons, and directly produces free
flow of urine with relief of suffering. —
Med. Fortnightly.
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January, 1919
LONDON LETTER
American Medicine
iVrom our Regular Correspondent)
THE PUBCHASE OF ALCOHOL AND
GLTCEBINE.
The purchase of alcohol and glycerine has
again become possible for pharmacologic and
pharmaceutical purposes, as well as for use in
laboratories and for scientific research. The
Ministry of Munitions is nearing the day when it
can put up its shutters, and notification has
Just been made by the Department that supplies
of alcohol will be available for other purposes
than for killing persons. All manufacturers
should now be able to obtain their requirements
for industrial purposes from the customary
sources and the supplies will only be restricted
by the usual regulations of the Board of Cus-
toms and Excise. Spirit restriction has been
in particular a bore to many, but the freedom of
glycerine is the most convenient thing In the
new order as far as medical practice is con-
cerned, for the withdrawal of this valuable
substance has been attended with great incon-
venience to all prescribers. It is now promised
in substantial quantities thru the ordinary re-
tall channels. A further concession might now
well be made in regard to alcohol, and that is
research workers might be allowed to obtain it
under favorable terms and not subject to the
heavy excise penalties. In the production of
alkaloids and the manufacture of synthetic
remedies alcohol is all essential and only, I
believe. In Great Britain are such activities
paralyzed by the high price of alcohol. British
manufacturers have In this way been penalized
to the great advantages of German rivals, and
It will be expected that such a contingency with-
in the future be guarded against. The disabili-
ties of our drug manufacturers In this direction
have often been explained to the authorities,
and apparently to sympathetic ears, but no re-
form has followed. Now would be a good op-
portunity to grant the concession, when the
businesses have to be largely reconstructed and
when everything to facilitate the reorganization
of trade should have support.
WHAT IS LEGITIMATE WARFARE?
A letter has been published recently In the
American press signed by the Regius Professors
of Physics In the Universities of Oxford and
Cambridge, and by the President of the Royal
Corporation In the three divisions of the King-
dom protesting against the use of noxious gases
!n war. The communication testifies to their
tender hearts but not to their hard heads. The
reasons for the protest are threefold: (1) That
gas Is an uncontrollable weapon whose efTects
cannot be limited to combatants; (2) that U
condemns Its victims to dea'th by long drawn-
out torture; (3) that It opens the door to Infinite
possibilities of horror. With regard to all these
points It can be pleaded that gas Is a menace
only to a greater extent than other weapons
of war, and It Is Impossible to say to nations at
war "thus far shalt thou go and no further."
DRINK RESTRICTIONS AFTER THE WAR.
The question of the control of drink now
that the war has ceased Is causing a great deal
of discussion, and very varying views are ex-
pressed even among medical men whose com-
mon consensus of opinion Is, and has been now
for a long time, that restrictions with regard to
the sale of alcohol are all for the good of public
health and national progress. But what restric-
tions should be made and by what machinery
they should be enforced. In such a way that
while preventing license we do not legitimatize
Prusslanlsm, Is a matter of considerable difli-
culty. Of course much of this difficulty will dis-
appear as the people become more educated,
more aware of the evils of alcoholism and more
alive to the many social disorders and disabili-
ties at the root of which indulgence in alcohol-
ism lies. At the present moment the people
of this country are puzzled as to the funda-
mental matter of cause and efTect in regard to
alcoholism, the same position exactly prevailing
In regard to tuberculosis. In both cases med-
ical men and publicists point to the vlllalnoua
housing conditions and say: In such an en-
vironment can you wonder that people are the
victims of tuberculosis? Are yeu surprised that
they take to drink? Undoubtedly bad housing
and Insufficient amenities for food and refresh-
ment do lead to the public-house habit, and thus
Increase the alcoholism of the country. But It
Is equally true that If the public houses were
better regulated, better found, and better man-
aged, the houses would enormously Improve
under the more Intelligent supervision of people
who would profit by the example of good man-
agement. In a short time ideas of order and
comfort with regard to domesticity would pre-
vail to a much greater degree if the public
house was a pleasant place of refreshment where
man and wife could go together. In such family
reunions drunkenness would soon be found to
be quite out of the picture. There is no sense
in maintaining alcohol restrictions because
housing Is bad, just as there is no sense In
withholding state Improvement in houslne: until
alcoholism has decreased. There Is an Interplay
between the two evils, neither Is exactly the
cause and neither Is exactly the effect of the
other. In England and Wales during the year
1913 there were no fewer than 188,877 convic-
tions for drunkenness, 153.112 men and 35,765
women. These figures have steadily risen be-
tween 1909 and 1913, and the problem of deal-
ing with drunkenness directly by punitive or
other individual methods has not been solved.
The conditions before the war had been thoroly
criticized altho nothing had been done. The
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LONDON LETTER
January, 1919
45
drink trade as a whole brought in enormous
fortunes, not however to the shareholders, as a
vast proportion of the money was squandered
in competition between the proprietors and in
wasteful methods of production and trade. Then
came the institution of State Drink Cbntrol as
a war measure, and with regard to the effects
of this enactment Lord D'Abernon, chairman of
the Central Control Board (Liquor Traffic) re-
cently made the following public statement re-
lating to alcoholism in women in England and
Wales in the years 1913-1917:
ions
nness
Ihh
from
is of
er
from
tion
ncy
(^
iiil3-
^l3-
5ii
1
Dea
Alec
excl
Cirr
the
Dea
Cirr
the
Dea
Suff
in I
1913.
..35,765
719
1,665
1,226
1914.
•..37,311
680-
1,773
1,233
1915.
..33,211
584
1.525
1,021
1916.
..21,245
333
1,163
744
1917.
..12,307
222
808
704
Cases of Delirium Tremens treated in certain
Poor Law Infirmaries*:
Period
Number of cases
Pre-war, 1913-14 214
Pre-control, 1914-15 239
First year of control, 1915-16.. 121
Second year of tsontrol, 1916-17 45
♦Women only.
These figures are not beyond criticism— for
example cirrhosis of the liver might obviously
cover pathologic conditions independent of
alcoholism — ^but their broad meaning is unmis-
takable. It is clear that under appropriate
regulations all the conditions of drunkenness
in women, as compared with the year 1913, were
reduced by 60 per cent. The decline in the
frequency of delirium tremens among women is
also remarkable, tho here again the figures
must be looked at closely, as delirium tremens
seems to occur in a very conspicuous manner
figuring with great frequency in some official
returns and being absent from others. There
is, however, another piece of evidence as to the
beneficial effect of drink control which should
be brought forward. A significant falling ofT
has taken place during the four years of war
in the number of drunkards amenable to the
Inebriates Acts. The admission to inebriate
reformatories has gone down to less than a
tenth of its previous total, and the same propor-
tionate decline has taken place in the number
of persons proceeded against for habitual drunk-
enness. There can be no doubt in anybody's
mind that the control of drink has diminished
drunkenness and that with the diminution of
drunkenness there has been an improvement in
public health, and a desire among the public
to do away with the evil effects of alcoholism.
The restrictions, however, as at present con-
stituted, do weigh heavily in certain directions
on the population. There is a sane and legiti-
mate use of alcohol which is penalized by the
excessive price prevailing for those who can en-
joy it intelligently, because there are others
who are unable to exercise self-restraint. There
is a vexatious curtailment of the hours at which
alcohol can be obtained, and it is quite likely
that this act has led to a certain amount of
secret drinking. Those who are opposed to
liquor control affirm that secret drinking has
taken place largely. Obviously if this drinking
has been really "secret" they cannot prove what
they say, and no one who contradicts them can
prove the reverse. The probability, however,
is that the evil has been grossly exaggerated,
but this is not to say that it may not exist. For
the time being the country is acquiescing in
liquor control of the pattern laid down as a war
measure, but the day will come when such con-
trol, like all other war measures, will be
questioned as an advisable procedure when
the country is at peace. A strong temper-
ance party will press for the maintenance
of existing restrictions and possibly for their
reinforcement. Those who, like the famous
Archbishop Magee of York, "prefer to see
England free than England sober" will de-
mand the abolition of the regulations and the
Government will have to find the Just course to
be pursued, where parties cannot be pleased.
There is one thing that should be done and
done quickly which would please all people, and
that is public house management should be re-
formed from top to toe. Many localities offer
too great facilities for the purchase of drink.
The worst • public houses, those, by the way,
which have fiourished most under the old
regime should be condemned in favor of the
better-class inns which should be required to
erect themselves into more agreeable places of re-
freshment where other than alcoholic beverages
could be obtained and more family atmosphere
found. The figure to be paid as compensation
for the destruction of unworthy public houses
is nowhere nearly so frightening as many think.
The large majority of public houses In the coun-
try are the prpoerty of the brewer, and the
business of the brewers would be actually more
profitable if the conditions of the drink trade
were restricted and cut-throat competition were
abolished. The brewers know that, and have
actually thriven duriufir the war and under the
restrictions. It is a little curious' that medical
men should appear to be so apathetic to a ques-
tion of such enormous importance, but as yet
medical evidence in both have made no appear-
ance, tho demobilization proceeds anace. The
best argument that could be used by medical
men in support of the maintenance of restric-
tions is that alcohol and venereal disease al-
ways ifo hand-in-hand, and that demobilization
is certainly going to be attended by grave
threats of venereal prevalence, even tho sailors
and soldiers obviously infected are kept with
the colors until they possess a clean bill of
health.
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January, 1919
PHYSICAL. THERAPY
American Medicine
D^UfiSfsS^I
Physical Therapy
Under the Editorial Direction of Albert C.
Geyser, M. D., New York.
IMPULSE CONDUCTION THRU
POLARIZATION.
There is no longer any doubt about the
manner of conduction of stimuli thru
nerves. The whole process may be summed
up in the one expression of "electro-chem-
ical-polarization."
What u P<darization?— The ultimate
of everything is energy-force. An atom of
hydrogen is supposed to be made up to one
thousand smaller bodies, each of which
carries electric charges. Those carrying posi-
tive charges are termed ions, while those
carrying negative charges are termed cor-
puscles. To gain some conception of the
composition of an atom of hydrogen, let us
compare the same to a molecule of water.
The chemical equation for water is H20. In
this instance the atom oxygen is bivalent.
When therefore the valency of the oxygen
is satisfied with two atoms of hydrogen —
H-O-H — we have represented one mole-
cule of water or H20. Since our knowledge
of ions and corpuscles is more or less specu-
lative we can only gain an idea by a crude
comparison. It has been calculated that
each atom of hydrogen is composed of about
seven hundred ions and about three hun-
dred corpuscles. In other words, when we
have in close association seven hundred
positive charges and three hundred nega-
tive charges, we represent one atom of
hydrogen. The positively charged ion at-
tracts as many negatively charged cor-
puscles as may be necessary for its satura-
tion. Every ion and corpuscle therefore
possesses a certain polarity. When these
polarities are turned in their proper or nor-
mal direction for attraction, there is a state
Df equilibrium. When some force or stimulus
exerts greater influence upon either the
positive or the negative charges, greater
than their mutual attraction, the equilibrium
becomes disturbed; stress or strain in the
opposite direction is manifested. When a
spirally wound steel spring is compressed
there is strain in the entire length of the
spiral. This strain or stress, the attempt to
return to a state of equihbrium, may be
utilized to perform labor.
So with a nerve, each smaller body in
the chemical constituent of the nerve cell
carries either a positive or a negative charge.
When in the case of a motor nerve a cere-
bral impulse turns the poles of the ions,
there is a stress or strain set up which,
if propagated from ion to ion, from atom
to atom, from molecule to molecule until
it reaches the end organ, there this stress
is converted into labor or a muscular con-
traction. An electric current, possessing
greater affinity than the normal polar force
of the nerve ions to each other, is capable
of disarranging their polarity for the time
being. When these actions and reactions
of ionic polar activity are summed up into
one expression, they may be designated as
"electro-chemical-polarization."
The axis cylinder of a nerve is the only
really and specifically active part in the
transmission of impulses. At this time the
chemical composition of nerve cells is as
yet totally unknown. When examined un-
der the microscope it gives the xantho-pro-
toplasmic character. We may conclude from
this that there is a generic analogy between
the chemical composition of the active sub-
stance of a muscle and that of a nerve. We
may conjecture that the transmission of
excitation along the nerve fibre is accom-
panied by chemical changes, similar to those
which take place in the muscle fibre. Some
of these changes, like polarization, are only
temporary, while metabolic changes are
permanent. The temporary changes are the
result of polarization, while the permanent
changes are the result of anabolic (build-
ing up) and catabolic (tearing down)
changes consequent upon the performance
of some physiologic function.
When we compare the rate of metabol-
ism between the gray matter and the pro-
toplasmic prolongation of the nerve cell, the
axis cylinder, we must come to the conclu-
sion that the rate of nerve metabolism is
very much slower than that of the gray
matter, because the entire gray matter of
the brain and spinal chord is irrigated by
a rich network of blood capillaries, while the
vascularization of the nerve is only slightly
developed. A better argument may be found
in the fact that the nerv^e, unlike the nerve
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PHYSICAL. THERAPY
January, 1919
47
center, is practically inexharustible even
when thrown in a state of activity for hours,
it shows no visible signs of fatigue. We
may well compare the axis cylinder to a
wire leading from an electric battery to a
bell. The changes which take place in the
battery may be considerable, the bell may
even be worn out, yet the conducting wire
be* practically immune from wear as a re-
sult of performing its function of conduc-
tion.
It seems impossible to doubt that the
metabolism is comparatively very low in the
nerve fibre, for even after strong and per-
sistent stimulation the power, as well as the
rate of conductivity, remains the same, which
evidently means that the work which the
nerve has to perform is inconsiderable. The
really important parts of the nervous mech-
anism are located at either extremity of the "
nerve fibre, the gray matter at the central
and the end organ at the peripheral end.
When an excitation is propagated from
the periphery to the center, as in sensory
nerves, or when it travels from the center to
the periphery as in motor nerves, the nerve
only needs to conduct a slight impulse, a
tiny spark, to the end organ with which
it is connected in order to effect a vigorous
process and a marked explosion of energy.
This is owing to the great power of creat-
ing stimulus at the sending end and inter-
preting the same at the receiving end. Yet,
however slight the metabolic changes may
be, the process of excitation conduction and
polarization must involve some consump-
tion of energy. The products of chemical
dissociation and the correlative development
of heat are not demonstrable even after
strong and and protracted stimulation. We
are warranted in concluding from this that
the chemical dissociation is rapidly compen-
sated by a process of restitution. It may
well be assumed that the restitution of the
chemical substances which have, of neces-
sity, been altered by excitation in any part
of the nerve is accomplished instantaneous-
ly at the expense of the next part, and that
upon this, the whole process of propagation
of the excitory impulse depends.
Electrical polarization of the substance of
the axis cylinder takes place whenever an
electric current traverses such tissue. It
must be assumed that ordinarily the poles of
the molecules are arranged in series to each
other, there is in other words saturation. A
cerebral impulse, an external sensory stim-
ulus or an electric current, changes momen-
tarily the normal arrangement.
When polarization is produced in a Ley-
den jar, a certain stress or tension is set
up in the dielectric, the glass itself, owing
to the change in the grouping of the elec-
trons. In this instance, the metal on the out-
side and the metal or other capacity on the
inside merely act as the two end organs of
a nerve. Since the outside charge is of op-
posite polarity to the inside charge, an at-
tempt is thereby made at equalization. The
moment that equilibrium is re-established,
the glass looses its stress and the normal ar-
rangement of its molecules is again mani-
fest.
A similar energy of stress is set up be-
tween cerebral activity and an end organ or
vice versa. It is this energy of stress, which
is conducted from molecule to molecule in
the nerve, that finally ends in an explosion
with the result of a muscular contraction.
Rate of CoDduction Speed. — ^The velo-
city of transmission of the excitation or
active state of a nerve may be sum-
marized as follows:
1. In the frog the mean velocity of nerve
vibration, the active or excitable state of the
nerve, is from 20 to 26 m. about 60 to 75
feet per second.
2. In warm-blooded animals this velocity
is increased from 30 to 40 m. about 90 to
112 feet per second.
3. It varies with a number of factors,
particularly with the temperature of the part
at the time of testing. This is especially
noticeable if the parts to be tested have just
been heated by the passage of a high fre-
quency current (diathermia).
4. It is not identical in every part of the
nerve.
From these facts we derive the important
conclusion that the internal excitatory
process, or active state of the nerve, is trans-
mitted at a rate that is comparatively speak-
ing so low that it must undoubtedly consist
of a chemico-physical change of the living
substance of the axis cylinder, propagated
by contiguity from one part to the next.
Since it is impossible to pass an electric
current thru a compound substance without
causing electrolysis, it follows that when
such currents are momentarily caused to
traverse a neuron, a chemical change takes
place, which is to all intents and purposes,
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48
January, 1919
PHYSICAL THERAPY
American Msdicinb
either identical with or at least similar to
the normal physico-chemical process of nor-
mal excitation.
It is further apparent, that since an elec-
tric discharge travels at the rate of about
186,000 miles per second, that the resulting
response of the normal nerve and muscle,
if at all, must be lightning-like; at least
much faster than the normal nerve excita-
tion and its response.
The term stimulus, as applied to nerve,
covers every agent capable of translating
its excitability into action, as directly ex-
pressed in the external sign of the current
of action, by which the physical change in
the nerve is manifested. The indirect sub-
jective proof of nerve excitation is sensa-
tion, when the stimulus acts upon our sense
organs ; consciousness of the voluntary im-
pulse, when it proceeds from the higher
centers. The indirect, objective proof is a
muscular contraction, when the stimulus
acts upon a motor nerve; a reflex motor
contraction, when it acts upon a sensory
nerve. In most of the work done upon the
nerve, the reaction of the muscle has been
taken as the index of activity, so that the
results for the most part apply only to motor
nerves.
We must distinguish between natural and
artificial nerve stimuli. Nerve, like muscle,
is excitable at every point of its course by
a great number of stimulating agents of
varying character, chemical, thermal, me-
chanical and electrical. Normally, however,
sensory nerves and aflferent nerves in gen-
eral are always excited from the sense or-
gans with which their peripheral termina-
tion is in relation ; motor nerves and effer-
ent nerves in general are always excited
from the central organs from which they
take origin.
It IS due to the lack of appreciation of
this unvarying law that so many errors
creep into the practice of electrotherapy. In
cases of paralysis following anterior polio-
myelitis,, the excitation does not generate
from the anterior gray horn cells, because
they are either injured or even totally
destroyed, hence the flaccid paralysis of the
limbs. The axis cylinder issuing from such
an injured trophic center may be excitable
thruout the entire length of its course by
electric stimuli, but this can in no way be
considered a physiologic substitute, altho
a muscular contraction does occur with
each application of the current. On the con-
trary, the oftener such muscular contrac-
tions are compelled to manifest themselves,
the sooner will the end organ in the muscle
wear out. The reaction of degeneration can-
not be prevented anyway, but it need not
be hurried by the useless application of
stimuli to a nerve which has been cut off
from its trophic center.
It is quite different when the paralysis is
the result of cerebral apoplexy. The muscle
in such cases does not contract because
cerebral or central stimuli are lacking;
hence the electric stimulation in any part
of the motor nerve not only produces the
usual muscular contraction but, maintains
the tone and the bulk of the muscle, be-
cause as the muscle functionates, the
trophic center, reflexly, takes part in this
'action and so is stimulated to perform its
function, that of nutrition.
The peripheral organ of the sensory
nerves is normally excited exclusively by
external stimuli of a definite character,
which are therefore known as specific
stimuli. The nerve endings of sense organs
are so constituted that they are highly sus-
ceptible to the influence of stimuli which
would be powerless to excite the nerves
themselves at the different points of their
course.
For this reason the natural stimuli for the
respective sense organs are also termed ade-
quate stimuli ; they are adapted to the
specific constitution of the sensory nerve
endings which they stimulate. The ade-
quate stimulus for the optic nerve is light,
which alone can excite retinal nerve endings ;
the adequate stimulus for the auditory nerve
is sound, which alone can excite the nerve
endings of the organ of Corti, etc.
Motor nerves, again, are normally excited
by specific stimuli, produced by the reflex
or automatic activity of the ganglion cells
of the central organ from which they orig-
inate, and on which they are morphologic-
ally and functionally dependent.
The fact that every nerve is excitable only
at one of its ends, peripheral or central,
and only to a definite kind of stimulus, is
one of the most admirable adaptations of
the animal organization, and prevents that
chaotic disorder in the activity of the whole
system which would occur if the nerves
were excitable at every point of their course
bv diflFerent external and internal factors.
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THE ANNOTATOR
January, 1919
49
e, g., the tissue fluids by which they are
irrigated, and which regukte their metab-
olism.
Altho under physiologic condition, excita-
tions never occur along the course of a
nerve, it is, as we have seen, excitable at any
point, when acted on by artificial stimuli
of sufficient strength. Its excitability is in-
dicated by the minimal intensity of the ef-
fective stimulus, when the latter can be
measured with sufficient accuracy. Speak-
ing generally, we may say that the mini-
mal intensity of effective stimulation is less
for nerve than for muscle, which shows that
nervous excitability is greater than muscular
excitability, and that the two forms of ex-
citability have a diflferent organic substrate.
THE
lANNOTATORl
Prdbibitioii and the Drug Danger. — It
is a very simple kind of mind which can an-
swer any problem with an emphatic "Yes"
or an emphatic "No." As often as not, both
answers will serve with equal truth, for
there are few questions with evidence in
their favor so irrefutable that much could
not be said one way or the other with equal
conviction. In fact, Sir Roger's favorite
evasion, "there is much to be said on either
side," is really a luminous comment on the
dual nature of every problem. The problem
of prohibition is in no sense an exception.
In our last issue we called attention to the
danger of unrest that has been associated
in many minds with the advent of prohi-
bition. Since then. Federal prohibition has
become a fait accompli. Thirty-six states
have signed the pledge and, unless the un-
foreseen occurs, the nation will be bone dry
by January, 1920. If we had an axe to grind,
all further discussion of the problem of
prohibition would be dropped forthwith as
no longer of any consequence ; but the pur-
pose of American Medicine in dealing
with this vital question has been such that
the enforcement of the amendment only
serves to inspire a greater effort to plant
danger signs along the various and tortuous
bypaths of prohibition. It is true that there
is a considerable balance of good in the
account of prohibition, but at the same time
it Is not to be denied that there is always
danger of a deficit of evil which must al-
ways be borne in mind — ^a deficit which has
been too often ignored by zealots who could
see but one side of the question. With pro-
hibition an accomplished fact, the obliga-
tion to urge caution and point the way to
safety thru the reefs and shoals that have
beset many a worthy movement increases.
The theory * that prohibition and social
unrest are closely related, tho extremely
interesting, is purely an academic one; but
there is a much more vital and seemingly
inevitable accompaniment of prohibition —
the increase in the sale of drugs which
usually takes place whenever a locality
goes dry. It is a commonplace, certainly
it is well known to physicians, that in cities
and states where liquor is prohibited, the
sale of preparations containing alcohol and
other stimulants invariably mounts to pro-
portions that cannot be justified on any pos-
sible ground. The amount of alcohol con-
sumed in this indirect manner in some cases
has almost proved equal to the amount dis-
posed of under a normal wet regime. Yet
this is by no means the most serious aspect
of the consequences of prohibition. Certain-
ly it is not a situation which the authorities
cannot remedy with wise legislation. But
the enormous increase in the public con-
sumption of drugs where prohibition is in
force has never been adequately understood
or combated by officials and, if we call at-
tention to the serious situation here now
that national prohibition seems about to
be enforced, it is in the hope that the au-
thorities will try to meet this situation
promptly and satisfactorily, and avoid the
pitfalls that beset a dry regime. It would be
tragic to court the destruction of one bad
habit by encouraging the cultivation of a
worse one.
Despite the well-intentioned skepticism
of some persons regarding the evil accom-
paniments of prohibition as regards the in-
crease in the consumption of drugs, there
is ample evidence in support of the con-
tention that the sale of drugs increases in
proportion to the decrease in the sale of al-
coholic stimulants. To understand this fact,
one must frankly acknowledge the depend-
ence of the average human being (the great
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50
January, 1919
THE ANNOTATOR
American Medicine
majority of human beings, in fact) on some
form of stimulant or other. And under the
head of stimulants come not only alcohol,
but tea, coffee, tobacco, opium, cocaine,
quinine and the innumerable table and
medicinal preparations. The severe strain
which modem civilization imposes has
made the use of these stimulants universal
and almost indispensable, and to remove
one of them from the list makes merely
inevitable that the other (perhaps the more
dangerous ones) will be resorted to. That
this is the case has been amply proved by
investigators. A very exhaustive investiga-
tion was made by the late Dr. A. P. Grin-
nell of Burlington, Vermont, some years
ago, in Vermont while it was a prohibition
state. The circumstances of the inquiry were
beset with many difficulties. Dr. Grinnell
invited information from drug stores and
general stores thruout the state, but many
proprietors, fearing a trap that would in-
volve them in legal prosecution, refused to
give any information. Others were frank
and helpful.
The data Dr. Grinnell thus obtained were
startling even to that level-headed investi-
gator. In one town, so small that it appears
only on the largest maps, there was sold
every month 3^ lbs. of gum opium, 6 oz.
morphine, 5 pints of paregoric, 5 pints of
laudanum, and 3 oz. of powdered quinine.
In other towns where there were two drug
stores (one of which refused to give any
information) the drug store that responded
reported the sale of 3 lbs. of opium, one
gallon of paregoric, three quarters of a gal-
lon of laudanum, 5 oz. powdered quinine
and one thousand 2 grain quinine pills. In
the words of Dr. Grinnell : "In the regular
drug stores, and in 160 of the 172 general
stores in the State of Vermont, they sell
every month 3,300,000 doses of opium, be-
sides what they dispense in patent medicines
and besides what the doctors dispense,
which gives one and one-half doses of opium
to every man and woman in the State of
Vermont above the age of twenty-one years
every day in the year. By dose I mean one
grain of opium, J^ grain of morphine, ^2
ounce paregoric and twenty drops of
laudanum. And the amount consumed would
average a half-dose to every man, woman
and child (without age qualification) in
the State of Vermont every day in the
year."
Further the report reads: "In 71 towns
of Vermont, being the only ones having
legally authorized liquor agencies, there
was sold during the last fiscal year $251,-
622.99 worth of liquor, or what was equiva-
lent to $1.38 worth of liquor for every man,
woman and child living in these 71 towns.
* ♦ ♦ A little further calculation from the
above figures will show that there was
enough liquor sold in the 71 towns men-
tioned to supply every man, woman and
child in the whole state with $.73 worth of
liquor for 'medicinal, mechanical or chem-
ical purposes.' In some towns in the list the
^medicinal' needs for liquor were very large,
as shown by the fact that nearly four dol-
lars' worth was consumed per capita, while
the average runs between this and one dol-
lar, the majority being above two dollars.
All in all, over one quarter of a million
dollars' worth of liquor was legally required
by a population of 182,356 people for
medicinal purposes, and the health reports
show no epidemic or undue prevalence of
disease !"
These facts, of indisputable accuracy,
speak for themselves. On the one hand, they
show a regrettable diversion of the frank
and open consumption of liquor to a sly,
underhand manner of obtaining it. On the
other hand, they show an inevitable ten-
dency to replace one stimulant by another,
often of a more dangerous nature. In one
case, the purposes of prohibition are de-
feated, with the same results ; in the other
case, the objects of prohibition are de-
feated, with infinitely worse consequences.
Those who have undertaken the responsi-
bility of bringing about prohibition must
bear these facts in mind. Their obligation
does not end with the legalization of the
measure they have advocated. It really be-
gins at this point, and, unless they can bring
about the benefits of prohibition without
incurring the many evil consequences with
which prohibition has been beset in the past,
their achievement will assume the nature
of a successful calamity. In the words of
the unlucky general : "God help me, another
such success and I am ruined !'*
The Failure of the Human Element.—
The recent tragic railroad wreck at Batavia
is so full of helpful lessons, so emphatically
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American Medicine
THE ANNOTATOR
January, 1919
51
demonstrative of one essential lesson that
has never been learned yet, that one cannot
resist the temptation to go out of one's way
to comment upon it. The newspaper report
of the tragedy is extremely illuminating:
"Batavia, N, Y., Jan. 12. — Twenty-one
sleeping passengers were crushed to death
when the New York Central's Southwestern
Limited crushed into the rear Pullmans of
the Wolverine Limited at South Byron, six
miles east of Batavia, at 3:36 o'clock this
morning. Several were injured, three of
them seriously. The cause of the wreck is
unexplained. Railroad officials declare that
the signals were set against Train No. 11,
the Southwestern, and that in addition a
flagman had gone back with a lighted fuse
to halt the onrushing train. John Friedley
of Buffalo, the engineer on the Southwest-
em, declares that the signals were clear,
and that the first he saw of the flagman's
warning light was when he was but a few
car lengths from the Wolverine."
Again we have the contrast between what
may be the invariable faultlessness of me-
chanical devices for the prevention of mis-
haps and the not infrequent faultiness of
the human device. It is unimportant which
is the case in the present instance, but ex-
perience has shown that nine times out of
ten it is the mechanical device which re-
mains perfect and the human device which
's a failure. In the vast majority of the rail-
road wrecks of the past, it is the human
element which has failed; and when, as is
all too often the case, it has been proved
that the signals all worked properly and
that it was the human element which was
to blame, both the public and the officials
throw up their hands, cast their eyes
heavenward and exclaim: "Well, what can
one do? You can't count on human nature
and you can't do anything to improve it."
And with that they feel they have dismissed
the case adequately. The railroad officials
particularly are not troubled with bad con-
sciences. For years they have spent an in-
ordinate amount of money on safety devices,
they have left nothing undone to obtain me-
chanical perfection in the various safe-
guards for the prevention of accidents, and
they have actually attained the desired me-
chanical perfection. Yet accidents occur, and
they occur altogether too frequently. The
disposition everywhere is to feel that so
long as human nature is so defective noth-
ing can be done, and such a conclusion takes
it for granted that human nature cannot be
corrected or improved. It has always been
the unreliable element and always will re-
main so. There can be no quarrel with such
a conclusion, and one can hardly censure
railroad officials for spending so much ef-
fort on the improvement of mechanical de-
vices and so little effort on the improvement
of the human element. One cannot change
human nature. The most conscientious en-
gineer will have a momentary lapse of vig-
ilance, a lapse so common to every human
brain — and then it is too late. Another
wreck has been added to the list.
But it is one thing to try to improve hu-
man nature, and it is another to attempt to
safeguard it; the failure of the rail-
roads lies in the fact that they have pro-
vided every safeguard for the proper work-
ing of signals, switches and fuses, but
they have provided insufficient safeguards
for the proper working of the human ele-
ment. All the effort has been on the side of
strength, and there has been too little ef-
fort on the side of weakness. Consider the
problem of the race-track. Why is there
always more than a single individual in the
judges' stand? At the race-track, it is the
human element which is depended upon
for a precise verdict and, knowing the falli-
bility of this element, tradition has always
provided for three or more judges as a
safeguard against the tendency toward hu-
man error. By multiplying the units of hu-
man element involved, the margin of error
is decreased. And in the case of the race-
track, the judges are not diverted by any
consideration other than the problem of the
race. There is no division of interest, and
yet allowance is made for error. In the lo-
comotive cab, the chances of error are in-
creased considerably by a divsion of inter-
est. The one man on whom the safety of
the passengers depends must not only give
his attention to signals but he must give no
small amount of thought to the actual oper-
ation of the locomotive. His responsibility
is divided. Of course, he has from time to
time the assistance of his stoker, but the
stoker's interest is also divided. Thus you
have two men, both with responsibility di-
vided between two jobs, burdened with a
serious care which should be absolutely un-
diverted by any other interest ; and the con-
sequence is — a wreck. If on the race-track.
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52
January, 1919
AMONG THB BOOKS
American Medicine
where interest is concentrated on a single
responsibility, discount is made for the lia-
bility of error, certainly the liability to err
in the locomotive cab is greatly increased.
And what safeguards are provided against
this tendency to diversion of interest ? Prac-
tically none.
The conclusion is obvious, and that the
railroads have missed this conclusion is
very strange. There should be a third man
in every cab, or somewhere among the crew
of a train, whose sole interest should be
in the careful observation of signals and
whose interest must not be divided by any
other responsibility. In such a measure lies
the only solution to our too frequent train
wrecks, and until such a step is taken the
much lamented weakness of the human ele-
ment will remain a source of the greatest
danger to railroad travelers. The greatest
attention to the mechanical device, but more
attention to the human device — ^that is the
commends itself for home use as well as a text-
book for secondary educational institutions.
answer.
AMONG
THE
BOOKS
DKSi^
Civic Biology* — It would not be unnatural for
pbysicians interested in the welfare of their
children to make use of a textbook presenting
biology in its civic aspects. Among the various
textbooks which have been presented few have
a loftier concept of civic biology than that writ-
ten by Hodge and Dawson (Civic Biology, Ginn
and Company). The recognition of the fact
that the progress of civilization is dependent
upon cooperation for the common good is not
as widespread as it might be. Civic Biology
aims to make clear the inter-relation of many
of the forces of nature, many of which cannot
be counteracted save by the harmonious action
of communities. Obviously, communal activity
becomes possible only when an intelligent
citizenry grasps the importance of the biologic
problem and is cognizant of the methods of
attacking the problems most successfully.
Birds, insects, spiders, rats, fungi, bacteria,
moUusks, Crustacea, fish, amphibia, reptiles and
mammals are not merely isolated families or
species only of interest to the naturalist. They
are very essential factors in the health and wel-
fare of the human family, and an understand-
ing of the problems in which they are involved
is essential that communal health may be ad-
vanced. In explanation of these relations
Hodge and Dawson have written a book which
Materia Medlca^— Drugs, generally speaking,
are not so largely employed as was formerly the
case, due somewhat to their unsatisfactory re-
sults and in no small degree to lack of knowl-
edge of their true therapeutic properties. It is
both instructive and curious to note the very
large number of drugs which once used to be
considered valuable, but which have fallen into
disrepute, or even been relegated to "the scrap
heap." In many instances these have first
been carefully, scientifically and clinically
weighed in the balance, and found wanting. On
the other hand, not a few others which have
been esteemed lightly have been discovered to
possess great remedial merits as they have been
studied more carefully and comprehensively.
Consequently, it may be stated that the ulti-
mate test of a remedy lies in a demonstration
of its clinical efficiency, rather than in the out-
come of laboratory experiments, valuable and
important as these are in their proper place.
Dr. Walter Bastedo, in his splendid work on
Materia Medica, Pharmacology and Thera-
peutics, Second Edition (W. B. Saunders Com-
pany, Philadelphia^, 1918) deals exhaustively
with this large subject of remedies and their
application to disease. The ruling object of
the book is to emphasize the importance of re-
search, both in the laboratory and at the bed-
side, and to point out any discrepancy between
the value of a remedy as established by such re-
search and its supposed value in therapeutics.
The author has succeeded admirably in his en-
deavor and has distinguished between the
values of the various remedies with rare
acumen. Dr. Bastedo is an optimist regarding
the future of therapeutics and he voices his
faith in the following striking words: "I be-
lieve that as the outcome of critical laboratory
research and the adoption of laboratory methods
in clinical research are properly appreciated,
we are at the dawn of a new era of simple and
practical therapeutics, an era in which knowl-
edge will supplant credulity on the one hand,
and skepticism on the other, and in which
fewer drugs will be used but better treatment
given."
Especial attention has been paid to the thera-
peutic uses of digitalis and the author has
drawn his conception of its action as much
from his own recent clinical studies and from
the recent investigations of others, as from
those of the pharmacologic laboratory. The
criticism may be made that an undue amount
of space has been devoted to digitalis but when
the value and the wide employment of the drug
in heart affections is borne in mind, it will be
allowed that this criticism is devoid of force.
A feature of the chapter on digitalis is the
really excellent diagrams showing the action of
digitalis upon certain heart conditions.
The section dealing with opium and its de-
rivatives is unusually complete and contains a
great fund of valuable information. Among
what may be termed the curiosities of morphin-
ism is the fact reported by McGuire and Lich-
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AMONG THB BOOKS
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53
tenstein, and now emphasized by Bastedo, that
in women habitute, a quite remarkable growth
of hair is often observed. The .section on
anesthesia is likewise worthy of high com-
mendation. In fact, the entire work has been
excellently conceived and the conception has
been as excellently put into execution. This, the
second edition, has been thoroly revised and
brought up to date, and into conformity with
the ninth revision of the U. S. Pharmacopeia.
Several new articles have been introduced,
among others, those on magnesium sulphate,
oil of chenopodium, and the Dakin-Carrel anti-
septic treatment for wounds, being especially
noteworthy.
Dr. Bastedo has given the profession a work
which cannot but prove of the greatest practical
value to medical practitioners everywhere, who
wish to apply their remedial measures with a
definite and comprehensive knowledge of their
action and effects.
Medical Practice*— A Practice of Medicine
that has gone thru thirteen editions needs
little eulogy. The fact speaks for itself and the
only thing to say concerning a work with such
a record is to notice the changes and revisions
which have been made. The Practice of Med-
icine by Dr. James M. Anders (W. B. Saunders
Company, 1917, thirteenth edition) has been
thoroly revised with the assistance of Dr. John
H. Musser, Jr., while the section on Nervous
Diseases has been practically rewritten by Dr.
Charles S. Potts. Much new matter has been
added on treatment of tetanus, acidosis, chylo-
thorax, etiology of aortic incompetency, treat-
ment of asthma, diverticulitis, functional tests
of hepatic InsufBciency, Oaucher's disease, esti-
mation of renal function, anaphylaxis, food In-
toxication, the pneumococdc infections, focal
sepsis, rat-bite fever, febris Wolhynlca and
pyorrhea alveolaris. Other subjects have been
rewritten, others have been classified In accord-
ance ^th the most modern and approved teach-
ing. On the other hand, the descriptions of yet
other complaints, of which the incidence has ma-
terially declined, have been abridged. Diagnostic
tables have been added and the entire work has
been brought into line with the most recent con-
cepts of prevention and treatment The book
is adequately illustrated and from all points of
view is a splendid exi>onent of medical knowl-
edge told in clear and concise language. Anders'
Practice of Medicine is one of the great con-
tributions to American medical literature that
has helped to place American medicine on its
present plane.
The Tliird Great Flagvcn-Tuberculosis is the
first great plague, because it is the longest
known and the best understood by the com-
munity at large. Dr. John H. Stokes in his
work, TTie Third Great Plague (W. B. Saunders
Company, 1917), terms cancer, the second great
modem plague and syphilis the third great
plague. Undoubtedly, there will be difTerence
of opinion as to tuberculosis being the first of
the great modern plagues, but many would place
bubonic plague second of the list. Perhaps,
however. Dr. Stokes refers particularly to com- -
municable diseases occurring among white men,
and if this be his meaning, then cancer may
be put down as second on the list. Moreover,
Dr. Stokes has reference to diseases which un-
dermine, slowly but surely, the very foundation
of life. Under this category cancer will natur-
ally stand dose to the front
With this preamble, Dr. Stokes' Illuminating
book points out what is perfectly true— that
syphilis is still shrouded in obscurity, en-
trenched behind a barrier of silence, and armed
by our own ignorance and false shame, with a
thousand times its actual power to destroy.
It is likewise true — and it is a lamentable com-
mentary upon the prudishness of dviliced peo-
ple— that despite the fact that it is known how
to prevent syphilis, and in a large proportion
of cases how to treat it successfally when con-
tracted, the general public prefer to remain
Ignorant on the matter, or refuse to learn the
truth.
Dr. Stokes al^o lays emphasis upon a point
which is ofttimes passed over, to wit, that the
power for evil of tuberculosis has been crip-
pled not so much by any marvelous discoveries
of its cause and the possibility of its cure, as
by the spread of knowledge far and wide of
rational means of prevention and treatment.
The author is sufficiently optimistic to believe
that cancer will be obliterated by similar wide-
spread propaganda. His slogan is "make a dis-
ease a household word and its power is gone."
Education of the masses with respect to the
most effectual modes of preventing and treat-
ing syphilis is the only method by which the
plague may be stayed. Dr. Stokes' book is a
step in this direction. It puts accepted facts
concerning syphilis in such a form that they
will the more readily become matters of com-
mon knowledge.
This book, therefore, should be widely read
and in this event would serve as an Important
part of a campaign of public education regard-
ing the third of the great plagues.
The author, commenting upon the method of
personal prophylaxis devised and developed by
MetchinkofF and Knox of an ointment contain-
ing a mercurial salt, to be applied within a
few hours after intercourse, claims that if in-
telligently applied, it is one of the Important
weapons for the extinction of syphilis at our
command at the present day. At the same time
he thinks that it may well be doubted whether
the indiscriminate placing of this ointment in
the hands of anybody and everybody would not
work as much harm as good, thru ignorant and
careless use. This very matter is being hotly
debated now in Great Britain, for altho this,
form of personal prophylaxis has met with
striking success in the British army in Egypt,
and is largely employed in Italy and in other
parts of Europe, there is a strong prejudice
against its general adoption among a large sec-
tion of the British public. In Great Britain,
however, the opposition to its use is based on
moral scruples. Under existing circumstances,
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January, 1919
ETIOLOGY AND DIAGNOSIS
American Medicine
Dr. Stokes* book should assist In awakening a
lethargic and indifferent population, not only
to the sinister menace of syphilis, but also to
the fact that it is preventable and curable.
ETIOLOGY
jlpiAGNOSI
Diagnosis of Peptic Ulcer. — From studies on
many cases of peptic ulcer in which X-ray ex-
aminations were made, Baetjer, in the Johns
Hopkins Bulletin for August, 1918, states that
we are justified in drawing the following con-
clusions:
1. The X-ray offers most valuable assistanoe
to the diagnosis of peptic ulcer and altho this
method is not yet sufficiently Well developed to
be relied upon alone without entering into the
clinical aspects of the disease, it is of the great-
est diagnostic help in obscure cases. Positive
X-ray findings are noted in about 84 per cent
of cases of peptic ulcers and in 79 per cent of
cases operated upon.
2. Duodenal ulcer shows excessive hyper-
motility of the stomach with rapid evacuation
of the contents, so that the greater portion is
extruded within the first half hour; there is
hypermotility of the duodenum with formation,
usually of a deformity which remains fixed in
all of the examinations.
3. The diagnosis of gastric ulcer is dependent
upon two conditions, namely, the functioning
of the stomach and the finding of the filling
defect. It is only when the filling defect is
situated along the anterior surface of the
stomach and along the anterior surface of the
lesser and greater curvatures that it can be
demonstrated. On the other hand, it matters
not what the situation of the ulcer is, the func-
tions of the stomach are materially affected.
We have in this condition an excessive irrita-
tion from the ulcer, with consequent hyper-
motility and a spastic condition of the pylorus,
so that for the time there is practically no ex-
pulsion of bismuth. It is only when the spas-
ticity relaxes that a portion of the bismuth is
expelled. In gastric ulcer, wherever its situa-
tion, we can always look for a certain amount
of retention of contents. There is always a
more or less marked hour-glass formation. Ac-
cording to our observations the functional signs
are often as important as the presence of the
filling defect in arriving at definite conclusions,
inasmuch as in 8 per cent, of our cases, altho
there were no defects found, the functional
changes pointed definitely to ulcer.
4. The greatest difficulties arise in the diag-
nosis of complicated cases; that is, when adhe-
sions are present. These so frequently mask
the usual findings that it is often impossible to
determine whether there is really an ulcer of
the stomach at hand or a lesion of some other
organ. When the ulcer is situated at or near
the pylorus, signs of partial obstruction fre-
quently aid in establishing the diagnosis.
5. The X-ray affords an almost absolute
means of differentiating between gastric and
duodenal ulcer.
6. By means of the X-ray examination we
can generally rule out the presence of ulcer.
7. We can approximately determine the de-
gree of healing as well as recurrence of an ulcer
which cannot be as certainly determined in any
other way.
8. One can obtain sufficient evidence as to
the extent and induration of the ulcer and de-
gree of obstruction to guide us, in a measure,
as to the necessity of surgical intervention.
The Early Diagnosis of Pulmonary Tuber-
cnlo8i8.^Early diagnosis Is the essential factor
in the treatment of pulmonary tuberculosis, but
there is still a tendency to attach too great
weight to the physical signs alone, claims an
editorial writer in the London Lancet (Oct. 12,
1918). We may recall two of the aphorisms of
the late Dr. Samuel Qee: "Therapeutics must
begin before physical signs have developed; for
if you wait for physical signs you wait too
long" ; and "In any case of phthisis the disease
is more extensive than the physical signs would
seem to indicate." Conversely, extensive phys-
ical signs may be left after arrest of the disease
and may be consistent with health and freedom
from all activity of the old pulmonary lesions.
It is necessary in every case, before making a
diagnosis or advising treatment, to review the
history, the symptoms, the physical signs, the
general condition of the patient, and sometimes
his reaction to varying conditions, especially
where there is no sputum for examination. We
publish in our present issue an admirably sug-
gestive article on this question by Mr. Alfred
Foster of Christchurch, New Zealand, emphasiz-
ing the importance of these considerations for
the general practitioner, to whom, in a large
proportion of cases, the opportunity for the
early diagnosis of pulmonary tuberculosis is
afforded. If the doctor suspects the. onset of
phthisis before the actual development of un-
equivocal physical signs and takes steps to
establish the diagnosis by a careful review of
all the information available, the patient may
be enabled to secure treatment under the most
favorable conditions. Mr. Foster was impressed
by the attacks which occur in sanatorium pa-
tients, usually induced by some indiscretion,
such as over-exertion. These he describes as
associated with loss of appetite, feeling seedy
all over, increased cough and with more or less
rise of temperature. Such attacks are some-
times referred to as due to autoinoculation and
are doubtless the result of the action of the
products of the tubercle bacillus. Mr. Foster
classifies these symptoms as follows: (1) cough
and expectoration, (2) loss of weight, (3) loss
of appetite, and (4) rise of temperature. He
urges that the concurrence of these conditions
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TREATMENT
January, 1919
55
should lead to a careful examination of the evi-
dence in favor of pulmonary tuberculosis and
in particular that a careful and continuous
record of the temperature should be taken. Too
often this association of symptoms is attributed
to recurrent influenza, or to trivial catarrhal
conditions and thus the opportunity for early
diagnosis and treatment may be lost. Such
evidences of autoinoculation, especially if con-
tinuous or repeated, should give point to slight
and dubious signs or tend to a diagnosis even
in the absence of signs. Attacks like this are
commonly observed within sanatoriums while
the patient is under treatment and Mr. Foster
thinks their nature should be recognized as
suggestive in patients vHthout sanatoriums
before a diagnosis is established.
Etiology of Multiple Osteoma of the Nasal
Accessory Sinuses^— Culbert (N, 7. State Jour,
of Medicine, Dec., 1918) in his article gives the
following conclusions:
(a) In cases of osteoma of the nasal acces-
sory cavities, there is in all probability an origi-
nal fault or tendency, congenital In the indi-
vidual.
(b) Such faults or tendencies, when not
irritated to activity, often probably remain
quiescent and never develop.
(c) Conditions likely to activate ostematous
growths are:
1. The great neoformative activity in the
frontal regions during adolescence.
2. External traumatism.
3. Ehidogenous irritations: inflammations
and infections of the nasal accessory cavities,
i. e., the sequelae of grippe influenza and the
whole range of naso-pharyngeal afTections.
These conditions are probably the most frequent
cauBC of trouble.
4. Constitutional maladies, particularly syph-
ilis and possibly other infectious diseases.
5. Above all, combinations of these different
causes; of the effect of such combination, the
literature furnishes many examples.
Theory of Acidosis*— In speaking of the
theory of acidosis. In the Mississippi Valley
Medical Journal for February, Shimer makes
the following summary:
1. Acidity of the blood is due to the presence
of fixed and volatile acids.
2. One of the volatile acids is CO, in solu-
tion.
3. One of the fixed acids is lactic.
4. In taking the H ion concentration of the
blood it is necessary to know the CO, tension
of the alveolar air. If a blood tested in this
manner has an increased H ion concentration
and a high CO, tension, the increased H ion
concentration is due to a volatile acid; if the
COi tension is low, the acid is a fixed one. If
the H ion concentration is normal and CO,
alveolar tension high, there is a lowered excre-
tion of CO,.
5. Acidosis is a comparative decrease in the
alkalinity of the blood and expresses the in-
ability of the body cells to neutralize the usual
amount of acids formed during metabolism.
REATMENT
Treatment of Tertlgo^— Empty the bowels
and prevent them from filling up. Young (Med.
Summary, Dec., 1918) states; first, by adminis-
tering full doses of Epsom salts to effect; then,
use mineral oil enough to cause a daily ac-
tion. Repeat the saline purge every two or
three weeks, and give from five to ten drops of
spirits of turpentine twice a day, one week, and
gum camphor the next week. One grain three
times a day, and let up for a week or ten days.
These remedies stimulate the spinal cord, and
brain, especially the cerebellum, oblongata and
pons.
The Dietetic Treatment of Liver Diseases.—
Eustis, in the New Orleans Med. and Surg. Jour.
for August, 1918, states that the diet in hepatic
diseases should consist essentially of an abund-
ance of carbohydrates, and while transient
glycosuria may be produced, this soon disap-
pears as the liver cells regenerate. The diet
must be selected according to the gastric func-
tion of the patient and, if vomiting exists, glu-
cose by drip protoclysis or hypodermoclysis
must be resorted to. Where there is little dis-
turbance of gastric function the following diet
list should be selected from, and the patient
maintained on this diet as long as there is an
intestinal toxemia:
DIET LIST FOR PATIENTS WITH DEFECT-
IVB LIVER FUNCTION.
May Take.
Soups: All clear soups, vegetable broths,
pur^ of corn, beans, peas, asparagus, spinach,
celery, onions, potatoes and tomatoes.
Farinaceous: Oatmeal, rice, sago, hominy,
grits, cracked wheat, whole wheat bread or bis-
cuits, com, rye and Graham bread, rolls, dry
and buttered toast, crackers, muffins, waffles,
batter cakes, wafers, grape nuts, macaroni,
noodles and spaghetti.
Vegetables: Potatoes (sweet and Irish),
green peas, stringbeans, beets, carrots, celery,
spinach, artichokes, alligator pears, eggplants,
lettuce and onions. All vegetables except cab-
baj?e, cauliflower anil turnips.
Desserts: Rice and sago with a little cream
and sugar, flgs, raisins, nuts, and syrup, stewed
fruit, preserves, jellies, Jams, marmalades and
gelatin; prunes, apples, and pears, either raw or
cooked.
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January, 1919
TREATMENT
American Medicine
Drinks: Tea and coffee (with cream, but not
milk), grape juice, orangeade, lemonade, lime-
ade and Vichy* cocoa. An abundance of pure
water, cold or hot.
Must Not Take.
Eggs: None.
Fish: None.
Meat, Game, or Poultry: None.
Veal, pork, goose, duck; salted, dry, potted or
preserved fish or meat (except crisp bacon) ;
oysters, crabs, salmon, lobster, shrimp, mack-
erel, eggs, turtle and ox-tail soup, gumbo, pat-
ties, mushrooms, mince pie, cabbage, cauli-
flower, turnips and cheese; alcohol.
Negative tests for urobilinogen and indican
extending over a week indicate that either eggs,
fish, or easily digestible meats may be taken
in moderation, in the practice of Eustis this
being limited to not oftener than once a day.
It will be found that buttermilk to which lactose
has been added is the best animal protein on
which to start, but he cannot too strongly urge
a constant control of the diet by frequent ex-
aminations of the urine.
Oil of Chenopodliim in the Treatment of
Amebic Dysentery*— Barnes and Cort in the
J, A, M. A, (Aug. 3, 191S) conclude as follows:
1. Oil of chenopodium relieves promptly the
clinical symptoms in many patients with chronic
and subacute amebic dysentery.
2. Oil of chenopodium administered by
mouth or by rectum possesses marked power as
an amebicide, as is shown by the rapid disap-
pearance of amebas from the stools, following
its administration.
3. There is a tendency to relapse in some
cases, but in their series this is not greater
than with the use of emetine.
4. The oil of chenopodium may be safely
administered, when combined with castor oil
in a single dose.
The Vaccine Treatment of CoryEa*— Attention
is directed to the end-results of ordinary catar-
rhal inflammations of the nasal mucous mem-
brane, especially when the attack is prolonged,
and frequently repeated. In these cases the
sinuses become involved and infection persists.
Fifleld {Med. Record, Mar 10, 1917) has found
autogenous vaccines to be very beneficial under
such conditions, and better than stock vaccines.
Patients who suffer from obstruction of the
nasal cavities must first have these lesions re-
lieved, before the vaccine treatment is applied.
The Prevention of Measles*— In The Practi-
tioner for April, 1918, Milne gives this advice:
Prevention. — Every "contact" and every child
that may become exposed to infection should
receive ten drops of the best pure eucalyptus
oil twfce (or, better still, three times) a day,
placed on the day shirt (front of chest) on ris-
ing, and at midday, and on the night shirt
when retiring.
Treatment. — Three points should be noted:
A. Rubbing: Before being allowed to mix
with other children the patient should have his
first rubbing. The patient is rubbed all over
(scalp included) with the best pure eucalyptus
oil, twice a day for the first four days, then
once a day for six more days — ten days in all.
B. Swabbing: The throat is to be gently
swabbed with ten per cent, carbolic oil every
four hours for three or four days. The swab-
bing should be carried out right between the
fauces, and may be done by means of a mop of
cottofi or wool on the end of forceps.
C. Gauze Tent: In measles one of the chief
sources of infection is probably the cough. A
bed cradle, or other substitute, Is put over the
patient's head, and over the cradle la spread a
layer of gauze. Just thin enough for Uie patient
to see thru. The gauze must cover the head
and neck and must be sprayed with eucalyptus
oil periodically, every four hours. This is con-
tinued until the cough ceases, or for ten days.
Treatment of Unclnariasls^n-McOulloch (8o.
Med. Jour.) states that hookworm disease is one
of the few diseases in which we fortunately
have what may be called a specific treatment.
Three drugs have this specific action: thjrmol,
oil of chenopodium and betanaphthol, and of
these chenopodium is the most efficacious, thy-
mol stands second, and betanaphthol third.
Gonorrhea In the Female. — ^Edward E. Ziegel-
man (Medical Sentineh Dec., 1917) claims that
gonorrhea in women is one of the most dif-
ficult of diseases to cure, requiring unlimited
perseverance and in many cases surgical skill
and Judgment on the part of the physician and
the explicit confidence of the patient. A cure
must bo determined only on bacteriologic and
serologic examination, not on amelioration of
symptoms. He believes that in order to control
this disease and obtain results it will be neces-
sary that all infected women should be under
civil Jurisdiction, or subject to the sa^e, and
that, if necessary, public clinics with salaried
attendants should be provided. It is useless to
treat a female gonorrheic who persists in hav-
ing intercourse with an infected man.
FlatfooL— H. V. Sails {Gorrespondenz-Blatt
fUr Schtoeizer Aerzte, Sept. 8, 1917) applies an
adhesive plaster bandage over the front part of
the foot and back of the toes, so as to force the
middle metatarsal bones upward and hold them
in the normal arch, after softening and remov-
ing the calluses from the foot. This is cut and
laced along the dorsum of the foot, and also for
a distance at the side near the ankle, so it can
be removed easily. He says that mild cases of
fiatfoot can be cured by wearing this dressing
some months, but in bad ones it has to be worn
permanently.
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In AdtBDoe
CONTENTS
BiDiTORiAi* commifT
MBOf AMU THINGS
ORIGHfAIi ARTICU98
LOlfDOBT UBTTBR
CORRBSPOlTDBlfOB
RATIONAL OaGANOTHBRAFY
PHYSICAL THBRAPY
TRBATMBINT • • • .
NEIW8 NOTB9 AND ANNOITNCBBIBNTS
87
ee
78
109
14M
106
107
111
118
(Contlniiad on vmm% <)
CONTRIBUTORS
HBNRY B. FBLLB, M. D., liOUlsVllle. Ky.
ALBBRT O. GBY8BR, M. D., New York Cit/.
GBORGB M. GOULD, M. D.» Atlantlo City, K. J.
CHARLEIS GRABF M. D., New York City.
BBVBRLBY ROBINSON, M. D., New York.
jr MADISON TAYLOR, A. B., M. D, Philadel-
L LINDBNBBRGBR, M. D., LouiariUe, Ky.
V. B. SIMPSON, M. D., Loulsville, Ky.
D. S. WILSON, M. D.« LouisvlUe, Ky.
A. R. BIZOT, M. D^ Louisville. Ky.
J. G. JiSB, M. D., Cairo. Bffypt. , __
JOHN P. DATIN, M. D., New York City.
KnltMd M Moond-dMB matter January 18, 1906, al Ihe Port Qffioe rt Borlinglon, YL, under Art of ComrMBS, ICaroh 8, 1879.
In the Treatment of
RHEUMATIC and
NEURALGIC ILLS
yon will obtain Bnbstantial aid from tlie thorongli nse of
K-Y ANALGESIC
This non-greasy, water-soluble local anodyne will enable you
to ease your patient^s pain and discomfort, while your internal or
systemic medication is combating the cause of his condition.
The advantages, moreover, of relieving the pain of a facial
neuralgia, an inflamed joint, or aching lumbar muscles without re-
course to coal tar derivatives cannot fail to appeal to medical men.
K-Y ANALGESIC is a safe and effective adjunct that will daily
grow mcMe useful to the practitioner as the many opportunities for
its effective use are realized.
YAN HORN & SAWTELL DEPARTMENT
NB^r BRUNSWICK, N. J., V. S. At
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•ftiJv<* *»'. -"■< .r <
4^i^Y;iii.':tLkliiii:-i*i-'^ """"'^
The Phylacogen Treatment
of Pneumonia
BECAUSE of its frequency and high mortality pneumonia ia
rightly regarded as one of the most serious diseases widi
which the medical profession has to contend.'
It is said upon good authority that approximately ten per
cent, of all deaths in the United States during recent years have
resulted from pneumonic infection.
These facts suggest this question: Is it justifiable to adopt
'"expectant treatment** when a product of specific character is
available?
Experience leads to the conviction that almost every case of
pneumonia seen within twenty-four hours after the initial, chill
will terminate, in recovery if perseveringly treated with Pneu-
monia Phylacogen.
To obtain the best possible results Pneumonia Phylacogen
should be employed in the early stage of the disease. Its
administration even in mild cases is earnestly recommended,
as by its use the diiration of the disease may be curtailed and
grave developments' prevented.
Bio. 605. Balbs of 10 mils, one in a package.
Bio. 607. Bulbs of 1 mil, five in a package.
NOTE.— Attention is directed to the new Phylacogen Syrinf e pictured
above. This is an ideal instrument for the administration of Pneumonia
Phylacogen. It is fully described in our catalogue.
Home Offices and Laboratories.
Detroit, Michigan.
Parke, Davis & G>.
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American Medicine
H. EDWm LEWIS, M. D., Mammrinr Editor
PUBUSBID MOIITHLT Vt ,THM AMBUCAX MBDICAL PUBLISHDIG COMPAMT
Connrigliled by Um AmeriMn Medieal PnbUihinc Co., 1919
IBA 8. WILE, Associafe Editor
Complete Series, Vol. XXV, No. S
New Svies, Vol. XIV, No. 3
FEBRUARY. 1919
#0 on YEARLY
^£,.\n3 In Advance
Organised Medical Leadership^-^At the
Seventh Annual Congress of the National
Safety Council, Dr. J. A. Cousins made the
following statement, according to the
Monthly Labor Review (November, 1918) :
"There are two ways in which employees
may be regarded, and only two: One as
machines, the other as men. They are no
longer content to be regarded as machines ;
they are going to insist, with ever-increas-
ing firmness and decision, on being re-
garded not only as men, as fellowmen, but
as fellow creators of the industries in which
they toil. They are going to insist that
a man wl\o invests his life in a business,
who puts his toil into it, is to be considered
before the man who merely puts his money
into it. From a physician's standpoint 'the
"human element" must not merely be recog-
nized, it must be predominant,' and this is
the only way to avoid unnecessary loss of
time and unnecessary waste of energy and
product."
The suggestion that the human element
must be recognized as predominant might
well be extended to other phases of medi-
cine besides the industrial. The medical
profession, as a whole, continues to be back-
ward in accepting or approving the funda-
mental truths of preventive medicine which
cluster about the human element in society.
No g^oup of professional workers in the
country is in a position to understand the
human side of mankind as thoroly as physi-
cians but, nevertheless, the organized pro-
fession has failed to take leadership in
promoting the social welfare of the indi-
vidual. It is a source of regret that medi-
cal societies as a rule are charged with be-
ing reactionary. The natural skepticism of
medical men can hardly be regarded as a
sufficient excuse for failing to lead in pub-
lic health affairs.
Despite meetings constantly going on of
county, state and national organizations
and the growing literature appearing in
medical journals, there are still very few
evidences of the practical study of the great
social problems manifested at the various
meetings of medical men. In the large
movements for the prevention of tubercu-
losis, the conservation of vision, the de-
velopment of mental hygiene, the control
of venereal diseases, the study and preven-
tion of infant mortality, lay groups have
been, with rare exceptions, the stimulating
elements, the founders, the promoters and
the agitators of all necessary reforms. In
many instances medical societies have been
forced thru public opinion to participate
actively in public health campaigns. Many
times It has been necessary to shame or to
dragoon them into cooperative effort to ad-
vance the general welfare. This is a serious
criticism of a group of the community which,
because of training, education, and profes-
sion, should assume leadership in health
matters. It is true that in the ranks of work-
ers are found many distinguished physi-
cians, but their efforts and endeavors have
been personal, and not infrequently has
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February^ 1919
EDITORIAL. COMMENT
Amkbicam Mbdicinb
their support been given in spite of the op-
position of a large proportion of their col-
leagues.
What great steps for the promotion of
public health in the City of New York stand
to the credit and the initiative of the large
medical organizations of the City of New
York? What is their record of accom-
plishment in formulating health programs
and securing their adoption by the com-
munity? Has the Academy of Medicine,
splendid organization as it is, for example,
discharged its full obligations as part of the
civic life of New York by inaugurating
schemes for the improvement of public
health ? Wherein has the New York Coun-
ty Medical Society with all its influence,
demonstrated its effective leadership in
aiding this community to secure improved
public health or social conditions? It is not
to be denied that both organizations have
at various times passed resolutions in sup-
port of policies projected by others. It is
true that committees of these organizations
have at various times appeared before pub-
lic bodies in support of requests for ap-
propriations or for the adoption of specific
regulations. As individuals, many members
have rendered faithful service in behalf of
important public health movements. But
have they, as representatives of organized
medicine, actually undertaken to start any
activities in the community and to urge
them as a result of their organized knowl-
edge and experience?
Singling out the organizations of New
York City is not for the purpose of criti-
cizing them any more than similar organ-
izations thruout the United States. Organ-
ized medicine has not lived up to its respon-
sibilities or obligations in proportion to its
numbers or potential power. * -The much
despised "social worker," "reformer," "up-
lifter" can point with pride to a series of ac-
complishments along health lines that far
surpass the efforts of medical societies. In-
dividual health commissioners, in numerous
cities and states, with their various expert
•subordinates, have been more successful in
promulgating health policies than medical
societies, and not infrequently they have
been obliged to fight for their ideas against
the active opposition of medical organiza-
tions which have failed to recognize the
human element in its public health relations.
Physicians frequently express themselves
as resentful of the lack of consideration
they receive at the hands of those endeavor-
ing to secure hygienic reforms. If the
medical profession, thru its organizations,
were in the forefront of health movements
and were less reticent in expressing their
views and convictions, it would not be neces-
sary for them to be constdted, but on the
contrary they would be in the position of
inviting the cooperation of those* who, un-
der present conditions, are accustomed to
going ahead without consideration of the
possible support to be secured from medical
societies. As long as this latter state of af-
fairs continues medical men cannot hope to
win and hold the place in their respective
communities to which their knowledge and
training give them a right to aspire.
In the .various reorganizations of society
now going on as a result of the tremendous
world upheavals, there is distinct need for
medico-social leadership. Unless medical so-
cieties swerve from their course of re-
actionary passivity, they will be ignored in
the development of the social organism that
is so apparent above the horizon. If real
leadership is not forthcoming, if oppor-
tunities are not seized, the general public
will have little faith in medical opinions and
ideas as expressed in resolutions.
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AMSRICA.N MeDICINB
EDITORIAL. COMMENT
February, 1919
59
One might ask, as a question of interest,
how far medical societies are responsible
for failures in health administration when
they fail to recognize the human element
in health administration and permit ineffi-
cient health administration, or do naught to
prevent the breaking down of effective ad-
ministration for political reasons? Medical
politics unquestionably represent an ex-
treme type of the selfish human element,
and to permit politics to enter into health
administration, or to weaken hygienic ma-
chinery is evidence of a complete failure to
understand the importance of the social
phases of health protection. Medicine must
not condone or tolerate political inaction or
chicanery in health administration.
Medical societies have been effective in
many ways in promoting medical progress
and the social intercourse of their mem-
bers, in advancing their intellectual life,
and in stimulating and encouraging col-
leagues to dwell together with reasonable
peace and amity. But the time has come
when they must serve the community as a
whole, as well as their membership. They
must have vision, courage, directness and
activity, in striking contrast to the egre-
gious passivity and inaction which has char-
acterized them in the past in most affairs
where the public welfare has been involved.
There must be more leadership in con-
structive action, and possibly fewer resolu-
tions whose value has departed after the
ink has been dried on their first publication.
Experimental Polyneuritis. — ^The study
of diseases due to dietary deficiencies is de-
pendent largely upon experimentation. In
The Public Health Reports (January 3,
1919), Voegtlin and Lake call attention to
their studies of "Experimental Mammalian
Polyneuritis Produced by a Deficient Diet,"
the detailed report of which is published
in the American Journal of Physiology
(January, 1919).
A resume of their findings demonstrates
that a polyneuritis can be produced in cats
and dogs as the result of an exclusive
dietary of lean beef which has been heated
for three hours at 120° C, in the presence
of sodium carbonate. The symptoms of loss
of weight, weakness, paralytic symptoms,
convulsions, muscular spasticity, disturb-
ances of circulation and respiration, and the
loss of body weight promptly clear up after
the oral administration of the antineuritic
substance of yeast.
Their investigations have determined that
polyneuritis is due to a dietary insufficiency
of the antineuritic substance, and not to a
deficiency of such other essential dietary
components as the amino-acids and fat-
soluble vitamines. The most practical ob-
servation resulting from their experiment is
that the ordinary cooking of meat for hu-
man consumption does not lessen its food
value, insofar as its antineuritic power is
concerned, because the cooking of meat for
three hours at the temperature of 120® C,
without the previous addition of alkali, does
not completely destroy its antineuritic pow-
er. From the standpoint of investigation, it
is worthy of noting that cats react to the
deficiency diet with greatest regularity and,
therefore, are best adapted for physiologic
studies of the function of the antineuritic
substance.
The food conservation movement and
concurring limitations in diet due to pre-
vailing high costs have focussed unusual
attention upon problems of nutrition. The
stress hitherto placed upon caloric feeding
has played a valuable part in awakening
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60
Fbbruabt, 1919
EDITORIAL COMMENT
American Mbdicinb
an understanding of food needs, but has
not sufficed to clear up our views regarding
nutritive values not dependent upon the
number of calories provided in the daily
food supply. Normal nutrition involves a
conception of vitamine and mineral metab-
olism which is still in the course of evolu-
tion. The light which has been shed upon
beriberi, scurvy, rickets, pellagra and mal-
nutrition in general establishes beyond
doubt the necessity of further investigation
of the function of food factors hitherto un-
known or underestimated.
Every fact added to our present state of
knowledge advances not merely the science
of nutrition, but directly improves the pos-
sibilities of advancing the general health
and vitality of communities. Empirically,
human foods have been developed along
various lines, but an estimation of their
health values becomes possible only when
there has been thoro investigation as to the
effects of culinary processes upon the di-
gestibility and essential nutritive values of
the foodstuffs involved. The test tube is
not the stomach, but the results of test tube
experiments, when supplemented by animal
experimentation, are deeply suggestive of
the effects of food in human metabolism.
Medicine as a Vocation. — In the en-
deavor to acquaint disabled soldiers, sailors
and marines with the possibilities of various
vocations, the Federal Board of Vocational
Education has prepared a large number of
Opportunity Monographs. This method of
familiarizing potential workers with the na-
ture, characteristics, educational qualifica-
tions, duration of study and possible re-
wards might well be emulated in all schools.
A recent publication. The Vocational Re-
habilitation Series, Number 17, January,
1919, deals with "The Practice of Medicine
as a Vocation." This monograph purposes
to answer various questions that may be
in the mind of returned soldiers who are
undecided as to their future occupation.
The brief exposition is well given and might
well serve as an introductory document for
students in medical colleges or, better, be
provided to all students in the graduating
classes of high schools previous to their
taking up a course of professional study.
It is patent that familiarity with the pos-
sibilities of a profession should exist be-
fore work is begun and before time, money
and energy have been expended. The
description of the nature of physician's work
and the degree of pre-medical education re-
quired is . excellent, despite its brevity.
It is improbable that a large number of
soldiers with disabilities will seek to pre-
pare themselves for the practice of medi-
cine, not merely because of the possible
handicap arising from the disability, but
because of the length of time essential in
preparation and in establishment in prac-
tice, as well as the high degree of prelim-
inary education demanded of candidates in
medicine. If, however, a course in medicine
is desired, and the applicant's request is ap-
proved by the Federal Board, the costs of
education will be furnished free by the gov-
ernment. In addition, the Bureau of War
Risk Insurance, thru its compensation, will
meet part of the expense, and the Federal
Board of Vocational Education will add to
that amount a minimum of $65 a month for
the purpose of meeting the expenses for
living, clothing, transportation, tuition and
incidentals.
This liberal policy should enable those
physically and mentally prepared to under-
take the work of medical or surgical prac-
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BDITORIAIi COMMBNT
February^ 1919
61
tice to accomplish results unattainable by
many who have not been injured in gov-
ernment service. There are many fields of
medical practice in which slight degrees of
physical defect will not interfere with suc-
cessful efforts. In all probability only a
small number of men will take advantage
of this liberal government policy which rep-
resents a remarkable opportunity for the
rehabilitation of men possessing the essen-
tial attributes physically, mentally and
morally to add luster to the medical pro-
fession.
Diphtkeria ContrdL — ^The prevalence of
diphtheria, despite our wide knowledge con-
cerning its causation and cur^, as well as
effective prevention, is a matter of consid-
erable concern. Bernard W. Carey, epidemi-
ologist of the Massachusetts State Depart-
ment of Health (The Commonwealth, De-
cember, 1918, and Boston Medical and Sur-
gical Journal, Jan. 8, 1919), calls attention
to the subject in a most interesting study
of one thousand deaths from diphtheria.
About 65 per cent, of all deaths from
diphtheria and croup occur in children un-
der five years, so presumably the morbidity
also is greatest during the first five years of
life. Carey points out that there is consid-
erable question as to the part that schools
play in the diphtheritic infection in chil-
dren under the school age, tho there can be
little doubt that the process of education in
crowded classrooms is a factor in spreading
the disease among school children. Efficient
school supervision, the taking of cultures,
the prompt detection of healthy carriers and
incipient cases serve as an excellent means
of prevention and control of diphtheria out-
breaks.
Study appears to show that, unfortunate-
ly, in many instances, the diphtheritic con-
dition is unrecognized, or is first treated
as a simple tonsillar infection until it is too
late to secure the efficatious action of anti-
toxin. In fact, many instances are recorded
of individuals suffering from nasal diph-
theria receiving no other treatment than
that which would ordinarily be given for a
simple catarrhal infection of the nose and
throat.
From the standpoint of public protection
it is almost axiomatic that the specimen for
culture should be taken in all conditions
where there is even a remote possibility that
diphtheria is present. It is similarly axio-
matic that individuals presenting s\ niptoms
which are at all suspicions should have
antitoxin administered at the time that the
culture is taken, instead of delaying such
therapeutic measure until a report upon the
culture will have been received from the
laboratory. The early administration bf
antitoxin is essential for securing the best
results. The diphtheria mortality rate can be
reduced only by the early injection of anti-
toxin when, perchance, only the suspicion
of the disease may exist.
Regrettably, the physician all ' too fre-
quently is not called upon until a large
variety of household remedies have been
tried and the disease has had an oppor-
tunity to advance into toxic states more
difficult of control or cure. The public re-
quires education as to the importance of a
large dose of antitoxin administered Ayithin
24 hours after the onset of the disease as
the first and principal step in the cure of
diphtheria. Carey reports that 11.8 per cent,
of the cases investigated "were found mori-
bund upon visitation by the physician." The
presence of various other diseases and the
general decline in the incidence of diph-
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Februabt, 1919
EDITORIAL. COMMBNT
Amkbigam Mkdicinb
theria have tended to make the profession
somewhat negligent in stressing its impor-
tance as a destroyer of child life.
A Serious State ot AflFairs.— Two items
merit particular comment because they rep-
resent a serious state of affairs. "7.6 per
cent, of the deaths occurred in 'unrecog-
nized* cases." This seems almost unbeliev-
able and since it occurred in the State of
Massachusetts, where the State Department
of Health is not only ready to examine all
cultures sent to it but reports results by
telephone or telegraph without cost and
gives free distribution of antitoxin, it prob-
ably is a lower percentage of unrecognized
cases than exists in other states of the Union
where similar facilities have not been af-
forded. In this day and generation failure
to recognize diphtheria may almost be re-
garded as prima facie evidence of careless-
ness, negligence, or ignorance. The cer-
tainty of laboratory investigations, the ease
with which cultures may be taken and the
promptness with which reports thereon may
be secured, increases the responsibility of
physicians for securing accurate diagnoses
of diphtheria. Of course, occasionally, posi-
tive cultures are not procured in an early
stage of laryngeal diphtheria owing to the
fact that cultures are not properly secured
from the larynx.
The second item is also a challenge to
medical practice. "In no instance did we find
antijoxin given intravenously." It scarcely
seems believable that with our present
knowfedge of the use of serums and their
efficacy when introduced 'directly into the
blood system that patients with diphtheria,
seen late in the course of the disease, should
fail to have the opportunity of an intrave-
nous injection of antitoxin. This single fact
is of more importance than the considera-
tions of the variations in dosage which have
been employed and the possible danger of
anaphylaxis which occasionally follows its
use when due precautions are not taken.
In view of the findings reported, it is
not unreasonable to quote two paragraphs
which would seem to be uncalled for, but
apparently should again be called to the at-
tention of the profession.
"With such a lack of uniformity in the
use of antitoxin it seems as if the medical
profession should be informed, from au-
thoritative sources, as to the most approved
method of its use, and its dangers thru mis-
use, either in dosage or method of admin-
istration.*
"Particular stress should be laid, in the
instruction of medical students, upon the
necessity of properly administering anti-
toxin, thus avoiding the chances for anaphy-
lactic reaction and there should be im-
pressed upon them the need of early and
sufficient treatment."
With the Schick test, the toxin-antitoxin
mixture for immunization, the cultural test
for diagnosis and the availabihty of anti-
toxin for free distribution, there is little
excuse for the present figures relating to
diphtheria mortality. Greater efforts must be
made, not merely to control the mortality
rate but to study the growing population
during the pre-school age with a view to
determining the diphtheria carriers and the
children susceptible or immune to diph-
theria, with a view to increasing the immu-
nity of all, thus decreasing directly the pos-
sibility of a large morbidity and mortality.
Very few diseases theoretically are
brought so completely within the field of
potential control, prevention and cure ias
diphtheria. The therapeutic and prophylac-
tic progress that has been made is indicated
by the reduction of the mortality rate of
diphtheria and croup from 43.3 in 1900 to
14.5 in 1916. It is difficult to estimate the
part that general prophylaxis has played in
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AlCBBICAN MBDICINS
BDITORIAL COMMENT
Februabt^ 1919
63
this most excellent decline, but a consider-
able share must be attributable to general
sanitary and hygienic measures. This is
strongly suggested by the decline in the
mortality rate of scarlet fever in the regis-
tration area from 12.2 in 1900 to 3.3 in
1916.
The fact that one per cent, of the of-
ficially registered deaths in 1916 was due
to diphtheria is sufficient reason for again
emphasizing the necessity of improved
methods and practice in the prevention, con-
trol and cure of diphtheria.
Tonsillectomy During QiildioodL —
Tonsillectomy has become increasingly
popular as a remedial operation for a large
variety of conditions from the relief of
chronic recurrent quinsy to mental dulness.
Its employment for purposes of prophylaxis
has been urged in order to prevent otitis
media and various pulmonary disorders.
Immediate results frequently are most satis-
factory and little thought has been given
to the remote effects of the operative pro-
cedure.
The general extension of tonsillectomy,
as a result of persuasion following upon
the efforts of medical inspectors of schools,
school nurses and others interested in build-
ing up the vitality of youth, makes it of in-
terest to inquire into "The Remote Result
of Tonsillectomy in the Young Child" as
pointed out by Zahorsky, Interstate Medical
Journal, January, 1919. The study of 150
children, aged two to twelve years, to as-
certain the effects of the removal of tonsils
and adenoid vegetations upon the healfh
and nutrition of the children six months to
five years after operation, casts a certain
suspicion upon the effectiveness and desir-
ability of this procedure among the very
young.
Zahorsky points out that the operative
removal of tonsils and adenoid tissue does
not suffice to clear up deficient nasal respira-
tion, nor prevent middle ear disease with
any great degree of certainty. While there
may be no causative relation, it is at least
of interest to note that many of the young
children had one or more attacks of pneu-
monia within the three years following the
operation. This is somewhat supportive of
the idea that tonsillectomy appears to in-
crease the tendency to bronchial and pul-
monary infection, altho no conclusive de-
ductions can be made from the few avail-
able facts. It is patent that the removal of
tonsils does not suffice to prevent rheu-
matism, endocarditis, or chorea, in the
etiology of which g^eat stress has been
placed upon the liability of the tonsils to
infection with the initial causative organ-
ism.
Malnutrition frequently serves as the ex-
cuse for tonsillectomy, but it is undeniably
true that this itself is without avail in im-
proving the general nutritive condition. Nor
does it build up a more vigorous vitality
without the benefits of supplemental feed-
ing and auxiliary hygienic care, tho a rea-
sonable percentage of children show per-
manent improvement as the result of the
improved oxygenation.
Tonsillectomy cannot per se add specific
anti-bodies to the blood and tissues. For
the most part these are dependent upon im-
munity developed thru attacks of disease or
fostered by means of prophylactic inocula-
tions. The entire question of vital resist-
ance and susceptibility to infections may be
independent of the tonsils, tho according to
Zahof sky :
"The child beginning his school life with-
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FSBRUABT, 1919
EDITORIAL CX>MMBNT
Ambricam Msdicins
out the tonsils is in greater danger of acute
diseases than one who still has his tonsils.
It is at this age that the tonsils are so fre-
quently removed simply because they are
large ; the physician apparently forgets that
this enlargement is a physiologic and a com-
pensatory process."
Regardless of the accuracy or relative
value of the data offered by Zahorsky,
which he recognizes as insufficient and par-
ticularly so by reason of having no data on
a control series, his conclusions merit earn-
est scrutiny. He demands that among chil-
dren under seven years of age the removal
of tonsils and adenoid tissue should occur
only after a careful study of the child's nu-
tritional condition and possible state of im-
munity. His plea is for a conservative at-
titude rather than a radical impulse to re-
move every tonsil that peeps beyond the
pillars. Pathologic conditions existent in the
tonsils, abscesses, infections, diseased states
following scarlet fever and diphtheria call
for remedial operation. Certainly cardiac
states following upon tonsillar infections
call for their removal.
Accepting all the alleged benefits of ton-
sillectomy it is the part of wisdom to inves-
tigate' statistically, insofar as may be pos-
sible, the relative health conditions of chil-
dren with and without tonsillectomy in vari-
ous age groups so as to establish approxi-
mate comparative forms of infection. The
question suggested as to the advisability of
tonsillectomy for slight or trivial causes
in children under seven years of age
can only be answered adequately and ac-
curately by a thoro study of the clinical his-
tories of a large number of children cover-
ing many years. Conservatism in tonsil-
lectomy should be the rule, as rational con-
servatism should be applied in th^ con-
sideration of all operative procedures.
Hazards of Qoth Sponging* — ^The mass
of data necessary for building up a system
of rational industrial hygiene receives con-
stant additions. The correction of con-
ditions inimical to the health of employees
is dependent upon the investigation, appre-
ciation, recognition and alteration of en-
vironal states which have grown up thru
the habit of years of building factories,
workshops and industrial institutions with-
out regard to the welfare of employees.
This state of affairs, however, is by no
means significant of intentional neglect, nor
of aggressive indifference. Only during the
past decade has there developed a sense
of responsibility for the welfare of work-
ers commensurate with its importance. The
awakening as to the importance of indus-
trial hygiene has been slow, and only re-
cently has it set in motion a widespread
movement for the reorganization of indus-
trial machinery tending towards the elim-
ination of unnecessary hazards.
The New York State Department of La-
bor, thru * the Industrial Commission, has
added a few more facts to the general sub-
ject of industrial hygiene by the publication
of a bulletin on "Health Hazards of the
Cloth Sponging Industry." The essential
dangers are twofold : First, the dangers of
the inhalation of fluff" by the cloth exam-
iners, which tends to cause respiratory irri-
tations; second, severe physical effort and
the presence of high temperature and hu-
midity serve to lower the vitality of those
actually engaged in the process of spong-
ing.
Knowledge has long been at hand to
demonstrate the unhealthful effects of hot,
humid air which increases bodily tempera-
ture, stimulates heart action and causes a
depletion of bodily moisture disproportion-
ate to the actual work performed. Studies
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65
of fatigue have pointed out the extra haz-
ard that ensues when the dilated blood ves-
sels of the skin rob the brain and spinal
cord of necessary blood, causing weariness
and apathy. The elevation of bodily temper-
ature reacts upon internal conditions unfa-
vorably, producing a febrile state, which,
when long continued, affords excellent op-
portunity for the development of fatigue.
Hot, moist atmospheres are particularly
hazardous if the temperature shown by the
wet bulb thermometer exceeds 78** F. In
the words of Barker (Heating and Ventila-
tion), "A temperature of 75 "* F. wet bulb
should not be exceeded, and a limit of 70°
F. is still more desirable." In an investiga-
tion of 37 factories, only 12 showed a wet
bulb reading below 76°.
An examination of the general health of
men who have worked in the industry in
periods ranging from one to thirty-five
years there was evident a marked prepond-
erance of diseases of the respiratory tract,
the most important one being pulmonar>'
tuberculosis. Nineteen per cent, of 95 men
carefully examined evidenced various stages
of tuberculosis. Among other diseases were
noted acute and chronic bronchitis, asthma
and pleurisy. The presence of this high re-
spiratory morbidity led to an analysis of the
mortality of the industry as shown by the
records of 17 men who had been thus en-
gaged and had died during the three pre-
vious years. The actual cause of death was
ascertained in eleven instances, in five of
which pulmonary tuberculosis was found to
be the cause of death.
It is obvious from this morbidity and mor-
tality that there has been an unusual re-
spiratory hazard in the cloth sponging in-
dustry, and that the main factors respon-
sible have been "fluff" on the one hand, and
undue heat and moisture on the other hand.
The recommendations of the commission
are based upon these two factors, and pro-
vide "that a dressing room, properly heated
to 68 degrees F. in winter, containing sani-
tary lockers be installed in each factory for
use of sponging workers.
"That suitable means shall be provided to
dry clothing of employees working in spong-
ing rooms.
"That fans should be of such capacity as
to maintain a wet bulb temperature in
sponging rooms not to exceed 75 degrees
F."
The simplicity of the recommendation,
to which must be added the suggestion that
a light mask or respirator be worn by cloth
examiners while at work, demonstrates how
easily some industrial dangers may be
averted. It is equally obvious that simple
as these recommendations are, they would
have been impossible had there not been
a careful study of the methods utilized in
the industry and a thoro investigation of
the factories themselves. Ninety establish-
ments were visited and a total of 88 orders
were issued against fifty factories.
It is necessary to place industrial hygiene
upon a scientific basis. Theories must give
way to proven facts. Industrial methods
must be altered from traditional forms in
order to be safe for the living machinery
upon which all industry is dependent. The
increased interest in industrial welfare car-
ries with it a certain measure of respon-
sibility for the medical profession which has
to deal with the workers who suffer from
diseases and disabilities resultant from in-
dustrial application. Medicine profits by
every additional discovery in the industrial
world, but from none more than the estab-
lishment of the underlying industrial con-
ditions causative of undermined health or
frank disease.
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FSBRUARY, 1919
MEN AND THINGS
Amebican Mbdicinb
MEN AND
>' THINGS
^Beer or BecBam." — In many com-
munities thruout the country there has been
set afoot a concerted movement against the
bone dry law that threatens to come into
effect at the close of the year, and it is high-
ly significant that the agitation against com-
plete prohibition is, for the present at any
rate, confined largely to industrial centers.
It is the workingmen who are protesting,
an increasing number of them showing the
"No beer no work" button in the lapels of
their coats. And it is of even greater sig-
nificance that it is their familiar and amiable
beer for which they are clamoring — of all
alcoholic drinks the least harmful and least
socially menacing. Whatever one's attitude
toward prohibition, one cannot but com-
mend the modesty, the restraint, the humil-
ity of the workers of this country. They
might have been tempted to assume an ex-
travagant air of protest and chosen "No
wine no work" as their slogan, which lends
itself to more alliterative persuasion. Or
they might even have assumed a decidedly
belligerent and vicious tone of defiance by
having "No whiskey no work" as their
device, the severity of their intentions bor-
rowing its viciousness from the very form
of alcoholic drink they adhered to thus. But
no ; they selected beer, and in doing so they
have shown excellent judgment, if it was
judgment and not instinct on which they
were depending when they made the selec-
tion. For even the unfriendliest prohibition-
ist cannot bring against that mild working-
man's drink the severe charges he can easily
summon against its more insidiously harm-
ful fellows. And the consequences may be
(from present indications it begins to ap-
pear that they probably will be) that a more
charitable attitude will be assumed when
the final disposition is made and that an at-
tempt will be made to allay the disgruntled
protests of the workingman and grant him
his modest allotment of beer.
However, the expedient of yielding on
this seemingly innocent point rs fraught
with no small danger. The concession of
beer is a concession to the working classes ;
but in this country, which has not ' yet
yielded to the lure of Bolshevism, the bour-
geoisie still remains a class that has claims
to a modicum of recognition and charity.
The leisurely and wealthy classes still retain
a few of their rights and privileges. And
these may very naturally be expected to
show a measure of the consideration that
is meted out to the lower levels. "If the
workingman has his beer," they might just-
ly insist, "we want our wine." What course
will be open to any just authority other
than to yield once more and grant the
wealthy man his wine ? And having yielded
on this point, having granted the wealth-
producing and wealth-owning classes the
privilege of the drink of their class, the
mid-strata of society may arise to claim
their individual preference in drinks as a
privilege. The actor will put in a claim for
his whiskey and soda, the tired business man
for his cocktail, the chorus girl for her
creme de menthe, the artist for his "grog
americain," the Bohemian for his absinthe.
Certainly the road to compromise and con-
cession is not the smoothest of paths.
Prohibition and Individual Rifl^ts. —
The temptation to be facetious on the ques-
tion of prohibition is an old and honored
temptation, but there is, of course, a seri-
ous side to the problem of the protest of
the working classes against the strict en-
forcement of the new law. The pessimist
will no doubt see in the agitation that is
going on in industrial centers the work of
the liquor interests, who stand to lose a
great deal under the new law and are will-
ing to spend a fortune to defeat it ; but the
less cynical critic will see a more funda-
mental motive in the insistence of the work-
er on the retention of beer. The contest is
more than a clash between the prohibition-
ists and the liquor interests; it is the old,
familiar clash between the individual and
society. The ground on which the working-
man threatens to maintain his stand is not
that he has a right to his beer but that
he has a right to his individual rights, that
the attempt to dictate whether he shall
drink or not is an infringement by the state
on his private privileges, that society is go-
ing beyond its function in invading the
home and controlling its free conduct.
"Stop public drinking, if you like," the
worker may say, "shut up jthe saloons and
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MEN AND THINGS
FBBKUAXT^ 1919
67
cafes, if you think best, but if you invade
my premises and forbid me my bottle of
beer at dinner you are going altogether too
far. You may say that it is a harmful prac-
tice. I don't grant that, but even if it is,
what of it? I have a right to harmful prac-
tices provided I alone am injured by them.
There is no law that will stop me from cut-
ting off my toes or trimming my ears. That
is my own affair. Your right to hinder me
only begins when I try to cut off my neigh-
bor's toes or trim his ears. I alone am mas-
ter of my own body or my own home."
Putting the problem in this way (and it
is being put this way more and more by the
more intelligent critics of prohibition) it as-
suredly takes on a different countenance;
it becomes a serious, even a dignified, con-
test between individual and social rights.
But of what value is the citizen's claim that
society has no authority to invade his in-
dividual domain? The simple, indisputable
answer, the answer that history maintains
as true, is that society invariably sacrifices
the individual for the sake of the whole
community. Society, in this respect, has a
double function: to encourage and defend
individual rights, and to limit them; and
the function of limiting them it has never
evaded when it has found it necessary to
do so. It has encouraged the privilege of
the individual when such privilege was
beneficial to organized society; it has in-
variably assumed the authority to limit that
privilege when it was deemed injurious to
society. The deciding factor was always the
consideration whether any individual prac-
tice was anti-social or not, and if it was
anti-social the individual was invariably
sacrificed. The clash on prohibition be-
tween society and the individual must be
judged in this way. Is the drinking habit
anti-social or is it not ? An honest man will
answer both yes and no. Drink has been
in many instances a force for disorganiza-
tion ; it has broken up homes, it has ruined
careers, and it has often been the inspira-
tion of lawlessness. To this extent it has
been anti-social. But there are aspects of
the drinking practice which are decidedly
closed to such criticism. The workingman's
beer, taken moderately and often in the
bosom of his family; the epicure's bottle
of wine, rarely abused by the fastidious
epicure — these certainly are not anti-social
and it would be unjust to condemn them as
such. Obviously, then, the protesting work-
er is well within the limits of reason and
justice when he protests that society is ex-
ceeding its authority when it takes away
his beer, the epicure is justly indignant
when society removes the bottle of wine
from his dinner table, and the consequence
is that both sides seem to be right. In such
a dilemma there is but one course open : to
preserve the element of right in each opin-
ion, which would mean, in this instance,
that the perfect solution would be for so-
ciety to destroy the drinking habit insofar
as it was anti-social and preserve it insofar
as it was in no sense a menace. Is such
a solution altogether impracticable? Abor-
tion is illegal, but there are instances where
it is practiced with the full approval of both
law and religion. The taking of life is for-
bidden, but there are special circumstances
in which it is condoned. The taking of
drugs is universally condemned, but doctors
prescribe them in numerous cases without
any hesitation. Is prohibition subject to the
same sort of treatment?
A Medical Journalist's Splendid Record
in the Army Medical Service. — ^The rec-
ord of the work of American physicians in
the great war will ever stand as one of the
brightest pages in the annals of the Ameri-
can medifcal profession. Early during the
period of the expansion of the Medical De-
partment to meet the needs of the enormous
army the United States was training and
planning to send abroad, there were heard
criticisms from many quarters to the effect
that medical men were backward in offer-
ing their services. This was most unwar-
ranted, for there were thousands of physi-
cians who wished to enlist but were pre-
vented from doing so because of being just
outside the age limit, or because of some
slight physical infirmity. If there was
any hesitancy or delay on the part of
the y.ounger members of the profes-
sion, it was due to red tape and mis-
understanding. As soon as the situation
was cleared up and certain misconceptions
were removed, the number of physicians
who sought to join the colors was so great
that the army authorities found it difficult
to issue commissions and assignments to
those acceptable. Never can the patriotism
of the American doctor be questioned or
held in doubt. A particularly gratifying
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February, 1919
MEN AND THINGS
Amkbican Mbdicins
feature of the demonstration of the loyalty
of the medical profession in connection with
the great war has been the large number
of doctors of large income and great im-
portance in their communities — men holding
selves to national needs, irrespective of their
own interests, was our good friend, Dr. Jos.
MacDonald, Jr., Editor of the American
Journal of Surgery, We are especially
proud of Dr. MacDonald's record, and take
Major Joseph MacDonald, Jr.,
Army Medical Corps, U. S. A.
the highest positions — who have cheerfully
sacrificed every personal interest to enter
the medical service of the nation.
Ainong the well-known medical men of
the United States who thus devoted them-
particular pleasure in referring to it briefly,
because in a way he has represented Ameri-
can medical journalism and the ideals it has
stood for since the fateful day when Ger-
many "unleashed the dogs of war." Dr.
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MEN AND THINGS
February, 1919
69
MacDcmald's qualifications as an executive
and administrator, unusual in a medical man
of his professional knowledge and attain-
ments, have enabled him to accomplish a
great deal that would have been impossible
for the average physician. In fact, we are
confident we are making no extravagant
statement when we say that few men have
done more thru their own personal effort to
aid and promote the organization of the
Army Medical G)rps than Major Mac-
Donald. According to the record, he was
commissioned in 1913 as a first lieutenant in
the Medical Reserve Corps, U. S. A. Hav-
ing a fondness for military work he at-
tended a number of camps of instruction
for medical officers, notably at Tobyhanna,
Pa., and took the special course for medical
officers arranged at Ft. Leavenworth,
Kansas. In March, 1917, at the organization
of the United States Army Medical Exam-
ining Board for New Jersey, he was ap-
pointed adjutant of the board and on April
10th, 1917, was commissioned a captain. On
December 10th, 1917, he was commissioned
a major in the Medical Corps, U. S. A., and
in April, 1918, was appointed by Surgeon-
General Gorgas president of the Army
Medical Examining Board of New Jersey.
Between June, 1917, and November of that
year he covered 3,200 miles in the State of
New Jersey in the interest of the examin-
ing board, which means many trips con-
sidering that New Jersey is only about 180
miles long and less than 100 miles wide.
Over 1,100 members of the medical profes-
sion of New Jersey were physically and
mentally examined by this board and over
1,000 were recommended for commissions
in the Medical Corps, U. S. A. In June,
1918, Major MacDonald was appointed by
Secretary of War Baker, a member of the
General Medical Board at Washington. Ma-
jor MacDonald's activities in the interest
of the Army Medical Corps have not alone
been confined to his work in New Jersey.
As secretary and treasurer of the American
Medical Editors' Association, he prepared
two special editorials a month for over 100
of the leading medical journals thruout the
United States, setting forth the needs of
the medical department of the United
States Army. This work he carried on from
June, 1917, until the signing of the armis-
tice.
Upon Major MacDonald's honorable dis-
charge from the army, he was highly com-
mended by the surgeon-general, who ex-
pressed his personal appreciation of the
splendid spirit manifested in giving such
faithful service and valuable assistance to
the army.
It is understood that Major MacDonald
as a civilian will remain a member of the
General Medical Board at Washington.
In closing these few words of tribute to
Major MacDonald, we believe his many
friends will feel as we do that in serving
the Nation in its hour of stress so faith-
fully and well, he has honored his col-
leagues, especially those who have been as-
sociated with him in medical journalism.
After all there are few who will be sur-
prised, for Dr. Joseph MacDonald's effi-
ciency has long been known, and his work
during the past decade as secretary of the
American Medical Editors' Association will
stand for many a day as a monument to his
fidelity and administrative ability.
Sleeping Car Sanitatioii. — ^The mys-
terious process by which certain reputations
are made and retained despite every indica-
tion to the contrary is distinctly a phenom-
enon worth reflecting upon. Take, as an in-
stance, the one-time magic of the "Made in
Germany" label — now, happily, a vanished
illusion. In pre-war days, the "Made in
Germany" stamp to many minds carried
with it an assurance of the cooperation of
the best of workmanship, the finest of ma-
terials, and the minimum of cost. For a
long time (for too long a time) this popular
illusion prevailed. Recently, a group of men
in a restaurant fell to discussing the quality
of German-made goods and the secret of
their success over many a British product.
One of the men asked all present to produce
their pen-knives and examine them. Of the
six men present, five had knives made in
Germany, one alone had a knife made in
England. The five German knives had ail
been sharpened often and were in poor con-
dition. The one English-made knife had
seen more service than any of its rivals, had
never been sharpened and was still in ex-
cellent condition. And everyone wondered
why the Germans had been able to sell five
knives for ever knife the English could sell
in the United States. Exit a grand illusion,
and enter a new wisdom.
American sleeping car accommodations
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February^ 1919
MEN AND THINGS
American Mkdicins
are noted all over the world as having at-
tained the highest point in perfection of serv-
ice. In Europe the American standard is
used in judging the qualities of the service
there, but to any one who has traveled
southward this winter it would appear that
this is only another instance of a great illu-
sion persisting in the popular mind for some
reason that is in the highest sense mysteri-
ous and inexplicable. Such a traveler would
be only too apt, provided his critical facul-
ties were at all operative, to conclude that
the service is the worst rather than the
best in the world and the service is
the worst in the one direction of night
travel where it should be scrupulously
good for excellent reasons. The drift
toward the south in the winter is largely
on the part of wealthy pleasure seek-
ers, but it is perhaps more conspicuously
noteworthy for the great number of people
in delicate health who seek the mild cli-
mate of the south during the trying months
of severe northern weather. More than any
other class, these ailing folk are entitled to
the greatest consideration on the part of
those to whom they entrust their well-being
and comfort during the period of transit —
a consideration for which they pay gener-
ously enough, when one considers the Pull-
man rates of today. One would think, then,
that the southbound railroad service would
be, in point of sanitation, at any rate, the
most carefully conducted of all; and yet
the traveler becomes at once strikingly
aware of one gravely unsanitary symptom
of neglect which compels him to indulge
in the most pessimistic speculation. He
observes in the first place a startling neg-
lect of the general rules of cleanliness in
the sleeping cars and then he notices a most
disheartening condition of blankets and
mattresses. These, if they are sterilized at
all, are sterilized at such long intervals
as to render them — one cannot resist the
temptation to say dangerous — dangerous
both to the ailing travelers, who are ex-
posed to accentuation of their ailments,
and to the sound passengers, who are ex-
posed to contagion from ills which they
have every right to be protected against. A
close inspection of the bedding on these
railways would lead one to the conclusion
that the sleeping car is one of the most ef-
fective carriers in the transmission of acute
respiratory infections. It has been frequent-
ly noted and wondered at that man/ north-
erners, a few days after arriving in the
south, develop mysterious colds and bron-
chial disorders, the origin of which is very
obscure; and it may not be at all unlikely
that these disorders may be traced to the
unsanitary conditions prevailing in the
sleepers in which they traveled. Both classes
of travelers, the well and the ill, are justly
entitled to better care on the part of the
railroad officials; and it would be well for
both to make it plain to the authorities re-
sponsible that they insist on better protec-
tion, that they expect more attention to be
paid to the primary rules of sanitation that
prevail in even the most modestly conducted
sleeping quarters. Pullman cars are not ex-
empted from these rules merely because
they are only temporary sleeping quarters.
Fletcherism.^ — Horace Fletcher, whose
name has not undeservedly been incor-
porated in the English vocabulary and who
died in Copenhagen recently, has left be-
hind him a legacy of food wisdom which
has been more applauded than it has been
heeded. During the past few years Horace
Fletcher had not been much in the public
view, but a dozen years ago and for some
time afterwards his philosophy of eating,
which came to be known as '*fletcherism,"
enjoyed an enormous vogue. It threatened,
in fact, to revolutionize the art (or would
it not be truer to say the practice ?) of food
consumption, and it did indeed win a mod-
est number of converts, but its promise of
huge results was not achieved. It would
perhaps be more precise to say that in-
numerable converts were won to the theory
but very few to the practice. But this
failure to alter the eating habits of a whole
nation (which was no doubt Fletcher's aim)
cannot be ascribed to the weakness of his
philosophy, which was distinctly convinc-
ing and which was demonstrated as potent
by a number of exhaustive tests. Fletcher's
system failed because it was a simplification
and because the trend of all modern progress
is toward complication. Civilization seems
to abhor simplicity as much as nature ab-
hors a vacuum. Wagner's "Simple Life"
created a huge stir and won great popular-
ity. For a long time it was the only topic
of conversation in drawing-room and cafe
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MEN AND THINGS
February^ 1919
71
alike, but, tho it taught many people to
speak eloquently and passionately of the de-
lights of the pastoral life, it persuaded very
few to go back to nature. The trend in re-
cent years, despite Wagner and the "Simple
Life," has been decidedly away from the
vast spaces of the open country and toward
the confinements and narrow alleys of the
great cities — away from simplification and
toward complication.
Compare a table d'hote menu of the mid-
dle ages with yesterday's dinner card at one
of the smarter hotels and the same unmis-
takable tendency will be revealed. The glut-
tonous wassailers of the romantic old days,
noted for their everlastingly yawning stom-
achs and insatiable palates, would flush
with envy at the refined gluttony of the
modem banquet table. The sin of the age
is not so much undernourishment as it is
overeating. Of any ten people of comfort-
able means chosen at random, seven eat too
much and two eat unwisely. It was Fletch-
er's hope that he might persuade these seven
to eat less and the other two to eat more
discreetly. And for a time it looked as
tho he might succeed. His was not a
laboriously scientific theory, minutely com-
puting calories, and proteins, and starches.
It had all the ear-marks of a popular con-
ception. "Eat as often as you like and
whatever you like," he said, "only see to
it that you masticate vour food properly and
that you do not swallow a morsel until you
absolutely have to. There are little tongues
in the back of your mouth which will draw
the food down when the stomach is ready
for it. Leave the business of swallowing to
them. All you have to do is just chew, chew,
chew." Anyone who has followed these
simple injunctions will be ready to testify
to their great wisdom. Food consumed in
accordance with the theory of "fletcher-
ism" fulfils not only the first function of
food, the satisfying of the appetite, but in
addition conduces to a fitness and alertness
of physical condition unknown to the
"heay\^" eater. No man has eaten well who
cannot, after a good meal, take a jog trot
around the square without feeling the ef-
fects ; and anyone who has fletcherized his
meal can do that. Such a result alone would
justify the value of the theory. Yet, what is
the verdict of the public? In the last decade
the number of "quick lunch" restaurants
has doubled ! It is a misfortune for any
man to choose a philosophy that counsels
a slowing down of the speed of living in
an age when the aeroplane and the jazz
band dictate the tempo to which most of us
respond.
Dangers of European TraveL — ^The of-
fices of the various steamship companies
thruoiit the country have been beseiged
with application for passage across the At-
lantic which run into the hundreds of thou-
sands, and it seems that the moment the
bars are let down there will be an un-
precedented rush of travelers who are keen
to visit the battle scenes of Europe or to
see how the capitals they knew so well in
peace time have altered under the strain
of four years of war. No doubt the people
of Europe look forward no less anxiously
to this rush of foreign visitors, who promise
an increase of revenue which will be wel-
come after the strain of expenditures which
the war has entailed. But there are two
good reasons why Americans should for
the time being postpone their proposed in-
vasion of Europe. One is that the officials
of the allied countries do not want them
to come at this time, when the transporta-
tion facilities are strained to their utmost
in the complicated task of demobilization
and reconstruction. Italy has already offi-
cially announced that she would regard a
postponement of any influx of American
visitors for the present as a favor, and
France has intimated as much thru more
than one of her spokesmen. But there is a
second consideration of forbidding impor-
tance— forbidding to the traveler — and that
is the danger such a traveler would expose
himself to in visiting Europe at a time when
contagious diseases are as prevalent as they
are abroad just now. The vitality of the
peoples of Europe, sapped by the burdens of
so long and so trying a war, are at low
ebb, and diseases such as typhus, pneu-
monia, smallpox and others have found
ready victims everywhere. Besides, many of
the returning prisoners are coming back
to France consumptive. These diseases are
a distinct menace to anyone exposing him-
self to them, and Americans would be ex-
ceedingly unwise to refuse to allay their
curiosity when it can be satisfied only at
the cost of such unnecessary exposure. It
would be more sensible to postpone that
projected trip to Europe until such time as
conditions there are restored more nearly
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February, 1919
MEN AND THINGS
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to normal and the dangler to the health of
the visitor is eliminated.
Making War Unprc^taUe^While doc-
tors of jurisprudence and authorities on
international law are examining and re-
examining the items of the League of Na-
tions Covenant, the average inquiring mind,
with only humane common sense to guide
it. will find embodied in the articles of this
Covenant a single, homely, unpretentious
item which will go a good way toward the
solution of the problem of war. One para-
graph in Article VIII reads: "The high
contracting parties agree that the manu-
facture by private enterprise of munitions
and implements of war lends itself to grave
objections, and direct the executive council
to advise how the evil effects attendant upon
such manufacture can be prevented," etc.
This can mean only one thing: government
ownership of the materials and facilities
for manufacturing the implements of war.
In reading this item, which seems to have
won so little notice for itself, one cannot
but recall the notorious instance of the mu-
nition magnates who bought out a French
paper and a German paper and promptly
began a campaign for armaments which
constitutes to our mind the most flagrant,
the most culpable and heartless flirtation
with war that history records. The German
paper came out editorially with a strong ar-
ticle on the need of a larger army, of more
copious supplies to meet the national need.
The French paper, owned by the selfsame
firm and fully aware of the intention of
this article, immediately took alarm at this
amazing stand. It responded quickly with
an equally emphatic article urging a larger
standing army for the French, pointing to
the threatening attitude the Germans were
taking and quoting the German article to
sustain its contention. The German paper,
in its turn, made conspicuous extracts from
the French article as a sign of the prep-
arations that were going on in France for
what could be interpreted only as aggres-
sion against Germany, and once more urged
the necessity of a greater army, and of in-
creased armaments. The shuttle worked back
and forth in this way for a long time, until
the reading public of both nations, believ-
ing what it read and being ignorant of the
single ownership of both papers, came to a
climax of nervous excitement and hyster-
ically began to clamor for protection against
a threatening enemy. Each side suspected
the other, each side accused the other —
and the net result was record dividends for
the munition magnates. One can imagine
that the responsibility of creating bitterness
between two nations already sufficiently
apprehensive of each other weighed very
lightly indeed on the consciences of the
enriched magnates.
It is a difficult and complicated adven-
ture to try to make war impossible, but it
is a comparatively simple and easily real-
izable aim to make war unprofitable; and
making it unprofitable will make it unde-
sirable to the malevolent forces which at
times are in power in most prosperous coun-
tries and which are unscrupulous enough
to consider their own selfish ends only. The
item of Article VIII quoted, tho not as
heroic and impressive an item as some of
the more ponderous ones in the Covenant,
has this far-reaching design in view. It will
disarm forever the selfish interests which
build their fortunes and their palaces on the
groundwork of international hatred. These
selfish interests exist in every country —
men who, one should admit, are not infre-
quently as much the victims of their own
greed as the millions whom they plunge
into bloody conflict, who are often even
convinced that their motives are genuinely
patriotic and utterly unselfish and who are
loudest in protesting their utter disinterest-
edness. It is wrong that any small group of
men should be able to grow rich by a means
which entails the impoverishment and suf-
fering of every member of the community
except themselves. No one likes war — ^that
is a sane, sensible, normal feeling — ^and no
one should ever be submitted to the tempta-
tion of compromising his instinctive hatred
of war by the consideration that he will
get something by it. There are two mo-
tives which control human conduct: love
and greed; and in the past international
relations have been regulated too often by
national greed. We can think of no better
first step toward the elimination of war
than that which makes it forever unprofit-
able to any element, and Article VIII of the
Covenant aims boldly and simply at that
end.
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ORIGINAL. ARTICL.BS
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73
ORIGINAL
RTI C LE S
SO-CALLED HEART BLOCK: RE-
PORT OF A CASE INCLUDING A
BRIEF REVIEW OF RECENT LIT-
ERATURE.
BT
HENRY B. PBLLE. M. D..
LouisYlUe, Kentucky.
From a scientific or at least a technical
standpoint, heart block seems totally inex-
pressive, inappropriate and a misnomer,
since the cardia itself does not become
"blocked." When and by whom the term
was originated and introduced into medical
parlance is of no importance ; it appears to
have been commonly employed since 1906
and will probably have to be retained until
a more expressive designation is invented.
Pulsus bigeminus, bradycardia, cardiataxia,
allorrhjrthmia, arrhythmia and other more
euphonious terms occasionally encountered
in the literature fail to dearly express the
evident meaning intended by heart block.
For many years the cause of the cardiac
cycle and particularly the avenue thru
which impulse is transmitted from auricle
to ventricle, has been the subject of con-
troversy. Certain physiologists have con-
tended that transmission of cardiac im-
pulse was thru the nervous system, while
others have defended the muscular tissue
theory. His (1903) discovered a mus-
cular band connecting the auricles and ven-
tricles, now generally known as the "bundle
of His," which in the human being is 18
mm. long, 2.5 mm. wide and 1.5 mm. thick.
That this bundle transmits the impulse from
auricle to ventricle has been experimentally
demonstrated by several careful observers.
It is stated that by compressing the bundle
of His, all stages of interruption of impulse
transmission from auricle to ventricle may
be obtained ; that slight compression causes
an increase in intersystolic pause, greater
compression an intermittency in ventricular
contractions, complete compression inde-
pendent auricular and ventricular contrac-
tions.
As at present used heart block may be
defined as a circulatory phenomenon or
symptom-complex in which the stimulus for
contraction transmitted from auricle to
ventricle by muscular fibers (bundle of His)
is stopped or blocked. Defective conducr
tion or transmission may be due to known
or unknown underlying pathology. Lesions
involving the auriculoventricular bundle
must be exceedingly rare. A multitude of
presumed exciting or contributing causa-
tive factors have been mentioned by those
indulging in theoretical speculation, but so
far as can be ascertained no definite or con-
stant etiologic factor has yet been estab-
lished.
There may be only an occasional pro-
longation of ventricular systole; the ventri-
cle may only respond to every second or
third auricular beat or even more infre-
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quently ; the block may be complete so that
no stimulus whatever reaches the ventricle.
In the latter event the auricle pursues one
rhythm and the ventricle an independent
(much slower) rate. The variation may thus
be slight or considerable depending upon the
degree of the so-called block and consequent
defective conduction or transmission.
Anatomically heart block has been clas-
sified, according to the location of the in-
efficiency, thus : (a) auriculoventricular,
when located at the auriculoventricular
junction, (b) sino-auricular, when at the
sino-auricular junction, (c) dextroauriculo-
septolevauricular, when at the line of union
of the right auricle with the left auricle
plus the interauricular septum, (d) septo-
dextroauriculolevauricular, when at the line
of union of the right auricle plus the inter-
auricular septum with the left auricle.
According to Blackford and Willius com-
plete (chronic) heart block owes its origin
to a functionally complete "break" in the
auriculoventricular bundle, i, e., failure of
conduction from organic severance. Path-
ologically, inflammation, degeneration, in-
filtrating gummata and neoplasms are the
chief lesions described. Valvular defects
and coronary sclerosis are usually present.
The most frequent valvular lesion is the
mitral. Progressive changes in cardiac
rhythm from definite prolongation of the
auriculoventricular interval to the "dropped"
beat, then to 2-1 and 3-1 rhythm and finally
to complete dissociation of rhythm, have
been recognized and described. The Stokes-
Adams syndrome results from circulatory
changes which produce cerebral anemia;
in certain instances exercise seems to be
the responsible factor, since there is no
compensatory increase in the ventricular
rate. Rare instances have been recorded
where complete block existed for many
years with little or no clinical discomfort
and in which no organic lesion was evident.
However, the majority of patients with
chronic heart block are confirmed car-
diopaths, subject to the Stokes-Adams
syndrome with its attendant dangers.
Mrs. K. C, aged seventy-one years, first
consulted me April 7, 1911, complaining
of brief attacks of "giddiness, fainty feeling
and slow pounding of the heart," constipa-
tion and its results, but no headache. Her
blood pressure was then 240 mm. Hg. ; the
urine contained albumin with hyaline and
granular casts. Marked improvement in
her physical condition resulted from about
two months' daily hypodermic use of the
Roberts-Hawley lymph compound. This
continued until June, 1913, at which time
she went to Seattle, Washington, where she
remained until early in November. Her
return trip was most exciting ; her program
was altered, and returning by a different
route than intended, she was compelled to
change trains eight different times. Her
rest was greatly disturbed, she slept little
and had tjie misfortune to lose her port-
manteau containing valuables, which was
afterward found, but too late to allow her
to make a continuous journey home and
she had to pay an additional fare from St.
Louis to Louisville. I mention these cir-
cumstances merely to show the strain under
which she labored for three or four days.
The patient returned to Louisville,
November 12, 1913, and had Br serious at-
tack of s)mcope on November 16th. Similar
attacks occurred from time to time during
the entire winter; she sometimes had as
many as twenty-five within twenty-four
hours; her pulse to my certain knowledge
was often as low as twenty beatis per
minute; the nurse reported the pulse as
fifteen just before some of the attacks oc-
curred. During the following summer the
patient remained free from syncopal S)mip-
toms and was allowed to go about with an
attendant.
The seizures began again in January,
1915, and were frequent until the latter part
of May. At this time the woman was
seventy-four years of age. The following
additional history may be interesting : There
had been no other serious illness since reach-
ing womanhood; she had always applied
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75
herself strenuously to business affairs and
"supposed financial troubles." No luetic,
tuberculous or "rheumatic" history. She
had given birth to eight children without
complications. Three yeairs ago her pulse
became intermittent and averaged 38 beats
per minute, while systolic auricular sounds
were 72. After first syncopal attack such
seizures became frequent, but later occurred
at longer intervals ; seven weeks' immunity,
then again becoming more frequent. One
day she had eight attacks, in five of which
she became unconscious, and three the next
day developing suddenly, with pale face,
cyanosed lips, absence of respiration and
radial pulse for three minutes. The pulse
returned at first weak and slow, gaining in
force and frequency until it reached 120,
continuing at that high rate for about thirty
seconds. Her sensations were described as
a "dizzy feeling in head" extending into the
body followed by unconsciousness and
sometimes involuntary defecation and
micturition. Her eyes were set with lids
half open and there was sometimes gagging
when consciousness was returning. Her
face was always pale and the pupils were
contracted; no headache and no pain, ex-
cepting occasional lumbar discomfort; no
dyspnea when patient was not excited. She
said that two years ago she had vertigo
which persisted for a month. For a consider-
able time her alvine evacuations were almost
as white as cotton. Average pulse rate 28;
average blood pressure 188-50; heart dul-
ness 3yj/i by 1,%; absolute dulness 2,J4;
apex beat diffuse and of moderate force;
extra systoles, occasional systolic mitral
murmur; auricular sounds 76 per minute,
irregular; no pulsation in suprasternal
notch. Left pulse full, right scarcely dis-
cernible.
Several of my confrerers saw this patient
with me in consultation and various
methods of treatment were faithfully tried,
including the administration of digitalis,
atropin, epinephrin, etc., without any per-
manent appreciable effect. On August 4,
1916, the patient became unconscious, ex-
hibiting the usual symptoms of apoplexy
and died August 6th. Autopsy refused.
Bridgman and King speak of a negro hav-
ing complete heart block, Stokes-Adams
syndrome and a strongly positive Wasser-
mann reaction. After less than five weeks'
antisyphilitic treatment conduction time
was practically normal and he became symp-
. tomatically well. Wassermann reaction
negative on two occasions four months later.
Of especial interest was the electrophono-
grams which showed auricular sounds dur-
ing complete block and after normal
rhythm had been resiuned.
Podmaniczky reports two cases of
"rheumatic" heart block. The first occurred
transiently during acute articular "rheu-
matism" in a young man. The attack
developed suddenly accompanied by dizzi-
ness; the radial and carotid pulse receded
to 32, that in the jugular vein being 94. The
next day the pulse was 50, both carotid and
jugular beating together. The second case
was in a male of twenty-nine with a history
of "heart trouble" for ten years following
articular "rheumatism." Pulse 40, pulsa-
tion in jugular vein 70 to 80. The cardiac
symptoms had entered a stationary phase
and persisted for years. There seemed to
be total permanent heart block from "rheu-
matic" myocarditis.
Thayer mentions a female who for two
and a half years had occasional S3mcopal
and eclamptic attacks with extreme brady-
cardia. Between these periods pulse
regular, about 30 per minute. Polygraphic
and electrocardiographic study revealed
synchronous slowing of both auricles and
ventricles, with greater prolongation of the
As-Vs interval than hitherto reported. In
polygraphic tracings a-c- interval from 0.7
to 1.0 second; in electrocardiograms P-R
time often over 0.7 second. Diagnosis dis-
ease of the auriculo ventricular bundle. In
a second case essential bradycardia occurred
in a male of thirty-five. For five years
pulse beat ranged between 30 and 40 with
patient at rest. There was no prolongation
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February, 1919
ORIOINAIi ARTICLES
AlORICAN MBDIOINB
of the As-Vs interval. Vertigo and nausea
five years ago, but no evidence that these
were associated with auriculoventricular
dissociation. Patient remained in good
health despite persistent bradycardia.
Four cases of sino-auricular heart block
are described by Levine showing pauses of
heart action equal to multiples of normal
heart cycle of the respective individual,
there being no evidence of auricular ac-
tivity during the pauses indicated blocking
of the impulse above the auricles, t. e,, at
the sino-auricular node. The first patient
had bradycardia on exertion. The ven-
tricular rate receded to 43 from acceleration
of sinus rate. Tracings showed block de-
pended on sinus arrhythmia. Whenever
the sinus rate increased beyond a certain
point the node failed to conduct impulse to
auricles. Three patients showed sino-
auricular block only after taking digitalis.
One patient had frequent pauses in which
one, two, three or four beats were blocked ;
at one time the electrocardiogram showed
total sino-auricular block for "many
seconds," the ventricles beating at their
slow idioventricular rhythm.
Two cases are cited by Lundsgaard : ( 1 )
a male of fifty-nine suffering from aneurism
of the aorta had transitory irregular pulse,
appearing at one time like intermittent heart
block, at another an arrhythmia perpetua;
(2) a male of thirty-three suffering from
"rheumatic" fever had intermittent heart
block which disappeared when the joint
symptoms ceased and the temperature re-
ceded to normal.
Laursen refers to heart block in a young
man with no history of scarlet fever, diph-
theria or acute articular "rheumatism" ; nor
was he guilty of excesses of any kind. He
complained two weeks of headache, then
sore throat and foot pains but no fever.
He suddenly became dizzy and fell; dizzi-
ness later returned with cardiac oppression.
Examination revealed total heart block.
- Laursen thinks "some otherwise latent rheu-
matic infection was responsible for this com-
plete dissociation of conduction between au-
ricle and ventricle ; and the subsidence of the
heart block under treatment, as for acute
rheumatism, confirmed this assumption of
an indolent rheumatic infection localizing in
the heart."
Leporsky describes a patient having heart
block with complete dissociation of auricular
and ventricular action caused by some
lesion of the bundle of His. The symptoms
were auricular fibrillation and ventricular
automatism. The complete heart block was
continuous and caused by congenital cardiac
lesion. As auricular fibrillation combined
with complete heart block was first observed
experimentally by Fredericq, it would be
appropriate, Leporsky thinks, to classify in
a special group cases of cardiac disease with
this syndrome as "Fredericq's phenomenon
in man."
Frank and Polak saw a female aged two
and a half years with heart block. The
child had been earlier examined by other
physicians and nothing abnormal noted,
thus excluding congenital heart block.
Symptoms were noticed while child was un-
der medical care for fever of unknown ori-
gin. There was no cyanosis, but a tendency
to dyspnea with slow, weak pulse. The heart
was enlarged and the beats synchronous
with the pulse. Auricle 107, ventricle 42.8.
Digitalis retarded slightly the auricular
rhythm, but had no effect on disturbed con-
duction.
In a case recorded by White acute tran-
sient heart block appeared as the first sign
of acute "rheumatic" fever. The conduc-
tion time between auricle and ventricle
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Fbbruabt, 1919
77
showed great delay before onset of joint
symptoms and returned to normal about
six weeks after the block was discovered.
The myocardium not only gave the first
evidence of importance of the illness, but
also showed at least temporary damage,
while no evidence was found of endocardial
or pericardial involvement.
A male of forty-four described by
Holterdorf presented the Stokes-Adams
syndrome and also attacks of petit mat with
complete loss of consciousness. The at-
tacks occurred forty or fifty times an hour
day and night; during five weeks the pa-
tient was in hospital he had nearly 25,000.
Toward the end, intermissions became so
short that attacks were practically con-
tinuous. The auricle beat three or' four
times to the ventricle once, but the regular
ratio was preserved, heart block being in-
complete. At necropsy several gummatous
cardiac nodules were found but the auric-
uloventricular bundle showed merely
small cell infiltration between the muscle
fibers. "The only case approaching this in
respect to the frequency of the epileptiform
seizures was one of Zong's with two hun-
dred in twenty-four hours, but in the pres-
ent case there were eight hundred."
Simon and Robinson report functional
recovery of auriculoventricular conduction
between attacks of complete heart block.
The electrocardiograms showed complete
heart block only on one occasion, but the
clinical observations and history make it
clear that such occurred repeatedly, while
records obtained between periods of block
revealed but slight depressions of auriculo-
ventricular conduction. Syncopal attacks oc-
curred frequently over a period of two
years. Between attacks the cardiac mechan-
ism was practically normal.
Falconer refers to a male of sixty who
for two months had suffered from "short-
ness of breath" on exertion, but continued
working until two days previously, when
giddiness and vomiting developed. On at-
tempting to rise next morning he lost con-
sciousness and fell. While under observa-
tion the patient had numerous epileptiform
attacks with marked slowing of pulse. The
apex beat was in fifth interspace just inside
the nipple line. There was a slight mitral
murmur. Sometimes ventricular beats were
but 12 per minute and between them auric-
ular beats of 78 were distinctly heard.
There was at first Cheyne- Stokes breathing,
but this later disappeared with diminution
of the heart block.
Four types of transient heart block are
described by Krumbhaar: (a) transient
partial A-V block of myocardial origin, oc-
curring during an exacerbation of acute
"rheumatic" carditis, varying with the de-
gree of arthritis, yet responding to atropin ;
(b) transient complete A-V block, due to
digitalis and temporarily reducible by atro-
pin to a 2-1 rhythm ; (c) the development of
defective conductivity in the right branch of
His' bundle in an old man suffering with
arteriosclerosis, chronic myocarditis and
anginoid symptoms; (d) transient periods
of prolongation of the P-R interval (to
more than 0.3 second) without adequate
cause in a young adult male who was also
the subject of paroxysmal tachycardia of
auricular (or sinus) origin occurring inde-
pendently of and not affecting the state of
the conductive system.
Four cases were recently reported in de-
tail by Blackford and Willius of the Mayo
Clinic: (1) Male of forty-two, no history of
"rheumatism," tonsillitis, chorea or lues.
Following diphtheria at twenty, occasional
palpitation and rapid heart action noted.
Slow pulse, at times, for eight or ten years
before coming to clinic. Two and half
years ago, during attack of measles, pulse
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was 42 and since ranged from 37 to 40. He
gradually became dyspneic and unable to
work, but had never been confined to bed.
Two weeks previously "sinking spells"
began ; he would suddenly become dizzy and
heart seemed to stop. There was momen-
tary unconsciousness without convulsions;
sometimes ten to twelve attacks daily.
Blood pressure 112-60, pulse 36; heart six
inches to left; loud, harsh, systolic mitral
murmur with heaving apical impulse. Diag-
nosis, bradycardia with mitral lesion, prob-
ably double, and myocardial insufficiency.
Electrocardiogram showed complete disso-
ciation ; auricles 71, ventricles 36. Wasser-
mann negative. (2) Male of sixty-four, no
tonsillitis or "rheumatism" ; denied venereal
infection ; "grip" twenty years ago followed
by dyspnea and "pounding of the heart."
Three years previously had dizziness and
was treated for "heart trouble." Edema of
legs noted two years later. Recently fainting
spells, possibly apoplectic. Slow pulse four
months; exertion caused dizzy spells last-
ing few seconds. Heart five inches to left,
one inch to right ; pulse rate 30 ; loud systolic
murmur at apex. Eye-grounds showed
arteriosclerotic vessels and hazy discs;
brachials sclerotic. Electrocardiogram
showed complete block ; auricles 66 ; ventri-
cles 32. Wassermann negative. (3) Male
of sixty-one, Neisserian infection twenty-
five years ago ; lues questionable. Wasser-
mann negative. Complained of stiffness of
spine and dizziness on exertion. Cardiac
history four to six years' duration ; attacks
of "all-gone feeling" and momentary diz-
ziness, usually following exertion, but oc-
casionally at other times. General condi-
tion fair; pulse 36 to 40. Heart four and
one-half inches to left ; loud systolic murmur
over entire pericardium. Marked spondy-'
litis deformans and large right branched
kidney stone. Electrocardiogram showed
complete block; auricles 107, ventricles 41.
(4) Female of twenty-five, married, no
venereal history. Wassermann not taken.
Repeated attacks of tonsillitis. Three years
ago fell and struck lower back ; pain severe
for week, then relieved by discharge of a
larp^e quantity of pus from rectum. Follow-
ing week tonsillitis, repeated vomiting,
"fainting spells," pulse 28. Year later
patient in fair health excepting dyspnea.
One morning she suddenly fell and
remained unconscious nearly an hour;
cyanosis and slow pus. Since then
repeated "sinking spells" with slow pulse
usually following exertion. Heart four
and one-half inches to left, pulse 42.
Blood pressure 158-78. Heart beats irreg-
ular, faint systolic murmur at apex, slight
transmission toward axilla. Tonsils mod-
erately enlarged, marked evidences of
chronic tonsillitis. Electrocardiogram first
day showed ventricular rate 60, due to re-
peated ventricular extra-systoles, auricles
The authors state that in addition to these
four cases there have been five other pa-
tients observed, but not treated since
November 1, 1914. The total number of
cases, three women and six men, may be
summarized as follows : One was twenty-
five years old, two were over forty, one
over fifty and five over sixty. One gave
history of "gonorrhea," none gave history
of syphilis; six showed negative Wasser-
mann. Only one gave history of "rheu-
matic" fever; two others admitted vague
"rheumatic" pains; in two the trouble
seemed to have followed diphtheria, and
"grip" may have been the etiologic factor in
four. Seven of the nine patients gave his-
tory of Stokes- Adams syndrome, and all but
one had cardiac murmurs. Three of
these showed clinical predominance of an
aortic lesion ; five predominance of a mitral
lesion. "Of the seven patients concerning
whom word has been received recently,
three are dead, all dying in typical Stokes-
Adams attacks."
"We know that the vagus gives branches
to the sinus node, to the auriculoventricular
bundle, and that stimulation causes slowing
of the heart by inhibition of the sinus and
of the conducting bundle. The cardiac ac-
celerator nerves have a similar distribution,
but they act to increase the sinus rate. So
far as has been proved, they cause no in-
crease of the idioventricular rate. Digitalis
is recognized as stimulating the vagus and
thus slowing conduction in the bundle, tho
therapeutic doses often produce no rate re-
duction in a sinus rhythm or tachycardia.
No drug or measure is known which in-
creases the idioventricular rhythm ; yet such
result is manifestly desirable in chronic
heart block. Thyroid extract will excite
a tachycardia in the normal organism. Such
eflfect is produced probably by action on the
accelerators or a direct stimulation of the
sinus node, tho no experimental work is
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available to prove this action. A large mass
of clinical evidence without laboratory proof
shows that thyroid extract markedly affects
the myocardium, as illustrated by the
irritable and rapid action, with concomitant
myocardial degeneration of the thyrotoxic
heart. During the examination of a case
of chronic heart block we thought of at-
tempting to increase the idioventricular
rate by the administration of large doses
of alpha-iodin, the active constituent of the
thyroid which Kendall has isolated recently.
The administration of this drug has been
followed in four cases by marked improve-
ment in the patients* nutrition, associated
with increased ventricular rate and cessa-
tion of the Stokes-Adams s)mdrome, tho
one patient has since died." (Blackford and
WiUius.)
Digitalis was administered in one of the
cases (case two) in the foregoing series.
The daily dose of alpha-iodin varied from
one-half to three milligrams. I have had
no experience with this drug in the treat-
ment of heart block, but based upon the re-
sults obtained by Blackford and WiUius,
its administration would seem advisable in
cases of this kind. The authors conclude
their admirable paper as follows^
(1) Alpha-iodin quickens the iodioven-
tricular rate in complete heart block; this
is followed by marked subjective relief to
the patient; the drug must be pushed to
tolerance and the dose then reduced to the
largest quantity which may be taken without
discomfort; the auricular rate increases
much earlier and to a much higher figure
proportionately than the ventricular rate.
(2) In nine cases of complete heart
block, eight patients gave evidence of
definite valvular disease, mitral lesions pre-
dominating; the ninth, patient had advanced
nephritis.
(3) In none of the nine cases was there
a probable venereal etiology.
(4) Six patients gave a history of prob-
able etiologic infections with the strepto-
coccic group, 1. e., chronic arthritis (one
case), "grip" and tonsillitis (five cases) ;
diphtheria seems to have been responsible
in two instances ; the ninth patient gave no
history of previous infection, but at autopsy
a large (mulberry) calcified nodule was
found involving the bundle and one cusp of
the aortic valve; no other pathology was
evident.
(5) Digitalis should be used in all cases
of chronic heart block in which there is
evidence of myocardial insufficiency.
(6) "We do not know the effects of long-
continued administration of large doses of
alpha-iodin in patients not suffering from
thyroid insufficiency; therefore we believe
that for the present this medication should
be used only to relieve the Stokes-Adams
syndrome in chronic heart block." (Black-
ford and WiUius.)
Heitz presents Routier's classification of
auriculoventricular dissociation as: (a)
simple heart block, (b) complete dissocia-
tion, and (c) partial dissociation, and sug-
gests that the trouble may be in conduction
or in generation of the impulse; that ex-
perimental research has demonstrated a cer-
tain connection between cardiac fibers of the
sympathetic and conduction of the impulse.
Routier arrested conduction by "nipping"
with forceps the bundle of His in dogs. The
auricle beat was 140, the ventricle 55, in
one experiment. "Then an injection of
epinephrin was made and in twenty seconds
the auricle beat became 115 and the ventricle
beat also 115, showing that the heart block
had been overcome; as the effect of the
epinephrin passed off, the auricle beat in-
creased to 120 while the ventricle beat
dropped to 42."
Atropin had no appreciable influence on
total heart block in one of Marui's cases.
In another the ventricle beat increased by
eight pulsations, showing with even total
heart block the vagus may yet exert a cer-
tain control over the ventricle. Injection of
epinephrin in a male of fifty-nine induced
the bigeminus picture. The extra systoles
with the total heart block are ascribed to
to stimulation of the accelerator nerves.
Danielopolu and Danulescu found exper-
imentally that where incomplete dissocia-
tion of auricular and ventricular beats ex-
isted, injection of epinephrin caused almost
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entire disappearance of the heart block and
pronounced increase in the pulse rate. "To
antagonize clinically the manifestations of
cerebral anemia^ sometimes fatal, which
occur in attacks of heart block, we should
resort to epinephrin instead of atropin as
has been customary, the former exerting a
far more marked and prompt accelerating
action on the ventricles."
REFERENCES.
Blackfobd-Wuxius: Collected Papers, Mayo
Clinic, 1916, vlii, 646.
Bbidghan-Kino: Abstract in Joumai of the
A. If. A., 1916, Ixvi, 62.
DANiELOPOLu-DANmjBBcu: Abbtfact in New
York Med. Jour,, 1916, ciii, 806.
Edttobial: Journal of the American Med,
A88n,, 1906, xlYl, 668.
EBi^iNOEB: Joumai of Experimental Medicine,
1906, Yiii, 8.
Pbank-Polak: Abstract in Journal of the
A. If. A., 1916, Ixvii, 322.
Falconeb: Abstract in Medical Record, 1916,
89, 970.
Hettz: Abstract in Journal of the A. M, A.,
1916, Ixvi, 1170.
Holterdobf: Abstract in Journal of the A. M,
A., 1917, Ixviii, 232.
Kbumbhaab: Abstract in Journal of the A.
If. A., 1917, Ixviii. 1781.
Laubsen: Abstract in Journal of the A. M, A.,
1916, Ixvi, 850.
Lundsoaabd: Abstract in Journal of the A.
M, A., 1916, Ixvi, 606.
Lbvine: Abstract in Journal of the A. M, A.,
1916, Ixvi, 457.
Lbpobskt: Abstract in Journal of the A. Jf.
A., Ixvi, 1434.
Mabxh: Abstract in Journal of the A. M. A.,
1916. Ixvi, 1665.
Podhaniczky: Abstract in Journal of the A.
M. A.. 1916, Ixvi. 68.
Simon-Robinson: Abstract in Journal of the
A. Jf. A.. 1917, Ixviii, 1004.
Thateb: Abstract in Journal of the A. M. A.,
1916, Ixvi, 466.
Whtte: Abstract in Journal of the A. M, A.,
1916, Ixvii, 1330.
Prophylaxis of Endemic Goiter. — ^Kling-
er {Correspondenz-Blatt fur Schweizer
Aerzte, April 20, 1918) advocates that at
least 2 or 4 mg. of iodine should be given
to each person daily in experiments in the
prophylaxis of goiter. Any amount less than
this is futile. Even this totals only from 1
to 1.5 gm. per year.
TUBERCULOSIS; SOME REMARKS
ON ETIOLOGY ON TREATMENT.
BY
ALBERT C. OBYSBR. M. D.,
New York City.
Tis a true saying that "It is a long road
that has no turning," especially if the road
of yesterday is walked upon in the same
direction for any length of time. Let us
turn about and review the familiar sign
posts we have passed in the study of tuber-
culosis. Before turning, however, let us
ask these pertinent questions : Why have we
been headed in this direction? What was
our goal? We were headed in a certam
direction because Prof. Koch discovered
that each little tubercle in the lung or other
tissue contained one or more acid-fast bacilli,
that they were always present in patients
with tuberculosis, that when such bacilli
were introduced into living animals, the
bacilli multiplied and formed more tubercles,
that the animal so inoculated finally died
of phthisis the same as the human being,
the original source of the infection. We
started on the road in this particular di-
rection to hunt down this bacillus to its
original starting place; to find something
that would destroy the bacillus either with-
in the human tissues or without, wherever it
might be found. We had become convinced
that the tubercle was the result of the
bacillus. If, therefore, the bacillus could
be traced to its original source, its starting
place and there completely annihilated, the
world would be freed from this bacillus ; in-
cidentally the White Plague would be no
more, and the crusades, all of them leading
in the same direction, to the same goal would
be unnecessary. For the past thirty-five
years we have traveled this road unceas-
ingly, until now we find ourselves in the
wilderness.
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81
Early in our travels we met certain sign
posts, each one instilled new hope, new
energy to keep on. Of late these benevolent
sign posts have been getting fewer and
fewer, we have become confused and are
wandering aimlessly, not knowing why or
where we are going.
Before we are hopelessly lost in the mire
and quicksands, following phantom lights,
let us halt, nay let us turn back; let us
again pick up the old familiar sign posts
and then pursue the road in exactly the op-
posite direction. The entire road that we
have been following led to pathology. Every
milestone that we passed brought us nearer
and nearer to pathology. Now we realize
that all of this pathology was merely the
end result of something that had preceded
it. Every adequate as well as every inade-
quate effort on the part of the system to
overcome the invasion of this bacillus left
its traces. At the autopsy we found bodies
of men well advanced in years, who during
their lifetime never suspected tuberculosis,
yet here they presented the unmistakable
signs of healed lesions. Sometimes it has
happened that the laboratory report showed
that a certain patient's sputum was loaded
with the bacilli, yet the patient lived on and
finally recovered and we labeled that pa-
tient as a "closed lesion." The sign posts
on our road led us to believe that nearly
all of the tuberculosis was the direct re-
sult of milk contamination. We finally traced
this bacillus to the cow. The veterinaries
of the country were enlisted and every cow
was injected with tuberculin. If it hap-
pened that such a cow reacted to the test,
she paid for it with her life. Fishberg in
American MsDiaNE, August, 1915, says:
"A cow which reacts to tuberculin in a
stable with cattle known to be free from
tuberculosis often brings about an infec-
tion of the cattle, so that ultimately they all
become reactors, altho it cannot be proved
that the cow which disseminated the bacilli
had any physical signs of the disease."
Now we know that the cow bacillus never
caused a single case of human tuberculosis.
Not content with that it was discovered
that the timothy or hay bacillus was an
acid-fast bacillus, the extermination of
which, however, seemed too big a task to
even start upon. Still later the smegma and
perhaps a host of other bacilli, one looking
as much like the other as two peas in a
pod, were discovered; they were accused,
tried but acquitted. Then we came to the
conclusion that the tuberculin test was
fallacious, because 95% of hiunan beings re-
sponded to it, and what was worse that
the more virulent the disease the less the
response ; this test was of course abandoned.
We also discovered that the bacillus or
even a billion of them were entirely harm-
less, but that they did pour out a certain
toxic material which was responsible for
the sickness and death attributed to tuber-
culosis.
One of the best things that we did discover
on that pathologic road was the fact that
this bacillus had a particular aversion for
the blood. It seemed to prefer blood-poor
areas, hence it was most frequently found
in the unused or upper portion of the lung,
the glands, the skin and the bones. Where-
ever there was anemia, there was the bacil-
lus, wherever there was a bacillus, there was
anemia. Whether the anemia preceded or
whether it followed is of little consequence,
it was pathologic in either case.
Retracing Our Steps, Now that we are
retracing our steps let us stop now and then
to read the sign posts : Edward R. Baldwin,
(New York Medical Journal, January 23,
1915) summarizes a very interesting ar-
ticle on Immunity in Tuberculosis as fol-
lows:
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"We have seen that there is no natural
immunity to tuberculosis in man or mam-
mal ; that there is no true immunity of
races; that inheritance tends rather to an
increased susceptibility than to an increased
resistance ; that long continued non-expo-
sure of a race to infection increases the
susceptibility of that race, while abundant
exposure for many generations leads to a
marked increase in the frequency of ac-
quired relative immunity; that the mild
infections of human beings in early life con-
stitute the most powerful means of relative
protection in adult life. From this latter
fact we may conclude that in the future
there should be a continued decrease of the
severer cases of tuberculosis in man, accomr
panied, probably, by an increase in the fre-
quency of the case of mild and minor in-
fections/*
If Baldwin is right, we must give up
studying the pathology if we are looking
for a cure. Instead, we must study the
physiology of our patients ; it is the physi-
ology that produces recoveries and cures.
Tubercle formation is a physiologic process,
it is Nature's best and only weapon with
which to overcome these bacilli, but more
of this later.
In Public Health Reports, Dr. George M.
Kober considers the influence of dust on
the prevalence of disease, particularly tu-
berculosis.
The tuberculosis rate among 472,000
males in the United States exposed in
fifteen occupations to the inhalation of or-
ganic dust was 2.29 per thousand, against
a rate of 1.55 for all occupied males; 42.05
per cent, of the deaths of printers, litho-
graphers, and pressmen who died at ages
between 25 and 44, were from tuberculosis,
as compared with 21.8 per cent, for farm-
ers, planters and overseers.
In Berlin, as shown by Sommerfeld, the
average tuberculosis death rate was 4.93
per thousand of the population. In non-
dusty trades it was 2.39, and in dusty
trades 5.42.
In Vermont in towns where granite and
marble cutting is carried on, in a popula-
tion of 34,899 the tuberculosis rate was 2.2
per thousand, against a rate of 1.3 for the
entire state.
Kober says it is estimated that "indus-
trial workers, constituting about one-third
of the population, contribute about one-
half of all the deaths from tuberculosis. By
factory sanitation and effective methods for
the prevention and removal of dust, fully
one-half of these lives could be saved. That
this is not speculative is indicated by the
figures from Solingen, Germany, where the
population is made up largely of employees
in the cutlery industry. The mortality had
been reduced from 20.63 per thousand in
1885 to 9.3 per thousand in 1910, and the
tuberculosis rate from 5.4 in 1885 to 1.8
in 1910 per thousand population. In the
German cement works also, diseases of
the respiratory organs have been re-
duced from 9.3 to 3.3 per cent, after the
installation of dust preventing apparatus.''
{Journal A. M. A,, Jan. 1, 1916.)
Figures do not lie, but statistics properly
manipulated will prove anything. It will be
admitted that dust, especially such dust as
found in granite cutters' places and cutlery
institutions, is by no means conducive to
good health or the prolonged action of life.
When we look back and recall the fact
that in all probability 95% of all these
workers had contracted tuberculosis dur-
ing their infancy, had recovered from the
infection and upon entering the granite
works or the cutlery shops were nothing
more or less than "closed lesions" our
surprise is not that there is such a high
percentage of tuberculosis cases, on the
contrary we wonder at the extreme small-
ness of the percentage, we marvel and won-
der not why so few die, but why so many
escape. If then, the dust laden atmosjphere
is removed, it is perfectly natural that
there should be a less number, who would
otherwise by the inhalation create an anemic
area in their lung tissue from a fibrosis.
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83
That these dust exposed workmen were in-
haling the germs is of course not claimed,
so that if they developed tuberculosis they
must have either had the bacillus prior to or
received it later on. Just what a dust laden
atmosphere has to do with tuberculosis we
see by the next sign post :
Tubercle Bacilli in Air and Dust, — Kaurin
inoculated animals with culture mediums
long left exposed to the air in rooms occu-
pied by the tuberculous. Also with dust from
the toilet rooms, hall and other parts of
the sanatorium where the inmates congre-
gated. No acid-fast bacilli could be de-
tected in any of the seven groups of tests,
and none of the fourteen animals showed
any sign of infection. These findings har-
monize with the experiences of the seven-
teen years during which none of the at-
tendants or other persons connected with
the sanatorium has contracted tuberculosis.
The bacillus of Koch does not thrive well
outside of the human body; neither does
it thrive in the blood of the patient.
Kessel has lately made new attempts to
grow tubercle bacilli directly from the
blood, and to demonstrate their presence
by direct microscopic examination and par-
ticularly by careful direct inoculation of
susceptible animals with the blood from
patients with advanced pulmonary tuber-
culosis. All with negative results, Kessel
admits that this outcome in forty-seven
cases examined by him does not conclusive-
ly prove that tubercle bacilli are never
present in the circulation; but they strongly
suggest that a bacillemia such as is present
in other infectious diseases is at least un-
common in pulmonary tuberculosis even in
advanced stages of the disease. It may be
that from time to time tubercle bacilli are
washed into the circulation from a pulmo-
nary focus, but it is shown by experimental
evidence from the effect of direct intrave-
nous inoculation that in such an event they
rapidly disappear from the blood.
On the contrary I have called attention
to the fact over and over again that the
bacillus of Koch can only thrive, multiply
and produce the disease "phthisis" in a
blood-poor area. Anemia must either pre-
cede or be concomitant with the entrance
of the bacilli.
To answer academically the questions,
Where do the germs come from? How do
they enter the system? would lead us too
far from the present theme. I will how-
ever venture a bold guess. Ninety per cent,
of the entire human race is infected with
the bacillus of Koch during the pre-natal
existence. We no longer believe that the
placenta acts as a barrier to germs, we may
still be right in saying that the disease is
not inherited but surely a disposition to the
disease. There is no reason why the physi-
ology in the fetus should not act with the
same vigor and under the same laws as in
post-natal life. Physiology is physiology, it
builds up the fetus from the union of two
elements into one perfect human individual.
Physiology has performed intra-uterine
amputations, so there is no good and valid
reason why an infection with the Koch
bacillus could not take place and at once
be followed by physiologic protective meas-
ures. In this way we can account for some
of the natural immunity. Again there is no
reason why the system might not fail in its
curative attempt, that would produce off-
springs more or less started on the road
of a future tuberculous "diathesis."
Personally I am not a believer in the in-
fection from person to person or from the
tuberculous to the healthy. Yet there is
every possibility that if an offspring came
into the world entirely free from any and
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all tuberculous taint, it would of necessity
become promptly infected.
"I have elsewhere shown that no intimate
contact is necessary to transmit the disease
among persons who have not met with tu-
berculosis before." (Fishberg: Tubercu-
lization and Immunization, N, F. Med.
Jour., Sept. 12th, 1914.)
"Given a virgin soil and a race of bacilli
already adapted to the species, an initial
infection takes place with little hindrance
from the non-specific defensive powers. The
ultimate survival of those who acquire a
relative immunity will tend to diminish the
severity of the disease, but many genera-
tions will be required to accomplish this."
(Editorial, Jour. A. M. A., Sept. 18th,
1915.)
In such infections, the patient usually
recovers, is tuberculized and no one is
any the wiser. Many of the "ephemeral
fevers" of early infancy are no doubt due
to the reaction of the system to the in-
vasion of the tubercle bacillus, the forming
of the tubercles and the overcoming of the
toxemia produced by the germs. Such a
patient is now tuberculized, a more or less
lasting immunity has been acquired. Such
a tuberculized subject is not freed from
the bacilli, they simply have been encap-
sulated, they have been made harmless, they
have been surrounded by certain groups of
cells forming the tubercles.
Should anything happen in later life,
whereby the natural resistance of the body
is lowered, where anemic areas are pro-
duced, these tubercles may give up their
lime salts in cases of acidosis and so liberate
the germs. A new infection with the same
old germs might be produced and on ac-
count of physical changes the patient might
not be able to again form the "tubercles,"
tuberculization could not take place, but in-
stead we would have a case of the disease,
"phthisis." .
TubercnlosM— Tubercidizatioii. — ^A tu-
bercle, as we view it in its final analysis, is
a nodule 1/10 to 2mm. in diameter, found
in all parts of the body. Favored sites are
the apices of the lungs, the glands, the skin
and the bones. We notice at once that all
these areas are not what is termed "vas-
cular." As a rule tubercles do not form
readily in vascular areas, yet every tubercle
is formed directly from the elements con-
tained in the blood. Let us trace a tubercle
bacillus after having gained entrance into
the human body. The germ is a foreign
body, and as such evokes when proper re-
sponse is made a reaction by the system for
its expulsion. The bacillus itself on the
other hand pours out a certain toxin, the
effect of which is to cause an anemia in
the immediate neighborhood. This anemia
is favorable to the future existence and
multiplication of the bacillus. Under ordi-
nary circumstances the tubercle bacillus is
anaerobic but may for a time acquire aerobic
properties. Anemia with its lack of oxygen
favors the prolongation and the multiplica-
tion of the germs. When such a germ, now
as a foreign body, is acted upon by the sys-
tem, the first thing that happens is the for-
mation of a zone of an inflammatory area
surrounding the germ. A leucocytosis and
a diapedisis follow. Giant cells are formed
in a circular manner enclosing the foreign
body. As soon as this is accomplished, the
blood vessels are obliterated and new ones
form on the outside of the wall of giant
cells. The previous process is repeated,
only instead of giant cell formation we
have a deposit of oval cells; they are in-
tended for strength and durability. Again
the blood vessels are obliterated and a new
vascular zone is formed around the shell of
oval, epithelioid cells. The third layer of
cells is composed of lymphoid corpuscles
which are capable under favorable circum-
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Stances of enmeshing among themselves
lime salts. When these three layers of cells
have been completed, the bacillus of tuber-
culosis is as securely locked in as a prisoner
in a stone fortress. In a completely formed
tubercle there are no blood vessels nor
lymphatics to communicate with the center.
Neither is there left any avenue of escape
for the bacilli except in to to, tubercle, ba-
cilli and all.
Tubercle bacilli never appear in the spu-
tum excepting for two reasons: First, the
system fails to respond to the foreign body
irritation, it does not form tubercles, there
is no tuberculosis, no tuberculization. The
bacilli multiply rapidly, poison the indi-
vidual cells of the system and cause the
disease "phthisis."
Secondly, the system may have responded
and held the disease in abeyance until the
system lost its resistive power, the tubercles
were drawn upon to furnish much needed
lime salts elsewhere, the rest of the tubercle
broke down and liberated the germs. The
germs multiplied under most favorable con-
ditions and "phthisis" was the result.
Phthisis Therapy. — Tuberculosis and tu-
berculization are the great factors in phthi-
sis therapy.
The formation of tubercles is the only
physiologic and natural prevention of
phthisis, it cannot be improved upon. Our
whole idea in therapy is not how can we
prevent, but instead how can we produce
and augment tuberculization?
A healthy, normal human blood contains
all the elements necessary for the produc-
tion of the tubercles. The production and
the formation of the tubercles is a physi-
ologic process and not a state, it cannot
be initiated or produced by artificial means.
We can, however, assist the system in
the carrying out of this physiologic process.
The farmer cannot grow potatoes or
wheat, but he can till the soil; he can in-
troduce into the soil all such elements as
Nature requires for the growth of the
plants; he can produce artificial heat and
moisture as in a hot house, but the actual
process of growth cannot be imitated by
artificial means. Phthisis therapy resolves
itself into the several kinds of therapeutic
measures which are usually requisite for
the production and the maintenance of good
health.
The Local or Pufanonary Treatment. —
A high frequency apparatus of low
voltage but high amperage is required
to furnish the diathermia for the local treat-
ment. The patient is connected to the ter-
minals of the apparatus in such a manner
that the electrodes cause the current to pass
thru the involved lung area. The entire
chest assumes a heat of 104-106° F. ; this
is allowed to run for 40-60 minutes either
daily or at least on alternate days.
The capillaries of the lung tissue are di-
lated, active hyperemia takes place, tubercles
are formed rapidly. At first expectoration
seems to increase, later it decreases, the
bacilli disappear from the sputum, not be-
cause that they have left the system, but
because tubercles have been formed and
the germs are no longer free in the tissues.
Clinically the patient has ceased to show
any manifestations of the disease while the
X-ray shows a greater deposit of tubercles
than before treatment. If treatment is con-
tinued even the tubercles are expectorated,
healing takes place by fibrosis or scar for-
mation much after the manner of artificial
lung compression, only this lung is as large
as ever and performs normal physiologic
function.
Tuberculosis is therefore the alpha and
the omega of phthisis therapy. It is pri-
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marily a wasting disease, rest is of even
more importance than motion.
Hydrotherapy, — Since a great deal of de-
pendence was placed upon the blood and
its elements it seems but natural that any-
thing which tends to ease the work of the
heart and at the same time increase the
circulation must be of especial value in this
disease. The patient is ordered to take a
bath every evening at 105** F. lasting from
20-30 minutes. During this time he may par-
take freely of cooling drinks such as wa-
ter, lemonade, orangeade or even a small
quantity of wine in water is not objected to.
At the end of 20-30 minutes a quick cooling
bath and a rub down and the patient is
ready to retire. The object of the bath
is complete relaxation of the entire external
vascular system. The effect is very analo-
gous to violent exercise minus the physical
effort, the blood becomes heated, a sort of
autogenous vaccine injection is simulated.
The patient by this means practices the
best autoserum therapy. This bath is re-
peated in the inoming upon arising after
which the patient again retires for one to
two hours.
Drugs. — If there is one disease in which
drugs have failed to show results it is in
phthisis pulmonalis. Since we have re-
traced our steps and are no longer trying
to change or influence the existing pathology
it is perfectly clear that drugs as such
could have no beneficial influence. Even
the injection of tuberculin is of question-
able value. Theoretically such injections of
either the dead bacilli or the metabolic sub-
stances of the living germs seemed to offer
some hope and personally I am not in a
position to condemn them, neither can I
recommend them for the simple reason that
they have seemed entirely unnecessary.
Why should a physician resort to a doubt-
ful procedure when positive results are ob-
tainable by perfectly natural means. Before
dismissing the question of drug therapy for
consumption, it is well to call attention to
one phase of medication. During the last
few years we have learned a great deal
about "intravenous medication." Since the
economy must react to everything put into
or on the body, there is not the slightest
doubt that there are also substances that
may be administered which can and do in-
fluence the forces of Nature for its good.
The intravenous route certainly spares the
digestive powers and this is worth a great
deal in every case of consumption. More
lives have been lost in this disease by the
administration of drugs per mouth than
have ever been benefited by it.
We cannot in this instance deal with the
"How and Why." The constituents of the
blood are increased by the intravenous ad-
ministration of iron and arsenic as prepared
by the Loeser intravenous medication
process ; there is no doubt of its efficacy
to rapidly increase the cell count in cases
of anemia. Let us bear in mind that we are
not using the iron and arsenic intravenous
solution for the cure of consumption, but
we do use it as an aid and a very material
one for the production of that kind of
blood so essential in the production of a
physiologic cure of phthisis.
Exercises, — Dr. Knoph in his interesting
treatise on this disease has laid down cer-
tain rules to be followed in exercises. As a
prophylactic measure they are .most valu-
able, again later on when the patient is con-
valescing, carefully observed rules in physi-
cal exercises are helpful. The most valu-
able of all is deep breathing. It is tiie only
one that should be made use of during the
time while the patient is under active treat-
ment.
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Diet, — Since the tubercles must be pro-
duced from the elements normally found in
the blood, it seems only pertinent to see
that the blood composition is normal at
least. Again since the structure of the tu-
bercle depended upon the amount of lime
salts, it seems reasonable that the blood
must contain these necessary elements
abundantly. Milk is a perfect diet. Bovine
milk with some slight modification may be
made to resemble human milk to all intents
and purposes. Sterilization and pasteuriza-
tion are make-shifts; while they are sup-
posed to kill pathogenic germs, they do so
at the expense of the vitamines present.
A patient, depending upon the age, di-
gestive power, etc., requires a certain
amount of fresh, good milk daily from a
healthy herd (clinically healthy). Such
milk and cream contain all of the elements
of the normal blood. In some special cases
where the patient seems to lack in recupera-
tive power, the yellow or the yolk of the
raw egg may be added to such milk. This
must not be done with a view of fattening
the patient.
At least twice weekly raw oysters, or
raw oyster broth must be partaken of.
Qams, oysters and their broth are not given
for their food value because they have none,
but they do contain the earthy salts so
necessary for the proper tubercle construc-
tion. The administration of the artificially-
produced lime salts does not compare with
that of the raw oyster or oyster broth.
It is made by Nature according to natural
laws, it is prepared for immediate absorp-
tion and assimilation. Of the above men-
tioned foods the patient must partake ac-
cording to his needs, each case is a law
unto itself. The rest of the diet may safely
be left to the patient, he should neither
stuff nor starve. A goose may be stuffed
and fattened, a phthisical patient is a goose
if he attempts it.
Prognosis. — In the N, Y. Medical Jour-
nal, Aug. 22nd, 1914, appears the Presi-
dential Address of Dr. Van Rensselear, the
Medical Director of the Albany Tubercu-
losis Camp, entitled "Diathermia in
Phthisis Pulmonalis." Doctor Van Rens-
selear in this address reported to the Thera-
peutic Society of this state that with this
system of treatment the recoveries or the
apparently cured amounted to the amazing
rate of 69%.
At the Albany Tuberculosis Camp this
system was given a thoro trial in the fol-
lowing manner : All of the patients regard-
less of the conditions were divided into
three groups. One-third received the usual
hygienic treatment in vogue in all of tiie
sanitaria. The recoveries were 15%. The
next third were given the same treatment
plus tuberculin injections. The recoveries
were 15%. The last third received the usual
hospital care plus the diathermic method of
treatment; it was in this one-third that
69% of recoveries took place.
Two points are worthy of our considera-
tion: In the first place the Albany Tuber-
culosis Camp is a public institution, the
selection of cases therefore not possible.
Secondly the results obtained by Doctor
Van Rensselear were obtained by instru-
ments far inferior to the ones in use at
the present time. In my own experience
during the past eight years, both private
and institutional, the percentage of actually
closed cases (cured?) is well above 90%.
If the patient is really willing to be cured,
not by the prestidigitator's process but, by
physiologic methods, there is no reason why
every case of phthisis during the first and
frequently during the second stage cannot
be converted into a closed case.
301 W. 91st St.
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MYOPIC SPECTACLES FOR HYPER-
OPIA.
BY
GEORGE M. GOULD, M. D.,
Atlantic City, N. J.
The mistake suggested by the title is far
more common than is suspected. It has long
been the routine habit of the oculists and
opticians of a great nation "over there,"
and is altogether too common over here. It
is especially the medical crime of the re-
fractionist who calls himself "ophthalmic
surgeon," and of the optician who "can pre-
scribe glasses just as well as the oculist."
It is based on the blunder of mistaking the
kind of ametropia present in the patient's
eyes and this is brought about by the non-
use of a mydriatic or by the fact that low-
power myopic lenses may at first seem to the
patient to give higher acuity of vision even
in considerable hyperopia. It is in a word
malpractice, altho much practiced. In at
least one European nation it has largely
contributed! .to its naJtional disaster, and
with our thousands of nonmedical and
other "refracting opticians," it is lowering
our own national efficiency. A case in point :
On December 12, 1916, a man 28 years
old came to me saying that he had "always
had good health." This report is not un-
usual by patients suffering much, and I at
once questioned him more closely as to its
truth. He corrected himself by saying that
ten years ago he had come to the conclusion
that his eyes were responsible for his
"round shoulders" and other symptoms.
Quizzing also elicited the vag^e statement
that he had had headaches at 14 or 15 years
of age, "frontal, and almost daily"; and,
also, that he had had some neuritis, but not
now. A ticket agent, and "reads all the
time," was illuminating.
He was wearing, at this visit, the follow-
ing lenses prescribed by an "oculist":
R. Sph.— 0.25 Cyl— 0.25 ax. 90^
L. Sph.— 0.12 Cyl.— 0.87 ax. 180^
Even without a mydriatic it was only a
minute's work to demonstrate that the
ametropia was not myopic but essentially
hyperopic. There was, of course, a strik-
ingly evident and powerful accommodation.
Temporary spectacles were ordered to re-
duce the hypertrophy, the amblyopia, etc.
Later visits and persistent quizzing
brought the confession that the patient had
previously gone thru eight operations for
anal fistula, and that he had also consulted
"a dozen or more" oculists, not only with-
out relief of any symptoms, but with in-
crease of suffering, systemic or local. He
was tall, yet weighed only 150 pounds. He
was cynical as regards any general bodily
diseases being caused by eyestrain.
Many general physicians consulted in the
past agreed that he "had consumption,"
"was going down all the time," and was
"doomed." The circumference of his waist
was 28 inches, his collar was No. 14; and
he was "a failure," "getting daffy," morbid
and hopeless.
In August, 1917, there was such improve-
ment in the general and local diseases that
after thoro mydriasis, I found the follow-
ing error of refraction, and prescribed :
R. + Cyl. 0.87 Ax. 90^ = 20/20 +
L. — Sph. 0.37 + Cyl. 1 12 Ax. 105^ = 20/20
Use of these lenses, as demonstrated
later, has revolutionized the man physically
and psychically. He has gained 60 pounds,
and "in some danger now of getting fatter."
He is in most perfect health. Instead of a
14-inch "loose" collar he wears one of 16
inches. His trousers-belt is now 42 inches,
some 14 inches longer than before. Instead
of "going daffy" and always "forgetting
things, and mixed," he is now "clear-
headed, happy, and confident ;" and instead
of a "business failure," he has secured "a
splendid job" in a large city.
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One swallow certainly does not make a
summer ; but there are no greater blunders
of ophthalmology than in the diagnosis of
ametropia.
Almost all pathologic conditions of the
eyes are caused by uncorrected and mal-
corrected ametropia. The greatest of all
causes of systemic diseases, both functional
and organic, may be and often are the re-
sult of ametropia, uncorrected or wrongly
corrected.
There are therefore millions of failures
in business and in life directly or sec-
ondarily arising from "errors of refrac-
tion." Frequently the error of refraction is
really hyperopic but blunderingly diagnosed
as myopic, and the organs of vision further
abnormalized, and lives ruined by the pre-
scription of glasses which should disbar the
prescriber from practice. Hyperopic astig-
matism in the patient may to a psychically
blind oculist be mistaken for the myopic
variety, but the patient should not have his
health and happiness ruined in double quick
time.
SOME INTERESTING BRAIN CASES.
BY
CHARLES GRAEF. M. D.,
New York City.
Ophthalmologist to Fordham and Ldncoln Hos-
pitals; Professor of Ophthalmology,
Fordham Medical College.
Acute affections of the central nervous
system are among the most interesting of
the problems which confront us in any field
of medical work, and the writer ventures to
record the following cases which have re-
cently been under his observation as em-
bodying features of some note.
Case /. — A. W., aet. 32, a laborer,
brought to the Lincoln hospital by the
ambulance in consequence of a fall. He had
stumbled and struck his head against some
boards he was carrying. The blow was not
considered severe and he did not lose con-
sciousness altho dazed and a good deal
shaken up for a few minutes.
On admission both eyes showed well-
marked ecchymoses. Nothing else noted ex-
cept some evidences of shock. He remained
in the hospital eight days. Slept well, com-
plained of no discomfort. Temperature nor-
mal thruout. Lowest pulse record 60, high-
est 76, He walked about the wards for sev-
eral days and was discharged seemingly
well on December 12.
The same evening he was re-admitted,
the ambulance being sent for because he
was taken with severe chills, feyer and head-
ache. He had then a temperature of 105;
pulse 104; respirations 28. His high tem-
perature continued notwithstanding sponges
for two days, falling to 100 on December
14. Pulse varied from 62 to 100. There
was now noted a conjunctival hemorrhage
in the right eye with slight fresh ecchymo-
sis in the left lower lid. Cheeks flushed,
respirations shallow and rapid. Some dul-
ness in right lower lobe, with diminished
breath sounds and crepitant rales. Pupils
were normal.
December 15, temperature remained
about 105°, the pupils became widely di-
lated and fixed. Patellar reflexes exag-
gerated. He had several severe chills alter-
nating with profuse sweats. I examined
him at this time and found paralysis of
both third nerves, as also of the fourth a«d
sixth. The right eye was slightly more
prominent than the left. Bleeding beneath
the conjunctiva and into the tissues of both
lower lids well marked. Ptosis of the left
upper lid. The upper nasal fossa on the
left side was swollen, the right nega-
tive ; fundus showed only blurred disc mar-
gins and fullness of the veins. Signs of re-
cent bleeding from left ear drum.
I made a diagnosis of fracture of the base
with septic infection of the exudate and
blood clot. Later on the patient became
comatose, and died the next morning.
Autopsy. — Inner table of the skull was
very noticeably thin and friable. Abundance
of pus and fibrin was found in the interped-
uncular space, extending beneath the pons
and down the spinal canal.
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There was a comminuted fracture of the
cribriform plate, a fissure extending up-
wards and outwards for three and a half
inches to the. right supra-orbital foramen.
Another smaller fissure of the orbital plate
of the frontal bone joined these fractures.
Case 11. — N. D., a boy of nine, was
brought to the hospital after being struck
by an automobile. The ambulance report
states that he struck on his head and when
picked up was bleeding from the nose but
was not unconscious. The right cheek was
discolored and there was ecchymosis of
the right eye. Pupils dikted; right more
than left. He remained in a semi-stupor in
hospital for several days and then grad-
ually cleared up.
I did not see this case until three weeks
after the injury. At that time I found his
right pupil widely dilated and not respon-
sive to light. The consensual reaction was
present when light was thrown on the left
retina but lost when the reverse was tried.
Left eye normal in every respect.
Right eyeball moved only down and out
with complete ptosis of the right upper lid.
Vision entirely gone even to light percep-
tion. The fourth nerve remained active giv-
ing movement down and outwards by the
superior oblique.
The fundus showed marked grayish pal-
lor of the disc and evidences of advanced
secondary optic atrophy.
The diagnosis of fracture of the or-
bital wall with damage to the sixth,
the optic and parts of the third nerve was
later confirmed by X-ray examination
which showed the line of fracture clearly
in the orbital plate of the frontal bone.
The case was closely analogous to that
just described but had the luck to escape
infection. Probably the damage to the eth-
moid in the first was a strong factor in
favoring infection.
In this case the optic atrophy was com-
plete with permanent blindness, but the
third nerve pressure disappeared, as the
exudate and hemorrhage absorbed, result-
ing in complete clearing up of the ptosis
and restored movement of the eyeball.
Case IIL—L. M., a girl of seven years,
was brought to Lincoln hospital in the am-
bulance with the history that for three days
the eyes had shown some swelling of the
upper lids and later she had vomited every-
thing ingested ; suflfered headache, and was
drowsy.
I saw her soon after admission and found
the left eyeball fixed and pressed forward
in the orbit, lids swollen, the upper one
dark in color, and the conjunctiva mark-
edly edematous.
The right ball could be moved about but
excursions were somewhat limited and the
right lids were slightly puffy.
The child was in a semi-stupor but gave
evidence of tenderness when the left eye-
ball was palpated.
Pupils were slightly unequal, the left be-
ing the larger, but both responded to light.
Fundus showed no faults except some full-
ness of the veins.
The child had hypeitrophied tonsils ; ears
normal ; nose clean J no sign of infection or
discharge from the ethmoids.
A diagnosis of orbital cellulitis with pos-
sible involvement of the cavernous sinus
was made.
Next day the conditions had grown much
worse; on the left side the proptosis so
marked that I explored for pus in the orbit
under ether anesthesia, getting none how-
ever. Neither could I find evidence of
ethmoid disease at this time.
The child died next morning and we
were fortunate enough to get an autopsy.
This showed the cellulitis of the orbit with
a few beads of pus here and there but no
collection at any point. Cultures made from
these showed only staphylococcus. The
cavernous sinus was filled with an infected
thrombus thruout.
The ethmoid cells were opened and found
clear. There was no history of injury, pre-
vious illness, or of any ear or other focal
infection in this case and the conclusion was
that infection must have reached the dis-
eased parts thru the ethmoid labyrinth,
without causing noticeable damage en
route.
Camphor in Influenza. — Narich and
Burgeat {Progress Medicale, Nov. 16,
1918) laud the efficacy of subcutaneous in-
jections of camphorated oil in treatment of
influenza, especially the bronchopulmonary
forms. They give from 2 to 6 gm, per day.
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NOTES ABOUT MALARIA: ITS DIAG-
NOSIS AND TREATMENT.
BY
BEVERLEY ROBINSON, M. D.,
New York.
Today, it is usual to make a sure diag-
nosis of malaria by a microscopic examina-
tion of the blood. If the malarial organism
is found, well and good, because an accurate
diagnosis can be positively affirmed and
without risk of error.
But, when the protozoon malaria cannot
be found, how then? It has been affirmed
by Osier, that it can invariably be found if
malaria exists, provided the research is care-
ful and repeated. I have stated more than
once, that I cannot uphold this absolute
view — I grant that in many instances, we
can find the distinct microscopic proof of
malaria, but there are instances where I
gainsay it. They are relatively rare, but they
do occur. When they do occur, one is apt
to believe either in pulmonary tuberculosis,
or typhoid fever, for the while. Later,
either one oi these diagnoses may prove
to be incorrect, or remain always some-
what uncertain, or doubtful.
Sometimes, the malarial organism does
not come to the surface and we cannot ob-
tain it unless we puncture the spleen and
withdraw blood from it. At present, we are
not permitted to do this, because of fear
of causing peritonitis. Again, if quinine be
given before the microscopic examinations
are made, these will often remain negative.
This fact is usually known by good prac-
titioners, but should be referred to here by
reason of its practical importance. I claim
that the previous history of the patient,
when microscopic examinations are nega-
tive and even if in addition the spleen is
of normal size, should confirm the diagnosis
in not a few instances. At all events, if we
still remain a doubting Thomas, we should
invariably, with the history of a previous
malarial attack, or even without this ascer-
tained fact, put the test of treatment in the
case.
To many today, quinine is the test meal.
If quinine fails to relieve, there is no ma-
laria, these wise men say. If quinine helps
relieve symptoms, or cures the patient they
simply shrug their shoulders — ^and repeat,
well ! quinine does well curatively, in many
cases of wholly different nature.
Now, I affirm that quinine is no abso-
lute test, either as to relief, or cure of
the patient. What then is? In some in-
stances, it is Warburg's tincture, or extract ;
in others, it is compound tincture of bark ;
in a few, it is arsenic, combined, or not,
with iron and maybe some quinine. In
those cases where the malarial poison has
been contracted in South America, or the
Isthmus, (formerly, called Chagres fever
at Panama), I rank first and foremost,
Warburg, especially when the attack is se-
vere and resists quinine. In other cases,
namely, where the malaria has been taken
in the temperate zone of the United States,
I rely very much upon the use of com-
pound tincture of bark. But, to be remedial
in certain cases, the bark must be given in
sufficient and frequently repeated doses — a
teaspoonful every two hours is often none
too much.
I cannot emphasize the value of this
preparation of bark too strongly. I have
seen too many instances in a long practice
where it was true, not to affirm its remark-
able effects.
Arsenic in certain chronic cases, as a
blood tonic, has indeed its value and I
would not Ignore it, but it should not be
mentioned in the same breath with War-
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burg, or Huxham's tincture of bark.
Of course, we all know the benefit to be
derived from a change of climate — notably
to the mountains and far away from the
seashore. But this change does not always
succeed. I have in mind, as I write, a young
patient who came to the Adirondacks, after
being dosed with quinine. The malarial at-
tacks persisted until compound tincture of
bark was given in sufficient doses.
I can but hope that what precedes may
strike a responsive chord in the minds of a
few old practitioners and indeed, among
my juniors who are not victims of labora-
tory research, to the point where their men-
tal vision in the practice of medicine has
been woefully limited.
AMONG MEDICAL SPECIALTIES
WHY NOT ONE OF HEALTH
CONSERVATION?
J. MADISON TAYLOR, A. B., M. D.,
Professor of Applied Therapeutics, Temple Uni-
versity, Medical Dept., Philadelphia, Pa.
The value of the human unit becomes so
urgent under war conditions it might be
worth while to consider the desirability of
specializing as a conservator of health and
physical efficiency, equally with that of a
repairer. •
Personally I should prefer, were it pos-
sible, to give my undivided attention to
this realm of endeavor. The attempt already
made has met with indifferent success,
hence I may be better qualified to discuss
the question from a practical basis than
would a better man from a more academic
standpoint. On the face of it there can be
alleged no tenable objection to limiting one's
efforts to so obviously commendable an en-
terprise. Numerous groupings of special
domains of medical industry are recog-
nized ; so much so that for example, in sur-
gery there are perhaps a dozen clearly dif-
ferentiated forms current.
A curious fact forced upon my con-
sciousness by candid efforts in this direc-
tion is that the idea is unwelcome to the
profession ; they subject him to the suspicion
of being a mere physical culture enthusiast
or strenuous ''athlete,'* or a proponent of
one of the anathematized extra mural cults.
The question has often been asked, "Are
you a physical culture fiend, an osteopath
or chiropractor or some such visionary?"
Such suspicions are not conducive to pa-
tience or humility — especially when to my
counter question consistently made "will
you kindly define what these experts do?"
there is then revealed an abysmal ignorance
of any or all of these or allied subjects;
mere fatuous, baseless prejudices. Not only
so but I am frequently able to retort "Why
did you send such and such a patient to a
gymnasium, to an osteopath or chiropractor
or to a physical culture expert?" You might
as well have sent the patient to a fashionable
druggist and told him to get some good
medicine with no expert instructions what
to take, when or how much.
The fact of the matter is — as readily
demonstrated — that the "laity," "the public
who constitute the sources of revenue to the
profession of medicine, are growing sus-
picious of the drug fetish, many of the an-
cient and honorable medical traditions of
treatment, often worn thin in spots. The
public are becoming restive under the
strains of adherence to outworn preferen-
tial beliefs to which many wide-awake but
timid physicians can no longer confidently
subscribe. Let me make clear my credo as
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to the potency of some drugs.
I hold the opinion that drugs, some old
and fully tried and some wonder-working
new ones, are absolutely necessary to the
saving and the conserving of human health
and life; that they will be imperatively
needed to the end of time. I use them with
an abiding faith and get results which even
in my state of enthusiasm for other remedial
agencies often far surpass expectations. Of
course I shall always use them when defi-
nitely indicated.
On the other hand I not seldom meet con-
ditions most distressful, disheartening and
disabling, in which no drug that I can learn
of can by any conceivable action render the
service required in the instance. What
then ? Am I to abandon the patient to fate ?
By no means. Hence it is my duty to find
and use that remedy which shall achieve
the desired result.
There is also the whole range of experts
in spheres of activity with which I have
only a distant acquaintance upon whom I
can call when needed ; who can and do sup-
ply me with expert guidance and counsel
for the salvation of the patient. But the sub-
ject of these remarks is the enormous and
expanding field of hygienic measures, con-
servative, constructive and reconstructive
which, rightly chosen and judiciously ap-
plied, are just as competent to win victories
within their domain, as are the uttermost
potentialities of medication in theirs. "Let
each man at arms select and use that weapon
best fitted to his hand."
The conscientious conservator of human
life and health should choose and apply
those remedial agencies for which his taste,
aptitudes, experiences and special training
have qualified him. Let me, if it be, I am
able to determine, select and apply hygienic
remedies most efficiently — ^and devote my
energies to that enterprise. Let others do
likewise in their spheres and thus outstrip
me, reach heights of achievement to which
I am a dub and a stranger.
Meanwhile, as a plain uncontrovertible
fact, there are those whose minds react best'
to one or other gjoup of intellectual stimuli,
the objective being the same. Approach to
any problem is not limited to one avenue,
nor to two, nor ten, nor a hundred.
Some mentalities think best in terms of
chemistry, some in psychotherapeutics,
some in symbolisms, some in religious
faiths, some in terms of biophysics. More-
over such separatists employing their type
of mind do win opinions, even victories,
which others could never parallel in the
same line of endeavor. In diflferent lines,
consonant with their own type of mind and
aptitudes, yet others can and do achieve
every bit as much. The proportion of suc-
cess is about the same in each instance.
Has not this principle of selected experts
done splendid service in our armies?
Take, for example, the experts in mental
hygiene (hemopsychiatry) as an example.
Not only do these devoted specialists weed
out the constitutionally unfit and thus re-
lieve the nation from useless burdens, but
choice is likewise directed for special work
where a man of particularized attributes is
most needed.
Also eflfort is made with increasing suc-
cess to select surgeons in accord with their
peculiar attributes and aptitudes and train-
ing and tastes to perform duties consonant
with personal qualifications. In this the ele-
ments of selection are both as to individual
make-up, conformation and type of mind,
as well as to acquired characteristics. More-
over in the industries this selection of men
in accord with differentiated characteristics
is now an accepted procedure, a necessity,
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leading to important productive economies
and often assuring safety to others.
To return to medical specializations : While
each and every competent practitioner must
have the same or similar training in funda-
mentals, in essentials, wide diversities ex-
ist among individual trends, determinants
and facilities. Every epoch adds to the bur-
dens of the neophyte an increment of diffi-
culties in mastering the whole field of
scientific and practical knowledge and pro-
ficiency.
Cooperation is imperative. In well or-
dered hospitals this is brought to a high
degree of perfection. Among the "field
workers," the great army of heterogeneous
practitioners, the primary assumption is that
one man qualifies to fill the whole gambit of
medical duties. In large cities adjustments
take place in accord with opportunities, sug-
gestions, deliberate choice; but only too
rarely in strict accord with inherent apti-
tudes. Hence a large proportion of fail-
ures or only partial successes.
Come we now to the specific application
of these facts the subject in hand :
Why not cooperate for the best advantage
of the patient?
And why should not certain M. D.'s leave
to others responsibilities which .they are
better qualified to assume and restrict their
own efforts to the factors of conservation ?
What should be the direction, the depart-
ments of remediation of a conservator?
Here I can best sketch out those par-
ticulars which my individual tastes, so far
as my experience goes, enable me to judge
of my personal qualifications.
Here at least is the domain in which I
should elect to become expert, had I the
ability: Let me confine my responsibilities
to searching out the peculiarities of con-
formation mental and physical — the psycho-
physical totality — and determine where and
how the individual requires orthopedia or
orthobiotics, that is adjustment, readjust-
ment, correction of minor deformations,
original or acquired limitations.
How should a conservator of health set
about appraising the status of a client?
We may begin by inquiring: Who are
those likely to make use of such service ?
They may be conceived as of two groups :
Those who themselves realize a need for
rehabilitation and those whom a physician
comes to appreciate would be advantaged
by a general survey of the case such as he
might not have the leisure or special train-
ing to make. This course is coming to be
recognized as the most economic, most ad-
vantageous for the patient and enables the
personal adviser to proceed with confidence
along the indicated lines to his own credit
and advantage. Let it be clearly understood
it is no disparagement whatsoever to the
physician any more than it would be to re-
fer the case to an eye, ear, skin, nose and
throat gynecologic or any other specialist.
We simply have not gotten into the habit of
recognizing the specialty of conservation.
In my years of service as assistant to
Weir Mitchell I learned invaluable lessons
in the desirability of the general all round
survey of a problem. It was my privilege
to take full notes of the cases, make such
examinations as were within my capabilities,
and submit my findings to him. Those who
came under his care either made their own
decisions as to why they should seek coim-
sel or were referred by their physician who
was kept in touch with the case thruout.
Whenever there is an esteemed home
counsellor it is always more satisfactory to
collaborate with him or to' return the case
with specific recommendations as might be
desired. It is a well established fact that a
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conservator prefers to assume only that kind
and degree of control which accords with
his point of view and to leave the residue,
and also the responsibility of cure, to the
family physician.
To be sure in my experience it occasion-
ally happens I can set some maladjust-
ments straight and thus remove the disabil-
ity promptly. This might seem trespassing
on the privileges of the home adviser, to
"spoil his job." None but a narrow-minded
and conscienceless man would feel thus
aggrieved. To afford relief is the aim of all
honest physicians. There are plenty of other
fsh in the sea; other clients.
To revert to experiences with Weir
Mitchell: He was kept overwhelmingly
busy, to the limit of his working power,
and altho he worked only seven months of
the year, yet made an annual income about
twice the salary of the President of the Uni-
ted States. Hence both parties in interest
were content; so indeed was the patient.
I constantly marvel that this view of
what Dr. Mitchell jauntily called "prac-
ticing on the higher planes of professional
satisfactions" is not more universally
adopted. The patient usually came to ap-
preciate his consultant as a valued friend
and his home counsellor even more highly.
Open competition to appropriate a patient
is to the last degree painful and to be de-
plored on every count.
The first step in conservation is to come
by a full personal and clinical history. The
personal, the intimate data is of even great-
er importance than a mere category of ail-
ments, weaknesses or diseased states. The
primary consideration is to learn the type
of make-up, the sort of man or woman it
is who has got into the depressed, depleted
or disrepaired state. This, so I learned from
Dr. Mitchell, is best achieved by a leisurely
companionability, an entering into the hopes,
fears, ambitions, the home atmosphere so
far as might be deemed desirable, to walk
with them ; to eat with them ; discuss affairs
of the day, books, science, art, literature.
Dr. Mitchell made a great point of reading
his own poems aloud and encouraging frank
criticisms. He claimed he could thus learn
more in a few interviews of what he needed
to know of their trends, tastes, methods of
thinking, their queemesses, prejudices and
the like, than by any other known measure,
and at the greatest economy in accuracy of
assessment of the patient as a whole.
His marvelous successes were due large-
ly to just such comprehensive dealings with
all aspects of person, pecuHarities and means
of getting at the directions for relief. Above
all he appreciated how different types of
confusions and distresses could be dealt
with by cooperation with experts in various
lines.
Dr. Mitchell was preeminently the con-
servator, the reconstructor, never content
with merely affording relief or repair of
the obvious. He led the client, the petitioner,
to earnestly desire to become all that was
in him to be. He fully appreciated and en-
joyed, indeed compelled the use of physical
training, always adjusting the measures to
capacities, limitations and tastes, in par-
ticular to rid the individual of false in-
hibitions, of absurd prejudices.
In an intimate personal survey there will
be found, in most instances, some local-
ized or well defined, or feared, trouble lead-
ing the patient to seek counsel. This will
serve as a text, a starting point for ex-
ploration. The conditions they "complain
of" are noted seriously. Only rarely is their
pet ailment the one for which they most
need rehabilitation; it may however, point
the way.
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Often during the search some defect or
disorder will be revealed entirely foreign
to that which they are aware of. None of
their precious "complaints" should be al-
lowed to obscure the real, or main issue.
This involves usually an anxiety psychosis,
a depletion of energies, of dynamics or
merely of perversions of good powers.
Symptoms are important but they are often
so mixed with psychopathies as to mislead.
When once the assumed or imagined, or
the main disorder is localized and ticketed,
the campaign just begins. Rehabilitation
is a large order but it is the largest service
a conservator can render. To refer again
to Dr. Mitchell: His aim was uniformly
to turn out the man or woman restituted, re-
generated, made over, better able to take his
or her place in the world and to do, and
wish to do, a man's or a woman's work
thereafter.
He displayed his highest qualities, in my
judgment, in his brilliant apperception of
the crucial points, the pet weaknesses, or
the whimsical disabilities. These he thrust
into the foreground of attention and de-
manded, or tactfully demonstrated, they
should be ruthlessly overcome.
For the average physician, even one of
a high order of trained ability, who does
not possess such exceptional acumen or in-
cisiveness a complete survey of personal,
not merely clinical, history is desirable.
By studying this repeatedly there will be
revealed, in perspective, much not first ap-
pearing.
Long years of training in making anam-
neses for him helped me to devise a great
time saver in the form of a preliminary his-
tory blank, so worded that the patient and
family can fill this out themselves in pencil.
I would strongly recommend some such
method in all complex or protracted con-
ditions. Few physicians can find time to
catechize a patient thoroly enough, but when
the brief is made out for them, they can
and gladly will, go over it, verify the per-
sonal understandings of the question, ratify
the answers, or take up one or other sig-
nificant point and search to the end of the
lead so opened. Most serious mistakes have
been made by physicians in omitting this
precise, uniform and thoro history taking.
A most significant, yet apparently trifling,
matter to the patient may be omitted unless
directly challenged. Similarly, no physician,
no matter how confident of his penetration
and memory of what he should do, can al-
ways bring out every point except by some
such memoranda.
Let me hasten to meet the objection
usually made by those urged to use the pre-
liminary history blanks. The task is by no
means so burdensome. The patient, the fam-
ily, or the home physician bears the brunt
of it. They usually are only too glad to be
thoro in so important a subject — themselves
or one of their home group. Thus the task
is at least painstakingly performed. Few
essentials escape "the drag net" or the "fine
tooth combing," as it is often signalized.
Moreover such self-searching serves to
bring to the consciousness many half for-
gotten facts along feared or voluntarily, or
unconsciously, suppressed. Moreover when
"the names of physicians who then attended
you" is called for (as constantly recurs in
the blank), one can consult that physician
if alive, and get the facts verified ; a most
important matter.
After the revision is completed by the
consultant, whatever point demands special
attention gets it. Fuller elaboration can be
made ; then the entire history is spread out
for inspection. It may be objected to, this
minute and emphatic self-searching leads to
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97
hypcxrhondriasis. No; because the role of
the consultant is to evaluate the items and
their entirety; to show how this or that
point is disposed of, a condition cured
perhaps ; or it may have no present bearing.
In any event the revelations furnish an ex-
act text for explanation, for encouragement,
for discriminative advice. It is by no means
wise to launch out into reassurances when
the data remain obscure, unclear, inade-
quately presented or understood. When the
whole is revealed it is time — and not till
then — to compel abandonment of erroneous
or baseless fears.
Then follows the physical explorations.
These should include removal of all cloth-
ing, bit by bit and with due tact. The ex-
ploration should include, in addition to the
customary procedures, a tactile assessment
of gross structures, of conformation, of
postures, of local tension, tonic spasms, re-
laxations, rigidities, resistencies, immobili-
ties, contractures, deep tendernesses, asym-
metries and their relationships one to the
other. Hence orthopedic or orthobiotic prin-
ciples come in for important contributions,
both in diagnosis and remediation.
Let me enumerate a few of the points
which deserve attention, some of which too
often escape.
Expression; revealing many significant
points, type, make-up, shape, size, apparent
age, confidence, timidity, self-esteem.
Voice, manner of speaking, phrasing, pe-
culiarities of self-estimation.
Poise, posture (the position one is com-
pelled to take) ; attitude (the position one
habitually assumes), due to any limitations
of movement, or error of development, to
diseased states of the static mechanisms, to
costume deformities, e. g., bad corsets, bad
shoes, bad methods of applying clothes, etc.,
to inherent weaknesses, e. g., ptoses, adhe-
sions, to weak backs, weak or deformed
bones, to feeble abdominal muscles, to wa-
ter logging of the abdominal organs, etc.
To occupations, to vanity, to apathy, to
self -consciousness, to over-tension, to men-
tal slouchiness and the like.
Note in particular the vertebral column,
in respect to those points of posture and at-
titude. I would urgently recommend that
observation be made of the backbone in its
entirety, noting its relationships to the
thorax, the neck, the pelvis, as revealing
significant matters.^
Here we have displayed the whole prob-
lem of body poise, equilibrium, of depar-
tures from the form and to what they are
due. Palpation of the muscles, the para-
vertebral structures reveal tendernesses,
edema or stagnation.
Much can be learned or reasonably in-
ferred, before employing X-ray studies.
The tone of the internal organs ; meteor-
ism, movable cecum, areas of segments of
flatulency, "gurgles," tenderness, e. g., old
or quiescent appendicitis, fecal masses, etc.
Note the circulatory peculiarities, super-
ficial and deep, of course the heart sounds,
position, areas of dulness but not less the
blood ptoses, the variations in blood pres-
sure lying, sitting and standing.
Disorders of the Heart from Goiter. —
Goiter causes endocarditis, premature con-
tractions, auricular flutter, auricular fibril-
lation and myocarditis. Sloan (Med. Review
of Reviews, Feb., 1919) states that removal
of goiter benefits or cures these conditions
when it has caused them. Heart-block and
defects in transmission of impulse are not
caused by goiter and are not benefited by
removal of a goiter that may be present.
* See paper American Medicine, April, 1918 —
Spinal Significances.
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HIGH ARTERIAL TENSION: TREAT-
MENT OF HIGH BLOOD
PRESSURE.'
BY
I. LINDBNBBRGER, M. D.,
Louisville, Ky.
Two months ago I was called to see a- fe-
male of sixty-seven who for some time had
been having periodic attacks of epistaxis.
I was asked to see her during one of these
attacks. Her blood pressure was found to
be 220 mm. Hg. No attempt was made to
arrest the bleeding, and within half an hour
it ceased spontaneously.
I would like to ask the members of this
society the method by which they attempt
to reduce the blood pressure under such cir-
cumstances. Examination discloses no evi-
dence of cardiac disease, nor are there any
renal lesions so far as can be determined
by careful urinalysis, there being no albu-
min nor casts in the urine. There is some
arterial hardening demonstrable at the wrist
and also the elbow.
Iodide of soda was administered continu-
ously for five weeks with no appreciable in-
fluence upon the blood pressure. During the
last four weeks the tension has varied from
220 to 170, and at times there has been
noted marked cardiac irregularity. Con-
trary to current teaching this has been im-
proved by the administration of tincture of
digitalis in five drop doses three times daily.
The bromides seemed to reduce the blood
pressure to some extent.
At a previous meeting of this society Dr.
Leo Bloch called attention to the value of
pilocarpine hydrochloride as an agent to
reduce blood pressure, which he had seen
in an article in the New York Medical
*A symposium before the Society of Physi-
cians and Surgeons of Louisville, Kentucky.
Journal. This has been prescribed in 1/40
grain doses three times daily, and seemed
to have a beneficial effect by inducing mild
perspiration. The patient is in fairly good
physical condition, and the functions of all
the emunctories are normally performed.
She is still taking the bromides, twenty
grains in a mixture of passiflora incamata,
after breakfast and supper. Why her blood
pressure should be 170 one day, and another
220, I am at a loss to understand. She is a
light eater, and for this reason the dietary
has been increased rather than diminished
as is the rule in such cases.
Some time ago I noticed in one of the
medical journals an article recommending
fibrolysin (thiosinamin) in doses of about
2 c.c. by hypodermic injection for the re-
duction of blood pressure. I wrote to Merck
& Company of New York, asking what they
thought about it, and they advised against
the use of fibrolysin for the purpose
stated.
I believe there are no drugs which will
certainly reduce blood pressure. In this
case at times the patient had occasion to
worry and did not sleep well, and the fol-
lowing day her arterial tension would be
higher. The bromides and passiflora incar-
nata seemed to have a quieting influence
upon the nervous mechanism and cause her
to sleep better, and in this way probably
reduction of the tension was accomplished
rather than by any direct drug action.
This woman does not show the usual
causative factors of high arterial tension^
excepting arteriosclerosis. Cerebral hemor-
rhage can be excluded. I believe no drug
will permanently reduce blood pressure^
especially when due to increasing age which
we know produces high tension sooner or
later. Rest, dietetic and hygienic measures
are to be recommended.
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99
HIGH BLOOD PRESSURE WITHOUT
CARDIAC LESION.
BY
V. E. SIMPSON, M. D.,
LouisYille, Ky.
Not infrequently patients are encountered
who have high arterial tension without or-
ganic lesion of the heart, liver or kidneys.
I now have such an example under observa-
tion in a female of fifty-four whose maxi-
mum blood pressure for some time has been
240 mm. Hg. which I have been unable to
reduce below 195. There is no albumin in
the urine, and there is no kidney lesion pres-
ent so far as can be determined by urinal-
ysis. The cause of the high arterial tension
is unknown to me.
One can readily understand why pilocar-
pine will reduce tension, but it has a marked
depressing effect upon the entire circulatory
apparatus. It causes a moderate temporary
slowing of the heart action; its influence
upon the vasomotor apparatus causes dila-
tation of the peripheral vessels thus ma-
terially enhancing capillary circulation and
increases the blood supply to the sweat
glands. Perspiration reduces tension by
lessening the amount of fluid and blood in
the vessels and tissues; induced in any
other way perspiration would have the
same eflfect, minus the lessening in activity
of the circulation which pilocarpine induces.
Bromides act in similar manner, except-
ing that in addition to their effect upon
the circulatory apparatus they materially
lessen the metabolic function and the motor
activity of the body. There is less tissue
change and the blood is correspondingly di-
minished, less food is taken and hence ten-
sion IS reduced.
I seriously question the use of such drugs
in high arterial tension, also that high ten-
sion does as much harm as has been sup-
posed, at least the high tension noted in pa-
tients with imperfect nutrition in conse-
quence of arterial change. If you add to that
the depressing influence of such drugs as the
bromides, the functional activty of the body
would be markedly lessened. The only pos-
sible harm that can be done the heart by
high arterial tension is hypertrophy, and
this may be regarded as a compensatory
hypertrophy which can be withstood by the
patient for a considerable period.
I have used the iodides and the iodine
preparations in the management of high ar-
terial tension. It is true that by virtue of
their influence upon embryonic cell struc-
ture the iodides have a beneficial effect if
administered before organization occurs,
and just to the extent this is accomplished
will they prevent progression of arterio-
sclerosis. After organization of the cell
structure has occurred, it is impossible to
induce resorption. Iodides simply assist in
the removal of embryonic cells within reach
of the blood and lymphatic channels.
I have also used sodium nitrite, which
seems more logical for the purpose of re-
ducing tension than bromides and pilocar-
pine. I usually give one grain two to four
times daily, depending upon its effect. I
prefer this to nitroglycerine because it is
better adapted to internal administration,
absorption is slower and the effect more con-
stant; whereas the influence of nitrogly-
cerine in proper hypodermic dosage is im-
mediately manifest and disappears within
forty minutes. Sodium nitrite is slowly ab-
sorbed from the gastrointestinal tract, great-
er sustained influence is therefore mani-
fested, and better results are obtained.
I seriously question the use of many of
the drugs ordinarily recommended to reduce
tension, bearing in mind the fact that the
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action of these drugs is detrimental to body
nutrition, as set over against the possible
harm that continued high tension may pro-
duce. Wherever there exists arteriosclerosis,
permanent reduction of tension is impos-
sible.
In the case I have mentioned the ten-
sion when the patient was first seen was
240; it has never been reduced below 195,
and that only after continued rest in bed.
I believe that baths, with regulation of diet,
with limitation of the fluid intake as far as
may be compatible with safety, together
with rest in bed, constitute the best method
of management in cases of high arterial
tension.
NITRITE OF SODA IN TREATMENT
OF HIGH BLOOD PRESSURE.
BY
D. S. WILSON, M. D.,
Louisville, Ky.
I wish to confirm what has been said
with reference to the nitrite of sodium. It
is probably the most reliable therapeutic
agent at our disposal for the reduction of
blood pressure.
It is questionable whether too much of
the clinical symptomatology is not some-
times attributed to the blood pressure. There
seems to be an overzealous effort on the
part of many physicians to reduce the blood
pressure as rapidly as possible by the ex-
hibition of drugs which may in their opinion
best serve the purpose. Such efforts may be
unwarranted from the standpoint of the pa-
tient. The use of baths, rest, regulation of
diet, etc., are to be recommended.
• With reference to the urinary findings in
cases of high arterial tension: The absence
of albumin in the urine is not always an in-
dication of the non-existence of a kidney
lesion. My idea may be wrong, but I have
been under the impression that interstitial
nephritis does not always mean that albu-
min must be present in the urine. In all
instances where arterial tension is per-
sistently high, urinary secretion with refer-
ence to the intake and output should be
carefully investigated. This may have an
important bearing upon blood pressure.
HIGH BLOOD PRESSURE AND
ARTERIOSCLEROSIS.
BY
A. R. BIZOT, M. D..
LouisYllle, Ky.
The idea that high arterial tension is al-
ways due to or accompanied by kidney
lesions is certainly erroneous. High blood
pressure with arteriosclerosis is a most seri-
ous matter.
I rbcall the case of a female of sixty-six
with this history: Father died of apoplexy
•at fifty-one; a sister was paralyzed for
seven years, and a brother for three years,
each having had three cerebral hemor-
rhages; another sister died suddenly from
apoplexy ; still another sister was blind for
years, and finally died from asthenia due
to organized clot. The patient in question
has marked arteriosclerosis; she had some
eye complication and was sent to Doctors
Ray and Lederman, where a retinal hemor-
rhage was discovered. Her blood pressure
was then 190. Iodides, bromides, sodium
nitrite, etc., have all been used without in-
fluence upon the blood pressure.
I have come to the conclusion that high
blood pressure is coincident with advancing
age, unless there exists arterial disease to
cause increased tension earlier in life. As
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101
soon as elasticity of the arteries is lost, high
blood pressure develops. In my opinion it
is not often due to renal and cardiac lesions.
In the case mentioned, notwithstanding
treatment, the patient's blood pressure has
ranged from 165 to 190; and there has been
about the same variation when no drugs
were administered. Warm baths, limitation
of the intake of fluid, and restricted diet
have accomplished more benefit than drugs.
In another case the patient is the sub-
ject of chronic interstitial nephritis and also
arteriosclerosis. Within the last few weeks
the woman has entered an institution for
treatment of her mental condition, and I
understand cerebral hemorrhage is antici-
pated. In most instances cardiac and renal
lesions can be excluded as causes of high
blood pressure ; arteriosclerosis is undoubt-
edly the caus^ in the majority of cases; and
cerebral hemorrhage with continued high*
pressure is to be anticipated.
A CASE OF FLOATING CARTILAGES
IN THE KNEE JOINT.
BY
J. G. JISR. M. D.,
Cairo, EJgypt.
F. M., a Sudanese, 85 years old and
belonging to the "Fungari" tribe, called at
the Civil hospital Gedarif (Sudan) for
treatment, complaining as he describes it,
of excruciating pain, practically forbidding
all motion and the presence of fluid and
three movable "bones" in his left knee joint.
He was admitted to the hospital May 5, 1917
and operated upon on the following morn-
ing. The knee joint was opened under local
anesthesia, letting the fluid escape and three
irregularly facetted concretions delivered
by manipulation. The wound was imme-
diately closed and no drainage left.
The concretions weighed respectively oi
gr. XX, 3i gr. xxv and 3i gr. xxx. A micro-
scopic examination of a section showed
them to be composed of "hyaHne cartilage."
The joint, however, began to fill again,
and as the wound had completely healed up,
paracenthesis was performed on the 8th day
and 2 c.c. (Jss) tinct. iod. B. P. injected.
The next morning the joint was hot and
swollen but the reaction disappeared com-
pletely on the fourth day.
It began to fill up again but on a very
much smaller scale, so the same operation
was repeated eight days later. This was
followed by a less marked reaction than
the former.
A week later there could be hardly any
fluid detected, but 2 c.c. of tinct. of iod.
were injected. The reaction being of no
consequence this time, the patient was dis-
charged three days later.
He was asked to report regularly, which
he did. He was last seen on the 15th of
March, 1918, quite happy with the result
obtained for there were no more "bones"
or fluid and he enjoyed a very much more
liberal use of the joint. So I think that one
feels justified to consider the case as cured.
Primary Perithdioma of Lsrmphatic
Glands* — From observation of a case of
this condition G. D'Oria (Riforma Medica,
Nov. 6, 1915) draws the following con-
clusions: It is possible to find a primary
origin of tumors of the peritheliomatous
type in lymphatic glands, and perithelioma
may be a tumor of the malignant type like
sarcoma and carcinoma. Many observers
are of the opinion that a perithelioma is al-
ways a benign new growth, but the case
in point shows distinct sarcomatous char-
acters and consequent malignancy.
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Fmbruary, 1919
LONDON LETTER
American Medicine
(From our Regular CorreBpondent.)
THE ANNUAL MEETING OF THE BRITISH
MEDICAL ASSOCIATION.
The customary annual meeting of the British
Medical Association has not been held during
the last four years. The meeting has been gen-
erally divided into what may be called domestic
and general subdivisions, the domestic conisist-
ing of the meetings of the Council and Repre-
sentatives and dealing with the internal work of
the Association, the general consisting of the
sections prepared to discuss the clinical and
scientific work of the year. During the war the
sectional debates on Medicine, Surgery, and the
other branches of professional learning have
not been held, as most of the prominent ex-
ponents of medical knowledge and skill were
busily engaged at home or abroad on the med-
ical work of the Navy or Army, and the annual
meeting resolved lUelf into a meeting of the
Council and of the Representatives. The war,
it may be remembered, began immediately after
the annual general meeting at Aberdeen in July,
1914, at which meeting it was arranged that the
meeting in the following summer, viz., July,
1915, should take place in Cambridge under the
presidency of Sir Clifford AUbutt, the Regius
Professor of Physics in the University. As that
date approached it became perfectly clear that
no adequate meeting could be held, while the
University, which had become practically a
large training camp for staff officers as well as
cadets, was so denuded of all accommodation
that the hospitality of its walls could no longer
be proffered. By this time all men began to see
that the end of the war was not far away, so the
question of the next annual general meeting of
tne Association has been held under considera-
tion ever since, and, now that hostilities are
suspended, the position of strain In the medical
profession has been so little relieved that it has
been thought wise to attempt no full annual
meeting until 1920, in which year, however. Sir
Clifford Allbutt has announced that the Univer-
sity is looking forward to entertaining the As-
sociation. In the circumstances it has been de-
cided that a special meeting should be arranged
by the Association this year for the discussion
of clinical and scientific subjects, but on a
smaller scale as to sections than had marked
all recent annual meetings.
It has now been provisionally agreed that this
special general meeting of the British Medical
Association should take place early in April
and should last for two or perhaps three days.
A General Committee has been appointed, to-
gether with two Sub-Committees, one taking
over the organization and the other dealing in
detail with the programme of scientific work.
The decision is an expression on the part of the
Association that the time has come to relay old
tracks and make plans for reconstruction, even
tho no attempts at a ccmiprehensive scheme can
yet be entered upon. The meeting will be held
in London and its main object will be to bring
together British workers and medical visitore
from the Dominions and the United States. It
is quite clear that before April there will be no
large disengagement from their duties either of
our Colonial or our American colleagues, so Uiat
an exceptionally strong medical voice ought to
be obtained on many subjects from a series of
oflflcers who during the recent troubled years
have studied war medicine and war surgery on
many spots and from many points of view. Col.
A. M. Whaley, speaking as United States liaison
Medical Officer with the War Office, has given a
warm welcome to the proposal, which has also
received the support of Col. J. G. Adami, Pro-
fessor of Physiology at the McGill University.
Montreal and Col. R. D. Rudolf, speaking for
Canada, and of Cbl. C. T. M. DeCrespigny and
Col. Bernard Myers, speaking respectively for
the Australian and New Zealand Army Medical
Services. Hearty acceptance of the proposal has
also been received from Sir William Norman,
Medical Director General of the Navy, Sir John
Goodwin, Director General of the Army Medical
Service, and Col. T. D. Barry, representing the
medical administration of the Royal Air Force.
. If the scheme of the meeting is well drawn up
and precautions are taken only to admit
authoritative communications, the net result for
good ought to be very great. But it must be
remembered that two days or even three, will
not provide much time in which to hear the
first hand experiences and opinions of many
men having many things of importance to say,
and those who have had experiences of inter-
national gatherings hope that time will not be
wasted in courteous preliminaries. Interna-
tional good feeling may be presumed to exist
and will not require to be emphasized by a lot
of introductory cackle. When formality is
shunted in this manner, there will still remain
the difficult question of overlapping. If a lot of
men, apparently equally well equipped with
knowledge, want to address the same meeting
on the same subject, much discrimination will
have to be exercised to prevent waste of time,
and some call will necessarily be made upon the
self-sacrifice of hard and original workers. The
success of the clinical meeting of the British
Medical Association may be great if those who
draft its program of scientific work are at
the same time tactful and firm. Waste of time
must be avoided.
SIR CHARLES WYNDHAM, M, D^ M, R, C. S.
Sir Charles Wyndham, who died this month
at the ripe age of 82, was known all over the
world as a brilliant and versatile actor, but it is
not so well known that he was a medical man,
and did service in the American Civil War as
surgeon to the Federal army. Sir Charles
Wyndham, whose real name was Culver well,
was the son of a Lancashire medical man, and
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received his medical education at Kings College
Hospital, from the medical school of which in-
stitution he emerged Just sixty years ago as a
member of the Royal College of Surgeons of
England. He was a keen doctor, altho already
attracted towards the stage, for he continued
after qualification to gain post-graduate experi-
ence at Scottish, Irish and German medical
schools, and when he arrived in America, just
In time for the Civil War, he had the degree of
M. D. Giessen. He saw much fighting, being
present at, among others, the battles of Gettys-
burg and Fredericksburg, and serving thru the
Red River campaign. It was actually during
the closing winter of the war that, under the
stage name of Charles Wyndham, he became a
professional actor in New York. Later, about
1865, he returned to England, and definitely
deserted medicine, tho he had a hard struggle
to make good his position in the theatrical
world. But by 1875 he made good both as an
actor, and as the manager of the Criterion
theatre, at the very center of fashionable and
business London, in Piccadilly Circus. He never
lost touch with the public, but always remained
a finished actor, and when he received a Knight-
hood from his personal friend. King Edward
VII, the honor was accepted by everyone as well
bestowed.
INFANT WELFARE.
In all countries, and notably in the United
States of America and in England the import-
ance of infant welrare has been much accentu-
ated by the mortality and conditions of the war.
The outstanding feature of the 1919 Baby Week
celebrations is to be a series of national con-
ferences on infant welfare, at which the chief
points for discussion will be (1) ante-natal and
neo-natal casualties, their prevalence, causes,
and prevention; and (2) the best neo-medical
means of combating infant mortality and mor-
bidity. The National Association for the Pre-
vention of Infant Mortality and the National
Baby Week Council are cooperating in the prep-
aration for these conferences, and arrangements
are being made for the holding of similar con-
ferences and Baby Week celebrations in every
allied and neutral country thruout the world,
at which the same subjects will be discussed.
Following on this an international congress will
take place in London, at which the findings of
the various national conferences will be con-
sidered, leading, it is hoped, to much light being
thrown on these important subjects.
The international congress in question is not
likely to take place before 1920, unless the
normal course of civilized life is more quickly re-
assamed than seems possible, but it is hoped
that all the various agencies possessed by coun-
tries with more advanced humanitarian views
will be put in motion to collect evidence for re-
port and debate, and to formulate schemes for
comparison and subsequent adoption. A great
international consensus of opinion upon the
most practical ways of combating infant mortal-
ity would have an overwhelming influence upon
the domestic legislation not only of those coun-
tries, but of less advanced nationalities who,
under the freedom of a world peace, will be
ambitious to deserve a high place in a league
of nations. The congenital and hereditary de-
fects of debility; the hereditary tendencies con-
nected with syphilis, drunkenness, ill-honsing;
the bad industrial conditions' leading to the em-
ployment of pregnant women and the relegation
of infants to care-takers — all these things should
be fought on a grand plan, for the good of the
old states and for the advancement of the new.
THE ILLEGAL SALE OF POISONS.
In London recently there has been a series of
cases where the public has been able to obtain
in illegal and irregular manner dangerous
poisons, especially such substances as opium
and its derivatives, cocaine and veronal. These
cases have come to public notice in police
and coroners* courts and some of them have
had, or will have, sequels in the higher criminal
courts. Whether self-drugging has increased
under the stringency of anti-alcohol legislation
or not is much debated, but that is not the mat-
ter now under discussion. The point is that the
public can obtain, thru the carelessness of doc-
tors, the laxity of pharmacists, and the un-
scrupulousness of individuals, access to danger-
ous poisons which is denied them by express
legislation. Not long ago a police superintend-
ent obtained from a druggist, without any com-
pliance with the regulations imposed by the
Pharmacy Act, a quantity of prussic acid and
immediately committed suicide with it. He was
known to the pharmacist as a police superin-
tendent and in deference to his position all the
usual restrictions were waived, on his simple
allegation that he desired to kill his dog.
Clearly In the mind of the pharmacist the en-
actment of the law was not a matter which
concerned either him as an individual trades-
man or his customer as an individual police-
man; it was a vague sort of regulation in the
interests of the public which could be put on
one side if individual interests were more
clamant. It is this willingness to go behind the
law which is one of the great sources of danger.
Doctors again are greatly to blame in the
form of prescriptions they give, rather than in
the readiness with which they prescribe, nar-
cotics. If prescriptions were carefully made
out for a certain number of doses and that num-
ber of doses only, and if it was made clear that
the prescription should only be renewed by the
same doctor and made up by the same chemist,
and would not be available unless so renewed,
a large number of self-druggers would be saved
from suicide, voluntary or involuntary, and a
great number of accidents would also be ob-
viated. The law provides exactly for this sort
of thing, but when the regulations are not kept
by the doctor they are not insisted upon by the
druggist, and so break down. It came out at a
recent inquest near London that a woman had
purchased morphine in huge quantities on some
prescription which she had obtained in a per-
fectly legitimate manner. Relying on this pre-
scription, she issued a series of written orders
to druggists all of Which were complied with
and, at the inquest which eventually ensued.
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CORRESPONDBNCB
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the verdict was death from cardiac and pul-
monary conditions accelerated by morphine
poisoning. How to stop this sort of thing is
exercising the wits of the authorities, and the
proceeding adopted in a totally different case
may indicate the policy which it is proposed to
pursue. Traps will be laid by bogus patients
both for doctors and chemists, the idea being
that in this way witnesses to the offense that
has occurred can be produced in courts of law,
who, only being technical sinners and not drug
takers, will have no objection to tell the truth
to a magistrate. This course has been pursued
to bring home to a druggist in the center of
London the penalties in force against unquali-
fied persons who attempt to administer treat-
ment for venereal diseases. A medical man ar-
ranged the introduction of a police detective to
the druggist in the character of a bona fide
patient. The druggist, tho unqualified, pro-
ceeded to treat the patient for venereal disease,
and in the police proceedings that followed, the
bogus patient, having no shameful pathr)logy to
confess to. was ajt)le to give a succinct story
of what had occurred, and the druggist was
heavily fined. No one likes to rely upon the
activities of the agent provocateur but there is
no doubt that in these cases it is the agent
provocateur who is most likely to secure a con-
viction which being attended with heavy fines
will act as a deterrent. There is a feeling of
course against members of the medical profes-
sion playing any part in such transactions and
it is generally hoped that however necessary it
may be to set traps for pharmacists who are
either lax in their regard for the poison regu-
lations or unscrupulous in assuming medical
duties, it will not be necessary that medical men
should assist in baiting these traps. The posi-
tion of the medical man who has lured either a
professional colleague or a tradesman closely
associated with medical administration Into
breaking the law cannot be a pleasant one.
CORRESPONDENCE
COMPULSORY HEALTH INSURANCE.
To the Editor,
American Medicine:
I beg to call your attention and that of your
readers to the enclosed letter to the President
of the Medical Society of the State of New York.
It will require the early and united action
of every physician in the State in the maimer
indicated in this letter to defeat for the fourth
time the scheme for "Compulsory Health Insur-
ance" now disguised as "Health Insurance."
The trade-mark "Yours for Health" long
monopolized by the late, if ever existent, Lydia
Pinkham has been appropriated bodily for
political purposes in the highest political quar-
ters.
Respectfully yours,
JOHN P. DAVIN, M. D.
ENCLOSURE.
February 2, 1919.
T. H. Halsted, M. D.,
Pres. Medical Society State of New York,
Syracuse, N. Y.
Dear Doctor:
In duty to the standards of our profession
and to the welfare of the public whom we serve,
I would like to call your attention, and that of
the Council of the State Society to a measure
now before the Legislature, and recommended
for passage by the Governpr in his message to
the Legislature.
This measure is a bill for what Is called
"Health Insurance." It is the same one es-
sentially, which under the name of Compulsory
Health Insurance has been defeated three times
already by the efforts among others of the en-
tire Medical Profession of this State. It Is now
advocated by the State Industrial Commission,
and by a so-called "Association of Manufac-
turers." There is no evidence that the public
and the medical profession upon whom would
fall the loss and burden accruing from the
passage of this measure have b^n consulted In
any way in regard to its provisions.
At an initial ouUay of $1,500,000 it would
place upon the State Board of Health the duty
of assuming charge of the health of the work-
ing population of the State, as well as those
who would apply to It for special advice or
treatment. It is a political attempt to put into
practice the theory of the "Socialization of Med-
icine," at a time when the political socializa-
tion of every other form of enterprise is fall-
ing Into disrepute.
Hitherto the State Society has waited until
the eve of the passage of Medical Laws, before
entering Its protest formally before the Legis-
lature. On all such occasions we have received
but a perfunctory hearing before a body more
or less biased against an attitude of opposition
to its findings.
I would suggest now, that this matter be
placed before every County Medical Society in
the State for their immediate consideration, the
results of which to be forwarded by the Secre-
taries of these Societies to the members of the
legislature representing the various Counties
in the State. In this way the profession would
command a hearing and compel a respect for
their representations that hitherto they have
not been able to command when this duty was
delegated to a committee appearing before the
Legislature generally at the eleventh hour of its
session.
Respectfully submitted,
JOHN P. DAVIN, M. D.,
Member Medical Society County of New York,
Secretary, Association for Medical Defence.
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RATIONAL. ORGANOTHERAPY
February, 1919
105
RATIONAL
ORGANOTHERAPY
The Inter-relation of Ductless Glands* —
Since the pioneer work of Qaude Bernard
with the ductless glands there has been
opened to medicine almost a trackless field
of research. The functions ascribed to the
ductless glands have been extended, how-
ever, says an editorial writer in the New
York Med. Jour,, (July 20, 1918), to include
other glands which have external secretory
functions. It is found now that such glands
as the pancreas, ovaries, kidneys, cardiac,
pyloric, and fundic glands have both an
internal and external secretory action. But
the term ''endocrinous glands" refers rather
to the glands with only an internal secre-
tory function, and include the pituitary,
thyroid, parathyroids, the adrenals and,
most likely, the spleen. The whole range of
glands having internal secretory function
is better designated as a system because of
their close interaction. All are so closely
bound to each other that a disturbance in
one will throw out of gear or out of action
all the others. Not only do these glands
secrete material which controls certain
phases of the organism, but in order that
this control shall be in harmony they secrete
material for the control of the action of
the others. This control may be inhibitory
of the action of the others or stimulating.
It is either antagonistic or supplemental.
Oversecretion of one gland soon becomes
toxic to the organism, and it is the function
of the others to control this. The antago-
nistic action of one over the other not only
prevents the overactivity of the others, but
keeps the line of action pulled taut. That
even the disturbance in one gland may have
dire results can be seen from the fact that
the action of these glands is concerned with
the control of such vital processes as the
vasomotor system, nutrition, circulation, di-
gestion, etc. Indeed, there is no phase
which they do not control and disturbances
may become manifest even with disturbance
of one gland. It is for this reason that in
conditions thought to have origin in this
form of disturbance gland medication, or-
ganotherapy, contemplates the giving of the
extracts of many glands, a sort of polyva-
lent gland extract. Whether the theoretic
basis for this action is correct or not, bet-
ter results do in fact follow the use of poly-
valent extracts.
But, while the whole system is strongly
bound together, some of the glands are more
closely related in their action to each other
than to other glands. The thyroid and the
adrenals control each other's action an-
tagonistically— ^that is, inhibiting the over-
action of the other. The pituitary, on the
other hand, seems to reenforce the action
of the thyroid. However, the thyroid seems
to be the most versatile, having a direct in-
fluence on all of them. The thyroid has,
moreover, a very definite control over the
ovaries and their generative and menstrual
functions. The thyroid and the adrenals are
probably most concerned in the control of
the sympathetic, altho all of the glands are
concerned in the maintenance of the equilib-
rium of this nervous system. Gland dis-
turbances may be either in the production of
deficient or of hyperactivity. Probably such
indefinite conditions as neurasthenia, malnu-
trition, sexual neuroses, and allied con-
ditions, and, more specifically cretinism and
dwarfism are produced by deficiency, while
goitre, acromegaly, gigantism, diabetes, gas-
tric and duodenal ulcers are caused by hy-
peractivity. These are but a few of the illus-
trations of the wide range of gland activity.
There can be no doubt that many of the ob-
scure and vague conditions will soon be in-
cluded among those conditions caused by
disturbances of the glands of internal se-
cretion, and amenable to the same treat-
ment.
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RATIONAL. ORGANOTHBRAPY
AmaiGAJf Mbdicinb
The EflFects <tf Under and Over Secre-
tion <rf the Ovaries.— The exact physi-
ology, or pathology, of total removal
of the ovaries according to Osborne
{New York Med. Jour,, Sept. 7, 1918)
depends upon the age of the individual
at the time of the removal. It is rarely
justifiable to remove both entire ovaries
in the human female, and of course it is ex-
cessively rare that such an operation should
be performed on a girl before puberty. Most
knowledge of early extirpation is acquired
by operating on animals. There is no ques-
tion that the early removal of the ovaries
causes the masculine type of development,
with a greater growth of the extremities.
A later removal of the ovaries causes
atrophy of the uterus, and may or may not
cause abortipn in a pregnant animal.
There seems to be a great disturbance
of the nutrition, and especially of the chem-
ical metabolism, after ovarian extirpation.
More especially is there a diminished cal-
cium excretion, and probably there is a dis-
turbance of the chloride and phosphorus
equilibrium. Waste metabolism is less act-
ive, and the body puts on weight largely in
fat, if the extirpation is after puberty. Other
endocrine glands are also disturbed by such
extirpation, notably the thyroid. The thy-
roid may have its colloid content increased,
but often it soon becomes less active, and
may even hyposecrete.
In early extirpation of the ovaries the
thymus has become enlarged and active, and
the pituitary and suprarenal glands may be-
come more active, to the production of a
masculine appearance and masculine ten-
dencies.
If a small portion of an ovary, or if a
supernumerary ovary is left in the animal,
there may be no signs of privation of this
secretion, or, if at first such signs are in
evidence, they may soon disappear.
Excessive ovarian secretion (probably
generally associated with increased thyroid
secretion) causes increased sexuality, even
to all kinds of sexual perversion. Simple in-
creased secretion may make girls coquettish
and constantly seek male companions. Even
if there are no other symptoms of increased
ovarian secretion except profuse menstrua-
tion, the body loses an excessive amount of
lime and other salts, as well as blood, es-
sential to the general welfare of nutrition
and of the nervous svstem. Often this ex-
cessive menstruation and increased waste
metabolism may be due primarily to hyper-
thyroidism. Excessive ovarian secretion in
girls may lead to masturbation or may be
caused by masturbation. It may cause in-
sanity, and the relation of the various in-
ternal gland disturbances to female insanity
should be carefully studied. Removal of a
diseased ovary or a diseased uterus has at
times cured serious mental disturbances.
Excessive ovarian activity, either de novo
or from too frequent pregnancies may cause
osteomalacia. Ovarian hypersecretion may
also cause parathyroid disturbance (per-
haps due to calcium shortage from a too
great loss) and therefore more or less nerv-
ous symptoms. Removal of one, or of one
and a half ovaries, and feeding calcium may
cure osteomalacia.
Treatment of Enlargement of the
Thsrmus. — A recent abstract in the Cor-
rcspondens-Blatt fur Schweizer Aerzte
{Jour, A. M. A,, Jan. 25, 1919) states that
W. Birk insists on the absolutely different
clinical picture presented with simple en-
largement of the thymus and that with the
thynius-lymphatic state. The former, simple
enlargement of the thymus, usually develops
during fetal existence, and the trachea is
compressed by the abnormally large thymus
even before birth. Death is the result of
suffocation, the already damaged trachea
becoming compressed to the point of suflfo-
cation. The status thymico-lymphaticus, on
the other hand, is not congenital and in this
the constitution and the food are of para-
mount importance, while these have no in-
fluence on the congenitally enlarged thymus.
But the latter can be modified by the
Roentgen rays, and Birk reports five cases
in which the excessively large thymus
promptly shrank to normal size under the
exposures. In one case the gland enlarged
again later, but in all the others the cure
was prompt and permanent.
Action of Pituitary Extract on Kidbey.
— Knowlton and Silverman {Amer, Jour,
of Physiology, Sept., 1918) found that the
oxygen consumption by the kidney is not in-
creased during the diuresis induced by
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PHYSICAL THERAPY
February, 1919
107
pituitary extracts. Using the oxygen con-
sumption as the criterion, there is no evi-
dence that pituitary extract stimulates the
renal cells. Thruout their experiments in-
creased blood flow thru the kidney was an
invariable accompaniment of pituitary diu-
resis. From the evidence at hand it seems
possible to explain the diuretic action of
pituitary extract entirely on the basis of
the vascular changes and increased filtra-
tion pressure obtaining in the kidney.
Under the Editorial Direction of Albert C.
Geyseri M. D., New York.
REACTION OF DEGENERATION.
Only so much of the anatomy and the
physiology will be considered as seems im-
mediately necessary for a clear comprehen-
sion of what is to follow.
Neuron structure and function. — By the
term neuron we include the entire anatom-
ical structure, beginning with the trophic
center, the protoplasmic prolongation and
the end organ.
The central motor neuron begins with the
motor ganglion cell in the cortical motor
area of the cerebrum. The protoplasmic
prolongation (the axis cylinder) passes
downward and crosses over to the opposite
side of the body. The end organ of the cen-
tral neuron consists of the end brush and
this is situated at its particular level in the
spinal cord.
The shortest central neuron begins at the
motor cortical zpne and after decussating
in the medulla ends in the cervical region
of the neck; the longest central neuron
passes downward as far as the beginning
of the lumbar enlargement. This bundle of
nerve fiber is therefore much thicker above
than it is below and is known as the py-
ramidal tract.
The function of a central neuron is to
convey the impulse from the cortical cell
along the path of the axis cylinder to the
end brush. When such a motor impulse
arrives at the end brush, it is translated
into an energy, which is then taken up by
a large multipolar cell in the gray matter
of the anterior horn of the spinal cord.
The multipolar ganglion of the anterior
horn is the beginning of the peripheral neu-
ron. This neuron consists of a ganglion cell,
a protoplasmic prolongation (the nerve)
and the end organs. The function of the
peripheral neuron is to carry into execution
the message of the central neuron. It
acts as a sort of a relay. The* motor cell of
the central as well as the motor cell of the
peripheral neuron, besides generating im-
pulses, presides over the nutrition of all
parts of which they themselves are formed
and the organs to which their branches are
distributed.
From this anatomical and physiologic re-
view we are in a position to appreciate just
what must happen, if a lesion occurs in any
portion of a motor neuron.
In cerebral apoplexy we may have pres-
sure exerted over the cells lying in the
motor cortical zonp. Such a lesion would
interfere with the generation of motor im-
pulses. No impulses arriving at the end
brush, none could be interpreted by the
multipolar ganglion cell of the peripheral
neuron ; the muscle supplied by this par-
ticular neuron would be without function,
therefore paralyzed.
Owing to the fact that the peripheral
motor cell controls the nutrition of the
muscle to which its branches are distributed,
this cell being intact, the nutrition of the
muscle would not suffer, there would be no
atrophy, excepting that which results from
non-use.
If a lesion is located in any other por-
tion of the central motor neuron, the path-
ologic result would be the same. Since the
central motor neuron cannot be tested in
a patient, these lesions cannot be dem-
onstrated electrically.
When a lesion occurs in the peripheral
neuron, conduction from the cell to the end
organ is interfered with. The trophic cen-
ter is cut off from the nerve and muscle,
hence there is a flaccid paralysis with early
and rapid atrophy. Upon testing such a
nerve electrically, the axis cylinder fails to
conduct the artificial stimulus because the
nerve has degenerated from lack of nutri-
tion, there is no muscular contraction, hence
we have the phenomenon of reaction of
degeneration. In reality, it is the failure to
react to the electrical stimulus that denotes
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FSBRUAKT, 1919
PHYSICAL THERAPY
American Medicine
the fact that the axis cylinder has degen-
erated.
Every lesion in the peripheral motor neu-
ron can be located with exactitude by the
electric test, not only that, but by repeated
examinations the prognosis can be foretold
with almost a certainty.
While the lesion of the central motor neu-
ron cannot be thus demonstrated by the
use of an electric current, nevertheless their
presence can be inferred by establishing the
non-involvement of the peripheral neuron.
Every muscle paralysis is due either to a
lesion in the central or the peripheral neu-
ron. The electric examination discloses the
InWniViijla k^ ^ iv«r
CelUttrt.1;
Fig. 1.
one and excludes the other. Every neuron,
the same as every individual cell, in the
whole economy is compelled to perform a
certain function, it does this and it cannot
do anything else.
A neuron obeys the "law of constant ef-
fect of nervous citation." It makes no dif-
ference whether a nerve is excited into ac-
tivity by a normal stimulus from its trophic
center or by the application of an electric
current to any part of the nerve, the effect
on the organ of reaction is invariably the
same. In the case of a motor nerve there
is always a muscular contraction, in the
case of a sensory nerve, sensation of some
kind is projected toward the center. Since
the effect of nerve stimulation is "constant"
an interesting phenomenon is worth men-
tioning. The localization and the character
of the muscular movement are determined
not by the site of stimulation but by the
number of fibers excited and their periph-
eral distribution to the muscle. So too, the
location and the specific quality of the sen-
sation, e, g.y pressure, heat and pain, which
occurs on stimulating* a sensory cutaneous
nerve at any point, is identical with that
produced by the action of natural stimuli
upon the end organ in the skin. The most
striking example that can be adduced in
proof of this law is that observed when a
limb has been amputated. "When the mem-
ber to which a nerve trunk is distributed,"
says Johannes Muller, "is removed by
amputation, the stump of the nerve which
contains the whole of the shortened nerve
fibers is capable of the same sensations as
if the amputated limb were still present.
This persists all thru life." (Luciani's Physi-
ology, p. 201.) Any irritation, injury or
inflammation which may occur at the stump
is immediately translated into a sensation
as occurring in the amputated member.
Upon recovery they have the same sensa-
tions that normal people feel in a healthy
limb, and there is often a persistent sensa-
tion of itching, or discomfort, which hap-
pens to be localized in the limb that no
longer exists. The writer is in position to
speak upon this peculiar phenomenon with
some authority. In 1912 it became necessary
to amputate the little and the ring fingers of
my left hand including their respective
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PHYSICAL. THERAPY
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109
metacarpal bones. The left hand had been
injured as the result of repeated exposures
to the X-rays. Altho the amputation oc-
curred more than six years ago, as far as
feeling or transmission of sensation is con-
cerned, the hand is still intact. When the
hand is exposed to the cold, the im-
pression conveyed centrally is as tho
the amputated fingers shared in the
feeling of cold. Many persons eventu-
ally become accustomed to these sen-
sations, and cease to notice them ; but they
surge up again when attention is focussed
upon them and are often distinctly felt in
the fingers, sole of the foot or hand. These
sensations are made more acute when pres-
sure is exerted on the stump or the scar.
It frequently happens that the end of a
nerve is pressed upon from adjacent scar
tissue. Nothing short of a freeing of the
nerve will relieve the painful sensation in
the missing member.
The symptoms of "anasthesia dolorosa''
are no less important to the demonstration
of peripheral projection of sensations.
Traumatic paralysis from compression or
section of a nerve trunk, in which more or
less extensive cutaneous areas become to-
tally insensitive to the strongest stimuli,
tho the patient still complains of intense
pains in them owing to the irritable state
of the nerve trunk, is not infrequent. In
surgery, division of a nerve may fail to cure
neuralgia, as it merely interrupts the con-
duction of external peripheral excitations to
the center, but cannot suppress the con-
duction of central irritation in the nerve
which gives origin to sensations projected
to the periphery similar to those produced
by extrinsic local stimulation.
This failure to arrest pain projection after
section is demonstrated especially well in
cases of tic douloureux of central origin.
The pain sense, while central, is nevertheless
projected to the peripheral end of the di-
vided nerve.
The phenomenon of peripheral projec-
tion of sensation can easily be demonstrated
under normal conditions by mechanical ex-
citation of one's own ulnar nerve in the
groove of the internal condyle at the elbow,
where it is accessible ; this produces a prick-
ing in the palm and the back of the hand,
and in the third and fourth fingers. In my
own case, altho the third and fourth fingers
are absent, any irritation of the ulnar nerve
between the condyles causes a tingling sen-
sation as tho these fingers were normal and
in their places. The motor nerves pass
thru a similar phase, of course motion in
the absent member cannot occur, neverthe-
less, if the desire to move the absent mem-
ber is strong enough, the individual,
as far as the central sensation is con-
cerned, appreciates every intended mo-
tion as tho it really took place. A medical
friend was obliged to undergo an amputa-
tion of the leg just below the knee. For
some years he experienced much difficulty.
Tie would make the attempt to step upon
the shortened leg without the support of
his crutch. So real was the muscular sense
projected to the periphery and into the ab-
sent member, that he forgot to make sea-
sonable use of proper support, often to his
detriment.
In order to have a muscle respond to a
stimulus of a motor nerve, four essentials
must be in a normal state.
First, a multipolar cell in the gray horn
of the spinal cord must send out an impulse,
second, this must be conducted along the
axis cylinder, the nerve fiber, third, to
the end plate which invests each sarcolemma
of the muscle and fourth, the entire mus-
cle bundle or the muscle itself must be in
a normal physiologic condition to perform
its function, that of muscular contraction.
A lesion located anywhere within the
peripheral motor neuron will interfere with
the end result, the intended muscular con-
traction.
An apparent paradoxical phenomenon has
been observed in nerve and muscle testing
and incidentally it has frequently brought
discredit upon electrotherapy, viz., that a
stronger or more frequent stimulus produces
less effect than a weaker or less frequent
stimulus. This is explained by the fatigue
of the end organs. The excitability of these
is depressed after each stimulation, recov-
ery takes place after an interval which is
longer in proportion with the strength of
the preceding excitation and the degree of
fatigue. If the stimuli are too strong and
follow too rapidly, there may be much de-
lay or no recovery, and a degree of inex-
citability ensues; if the stimulus is weak-
ened, or made less frequent, the reaction
reappears. Under normal conditions these
eifects of fatigue are manifested only in the
muscle and particularly in the motor end
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110
Februaby, 1919
PHYSICAL. THBRAPT
American Mboicins
plates. Under certain pathologic conditions
even the nerve trunk shares in this phe-
nomenon altho to a much less degree.
It is probable that the waste products
developed by the muscle during tetanus have
some significance in the production of ex-
haustion in the end plates, as they may ex-
ert a toxic action on the motor nerve end-
ings similar to that of curare.
For many years the interrupted galvanic
current and the faradic currents have been
employed therapeutically in poliomyelitis
for no other purpose and with no other
aim in ^iew than the causing of muscular
contractions. Simply because voluntary mus-
cular contractions could not be produced
by the patient, these currents were made
use of in order to produce that which was
lacking. When we consider that in poliomye-
litis the lesion is located in the gray matter
of the anterior horn, that the axis cylinder,
the end plates and the muscle are cut off
from their trophic center, we may well
pause and consider the effect of causing
such muscular contraction under an arti-
ficial stimulus. If there was any possibility
of regeneration by a normal process of re-
covery, it must have been much delayed,
if not entirely removed by such unscientific
meddling. Not only was there more or less
injury to ganglion cells as a result of the
poliomyelitis toxemia, but to this was added
the fatigue poisons of the forced muscular
contractions and their destructive effect
upon the delicate end plates. Muscular con-
tractions brought about by artificial stimuli,
when the trophic centers are cut off, are on
a par with driving a horse after its food
trough has been cut off.
Altho under normal conditions the nerve
is almost inexhaustible to prolonged arti-
ficial stimuli, so long as these do not alter
its substance. Its specific activities, exci-
tability and conductivity may progressively
diminish and eventually disappear when it
is deprived of the essential conditions for
its existence. An important condition of the
vitality of the nerve lies in its anatomical
continuity and connection with its central
organ. A long series of well established facts
proves that when this connection is inter-
rupted, its normal nutrition and morpho-
logic structure are altered as well as its
excitability and conductability.
Reaction of Degeneration. — The practical
value of the recognition of R. D. lies in the
fact that, when present, it points to some
defect, to some degenerative lesion in the
neuro muscular area exhibiting its phenom-
ena. R. D. always means some nutritive dis-
turbance in the nerve or muscle involved. It
must be remembered that the lesion may be
either in the trophic cells, the axis cylinder,
the end organs or the muscle itself. In other
words R. D. always means a peripheral neu-
ron lesion; it can, therefore, not be elicited
in purely cerebral palsies, it is not present
in muscular atrophy, the result of non-use
or inflammatory changes, neither can it be
elicited in hysterical paralysis or shamming.
It is a common occurrence that a com-
plete cerebral hemiplegia may not show
R. D. even after years of existence, yet a
pressure paralysis such as the drunkard's
brachial paralysis or the facial paralysis,
Bell's palsy, when the nerve is compressed
within the bony canal may show R. D. im-
mediately and extensively. The former of-
fers little or no hope of recovery while the
latter usually become normal in the course
of a few days or weeks. The mere presence
or absence of R. D. is not prognostic tho
it is invariably diagnostic at once,
While the presence of an R. D. means a
neuron lesion in the peripheral motor tract,
it also excludes the lesion from the central
tract. This does not mean that while we
are dealing with a peripheral neuron lesion,
that it is precluded thereby that no lesion
exists in the central tract. Let us suppose
that a patient is suffering from an apoplec-
tic paralysis. The lesion is located some-
where in the motor cortical zone of the
cerebrum or in the internal capsule. The re-
sulting paralysis is most extensive, yet R.
D. cannot be demonstrated because the nu-
trition and the conduction from the trophic
center in the spinal cord, the entire periph-
eral neuron, is not involved. It is true mo-
tor impulses are not conducted along the
peripheral neuron, but that is because none
arrives in the spinal cord from the cerebrum.
Let such a patient fall asleep with the
paralyzed arm in such a position that long
continued pressure would be exerted upon
the musculo-spiral, median or any other
nerve of the brachial plexus ; almost at once
there would be failure of conduction, at
least conduction would be impaired and ac-
cordingly we would have added to the hemi-
plegia, a pressure paralysis with the lesion
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American Medicinb
TREATMENT
February, 1919
111
in the axis cylinder of the peripheral neu-
ron. Within a few hours R. D. could be
demonstrated which would have nothing
in common with the pre-existing central
paralysis, it would simply mean the co-ex-
istence of a central and a peripheral motor
neuron lesion.
R. D. occurs:
1. In paralysis which is the result of
injury or disease of the multipolar ganglion
cells in the anterior cornua of the spiral
cord and the motor nerves of the bulb.
2. In paralysis which is the result of
injury or disease of the anterior roots and
the peripheral axis cylinder where the physi-
ologic function of the trophic centers fails
on account of the interruption of conduc-
tion or nutrition to the end organs in the
sarcolemma.
R. D. is present in poliomyelitis because
early in the disease the infective process in
the cord, whether due to germs, toxin or
a virus, produces a local tissue reaction.
This reaction in the cord is essentially in-
flammatory and intended as a reparative
process. During this localized inflammation
leucocytosis and diapedisis are marked fea-
tures. Thru the overactivity of this process
there is crowding, compression of destruc-
tion of the gray matter. Since the motor
cells are imbedded within the anterior
horn and since they are the most highly
organized cells in this area, they suf-
fer correspondingly. The higher the func-
tion of a cell, the easier and the more per-
manently is its function altered or destroyed
by injury. From the very moment of inter-
ference with the function of a multipolar
nerve cell, nutrition to all its parts is modi-
fied. It IS because the nerve fiber, the en(\
plates and the muscle it supplies depend for
their nutrition upon the integrity of this
cell that degeneration must take place when-
ever the trophic cell is injured. The distal
paralysis is due to the fact that the cells
send out no more impulses, the degeneration
is the result of failure to provide the neces-
sary nutrition and as a result we have a
gradually increasing descending degenera-
tion.
Cystitis. — Curtis asserts that urinary
retention is more active etiologically in
cystitis than the misuse of the catheter. —
IJr. and Cutan. Review.
— in
REATMENT
The Use of Yaccines in Acute Inflnensa and
Influenzal Bronehopneumonia.— Wynn {The
Lancet, Dec. 28, 1918) refers to the fear and
reluctance so frequently manifested in the use
of vaccines for treatment. He considers the
vaccine dosage recommended by the Conference
held at the War Office last October, and adopted
by the Army and Local Government Board, en-
tirely inadequate and points out that in the
treatment of influenza and its secondary bron-
chopneumonia Lord Fisher's advice is appropri-
ate: "Strike early and strike hard." Every case
should be regarded as serious and a dose suffi-
ciently large to produce a satisfactory response
within a few hours should be given when the
patient is first seen. When the author first used
vaccines in the diseases in question, doses as
small as 5 million were given; and results, tho
occasionally good, were uncertain. Larger doses
were then given, with better results. It is im-
portant that the first dose should be effective.
The doses now recommended in acute infiuenza
and influenzal bronchopneumonia are: For an
adult man, 80 to 100 million pneumococci, strep-
tococci, and B. influenzae; for an adult woman,
60 to 80 million; for a child of 12 to 14, 40 to
50 mUlion; for a child of 2 or 3 years 10 to 20
million. In deciding the dose the size of the
patient is more important than the age. The
dose should not be reduced because of the
gravity of the illness. If the first dose gives
no, or an insufficient, response the next dose
should be larger, the doses being repeated on
alternate days, or even in some cases every day.
With a first dose of 100 million it is rarely
necessary to increase this.
The timidity so often shown even by those
who use vaccines in chronic diseases towards
their use in acute diseases apparently arises
from theoretical considerations as to the pos-
sible harm caused by negative phases. This is not
the place to enter into a theoretical discussion
on the mode of action of vaccines in acute dis-
eases. My attitude for tne moment Is the prag-
matisms, "It is true because it works." But it
may be pointed out that the doctrine of the
negative phase was worked out in patients suf-
fering from chronic localized diseases. The
conditions existing in healthy persons and in
patients with acute disease are very different
and not comparable.
Those accustomed to vaccine therapy know
that in the treatment of chronic localized dis-
eases— chronic arthritis, mucous colitis, chron-
ic bronchitis and asthma — considerable reac-
tions may be produced by quite small doses,
and great care is necessary in increasing the
doses. The patient appears to be "sensitized"
in a different manner to those suffering from
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112
Fkbruabt, 1919
NOTES AND ANNOUNCEMENTS
American Medicine
acute disease. Again, a dose of 000.0001 c. cm.
tuberculin may cause a smart reaction in a case
of chronic localized tuberculosis, but would
have no effect in a case of advanced phthisis or
acute caseous bronchopneumonia. One pos-
sible explanation may lie in the very different
amount of infection in the two cases. A dose
of 100 million pneumo cocci is very small as
compared with the inconceivable number of
cocci in the body of a patient suffering from
acute pneumonia, but becomes appreciable when
compared with the number present in a case of
chronic otitis media.
Prophylactic injections have been given to 230
persons, 100 million of streptococci and pneu-
mococci and 60 million B. influenzae being used
as a first dose, and after a week double these
doses to 90. but as there is no good reason for
reducing the number of influenza bacilli the
last 140 have had equal numbers of each organ-
ism. In come cases a third dose of 400 million
and in a few a fourth of 800 million has been
given.
NEWS NOTES*"
ANNODNCEMENTf
Amerieaii Chemicals Established High Rec-
ord in Exports for Year*— No industry in the
United States has shown a more wonderful
growth during the war than that of chemicals.
The exportation of chemicals from the United
States in the year which ends with this month
will show a total of approximately $175,000,000,
against $27,000,000 in the year immediately
preceding the war.
While of course the exportation of strictly
war material such as explosives, shells, etc.,
shows perhaps a larger increase during the war
period, the growth in the production and ex-
portation of chemicals for which a permanent
demand could be expected is especially suggest-
ive in this country with such large possibilities
in this line, both for foreign and domestic
markets. A compilation by the National City
Bank of New York shows that the value of
chemicals exported steadily grew from the be-
ginning of the war, and as above indicated will
approximate $175,000,000 in the current year,
against about $27,000,000 in the year immedi-
ately preceding the war.
The United States has always been a large
importer of chemicals, the total value of this
class of merchandise Imported prior to the war
being about three, and in some instances as
much as four times the exports, and while the
demands of the war have been such as to some-
what stimulate the importation, meantime the
percentage in the growth in Imports has been
small compared with the percentage of growth
in exports. The imports grouped under the
head of chemicals consist largely of classes of
materials not produced in the United States,
and included in the fiscal year 1918 $70,000,000
worth of nitrate of soda, a Chilean product, and
$22,000,000 worth of gums, strictly tropical prod-
ucts.
Eliminating these strictly tropical articles
which have been classed by the Government as
"chemicals," the present importation of manu-
factured chemicals is extremely small, indicat-
ing that our own manufacturers are at present
supplying the great markets for chemicals in
the United States, and at the same time send-
ing nearly $150,000,000 worth a year to foreign
markets. In the full fiscal year 1918, the chem-
icals exported aggregated in value $152,000,000
against $27,000,000 in the year preceding the
war; $46,000,000 in the first year of the war and
$124,000,000 in the second year of the war.
The Pennsylvania Bareaa of Drag ControL—
A special bulletin has been issued by the De-
partment of Health of the State of Pennsyl-
vania, explaining the antinarcotic law of that
state to every physician, dentist, veterinarian,
pharmacist, druggist, and registered nurse in
the State. The law declares it illegal for any
one either to have possession of or to traffic in
narcotic drugs except persons belonging to cer-
tain designated classes. The regulations re-
garding the handling and prescribing of these
drugs by pharmacists, physicians, dentists, and
veterinarians are detailed and explicit. A
bureau of drug control has been organized
under the direction of Dr. Thomas S. Blair
which will be charged with the execution of
the law.
A Journal Devoted Especially to the Dis-
abled*— ^The "American Journal of Care for Crip-
ples," which is the only special periodical in
English on provision for the disabled, becomes
a monthly with its January issue, according to
announcement by its editor, Douglas C. Mc-
Murtrie. Altho dealing extensively with the
rehabilitation of the invalided soldier, the Jour-
nal is in no sense a war product, as it is now
entering upon Its eighth volume.
This periodical will contain in the future the
studies, translations, and abstracts produced by
the research department of the Red Cross Insti-
tute for Crippled and Disabled Men, which ma-
terial has hitherto appeared in a special series
of publications. The Journal also continues as
the official organ of the Federation of Associa-
tions for Cripples.
Physicians Needed in Rural Districts. — Dr.
Hermann M. Biggs, State Health Commissioner
of New York, calls attention to the fact that
many rural communities in New York are ab-
solutely without a physician, and in many cases
the condition is serious, as neighboring towns
can no longer be depended upon for medical
assistance In emergencies on account of the bad
conditions of roads.
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BMERIfflNllEDI
PDBLI8HBD MONTHLT
B4itorUl €HH9»m* 18 East 41*« St., lf«w Tork City. Publieatfon OHImss , 189 College. St., Bnrllnitoai. Vt.
CoBvMe Series, YoL XXY. Mo. 8
Hew^Seilee, YoL HY. Ho. 8
MARCH, 1919
$2.00 'f*^'
In AdTtnee**
CONTENTS
118
1»
BDrrOBlAX OOMMBNT . . . «
MBlf AND THIN08
01UOIlfAI« ARTIOIiBS t2B
LOlfDON liSrmUEt 168
PHYSICAI^ THBSRAPT 170
BTIOLOOT AND DIAGNOSIS 179
TRBATMBNT 178
COBRBSPONDBNCBl .' 178
NBWS NOTBS AND ANNO VNGBMBNTS . . . 175
(OoBtlBiMd OB paso 6)
CONTRIBUTORS
Im DUNCAN BVLXJLBYp A. M,, K. D., New Tork
City.
LBO MAYBR, A. M,, K. D., New York City.
70 i^ WARD o. OTIS, M. D., Boston, Mass.
M. NBUSTABDTB2B» K. D„ Fk. D., New York
City.
MAJOR J. PRATT JOHNSON. K. C D A. D, K.
8., 8. Am M. €•» Johanneaburs, South Afrloa.
BIARGARSST SANORR, New York City.
ROYAIi 8. COFRI^AND, M. D,. New York City.
Bnlend ■• eeeond-«lu8 metter Janaary 28, 1906, ak the Post Office at BurMngton, Yt, onder Act ot Congieee, March 8, 1879.
In the Treatment of
RHEUMATIC and
NEURALGIC ILLS
jon will obtain substantial aid from the thorough use of
K-Y ANALGESIC
This non-greasy, water-soluble local anodyne will enable you
to ease your patient^s pain and discomfort, while yotir intemai or
systemic medication is combating the cause of his condition.
The advantages, moreover, of relieying the pain of a facial
neuralgia, an inflamed joint, or aching lumbar muscles without re-
course to coal tar derivatiyes csannot fail to appeal to medical men.
lk"Y ANALGESIC is a safe and effective adjunct that will daily
grow more useful to the practitioner as the many opportunities for
its effectiye use are realized.
VAN HORN & SAWTELL DEPARTMENT
NBW BRUN8WICK, N, J„ U, 8. A.
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I^ophylaxis and Treatment
of Influenza
Pkwvrabon
with
Influenza-
Pneumonia
Vaccine
Curative
Treatment
with
Pneumonia
Phylacogen
CONVINCING evidence in mipport of specific
^^ prophylaxis in influenza is cifforclecl by hun-
cireas of reports on the use of our Influenza-.
Pneumonia Vaccine (Prophjriactic). This vaccine,
Br^pared in strict accordance with the formula of
^. E. C Rosenow of the Mayo Foundation, is
composed chiefly of pneumococci, streptococci and
influenza bacilli, all cultures being freshly isolated
from cases occurring during the recent epidemic.
Results from its use in military camps and other
places where influenza has prevailed leave no
doubt of its prophylactic value.
Botdec of 20 mils, one in a package.
Bulbs of 5 mils, one in a package.
DROOF of the efficacy of Pnetunonia Phylacogen
in the Ireoffnen/ of influenza is abundant and con-
vincing. This Phylacogen has been used in many
sections of the Un^ed States with highly satisfactory
results. Cases so treated and reported during the
recent epidemic number many hundreds, the per-
centage of recoveries being surprisingly large. One
physician has used Pneumonia Phylacogen in over
a hundred caaes without a fatality. He gives an
initial dose of Phylacogen (I mil) with the first
sign of fever, repeating in four to six hours.
Bio. 605. Bulbe of 10 mik. one in
Bio. 607. Bulbe of I mil, five in a package.
If sflff prmtaUnif and u Hkmfy to nmain go for going iimm^ in i
cfiho inMioa9 character of thm dUeoMO^ phymciana Mhontd haoo oa^y aeemaa to
voUabio agenta for annumixation and treatment. Som that your draggitt It
aappUmd arith influonza-Pmoomonia Vaccinm andFnmumonia Phyiaeogon^
PARKE, DAVIS & COMPANY
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American Medicine
H. EDWm LEWIS, M. D., Mamaging Editor
PUBUBHBD MOHTHLT BT TBI AMBRICAN MlDICAL PUBUSHDia COMPANT
Conyriffktod by the AmeriMn Medieal Pnblishinff Co., 1919
IRA 8. WILE, Associate Editor
CoBDkta Scti«, Vol. XXV, No. 8
NewSOTMS, Vol. XIV, No. 8
MARCH, 1919
to Ol[\ YEARLY
^CAnJ In Advance
Lethargic Encephalitit^ — ^The appear-
ance in the United States of a disease char-
acterized by drowsiness and paralysis of
some of the cranial nerves, particularly the
ocular, raises the question as to whether a
new form of disease has started to invade
the land. During the early part of 1918,
there were observed in England and France
small epidemics which were regarded as
possibly due to botulism, poliomyelitis, a
meningeal form of influenza, or possibly a
new symptom-complex or an unknown
cause. For the present, the term "lethargic
encephalitis" is accepted as a name, despite
the fact that there is some question as to its
being a new disease.
In the Journal of the American Medical
Association of March 8th, there appeared
side by side two articles, one by Josephine
B. Neal discussing ^'Meningeal Conditions
Noted During the Epidemic of Influenza,"
and the preliminary report of A. L. Pothier
on "Lethargic Encephalitis," describing a
number of cases which were observed at
Camp Lee, Petersburg, Virginia. In Neal's
experience, few cases of meningitis are
found to be directly due to the influenza
bacillus. A moderate number of patients '
were found to be suffering from meningitis
following an attack of influenza. In about
twenty instances, during convalescence from
clinical influenza, meningeal symptoms such
as headache, stiffness of the neck, Kemig's
sign, and drowsiness appeared, with the
spinal fluid clear in character, but under in-
creased pressure. The spinal fluid reactions
point to changes similar to those found in
cases of poliomyelitis and poliencephalitis.
She reports, also, three cases evidencing a
more severe type of infection, involving
cardiac and respiratory centers, and, one
instance at least presenting the general
rigidity that has been reported by English
writers as symptom-complex of lethargic en-
cephalitis.
Pothier enumerates eight cases character-
ized by a tendency to cranial nerve involve-
ment, fever and slight changes in the spinal
fluid. Other symptoms noted were nystag-
mus, tremor, drowsiness, delirium, vertigo,
diplopia, headache and a spinal fluid show-
ing a definite lymphoc)rtic pleocytosis (from
20 to 66 cells.) At the camp, there were no
cases of poliomyelitis, and the patients
came from widely separated organizations.
Cases of this general type have been re-
ported also from Chicago and New York,^
and are more or less in accord with the
general descriptions which created interest
and alarm in England, France and Austria
during the past few years. According to an
editorial writer in the Journal of the Ameri-
can Medical Association, "The English in-
vestigators consequently regard lethargic
encephalitis as due to an as yet unknown
virus which causes inflammatory changes,
especially perivascular infiltrations, in the
' See letter, page 175.
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114
March, 1919
EDITORIAL COMMENT
American Msdicins
basal ganglions, the upper part of the pons,
especially in the gray matter of the floor of
the fourth ventricle, and in less degree else-
where in the medulla. It is distinctly a poli-
encephalitic disease ; the outstanding clinical
features are a more or less pronounced
lethargy, often progressive, and paralysis of
the third and less often other cranial nerves
ensues. Ophthalmoplegia was observed in
about 75 per cent, of the English cases."
Stress has been placed upon the similarity
of the cerebral and bulbar forms of epidemic
poliomyelitis, but thus far data are lacking
to prove the identity of the two diseases.
Intra-cerebral inoculation of monkeys has
failed to produce the lethargic encephalitis,
despite the fact that the anatomico-path-
ologic evidences are most similar.
Is Lethargic Encephalitis Due to
Influenza? — ^The question promptly arises
as to whether lethargic encephalitis
is directly related to influenza, in
the wake of which the epidemics have
occurred, or whether it constitutes a
definitely new pathologic entity. It is
unfortunate that the term "sleeping
sickness" has been popularly applied to this
new manifestation of the epidemic, because
of the possible confusion it may cause in
the minds of non-medical persons as its
real origin. The fact that somnolent con-
ditions arise and ophthalmoplegia is a com-
mon concomitant, and that these two states
have been previously reported in connection
with earlier epidemics of influenza are
strongly suggestive of the probability, that
lethargic encephalitis is not to be regarded
as a new disease. At the present time, how-
ever, evidence is inadequate to permit the
formulation of a definite opinion. The ap-
pearance of this symptom-complex de-
mands most careful investigation, chemical,
bacteriologic, cytologic and pathologic in
order to determine its real place in the
category of disease states. The variations
in the mortality are marked, but no more
so than occurs in other poliencephalitic
conditions.
It is to be hoped that further investigation
will demonstrate that this unfortunate con-
dition bears some relation to influenza, and
is not to be dignified by a place among ac-
tual diseases referable to a new, tho un-
known cause.
Birth Omtrol Opinions.— The subject
of birth control continues to create interest
and discussion. A symposium on the sub-
ject, appearing in the Medical Review of
Reviews, March, 1919, contains a number
of expressions of opinions and beliefs of
physicians. The subject matter expressed in
the numerous letters resulting from a ques-
tionnaire, offers nothing that is new in the
way of argument either for or against the
subject.
The most significant contribution of the
symposium is secondary in nature and in-
cidental in origin. While answers were re-
ceived from 47 physicians, four did not
wish to express any opinion ; two were too
busy to give it attention; twelve had not
given the subject sufficient study to war-
rant the expression of an opinion ; two had
gone to war ; and three thought the matter
should not be discussed in war time. These
facts are enlightening, particularly as 25
per cent, of the replies stated that the writ-
ers had not given the subject sufficient study
to warrant the expression of an opinion. It
scarcely seems possible that physicians con-
stantly facing the facts of life, understand-
ing well the difficulties in family relations,
developments and adjustments, should es-
cape the impress of social conditions and
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Amxrican Msdicins
EDITORIAL COMliENT
March^ 1919
115
therefore feel incompetent to express an
opinion.
It were far better, from the standpoint
of judgment, to possess opinions contrary
to current trends, traditional beliefs, to be
ultraconservative or ultraradical, than to
evidence lack of interest in the phenomena
of life constantly presenting themselves to
medical men. It is almost unbelievable that
such a large proportion of physicians should
admit a lack of knowledge upon a subject
concerning which they might be and are
consulted by members of the laity. It is un-
doubtedly more rational to think wrong
than not to think at all.
The questions which were submitted were
as follows :
"1. Do you believe in the doctrine of birth
control, or are you unequivocally opposed to it?
2. Do you believe the laws against the dis-
semination of information regarding contra-
ceptive methods are equitable and just, or is
it your belief that these laws are harmful and
should be repealed?
3. Do you think that birth control has any
connection with the economic situation, or is
it an ethical issue exclusively?
4. Do you think the widespread knowledge
of birth control would result in an increase of
immorality by permitting sexual indulgence
without the responsibility of parenthood; or do
you think it would tend to decrease immorality
by enabling young men to marry without the
immediate fear of having to support a family?"
Physicians, representing an educated seg-
ment of humanity, should possess some
ideas, theories, beliefs, opinions or judgment .
upon every one of these simple, direct, frank
queries. If the medical men desire to main-
tain their cherished reputation along edu-
cational, medical and humanitarian lines they
cannot escape the necessity of thinking. To
avoid being on the wrong side of a question,
hesitancy of expression is useful. To dodge
an issue by wilful silence is cowardice. To
agree with the demands of a majority is no
more evidence of good faith than an honest
conviction as to the correctness of the views
or ideas of a minority.
Neutrality in thinking processes testifies to
indecision, lack of interest, or mental hebe-
tude. Acknowledgment of ignorance may
be an honest confession but when tinctured
with a sense of fear of being registered is
a weak evasion. Where do physicians stand
on the subject of birth control? What does
the physician think concerning birth release ?
Are doctors unwilling to give their opinions
to the public? Apparently a regrettably
large percentage of the profession requires
time to think, or the courage to think out
loud, and birth control is merely a type of
topic that shows one weakness that demands
a remedy.
Public Health Adbninistratioiu— The
developments in public health administra-
tion have been rapid. The critical days thru
which we have passed and are passing have
taxed the ingenuity of administrators and
opened vast vistas in the realm of public
service. The institutions of war created new
problems requiring many alterations in
methods and management. The protection
of civilian health has made continuous de-
mands, many of which require adaptations
in administration, particularly in the face
of severe epidemics of respiratory afflictions.
The training and experience requisite for
public health service of a high order have
not been fostered to any great extent thru the
existent educational machinery, despite the
fact that courses leading to a doctorate in
public health exist in at least five of our
largest medical institutions. The impetus of
the times has forced men into varying
spheres of activity for which adequate prep-
arations had not been offered. Among the
leaders in public health work, the trials have
been severe, but for the rank and file, the
obstacles have been overwhelming. The gen-
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March^ 1919
EDITORIAIi COMMENT
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eral field of public health administration
has broadened, and the progress which has
been made thru the acceptance of new ideas
and the expansion of higher ideals has not
been reflected in the accomplishments of
public health work thruout the coimtry.
While this may be a criticism of public
health work, it is not condemnatory in spirit,
but merely a recognition of the rapidity
of growth of the public health movement
and the slowness with which methods per-
meate to the general health administrators
in all sections of the country.
The improvement of the welfare of the
nation is dependent in part upon the general
improvement of civic health. In order to
achieve the utmost for the familial, economic
and social interests of each community,
it is imperative that public health leadership
be extended thruout the land. Intensive
courses have been provided in various fields
of work under the auspices of the govern-
ment in order to meet the needs growing
out of the transformations demanded by
the military activity of the country and the
consequent alterations in the industrial and
social world. These intensive courses have
proven their worth, and the lessons they
have taught merit inculcation and imitation
along many lines. For this reason, a word
of congratulation is merited at the institu-
tion of a course in public health administra-
tion that is to be given in New York City
under the auspices of the Training School
for Public Health Service of the New York
Bureau of Municipal Research, in coopera-
tion with the Public Health Committee of
the New York Academy of Medicine. The
projected course involves three and one-half
weeks devoted to daily conferences, with
two. weeks spent in field study of public
health agencies and institutions^ in New
York City.
The ssmopsis of the conference progmm
involves three parts : "Part I — Introductory,
covering public health progress in the Uni-
ted States and the relation of federal,. state,
municipal and private health agencies to the
health movement. Part II — The organiza-
tion of a health department and the legal
and financial aspects of health administra-
tion. Part III — The administration of
special health services, covering the follow-
ing subjects : Vital statistics, communicable
diseases, contagious disease hospitals, tu-
berculosis, venereal diseases, industrial
hygiene, mental hygiene, hospitals and dis-
pensaries, child hygiene, medical inspection
of schools, public health nursing, public
health education, rural hygiene, maritime
quarantine, food and drugs, general sanita-
tion, the public health laboratory."
The list of conference leaders and speak-
ers is excellent, and contains the names of
recognized leaders in the public health field,
drawn from various parts of the United
States, from municipal, state and federal
agencies, as well as those specialists whose
experience in connection with specific prob-
lems makes them the paramount leaders
and teachers.
The status of post-graduate medicine in
the United States is not exceedingly high,
and this movement to oflfer a post-graduate
course in public health administration re-
dounds to the credit of the two organiza-
tions cooperating in its development. There
is every reason to believe that a course of
this character, if attended only by the fifty
persons to be accepted for the course, will
be of marked benefit to the commimities
whose representatives attend. There will be,
furthermore, a marked influence upon the
general level of public health administration
if these fifty persons are intensively pre-
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EDITORIAL COMMENT
Mabch, 1919
117
pared to assume a finer type of leadership
in public health affairs.
The results of post-graduate instruction
along ordinary medical lines benefit the indi-
vidual patients, but gains in knowledge
concerning public health administration in-
fluence the lives and destinies of entire com-
munities. The wholesale administration of
health must necessarily be more effectual
in its end results than what has been termed,
the retail practice of medicine.
The medical profession should support
an opportunity to better prepare itself to
lead in public health and to reach and main-
tain a high plane of efficiency. The fact that
the Public Health Committee of the New
York Academy of Medicine is cooperating
in this project is a source of pleasure and
congratulation. It represents a rational and
significant effort to work along acknowl-
edged lines of effectiveness for the better
education of medical men and for the ad-
vancement of the health of the nation.
Some Selective Service Facts. — ^The
vast number of reports growing out of na-
tional activities during the past two years
affords a valuable opportunity for studying
conditions as they exist and formulating
plans for modifying undesirable states of
affairs. Some reports, such as that of the
provost marshal general, are remarkable
presentations of the modus operandi of
newly established pieces of national ma-
chinery. The operation of the selective
service system was remarkably successful,
and the submission of the report by the
Provost Marshal General E. H. Crowder
effectively details, with much human under-
standing, the numerous problems involved
in registration, the process of selection and
the principles of classification, with their
results.
Some of the most valuable informative
material is, as usual, hidden in an appendix,
replete with statistical tables. Cc«iscription
during the Civil War period afforded little
opportunity to judge of the real health
status of the citizen soldiers because less
than two per cent, of the total fighting
forces raised by the Union was secured by
this means. The recent selective service
registration, involving 24.234,021 men, gave
an ample opportunity to secure a general
view of the physical condition of a larger
number of men than had been previously
possible. It is, therefore, interesting to note
variations in health conditions which really
were causative of physical rejections.
Of one hundred thousand men examined
in urban regions, the rejections amounted
to 21.68 per cent, while of a similar num-
ber examined in rural regions, the rejections*
were only 16.89 per cent. This, in a meas-
ure, would point to a superior physical con-
dition of men dwelling tmder rural con-
ditions, a fact thoroly in consonance with
our previous opinions upon the relative ad-
vantages of rural and urban life.
Considerable significance attaches to a
consideration of the causes for physical
rejections in the rural and urban districts.
Numerous reasons may be given for the
variations noted, tho a very close analysis
is requisite to determine upon the actual
underlying factors determinative of a pre-
ponderance of one t)rpe of defect in urban
districts or in rural districts. Taking the
facts as revealed in the statistical tables, it
is significant that the following disqualifying
defects caused higher percentages of re-
jections in urban districts than in rural dis-
tricts: Alcohol and drugs, developmental
mental defects, defects of the ears and
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EDITORIAL COMMBNT
AlCBRICAN MSDICINB
eyes, flat foot, and hernias. On the other
hand, the disqualifying defects most respon-
sible for physical rejections in rural districts
include defects of the bones and joints, of
the digestive system, non-venereal genito-
urinary diseases, diseases of the heart and
blood vessels, mental deficiency, non-tuber-
culous respiratory diseases, defects of the
skin, teeth and thyroid gland. It is inter-
esting to note that venereal genitourinary
diseases had very little variation in the two
districts under consideration, while nervous
and mental disorders, respiratory and non-
respiratory tuberculosis, similarly showed
very slight differences.
The cKflFerentiatioii of dUqiwlifsring de-
fects becomes more suggestive when one
notes that alcohol and drugs caused three
times as large a percentage of disqualifica-
tion in . urban as in rural districts, while
mental deficiency was twice as great per-
centally as the cause of rejection in urban
districts as compared with the rural sections.
The increase of defects of the eyes and ears,
the presence of flat feet and hernia are
readily interpreted in terms of conditions
of urban life, while defects of the teeth and
skin, bones and joints are not difficult to
understand when considered in relation to
the difficulties of adequate and immediate
surgical care after accidents. It is astonish-
ing, however, to find that respiratory tu-
berculosis constituted only 5.6 per cent, of
the rejection in urban areas as opposed to
5.3 per cent, in rural districts. The states
whose rural and urban districts were com-
pared include Maryland, Massachusetts,
Illinois, Ohio, New York, Pennsylvania and
Missouri.
Another fact of more than passing
interest is that while the number of
whites examined was five to one of the
blacks, only 69.71 per cent, of the whites
were put into Group A as opposed with
74.6 per cent, of the blacks who were placed
in Group A. Offhand, it would appear that
the physical condition of the whites was in-
ferior to that of the blacks. It is possible,
however, that the relation of rural to urban
conditions may account in part for the
seeming large diflFerence in A-fitness be-
tween the two types of men.
A thoro analysis of the physical rejections
at camps by local boards and by camp sur-
geons indicates that the local boards made
only one-tenth per cent, of rejections be-
cause of drugs and alcohol, while camp
surgeons made 0.72 per cent, of their re-
jections for the same reason. Similarly, the
study reveals a higher percentage of rejec-
tions for hernia by camp surgeons (10.67
per cent.) than were rejected by the local
boards, 3.3 per cent. Despite these and vari-
ous other differences in judgment which are
evident from the statistical report of the
sifting process, which varied indeed, in
various parts of the country, in different
camps in separate states, and even within
the zones of influence of specific local
boards, there is abundant evidence that the
administration of the selective service sys-
tem on the part of the medical profession
was well done. It was by no means a simple
matter to secure, without draft, a large
number of examining physicians, to train
them in part to an understanding of the
rules and regulations of the provost marshal
general, which varied from time to time in
the establishment of physical standards of
qualification.
The report bears witness to a deep sense
of appreciation of the collective efforts,
in which the medical profession played no
small part, upon which the successful opera-
tion of the selective service system de-
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BDITORIAL. COMMENT
MabgHj 1919
119
pended. When all statistical material is avail-
able, it is to be hoped that part of the re-
ward of the profession will be a series of
special studies of the statistical material
that has been accumulated with a view to
aiding the medical profession in advancing
the status of modem medicine.
Reasonable Medical liutrudioiu.— The
provision of workmen's compensation was
based upon the theory that industry should
pay for the accidents arising therefrom, and
the individual workman should not be penal-
ized or his family suffer because of cir-
cumstances for which he is not completely
responsible. It should be obvious that an
injured workman who claims compensation
because of his status as a productive unit
of society "owes a reciprocal duty to make
the most advantageous use of the provision
afforded him."
Bulletin of the United States Bureau of
Labor Statistics, No. 243, calls attention to
some decisions relating to medical treatment
which indicate that injured workmen should
comply with reasonable medical instructions
if they desire the continuation of compensa-
tion payments. The Supreme Court of
Illinois has held that it is unreasonable for
an employee to refuse to undergo an opera-
tion for the removal of a cataract caused
by accidental injury, and has authorized
the withholding of an award while such re-
fusal continued, it being held that the "loss
of sight was probably due to such refusal
and not to the accident." Similarly, the
Industrial Accident Board of Massachu-
setts ordered the discontinuance of com-
pensation payments until a woman who had
lost a hand "should agree to undertake to
wear and accustom herself to the use of an
artificial hand furnished by the employer."
The use of the artificial hand, it was be-
lieved, would enable her to earn wages and
thus reduce the amount of compensation
necessary.
A number of the state laws direct com-
pliance with reasonable medical directions
of this character. Inasmuch as a number of
the provisions of the compensation laws are
designed to restore injured workmen as
rapidly as possible to their maximum state
of capability, it becomes necessary to es-
tablish reasonable mandates for securing
compliance with the procedures deemed
necessary for the fullest restoration to po-
tential usefulness. If advice and instruction
be given and accepted and untoward results
unfortunately should follow, the final state
of disability resultant from carrying out the
provisions of the law would then be open
for a question of compensation for the
permanently existent disability or handicap.
It is difficult to determine with definite-
ness the end results of operative procedures,
tho prognoses may be given with reasonable
assurance. The responsibility of advising
injured employees naturally rests upon the
medical examiners. Pressure or coercion by
employers plays no part in determining the
functional handicap, or the method for se-
curing its palliation or elimination. The
medical examiner is, in a sense, a disinter-
ested witness, whose advice is offered not
merely for the benefit of the injured em-
ployee or the employer, but really in the in-
terests of the state which has enacted the
compensation law for the greater protection
of its social and economic welfare. The
principle, therefore, of compliance with rea-
sonable medical instructions dignifies the
authority of the medical examiner, and in-
creases his obligation and responsibility for
recognizing the operative necessities in
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EDITORIAL COMMENT
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specific types of injury and the actual bene-
fits to be derived therefrom. The question
of compensation as such does not concern
the medical examiners ; that is a matter for
the decision of commissions duly author-
ized. Their major interest lies not merely
in the injury incurred, but in the physical
fitness of the person injured. From the
medical standpoint, the compensation laws
throw out two challenging questions: How
nearly whole can the injured workman be
made? How quickly can he safely return
to occupation after having been restored to
the maximum power?
For this reason, industrial surgeons are
coming to possess certain powers and stand-
ing which grow out of the responsibility of
the employer to supply adequate medical
care. This runs counter to a definite tend-
ency to allow the injured workman a meas-
ure of freedom in the selection of his own
physician. The personal relations, and the
feeling of confidence in the physician of
personal choice are of the utmost value, but
do not necessarily suffice to insure the most
successful end results from the standpoint
of industrial efficiency. This is a matter,
however, which, in many laws, lies within
the power of the employer, who may grant
the right to the workman to select his own
medical attendant within provisions laid
down by the law. The question as to which
physician is in attendance is subordinate to
the question of the capability of the medical
attendant and his conception of his duty to
the state. Compensation laws are not per-
sonal in their application, but must be con-
sidered in their complete relation to the
welfare of the state.
Fighting Venereal Plagues. — One of
the most pronounced post bellum benefits
to the nation arises from the increased
general interest in the venereal diseases.
The numerous activities organized and ex-
tended during the war for the purpose of
protecting the welfare of military and
naval forces within the confines of America
and overseas represent a marked advance
in anti-venereal disease campaigning. Un-
der the stress of pressure exercised from
Washington, largely thru the medium of
the Commission on Training Camp Ac-
tivities and the offices of the respective sur-
geons general, legislative action was taken
by numerous states; and a large number
of local ordinances were established with
a view to decreasing the venereal peril.
Publicity, the regulation of extra canton-
ment zones, the establishment of venereal
clinics, and legislation have resulted in
crystallizing a sluggish public opinion into
an active opposition to the diseases and
their underlying causes. Combative opin-
ions are organized into activities required
for anti-venereal disease campaigns.
The summary of conditions as they ex-
ist today as tabulated in Public Health Re-
ports, February 7, 1919, indicates that in
13 states a bureau or division of venereal
disease has been established by their depart-
ments of health. The more significant
legislation, however, is that which involves
the reporting of those afflicted with gonor-
rhea and syphilis or other venereal disease.
Six states, namely, Colorado, Indiana,Mary-
land. New Jersey, Ohio and Vermont now
demand the reporting of patients by name,
while 39 states call for the regular report-
ing of the venereal diseased by number,
altho 27 of these call for the giving of the
name upon failure to comply with certain
definite conditions laid down in the law. In
34 states, quarantine is required by law,
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EDITORIAL COMMENT
Mabch, 1919
121
altho in all probability the practical observa-
tion of these regulations is limited by lack
of adequate facilities to comply with them.
In the instances where serial numbering
is the first step, the reporting by name is
contingent upon the discontinuance by the
patient of treatment prior to reaching the
non-infectious stage, or laxity on the part
of the patient whereby he wilfully or care-
lessly fails to observe the precautions
deemed necessary to prevent the spread of
infection to other persons. This form of
cooperation to prevent the exposure of
names appears to possess a certain measure
of potential force, greater than that in-
volved in the mere reporting by name. The
establishment of quarantine regulations is
obviously a supplemental factor in guar-
anteeing the community a certain measure
of safety against those lacking the home
facilities to enable them to have a fit and
proper hygienic environment and treatment
during the period of greatest infection.
The development of efforts to protect
the community from the black plagues is
similarly reflected in the t3T)e of literature
now being issued thru the bulletins of the
various State Health Departments. From a
certain uniformity in publicity it is patent
that the new work being carried on under
the general direction of the division of
venereal diseases of the United States Pub-
lic Health Service is bearing fruit. Even the
prudish press has felt called upon to dis-
regard its traditions and to publish, with
various degrees of expurgation, bulletins
undoubtedly emanating from Federal
sources. For the first time, the entire coun-
try appears to be ready to accept pronounce-
ments from authoritative sources concern-
ing the dangers from venereal diseases and
their absolute and relative leading impor-
tance as a factor in racial deterioration and
as a cause for physical disability and eco-
nomic incapacity.
MecEcal cooperation is still the great
need of the hour. The attitude of the
medical profession towards venereal dis-
eases as related to public health has been
indefensible. The individual patient has
been regarded as a sick individual, altho too
frequently, without a feeling of responsi-
bility that he is also a public health menace.
There has been, in many ways, a lack of un-
derstanding of the importance of construct-
ive educational measures in lessening the
evils in particular communities. Dwelling
upon the pathologic aspects of the venereal
diseases is insufficient. There must be a
definite, constructive program from the
standpoint of public treatment and preven-
tion. The demand by educators at the pres-
ent time for the introduction of courses in
sex education in secondary schools is in-
dicative of an altered sentiment on the part
of teachers, the leaders of whom apparently
are now willing to assume their obligations
towards the growing generation. A sec-
ondary school teaching, however, will not
suffice to meet the problem. There is a vast
amount of educational work requisite dur-
ing the elementary school period which
problem can best be conducted thru the
medium of home education. The average
parent is notably lacking in knowledge of
the content or the methods of imparting the
essential facts necessary to protect growing
children from the dangers arising from an
uncontrolled environment and from the
gross and inaccurately alleged facts which
are spread thru the medium of loose tongues
and prurient literature. In order to secure
effectual modification of present methods of
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MEN AND THINGS
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home education, the medical profession
must realize its duties and obligations to
the growing generation.
The mental attitude of the old type fam-
ily physician must carry on with an ad-
vanced idea as to the necessity of aiding
parents in handling sex problems. The
physician as an educator is not a new role
in practice, altho in this special field his
efforts have been sadly lacking. The public
health program for combating venereal
diseases takes notice of the part the hom^
must play in the problem, but its achieve-
ments will be limited unless there is the
fullest support of the medical profession.
Education should precede legislation. Un-
fortunately, the exigencies of martial con-
ditions require some degree of reversal of
this process, altho the degree of education
afforded the moral elements of the com-
munity was greater than any previously
made possible thru the efforts of those in-
terested in public health.
The present campaign is not following
moral lines directly, altho ethical values are
by no means forgotten in the attempt to
achieve the acceptance of a rational program
in attacking the venereal diseases. The legis-
lative enactments thus far have been prac-
tically uniform along lines designed to con-
trol the physical phases of venery, because,
after all, in these lie the greatest danger to
public health, namely, contagion. The moral
phases will be left as a supplemental part
of the program, tho of by no means inferior
importance. The press, the' pulpit, the med-
ical profession, the philanthropist, the pub-
lic health officer, the eugenist, the reform-
er, and the intelligent citizen must unite in
order to effectively conquer the venereal
peril and protect the growing generation,
and those that are to come.
MEN AND
THINGS
Birth Omtrol and Birth Prevention.—
Dr. Hilda Noyes, an authority on eugenics
and the care of babies, is an advocate of
birth control. Needless to say, she is thoro-
ly well informed about the methods of con-
traception. In view of this, the critic of birth
control (even the friendly critic perhaps)
would be freely disposed to judge that Dr.
Noyes, informed as she is and aware of the
grave responsibility of motherhood, might
be the mother of one child, possibly of two
children at most. The fact is that she is the
mother of six splendid children. This inter-
esting instance of the philosophy of birth
control and its effect on the family is here
mentioned not in approval of the doctrines
of birth control, but in disapproval of a
misunderstanding of the movement which is
almost universal. It has always been the
policy of American Medicine (as it is the
policy of every just critic) to examine both
sides of the shield before committing itself
to a final judgment, and we have adhered
to this policy in the faith that the majority
of the profession are of our own mind,
which is, we trust, not an unduly prejudiced
one. In printing Mrs. Sanger's article in this
issue, American Medicine feels that it is
fulfilling its obligation to its readers; and
in recording its own impressions here it is
fulfilling its obligation to itself.
In two important respects the birth con-
trol movement is very much misunderstood.
In the popular mind it has come to signify
but one thing, birth prevention — an in-
complete and erroneous impression. It also
is charged with advocating the small fam-
ily, distinctly an undisceming judgment.
The emphasis of the philosophy of birth
control is clearly indicated in its name; it
is toward control. Prevention is but one
of the methods of control found ex-
pedient in some cases, but it is by
no means the only solution recom-
mended. There are two ways of avoiding a
train wreck when there is a dangerous ob-
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MEN AND THINGS
March^ 191d
123
stacle on the track: one is to stop the
train, the other to clear the track; and
of the two the latter is distinctly the method
to be preferred. The advocates of birth con-
trol lean toward this method, and their
efforts to clear the family track of eco-
nomic, social and health obstacles are too
often not sufficiently recognized. Hence the
popular misapprehension that they encour-
age small families. The truth is that they
encourage small families where large ones
would seem detrimental to society, but they
advocate with just as great insistence large
families where small ones are an injustice
to society. They frown upon the ignorant
poor whose numerous children, brought
into the world often under the most unfa-
vorable circumstances, are a burden to
themselves, a menace to the health of the
not infrequently unwilling mother, and an
obstacle to social progress. But they frown
with equal disapproval on the well-to-do,
cultured parents who can offer their chil-
dren all the advantages of the best care and
education and who nevertheless selfishly
withhold these benefits from society. More
children from the fit, less from the unfit —
that is the chief issue in birth control. The
emphasis is on "control" rather than on
"prevention." Seen from this point of view,
the movement certainly assumes a different
aspect. Its intention 'is not hostile to the
family but rather favorable to it, so that,
if there is anything to criticize in the issue,
it IS not the motive but the program alone
which IS open to attack.
Want^: A Program. — In one respect
certainly the advocates of birth control have
a clear advantage over its opponents — the
advantage that President Wilson and the
friends of the League of Nations have over
its opponents. Despite their voluble and
heated protests, Senators Lodge, Borah and
others have been very slow to suggest a
substitute for the League which will be ac-
ceptable to a war- weary world. The op-
ponents of birth control, tho they have been
emphatic enough in their criticism (some
of it, it may be admitted, quite just and
convincing) have nevertheless failed to
Come forward with a program of their own.
That a program is necessary, that some
form of decision or legislation is advisable,
it would be rash to deny. Take, at random,
a case reported by a nurse in the poorer dis-
tricts of New York City: "One of my
mothers has been the victim of fifteen preg-
nancies. She now has five living children;
one of them is permanently deaf from an
old case of otitis. Another has had a foul
discharge from the ear for nearly two years.
Only an operation can cure this ; the parents
refuse to have it done. Two of the other
children have rachitic deformities. Of the
fifteen pregnancies, one resulted in a mis-
carriage. Nine children died during infancy,
death being due to ignorance and neglect.
All who lived thru the first year were more
or less enfeebled by being kept at the breast
long after the milk had lost its value as
nourishment. This one thing is, I believe,
the greatest wrong done to babies among
the poorer classes. The women hope in this
way to escape pregnancy — an erroneous
method of birth control. This explains the
reason for the great number of children
who are afflicted with bow legs, knock-
knees and the various deformities resulting
from the lack of proper bone-making ma-
terials." This Odyssey of motherhood
among the ignorant poor is as typical and
disheartening a picture as one can imagine.
Pathetic in the extreme is the dumb, ignor-
ant effort at prevention which was perhaps
the direct clause of the death in infancy of
nine of the children and the deformity of
the surviving ones. And this case is by no
means exceptional. Any frank practitioner
familiar with family history in the poorer
quarters will readily admit that it is rather
the rule, and will be able to cite instances
that are even more distressing. Who can
deny that such a situation is dangerous in
the extreme to both society and the family ?
Society and the family are the concern of
both sides of the dispute. In her article.
Mrs. Sanger frankly owns that she does
not "question the intent nor the high pur-
poses of these physicians (who oppose birth
control), or that they are working for the
improvement of the race." Knowing Mrs.
Sanger's sincerity, one may unhesitatingly
return the compliment and credit her with
the highest motives. In this respect, both
sides are beyond impeachment in the
genuineness of their interest in the good of
the race. However, the strength of Mrs.
Sanger's case lies in the fact that she has
a definite progpram, while the weakness of
her opponents lies in the fact that they have
none. They still approach the problem as
tho it were a question whether or not we
should have birth control. The fact is that.
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MBN AND THINGS
AMIBICA.N MSDICINX
in nine families put of ten at least, we have
birth control — ignorant, unenlightened, dan-
gerous birth control. The case quoted and
the innumerable instances that come imme-
diately to the mind of the practitioner are
evidence of this. The question, then, is
whether we are to have intelligent birth
control, directed toward the improvement
of the family and the uplift of society; or
unintelligent, dangerous birth control as at
present practiced, endangering, often break-
ing, the health of the mother, imposing a
burden on the family and on society of
which both should be relieved, and clutter-
ing the highway of progress with cripples,
imbeciles and mendicants who are the by-
product of a stolid attitude of laissez faire
or let well enough alone. To brand birth
control, as so many of its opponents do, as
the philosophy of the licentious, is to ignore
its value as a scientific contribution to the
study of race improvement. It must be
frankly admitted that the knowledge of
birth control, placed in the hands of the
public, is a dangerous weapon; but all the
tools of civilization are edged tools. Many
excellent men, of high standing in their
profession, are bitterly opposed to birth
control ; but it is regrettable that they have
preferred, up to the present, to state their
objections in emotional rather than in scien-
tific terms. They have submitted no pro-
gram. Dr. Harvey W. Wiley, an opponent
of birth control, asserted recently that every
educated, well-to-do family should be obliged
by law to contribute a minimum of four
children. That is the nearest approach to a
definite program he saw fit to venture upon,
but there is little in it that the most ardent
advocate of control would object to. Are
the opponents of birth control content to
have it said of them that their strength
lies merely and only in the fact that they
have the approval of precedent and age-old
sentiment on their side ?
There is an amusing aspect to Dr. Wiley's
suggestion which tempts comment. Opposed
to control tho he is, he reveals himself in-
advertently and innocently as an advocate
of that philosophy. A well-to-do and edu-
cated couple, left to the natural course of
nature, would contribute a dozen or more
children to the well-being of society. To
limit themselves to four offspring implies
the employment of the very birth control
methods to which Dr. Wiley is so warmly
opposed.
The High Cost of Winning. — ^Norman
Angell's book, "The Great Illusion," startl d
the thinking world on its appearance some
years ago with the revolutionary theory, ad-
mirably sustained and logically demon-
strated, that the victor loses as much by
war as the vanquished. Mr. Angell brought
so many facts to bear in proving his case,
facts that were for the most part undeniable,
that he won many converts to his way of
thinking. Unfortunately, however, he did
not convince the world and the great war
came despite his revelation of the cost of
war even to the winner. The Allies have
won, but the triumph of the Allies is threat-
ening to prove a triumph at the same time
for Mr. Angell — ^a demonstration of his as-
sertion that the victor is always the loser —
for the Allies are well on the way toward
losing all they had hoped to gain by the de-
feat of Germany. It is an unhappy
fact that victpry has a tendency in
any country to restore to power and
confidence all the reactionary elements.
During the war these elements were obliged
to withdraw to the obscurity they deserved
and gave way to an idealism, a hopefulness
and a forward-looking tendency toward
reform which promised great things for the
future. This idealism was t)rpified by the
United States. America entered the war un-
der no suspicion- ot pursuing selfish ends.
We had nothing to gain in money or ter-
ritory and we expected nothing. All that
was asked was that the old order of things,
the pernicious system of "balance of power"
which was an invitation to war, should come
to an end,. that heavy armaments cease, that
secret and selfish scheming among the na-
tions be forever terminated, that the peoples
of the earth be forever guaranteed against
the hideous mistakes of the past. This ideal-
ism won an immediate response every-
where. America was recognized as the
moral leader of the Allies, and the people
of Europe flocked to the standard that was
to be the emblem of the new order. It was
this element of idealism alone which made
it possible for the discouraged elements in
all Allied countries to continue a war
which had come to pall on them. It won the
War.
But the idealism which was bom in the
dark days of seeming defeat vanished in
the hour of victory. The reactionary forces
came into their own again, and the people,
lulled for the moment into security and too
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125
happy in their triumph to quarrel, allowed
the reactionaries to speak for them. Italy
boldly and stubbornly reverted to her old
territorial claims, contrary to her acceptance
of the Wilson propositions. Reactionary
elements in France spoke up for excessive
claims that would only mean another war
in the near future. Wilson alone, mindful
of his obligation to the masses of the world,
remembering the idealism to which this
country and the Allies had pledged them-
selves, held out stanchly for sacrifice on all
sides in order to bring about the new order.
And, despite much opposition, he persuaded
the Allied delegates to accept a program for
a league of nations. They did this unwill-
ingly, r^retfully even, but they did it be-
cause they were wise enough to understand
that behind President Wilson's insistence
was the silent backing of the masses of
every country, and that their refusal would
bring down on their heads the bitter con-
demnation of these masses;
The President's Critics^— But the re-
actionaries in this country were more out-
spoken and bolder than those in Europe.
Being politicians, they forgot the promises
made during the war, just as every good
politician forgets the promises he made be-
fore election. President Wilson came home
from Paris only to find himself exposed to
the bitterest campaign to which an executive
has had to submit in many years. The pro-
gram of his league of nations was ripped to
shreds by the critics. It was faulty, it was
dangerous, it was foolhardy, they cried. And
perhaps they are right. That the league pro-
gram is imperfect no one will hesitate to
deny. It would be rash to claim perfection
for it, but the President had a right to ex-
pect that those who did not agree with him
would at least offer him friendly criticism,
helpful cooperation, that they would support
him in his fight against the reactionary ele-
ments in Europe and his efforts to give the
world the thing it had fought for and was
expecting. This friendly criticism, this help-
ful cooperation he did not get. Instead, he
was met with bitter and violent opposition.
And the result was that President Wilson
returned to Europe only to find that the re-
actionary elements, encouraged by the op-
position shown in America, had made bold
to revert to their frank wish for conquests,
regarding the American chief as no longer
a factor of any great consequence. The
Paris Conference began to take on the ear-
marks of the Congress of Vienna, and
President Wilson had to begin his labors
anew, under less favorable circumstances.
Whoever has his finger on the pulse of the
masses cannot but insist that the course so
many political leaders in this country have
chosen is fraught with great danger. The
masses in the Allied countries are for the
moment silent. They are still too dazed with
victory to be articulate ; but, if this war ends
as wars in the past have ended, with a tem-
porary peace that sacrifices the security of
the future for the gain of the present, they
will make themselves heard. The tempta-
tions of such a peace are great. The Con-
gress of Vienna submitted to the tempta-
tion. The victors seemed enriched, the van-
quished seemed forever crushed, but the
world knows the sequel. The crushing of
Germany now would seem to assure peace
permanently, but it seems to be forgotten
that the war was fought not only to destroy
Germany but to destroy war; unless some
vigorous effort is made to do away with
war effectively, the war will have been
fought practically in vain. It was for this
that the masses gave their blood. Every-
where they are restive, impatient. In almost
every country in Europe, revolution is
knocking at the door. To deny them what
they have fought for, what they are awaitinr .
for, would be to thrust them into the arms
of revolution. It would place them at the
mercy of the temptation of Bolshevism,
which promises them international brother-
hood, international peace. Europe would
once more go thru a period of revolt and
ruin which it went thru for thirty years
after Napoleon. That is the issue the op-
ponents of a league of nations face. If the
present program is unsatisfactory, let them
suggest a better one. One cannot quarrel
with them because of their assertion that
the progpram as it stands is faulty — it is —
but one may justifiably object to the
grounds on which they attack it. Colonel
George Harvey, a bitter opponent, writes:
"We fought one war of independence. Do
you want to fight another? Do you wish
to resume our ori^nal subject condition as
a British colony ? Do you want our country
to forfeit the independence won by Wash-
ington and the Continental army and again
become in effect a vassal state? If so. all
that you and the majority of your fellow
countrymen have to do is to indorse this in-
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MEN AND THINGS
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famous proposition, which I say to you con-
stitutes nothing less than a betrayal of our
great Republic !" That is the kind of think-
ing which has been relegated to the past.
It bases its force on distrust of England, it
breeds suspicion, jealousy, hatred among
nations, it is the sort of thing that has been
at the bottom of many wars in the past. It
is a compound of infatuated nationalism
and narrow provincialism. Naturally a
league of nations would mean, in a measure,
a surrender of sovereignty, but is that neces-
sarily fatal? New York State is a member
of a league of nations on a smaller scale,
known as the United States of America. In
order to join this league it has had to sur-
render a measure of its sovereignty. Would
any one say that New York State has become
an abject vassal of the nation? Such logic is
unconvincing and faulty in the extreme. The
opponents of the league should come for-
ward with something more substantial than
negative criticism. Such criticism will not
advance the cause of lasting peace a single
step. There is ample occasion for helpful
suggestions, but thus far such suggestions
have not been forthcoming.
The Problem of Divorce.— In 1916, there
were in this country 1,050 marriages in
each 100,000 of population. Of these mar-
riages, 112 had ended or were destined to
end in divorce. That is the testimony of the
figures officially compiled by the Bureau of
Census, which discovers that there are 112
divorces for every 100,000 of population.
In other words, one marriage in every ten
in the year 1916 will terminate in the divorce
courts. In the year 1867, there were only
27 divorces in every 100,000 of population,
hardly one-fourth as many as there are to-
day. This is hardly a surprise to those who
have been studying the divorce situation, but
no doubt the stanch defenders of the noble
institution of marriage will make this an-
other occasion for alarmist agitation for a
tightening of the divorce laws. That the sit-
uation is as serious as these alarmists would
make it appear there is no doubt, but that
the changes and reforms they, recommend
will improve the situation at all is much
more doubtful. It is amazing how little clear
thinking has been done on the divorce prob-
lem. The predominant element has been
emotional rather than logical. In 1914, Sena-
tor Ransdell of Louisiana, alarmed at the
rapid growth of divorce, proposed an
amendment to the Federal Constitution
abolishing absolute divorce with the right
to remarry. In almost every case, this has
been the course advocated by reformers — ^a
rigorous tightening of the divorce laws. But
these earnest but misguided reformers seem
unaware of the patent fact that tightening
the divorce laws will not tighten the mar-
riage bond. If anything, it will strangle it.
Certainly that is not the way out. It would
be just as unwise to urge the abolition of
solitary confinement by putting the jailer
into the solitary cell with the pris-
oner. Such a course would only increase the
prisoner's capacity for mischief and would
no doubt prove very trying to the
jailer. The abolition of divorce would
prove infinitely more dangerous, to both
the individuals involved and to society,
than the present lax laws. It would incline
toward the destruction of the very family
life which such a measure means to keep
alive. Considering the good of the race, it
would be extremely shortsighted.
In part the. alarm of the reformers is due
to the fact that they consider that the in-
crease of divorce is coincident with the in-
crease in corruption or immorality. That this
assumption is unfounded is interestingly
demonstrated by the figures. New York City
is by no means the most innocent metropolis
in the world nor is it particularly dis-
tinguished among the cities of America for
its virtue. Yet New York State shows an
amazingly low number of divorces, despite
the fact that its leading city comprises one-
tenth of its population. This may be due in
part to the fact that divorce can be had in
New York on only one ground, but it has
been shown often enough that evidence of
infidelity is easy enough to supply.
In considering the situation that confronts
society and the menace offered to American
homes, it is apparent that there is need for
more intelligent and earnest thinking on this
problem, for it is inevitable that it will
grow worse rather than better with tlie
passage of time. Now that woman is rapidly
becoming a social entity, now that she has
discovered her individuality and is demand-
ing the right to develop it fully, there may
be two reasons for divorce where there was
only one before. If the reformers mean to
anticipate this development, it would be wise
for them to realize in time that they cannot
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127
bring down a wild duck by calling it bad
names. Likewise, it might be wise for them
to concern themselves a little more with the
task of making marriage more attractive
rather than with that of making divorce
less attractive.
False Economy and Proposed Narcotic
Drug Legislation.^— In recommending
abolition of the Narcotic Drug G>mmission
and the transfer of its duties to the Health
Department, Governor Smith has either
been badly advised, or has failed to give
the proposition the close thought he has so
generally shown in other matters. Un-
doubtedly he was prompted by the laud-
able spirit of economy that has character-
ized so many of his suggestions to the legis-
lature, but economy may be as harmful and
pernicious under some conditions, as it is
beneficial under others. This plan to do
away with the Narcotic Drug Commission
is certainly such an instance of false
economy, when all the facts of the situation
are duly considered.
At the time the Whitney law was passed,
after a most comprehensive study of the
problem of the narcotic drug evil by the
special committee appointed for the pur-
pose. Senator Whitney and everyone inti-
mately connected with the investigation,
would have been quite willing, we under-
stand, to have had the administration of the
law placed under the charge of the State
Health Department. But this was not fa-
vored by the legislature and a special com-
mission was duly provided for. This com-
mission was appointed in due course, and
its personnel is highly gratifying to those
who appreciate the importance of the work
it is expected to do.
The commission has just started its of-
ficial labors, and in January, registration
forms, official order blanks and copies of
the law were sent out to 30,000 physicians,
dentists, druggists and others having any-
thing to do with the sale and use of nar-
cotic drugs.
Now comes the introduction of the Two-
mey bill to abolish the Narcotic Drug Com-
mission, obviously in accordance with the
governor's suggestion.
In stating our earnest belief that passage
of the Twomey bill will be a very grave
mistake, we are not questioning its good
faith, nor the motives prompting it. The
Whitney law has not been given a fair trial.
Based as it is, on as thoro and intelligent
investigation of drug addiction as has ever
been conducted, definite and far reaching
results have been anticipated from this law.
It is complicated to be sure, and has several
points open to controversy. But it rep-
resents an honest, sincere attempt to relieve
in a 'human and broad-minded way, one of
the greatest evils of the day. Justice to
all concerned has been a fundamental con-
sideration thruout the law. Some incon-
venience and annoyance may be caused
medical men and druggists in the practical
operation of the Whitney law, but this has
been made necessary by the depravity of a
few unscrupulous members- of the medical
and drug professions, and after all, cheerful
as well as faithful compliance with the un-
pleasant features of the law should be
looked on as the contribution of honest in-
dividuals to the attempt at correction of a
terrible social menace.
The" Whitney law, even with such faults
as it may have, is certainly the most sensible
and practical attempt to correct the abuse
of narcotic drugs, stop their illicit and
clandestine sale, and to try to restore those
who suffer from drug addiction to health
and lives of usefulness. To interfere with
the operation of the Whitney law now —
a piece of legislation prepared only after
the most careful and painstaking considera-
tion of the problem — will do immeasurable
harm. It is ridiculous to suppose that the
administration of the absolute essential fea-
tures of any effective law to regulate the
sale and use of narcotic drugs can be at-
tended to as efficiently by one man in the
Health Department, possibly with other du-
ties to perform, as it can be by the five
members of the present commission, with
their special interest in the problem of drug
addiction and the knowledge of the evil they
are known to possess. The actual saving in
expense is so comparatively small, that the
proposed change might raise the suspicion
of some ulterior motive, but for the con-
fidence we have in the purposes of Governor
Smith, and the fact that the proposition is
in line with his avowed eflFort to reduce all
State expenses to the minimum.
In all fairness,- however, to those who
gave so much thought and conscientious ef-
fort to the investigation responsible for the
Whitney law, and because we realize, not
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March, 1919
MBN AND THINGS
AmsiCAN Mbdzcinb
only the confusion that will be caused
among honest doctors and druggists who
have prepared themselves to fulfil the pres-
ent law in a spirit of cooperation, but be-
cause we know the joy that will be felt in
the ranks of the crooks who supply the
"underworld" with its "dope," we earnestly
protest against emasculating the Whitney
law by abolishing the Narcotic Drug Com-
mission until it has been given at lealst a
year's fair test.
We sincerely hope our legislators will see
the justice of our plea and kill the Two-
mey bill, since its passage at this time will
not only invalidate the work of those who
have tried so hard to solve the problem of
drug addiction, but will render the situa-
tion more menacing than it has ever been.
The Drug Situatioii.^ — ^According to an
editorial writer in the Survey (Mar. 15,
1919) "the United States Supreme Court
has handed down two decisions which will
have an important bearing on the future ad-
ministration of the Harrison law regulating
the use of narcotic drugs by forbidding any
person to dispose of them to another person
except upon a written order on a form fur-
nished by the commissioner of internal rev-
enue, or upon a physician's prescription. As
the order forms could be obtained only by
dealers, physicians, druggists and the like,
the only way in which anyone could legally
obtain narcotic drugs for personal use was
from a physician or upon his prescription.
While there was some doubt as to the con-
stitutionality of the provision of the act
limiting the persons who could obtain order
forms, this provision has always been en-
forced pending a Supreme Court decision
definitely settling the point. The provision
with regard to physician's prescriptions,
however, has been open to serious question.
Early rulings of the commissioner took the
ground that a physician had no right to pre-
scribe for a d^ug addict except in connection
with treatment for the purpose of curing the
habit, the good faith of such treatment to
be evidenced by progressively reduced
doses. Since there was considerable doubt
as to whether the law really supported this
construction and also as to its constitution-
ality if so construed, and because, further-
more, of the medical opinions referred to be-
low, this ruling was allowed to lapse; and
the practice has grown up among reputable
physicians, with the tacit approval of the
federal officials, of prescribing or dispens-
ing to addicts their customary daily or
weekly supply until such time as it might
be practicable or convenient for the addict
to undergo treatment for a cure.
Now comes the decision of the Supreme
Court, rendered March 3 in the Webb and
Doremus cases by a vote of five to four,
holding not only that the clauses relating to
order forms and r^^lating the dispensing
and prescribing by physicians are constitu-
tional, but holding further that the latter
clause is to be construed in such manner as
to forbid a physician to prescribe for an
addict except as part of a course of treat-
ment for the purpose of curing him. En-
lightened medical opinion holds that drug
addiction, once firmly established, is not a
mere habit or symptom of weakness of will,
but that it is a physical disease. Specialists
holding widely different views, as to the pre-
cise pathology of the condition and as to
the proper technic of treatment, agree that
a confirmed addict physically needs his cus-
tomary dose, and that it is dangerous to his
health, and sometimes to his life, to cut off
his supply without appropriate medical
treatment. Most of the medical authorities
are convinced also that the so-called "grad-
ual reduction" method, unaccompanied by
medical care in an appropriate institution,
is not capable of successful application. The
average addict is earning his own living, if
not supporting a family, and the eflFect of
gradually reducing his dose, while not so
severe as complete withdrawal, is such as
to render him incapable of attending to his
business while the process is going on. Since
the gradual reduction method takes much
more time than any other, the addict as a
rule cannot afford it, and most intelligent
addicts have no faith in it as a satisfactory
cure even where it is practicable to use it.
It was these considerations, coupled with
the fact that there are not sufficient accom-
modations for even a respectable fraction
of the total number of addicts in existing in-
stitutions available for their treatment at any
one time, that were largely followed with-
out delay by public authorities thruout the
country where there is not sufficient equip-
ment already in existence; the result may
be great numbers of acutely suffering men
and women whose customary doses have
been suddenly withdrawn."
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ORIGINAL. ARTICL.BS
March. 1919
129
ORIGINA]^
RTICLES*^^
THE PRESENT STATUS OF THE
CANCER PROBLEM.'
BY
L. DUNCAN BULKLBY, A. M., M. D.,
Senior Physician to the New York Skin and
Cancer Hospital, etc.
Cancer is still a pressing problem, as it
has always been. In spite of millions of
dollars spent or invested in cancer re-
search, countless animal lives sacrificed,
and uncountable hours of patient and unre-
mitting investigation by numberless intelli-
gent and able workers, it is acknowledged
by all that the laboratory has not discovered
the cause of cancer or aided materially in
the solution of the "Cancer Problem;"
It is also well recognized that the strenu-
ous and untiring efforts of innumerable
surgeons, many of them of very great skill,
have not solved the problem of the cure of
the disease; for, according to the yearly
Mortality Tables issued by the United
States tbe death rate of cancer has steadily
risen, with a fearful certainty, almost 30
per cent, since 1900, while that from tuber-
culosis has fcUlen in the same degree, 30
per cent, during the same period, under
careful medical surveillance. Moreover, dur-
ing 1915, when surgical activity was at its
highest, owing to the active propagandism
for early and radical surgical removal, the
'Read before the Middlesex (New Jersey)
County Medical Society, March 19, 1919.
year before, the increase in the death rate
from cancer was over double the average
increase of the five previous years.
It is acknowledged by all that under the
past views as to the local nature of cancer,
and its treatment by excision, the ultimate
mortality of the disease is 90 per cent, of all
those once attacked. Would it not be well,
therefore, to stop and consider whether our
former attitude toward cancer is correct, or
whether there is not a "Real Cancer Prob-
lem" which will give better results? If any
other disease presented such a steady and
alarming increase in its death rate would
we not stop and consider if our treatment
were the best possible? If with the intro-
duction of antitoxin the mortality from
diphtheria had steadily risen until it was
about 90 per cent, of all cases, would we
persist in employing it ? And yet the profes-
sion and the laity go blindly on, with the
idea that surgery offers the only hope of
reaching cancer. The value of the X-ray
and radium may be serviceable in certain
cases to remove actual lesions, but their
value is extremely limited, and can no
more reach the real cause of cancer than
can surgery.
A brief consideration of the present
status of the cancer problem, therefore, may
not be without interest.
While the laboratory has not at all solved
the cancer problem, it has contributed not a
little toward establishing negative facts.
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March. 1919
ORIOINAIi ARTICLBS
Amsbigan Mbdicinb
and also some positive, which lead up to a
more correct understanding of the real
nature of the disease and its prevention and
treatment. The reason why many of the
research studies on cancer have not been
productive of positive results is because
they have proceeded largely along histologic
lines and inoculation experiments on lower
animals, and not enough on clinical grounds
and bio-chemistry.
But all this laboratory and other research
work has established some facts which are
of the utmost value in connection with a
study of the constitutional relations of can-
cer, which may be briefly mentioned. The
best authorities agree that:
1. Cancer is not contagious or infec-
tious, altho certain new growths can be in-
oculated in some animals ; but human cancer
cannot be transplanted on animals, and no
surgeon, nurse or pathologist has been in-
fected.
2. Cancer is not caused by a micro-
organism or parasite, altho many micro-
organisms have been found in cancerous
lesions, but none of them have been estab-
lished as a cause.
3. Cancer is not wholly the result of
traumatism, altho local injury may induce
its localization in some particular region.
4. Cancer is not to any appreciable de-
gree hereditary, altho some tendency in
that direction has been found in certain
strains of mice.
5. Cancer is not due to occupation, al-
tho it is more common in some pursuits
than in others.
6. Cancer is not altogether a disease of
older years, altho its frequency is influ-
enced by advancing age.
7. Cancer does not especially belong to
or affect any particular sex, race, or class
of persons.
8. Cancer is not confined to any location
or section of the earth, but has been ob-
served in all countries and climates.
While laboratory and other research have
yielded mainly negative results, and have
not demonstrated any real cause of cancer,
they have by elimination opened the way
for study along other lines, which are
bright with promise, and confirm views
which have long been briefly expressed by
surgeons and others regarding the constitu-
tional nature of the disease.
Some positive results of research are
therefore encouraging.
1. The local mass, which we call cancer,
represents but a deviation from the normal
life and action of the ordinary cells of the
body.
2. Certain changes have been demon-
strated microscopically in the polarity of
cells about to become cancer-genetic, with
altered relations of the centrosome to the
nucleus, all being influenced by disordered
metabolism.
3. Much in laboratory studies on the
bio-chemistry of cancer has confirmed the
clinical and statistical observations fast ac-
cumulating.
4. The blood in advancing cancer shows
many manifest changes, indicating vital de-
rangement of the organs which form blood,
and which therefore control the nutrition
of cells.
5. The secretions and excretions of the
body in the early and late stages of cancer
have been shown to exhibit departures
from normal which are of importance in its
causation.
6. Cancer tissue has been shown to con-
tain an element which is poisonous to ani-
mals and which probably hastens the lethal
progress of the disease.
7. Diet has been repeatedly shown by
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ORIGINAL. ARTICLES
March^ 1919
131
the laboratory to inhibit the development
of inoculated cancer in mice and rats.
8. As laboratory and other research have
eliminated the local nature of cancer, they
have also established certain medical aspects
of the disease which are of the utmost im-
portance.
Finally clinical and statistical studies have
abundantly confirmed the correctness of
the internal basic cause of cancer.
1. The mortality from tuberculosis has
steadily and greatly diminished under care-
ful medical guidance, while that from can-
cer has increased in almost the same ratio,
without proper medical care.
2. Cancer is almost absent among
aborigines, living simple lives, largely vege-
tarian, but has increased steadily among
them in proportion to their adoption of the
customs and diet of so-called modern civili-
zation.
3. Self-indulgence in eating and drink-
ing, with indolence, has been shown by
many to result in increased cancer mortal-
ity.
4. The increased consumption of meat,
coffee, and alcohol has been shown by sta-
tistics from many countries to be coincident
with increase in cancer mortality.
5. Great nerve strain and shock have
repeatedly been shown to affect the develop-
ment of cancer, and the enormous nerve
strain of modem life seems to be effective,
both thru metabolic derangement and by
direct action on living cells.
6. While it is impossible to explain just
how disordered metabolism induces cancer-
genetic changes in cells, it is no more dif-
ficult to believe that it does so than it is to
understand the intrinsic cause of arterial
degeneration, bone changes, obesity, etc.,
which are recognized as due to metabolic
derangement.
7. The spontaneous disappearance of
cancer, as occasionally reported, shows that
conditions of the system may arise which
are antagonistic to carcinosis.
8. Finally, the complete removal of can-
cerous lesions, in various localities, by most
careful dietary, hygienic and medicinal
measures alone, without surgery. X-ray or
radium, as has been repeatedly reported,
shows that there is a constitutional basic
cause, of which the local lesion, which we
call cancer, is but the product.
What then is the present status of the
cancer problem? Are we to ignore the ac-
cumulating mass of evidence regarding the
constitutional origin of the disease, and
adhere to the pre-conceived idea that a can-
cer mass is an idiopathic, rampant, cell
growth, without definite cause ? Are we to
ignore all new teachings, from ignorance,
or to neglect them, thru negligence?
The present status of the cancer prob-
lem, therefore, resolves itself into this:
The disease must be either of a local or of
a constitutional nature.
Those who hold to the former idea must
show that the cells of the body are capable
of an independent, autogenetic power to
take on and continue a misgrowth of a
virulent and lethal character, irrespective
of the nutritive elements in which they are
bathed — ^and that without any assignable
cause. We have seen that laboratory and
other research have excluded parasitism,
and clinical observation has fully demon-
strated that the disease is not contagious.
Chronic irritation is undoubtedly often the
cause of the disease developing in some par-
ticular locality, but it must be recognized
that any amount of chronic irritation will
not determine the presence of a cancerous
tumor in every individual, and malignant
growths in many internal parts of the body
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cannot have such a cause. Hereditary in-
fluence has been excluded by Life Insur-
ance Statistics and close clinical studies of
intelligent private patients, as has also old
age, as the disease occurs both in the young
and old. The suppositious influence of
"embryonic rests", or pre-natal displace-
ments of epithelial tissue in the production
of cancer "wholly fails to reveal why the
embryonal cells begin to grow and when
growing produce malignant tumors instead
of normal structures," as Ewing says.^
Thus each and every support of a purely
local origin of cancer, and its local treat-
ment, has fallen away, leaving nothing to
stand on, for laboratory and other research
has apparently covered every possible
ground.
It is not necessary here to go fully into
the argument for the constitutional nature
of the disease, the facts regarding which
have often been so fully presented on re-
peated occasions.^ The more one sees pa-
tients with cancer, early or late, in private
practice and studies them most carefully in
all respects, the more convincing is the evi-
dence of the correctness of this view. And
when one sees day by day the changes
which can be produced in them, and the
steady disappearance of cancer masses, with
a continued improvement in general health,
weight and blood condition, under proper
dietary and medicinal treatment, as have
many physicians and surgeons who have
watched cases with me, now for years, the
more the conviction forces itself upon one
that the local lesion, which we call cancer,
is but a local product of faulty metabolism
which has long existed.
The treatment of these cases is by no
' Ewing: Neoplastic Diseases. Saunders, Phil-
adelphia, 1919, p. 97.
'Bulkley: Cancer, Its Cause and Treatment.
Vols. I and II. Hoeber, New York; 1915, 1917.
means an easy task, but requires the most
patient, painstaking and prolonged em-
ployment of every possible line of investiga-
tion and thought, and the broadest applica-
tion of medical acumen and skill in the use
of dietary, hygienic and medicinal meas-
ures to meet the varying conditions which
may arise. With this there must be a firm
conviction which can develop in the patient
a confidence in this mode of treatment over
a long period. I am sorry to say that in re-
gard to this latter I have sometimes failed,
and occasionally when doing well a patient
has slipped away to a surgical operation,
which has been later regretted, when a
recurrence has happened, on the neglect of
the proper treatment. It is understood
that in all our study of cancer reference is
made to true cancer, mainly of deeper
organs, and not to cutaneous epithelioma,
which is really a local affair, often easily re-
moved by various local measures; and yet
many of the arguments for the surgical
treatment of cancer have been based on the
successful treatment of skin lesions, often
with elaborate presentation of screen pic-
tures and patients.
There must, of course, be some beginning
of cancer, in the departure of a normal cell
or cells from a previous habit of homolo-
gous formation of other*cells, to a heterolo-
gous action. As Ewing\says ''carcinoma
does not necessarily spring full fledged into
being, but is to be regarded as a process
which exhibits stages of evolution, which
gather momentum as they progress." But
how this beginning occurs no one has ever
known, and possibly no one ever will know,
as Ribert says "no one has ever seen the
beginnings of mammary cancer."
The present status of the "Cancer Prob-
* Ewing: loc. cit, p. 453.
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lem" is therefore to decide between two
quite opposite positions. First, a hypo-
thetical and problematical view, of a local,
independent, unexplainable, autonomous
decision of certain cells to take on and con-
tinue a destructive course, for which im-
mense research has failed entirely to find
any ground to stand on. Or, second, the
simple and rational belief that a perverted
nutrition, perhaps of long standing, influ-
ences certain cells to depart from their
normal mode of action, and take on an ab-
normal activity, and pursue a malignant
and destructive course, which is naturally
kept up by the continued metabolic disturb-
ance. We accept this latter position in re-
gard to many other diseases, why not in
regard to cancer?
531 Madison Ave.
OPERATIVE IMPROVEMENTS IN
THE TREATMENT OF INFAN-
TILE PARALYSIS.^
BY
LEO MAYER, A. M., M. D.,
New York City.
The title of this address is somewhat
broader than I had intended, since I wish to
confine my remarks^entirely to the subject
of one phase of the operative treatment of
infantile paralysis, namely the transplanta-
tion of tendons.
The idea of this procedure is not new.
As early as 1880 Nicoladoni proposed at-
taching the tendon of the peroneus longus
to the Achilles tendon in cases of paralytic
calcaneus deformity, but his results were
such as to discourage the operation for al-
most a score of years. Since 1900 the
* Address delivered before the N. Y. Physi-
cians' Association, Nov. 27, 1918.
operation has been practiced more and more
frequently. Two methods have been in
vogue: First, that based upon the original
Nicoladoni technic, in which the para-
lyzed tendon is spliced to a strong tendon ;
second, the method of direct implantation
of the substituting tendon into the bone
near the insertion of the paralyzed tendon.
When the substituting tendon was too short
for this purpose, it was lengthened by
strands of silk, a method first devised by
Lange of Munich.
It was in 1912, while working in Lange's
clinic, that my attention was first drawn to
the necessity of improvements m the opera-
tive technic of tendon transplantations.
Lange himself, despite the fact that he had
already performed some 2,000 operations,
realized that there were imperfections in
the method, since his results were all too
frequently nullified by the development of
postoperative adhesions. He suggested an
investigation into the cause of these adhe-
sions and assigned this problem to Dr.
Henze of New Haven and me.
In the course of our experimental investi-
gations, which were conducted chiefly on
rabbits, we utilized all manner of mem-
brane, thin tubes of rolled silver, petrola-
tum, bismuth paste, fascia, peritoneum and
a vein as a means of ensheathing the ten-
don. None of these substances, however,
prevented the development of adhesions ; in
fact, with the exception of the Cargile
membrane, more adhesions were present
after their introduction than in control ex-
periments in which nothing was used.
Finally we followed the suggestion of
Biesalski and utilized the sheath of the
paralyzed tendon as a physiologic pathway
for the transplanted tendon; that is, one
tendon was withdrawn from its sheath, cut
away from the paralyzed muscle, and the
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substituting tendon drawn downward by
means of a guide suture so as to occupy ex-
actly the position of the original tendon. In
all of the cases observed there was complete
absence of adhesions, even when the limb
was immobilized for thirty days subsequent
to the operation.
This clear cut evidence in favor of
Biesalski's method indicated to me the im-
portance of coordinating the operative
technic with the physiology of the struc-
tures involved. Just exactly as the normal
relationship between tendon and sheath
should be maintained, so, too, the fascial
relationship, the tension and the fixation of
the transplanted tendon should be made as
nearly like the normal as possible. When,
however, I tried to follow out this line of
thought, I found that our knowledge of the
physiology and anatomy of tendons was
entirely inadequate for the purpose. No
one had as yet considered the nature of the
gliding mechanism of tendons.. In no book,
physiologic or surgical, had the subject of
tendon tension ever been brought up for
discussion. Despite the thousands of ten-
don operations, some of the simplest facts
relative to their anatomy had never been
investigated. It was necessary, therefore,
before any comprehensive operative technic
could be formulated, that these fundamental
questions be investigated. The work was
conducted by research on the cadaver,
animal experimentation and observations
on human beings.
I can best introduce the subject of the
anatomy of tendons by a series of cross-sec-
tions showing a tendon at various levels
above and within its sheath. The first
(Fig. 1) shows the tendon about 1 inch
above the upper pole of the sheath; note
that between the fascia and the tendon is a
distinct gap not described in the textbooks.
This space is filled with a peculiarly elastic
tissue, consisting essentially of fat cells and
elastic fibers. This tissue completely sur-
rounds the tendon and the lowermost mus-
cle fibers, and by means of its elasticity al-
lows the tendon to glide freely to and fro
Pig. 1. — Cross-section (diagrammatic) thru
the tibialis anticus tendon 1 inch above the
upper pole of the sheath.
beneath the rigid fascia. How great this
elasticity is can be seen by incising the
fascia and lifting the tendon out of its bed.
It will then be seen to stretch from 5 to 7
cm. without rupture of its fibers. It is the
important tissue in the gliding mechanism
Fig. 2. — Cross-section (diagrammatic) thru
the tibialis anticus tendon at the level of the
upper pole of the sheath.
of the tendon, and in every operation on
the tendons its presence must be recognized
and due emphasis laid on conserving its
function.
The next section (Fig. 2) is taken thru
the upper pole of the sheath. The signifi-
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135
cant fact is that the gap representing the
tendon sheath does not develop between the
fascia and the tendon but between the fascia
and this gliding tissue, which I shall hence-
forth term the "paratenon."
In the next section (Fig. 3), which lies
ktenon
Fig. 3. — Cross-section (diagrammatic) thru
the tibialis anticus tendon one-half inch distal
to the section shown in Figure 2.
about half an inch distal to the preceding,
the sheath is seen to be divided into two por-
tions by a transverse band, the tissue of
which is microscopically identical with the
paratenon.
In the fourth cross-section (Fig. 4), about
1J4 inches distal to the preceding, the ten-
Pig. 4. — Cross-section V,^ inches distal to the
section shown in Figure 3.
don sheath is interposed between fascia
and tendon and is seen almost to surround
the latter. A longitudinal section (Fig. 5),
enables us to correlate these four cross-sec-
tions. It is evident that .the paratenon is
prolonged downward into the sheath as a
tongue-like structure. The significance of
this is appreciated only when the muscle
contracts and the tendon moves upward;
then it is seen that a kind of invagination
occurs (Fig. 6). The deep pocket of the
Sections: 1
SUntH
Fig. 5. — ^Longitudinal section (diagrammatic)
of the tibialis anticus tendon, to correlate the
preceding cross-sections. Note that the para-
tenon is prolonged downward into the sheath
as a loose fold — ^the plica.
TAtCIA
Mi;»el.C FOILY COi^TRAtTEO
Fig. 6. — Diagrams representing the changes
occurring in the form of the sheath during the
contraction of the muscle and the consequent
gliding of the tendon. Note that the deep pocket
of the sheath between plica and tendon in-
creases markedly in length, allowing the ten-
don to move upward without rupture of the
sheath wall.
sheath becomes much elongated, thus allow-
ing the tendon to glide, without destroying
the continuity of the sheath wall. The
essential, of course, is the elasticity of the
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paratenon which allows this degree of
stretching.
By means of simple experiments on dogs,
the normal tension of tendons was accu-
rately determined. The method consisted
in the division of the tendon shortly above
its insertion. The tendon ends separated
Fig. 7. — Typical physiologic tendon transplan-
tation— transfer of the tibialis anticus for
paralytic clubfoot. The probe passing thru the
{Sheath of the extensor longus digitorum emerges
at the insertion of the peroneus tertius and
serves to draw the tibialis tendon downward
thru the sheath of the paralyzed evertors. A,
retracted fascia; B to D, probe passing thru
sheath of extensor longus digitorum; C, tibialis
anticus.
for a distance of from 1 to 2 cm. because
of the tension to which they were subjected
by the muscular pull ; by means of a record-
ing instrument, the proximal tendon stump
was pulled downward until brought into
apposition with the distal. The degree of
force represented the tension to which the
tendon was subjected. The figures varied
markedly, according to the varying condi-
tions of the experiment, but one fact re-
Fig. 8. — Marked valgus deformity of the foot
due to paralysis of the tibialis posticus and
anticus.
Fig. 9. — ^The same foot one year subsequent
to tendon transplantations. The patient, a boy
of nine, was able to walk without a splint.
mained constant, irrespective of the size of
the animal and of the strength of the mus-
cle ; when under anesthesia, the limb was
held in such a position that the origin of
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137
Fig. 10. — A: — Paralytic valgus deformity due to paralysis of the Inverting muscles. B: —
The same 6 months after transplantation of the peroneus longus tendon. C: — Two exposures
on one plate illustrating the voluntary power of inversion and adduction subsequent to the
transplantation.
Fig. 11. — Two exposures on one plate illustrating the voluntary range of extension sub-
sequent to transplantation of the hamstring muscles in a case of complete paralysis of the
quadriceps.
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the muscle and its point of insertion were
brought as near together as possible, then
the tendon tension equaled 0; in other
words, with the tibialis anticus divided and
the foot held in the position of calcaneo-
varus, then under anesthesia the two tendon
ends came into exact approximation without
the use of any force whatever. This simple
physiologic fact is readily applicable to ten-
don transplantation. The normal tension
is restored by holding the limb in such a
position as to approximate the origin of the
planted tendon is to be brought since the re-
sulting osteogenic activity of the periosteal
cells anchors the transferred tendon firmly
in place.
The second incision runs along the exten-
sor proprius hallucis. Not the entire ten-
don but only the upper portion is exposed
at first. The idea is that the tendon should
be protected against drying until every-
thing is ready for its transfer. When the
sheath of the extensor proprius hallucis is
opened, it will be seen that it is separated
Fig. 12. — Complete paralysis of the quadriceps femoris subsequent to transplantation of
the hamstrings. The boy is able to support the body weight by means of the transplanted
tendons.
muscle and the new site of tendon im-
plantation.
The application of the physiologic prin-
ciple to the technic of tendon transplanta-
tions can best be illustrated by describing a
typical operation, for instance, the transfer
of the extensor proprius hallucis for the
paralyzed tibialis anticus. The first inci-
sion exposes the insertion of the paralyzed
tendon. The tendon itself is slit longitudi-
nally and the subjacent bone is traumatized.
Against this traumatized surface the trans-
from the sheath of the tibialis anticus by a
fascial septum; by prolonging the incision
a short distance upward one reaches a point
where this septum stops short and the two
tendon sheaths are separated only by para-
tenon. At this point a small opening is
made directly into the sheath of the tibialis
anticus ; a probe containing a guide suture
is passed downward thru the sheath and
emerges just over the insertion of the
paralyzed tendon. By means of this guide
suture, the extensor proprius hallucis ten-
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139
don, which is rapidly freed, is drawn down-
ward thru the sheath of the tibialis anticus
and anchored firmly in the bed already pre-
pared for it. In fastening it, the foot is
held in the position of calcaneovarus and
the tendon is pulled on with just enough
force to render its course a straight one.
Immobilization should not be continued
more than three weeks because by that time
firm union has occurred. The patient is
then allowed to exercise the transplanted
toration of muscle balance is most gratify-
ing.
The clinical results are best illustrated
by photographs showing the action of the
transplanted tendons. (See Figs. 8, 9, 10,
11, 12 and 13.)
That further research, both clinical and
in the laboratory will help to perfect our
operative methods is my firm hope, as well
as that of all men interested in the treat-
ment of infantile paralysis.
Fig. 13. — Paralysis of the triceps surae (Achilles tendon) subsequent to transplantation
of flexor longus hallucis and peroneus longus. The patient is able to press the foot downward
against the resistance of a 10-lb. sand bag.
tendon, and three weeks later to walk with
the transplanted tendon protected from un-
due tension by an appropriate splint.
Altho no exaggerated claims should be
made for the merit of the operations based
on these physiologic studies, it is, I think,
safe to say that they constitute a distinct
advance over our previous technic. Adhe-
sions do not occur to the same degree ; the
transplanted tendon with practically no ex-
ceptions functions excellently and the res-
Reading the Pulse. — In reading a per-
son's pulse, we have to take into considera-
tion the temperament of our patient, (Jones,
Med. Summary) the slow pulse of the
lymphatic, the quick pulse of the nervous
temperament, also the large full pulse of the
vital temperament. Then again, we must
keep in mind the fact that all the emotions
are registered in the pulse ; joy, grief, anger,
fear and sexual excitement ; also the pulse
will tell you if the patient has had alcoholic
stimulants, glonoin, strychnine, quinine, or
arterial sedatives to slow the action of the
heart.
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SOME GENERAL PRINCIPLES IN
THE MANAGEMENT OF PNEU-
MONIA.
BY
EDWARD O. OTIS, M. D.,
Professor of Pulmonary Diseases and Clima-
tology, Tufts College Medical School,
Boston, Mass.
The recent and recurring epidemic of in-
iiuenza, followed in so many cases by pneu-
monia, has given the physician exceptional
experience in the observation and manage-
ment of the latter disease, which at all times
is very prevalent and is most treacherous
as regards prognosis and most unsatisfac-
tory as regards treatment, especially with
drugs. As John Bunyan said of tuberculosis
that it was the "Captain of the Men of
Death," so likewise can the same be said of
pneumonia. And as tuberculosis strikes
down its victims in the heyday of their ac-
tivity, so does pneumonia in very many
cases, and this has been true particularly in
the recent epidemic.
It was the privilege of the writer to see
many cases of influenza-pneumonia in the
late epidemic, with other physicians,
and to observe their methods of treat-
ment, with the view of determining if there
was any unity or standard which could be
said to exist among various physicians,
particularly with regard to the use of drugs.
The conclusion arrived at was that each
physician, so far as he followed any definite
plan, followed his own individual method or
scheme which his experience had led him
to believe was of value and which he ap-
plied in every case— or only treated his
cases expectantly or symptomatically. In
either case the results were probably not
materially different, and the obvious reason
is that there is at present no known way
of aborting pneumonia or cutting its course
short. It is a disease without any known
specific. If, however, any fixed or standard
medicinal treatment is of doubtful value,
there are certain general principles of man-
agement which can and should be rigorous-
ly applied to all cases and which put the
patient in the most favorable condition for
making the struggle against the infection,
and they are very much like the principles
applicable to all acute infectious diseases.
The paramount importance of these gen-
eral principles, it has seemed to the writer,
has not always been fully appreciated, or
in part neglected by the physician in his en-
deavor to obtain results from drugs or other
special methods of treatment. When men-
tioned they are self-evident and sound but
truisms yet they are the basic foundation
upon which any and all other treatment
must depend and are of infinitely more
value than any special medication.
In the first place, as in all acute in-
fectious diseases, rest is one of the great
essentials; absolute rest, what might be
called "typhoid- fever rest,'* as the term is
applied to the rest of active cases of pul-
monary tuberculosis with fever. This rest
should be both mental and physical. The bed
of the pneumonia patient should be so
arranged that he can be made as comfort-
able as his condition permits, a firm mattress
so that there will be little or no sagging in
the middle, and the bed and body clothing
so arranged that they may be smooth and
without irritating wrinkles. For this pur-
pose, and to facilitate the nurse's duties, a
narrow bed is the most desirable. It also
enables the physician to make his examina-
tions with greater ease and less disturbance
to the patient. Once the diagnosis is made
the patient should not be disturbed by fre-
quent examinations, especially by having
him sit up in bed for such examinations.
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141
Knowing that he has pneumonia and know-
ing that if he dies this untoward result is,
as a rule, from the toxemia and not from
the extent of the local inflammation, it
makes little difference whether there is a
little more or a little less involvement of
the lung so far as the welfare of the pa-
tient is concerned, and any added informa-
tion the physician may obtain from frequent
examination is not commensurate with the
evil wrought by the disturbance of the
patient. The "peace" of the sick room should
scrupulously be observed and only the nurse
or attendant be allowed there. A calm and
peaceful environment is most important for
an acutely sick person. All conversation
should obviously be interdicted. Again, as
long periods of absolute rest as possible
are of vital importance and are of more
value than a little extra nourishment or too
frequent exhibition of drugs, it should be
a cardinal rule never to awaken the patient
for anything. No medicine is comparable
in value with sleep — "tired nature's sweet
restorer."
Coughing is violent exercise and no one
can rest who has frequent paroxysms of
coughing. Therefore the condition not in-
frequently occurs when, in order to obtain
the needed rest, some sedative is indicated
solely for the purpose of obtaining rest.
Whatever measures will accomplish this
should be employed, and these will generally
be some form of opium, preferably some
of the milder forms. Any danger feared
from shutting up the secretions is, in the
writer's opinion, less than that incurred
from the loss of rest. Likewise pain pre-
vents rest, and in some way or other this
must be relieved. Sometimes it is a constant,
harassing headache, or more frequently the
pain of pleurisy, which makes breathing a
penance. Whatever means, either external
or internal, which will alleviate pain, and
the simpler the better, should be employed
for the purpose of obtaining rest. It should
never be forgotten that there is no known
method of combating the toxemia of an
acute infectious disease so efficacious as
rest — absolute rest of mind and body. This
fact has been signally demonstrated in the
rest treatment of active pulmonary tuber-
culosis.
A second fundamental principle in the
management of pneumonia is fresh air. The
open-air treatment of pneumonia both with
children — even infants — and with adults has
abundantly demonstrated the efficacy of
fresh air. In the recent epidemic of influ-
enza-pneumonia, the fresh air plan of treat-
ment in the emergency hospitals gave strik-
ing results. In many cases the patients were
placed directly in the open all day long. At
all events the patient should be placed in a
room which can be constantly and freely
ventilated by sufficient window openings.
Often by placing the bed in the middle of
the room a free current of fresh air can best
be obtained. All too frequently one will find
his patient occupying a small room with
only one window, and that opening upon a
court or in close proximity to an adjacent
building or a brick wall. The writer has
seen many a case of pneumonia in such a
room with the air so foul that it was hardly
endurable. Of course, the most perfect ar-
rangement is entirely in the open either on
a veranda or sleeping porch. And this holds
true as well in the winter as in the milder
months of the year.
Third : The feeding of the patient. The
writer has always been of the opinion that
as pneumonia is a self -limited disease of
short duration, the amount of nourishment
taken should be moderate and less than in
the protracted exhausting acute infectious
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diseases like typhoid fever for example.
All pains, however, should be taken to
administer such nourishment as is most
easily digested and assimilated. Above all
things flatulence and distension should be
avoided, a condition which distinctly in-
creases the gravity of the case. If the physi-
cian at each visit will pass his hand over
the abdomen, a procedure which can be
done without disturbing the patient, he will
quickly learn if this condition exists and
take speedy measures to remedy it. Milk, as
we know, is one of the principal forms of
nourishment for fever patients, but it should
be mixed with some alkali which lessens the
size of the curds. Lime water is a common
means of doing this, or it may be accom-
plished by simply diluting the milk with
vichy or Apollinaris water or with barley,
oatmeal, rice or egg water. Egg albumen,
either raw, slightly cooked, or perhaps as
albumen water, is very easily digested.
Gelatin preparations are also of value
and easily digested. It is doubtful, in
the writer's opinion, if meat prepara-
tions, such as beef-tea and broths, are
either of much nutritive value or neces-
sary and they may cause intestinal putrefac-
tion and distension. The patient should
take an abundance of water either pure or
acidulated with lemon juice or other acids.
To some patients ginger ale is a very ac-
ceptable drink. Water should not only be
^iven internally in large quantities but used
as well externally by means of sponging or
cold packs, when the fever is high. A diet
plan should be carefully arranged by the
physician in detail, and both the quantity
and the hours at which food should be
taken indicated. The nurse in turn, or the
attendant, should keep an accurate record
of the nourishment actually taken. The
digestion should be carefully watched and
instant changes made in the diet if digestive
disturbances are observed.
Fourth: The care of the bowels. At
the outset the bowels should be freely
opened, and the common procedure of a
mercurial, generally calomel, followed by a
saline, has received the approval of long
experience. Citrate of magnesia is perhaps
the most agreeable and simplest of the laxa-
tive salines and this or some other saline
should be continued daily in such doses as
will ensure free daily movements. If these
means are non-effective, enemata may be
resorted to.
When the four cardinal principles, vis.,
absolute rest, fresh air, proper feeding and
care of the bowels are scrupulously ob-
served it is probable that we have done the
most we can do for our pneumonia pa-
tients. Whether drugs, except for emer-
gencies, are of any deciding or definite
value is, and is likely to* remain, a
debatable question. Physicians will always
hold varying opinions as to the value
of any method of standard medication
and whatever their personal experience
happens to be in the use of one or another
kind of drug treatment they will either be-
lieve in it or be skeptical as to its value ac-
cording as they have been fortunate or
imfortunate in its use. Certain it is that in
a century of the treatment of pneumonia
with all kinds of medication and with no
medication at all the mortality has been
abi^ut the same. The writer is unable to see
why any special drug treatment should in-
fluence the course of the acute pneumonia
infection any more than in the case of an
acute tuberculous infection, for example.
And it is his conviction that when the pneu-
monia patient is placed under the best pos-
sible conditions, as outlined above, for re-
sisting the specific toxemia of the disease
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the most has been done for the patient
which can be done for him. When, however,
in the later stages of the disease symptoms
of vasomotor disturbance or heart failure
seem imminent, this is another proposition
and appropriate means should, of course,
be taken to combat these untoward compli-
cations, and each physician will have his
chosen remedies for such a purpose.
The one hopeful ray of light looking to-
wards a specific treatment of pneumonia is
the recent employment of autogenous vac-
cine and the results obtained in the use
of such a vaccine for the so-called Type
One have been so favorable that hope is
aroused that eventually we may be enabled,
thru this form of treatment, to do arti-
ficially, what nature does so dramatically at
the time of the crisis.
The writer is conscious that he has only
been stating axioms in the treatment of
pneumonia, but in the endeavor to obtain
a specific solution of a problem the funda-
mental principles involved are sometimes
neglected. In the management of pneu-
monia, as well as in that of many other
acute infections, one is reminded of the
witty saying of Doctor Holmes many years
ago that "if all drugs were thrown into the
sea it would be better for men and worse
for the fishes."
HEADACHE.
Fever Dietaries. — Foods of particular
value in fever dietaries are milk, cream,
fruit, juices, broths, beef juice, gelatin,
tggs, buttermilk, koumiss, cereal waters and
gruels, cocoa, malted milk, custards and
junket.
No fever needs such careful dietary man-
agement as does typhoid.
Physicians acknowledge that the success-
ful treatment of a severe case of typhoid
is especially dependent upon two things:
proper feeding and careful nursing. — Med.
Sutnmary,
BY
M. NEUSTAEDTER, M. D., Ph. D.,
Lecturer In Neurology, N. Y. U. and Bellevue
Hospital Medical College, New York
City.
When we consider that the great ma-
jority of our patients in private and clinical
practice come with no other complaint than
headache, pain or discomfort in the head, I
may be pardoned for discussing this all-im-
portant symptom, for headache is only a
symptom, the result of some underlying
condition, and frequently the only symptom..
While we must remember that in some in-
stances it is a symptom of a gjave condition,
in most cases the underlying cause should
not inspire one with a grave prognosis.
Two problems, then, loom up in its dis-
cussion. First, what is the genesis of head-
ache, and second, what etiologic factors con-
tribute to its genesis and what are its con-
comitant manifestations?
I. How does headache come about? —
All forms of headache are perceived in areas
supplied by the trifacial and only in certain
forms in limited areas supplied by a few
branches of the upper cervicals. These
nerves, as we know, enter as roots into
their ganglia and thru their dendrites
come into contact with the central neurons.
Irritation of these sensory filaments or their
roots and ganglia produces pain, which is
perceived in the area of their distribution.
Lesions in the upper neurons are not known
to have been productive of pain. But it is
a known fact that a lesion in the lower
ventral part of the thalamus which contains
many sensory tracts, if that be of an irrita-
tive nature will produce considerable pain
in the opposite half of the body and destruc-
tive lesions are known to produce hemianes-
thesia. Besides the filaments of the fifth in
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the dura there are also other sensory fila-
ments, notably those of a vago-sympathetic
system, as in cases of headache with vomit-
ing and accompanying pupilary changes. It
seems to me to be rational to assume that
there are cortical areas which record pain-
ful sensations of the type we speak of as
wtll as other sensations, altho we have not
been able as yet to demonstrate the par-
ticular place by experimentation.^
How, then, are the dural nerve filaments
irritated? Intracranial pressure, we know,
produces headache ; but the pressure as such
does not alone produce it. We know that
pressure on the dura in a circumscribed area
may be painless and even brain tumors, altho
constantly growing, are frequently attended
by periods of rest from headache. There
must, then, be an additional factor alongside
the pressure. This factor, in all probability,
is the accompanying disturbance of circula-
tion in the vascular and lymphatic systems
within the tissues surrounding the dural
nerves. The neuralgias accompanied by hy-
peremia of the veins are examples corrobo-
rating this hypothesis. Anemia or hyper-
emia of the dura and, perhaps, also of the
pia produce headache as in vasomotor dis-
turbances and in inflammations attending
infectious diseases. Such disturbances may
also come about thru reflex conditions from
disturbances outside of the cranial vault,
as from the eyes, nose, ears, etc., which
cause contraction of the vessels. It does not
seem to me quite rational to attribute head-
ache as a result of toxemias to such reflex
vasomotor disturbances, but rather to an
irritation of the nerve filaments. Of course
all this is purely hypothetical and may con-
ceivably be wrong, but as yet no other theory
has been proven.
This leads us to the consideration of the
second problem : What are the etiologic fac-
tors contributing to the genesis of headache ?
It is quite obvious from our clinical as well
as pathologic experience that there are
functional and organic diseases that are ac-
companied by headache.
A. Functional headaches. — Frequent
forms of headache or rather pains in the
head are the various forms of neuralgias,
which constitute a gjeat difficulty in the do-
main of exact diagnosis. The patients usually
describe these pains as limfted to a particu-
lar area of the head supplied by the nerve
involved. These pains are sharp, shooting
along the course of the nerve, occurring at
intervals to be succeeded by a period of free-
dom. There is also at times a numbness,
tingling or burning feeling over the surface
of the skin of the involved area and pres-
sure upon the nerve causes the pain to be-
come more intensified, or if no pain present
at the time of examination, an attack will
be ushered in by such procedure. Some-
times the pain is so severe that automatic
spasms are called into play, because stimuli
enter into the motor filament completing the
reflex arc. Thus trigeminal neuralgia limited
to the supraorbital branch will cause twitch-
ings of the eyelids and facial muscles. There
is a marked hyperesthesia to cold and pin-
prick on the aflfected area. This condition
should not, however, be mistaken for frontal
sinusitis which stimulates in some respects
a localized neuralgia. Pressure upon the
bone along the sinus will cause a dull pain
and a transillumination and an X-ray pic-
ture should clear up the diff'erence promptly.
In addition the nasal discharges of a muco-
purulent character should not be over-
looked.
Beside the real neuralgias, frontal and
occipital alike, there are radiating pains
along the course of nerves passing thru in-
fected foci, as is not infrequently the case
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145
in caries of teeth. A careful examination
of the teeth should in all cases be made and
an impacted or carious tooth removed will
promptly relieve this distressing symptom.
In unilateral headache it is also advisable
to examine the condition of the throat and
the middle ear, for in some instances path-
ologic processes there are the underlying
causes of the trouble. The cure of an otitis
media or a suppurating tonsil will soon re-
lieve the localize<J headache.
A severe form of localized headache is
the so-called hemicrania or migraine. This
is a familial disease and on careful inquiry
into the family history one finds that many
members of the parents' and grandparents'
branches of the family were subject to the
disease. These patients will tell you that
they are not always subject to headaches,
that only at certain periods of time of short-
er and again of longer intervals, even after
months of rest, they would suddenly ex-
perience an intense, boring pain in the tem-
ple and at the back of the head. They be-
come completely prostrated, are hypersensi-
tive to light, sound and touch and they
prefer to lie quietly alone and not be spoken
to in loud tones. They are annoyed by the
least disturbance, even if their resting place
is only slightly shaken. Nausea and vomit-
ing are frequent accompaniments and oc-
casionally diarrhea also. During the attack
the patient, as a rule, feels cold, and heat
is disagreeable. There is usually pallor of
the surface; occasionally there is a cold,
clammy perspiration, but the face may also
be flushed on the affected side.
In some patients there is an aura the eve-
ning before the attack characterized by irri-
tability, indifference and inability to perform
exacting physical or mental work. In most
cases, however, significant prodromata ap-
pear in the early morning. They arise with
a feeling of lassitude, they feel that the
sleep was deep and heavy, they dreamed
restlessly and feel broken up. Within a few
hours the characteristic unilateral pains be-
gin. They are deepseated and the patients
complain of a feeling "that the head is
bursting." These attacks last from eight to
twelve hours and vary in intensity with dif-
ferent individuals. The attack may in some
instances last for a few days and develop
into a status hemicranicus. After the attack
the patients of a robust constitution recover
completely and quickly, but the weaker ones
recover slowly, still suffering from after-
effects.
Without going into an extensive discus-
sion of the many therapeutic measures ad-
vocated from time to time, I prefer to state
that I have met with fair success with the
following measures : Daily evacuation of the
bowels, a non-stimulating, bland and easily
digestible diet, no canned or preserved foods,
regular habits of life and as a medication
I give thyroid extract in 1/10-J4 gr. doses t.
i. d. on the hypothesis that the affection is
caused by an excess of secretion of the
choroid plexus in the lateral ventricle on
the affected side as a result of a vasomotor
disturbance. Whether this is so or not, the
fact is that the most intractable cases that
did not yield to the old form of treatment,
with coal tar preparations and salicylates,
were very much improved. The intervals
between attacks became longer, the intensity
of the seizures became lessened and finally
complete cures were effected.
Anemia, whether of a chlorotic charac-
ter or as a result of loss of blood, is as a
rule accompanied by headache of the dull
and pressing type, not very severe in most
cases. This headache may be frontal or
parietal only and also general. It starts
late in the day and the patients are relieved
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after a night's rest. It is obvious that the
anemia requires intense treatment. A
nourishing diet and long periods of rest in
a recumbent position, best perhaps to keep
the patient in bed for several weeks and
with that iron and arsenic will prove very
effective. In cases of severe loss of blood
as in menstruation or affections requiring
surgical interference, prompt treatment
along these lines is indicated.
A form of headache that frequently
proves intractable for a long time we meet
in toxemias and the so-called autointoxica-
tion. It is general in character and most in-
tense on rising. In the latter type we have
a history of indigestion and obstipation
which give rise to absorption of toxic prod-
ucts into the circulatory system. Some au-
thors believe that the headache in toxemia
may be due to a reflex action as in uremia
and acetonemia. In all probability, however,
it is due to irritation of the dural nerve fila-
ments of the fifth and sympathetic nerves
by the toxic products. It is perfectly ob-
vious that the removal of the underlying
condition will eventually cause the head-
ache to subside.
Next in frequency to hemicrania is the
exhaustion headache of the neurasthenic. It
is characterized by a sense of oppression, a
constriction and a heaviness of the head.
The pressure is most frequently described
as situated behind the forehead and radiat-
ing down into the eyes and root of the nose ;
less frequently in the temples. Some neu-
rasthenics complain of paresthesias of the
scalp in the form of sensations of itching,
numbness and formication. The intensity of
the headache may become aggravated to that
of pain, particularly after irritation, exces-
sive worry or undue mental exertion. No
matter how intense the suffering may be,
at no time do we hear the complaint that
nausea or vomiting accompanies the head-
ache. As a matter of fact these neuras-
thenics have no gastric disturbances and ap-
pear quite well fed. The patients complain
of constant headache and never remember
when they first began to suflfer. "It is
months or years," they tell us. If along-
side of this form we find a history of back-
ache, gastrointestinal atony, neuromuscular
weakness, cerebral depression, mental irri-
tability and insomnia, you may be reason-
ably certain that you are not dealing with
an organic affection. •
As you know the outlook is good in the
great majority of the cases, who recover
after months of treatment. In some cases,
however, we face a complete breakdown
and the patient becomes a confirmed nerv-
ous invalid. These patients are usually of
a psychopathic stock and develop some form
of psychosis. Cases before twenty are apt
to yield readily and relapse frequently. After
forty the prognosis is less hopeful as a rule,
for we are dealing here in all probability
with a psychopathic constitution.
As to treatment very little can be said.
Bodily and mental rest are the first pre-
requisites. A sojourn in the south during
the winter months and in the mountains in
the north during summer is ideal. But what
of the poor shop girl ? And a great number
of them are neurasthenics. And yet we need
not despair. We can well regulate their life
in a manner as to make the condition bear-
able and in time improve them greatly.
Fresh air and sunshine in their dormitories
and workshops is now obtainable and a
warm bath every day before retiring every
one can afford. A plain, bland, nourishing
and easily digestible diet is cheaper than the
various delicatessen, canned foodstuffs and
preserved articles of diet with the beauti-
fully looking French pastries. To eat reg-
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147
ularly on time and have their regular sleep
of nine hours daily the poorest of the poor
can well afford. In addition a little bromide
of potassium, say gr. XV t. i. d. after meals
well diluted with water, will afford relief
in most cases in the long run.
Of the headache of hysterics we can say
that since hysteria will imitate any disease
and since it is a condition as a result of
suggestion, it can best be dealt with, if at all,
by suggestion. It may assume the charac-
teristics of any form of headache. It is
comparatively easy to differentiate it from
the true forms, since the concomitant mani-
festations are invariably the well known
stigmata of hysteria.
And finally there is a form of functional
headache as yet little known and frequently
subsumed under migraine or neurasthenia,
namely, nodular or rheumatic headache.
The majority of the patients are women of
middle or advanced age. They complain of a
persistent pain over the whole head, begin-
ning in the occiput and nape of the neck
and radiating towards the back and the
shoulders. It does not cease at night and is
rarely associated with nausea and never
with vomiting. Chills are a frequent com-
plaint especially during inclement weather
and when associated with exposure to
draughts. Edinger considers the exposure
to localized chill from wa'shing the hair
without properly drying it to be a fre-
quent cause. The underlying cause is a
rheumatic affection.
On careful examination one can find no-
dular indurations of various shapes and
sizes from a millet seed to a bean in the
subcutaneous tissue of the scalp, the occipi-
tal fascia and fascia of the nucha and sides
of the neck as far as the shoulders. They
are very tender to touch. They are not
commonly found in the frontal and tem-
poral regions.
The prognosis is entirely favorable. The
treatment consists in a purin free diet, sali-
cylates, moist hot applications and massage.
B* Organic headaches. — ^The most intol-
erant form of organic headache and not al-
ways amenable to treatment is the headache
due to intracranial pressure. It is most in-
tense in the frontal and occipital regions
and rather constant, accompanied in most
instances with projectile vomiting. At times
there are intervals of freedom from pain of
longer or shorter duration, because the brain
seems to be able at times to accommodate it-
self to this pressure for a short time until
it becomes overwhelming again. It is rather
slow and insidious in onset and in most
cases we find early a choked disc in the eye
grounds.
This intracranial pressure headache we
find in a brain tumor, a brain abscess and
in internal and external hydrocephalus. The
concomitant symptoms depend entirely upon
the site of the neoplasm, and not upon the
character of it. Thus we might have a hemi-
plegia, motor or. sensory aphasia, convul-
sions of the epileptiform kind, tremors,
ataxia, nystagmus, speech defects, a paral-
ysis or irritation of one or more cranial
nerves, the syndrome of acromegaly or
dyspituitarism or even a psychosis, or again
no other sign than choked disc. In cases of
involvement of the hypophysis the X-ray
will be of service as it shows an enlarged
sella turcica.
Relief, if only temporary, can only be
afforded by surgical measures, such as a
decompression in the case of tumors, fre-
quent lumbar punctures in hydrocephalus
and the prompt evacuation of pus in cere-
bral abscess. I know of no medication that
may be of any service.
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Then we have headache in brain syphilis.
Like leutic pains elsewhere it displays noc-
turnal exacerbations and not infrequently
restricted to that time. As a rule it is most
intense in the occipital region. An irregular,
unequal pupil reacting sluggishly to light and
accommodation or even an Argyll-Robertson
pupil is the constant accompaniment and at
times the only objective sign. Then again
optic atrophy is not infrequent. Of the other
cranial nerves- the third, fourth and sixth
are most frequently involved, giving us
diplopia, unilateral or double ocular ptosis
and ophthalmoplegia. At times a Bell's
palsy is present with complete reaction of
degeneration. In one instance I have seen
a double facial paralysis. Then again, like
in cerebral neoplasms we may have all sorts
of focal signs, even epileptiform convulsions,
depending entirely upon the site of the
lesion. A history of venereal infection is
as you well know, not infrequently denied.
The Wassermann reaction of the blood and
spinal fluid should in all cases not be
omitted. If negative it should not deter us
from subjecting the patient to antiluetic
treatment. The results are as a rule very
gratifying.
Of a rather rare occurrence are organic
affections of the skull attended by headache.
This is as a rule purely local and should not
be mistaken for the general type. A careful
percussion of palpation will at once reveal
either rarified or thickened places. The
traumatic periostitis and syphilis of the
skull and metastatic carcinomata reveal
such defects. Of course it goes without say-
ing that the X-ray will at once clear up any
doubt. In the case of the traumatic affection
surgical interference may prove of value, in
the case of syphilis antiluetic treatment is
indicated and in the case of carcinoma fu-
ture generations may have something to say
about it.
And finally I may mention a disagreeable
form of headache in cases of cerebral ar-
teriosclerosis. It doubtless occurs mainly
because the control of the regulating vaso-
motor apparatus over the inelastic vessel
walls of the brain and its membranes have
become uncertain and irregular, and in most
advanced cases paralyzed. The vasomotor
nerves themselves supplying the vessels un-
dergo alteration thru the atheromatous
process. To this must be added the anemia
resulting from the narrowing of the vessels
and the resulting malnutrition. This head-
ache is associated with vertigo, quite ob-
stinate in character, paresthesias, at times
dyspnea, and not infrequently memory and
intelligence defects. It generally manifests
itself as an oppression localized in the fore-
. head and may assume an obstinate and har-
assing character. At times the patients com-
plain of exacerbations of severe pain. And
the severity frequently is a prodromal sign
of an impending cerebral hemorrhage or
thrombosis. The examination of the eye
grounds will reveal tortuosity of the vessels
and in that case complete rest may ward
off a hemorrhage.
Of course the prognosis of this affection
is unfavorable. As to treatment one can ad-
vise the rationale of that in general arterio-
sclerosis, namely, physical and mental rest,
regular habits of life, a non-stimulating diet,
exclusion of all forms of alcohol and small
doses of iodid of potash, say 5 gr. t. i. d.
I have attempted here to enumerate the
forms of headache we meet in our ambulant
practice, not considering the headaches of
adolescence and those of acute infectious dis-
eases. To attempt to incorporate those and
others of rare occurrence would not be pos-
sible within the scope of a short paper. It
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was my intention to show that it is not after
all a simple matter to treat headache suc-
cessfully and that each case is a law unto it-
self and must be most carefully examined
so that proper treatment may be instituted.
1215 Park Ave.
THE PNEUMO-CATARRHAL DIATH-
ESIS, PREVENTION AND TREAT-
MENT OF PNEUMONIA AND
OTHER RESPIRATORY INFEC-
TIONS BY MIXED VACCINES.
BY
MAJOR J. PRAtT JOHNSON, M. C, D. A. D.
M. S., S. A. M, C,
Director Clinical Research Laboratories,
Johannesburg, South Africa.
The scope of this subject is so wide and
expansive that no more can be attempted in
this preliminary communication than a
rough outHne of the general principles gov-
erning the prevention and treatment of bac-
terial infections of the respiratory tract.
Material Available for Investigation, —
Diseases of the respiratory system are com-
mon in South Africa; and the community
scattered along the sixty miles of "Reef,"
aggregated into various townships of the
Witwatersrand is no exception. The
prevalence of these infections on the Rand
is partly due to the dry, dusty climate with
its rapid changes of temperature, partly to
the almost universal incidence of catarrhal
infections among workers, native and Euro-
pean on the Witwatersrand goldfields, the
inhalation of the fine particles of silica,
always present in mine air and the rapid
changes in temperature experienced in gold-
mining being contributory causes. Consider-
able material, therefore, is available on all
sides for the study of this most interesting
and important group of diseases.
As Acting Bacteriologist for the Trans-
vaal, Acting Pathologist to the General Hos-
pital, Johannesburg, subsequently Assistant
Medical Officer of Health, Johannesburg,
and later as Director of the Clinical Re-
search Laboratories, my various duties have
brought me into close contact with these
problems in South Africa during the last
eight years. In addition, my researches into
the pathology of silicosis in man and white
rats, and tuberculosis on the Witwatersrand,
in association with Drs. Andrew Watt, L.
Irvine and W. Stewart, afforded me valu-
able material for study. Furthermore, a
considerable portion of my private practice
as a consultant and bacteriologist in recent
years has been composed of this type of
case. Recently, however, during the wide-
spread incidence in South Africa of pneu-
monia and other diseases associated with or
following on Spanish influenza I have had
a unique opportunity of testing the sound-
ness of one's conclusions in this matter on
a very large scale. A large number of doses
of compound catarrhal vaccine have been
issued for the treatment and prevention of
the prevailing pneumonia. The results of
this mass inoculation will be available short-
ly for publication, but at the presentj'unc-
ture it is not possible to say more than that
the results have been most satisfactory and
significant and go far to support the atti-
tude taken up by this paper in regard to
the etiology of pneumonia and other respira-
tory infections.
It appeared necessary to introduce this
subject in this way in order that it may
be appreciated that altho no statistical evi-
dence will now be produced these conclu-
sions have a definite exoerimental and ex-
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periential basis, which will be elaborated in
a later publication.
Method of Investigation, — It is not in-
tended to minimize the importance of the
recognition of the various antibodies which
have been identified and described from time
to time during the last twenty years. It is
by such means that we are able to appre-
ciate something of the struggle which goes
on between pathogenic microorganisms and
the body, and the nature of the various im-
munologic processes called into play. In re-
cent years the extraordinarily interesting
phenomenon which has been named anaphy-
laxis has attracted considerable attention.
Much remains to be learned in regard to
this most important factor in immunity
problems and it would appear that a closer
study of anaphylaxis as applied to the em-
ployment of vaccines and sera for the treat-
ment and prevention of infective diseases,
will supply the missing link in the chain of
oadence required for a more complete un-
derstanding of what takes place when these
therapeutic agents are employed. Since
Richet's pioneer work, an outstanding pub-
lication, is Besredka's "Anaphylaxie et Anti-
anaphylaxie." Besredka shows that the dan-
ger of anaphylactic shock in a sensitized in-
dividual can be prevented by the administra-
tion by various routes, of small doses of the
particular serum applicable. Such a protec-
tive injection he names the anti-anaphylactic
injection. It is necessary to emphasize the
importance of these phenomena here as the
writer is firmly convinced that these factors
play a very important part in vaccine and
svrum therapy, especially in therapeutic in-
oculation. In no group of diseases are
anaphylactic phenomena more evident and
important than in the group of respiratory
diseases under consideration. No satisfac-
tory explanation can otherwise be oflFered
of the fact that an injection of mixed vac-
cine of moderate strength, such as is com-
monly used for prophylactic inoculation
against respiratory catarrhs, when inocu-
lated into an individual comparatively free
of catarrh produces very Httle local reaction
and practically no general reaction; if the
same dose be inoculated in the same indi-
vidual in the presence of an acute respira-
tory cold or catarrh, the local and general
reaction is enormously increased, out of all
proportion to the amount of vaccine used,
and the resulting effects may be so severe as
to confine the patient to bed for a week.
Obviously some change must have taken
place in the individual to produce such vast-
ly different results in the two circumstances
indicated. This astonishing change is due
to the development of anaphylaxis, produced
by the activities of the causative bacteria
present in the acute attack. This phenome-
non is so constant that it is possible to diag-
nose the presence or absence of respiratory
catarrh without any clinical evidence by
merely noting the results of the inoculation
of a suitable dose of mixed vaccine, pre-
pared from the organisms commonly found
in respiratory infections. The symptoms,
local and general, following the inoculation
of a mixed vaccine in an individual suffer-
ing from respiratory catarrh are closely
analogous to similar conditions set up by
the inoculation of tuberculin in individuals
suffering from pulmonary tuberculosis. In
both cases the phenomena are largely
anaphylactic. I am satisfied that anaphylac-
tic phenomena afford a much more reliable
guide to the practitioner as to dosage and
interval in vaccine therapy than any observa-
tions and investigations, no matter how
elaborate, in regard to the presence or ab-
sence of demonstrable specific antibodies in
the blood. The latter method is of purely
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historic interest. I have, therefore, not fol-
lowed the method of investigation adopted
by previous workers in this field of research,
that of almost slavish adherence to sero-
logic tests, such as agglutination and opsonic
estimation — ^as I do not regard these tests
as satisfactory guides or reliable indicators
of established immunity, or of practical
service in the carrying out of treatment with
vaccine or sera. The presence of specific
agglutinins in the blood is of service in the
diagnosis of certain massive systematic in-
fections, and in certain laboratory experi-
ments, but in the investigation of prophylac-
tic and therapeutic inoculation other factors,
immeasurably more important, are to be
considered.
Symbiotic Activities of Microorganisms.
— It would appear that the very important
part played by symbiosis in bacterial in-
fections of the respiratory organs is not suf-
ficiently appreciated. There is no doubt,
however, that the phenomenon is more fully
appreciated at the present time than some
few years ago. The attitude taken up in
regard to the preparation of an autogenous
vaccine for a case of bronchitis, for ex-
ample, some seven or eight years ago, was
that it was only necessary that the vaccine
should be prepared for the predominant or-
ganism found in the sputum, very commonly
streptococcus. The next stage, however,
was the appreciation of the possibility that
all microorganisms commonly found in the
sputum in these cases might have some eti-
olog^c significance. .
The result was the preparation of what I
used to call a pot pourri vaccine, prepared
as it was from all the organisms isolated.
At this time, however, no attempt was made
to isolate each organism separately in pure
culture, the vaccine being prepared in a more
or less haphazard manner from the organ-
isms developing on culture. A still further
development was to isolate all the micro-
organisms from the sputum, to prepare and
standardize separately the emulsion of each
organism isolated, finally combining all
emulsions in definite proportions in a mixed
vaccine. Experience has proved that pro-
vided the specimen of sputum is properly
collected, the mouth and teeth having been
previously well cleaned with a brush and
boiled water, it is not wise to ignore any
pathogenic organism developing on human
blood agar. At this point it is necessary to
emphasize the importance of the nutrient
media employed. In regard to respiratory
infections it is advisable to employ always
blood agar, preferably human blood agar,
and to observe cultures and sub-cultures for
at least four to five days, owing to the slow
growth of some of the organisms. The em-
ployment of a mixed vaccine, prepared in
this manner, has been justified by the more
efficient preparation obtained and the in-
finitely more satisfactory clinical results.
All this is a tribute to the importance of
appreciating the role of symbiotic mixed
infections in diseases of the respiratory
system.
The Pnemno-Catarrhal Diathesis, — It is
a matter of common observation that while
some individuals go thru life entirely free
of respiratory diseases such as catarrhs,
bronchitis, broncho-pneumonia, pneumonia,
etc., other individuals suffer to a greater or
lesser degree from one or all of these affec-
tions from time to time. In some instances
one attack succeeds another until a chronic
inflammatory condition is established which
occasionally shows more acute exacerba-
tions. In view of the mode of spread of
these diseases by means of infected drop-
lets of sputum sprayed into the air in cough-
ing, sneezing, etc., these infective conditions
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are liable from time to time to assume epi-
demic and even pandemic incidence as illus-
trated by the prevailing influenza pandemic.
There is no doubt that the initial infection
in the majority of cases in this epidemic is
B. inftuenzae but that sooner or later other
organisms, notably streptococcus, and M.
catarrhalis, streptococcus mucosus capsula-
tus and pneumococcus become of consider-
able etiologic importance. Doubtless many
of the cases diagnosed as influenza are not
true influenza but due to one or other of
the catarrhal organisms acting separately
or as a mixed infection. An interesting point
in the influenza epidemic in South Africa
is that the most serious and fatal cases do
not necessarily occur in young, old, or feeble
members of the community, a heavy mor-
tality being noticeable among adults in their
prime. It is evident, therefore, that mere
physical fitness is not an adequate protec-
tion against the onslaught of these respira-
tory infections. These phenomena can only
be sufficiently explained by the appreciation
of the etiologic significance of the pneumo-
catarrhal diathesis, which may be defined as
a constant diminished resistance to respira-
tory infections, constituting a definite pre-
disposition to bacterial diseases of the respi-
ratory organs. This diathesis must be care-
fully distinguished from the irritating ca-
tarrhs associated with Various industrial
processes in which the symptoms are ex-
cited in all workers by the inhalation of irri-
tant particles suspended in the air, e, g.,
silicious particles in the air of gold mines.
Doubtless, however, the individual possessed
of a pneumO'Catarrhal diathesis exposed to
such conditions would suflFer more severely
from respiratory infections than the ordi-
nary individual in whom the resulting ca-
tarrhal processes may be regarded as large-
ly protective.
The success of prophylactic inoculation
against infective catarrhs of the respiratory
passages indicates that the pneumo-catarrhal
diathesis can be artificially combated by
means of specific immunization. The tissues
of the lungs are richly supplied with blood
so that it is not at all surprising that bac-
terial disease of these organs should be so
amenable and sensitive to specify therapy.
On the other hand the failure of all other
non-specific remedies to influence the pneu-
mo-catarrhal diathesis is not surprising from
an anatomical and bacteriologic point of
view. The frequent presence of virulent
microbes in the air from coughing, sneezing,
etc., their ready access thru the inspiratory
current of air to vulnerable points of attack,
the rapid absorption of bacterial toxins
from the lung tissues richly supplied with
blood and the vulnerability of the lung tis-
sues to irritant and noxious vapors and for-
eign bodies suspended in the air, all require
the most efficient system of protection to
maintain freedom from respiratory diseases.
A constitutional weakness in such defensive
measures indicates a pneumo-catarrhal dia-
thesis which can only be successfully re-
versed by specific immunization against all
those pathogenic bacteria commonly con-
veyed in the air breathed.
Etiology of Pneumonia. — In 1883 Fried-
lander described an organism now known as
B, Friedlander, as the causal organism of
pneumonia.
la 1884 Fraenkel published a very full
and accurate description of the characters
of the pneumococcus which he showed was
identical with the coccus of sputum septi-
cemia previously described in 1880 by Pas-
teur and Sternberg as being present in
healthy human saliva.
Since this time pneumococcus has been
recognized as the chief etiologic factor in
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acute pneumonia. From a bacteriologic and
clinical point of view there are various dis-,
quieting factors which call in question the
soundness of this view and it is now pro-
posed to show that this conception of the
etiology of pneumonia is always narrow and
incomplete, and frequently totally incorrect.
( 1 ) The pneumococcus is not present in
all cases of acute lobar pneumonia. This
point is well illustrated by a careful investi-
gation into six cases of acute lobar pneu-
monia selected by a leading practitioner with
expert knowledge in this disease as typical
cases. The sputum was carefully collected
and within an hour or two inoculated into
white rats. Cultures were also made on
human blood agar in each case. Two rats
died within twenty-four hours, the heart
blood in each rat when cultivated on human
blood agar giving a growth of pneumococ-
ci. Cultural examination of the sputum
in these two cases, however, gave -staphylo-
coccus, M, catarrhalis, streptococcus, and
pneumococcus, in one of these cases, and
streptococcus, M. catarrhalis, streptococcus
mucosus capsulatus, B. influenzae and pneu-
mococcus in the other case. The other rat
also died but streptococcus only was re-
covered.
In the three other cases the rats were
unaffected and cultivation of the sputum
gave respectively:
(1) M. catarrhalis, streptococcus and
B. inftuensae,
(2) M. catarrhalis, streptococcus, sta-
phylococcus.
(3) M. catarrhalis, streptococcus.
Thus in six typical clinical cases of acute
lobar pneumonia pneumococcus was only
present in 33% of the cases.
(2) There is t^o consistent lesion in the
lung in pneumococcal infections. The path-
ologic conditions found are extremely
varied, sometimes lobar, sometimes broncho-
pneumonic, sometimes quite indefinite as
to anatomical distribution of the pathologic
process. Histologically moreover the lesions
are not uniform.
From a purely bacteriologic point of view,
therefore, the objections to the acceptance
of pneumococcus as the sole etiologic factor
in acute lobar pneumonia are weighty.
Clinical Objections. Atypical Pneumonia,
— Whatever may be accepted as to the eti-
ology of acute lobar pneumonia the out-
standing fact in regard to the disease diag-
nosed as pneumonia in general practice is
that the majority of cases are atypical. Re-
finements of diagnosis such as catarrhal
pneumonia, broncho-pneumonia may be at-
tempted but the attitude taken up is that
any inflammatory condition of the lungs
producing adventitious sounds, such as rales
or crepitations, some dulness, cough and
sputum, purulent or blood-stained, is broad-
ly pneumonia and that this disease is due
to the pneumococcus.
This is an illustration of the disadvantage
of watertight compartments and over spe-
cialization in medical practice. The bac-
teriologist is not a clinician ; the clinician is
not a bacteriologist.
Extensive experience has demonstrated
without any shadow of doubt that these
atypical conditions are invariably due, from
first to last, to a mixed infection with or
without pneumococcus. This fact is sup-
ported by hundreds of examinations of
sputum which have been carried out both
culturally and by mouse inoculation. The
commonest organisms in atypical pneumonia
in my experience, are M. catarrhalis and
streptococcus, other organisms being
streptococcus mucosus capsulatus, pneumo-
coccus, B. Friedlander, B. influenzae, B.
septus and staphylococcus. Furthermore, in
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those cases of acute lobar pneumonia in
which pneumococcus is found, cultivation
of the sputum rarely gives a pure culture,
other organisms being demonstrable com-
monly in the early stages, and invariably in
the later stages.
It will be readily understood therefore,
that the etiologic factor in pneumonia typi-
cal and atypical is definitely a mixed in-
fection. It is not necessary to dwell on. the
mortality from pneumonia in spite of the
exhibition of pneumococcus vaccines and
sera. It is certain, however, that these
specific preparations are used in many cases
in which they are partially or totally inap-
plicable as they provide only for the pneu-
mococcus element, the symbiotic activities
of other microorganisms being ignored.
It is difficult to estimate, but probably
less than 25% of the cases diagnosed as
pneumonia in the average general practice
are due to an initial infection with the pneu-
mococcus and in any case secondary infec-
tions are present sooner or later in all cases
of pneumonia.
The majority of cases diagnosed as pneu-
monia are due from first to last to a
mixed infection in which pneumococcus
may or may not be included. Briefly, the
evidence which is accumulating as to the
value of therapeutic inoculation in cases
diagnosed as pneumonia with a mixed vac-
cine prepared from numerous strains (150)
of M. catarrhalis, streptococcus, pneumo-
coccus, B. influenzae and B, septus, strepto-
coccus mucosus capsulatus, B. Friedlander,
and staphylococcus, indicate that whatever
objections may be raised to the etiology of
pneumonia as set out above, the clinical re-
sults fully justify this statement. Prophy-
lactic inoculation of a stronger vaccine from
these organisms has similarly given most
gratifying results in preventing the onset
of pneumonia, the mortality in inoculated
.cases which have contracted influenza being
trifling.
The prevalence of pneumonia in South
Africa during the past few weeks in
which the influenza epidemic has raged thru-
out the land has been very marked, the ap-
palling mortality being almost entirely due
to pneumonia. Numerous examinations of
the sputum have demonstrated that the
symptoms are due to a mixed infection, the
virulence of the organisms being enormous-
ly raised by rapid passage so that many
of the cases are septicemic in type. The
employment of the above mixed vaccine in
these cases has been the general practice
thruout South Africa for some time, and
judging from personal observation and
numerous reports received, the results have
been astounding. Numerous cases ill with
pneumonia for weeks have, after one or
two injections, shown a normal temperature
and pulse, and made, in the circumstances,
a rapid uninterrupted recovery. The mor-
tality from pneumonia has also been
enormously reduced by therapeutic inocula-
tion with a mixed vaccine. One practitioner
reports over a hundred cases and another
two hundred cases of pneumonia treated
with mixed vaccine without a single death.
As soon as the epidemic started numerous
requests for pneumococcus vaccine arrived
from all quarters. Steps were taken by
urgent circulars to advise in preference the
employment of compound catarrhal vaccine,
which has produced highly satisfactory and
astonishing results. It should be remem-
bered, moreover, that a fair proportion of
the cases which have occurred have been
diagnosed as acute lobar pneumonia.
The use of a comprehensive mixed vac-
cine for the treatment of respiratory infec-
tions, including pneumonia, largely relieves
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the clinician — who is often without the aid
of an experienced bacteriologist — of the re-
sponsibility of deciding in his own mind the
bacteriology of the case before him. No
matter what respiratory diseases the pa-
tient may be suffering from, whether ton-
silitis, bronchitis, bronchiolitis, broncho-
pneumonia, pneumonia, pleurisy, etc., such
a vaccine prepared on such lines would be
distinctly applicable. The very simplicity of
this line of action must commend itself to
the medical practitioner to whom the bac-
teriology of respiratory infections cannot be
without some difficulty. In view of the fact
that the sensitiveness of patients suffering
from respiratory infections to mixed vac-
cine, is very marked, the greatest care must
be exercised in carrying out therapeutic
inoculations to avoid overdosage which is
distinctly harmful.
It is realized that it is not possible to close
this preliminary communication without
careful reference to the valuable work on
pneumonia carried out on the Witwaters-
rand by Dr. F. S. Lister, bacteriologist to
the South African Institute for Medical Re-
search. Unfortunately I have for many
years been unable to accept the findings of
Dr. Lister in this field of research, and feel
that the time has now come to place on
record my views on the work published in
regard to prophylactic inoculation with
pneumococcus vaccine for the prevention
of pneumonia among the natives employed
on certain experimental mines on the Wit-
watersrand.
Problem of Pneumonia Prevention on
the Witwatersrand Mines. — The subject of
pneumonia is of no little interest in South
Africa, especially on the Rand, where ex-
periments on a large scale have been car-
ried out for a number of years in regard
to the prevention and treatment of this dis-
ease to which the natives are so liable. The
heavy mortality among native laborers, es-
pecially those imported from tropical areas,
first attracted the attention of the govern-
ment, many years ago, and to this day the
mining industry copes with difficulty with
the shortage of labor created by the re-
strictions imposed by the government on
the recruiting of natives for the mines. To
obviate this difficulty towards the end • of
1911 and thruout 1912 Sir Almroth Wright
and his co-workers, Drs. Parry Morgan,
R. W. Dodgson and L. Colebrooke, carried
out investigations into pneumonia on the
Rand at the invitation of the Chamber of
Mines. The results of their investigations
were put on record in a report, published
in December, 1913.
In spite of the thoro manner in which these
workers went into the matter the results of
their researches were largely fruitless and
they claimed '*a lamentably small harvest
of suggestive and interesting facts."
The vaccine employed by Wright was
prepared from local strains of pneumo-
coccus, grown on glucose broth. The method
of investigation consisted in carrying out a
very large number of opsonic and agglutina-
tion tests on the sera of pneumonia cases
and of natives inoculated with varying doses
of pneumococcus vaccines, and the exam-
ination of statistics in regard to the incidence
of lobar pneumonia in inoculated and un-
inoculated groups. The results obtained by
these workers were distinctly discouraging
as to the value of inoculation with pneu-
mococcus vaccine of native laborers on the
Rand.
The problem was then taken up by Dr.
F. G. Lister of the South African Institute
for Medical Research, who has strenuously
and continuously labored in this matter
since 1912.
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The chief difficulty experienced by
Wright and his co-workers in investigating
this problem was the fact that the ordinary
laboratory tests, such as agglutination and
opsonic estimations, were not definitely or
constantly available as a guide in their ex-
periments. They found that:
**The agglutination reaction is with the
pnemnococciis only very irregularly ob-
tained, and that in regard to sub-cultures of
the pneumococcus from blood and lung
punctures. The vast majority of these gave
no agglutination reaction; with the blood
and lung punctures the vast majority of
these gave no agglutination reaction with
the blood of any patient."
"Moreover, in the case of these excep-
tional cultures which gave agglutination we
obtained the reaction not only with a large
number of sera from pneumonic patients,
but also with a number of normal sera. By
consequence we put aside the agglutination
test as one that could not be utilized for
the purpose of estimating the effect pro-
duced by pneumococcus vaccine."
It is clear from the published writings of
Dr. Lister that his method of demonstrat-
ing the presence of agglutinins and opsonins
in the blood of individuals suffering from
pneumonia, or inoculated with pneumo-
coccus vaccine, differed entirely from the
generally accepted methods as carried out
by Wright — the originator of opsonic work
— and his co-workers. It is necessary to
emphasize this point as this particular tech-
nic constitutes the keystone to the whole
of Dr. Lister's otherwise careful researches.
Lister's Method of Determining Agglu-
tination and Opsonic Estimation. — Dr. Lis-
ter states: 'The technic I have employed
to ascertain the agglutinating and opsonisin-
ing power of sera of my inoculated animals,
including man, has been essentially that
originated by Sir Almroth Wright in con-
nection with his work on the opsonic index."
This is liable to be misunderstood in view
of the fact that Wright's technic is used only
for the estimation of the opsonic index, and
has nothing whatever to do with the estima-
tion of agglutination. The two, however,
are combined by Lister into one examina-
tion.
Sir Almroth Wright in his opsonic technic
uses one volume each of white blood cor-
puscles, sera and emulsion of microorgan-
isms. Lister, however, departs from this
method and uses proportions of serum 2, 3,
4 and even 5 times as much. The mix-
ture thus obtained is used to prepare films
which are stained and examined micro-
scopically. This film is then used to deter-
mine both the phagocytic index and the de-
gree of agglutination. The adoption of this
technic obviously would reflect entirely dif-
ferent results to those obtained by Wright,
and explains the entirely opposite views held
by Wright and Lister.
Opsonic Index, — No one will deny that
from a theoretical and academic point of
view the discovery of opsonins by Wright
has been of the greatest service in directing
our studies and aiding us in a concrete
appreciation of the process of protection
against invasion by pathogenic bacteria, but
it is well known that the employment of
opsonic estimations as a practical diagnostic
method has been largely given up by prac-
tically all workers thruout the wodd. The
difficulty and complexity of the technic, the
impossibility of avoiding numerous pitfalls,
the widely different results obtained by in-
dividual workers on the same specimens,
and the limited number of diseases to which
this method may be applied have all com-
bined together to make the opsonic index a
matter of purely historic interest. This
phenomenon, however, is first of all ac-
cepted as of practical utility by Lister, and
then profoundly modified in its technic and
is used by him as one of the main factors
on which he found his researches. One of
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the first principles in carrying out the
opsonic estimation, is that there shall be no
clumping in the emulsion of the bacteria
employed for the test. A necessary precau-
tion in utilizing an emulsion of bacteria is
to examine the emulsion and to be satisfied
that non-clumping of bacteria is present. The
employment by Lister of 2, 3, 4 and 5
volumes of serum, however, stated by him
to contain agglutinins, and producing —
as he states — evidence of agglutination, in
just those cases in which he expects a high
opsonic index, largely destroys the value of
his observations on the opsonic index of
any particular blood. Some years ago I saw
some of Dr. Lister's slides, an examination
of which did not satisfy my objection. The
doubts and misgivings, which I had at that
time as to the value of researches built up
on such a method, have now crystallized
into a definite conviction that reliance on
such methods can spell only failure and dis-
appointment.
Agglutination, — The phenomenon of ag-
glutination is an extremely variable and un-
reliable factor except under certain con-
ditions. It is the observance of these very
conditions which is so especially necessary
before an opinion as to the presence of
specific agglutinins in the blood against a
given microbe can be seriously accredited.
Dr. Lister's method of estimating agglutina-
tion constitutes an entirely new method,
which is open to the very gravest objections.
It depends on the examination of a slide,
prepared by placing a small drop of his
phagocytic mixture on the end of a slide,
and making an ordinary smear. He then
observes the degree of clumping among the
bacteria, dried, fixed and stained on this
slide. In my opinion no reliance can be
placed on observations in regard to agglu-
tination carried out by such technic. Nu-
merous factors combine together to destroy
the value of such an observation.
The usually accepted methods of carry-
ing out an agglutination test are by a mi-
croscopic method, in which the microorgan-
ism is suspended in various dilutions of
serum and examined by the microscope at
the end of definite intervals of time; and
a similar method carried out microscop-
ically, with larger volumes of fluid, the
clumping of the microbes being sufficiently
definite to be visible to the naked eye. Nu-
merous difficulties and pitfalls may be ex-
perienced even when this test is carried out
with these elaborate methods. It was by
such methods that Wright and his co-work-
ers came to express their opinion that:
"The agglutination reaction is, with the
pncumococcus, only very irregularly ob-
tained."
Lister's method of carrying out a com-
bined opsonic and agglutination test has
been deliberately criticized as it is quite
clear from a careful examination of his
published writings, that his researches on
this subject, and the conclusions formulated
by him largely rest on the results obtained
by the very questionable methods outlined
above.
Strains of Pneumococcus, — During re-
cent years advances in our knowledge of
bacteriology have made the subject more
complex and difficult. At one time it was
thought that only one organism caused ty-
phoid fever, only one organism caused
dysentery, and so on. Since that time, how-
ever, various strains of typhoid, para-
typhoid and dysentery organisms have been
identified.
We have now entered on a transition
stage in which it has become obvious that
the dogmatic detailed classification of bac-
teria must be approached with caution, in
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view of the increasing evidence as to the
phenomena of "mutation." Some have gone
so far as to state that B, typhosus can ac-
tually be changed into S. coli communis,
and so on. Fortunately, altho mutation un-
doubtedly has its place in the life history
of microbes, yet the statements in regard
to radical changes of all the specific charac-
teristics of a microorganism at the same time
must be accepted with reserve. It is true
that one or other of the characteristics ex-
hibited by a microorganism, e, g,, agglutina-
tion, motility, virulence, etc., is subject
to change, but that all the characteristics
by which such organisms can be identified,
should undergo a complete sudden mutation,
must be accepted with considerable reserve.
Time will prove, however, as to how far
conservative bacteriologists are justified in
maintaining this attitude. The proposition
before us, however, is of an entirely dif-
ferent nature. We are asked to believe that
a microbe, pneumococcus, is represented by
a large number of named strains, eight of
which have been identified as A, B, C, D, E,
F, G, X, all other pneumococci not falling
into any of these groups being classified as
undassifiable. It is claimed that each of
these strains is a definite entity and can
readily be distinguished one from the other ;
each has its own serologic characteristics
whereby identification can be effected. Quite
apart from other considerations, in the pres-
ent state of our knowledge it is surely too
much to expect that such a statement can
go unchallenged. Apart from this general
expression of opinion, however, on reflec-
tion we find that the identification of Lis-
ter's various strains of pneumococcus is
based upon a technic which it is considered
is totally unreliable. In other parts of the
world not more than four strains have been
identified, but we find no sound reason —
if identification is to rest upon such technic
as has been criticized above — why an in-
definite number of strains of pneumococcus
cannot be identified. It is significant that
the enthusiasts who insist on the importance
of identification and naming of strains of the
pneumococcus reserve an undassifiable
group for types which do not fit into their
named groups. Further the number of
named groups is steadily increasing. It
should be remembered that the identification
of these strains rests upon properties of
agglutination and opsonic estimation which
have been shown by Wright and others to
be variable and useless for purposes of in-
vestigation into pneumonia. Certainly the
recognition of different strains of micro-
organisms has been of distinct practical
value in that attention has been directed
to the importance of preparing vaccine not
from individual strains, but from a number
of different virulent strains.
The tendency in recent years in bacteri-
ology has been when success has not been
achieved by vaccine therapy or prophylaxis
to attribute such lack of success to the
presence of a new and unidentified strain
of the particular microorganism commonly
accepted as the sole etiologic factor in the
disease. This attitude is well known in
South Africa notably in regard to the nu-
merous experiments which have been car-
ried out in regard to the prevention of
pneumonia among native laborers on the
Rand. Failure to afford protection to the
inoculated who have developed a fatal pneu-
monia has always been attributed to the
presence of a strain of pneumococcus pre-
viously unrecognized or not included in the
particular vaccine used. The hope also has
always been held out that when further
additional strains of the pneumococcus are
included in the prophylactic vaccine advo-
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cated and employed that success will be
achieved. I must put on record most em-
phatically my entire disagreement with this
attitude. The chief practical importance of
the recognition of various strains of the
same microorganism is that the practice
hitherto almost universally carried out, of
preparing therapeutic vaccines and sera
from one individual representative of a mi-
crobe, is no longer justified. My experience,
however, extending over a number of years
in the preparation of various vaccines is
that the problem of variation in bacteria is
adequately and successfully solved by the
preparation of vaccmes and sera from a
large number of unidentified virulent strains.
Practically speaking there is no limit to
the number of strains which might be em-
ployed, and from a general point of view,
the more the better provided each strain
is a virulent specific organism exhibiting all
the chief characteristics of the particular
microbe and is recently isolated from a
definite pathologic condition, exhibiting
typical signs.
Preparation of Dr, Lister's Eight Group
Pfieumococcus Vaccine, — It is proposed now
to deal with the actual technical details
connected with the preparation of Lister's
pneumococcus vaccine, as set out in the pub-
lications of the South African Institute for
Medical Research. This vaccine is prepared
by growing pneumococci on what may be
briefly called glucose broth, instead of on
solid media, because "to obtain sufficient
culture for the vaccine it is not practicable
to make use of solid media owing to the
great quantities of it which would be re-
quired, and the relatively poor growth of
pneumococcus in such circumstances." The
serious danger, however, in such a method
of preparation is dearly stated by Lister
as follows:
When growth of pneumococcus has oc-
curred in this medium autolytic changes
rapidly take place ; after 12 hours therefore
a close watch must be kept or the growth
may speedily be rendered useless for the
•preparation of vaccine."
Dr. Lister further states:' "That pneu-
mococci sedimented in a 40 hour old glucose
serum broth culture are devoid of anti-
genic properties both for rabbit and man."
It is, therefore, clear that the seri-
ous risk of deterioration of vaccine
during the course of preparation is
taken because it is considered that the prep-
aration of vaccine on solid media, which
is preferable in every way, cannot be prac-
tically carried out. In this I entirely dis-
agree with Dr. Lister as there are no prac-
tical difficulties in preparing the vaccine
from cultures grown on a suitable solid
medium. It is merely a question of mak-
ing suitable arrangements on an adequate
scale. The antigenic value of vaccine de-
pends largely on the suitability of the
medium used and in regard to pneumo-
coccus, blood agar is the best medium to
employ. Autolytic changes must be avoided
at all costs. It is not intended, however, to
minimize unduly the difficulty which might
arise if inoculation were generally carried
out of the whole native labor population but
the difficulties could certainly be overcome.
The same anxiety, no doubt, has forced
Dr. Lister to adopt the extremely question-
able technic of concentrating the weak vac-
cine prepared by a growth of short dura-
tion in glucose broth, by means of a power-
ful centrifuge, which is nothing more or
less than a cream separator. The contamina-
tion of the concentrated vaccine is evidently
unavoidable as Dr. Lister admits. To quote
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from his own paper :
**As might be inferred from a considera-
tion of this method a few spores of B, sub-
tilis are unfortunately present in the sus-
pension, and they are not easily killed." One
difficulty thus leads to another as this con-
centrated vaccine has to be treated with a
powerful disinfectant for a period of any-
thing up to 5 days in order to kill out the
contaminating organisms which are un-
avoidably drawn into the vaccine during the
process of rapid centrifugalization. What
the effect of this severe prolonged treatment
by means of strong disinfectant on the con-
centrated vaccine may be no one can say;
but it is obvious that such a complication is
better avoided if possible. Vaccine pre-
pared from solid media entirely obviates all
the difficulties pointed out above. Such a
method allows of the preparation in a sterile
manner and its accurate standardization.
Moreover it is possible to keep each batch
of vaccine of known composition and uni-
form strength, which is of vital importance.
Unless the vaccine be capable of issue in a
uniform strength it is necessary to find the
appropriate dose for each batch of vaccine
issued. Furthermore, it is noteworthy that
Lister's vaccine is prepared from cultures of
considerable laboratory age. Recently iso-
lated strains are preferable for the prepara-
tion of vaccine.
Dosage of Lister's Eight Group Pneu-
mococcus Vaccine. — At first sight the dose
recommended of the vaccine under con-
sideration for the treatment and prevention
of pneumonia is nothing short of astound-
ing, and demands the most careful examina-
tion. When a statement is made that a case
of acute lobar pneumonia can safely be
given a dose of seven thousand million
pneumococcus vaccine, it is obviously neces-
sary to seriously question the antigenic titre
of such a preparation, or the possibility of
the illness not being due to pneumococcus,
I am aware that when Lister's vaccine
was first employed for the treatment of
cases of pneumonia that no clinical response
whatever was obtained until the dose given
reached about ten thousand million. In cases
of pneumococcal pneumonia I usually ob-
tained definite response with doses of twen-
ty-five million to one hundred million pneu-
mococcus vaccine carefully standardized
and prepared from blood agar. The obvious
inference therefore is that the antigenic
value of Lister's ten thousand million pneu-
mococcus vaccine is roughly equivalent to
from twenty-five million to one hundred
million pneumococcus vaccine prepared on
blood agar and carefully standardized. It
is therefore clear on these grounds
alone that the process of manufac-
ture enormously reduces the antigenic
value of the vaccine. Autolytic changes
probably represent the chief factor in this
amazing lowering of its efficiency. It will,
therefore, be seen that the objections to this
method of preparation of Lister's pneumo-
coccus vaccine are very weighty, vh.,
the impossibility of preventing autolytic
changes, the contamination of the vaccine,
and its consequent prolonged treatment with
a strong disinfectant, its astonishing reduc-
tion and consequent wide variation in anti-
genic value.
From a close study of the treatment of
respiratory disease with vaccine I have for
many years been satisfied that the above
facts afford the only explanation available
as to how such apparently large doses of
vaccine can be employed in the treatment of
such an acute disease, so sensitive to vac-
cine as lobar pneumonia.
That the success or failure of vaccine in
the treatment of various diseases depends
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161
very largely on the actual dosage employed
need not be emphasized here except to say
that the correct dosage of vaccine is just as
important as the selection of an appropriate
vaccine. To put the matter shortly, it should
clearly be understood that the dosage of
pneumococcus vaccine recommended by Lis-
ter can and should only apply to Lister^s
vaccine. This is probably not sufficiently
well understood. Altho for many years
I have known of the large doses recom-
mended by Lister of his vaccine I have not
found it necessary to, in any way, modify
the doses which I myself employ of pneu-
mococcus vaccine for the treatment of pneu-
mococcal infections.
Statistical and General Evidence. —
The fallacies liable to be associated with
deductions based on statistical examination
are too well known to need further em-
phasis here. The valuable paper by Dr. G. D.
Maynard, late statistician to the Institute
for Medical Research, Johannesburg, en-
titled Pneumonia Inoculation Experiment
No, 5 emphasizes this matter to an extraor-
dinary degree. It will be remembered that
a large experimental inoculation was car-
ried out at the Premier Mine, the results
of the inoculation showing a most marked
degree of decrease in the incidence of pneu-
monia among inoculated natives. As Dr.
Maynard states "this result was totally out
of keeping with the results on the Rand
but in spite of this in some quarters great
stress was laid on these returns. A critical
examination of these figures showed, how-
ever, that the great decrease in pneumonia
among the inoculated was spurious and
that the results obtained were in a large
part due to the adoption of a faulty system
of allotting the controls, and to other statis-
tical fallacies. A further experimental in-
oculation was undertaken by the Rand
Mines the result of which was not favor-
able to inoculation. Dr. Maynard's paper
then deals with the investigation of ex-
perimental inoculation carried out with Lis-
ter's vaccine, in which 55,900 natives were
employed, half being inoculated and half
serving as centrals and confirms the con-
clusion of a previous investigation as fol-
lows:
(1) That the attack rate from pneu-
monia is apparently lessened by inoculation,
a small positive correlation being obtained.
(2) That there is little or no evidence
that the case mortality is favorably affected
by inoculation.
He further states that he is unable to give
any satisfactory reply as to whether the
vaccine prepared by Lister from identified
. strain offers any advantage over the vaccine
previously prepared by Wright from non-
identified strains. On the face of it these
conclusions are paradoxical. To claim pro-
tection against a particular disease, and at
the same time to admit that the mortality
among the inoculated is not favorably af-
fected, is entirely at variance with the ex-
perience gained of preventive inoculation
in other diseases. It has been the universal
experience that among these individuals
previously inoculated against typhoid and
paratyphoid fevers, who in spite of inocula-
tion developed the disease, the mortality is
considerably reduced, the disease tending
to be mild and free from complications. It
is stated however, that after prophylactic
inoculation against pneumonia, altho the
attack rate is lessened that the case mortal-
ity is not affected. Under these circum-
stances, it is clear that the evidence in
favor of inoculation with Lister's pneumo-
coccus vaccine must be trifling. Without
going into details of the statistics dealt with
by Dr. Lister in his more recent publica-
tion, November, 1917, the concluding para-
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graphs of this paper are significant. Dr.
Lister states: "I have not lost sight of the
fact that a reduction of the mortality from
pneumonia has occurred' of late among
the whole population of native mine laborers
in the Transvaal. This is especially obvious
during the present year and critics have lost
no time in expressing the opinion that this
fact indicates that the reduction recorded
on the experimental mines is merely part
of a general decrease due to natural causes."
* * ***This bare expression of opinion, how-
ever, constitutes a very glaring instance of
suppressio veri. The fact that while there
is a total of about two hundred thousand
native laborers nearly three hundred thou-
sand doses of pneumococcal vaccine have
been used by this institute for their prophy-
lactic inoculation during the past twenty-
two months is ignored. Until the statement
that A, B and C pneumonia has been com-
pletely abolished, under experimental con-
ditions, is refuted, all such speculative
criticism is futile and scarcely deserves
serious consideration."
As each boy received three inoculations
it would appear that some fifty thousand
boys were inoculated during the year. But
it should be remembered that the vast ma-
jority of native workers only work for short
periods, on an average about six months,
on the mines, so that the actual proportion
of inoculated boys to the total amount of
population must constitute a small propor-
tion, about 10%. It is, therefore, clear that
the incidence of pneumonia has decreased
on all mines, possibly owing to the im-
proved sanitation, better feeding, and more
careful selection of recruits — the suscep-
tible tropicals being excluded — and that in-
oculation has been applied up to the pres-
ent to only a small proportion of native
labor engaged on the mines. But there is a
further factor to be considered in regard
to the general decline in the incidence of
pneumonia in the mines. I am aware of an
occasion when twelve boys, picked out for
demonstration purposes as cases of lobar
pneumonia, were found on investigation,
in every case, to be cases of tuberculosis.
The difficulty of differential diagnosis under
the conditions of pressure of work obtain-
ing on many of the mines, the wide inci-
dence of silicosis with or without pulmo-
nary tuberculosis among the natives, on the
mines, and the fact that as mentioned by
Dr. Lister "Tuberculosis is unfortunately
increasing rather than decreasing among
the native mine laborers" all raise the very
important query as to how far statistics
based on rapid diagnosis, which is liable to
be bacteriologically incorrect, can be seri-
ously considered? The fact remains that
while the incidence of pneumonia has de-
clined the incidence of tuberculosis has in-
creased. In addition to this evidence, how-
ever, it will be remembered that preventive
inoculation against pneumonia was largely
carried out among the native labor contin-
gent which went overseas to Flanders. In-
vestigations, however, have proved that the
incidence of pneumonia among the inocu-
lated and uninoculated members of this
contingent showed no advantage in favor of
inoculation with Lister's pneumococcus vac-
cine. Furthermore, it is known that experi-
ments carried out in areas other than the
Rand on a fairly large scale have given ab-
solutely negative results. It will, therefore,
be seen that quite apart from the very seri-
ous objections which have been raised in
regard to a selection of strains and the ac-
tual method of preparation of this vaccine,
there are many disquieting factors which
call into question the validity of the claims
which have been publicly put forward as
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163
to the success of prophylactic inoculation
against pneumonia on the Rand. Further-
more, the evidence which is forthcoming in
regard to the incidence of pneumonia
among inoculated natives during the pre-
vailing epidemic is significant. I under-
stand no advantage in favor of inoculation
has been demonstrated, a particularly heavy
mortality occurring at Kimberley where in-
oculation had been largely practiced, and
on the Rand no marked diflference was ap-
parent between inoculated and uninoculated
groups. These results are in accordance
with bacteriologic findings as pneumococcus
alone has been a comparatively unimportant
factor in the heavy mortality during the pre-
vailing epidemic. In conclusion it is neces-
sary to state that the failure in the present
method of prophylactic inoculation against
pneumonia is due not to the presence of an
unidentified strain or strains of pneumo-
coccus but to the fact that the etiologic im-
portance of other microorganisms especial-
ly Af. cc^arrhalis, streptococcus, strepto-
coccus mucosus capsulatus, B, influensae,
B. Friedlander, B, septus and staphylococcus
has not been appreciated. The employment
of a highly multivalent vaccine prepared
from numerous recently isolated virulent
strains of the above microorganisms enor-
mously reduces the incidence of pneumonia
and other respiratory diseases (excluding
tuberculosis) and markedly reduces the
mortality from these diseases. It is also
significant that the individuals inoculated
prophylactically with this mixed vaccine
shortly before the prevailing influenza epi-
demic appeared in South Africa have es-
caped infection or only suffered from mild
attacks free from complications.
In conclusion I should like to place on
record my appreciation of the valued assist-
ance and loyal support in these prolonged
investigations of Mr. F. Russell, chief lab-
oratory assistant, forinerly of the Lister
Institute, Mr. D. J. Russell, and Mr. J. A.
Colverd, laboratory assistants. Clinical Re-
search Laboratories, Johannesburg.
Summary.
L Anaphylactic and anti-anaphy lactic
phenomena play a very important part and
are valuable guides in vaccine therapy,
especially in diseases of the respiratory tract.
Serologic tests are not satisfactory guides
or reliable indicators of established immu-
nity, or of practical service in the carrying
out of treatment with vaccines or sera.
2. The very important part played by
symbiosis in bacterial infections of the re-
spiratory organs cannot be too strongly
emphasized. The clinical results of thera-
peutic and prophylactic inoculation with
mixed vaccines lend strong support to these
views.
3. A constitutional weakness in the elab-
orate defensive organization against inva-
sion by the causative microorganisms of re-
spiratory diseases indicates a pneumoca-
tarrJwl diathesis. This constant diminished
resistance can be successfully reversed by
specific immunization with a highly multi-
valent mixed vaccine prepared from numer-
ous recently isolated virulent strains of
those pathogenic bacteria commonly con-
veyed in the air breathed. Non-specific
treatment is of no avail.
4. Roughly less than 25% of cases diag-
nosed as pneumonia in general practice are
due primarily to infection with pneumo-
coccus, the proportion varying from time to
time. In all cases of pneumonia, however,
the condition is sooner or later a mixed in-
fection in which any of the causative bac-
teria of respiratory diseases may be present.
M. catarrhalis and streptococcus are the
commonest in South Africa. Pneumococcus,
B, Friedlander, B. injiuen::ae, streptococcus
mucosus capsulatus, staphylococcus, B, sep-
tus are also regarded as important organ-
isms in the etiology of pneumonia.
5. Whatever theoretical objections may
be raised to this stotement,the clinical results
in practice, both of therapeutic and prophy-
lactic inoculation for pneumonia, with a
mixed vaccine afford overwhelming evi-
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ORIGINAL ABTICLBS
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dence -as to the soundness of these views.
The mixed vaccine used is prepared from
150 virulent recently isolated strains of M.
catarrhalis, streptococcus, pneumococcus,
streptococcus mucosus capsulatus, B. Fried-
lander, B. influenzae, B, septus and staphy-
lococcus. Each organism is represented in
a curative therapeutic dose, the actual dose
used being somewhat less than the amount
required "when each organism is used sep-
arately.
6. These views have been strongly con-
firmed and widely tested on a very large
scale in South Africa during the prevailing
epidemic of Spanish influenza, the very
heavy mortality being due almost entirely
to pneumonia. The mortality from pneu-
monia has been greatly reduced by thera-
peutic inoculation with mixed vaccines.
Similarly prophylactic inoculation with
larger doses of this mixed vaccine has re-
duced the incidence of influenza and pre-
vented pneumonia, fatalities in individuals
inoculated twice being rare.
7. The failure of preventive inoculation
against pneumonia with various pneumo-
coccus vaccines is due to a false or incom-
plete conception of the etiology of the dis-
ease broadly diagnosed as pneumonia. This
want of success is not due to faulty dosage
of pneumococcus vaccine, or the absence of
unidentified strains of pneumococcus. If
pneumococcus vaccine was of definite value
proof would have been forthcoming long
since in view of the numerous experiments
which have been carried out on a large
scale.
8. This failure is due to the fact that the
etiologic significance of other microorgan-
isms has not been recognized. The organ-
isms in addition to pneumococcus are M. ca-
tarrhalis, streptococcus, streptococcus mu-
cosus capsulatus, B. Friedlander, staphy-
lococcus, B. influenzae and B. septus. That
the incomplete and inaccurate views in re-
gard to the etiology of pneumonia have
survived so long is due to the modern de-
velopment of water-tight compartments in
medicine. The clinician is not a bacteriol-
ogist. The bacteriologist is not a clinician.
9. Prophylactic inoculation with mixed
vaccine prepared from the organisms
enumerated will enormously reduce the in-
cidence of pneumonia and other respiratory
diseases (excluding tuberculosis) and large-
ly abolish the mortality from these diseases.
The actual composition of the vaccine and
proportion of each organism represented in
the mixed vaccine used should be decided
from a close and extensive study of the bac-
teriologic flora found in respiratory dis-
eases.
WHY NOT BIRTH CONTROL CLINICS
IN AMERICA?
MARGARET SANGER,
New York City.
The absurd cruelty of permitting thou-
sands of women each year to go thru abor-
tions to prevent the aggravation of diseases,
for which they are under treatment, as-
suredly cannot be much longer ignored by
the medical profession. Responsibility for
the inestimable damage done by the practice
of permitting patients suffering from cer-
tain ailments to become pregnant, because
of their ignorance of contraceptives, when
the physician knows that if pregnancy goes
to its full term it will hasten the disease
and lead to the patient's death, must in
all fairness be laid "at his door.
What these diseases are and what dangers
are involved in pregnancy are known to
every practitioner of standing. Specialists
have not been negligent in pointing out the
situation. Eager to enhance or protect their
reputations in the profession, they con-
tinually call out to each other: "Don't let
the patient bear a child — don't let preg-
nancy continue."
The warning has been sounded most
often, perhaps, in the cases of tubercular
women. "In view of the fact that the tu-
bercular process becomes exacerbated either
during pregnancy or after child birth, most
authorities recommend that abortion be in-
duced as a matter of routine in all tuber-
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ORIGINAL. ARTICLES
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165
cular women," says Dr. J. Whitridge Will-
iams, obstetrician-in-chief to the Johns
Hopkins Hospital, in his treatise on "Ob-
stetrics." Dr. Thomas Watts Eden, ob-
stetrician and gynecologist to Charing
Cross Hospital and member of the staffs
of other notable British hospitals, extends
but does not complete the list in this para-
graph on page 652 of his Practical Ob-
stetrics. "Certain of the conditions enu-
merated form absolute indications for the
induction to abortions," he says. "These are
nephritis, uncompensated valvular lesions of
the heart, advanced tuberculosis, insanity,
irremediable malignant tumors, hydatidi-
form mole, uncontrollable uterine hemor-
rhage, and acute hydramnios."
We know that abortion, when performed
by skilled hands, under right conditions,
brings almost no danger to the life of the
patient, and we also know that particular
diseases can be more easily combated after
such an abortion than during a pregnancy
allowed to come to full term. But why not
adopt the easier, safer, less repulsive course
and prevent conception altogether? Why
put these thousands of women who each
year undergo such abortions to the pain
they entail and in whatever danger attends
them?
Why continue to send home women to
whom pregnancy is a grave danger with
the futile advice: "Now don't get this way
again !" They are sent back to husbands
who have generations of passion and pas-
sion's claim to outlet. They are sent back
without being given information as to how
to prevent the dangerous pregnancy and are
expected, presumably, to depend for their
safety upon the husband's continence. Back
comes the patient again in a few months
to be aborted and told not to do it again.
Does any physician believe that the pic-
ture is overdrawn? I have known of many
such cases. A recent one that came under
my observation was that of a woman who
suffered from a disease of the kidneys. Five
times she was taken to a maternity hospital
in an ambulance after falling in offices or
in the street. One of the foremost gynecol-
ogists of America sent her out three times
without giving her information as to the
contraceptive means which would have pre-
vented a repetition of this experience.
Why does this situation exist ? One does
not question the intent or the high pur-
poses of these physicians, or that they are
working for the improvement of the race.
But here is a situation that is absurd —
hideously absurd. What is the matter?
Several factors contribute to this state of
affairs. First, the subject of contraception
has been kept in the dark, even in medical
colleges and in hospitals. Abortion has been
openly discussed as a necessity under cer-
tain conditions, but the subject of contra-
ception, as any physician will admit, has
only recently been brought to the front.
It has been permitted to lie latent ; it has
escaped specialized attention in the labora-
tories and the research departments. Thus
there has been no professional stamp of
approval by great bodies of experimenters.
The result is that the average physician
has felt that contraceptive methods are not
yet established as certainties and has, for
that reason, refused to direct their use.
Specialists are so busy with their own
particular subjects and general practition-
ers are so taken up with their daily routine
that they cannot give to the problem of
contraception the attention it must have.
Consultation rooms in charge of reputable
physicians who have specialized in contra-
ception, assisted by registered nurses — in a
word, clinics designed for this specialty —
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Mabch^ 1919
ORIGINAL. ARTICLES
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would meet this crying need. Such clinics
should deal with each woman individually,
taking into account her particular disease,
her temperament, her mentality and her con-
dition, both physical and economic. Its sole
function should be to prevent pregnancy.
In the accomplishment of this, a higher
standard of hygiene is attained. The re-
sult would be not only the removal of a
burden from the physician who sends her
to the clinic, but an improvement in the
woman's general condition that would re-
flect itself in a number of waya to the bene-
fit of her family.
All this for the diseased woman. But
every argument that can be made for pre-
ventive medicine can be made for birth con-
trol clinics for the use of the woman who
has not yet lost her health. Sound and vigor-
ous at the time of her marriage, she could re-
main so if given advice as to by what means
she could space her children and limit their
number. When she is not given such in-
formation, she is plunged blindly into mar-
ried life and a few years is likely to find
her with a large family, herself diseased,
damaged, an unfit breeder of the unfit, and
still ignorant. What are the fruits of this
woeful ignorance in which womerf have
been kept ? First, a tremendous infant mor-
tality— hundreds of thousands of them dy-
ing annually of diseases which flourish in
poverty and neglect. Next, the rapid in-
crease of the feebleminded, of criminal types
and of the pathetic victims of toil in the
child labor factories. Another result is the
familiar overcrowding of tenements, the
forcing of the children into the street, the
ensuing prostitution, alcoholism and almost
universal physical and moral unfitness.
These abhorrent conditions point to a
blunder upon the part of those to whom we
entrusted the care of the health of the in-
dividual, the family and the race. The
medical profession, neglecting the principle
involved in preventive medicine, has per-
mitted these conditions to come about. If
they were unavoidable, we would have to
bear with them, but they are not unavoid-
able, as shown by facts and figures from
other countries where contraceptive infor-
mation is available.
In Holland, for instance, where the in-
formation concerning contraceptives has
been accessible to the people, thru clinics
and pamphlets since 1881, the general
death rate and the infant mortality rate have
fallen until they are the lowest in Europe.
Amsterdam and The Hague have the lowest
infant mortality rates of any cities in the
world.
It is good to know that the first of the
birth control clinics of Holland followed
shortly after a thoro and enthusiastic dis-
cussion of the subject at an international
medical congress in Amsterdam in 1878. The
first birth control clinic in the world was
opened in 1881 by Dr. Aletta Jacobs in
Amsterdam. So great were the results
obtained that there has been a gradual
increase in the number of clinics, until to-
day there are fifty-two in operation in that
country of some 6,000,000 people. Physi-
cians have found that nurses trained for
this work by specialists are highly com-
petent to take care of it and it is the almost
invariable rule that birth control clinics are
conducted by such nurses. Dr. J. Rutgers
of The Hague, secretary of the Neo-Mal-
thusian League, is the specialist who trains
and instructs the nurses. The general re-
sults of the work are best judged by the
tables shown on page 167, taken from The
Annual Summary of Marriages, Births and
Deaths in England, Wales, etc., for 1912:
In conclusion, I am going to make a
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ORIGINAL ARTICLES
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167
statement which may at first seem exag- They will continue to mark time until they
gerated, but which is nevertheless carefully get at the source of these destructive con-
considered. The effort toward racial ditions and apply a fundamental remedy,
progress that is being made today by the That remedy is birth control.
Amsterdam (Malthusian [Birth Control] League started 1S81; Dr. Aletta Jacobs gave ad-
vice to poor women, 1885.)
1881-85 1906-10 1912
Birth rate 37.1 24.7 23.3 per 1,000 of population
Death rate 25.1 13.1 11.2 per 1,000 of population
Infantile Mortality:
Deaths in first year 203 90 64 per thousand living births
The Hague (now headquarters of the Neo-Malthusian [Birth Control] League)
1881-85 1906-10 1912
Birth rate 38.7 27.5 23.6 per 1,000 of population
Death rate 23.3 13.2 10.9 per 1,000 of population
Infantile Mortality:
Death in first year 214 99 66 per thousand living births
These figures are the lowest in the whole list of death rates and infantile mortalities in
the summary of births and deaths in cities in this report.
Rotterdam.
1881-85 1906-10 1912
Birth rate 37.4 32.0 29.0 per 1,000 of population
Death rate 24.2 13.4 11.3 per 1,000 of population
Infantile Mortality:
Deaths in first year 209 105 79 per thousand living births
Fertility and Illegitimacy Rates:
1880-2 1890-2 1900-2
Legitimate fertility 306.4 296.5 252.7 [ Legitimate birth per 1,000 married
J women aged 15 to 45
Illegitimate fertility
16.1
16.3
11.3 ( Illegitimate births per 1,000 unmar-
J ried women, aged 15 to 45
The Hague.
1880-2
Legitimate fertility 346.5
niegltimate fertility 13.4
Rotterdam.
1880-2
Legitimate ferUlity 331.4
Illegitimate ferUlity 17.4
1890-2
303.9
13.6
1890-2
312.0
16.5
1900-2
255.0
7.7
1900-2
299.0
13.1
medical profession, by social workers, by
the various charitable and philanthropic or-
ganizations and by state institutions for the
physically and mentally unfit is practically
wasted. All these forces are in a very em-
phatic sense marking time. They will con-
tinue to mark time until the medical profes-
sion recognizes the fact that the ever-in-
creasing tide of the unfit is overwhelming
all that these agencies are doing for society. .
Mineral OiL — If mineral oil disagrees
with your patient, give him olive oil; but
give enough of it, so that some goes thru
undigested. — Med. Council.
Enthusiasm. —
"Now I get me up to work,
I pray the Lord I may not shirk,
If I should die before the night,
I pray the Lord my work's all right.
—Drug Topics.
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March, 1919
LONDON LETTER
Amsrigan Mxdicinb
(From our Regular Correspondent.)
THE MEDICAL PARLIAlIEBrTART
COMMITTEE.
The outstanding feature in English medical
politics during the last month has been the in-
stitution of the Medical Parliamentary Com-
mittee. This body came into a stormy exist-
ence at a public meeting of the medical profes-
sion held late last year on the eve of the Qen-
eral Election. At the meeting a group of men
representing very diverse medical positions, in-
stitutions and movements were chosen with the
general mission to improve the chances of med-
ical men who desired to enter Imperial Parlia-
ment. Before the Medical Parliamentary Com-
mittee could get properly to work the General
Election arrived, the constituencies had se-
cured their candidates, and all that remained
for the committee to do was to supply speakers
for the platform of such adopted candidates as
were medical men. There was no chance of
nominating any new medical men. The com-
mittee rose to its chances, and supplied forceful
speakers to medical platforms, entirely regard-
less of party politics, for the Medical Parlia-
mentary Committee knew no party politics, but
only one party — ^the party of improved health for
the nation. It was recognized by all who
fathered the movement that a medical man had
a right to his political views, and that those
views, and not his medical ideals, could obtain
him a seat in Parliament — for no constituency
will elect a "member for medicine'*; but what
the committee desired to impress upon the
public, as well as the medical profession, was
that in all social legislation the public health
aspect will be the one at which medical men
must look— the health of the people is their
first charge.
The General Election resulted in the election
of seventeen medical members of Parliament, of
whom five or six will not take their seats, be-
ing committed to the principles of separation in
Ireland. Of the others the best known are* Dr.
Christopher Addison, the President of the
Local Government Board, Sir Auckland Geddes
also a cabinet minister. Sir Watson Cheyne, the
former surgeon, representing the University of
Edinburgh, Sir Robert Woods, the laryngologist,
representing the same seat of learning, and Sir
William WhiUa, the most learned British phar-
macologist, representing the Queen's University
of Belfast. The Medical Parliamentary Com-
mittee then resolved to get into close touch with
the medical members of Parliament, themselves
formed into a sort of informal committee in the
House of Commons. In this way it was thought
that a group of medical men, within the legis-
lature, who had arrived there for other than
professional reasons, could be instructed by a
group of medical men outside the house selected
entirely for professional reasons; and to make
the cooperation outlined above a real one, be-
came the immediate objective of the Medical
Parliamentary Committee. The policy was not
long to remain unchallenged. First, the British
Medical Association, possessing a committee
working to secure the election of medical men
to Parliament, considered the formation of the
Medical Parliamentary Committee an encroach-
ment upon the activities of the Association, and
withdrew all support. Secondly, a group of
medical men who wish to see the medical pro-
fession transformed into a trade union, ready
to strike for higher wages if its terms cannot
otherwise be obtained from the public, resistCMl
the desire of the Medical Parliamentary Com-
mittee to become a central body of the profes-
sion, because it had very different ideals. At
public meetings the committee did not gain
any enthusiastic support; The British Medical
Journal ignored it, and The Lancet blessed it,
but not over-enthusiastically.
But when Parliament opened the Medical
Parliamentary Committee had the not wholly
original idea of giving a dinner to explain itself
more fully. So the committee Invited all the
medical members of Parliament to meet certain
leading medical men at dihner, and Dr. Chris-
topher Addison attended the dinner as his first
social function after election to the Local Gov-
ernment Board. The dinner was a great suc-
cess, the speakers were good and the fare ad-
mirable, and Dr. Christopher Addison told his
hosts his policy with regard to the Ministry of
Health, the bill for the erection of which is in
his charge. Speeches were also made by Sir
Bertrand Dawson, Dr. Squire Sprlgge, Sir Wat-
son Cheyne, Sir James Galloway and others all
insisting upon the necessity of some unanimity
of view and design in medical politics, whereby
legislation in Parliament, when it touched up-
on the health of the people, should be inspired
by real medical knowledge obtained from the
outside. The Medical Parliamentary Committee
is a young thing; it has hardly escaped the risks
of infant mortality; but it is now shaping well.
E^ven if, in my next letter, I should have to
chronicle its early death it would not have lived
in vain, for it has given many medical men a
higher view of what is, or should be, meant by
medical unanimity. It does not imply the stand-
ing together of a professional class to exact the
highest payment from the public; it does imply
the union of the best medical thoughts for the
public good, and thereafter proper payment
from the public for work done.
THE SUPPLY OF NURSES THE PUBLIC
NEED.
In this country, as in America, considerable
difficulty exists as to the standing, training,
duties and responsibilities of the sick nurse.
On the one hand she is eulogized as par excell-
ence an example of self-denial, altruism and
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169
technical skill, and on the other hand she is
found wanting as a hybrid between the rule-of-
thumb routine which prevailed in nursing fiye-
and-twenty years ago and the high develop-
ments of clinical medicine which have been the
feature of our Science since that date. If the
glowing picture is the right one, her position is
obviously wrong. If the more unfavorable
estimate comes nearer the truth, the methods
employed in training nurses must be sadly to
seek. The trained nurse has become a necessity
in our present civilization, yet her cost makes
her services a luxury that only those in good
circumstances can enjoy. Dr. John Dill Robert-
son, Commissioner for the Department of
Health In Chicago, issued in a recent bulletin
from the Chicago School of Sanitary Instruc-
tion, a remarkable little paper upon the posi-
tion of nursing in the United States. While in-
sisting on the truth that In sickness a nurse is
a material necessity, he indicates that her
training and her salary should be better di-
rected towards turning out an article that
meets the practical wants of the community,
and every word which he says has as much
bearing in this country as in America. Dr.
Robertson finds that the nurse who has spent
three years in a training school, who has spe-
cialized in surgery, obstetrics or public health
by taking out a special course, cannot on the
one hand be expected to demand less than a
snm equivalent in British money to a pound a
day — which at once places her services out of
the reach of two-thirds of the British com-
munity— and yet is not the article that is re-
quired in bulk. His recommendation is that a
new order of what he calls "Practical Nurses"
should be instituted; that the standard of train-
ing for these nurses should be lower than that
to which the trained nurse usually aspires;
that the time of training should be six months
and IntenBive in character; and that knowledge
of practical housekeeping and domestic science
should be considered an important requirement.
He considers that this order of "Practical
Nurses'' ought to be well paid at half the price
now paid to trained nurses; but In the Bulletin,
from which we are quoting, we do not see any
suggestion from what social order these women
are to be drawn or what particular inducement
there would be for them to enter domestic serv-
ice of a hard nature at a moment when domes-
tic service of all kinds is regarded with dis-
like.
In this country we cannot conceive of an in-
ferior order of nurses obtaining any locvs
stantfi. The candidates for the service would
probably be few,^ while the public would never
be able to distinguish between the lower stand-
ard nurse and her superiorly trained sister.
There is no compulsory registration for nurses
in Great Britain, so that it would not. at any
rate at the present moment, be available to say
that the public would easily learn the difPerence
because one class is registered and the other
uncertified. The consequence is that the Intro-
duction of an inferior order into the profession
of nursing would not elevate that order, but
would degrade in popular eyes the superior
order. In this country we are committed to
the higher standard, but it is certainly true that
the education of our nurses might be vastly
more economical, take a much shorter time,
and be better directed to practical issues. The
length of time necessary for the training of a
nurse, according to the English estimate, is
three years. This is regarded as the minimum
required before she should be allowed to receive
a certificate as having learned her business in
connection with a hospital or institution of the
necessary opportunities for instruction, but as a
matter of fact the hospital training of nurses
does not occupy three years, for at least one
year is spent as probationer in largely doing a
course of domestic work, scrubbing of floors,
cleaning of bathrooms and so on, should not be
performed by a nurse, and if this drudgery were
gotten rid of there is no reason to suppose that
^ the education of the nurse could not be accom-
' plished in at least two-thirds of the time, with
better scientific results. During that two years
the training should be directed in certain main
ways. First, the nurse should receive instruc-
tion, up to the necessary point, in anatomy and
physiology, medicine and surgery, and any par-
ticular specialty she might choose to adopt;
and secondly she should obtain clinical instruc-
tion of the kind that would enable her to see
the danger signals when manifest in her
charges, for, to obtain a trained eye for sick-
ness is as important to a nurse as to carry out
implicitly the doctor's orders.
The cost of employing trained nurses could
probably be lowered not only by abbreviating
their period of probation and training but by
improving the organizations thru which they
are distributed to the public; but as a matter
of fact the institution of paying hospitals will
probably be the step necessarily precedent to
obtaining for the less wealthy members of the
public adequate nursing during sickness. The
poor obtain trained nursing at the hospitals.
The rich buy it for a high figure and enjoy
it at home. The middle class either goes with-
out it thru lack of means or -pays for it with
money which in too many cases is sadly re-,
quired for the after period of convalescence.
It will be seen that the whole profession of
nursing is in a muddled plight in England and
Scotland; in Ireland it is worse. Registration
would certainly prevent impersonation, and so
far be to the good; but it would probably in-
crease the cost of eervice which is already pro-
hibitive. ±x national scheme of district nursing
and a wide provision of paying hospitals will
probably supply the way out, but only after
the lapse of much time.
Jast Keep On Keepin' On.
If the day looks kinder gloomy
An' your chances kinder slim,
If the situation's puzzlin'
An* the prospect's awful grim.
An' perplexities keep pressin'
Till all hope Is nearly gone.
Jus' bristle up an' grit your teeth,
An* keep on keepin' on. — Ex.
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170
March, 1919
PHYSICAL THERAPY
Amsrioan Mkdicinb
Under the Editorial Direction of Albert C.
Geyser, M. D., New Tork.
REACTION OF DEGENERATION.
Much confusion exists as to the mean-
ing of ascending and descending degenera-
tion. In the spring time, when the bushes
are just beginning to sprout, if a twig is
broken off, it is separated from its trophic
center, the root of the plant. If such a twig
is left to itself the drying up begins at the
point of separation, the distal end remains
unaffected to the last. The life of the distal
end can be materially prolonged by placing
the broken end in water. For a certain
length of time the injured end will perform
the function of the root and absorb nutrition
from the water. In some cases, roots will
develop and a completely independent plant
is thus created ; this is akin to regeneration.
When the motor cells of the motor cortical
zone of the cerebrum are injured as in
apoplexy, nutrition is interfered with and
the nerve fibers coming from these cells de-
generate from the point of injury. These
nerve fibers make up the pyramidal tract,
hence in central motor cell injury we have
a descending degeneration of the pyramidal
tract. The sensory nerve tract conducts its
impulses upward thru the spinal cord, hence
•a peripheral injury causes loss of sensation
and produces an ascending degeneration in
the nerve fibers.
When a nerve is tested immediately after
injury there will be a partial or incomplete
R. D.^ This may either be qualitative or
quantitative. A little later, when the end
organs have- suffered from nutritional
changes, there will be complete loss to the
faradic and partial or complete loss to the
galvanic current. If there is loss to both
currents then complete R. D. is established.
After a few days or weeks regeneration may
take place, either thru the recovery of the
trophic cell or by the establishment of col-
lateral nerve supply. Under such circum-
stances, if the nerve is tested carefully every
two to four weeks, with a condensor ap-
' Reaction of Degeneration.
paratus, a reasonably correct prognosis may
be given. Returning R. D. after complete
absence of all reaction always means that
the axis cylinder is again in contact with
the trophic cell. The future prognosis de-
pends upon the recovery of the end organs
and the muscle fibers.
In chronic spinal progressive muscular
atrophy the lesion is located in the mo-
tor nerve nuclei which are found in the
medulla oblongata. The ganglion cells,
which are the most important components
of these nuclei, gradually degenerate, lose
their processes and finally disappear en-
tirely. The lesion of this disease, being in
the trophic cells, there naturally follows a
partial, and later a complete R. D. Owing
to the involvement of so many of the smaller
muscles of the face, the electrical reactions
are demonstrated with some difficulty until
late in the course of the disease.
In amyotrophic lateral sclerosis the
lesion is spread over a large area, com-
plete degeneration o.f the pyramidal tracts
having been observed. The reason that R. D.
is present is not due to central fiber involve-
ment but to the fact that the cells in the
anterior horn have also become affected.
Many cells, otherwise normal in appearance,
have no dendric processes or only imperfect
ones; some of the cells are tumified, nu-
trition and conduction are interfered with,
hence, the peripheral symptoms of a central
paralysis.
In cases of neuritis of all kinds, while the
trophic cell in the cord may be normal, the
axis cylinder or the conducting portion of
the neuron is affected. This, of necessity,
modifies the electric conduction, hence R. D.
As a rule the regeneration of nerve fiber
shows a progressive improvement in the
electrical tests which distinguishes it at once
from the lateral sclerosis type of cases.
In the rheumatic and toxic paralysis the
reaction of degenerations is present because
the end organs of the motor neuron are in-
capacitated as a result of the toxemia.
When the end plates of a motor neuron
fail to perform their function, the same
electrical manifestations are present as tho
the lesion was located in any other portion
of the motor neuron.
The very fact however that R. D. is
present in a given paralysis, at once estab-
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PHYSICAL THERAPY
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171
lishes the fact that the paralysis is not of
central origin. It further speaks against
myopathic paralysis as well as against all
functional or hysterical paralysis or sham-
ming. We must distinguish between muscles
which suffer as a result of their separation
from their respective trophic centers and
muscles which suffer degenerative changes
from non-use, toxines, atrophies and hyper-
trophies. As long as the peripheral motor
neuron system is not involved, so long will
there be no R. D. tho the muscle may have
undergone serious tissue changes. This
statement reversed would mean that no
matter how serious the muscle changes may
be, so long as there is no R. D. it is a myo-
pathic disease and not a neuron affection. It
establishes at least a differential diagnosis,
in an apparently similar condition between
a disease of the muscle itself and a neuron
disease.
Of course it must ever be borne in mind
that a person having all the evidence of
hysteria may have at the same time a cen-
tral or even a peripheral neuron lesion, the
one does not preclude the other. Complete
absence of R. D. in a paralysis positively ex-
cludes lesions in the lower neuron, but does
not exclude severe lesions in the cerebrum.
Again the presence of R. D. points conclu-
sively to a lesion somewhere in the lower
motor neuron, but does not always exclude
disease of the central or upper neuron. There
are other types of paralysis with marked
atrophy where no lesion exists either in the
central or the peripheral neuron. In such
paralysis R. D. cannot be present for obvi-
ous reasons. It is just in such cases that
the electrical reaction throws much light
upon the diagnosis.
Some of these diseases are:
(A) Primary myopathies or muscular
affections, not due to any disturbance of the
neuron system.
1. Pseudo hypertrophic paralysis. The
hypertrophy is caused by the overgrowth of
fibrous and fatty connective tissue. The
muscles most commonly affected are the
calf muscles, but it may occur in the upper
limbs such as the biceps and the deltoid
muscles. R. D. should of course not be
present. When it is present, it should arouse
the suspicion that the atrophy may be both
myopathic ,and myelopathic.
2. Progressive muscular dystrophy. The
lesions are in both cases purely muscular.
The atrophy in this disease may be so in-
tense that no muscular fibers remain. Some
investigators claimed to have demonstrated
lesions in the gray matter of the cord. Since
however we have no R. D. present, we are
safe in assuming that the lesions of pro-
gressive muscular atrophy are primarily
muscular. An injury to one portion of a cer-
tain system is eventually an injury to the
immediately adjoining one. It is easy to un-
derstand that when a muscle has for a long
time failed to functionate, that a certain
amount of stimulus has been withdrawn
from the neuron system which supplied
these muscles. It is not difficult to account
for a certain amount of nerve degeneration
simply from non-use.
When a muscle atrophy follows trauma,
contusions, wounds or fractures, we get a
hypo-excitability to both currents, but R. D.
is never present unless the nerve is also in-
volved. In the myalgias, lumbago and tor-
ticollis, R. D. is never present unless there
is also a toxic neuritis.
(B) R. D. is always present in affections
of the peripheral nerves in any portion from
the motor cells in the cord to the muscles
which they supply. The reaction of degen-
eration is due to the destructive alteration
of the axis cylinder or some of the small
branches of the main nerve in all cases of
neuritis and polyneuritis caused either by
exposure to cold or some toxic or infectious
agent. All varieties are characterized by
R. D. more or less complete.
In cases of toxic or infectious neuritis
followed by peripheral paralysis our first
attention was drawn to the pain without,
the paralysis. Later the paralysis developed.
If we test such a paralysis the R. D. is not
apparent until from six to eight days after
the commencement of the paralysis. If this
late paralysis should happen to be of cen-
tral origin, we would never get the R. D.
but instead a quantitative or qualitative
modification for either one or both currents.
(C) 1. Lesions of the nerve centers of
which there are two divisions. Lesions of
the zchite substance of the cord. Let us re-
call that the white substance of the cord
is principally composed of conducting
fibers, either main or collateral branches
passing up and down in the cord to cells
lying at various levels. These white columns
are the site of degenerative changes in lo-
comotor ataxia. It is not until all of the
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172
MarcHj 1»19
ETIOLOGY AND DIAGNOSIS
Amsrican Mkdicini
fibers have been destroyed that we get R. D.
Hence, in any given caseof locomotor ataxia,
so long as R. D. is absent, so long is the
prognosis for the arrest of the disease good,
more or less complete recovery is not im-
possible. These are the cases that respond
to combined treatment of diathermia and
muscle re-education. It is easy to see why
this should be so. Heat applied to a degen-
erative process in the cord stays that proc-
ess, while re-education develops the col-
lateral nerve fibers.
2. All the lesions of the cord substance
itself, such as poliomyelitis and progressive
muscular atrophy as previously mentioned.
The lesions here are due to some change in
the gray matter of the anterior horn caused
by fibrosis, sclerosis, trauma, acute inflam-
mation or hemorrhage. In these lesions the
R. D. is present early, before any atrophy
is visible, because the conducting mechan-
ism is interfered with, as a matter of fact
no impulses are generated in the trophic
centers to be conducted.
Altho in these lesions the R. D. is present
early and usually of a marked degree, the
prognosis is not bad if treatment is begun
before too much destruction in the cord
has taken place and before the end organs
have been completely destroyed from two
reasons, first, because their trophic center
has been destroyed and secondly, because
from non-use a natural atrophy and a pos-
sible absorption may have taken place.
In acute diffuse myelitis there may and
there may not be any destruction of the
trophic centers ; there may or may not even
be destruction of any of the white substance,
so that impulse generation and conduction
may be interfered with very slightly. If
such is the case, then there will be perhaps
only some loss to faradic excitability, there
may even be hyper or hypo-excitability to
the galvanic current. This would constitute
a qualitative or quantitative change and the
prognosis would be correspondingly good.
On the other hand, if in a case of diffuse
myelitis, the normal galvanic formula is re-
versed and complete R. D. is present, the
prognosis is equally grave.
A paralysis which is due to cerebral hem-
orrhage, a simple irritative lesion will show
increased excitability to both the faradic and
the galvanic current immediately after the
onset. This hyper-excitability is most
marked during the second or third week. In
older cases when more or less absorption
of the localized hemorrhage has taken place
and the irritability reduced, we find hypo-
excitability to both currents. Since this
lesion is of the central neuron, no impulses
reach the peripheral motor, hence the
paralysis. Because the peripheral neuron or
its trophic call is in no way disturbed, there
can be no R. D.
ETIOLOGY
AND
lAGNOSI
Diagnostic Yalne of Dnlness In Tnnmatie
Intnuibdomlnal Extrayasations*— Oostantini and
Vlgot {Paris Medical November 2, 1918) lay
great stress on the importance of recognizing
a fluid extravasation in penetrating wounds of
the abdomen as well as in abdominal contusions
complicated with visceral or vascular injury,
such an extravasation indicating immediate
operation. Simple perforation of the alimentary
tract seldom results in marked extravasation,
but let the smallest artery, e. g., some small
omental vessel, be injured, and a litre of blood
will easily escape into the abdominal cavity. Of
the three recognized signs of viscera] injury,
e. g.f rigidity, prehepatic sonority, and iliac
dulness, the first is unreliable because it is
lacking where there has been a simple hemor-
rhage without visceral injury and present
where there is merely a wound of the dia-
phragm; the second is simply a sign of meteor-
ism, but the third is a definitely valuable indi-
cation. The migration of blood toward the
right iliac fossa, however, as mentioned in the
usual textbooks, is an erroneous deduction. As
a matter of fact, blood extravasated in the ab-
domen tends generally to sag into Douglas'
cul-de-sac. Unless the amount exceeds 200
grams it does not rise above the brim of the
pelvis, and cannot be detected clinically. Where
it does rise higher, it will usually yield dulness
in the right iliac region rather than in the left,
for the latter is almost always occupied by the
sigmoid loop, which is not displaced by the fluid
and continues to yield a tympanitic note to per-
cussion. Less frequently, the cecum is inserted
low, while the mesosigmoid is very short and
the extravasated fluid passes above it; left-sided
dulness is then found, with marked tympany at
the right. Where the extravasation is relatively
slight, rendering comparison of the two sides
difficult, both heavy and light percussion should
be tried; if a difference between the two sides
can be definitely established, an extravasation
is present and operation is indicated. In pa-
tients who have been lying on the side, the cul-
de-sac has not been the most dependent portion
of the abdomen, and dulness in the iliac fossae
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TREATMENT
March. 1919
173
will be sought in vain. On the other hand, an
area of dulness will easily be found on the side
of the abdomen upon which the patient has
been lying. If now the patient is turned on the
back, the dulness will be observed gradually to
descend and occupy the iliac fossa of the same
side; under such conditions celiotomy is clearly
indicated.
Etiology of Prnritiis AnL— Murray (Journal
A. M. A., Nov. 2, 1918) states that true pruritus
ani is due to infection of the skin with the
streptococcus faecalis, and that in cases of
pruritus this organism cannot only be culti-
vated as the preponderant one from the affected
region, but also the patient's blood shows a
marked reduction in its content of opsonins
toward the organism. The same etiology holds
for pruritus vulvae and scroti, as well as for
the anal variety. Further support of this con-
ception of the etiology of the pruritus is found
in the fact that there is no relationship between
the occurrence of pruritis and the various rectal
pathologic conditions. The discovery of the
etiologic factor gives a logic basis for the
treatment of the condition. Since the infection
is not merely a surface one, but is one which
involves the deeper portions of the skin, it is
not possible to attack it by external local appli-
cations. As is to be expected, the various sur-
gical methods advocated have usually failed in
the cure of pruritus, at best giving but tem-
porary relief. Further, the cure of associated
rectal affections does not relieve pruritus. The
most satisfactory treatment and one which is
quite rational, is by the administration of an
autogenous vaccine, made from the streptococ-
CVS faeoalis. This vaccine contains 2.000.000.-
000 organisms per mil. killed by one-half per
cent, phenol or one-third per cent, tricresol. The
initial dose is about 0.2 mil subcutaneously. The
doses are raoidly increased in size until a good
reaction is produced, the number given varying
with the individual case. Along with this treat-
ment proohviactic measures to prevent rein-
fection should be taken, such as bathing the
anal skin after each defecation. The treatment
will not cure every case, but it is far more suc-
cessful than any other so far employed by the
author.
RU^kets »« an Etiologic Factor In the Pro-
diet'ovi of Wenk Feet In Children.— Rickets as
an etioloric factor in the production of weak
feet in children has not frequently been con-
sidered. Horwitz (Interstate Med. Jour.. Aug.,
1918) says little attention has been paid, as a
rule, to rachitic children in order to prevent
and correct foot weakness. In older children in
whom a foot defect has been noted, some
method of correction has been instituted, but
in the Infant and the child beginning to walk it
is neglected.
If we were to consider rickets as a constitu-
tional disease, leading to foot weakness and
disturbance, at times resembling true paralysis.
we would render humanity a service. If we
were to regard rickets much in the same light
as poliomyelitis, and remember that foot dis-
turbance both in form and function must result,
much as we remember that foot deformity in
poliomyelitis will and must result if the limb
were left to itself, a different attitude would be
assumed by the practitioner and even by the
pediatrist, and more useful feet and less weak-
ened feet in children, and consequently in
adults, would result A larger amount of
weak feet exists than is the general supposi-
tion, and to leave rachitic children alone, with
the idea of self-correction, is not wise.
In rickets, as in poliomyelitis, the muscle
weakness is not symmetrical, and the action of
the synergists is disturbed. While, as in polio-
myelitis, gravity plays an important part in
rickets weight-bearing is the controlling factor.
In the former the deformity may take place
before the child is able to walk; in the latter
it does not take place until walking has been
begun. This ought to give us a better oppor-
tunity to prevent deformity.
This deformity in rickets is just as easy to
foretell as in poliomyelitis. In a limb weak-
ened by rickets the child persists in the walk
used by an infant — that is, the legs are widely
separated to give a larger base for support. In
this attitude, if prolonged, the feet are naturally
abducted and pronated. This in itself leads to
deformity of the leg.
Whether the leg in rickets shall be bowed or
knocked depends on this early walk of the
child. There are, however, two strong predis-
posing factors. One is that in the female an
approach of the knees is the normal, predispos-
ing to actual knock-knee. Another is the normal
slight lateral bowing of the tibia, predisposing
in some to bowlegs. Where the tendency to
knock-knee does not exist, the bowing has the
ascendency. Added to this the separation of the
legs and the eversion of the feet in the gait
of the rachitic child, the knocking would be
exaggerated. The points, therefore, to bear in
mind are that rickets produces a muscle weak-
ness much as poliomyelitis does, and that cer-
tain deformities can be foretold, and prevented
if proper methods were instituted.
REATMENT
3lL
Allen Treatment of Diabetes*— Of great
importance, says Allen (Northwest Medicine
March, 1918), is the need of observing certain
important matters in the conduct of this method
of treatment if the best results are to be ob-
tained. In the first place a complete physical
examination should be made to discover all
abnormalities associated with diabetes or which
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March, 1919
TREATBIENT
AMBHICAN MKDICINB
may Influence the results of treatment. Thus
all foci of infection should be eliminated be-
fore treatment is started, the Wassermann test
should be performed to determine the presence
or absence of syphilis, tuberculosis should be
sought for, and the circulatory system should
be examined carefully. In the second place it
is absolutely necessary that the treatment be
individualized for each patient. In severe cases
residence in hospital with the care of a com-
petent nurse is essential at the beginning. In
less severe cases daily visits to the physician's
office are essential during the fasting period
and the urine must be examined daily, a twen-
ty-four hour specimen being used. In general
alcohol and soda should not be given, but some-
times one or the other may be helpful. Patients
must be taught to approximate the caloric values
of the foods which they eat and to know the
approximate content of each in fat, protein and
carbohydrate. Continual use of the proper foods
within the limits of tolerance is the most im-
portant of all factors. The weight of the pa-
tient should be kept below normal, but not more
than fifteen per cent, below. Excess of food of
any form is harmful and a daily Intake be-
tween 1,600 and 2,000 calories is usually suffi-
cient. Frequent careful determinations of acido-
sis are essential. Physical exercise Is extremely
important to shorten the period of fasting and
to restore and increase the patient's strength
and tolerance. Self-denial and will power should
be encouraged and the patient's environment,
habits and mental attitude deserve investiga-
tion and control. Work should be limited to
eight hours daily and an abundance of rest
assured.
Rectal Feedinpr.— As Cornwall points out
(Jour. A. M. A., Mar. 18, 1918), the colon does
not possess adequate digestive functions and
that, therefore, the food administered thru it
must be predigested or such as is absorbed
readily. Rectal feeding should also aim to pro-
vide an adequate protein ration in the form
of the aminoacids in proper proportions, salts,
the vitamlnes, and carbohydrate for fuel. Milk
provides the protein constituents, a large pro-
portion of the mineral salts, and some of the
requisite vitamlnes. It should be peptonized" and
pancreatized completely before being used.
Owing to Its capacity of undergoing lactic acid
fermentation it tends to prevent protein putre-
faction and is of advantage on this account.
Fruit juices provide the vitamlnes and other
mineral salts, and glucose is the ideal carbo-
hydrate. A satisfactory prescription for rectal
feeding, based on these facts, is: Glucose, thirty
grams (one ounce); strained juice of a half
an orange; sodium bicarbonate, two grams
(thirty grains); a like amount of sodium
chloride, and water to make 300 mils (ten
ounces). This Is to be given at 6 a. m., and at
8 a. m., 150 mils (five ounces) of peptonized
and pancreatized skimmed milk are given. Then
the same mixture as for 6 a. m. is repeated at
4 and 10 p. m., whilq the milk is repeated at
noon, 6 p. m., and midnight. This diet provides
twenty grams of protein and a fuel value of
700 calories. It may be altered as required by
increase or decrease of the glucose, addition of
glucose to the milk, addition of 0.3 gram (five
grains) of calcium chloride to the glucose
enemas, and by adding a culture of acid-
ophilic bacteria to any of the enemas. A sec-
ond plan providing the same amount of fuel,
but no protein, consists in the administration
every four hours of the glucose mixture of the
preceding. The enemas should be given at 100^
F., injected slowly, and the patient's buttocks
should be elevated while he lies on his right
side during the injection. He should maintain
this position for half an hour after the admin-
istration of each feeding. Every second day he
should be given a colonic irrigation with
physiologic salt solution.
Antfscorbntic Talne of Raw Juices of Boot
Vegetables*— Harriette Chick and Mabel Rhodes
In their exceedingly practical and valuable arti-
cle {Lancet, December 7, 1918) call attention to
the relative deficiency of raw cows' milk in
antiscorbutic substances and to the further fact
that the heating of milk materially reduces the
small antiscorbutic properties present Since
most cows' milk now fed to infants is heated at
some stage or In the preparation of the diet, it
is necessary to provide additional sources of
these vitamlnes. Fresh oranges are the best
for this purpose in point of activity, but they
are often difficult to secure and are frequently
very expensive. In the desire of finding some
substitute, the authors investigated the anti-
scorbutic properties of various root vegetables
and found that the fresh juice of raw turnips
was actively antiscorbutic j that of raw carrot,
slightly active; and that of beets about the
same as carrot juice. Steamed potato was fairly
active. The juices of the raw vegetables can
be obtained by grating the vegetable, putting
the material into muslin, and squeezing it
gently between the fingers. The juice should be
prepared fresh daily, as it undergoes changes
readily and loses Its antiscorbutic properties
rapidly.
The Heart of a Pregnant Woman.— According
to Burckhardt (Amer. Jour, of Ohstetrics, Dec,
1918) an early diagnosis of a heart lesion is es-
sential for successful therapeutics. The history
of the case is important: Menstrual disturb-
ances, aversion to exertion, vasomotor disturb-
ances, a multipara who has never regained her
full strength after a previous delivery, pyelitis,
other forms of sepsis, and toxemias should be
looked upon as suspicion. To depend on marked
objective changes in the heart and the general
system means the loss of valuable time. Low
pressure, the absence of accentuation of the
pulmonic or aostic second sound, the displace-
ments of the cardiac outlines, and the change in
intensity of murmurs over the ostia, are of
greatest importance. The frequent slmultane-
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American Mbdicinb
COURBSPONDENCE
March, 1919
175
ous occurrence of a toxemia and a cardiac dis-
turbance, caused perhaps by the same factor are
important; relatively low pressure, with a stead-
ily increasing amount of albumin, of blood
nitrogen, granular casts and blood cells pres-
ages early collapse. Drastic measures, if un-
avoidable, include prolonged and absolute rest
in bed, the use of opiates, and larger doses of
digitalis, all of which interfere with the es-
sential metabolism. Impregnation should be
prevented if possible; if conception has oc-
curred, it should in all but the severest treat-
ment be carried to term. Rest and exercise,
neither half-heartedly, should be prescribed.
Blood pressure readings, especially between the
thirty-fourth and thirty-fifth week when daily
observations are necessary in order to deter-
mine the proper time of interference and when
patients should be confined to bed, assist greatly
in controlling the patient's work. Settling
usually gives a considerable amelioration of
symptoms and patient may be given more
liberty. Offending tonsils or teeth should be re-
moved; any nasopharyngeal or dental work
should be attended to. And last but not least,
digitalis to regulate the work and rest of the
heart
EXCEPHALITIS LETHABGICA.
March 14, 1919.
To the Editor,
American Medicine, New York City:
Reports have been received from various
European cities which indicate the prevalence,
in epidemic form, of a disease which has been
named encephalitis letharglca. The first case
of the disease in this city was reported to this
Department on March 12, 1919, and information
has since been received from authoritative
sources that there are eight other cases under
observation in which this disease Is suspected.
In view of the fact that it is essential for us
to be apprised as promptly as possible of the
occurrence of cases of this disease so that we
may take such measures as may in the premises
be necessary, I would earnestly request the co-
operation of the physicians of this city in mak-
ing prompt report to the Director of the Bureau
of Preventable Diseases of any case in which
encephalitis letharglca is definitely diagnosed
or suspected.
The situation at the present moment does not
seem to warrant our making this disease re-
portable by a Sanitary Code enactment, and I
look forward with confidence to the cordial and
helpful cooperation of your readers in giving us
prompt information as to cases of this disease.
Will you kindly bring this request to the
notice of the readers of your journal?
Very truly yours,
Royal S. Copeland,
Commissioner.
NEWS NOTES""
ANNOONCEMENTi
IP
New Red Cross Head a Medical Maiir— Dr.
Livingston Farrand, who has just assumed his
duties as chairman of the Central Committee of
the American Red Cross, succeeding William H.
Taft, is a graduate of the College of Physicians
and Surgeons, Columbia, class of '91, which he
entered after his graduation from Princeton
in 1888. He supplemented his studies in this
country by courses at Cambridge and Berlin,
spending three years abroad. From 1905 to
1914 he was executive secretary of the National
Association for the Study and Prevention of
Tuberculosis. He resigned to become president
of the University of Colorado, which post he
held when he went to France to become director
of the tuberculosis work of the International
Health Board in 1917. He entered the field
when both countries were staggering almost to
the earth and the white plague was working
untold havoc in the army and among the women
and children. Under his leadership the cam-
paign by American agents achieved results
which only can be estimated fully by those
familiar with the conditions.
Thru his varied experience in this coun-
try and abroad Dr. Farrand is peculiarly well
fitted to become the national leader of the Red
Cross in its broad, projective peace program.
He has always been closely affiliated with the
societies concerned with preventive medicine
and at one time served as treasurer of the
American Public Health Association. He is
also a member of the American Psychological
Association, the American Anthropological' As-
sociation, the American Folk-Lore Society, the
American Climatological Association, the Ameri-
can Statistical Association, the Society of
American Naturalists and a fellow in the A. A.
A. S.
The new chief executive of the Red Cross was
born in New Jersey fifty- two years ago and
comes of a family which has long cherished
ideals of scholarship and social service. One
of his brothers is a professor of history in
Yale and another is headmaster of the Newark
Academy.
Dr. Farrand, who returned to this country
the last week In January, was chosen by Presi-
dent Wilson for this responsible position not
alone for his personal attributes and his broad
knowledge of social and political situations in
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176
March, 1919
NOTES AND ANNOUNCEMENTS
American Medicini
this country and abroad, but also because of his
proved reputation as an able executive and a
progressive leader.
Golden Jubilee- Ylctory Celebration Meetings—
The fiftieth annual meeting of the American
Medical Editors' Association will be held at the
Marlborough-Blenheim Hotel, Atlantic City, on
Monday and Tuesday, June 9th and 10th, and
will tak^ the form of a semi-centennial cele-
bration and a victory meeting, emphasizing the
part which this Association and its members
have taken in the world's war.
The enthusiasm manifested upon the part of
the president, ex-presidents and officers of this
Association is an assurance of its successful
outcome.
A most attractive program is now being pre-
pared and every physician, even remotely In-
terested in medical journalism, will find it to
his advantage to attend.
Red Cross Plans Xation-Wide Public Health
Campaign. — A nation-wide campaign for public
health education is one of the first of the peace
time activities to be undertaken by the Red
Cross and plans for this are well under way.
Realizing that the Chautauqua itineraries
offered unusual opportunities to reach commu-
nities most in need of health work, the Red
Cross Department of Nursing Is assigning
between thirty and forty of its most able nurses,
who have just returned from overseas, to lecture
on the principal Chautauqua circuits thru-
out the country. These lectures are to start
about June 1. In each instance the lecture will
be followed by a squad of other nurses and
Red Cross workers, who will conduct a health
exhibit and give practical demonstrations.
A Good Opportunity to Start in Practice* —
There is a good opportunity for a first class
physician in Wibaux, Mont, one that also can
do surgical work.
We would like to get one to locate here right
away, and a physician of good appearance and
personality would get the support of the town
and surrounding country.
Any information which a physician might
like to obtain in regard to this town can be ob-
tained from Mr. R. B. Chappell, Vice-President
First State Bank, Wibaux, Mont.
Free Clinic for Speech Defects.— The first
free medical clinic devoted to the treatment of
defective voice and speech conditions has been
opened at 143 East 37th Street, New York.
The clinic has as its objects to cure all forms of
speech and voice disorders such as stuttering,
stammering, lisping, nasality, cleft palate
speech, etc. It will take care of defective
teeth, mouth, or jaw conditions, when such con-
ditions are the causative factors of defective
speech. It will educate or re-educate patients
who are deaf or hard of hearing. There will be
evening classes three nights a week. The clinic
will also maintain a Central Information
Bureau and Clearing House for Speech and
Voice Disorders.
DTarcotic Control Regulations.— For the en-
forcement of the new antinarcotic law of the
State of New York, the State has been divided
into three districts. The Metropolitan district
of New York has been assigned to the first
deputy, George H. Whitney, of Mechanlcsville^
N. Y., and to the tliird deputy, Mrs. Rita A.
Yawger. The Western district has been as-
signed to the second deputy. Dr. Addison T.
Halstead, of Yates County, and the Albany dis-
trict will be under the immediate supervision
of the commissioner, Frank Richardson. Blanks
have been sent out to 30,000 persons who will
be required to use such blanks either in the
purchase, the sale, or the prescribing of nar-
cotics.
War Increases Mental Disease.— Figures com-
piled by the New York State Hospital Commis-
sion show that 3,995 more patients have been
admitted to the State hospitals during the forty-
four months since war was declared than for
the similar period of time prior to the begin-
ning of hostilities, the admissions prior to the
war being 29,316, as against 33,311 afterward.
The State hospitals are actually housing 6,500
more patients than they were built to accom-
modate. The State Commission on the Feeble-
minded has mapped out a program for the relief
of this condition, which has been presented
to Governor Smith.
Gnard Port of Kew Toric Against Smallpox^ —
A statement recently Issued by Health Commis-
sioner Royal S. Copeland calls attention to the
fact that smallpox of a virulent type is raging
in certain sections of Italy, and to guard against
the disease being brought into New York the
strictest precautions must be observed. The
closest^ possible inspection is made of every in-
coming vessel from an Italian port Every pas-
senger from Italy will be vaccinated if the time
since the departure of a ship from an Infected
port has been less than sixteen days. No pas-
senger will be permitted to land until that time
has elapsed. The New i^ork Health Depart-
ment is given the name and destination of every
person who enters the United States. If he tar-
ries In New York City he will be kept under
the observation of the officials of the Health De-
partment until all possible danger has passed.
If he does not remain in the city the health
officials of the place to which he is going are
notified. The health commissioner announces
that there is no occasion for alarm at the pres-
ent time, the purpose of the statement being to
avoid disquieting rumors and to fortify the
public against groundless fears.
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HMERICaifflfiDKW
PUBLISHED MONTHLY
BdiiariAl Olli«eai 18 East 41a« St.. New Tork Citr. PubUoatlon Ollie«ai 189 CoUefte St.. B«rlla«toB. Vt.
Complele SwIm. Yd. XXY. No. 4
HewASnlafl, VoL UV. No. 4
APRIL, 1919
CO no niALT '
CONTENTS
EDITORIAL COMHBNT 177
MEN AlVD THINGS 187
ORIGINAL ARTICLES 198
LONI>ON LETTER. , 226
RATIONAL ORGANOTHERAPY 228
PHYSICAL THERAPY 280
AMONG THE BOOKS 288
ETIOLOGY AND DIAGNOSIS 286
TREATMENT 287
NEWS NOTES AND ANNOI7NOEMENT8 . . . 288
(CoatlBiied on pac6 6)
CONTRIBUTORS
Llevt.-CoL Sir James B«zt» M. D.» LL. D.^ F. R. O.
P.. F. R. S. E.9 Liverpool. England.
Geoxve T. Steveiui, BL D.» Ph. D.» F. A. CL S.» New
York City.
Emeet ZnebUn* M. Dt. F. A. C. O. P.* Oindnnatl,
Ohio.
Lnrad Bnun* BL D., Philadelphia, Pa.
Edmond Sovehon. M. D.» F. A. O. S« New OrleanB,
Sntared as MCond-elMt nutter Jannaiy 28, 1906, at the Port Office at Bgrllagton, Vt, under Act of Congrett, March 8, ISTO.
In the Treatment of
RHEUMATIC and
NEURALGIC ILLS
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K-Y ANALGESIC
This non-greasy, water-soluble local anodyne will enable you
to ease your patient^s pain and dis<M>nifort, while your internal or
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The advantages, mMreoyer, of relieving the pain of a facial
neuralgia, an inflamed joint, or aching lumbar muscles without re-
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K-Y ANALGESIC is a safe and effective adjunct that will daily
grow more useful to the practitioner as the many opportunities for
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VAN HORN & SAWTELL DEPARTMENT
NEW BRUNSWICK, N. J^ U. S. A.
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O ILVOL containa •ppraziiiuitely 20 per cent of
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SILVOL POWDER (granular): Bottlea of one
SILVOL CAPSULES (6.grain): Bottles of KM.
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SILVOL SUPPOSITORIES (Vaginal) (5«):
Boxes of one dozen.
SILVOL BOUGIES (5^): Boxes of 25 and 100.
In its various forms Sikrol is extensively used in
tlio treatment of acute and chronic conjunctivitis,
eomeal ulcer, trachoma, rhinitis^ sinus infections,
otitis media, pharyngitis^ tonsillirisb gonorrhea, cys-
titisb vaginitii^ posterior urethritiib cervical eiosiocis.
endometritis^ etc
Medical authorities have pronounced Silvol the
most satisfactoiy proleifUsilver compound obtainable.
Literature accompanies each package.
DETROrr. MICHIGAN
U.S. A.
Parke, Davis & G>e
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American Medicine
H. BDWUi LEWIS, M. D., Afamarinjr Editor
PuBUBHKD Monthly by thb Ambiucam Mbdioal Pubushimg Company
CovyTightod by the American Medical PnblishliiK Co., 1919
IRA a WILE, Associate Editor
Complete Series, Vol. XXV, No. 4
New Series, Vol. XIV, No. 4
APRIL, 1919
to (\(\ YEARLY
^^.W In Advance
Deficiencies in Medical Education. —
The results achieved by medical men in the
war have been adjudged excellent, and re-
flect credit upon the profession. There were
numerous errors shown, however, in the
process of selecting the personnel so as to
eliminate those for one reason or another
unfitted for types of service demanded by
the military authorities. The shortcomings
revealed are considered by Brigadier Gen-
eral E. L. Munson {Journal of the American
Medical Association, April 12, 1919).
Whether or not his criticisms will be fully
substantiated by official statistics when com-
piled is a matter of conjecture. His impres-
sions, however, merit consideration, par-
ticularly, in view of the fact that they call
attention to real problems which had to be
met in the development of the Medical Re-
serve Corps.
The old Medical Reserve Corps of the
United States Army, whose existence proved
its practicability as a first-line medical
defense in meeting the emergency needs
of the government, underwent investiga-
tion and examination with a result that
probably about 15 per cent, were deemed
to be professionally undesirable. The orig-
inal method of commission of medical of-
ficers was so unscientific that many medical
officers were inducted into service, tho not
actually qualified for the work to be done.
Readjustments were therefore necessary
for both the "misfits" and the "unfits." Ac-
cording to Munson, probably 10 per cent,
of the men who came to training camps
might be grouped as substandard as far as
professional efficiency was concerned. This
view is partially supported by the fact that
"salvage classes were begun in camps for
the purpose of raising the standards of med-
ical knowledge, and in order to refresh the
memory of candidates for commission." At
some times the reclamation classes at Camp
Greenleaf amounted to as large as six to
eight per cent, of the student officers group.
It is significant that from a study of quali-
fication of candidates, the Board of Ex-
aminers found the proportion of really high
grade men in internal medicine to be small,
and "only about six per cent, were really
high class surgeons." It is patent that if
this represents the average of professional
qualification, our system of education and
practice cannot be regarded as satisfactory.
There is nothing in Dr. Munson's article to
differentiate between the educational and
practical qualifications of graduates of
fifteen years' standing, and those who
gained their professional training before
that period. It is only natural that men who
were graduated from poor medical schools
revealed lower qualifications than those who
were graduated from schools of the better
type. Similarly, the mental standards of
these graduates of inferior institutions were
on a lower scale than those trained by the
class A medical institutions. It is a cause
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178
April., 1919
EDITORIAL. COMMENT
American Medigins
for wonderment and astonishment to learn
that the psychologic tests of officers and
men at Camp Lee indicated that "the group
of physicians ranks lower in mental alertness
than any other group of the military class,
except the supply train, dentists and veteri-
narians." Investigation indicated that this
condition was largely due to the number
of applicants who had come from poor
schools and small communities where op-
portunities for development were lacking
as the supplemental cause of inferiority to
ordinary hereditary weaknesses.
From the standpoint of civil practice,
there is greater cause for interest and in-
quiry over the fact that a large proportion
of alleged specialists were only partly
qualified for the work they represented
themselves capable of performing. As Mun-
son rightly maintains, "For a man to claim
the qualities of an expert, even if his claims
are accepted by the general public, does not
make him an expert, and one of the chief
functions of medical education is to safe-
guard the community."
The deficiencies of medical education, as
suggested, refer more specifically to pre-
ventive medicine, hygiene, sanitation and
fitness to practice specialties. It is unfor-
tunate, but not entirely unexpected, that the
general average of the profession was not
revealed to be higher than described, but
unless there is contrasting evidence as to
the status of recent products and those of
licentiates of many years' standing, it is
impossible to establish definite conclusions
or to point out the most satisfactory method
of adjusting the difficulties. Medical educa-
tion in the United States has been so free
and generous that there has been developed
about one physician to every 700 prospective
patients in the United States. This is in
sharp contrast to the one physician to each
1,537 persons in England and Wales, one
per 1,969 persons in France, one per 2,124
persons in Germany before the war.
In 1901, there were 154 medical schools
in the United States which, because of the
pressure of publicity as to inferiority in
equipment and teaching, were gradually re-
duced to 100 in 1914. Similarly, the student
body declined from 27,000 in 1903, to only
14,000 in 1916. It is probable that a com-
parison of the relative merits of the grad-
uates of the past ten or fifteen years with
those of years antedating 1904 would indi-
cate the marked advances in professional
standards of ability and efficiency to the
great advantage of the younger generation
of medical practitioners.
It is manifestly important to recognize
the numerous difficulties of medical educa-
tion directly or indirectly referred to by
General Munson in the interest and the im-
provement of the educational status of
physicians. His case, however, is by no
means proven, and his numerous allegations
will require considerable supportive testi-
mony in order to demonstrate their com-
pleteness and accuracy.
The accomplishments of the medical pro-
fession in the war reflect considerable credit
and distinction upon its members and, in
all probability, the errors committed were
not in excessive proportion compared with
similar deficiencies which occurred in other
branches of the service because of a similar
degree of inexperience and lack of special-
ized training for a military career. The type
of work performed under the stress of war
was largely emergent in character, and the
response of the profession to this emer-
gency was quantitatively satisfactory, and,
undoubtedly, qualitatively gratifying. Pro-
fessional standards have not been deter-
mined and an ideal state has not been
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American Medicine
EDITORIAL COMMENT
April, 1919
179
achieved. Measured by the criterion of ideal
performance, undoubtedly many criticisms
are deserving, but from the standpoint of
human accomplishment in the light of med-
ical progress and education, which has been
too free and unrestricted, the results of the
medico-military forces may be regarded as
excellent, and the criticisms, while legiti-
mate, may be condoned because of ex-
tenuating circumstances.
It cannot be gainsaid, however, that con-
structive criticisms of our system of medi-
cal education are always welcome and
should receive the thoughtful attention of
those responsible for the development of
graduates in medicine. For this reason. Gen-
eral Munson's allegations and comments
should receive a cordial hearing and not only
result in a more careful scrutiny of the prod-
ucts of our medical institutions, but possibly
lead to a revision of some of the anti-
quated methods still persistent with refer-
ence to standards at entrance, the distri-
bution of subjects in the curriculum, and
the determination of qualifications for li-
censure.
Various lines of improvement in medical
education are suggested by Robert W.
Lovett (Boston Medical and Surgical Jour-
nal, AprillO, 1919). As he properly states,
"the object of the medical school is to make
good and efficient doctors; and no matter
how good or elaborate the medical curric-
ulum may be, if it fails in furnishing such
good and efficient doctors it needs revision
and improvement."
Handshaking. — ^The difficulties of avoid-
ing contact infection are interestingly por-
trayed by Captain G. T. Palmer of the Sani-
tarj' Corps (American Journal of Public
Health, April 19, 1919). He presents in
tabulated form the chances for acquiring
infection during the course of an ordinary
day's living. His table of contacts includes
119 different items, from the touching of
doorknobs and faucets, various eating uten-
sils and money, to handshaking, receiving
newspapers and performing the ordinary
acts involved in the simplest living, exclu-
sive of the touching of things, such as pen-
cils, pens, and other articles which are only
remotely handled by others. As he properly
notes, the mere infection of the hands is
not of great significance, except insofar as
pathologic organisms are received and
transmitted to the mouth or nose, where
they may become sources of infection.
His experiences point out that the major
contacts were in touching articles that were
or might have been touched by others im-
mediately before, in shaking hands, in car-
rying to the mouth articles possibly infected
by others. In a few instances, the hands
were brought directly in contact with the
mouth, and in other instances, the hands
were touched to the nose indirectly thru the
handkerchief. His* records really present,
thru a day's functioning, seven hand-to-nose
contacts, and two direct hand-to-mouth con-
tacts. The lessons of practical value that he
draws are as follows:
"1. That we should use handkerchiefs
one side of which is conspicuously colored
or marked so that we may always apply the
hands to one side reserving the other side
for the nose. This will protect our own
nose from our hands and help to prevent
the infection of our hands.
"2. That we should abandon the uni-
versal practice of shaking hands, substitut-
ing some other less intimate method of
salutation.
"3. That we should encourage means
which will lessen the opportunity for public
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EDITORIAL. COMMENT
American Medicinb
restaurant employees to handle eating uten-
sils."
The suggestion in section one undoubt-
edly possesses certain advantages and rep-
resents the procedure that was utilized in
the employment of masks during the influ-
enza epidemic. It represents a refinement
of procedure, however, which it would be
difficult to accomplish, unless handkerchiefs
were only used in the light, and even with
adequate lighting it would prove to be dif-
ficult for those anxious to cover up a sud-
den cough or sneeze.
The second suggestion is psychologically
unsound, and instils a degree of fear for
personal contact which is by no means com-
mensurate with the existing dangers. There
are social and psychologic values in the hand-
clasp, which are of far greater importance
in the welfare of human beings than
can be nullified by any potential hazard in-
volved by this social amenity. It would be
far more rational to advocate a great fre-
quency of handwashing before eating or
before bringing the fingers in contact with
the mouth, eyes or nose. Even this pro-
cedure has marked limitations, particularly
in relation to the free and easy habits of
infancy, childhood and adolescence, not to
mention the shortcomings which are found
in the lack of hygienic facilities in the in-
dustrial world.
The third suggestion is obviously sane,
and represents a form of sanitary improve-
ment which is economically adopted in con-
nection with cafeterias. Washing-machines
are used in increasing number in all save
the smallest of restaurants, and personal
contact of food handlers with dishes and
other utensils is being eliminated with in-
creasing success. Various regulations are
being enforced for the examination of food
handlers so as to insure their freedom from
contagious disease while performing public
service in connection with administering to
the dietetic needs of the public. Habits of
cleanliness are being instilled and the vari-
ous abuses, such as wiping plates and silver
with towels ceremoniously carried under the
arm, are being corrected. There is still a
wide opportunity for improvement in this
direction, but at least health departments
are cognizant of the necessities of improved
sanitation in public eating places, and are
taking steps thruout the country to secure
the abatement of what amounts to unsani-
tary nuisances.
While it is true that the theory of air-
borne infection is rapidly becoming sec-
ondary to our belief in direct contact infec-
tion, it must not be deemed as heretic to
regard contact transmission of epidemic
diseases as not universally proven. Un-
doubtedly, the dangers of disease transmis-
sion thru coughing and sneezing are as
great, if not greater than the hazards in-
cident to hand to mouth infections in the
vast majority of communicable diseases. It
cannot be gainsaid that direct and indirect
contacts with infected material reaching the
mouth and nose are responsible for a cer-
tain degree of dissemination of typhoid
fever, tuberculosis, syphilis, gonorrhea and
diphtheria, but it is doubtful if these play
much part in the spread of influence, per-
tussis, measles, scarlet fever and others of
a similar series of contagious diseases.
Considering all phases of contact infec-
tion, it is quite probable that the smallest
amount of danger is to be found in the prac-
tice of handshaking. The practice of oscula-
tion, theoretically, has numerous and sun-
dry objections, altho the general employ-
ment of this means of greeting is certainly
not followed by a high degree of transmis-
sion of the diseases potentially capable of
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American Mbdicinb
EDITORIAL COMMENT
April, 1919
181
being transmitted by this means. Obviously,
handshaking is far less hazardous than os-
culation. In our desire to promote hygienic
and sanitary improvements in personal and
home hygiene, sight must not be lost of the
practical, esthetic and social advantages
that are involved in the remedies suggested.
The creation of unnecessary fears is far
more dangerous to public health than the
continuance of a comparatively harmless
ceremony. The gain that would obtain from
the cessation .of handshaking would be more
than offset by the underlying fear serving
as the reason for the discontinuance of
this social practice. Pedagogically speaking,
it is far wiser to eliminate many of our
"don'ts," and to substitute more "do's."
The relief from the dangers of contact
infection is to be found in more handwash-
ing, more bathing, more use of the hand-
kerchief, more constructive directions as to
the manner of right living, rather than em-
ploying the ultra refinements of a black spot
on the handkerchief, or an abandonment of
handshaking.
The BiolojBric Food Tests.— Since 1911,
when Funk described what he termed "vita-
mines," the problems of nutrition have been
undergoing a more thoro investigation. Un-
der the term "deficiency diseases," there
have been included beriberi, scurvy, pellagra
and rickets, on the theory that deficiencies
of certain substances accounted for the oc-
currence of the diseases. Funk differentiated
vitamines into various types such as the
antineuritic, antiscorbutic, and so forth.
According to McG^Uum and numerous
coworkers, it appears to be undesirable to
continue the term "vitamine," "because the
prefix vita connotes an importance of these
dietary essentials greater than other equally
indispensable constituents of the diet, such
as certain of the amino-acids which play a
role in protein metabolism. The ending
amine has a definite and specific meaning
in organic chemistry, being used to desig-
nate a compound derived from ammonia by
the substitution of one or more of its hydro-
gen atoms by various organic radicals. Any
substance to be properly designated as amine
must contain the element nitrogen. There
is no evidence that either of these unidenti-
fied dietary essentials is an amine, and in-
deed fat soluble. A probably contains no
nitrogen, for it is especially abundant in
butterfat, and the latter is practically free
from this element."
Recent studies are strongly suggestive
that two substances of an unknown chem-
ical nature are essential for adequate nu-
trition, and McCollum and Kennedy have
provisionally termed them fat soluble A
and water soluble B, because of their
characteristic solubility in fats and in water
respectively.
The use of terms should carry with it
u certain degree of exactness and definite-
ness, and it is not quibbling to seek to estab-
lish a nomenclature that is accurate and
descriptive. For this reason, the use of such
expressions as "accessory foods," "growth
substances," "growth determinates" and
"food hormones" are undesirable, if not ob-
jectionable, to describe substances, the exact
nature of which remains undetermined
save to the extent that they have been
proven to be essential for optimum nu-
trition.
The use of fat soluble A and water
soluble B in terminology is hardly accept-
able permanently because of their indefinite-
ness, tho virtually the expressions include
most of the chemical facts known regard-
ing them. From a biologic standpoint,
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EDITORIAL COMMENT
Ambrican Mbdicinb
however, it has been amply demonstrated
that a dietetic regime, failing to contain a
relative abundance of these two substances,
results in certain forms of malnutrition, or
in the development of the eye disease,
xerophthalmia. Biologically speaking, there-
fore, the foods containing large amounts
of fat soluble A and water soluble B, the
unidentified dietary essentials, are properly
termed by McCoUum and his coworkers as
protective foods.
There are marked differences, from the
standpoint of nutrition, between diseases di-
rectly due to lack of these unknown sub-
stances A and B, and states of nutrition de-
pending not so much upon their absence,
as upon maladjustments in the quantity and
quality of the protein or the character and
amount of the inorganic constituents of
foods. Predispositions to disease, by reason
of faulty diet, are manifestly different than
diseases themselves dependent upon the lack
of an essential constituent of the dietary.
It is patent that biologic methods possess
an inherent worth superior to chemical •
analysis. Chemistry in vivo and in vitro are
not necessarily identical. The determination,
therefore, of nutritive values is far more
satisfactory when based upon animal ex-
perimentation than when based upon the
theoretic constitution of foods as deter-
mined in terms of protein, fat, carbohydrate
and ash. All proteins are not alike, nor
is the quota of energy identical in foods of
the same chemical formula. Chemistry fails
to present biologic values. The values of
chemistry and the problems of nutrition are
not to be underestimated, but deserve to
be evaluated in relation to human metab-
olism. To assume a conclusive knowledge
upon comparative food values on the basis
of chemical structure at the present time is
inadequate because chemical analysis is in-
sufficiently developed to make possible a
quantitative determination of more than a
small fraction of the digestive products of
the proteins and, in consequence, fallacious
deductions must inevitably result. For this
reason, in the interest of accuracy, some
other means must be sought to determine
the components of a dietary in terms of
types of protein to be supplied.
The practical results of biologic studies
already appear to be considerable, and there
is reassurance in the facts thus far avail-
able tending to show the benefits of a satis-
factory mixed dietary providing that it con-
tains, in addition to protein, fat and carbo-
hydrates, a due proportion of needed in-
organic salts and the essential nutritive sub-
stances, fat soluble A and water soluble B.
These two nutritive factors are freely avail-
able, and milk, eggs, and the leafy vege-
tables are therefore to be eaten in liberal
amounts. On the basis of chemical compo-
sition, the leafy vegetables would appear to
be inferior to seeds, tubers and roots, but
they possess a particular and peculiar worth
which gives them higher standing in the
vegetable kingdom because of their abund-
ance of mineral elements and fat soluble A.
Even such excellent foods as the peanut and
the soy bean, with their high protein and
fat content, possess the characteristics of
seeds in that they are low in the elements
calcium, sodium and chlorine and do not
possess the ability to sustain optimum nu-
trition without the use of protective foods
such as milk and the leafy vegetables as
supplemental in the food supply.
The growth-promoting powers of fats
from different sources vary, and it has been
thoroly demonstrated that fats derived from
plant tissue cannot be placed in the same
growth-promoting class with butterfat, the
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A.MCRICAN MBDICINB
EDITORIAL COMMENT
April, 1919
183
fats of egg yolks and the glandular organs.
Meat, itself, is unacceptable as a ration
along with seeds unless there is an additional
liberal use of leafy vegetables and milk. The
evidence of biologic study tends, to em-
phasize the greater need of milk and leafy
plants as protective foods in the dietary. A
study of the dietetic deficiencies on the
basis of chemical constituents is unsatisfac-
tory because qualitative relations cannot
be determined along with quantitative. Nor,
indeed, can chemical investigation success-
fully give the bases for judgment regarding
digestion or absorption which are essential
factors in estimating the nutritive character
of food.
The biology of foodstuffs is destined to
play a more important part in solving the
problems of nutrition, and its growth and
development will afford a more rational
basis for improving the standards of com-
munal health. Chemistry will continue to
play its important part in determining the
physical constituents of foods, while biology
applies the vital tests to the chemical studies
in the relation to the needs of the human
economy.
Americanization and Health. — ^The vari-
ous efforts now being made to secure the
Americanization of the large foreign popula-
tion resident in this country evidence an
awakening to the fact that national solidar-
ity cannot be achieved without greater co-
ordination of the ideas and ideals of our
heterogeneous population. Rational public
health administration also depends upon the
Americanization of the foreign born, but
in addition demands an understanding of
the peculiar health problems of the foreign
bom.
In the American Journal of Public Health,
February, 1919, Walter H. Brown points
out some of the "Health Problems of the
Foreign Born." To many, it would not seem
apparent that the health problems of the
foreign born differ from those bom and
educated in the United States. The fact,
however, that from 1820 to 1915 more than
32,000,000 persons arrived, of all races and
nationalities, indicates that there must have
been some effect upon the customs, man-
ners and habits of the American people re- '
sultant from the imported customs and
health and habits brought in to the national
life. It is obvious that a comparative study
of racial hereditary health and habits is
essential in understanding the peculiar
problems attributable to the various
stocks constituting our populations. Vari-
ous studies have already been made by
Billings, Hoffman, Dublin, Guilfoy and Da-
vis, but despite their significance they sup-
ply an insufficient data for the establishment
of conclusive judgments.
The continuance of European customs
niiust be fully recognized in any attempt of
health administration that seeks to counter-
act the results of such hold-over ideas in an
environment for which they are physiolog-
ically inadequate. The relation of social and
economic factors to the morbidity and mor-
tality of the foreign born population merits
careful investigation as a pre-requisite to
drafting any administrative program for the
reduction of infant mortality, the control
of communicable diseases, or the improve-
ment of personal hygiene or public sanita-
tion.
The general health problems are undoubt-
edly universal in character, but offer cer-
tain peculiarities insofar as administration
is concerned, according to the racial origin
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ApriLj 1919
EDITORIAL. COMMENT
American Medicinb
of large segregated or distributed groups of
the population of foreign extraction.
The for^gner must not be regarded as
an outsider, nor even as a stranger within the
gates. There must be no evidence of su-
periority such as is represented in the use
of terms suggestive of inferiority. From the
public health standpoint, men are not classi-
fied as "wops," '^chinks," "fritzies,"
"frogs," nor are they registered other than
as vital units in the organization of a city,
state or nation. They are equally problems
of a community, with native born Americans
of American stock ; and from a health stand-
point present no greater difficulties than do
native Americans, save insofar as linguistic
difficulties, racial customs and habits inter-
fere with their normal understanding of the
health problems of America.
At the very basis of public health admin-
istration lies a complete understanding of
all the elements entering into a public health
problem. With the understanding there must
be sympathy and appreciation of the inher-
ent health potentials of all national groups
in the population. In all probability it will
be found that the main health problem, con-
stituted by the foreign born population, lies
in their economic and social position rather
than in their accident of foreign birth. In
most instances, the hereditary elements will
be found as possessing distinctly helpful
health tendencies if properly fostered and
permitted to develop along normal lines in
a hygienic environment.
In the program for Americanization,
there must of necessity be incorporated
some scheme involving a consideration of
health. If the foreign born are accepted as
potential Americans and an effort is made
to approach their problems in the spirit of
friendliness, constructive criticism and
sympathetic understanding, a great gain to
public health will result. To ignore them or
condemn them for sins of omission or com-
mission for which they are not responsible
is to retard the development of any public
health program. The interdependence of
public health and private health is so mutual
that one may readily appreciate that the
foreign born population may be just as much
sinned against as sinning, insofar as matters
of hygiene and sanitation are involved. The
health problem of the foreign born may
require more change of sentiment and feel-
ing on the part of the health adminis-
trator than it will on the part of foreign
born families. Americanization in public
health carries with it the dual responsibility
of aiding the foreign bom to understand
his new environment, and to assist the na-
tive born to grasp the health values that may
arise from the presence of the foreign born.
New Opportunities. — ^The conservatism
of physicians is fully reflected in their fail-
ure to grasp opportunities for professional
expansion. This is recognized at once in a
consideration of the growth of professions
whose membership should boast of high per-
centages of medical men, but which appar-
ently have been more promptly accepted,
appreciated and absorbed by those ordinar-
ily designated as laymen. The public health
field, for example, is by no means dependent
upon the medical profession, altho it may
bp said, fortunately, that the brightest lights
in public health work possess the degree of
doctor of medicine. Psychologists have taken
up fields of mental hygiene, while pedagogs
have been vitally interested in the problems
of mental defectives, and handicapped chil-
dren generally. Psychoanalysts have been
drawn from various fields and, in fact, al-
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American Medici2<is
MEN AND THINGS
April, 1919
185
most any person who has undergone psycho-
analytic treatment feels competent to set
himself up as a trained worker in this di-
rection. In the efforts to study the mental
problems of childhood, one finds the medi-
cal profession lagging far behind others of
non-medical training, as is excellently ex-
emplified by the short course Binet testers,
who are doing irreparable harm in publish-
ing their conclusions regarding subjects for
which their preparation has been totally
inadequate.
The inauguration of various public health
movements, such as those for the prevention
of tuberculosis, the prevention of infant
mortality, the conservation of vision, the
control of cancer, the introduction of medi-
cal inspection of schools, the control of
venereal diseases, may be attributed more
largely to the interests and efforts of non-
medical men and women than to the
initiative and influence of the medical pro-
fession.
With the development and expansion of
public health programs, it is patent that a
large variety of new positions are to be
created involving more than a knowledge
of traditional medicine. Time will determine
in how far physicians recognize the im-
portance of these new fields and prepare
themselves for taking up phases of activity
for \vhich the demand already exists, and
for which demands will be created. If the
same backwardness in accepting alterartions
in the medico-social machinery continues,
the profession will suddenly find itself
faced with a marked limitation of its field,
with a corresponding decline in public use-
fulness. There is a vast difference between
the scientific balance of values and a
general tendency to oppose innovations. The
world is moving rapidly, and unless physi-
cians awaken to the fields of progress to be
cultivated in the future, there will be a day
of reckoning in which the balance will re-
veal marked losses to the profession.
MEN AND
THINGS
mm
Psychoanalysis and the Kaiser* — For
the simplest explanation of the Kaiser's
grotesque personality one must go to the
most complicated of sciences — psychoanal-
ysis. His interview, given out to the world in
a querulous moment and retracted in the
panic that followed such an extraordinary
self -revelation, must remain as a psycho-
logic monument for all time. The Kaiser
was always a garrulous old paranoiac, and
the generals who conducted his pathetic
career knew what they were doing when
they assigned Karl Rosner to him as a press
agent and let him talk his heart out over
tear-stirring violets and such-like things for
the benefit of a public to which Wilhelm
had successfully played for thirty-odd years.
His interview granted to Harold Begbie
was very much in character, but for once
the Kaiser spoke honestly, and immediately
afterward he regretted it. His denial that
he ever gave an interview to anyone is of
no avail; any student of character knows
that the strange things he uttered were so
genuine a product that it could not have been
manufactured. To those who knew the man
only as a boastful, swashbuckling, blood-
and-thunder imperial hero, the whimpering,
sniveling nature of his message to the world
must have come as a surprise; but to the
psychoanalyst the man who acknowledged
a partnership only with Gott (and Gott the
junior partner) was never a puzzle. Long
before the interview was made public, a well
known disciple of Freud set him down as
suffering markedly from an inferiority-com-
plex, and it is this inferiority-complex
which is at the basis of all the Kaiser ever
said, thought or did.
It is common knowledge that Wilhelm
Hohenzollern is a cripple, and it is almost
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MEN AND THINOS
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as well established that he came into the
world under the handicap of inherited dis-
ease. This scion of a great imperial house,
destined to become the ruler of an aggres-
sive, masterful race of Nietzschean blond
beasts, was in no wise suited for the role
destiny had imposed on him. His shrunken
arm, his pathetically puny figure, his whole
unheroic and unprepossessing makeup were
a constant source of humiliation to him.
Realizing this, the one aim of his life was
to deceive the world, to draw attention away
from these shortcomings, to impose himself
on the public as a giant, physically and in-
tellectually, as a colossus of courage and
ability, as the perfect symbol of perfect
kinghood. And every utterance of his career,
every act of his rule, was designed toward
this end. Charity might betray weakness;
he must not be charitable. Kindness might
betray a desire for sympathy; he must not
be kind. An inclination toward peace might
indicate cowardice ; he must become known
as the greatest war-lord of all time. Hence
his coalition with the heartless war party
of Germany in the effort to build up the
vast war machine which drained the re-
sources of Germany ; hence his famous Hun
speech to the German troops who were dis-
patched to China during the Boxer rebel-
lion; hence his periodical, blustering chal-
lenges to the world at every crisis in which
his country was involved. And in time the
world began to believe that the man was
really modeled after a heroic pattern. Many
able observers were deceived. Even such a
shrewd judge of character as the late Col.
Roosevelt was taken in. But the great test
came when Germany lost the war and the
Kaiser had to flee the country. His career
had come to an end, he was a failure, he
was found out. And what defense did he
offer to an imdeceived world? What justi-
fication did this fearless hero offer for the
course he had pursued so confidently for
three decades? His famous interview is the
answer. Robbed of his glittering entourage
of impressive uniforms, of the camouflage
of royalty that always protected him, he
stands revealed for what he is and always
was — a maudlin, quaking, whimpering
weakling. And, cowering under the lash of
the world's accusation, he tells more of him-
self than the public has ever suspected.
"Don't blame me!" he cried. "It wasn't
my fault. I didn't do it. My generals are re-
sponsible. I didn't want the war. I was a
lover of peace. My generals and my diplo-
mats wanted war, and I was thrust aside
without any consideration. My generals did
as they liked and they never told me any-
thing. I was only a figure-head. When an im-
portant message arrived at headquarters,
I was shoved out of the room, so they could
take it up among themselves. They tacked
Karl Rosner on to me, and sent me around
the country making pretty speeches — any-
thing so long as they had me out of the
way. Those nasty diplomats were the ruin
of me. If it were not for them, I'd still be
a great man in the eyes of the world. I
didn't dare open my mouth to protest. I was
a puppet in their hands. Don't blame me. I
couldn't help it !" All of which is so amaz-
ingly interesting because it is amazingly
true. The Kaiser was nothing but a puppet
in the hands of the German war-makers. He
acknowledges it now. Trapped by defeat, he
frankly admits the inferiority which it had
been his life-work to conceal. Robbed of his
pose, he cringes and squirms and begs for
mercy. He didn't do it ! Fearing punishment
at the hands of the English, he goes to
great lengths to assure his English inter-
viewer that he has always loved the people
whom his Zeppelins murdered in cold blood.
Fearing French retribution, he effusively in-
sists that he has always been an admirer of
French culture. Fearing the vengeance of
the deceived German people, he swears that
he has always tried to lead them into the
ways of peace. Fear is the keynote of his
whole confession. For the first time in his
career, he utters the truth ; and then, aware
of how much he has revealed, he grows
alarmed, and retracts the confession. He
didn't do even that! There never was a
more clear case of inferiority-complex.
John Barleycorn and Lady Nicotine. —
Well may the gentle epicure, long secure in
the enjoyment of his pleasant vices, tremble,
for the horizon is black with clouds of re-
form. Intoxicated by their successful battle
against intoxicants, the reformers are gath-
ering their forces for a nation-wide crusade
against tobacco, tea and coffee, in an effort
to wipe out all the stimulants which enslave
modern humanity. Flushed with an exalta-
tion which only the privileged missionary
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MEN AND THINGS
April, 1919
187
can feel, they have firmly resolved to rid
mankind of all its wicked habits. Having
struck the death-knell of John Barleycorn,
they now aim at making a cemetery of
man's most innocent and consoling sins.
Their program is a sort of Bartholomew's
Slaughter of stimulants. The epicure must
blanch with terror as he contemplates this
dire campaign to make his life one monot-
onous, grey, uninspired routine of virtuous
living. To the disciple of refined corruption,
the Day of Doom seems to be approaching.
With what measure of success will this
new campaign meet? After all, the bond
between John Barleycorn and mankind was
only one of platonic friendship — the most
difficult of all relationships to maintain. For
that reason the divorce was not hard to
achieve. But the bond between mankind
and Lady Nicotine is of another kind alto-
gether. Lady Nicotine has been man's mis-
tress, her place undisputed, for many gen-
erations, and the bond between them has al-
ways been a passionate one, yielding to no
other in the fidelity with which it has been
observed. So long has it endured, that it has
become nothing less than a morganatic mar-
riage, recognized the world over as a legiti-
mate and binding tie. And the marriage has
been a fruitful one. Under the spell of
Lady Nicotine, the amber mistress of un-
paralleled beauty, the artist has created his
most impressive canvases, the poet has
penned his immortal lines, the dreamer has
woven his imperishable dreams. Lady Nico-
tine has been wife, mistress and mother to
the creative individual. She has brought him
consolation in his darkest moments, inspira-
tion in his barren moods, and she brought
forth the children of his brain. She has
strewn the paths of creation with flowers.
Tobacco has been the twilight sleep which
reduced the labor-pains of some of the
world's greatest ideas, the ideal anesthesia
of artistic creation. But the reformers, un-
mindful of the splendid tradition that has
grown about Lady Nicotine, have filed di-
vorce papers and will soon institute pro-
ceedings against the cruelly maligned lady.
And, if we go by the promise of the re-
formers, the suit will be pressed with all the
energy they can command. The movement
is well backed and the financial contribu-
tions are already of such proportions as to
assure a long and bitter contest. To quote
Professor Frederick M. Roman, of Syra-
cuse University, leader of the campaign
against tobacco, big business in America is
behind the efforts to eliminate habit-form-
ing drinks and drugs, and all the financial
backing needed for the anti-tobacco move-
ment has been secured. Professor Roman's
statement, however, is misleading. The to-
bacco industry comes very easily under the
head of "big business," and that industry
will not be found among the contributors
to the reformers' funds. The coffee and tea
industries will be no more inclined to assist
in the cause. They represent millions, and
one can readily believe that these millions
will be used freely to combat the movement.
A contest of the greatest magnitude may
therefore be looked forward to. Already
spokesmen for these industries have accepted
the challenge. Mindful of the errors which
the liquor interests made in allowing the
prohibitionists to carry on their work with-
out opposition, there is a strong disposition
to anticipate the new movement, to disarm
it at its very inception, to institute a counter-
campaign without 'any loss of time. The
fight will be a most interesting one. The
reformers were able to make out a convinc-
ing case against liquor, which laid itself
open to many just charges. But it will be a
more difficult task to show that tobacco is a
vicious element in the life of the individual
or of society, and it will perhaps be even
more difficult to prove that tea and coflfee
are forces for evil. On the side of those
who will fight to maintain these elements
will be the natural affection which the pub-
lic has for these lesser evils of civilization,
which, in the intense and trying circum-
stances we are living under today, have be-
come a necessity to those who need a whip
to goad on their highly taxed energies and
their greatly tried nerves. That this necessity
is recognized is manifest from Professor
Roman's admission that the campaign to
eliminate tea and coffee will not be com-
menced until a fitting and harmless sub-
stitute for these drinks is found. A sub-
stitute, to be effective, must be adequate;
and how can it be adequate unless it has all
the marks and the properties of that which
it replaces? The task of the reformers in
this instance will certainly not be an easy
one.
DrugSy Good and Bad. — The indiscrim-
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MEN AND THINOS
American Medici2«s
inate use of the word "drug" in the news-
papers of the country has aroused consid-
erable disquietude among the drug dealers,
who feel that the public is being prejudiced
and misinformed in such a way as to do
harm to the legitimate trade in drugs.
Alarming headlines, announcing "drug"
raids and campaigns against the use of
"drugs," have been appearing in newspa-
pers everywhere with such persistency
that an effort is being made to enlighten the
public and correct the false impression
which such abuse of the word must lead to.
"This practice," announces the literature of
one conscientious firm, "is alarming the
legitimate doctors and druggists, for it
tends to discredit them both and to weaken
the confidence in essential drugs We
are certain that most druggists and doctors
are doing all they can to restrict the use of
narcotics, and therefore they should not be
needlessly handicapped by the false impres-
sion created in the minds of the public by
the misuse of the word 'drug' on the part of
the newspapers. The legitimate physician
and druggist should be upheld in their ef-
fort to maintain the high standard of char-
acter they have set for themselves." Ameri-
iCAN Medicine is glad to give space to this
appeal and help correct the mistaken im-
pression that is sure to arise as a result of
a failure to distinguish between harmful
trade in narcotics and the legitimate manu-
facture and dispensation of essential drugs.
In justice to the well-meaning doctor and
druggist this distinction should be made
clear in the mind of the public. It is wrong
to assume that there is any intentional de-
sign among the newspapers to mislead their
readers. The word "narcotic" does not lend
itself to space conditions as readily as the
shorter and more convenient word "drug,"
and it is this consideration alone, without
doubt, which has been instrumental in the
choice of the shorter word by the writers
of newspaper headlines. Nevertheless, the
exclusive use of this word, almost al-
ways in a derogatory sense, involves a real
injustice which" should be discouraged.
Editors would be doing a real service to
the essential commerce in drugs by dis-
criminating between the good and the bad.
The Strange Psychology of the People
in Germany. — Too much has been made of
the alleged unfathomable mystery of the
German psychology, of the incomprehen-
sible and all too often grotesque working
of the German mind. Thruout the war
there had been a tendency on the part of the
shrewdest thinkers among the Allies to
throw up their hands in despair at the
amazing antics of the German process of
logic and to confess that science is baffled
in the presence of such unparalleled meth-
ods of thinking. Now once more there
is a general throwing up of hands, a general
confession of inability to understand the
mystery of the German mind. The occasion
is the protest of German scholars against
the treatment of some of their colleagues
in the University of Strassburg at the hands
of the French command. Some of these
scholars, it is said, have been forced to leave
the University on twenty- four hours' notice
on the order of the French authorities ; and
German scholars have lodged a complaint
with the rector of the University of Upsala,
Sweden, on the ground that such dismissal
is prejudicial to the interests of science.
They appeal to university men the world
over to rally to the defense of science —
and their colleagues. This appeal has been
made public, and Dr. Butler, president of
Columbia University, has replied to it. In this
reply, he shows amazement at the impu-
dence of the German scholars. The memory
of Lou vain still fresh in the minds of all
students, the memory of so many outrages
and atrocities against art and culture still
un forgotten, he voices his astonishment that
these German scientists can have the hardi-
hood to speak in the name of scholarship
in protesting against the unjust treatment of
their comrades. Have they so soon forgot-
ten the cruelties suffered at the hands of
the German militarists, cruelties which were
never protested by the German scientists
who seem to be shocked by allied irreverence
for culture ? The world is once more puzzled
to understand the strange composition of
the German brain.
And yet we can conceive nothing quite
as simple (as pathetically simple) as the
German psychology. It is amazing that it is
so little understood. Ever since the victories
of 1864, 1866 and 1870-1871, the German
nation has been nurtured on the belief that
it is the chosen of God, that it is the Super-
man of nations. The philosophy of Nietzsche
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MEN AND THINGS
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189
was the philosophy of every individual ; the
ideal of the cruel "blond beast" was the
ideal of every German. The race was to
the fleet, the combat was to the strong, and
Heaven pity him who showed the slightest
trace of Christian sympathy, of hesitation
and weakness. These were the vices of
modem civilization which the Superman
must avoid. He must not fear cruelty, he
must crush under heel anything or anyone
that rises in his path. Infatuated with this
philosophy, infatuated with the flattering
belief that he was the triumphant symbol
of this philosophy, the German swung
flamboyantly onward toward his great des-
tiny. And, for more than forty years, he
was able to make good his bluflf because he
was never challenged. It was a noble atti-
tude and a brave one, guaranteed not to
fade or shrink — ^but the first rain that came
reduced it to a mere pulp of fabric and dye.
The war lost, the bubole of boastfulness
pricked, the Superman squirming under the
heel of the conquering dwarf, all his
bravado and superiority disappeared and he
was revealed for what he was, a cowering
bully, trapped in the debris of his false
philosophy, without even the courage of his
vices, unashamed of his yowling complaint
at the slightest threat to handle him with
anything but kid gloves. If only he would
take his medicine like a man ! It will never
be forgotten that the German scholars,
from the very first, rallied to the support
of the militarists and became the spokes-
men of German culture, which was to
sweep the world, laying low everything that
stood in its way. In a formal appeal to the
civilized world in September, 1914, Ger-
many's leading professors announced them-
selves as standing solidly behind the mili-
tarists and their aims. Thruout the war they
were the apologists for all the atrocities
committed by the war machine. In the Allied
countries, on the other hand, the men of
science were constantly working to keep
the military leaders to a high idealism with-
out which they could never accept the war.
This "prostitution of scholarship and
science," as Dr. Butler calls it, will remain
forever as an accusation against the lead-
ers of German thought. The record of the
Allied scholars is clean. The proper attitude
of the German scholars, in view of their
past, is one of meek and humble silence.
The Problem of Narcotic Drug Ad-
dictionw — On repeated occasions during
the past few years we have called attention
to the seriousness of the problem of nar-
cotic drug addiction. Especially have we laid
emphasis on the desirability of medical men
taking up the study of the pathologic and
physiologic phenomena presented by the
prolonged use of narcotic drugs, with the
same thoroness and fidelity that they have
given to other medical questions. At
the hearings held last year by the Whitney
Commission the need for comprehensive
medical investigation was clearly shown, and
the medical profession was urged to give
narcotic drug addiction the attention it de-
serves. Thanks to the work of a few physi-
cians, notably Dr. Bishop of New York
City, it has been recognized that this con-
dition of addiction to narcotic drugs is a true
disease, with a pathology and a clinical iden-
tity as distinctive as those of any other
physical disease or condition of perverted
physiology. This being so, the necessity for
comprehensive medical consideration and
treatment of individuals thus afflicted is
readily apparent. But still medical men have
held themselves aloof, and with the excep-
tion of the few reputable physicians, whose
sympathies and keen sense of obligation
have led them to give intelligent and com-
petent thought to the problem, and a small
group of unscrupulous practitioners who
have sought to enrich themselves by trading
on the afflictions of drug addicts, medical
men generally have devoted little or no at-
tention to this class of patients.
That this attitude has been most unfor-
tunate has been shown by first, the little
success the average physician has had when-
ever he has tried to treat narcotic drug ad-
diction; second, the erroneous views that
have developed generally in the lay mind
concerning the nature of drug addiction and
those afflicted; third, the lack of any ac-
cepted plan or method of coping with either
the public health or sociologic problems pre-
sented ; and finally, the confusion and harm
as well as the meager success that have re-
sulted from attempts to control the evils of
drug addiction.
The truth of the foregoing has been par-
ticularly exemplified by the eflforts of the
New York City Board of Health to meet
the situation created by the recent arrest by
the Federal authorities of a group of doc-
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MEN AND THINGS
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tors and druggists, long suspected of traf-
ficking in narcotic drugs. The arrest of
these men forced a large number of drug
patients to find other places from which to
obtain their supplies of narcotics, and to
save these unfortunates from going to illicit
and criminal dealers in narcotic drugs, the
Health Commissioner opened a bureau, at
which, it was announced, those in need of
narcotic drugs could obtain the amounts re-
quired, and at honest prices. Realizing that
the Department of Health could not under-
take to supply narcotic drugs indefinitely
to those addicted to their use, without at-
tempting to cure them, a clinic was duly
established, and arrangements made to pro-
vide hospital treatment for those who could
be induced to take advantage of it.
Unfortunately these plans did not work
out as well as those responsible for them
hoped and expected. Owing to a lack of
trained nurses, the Commissioner was oblig-
ed to call on a number of sociologic workers
who undertook the work assigned to them
with a fine spirit of kind and sympathetic
service. These ladies have given freely of
their time, energy and money, and too much
credit cannot be accorded them for their
laudable motives and faithful eflForts. But
while they have done much good and it
would be most unfair to say that their eflForts
have been wasted, it must be admitted that
they have been able to accomplish very little
in the direction of curing drug addicts. This
is not a reflection on their work, nor on the
purposes of Dr. Copeland. Rather is it a
reflection on the knowledge — or lack of
knowledge — of all concerned of the funda-
mental details of the problem they sought
to solve. As a consequence of such lack of
knowledge, the plan was essentially handi-
capped and limited from the start. As a
temporary expedient, or emergency means
of restricting some of the evils of drug ad-
diction, the clinic for drug addicts has prob-
ably done considerable good, and as it de-
velops the plan may serve a useful and valu-
able purpose. We believe we can see a
definite work which a cHnic for drug ad-
dicts can perform, and a place it can fill in
the elimination of certain evils.
As always happens, however, when a
man attempts to accomplish something af-
fecting the welfare or interests of a class or
group of people, this movement promoted
by Dr. Copeland promptly came in for all
manner of attack. No allowance or credit
was made for clean, kindly motives. The
papers, ever ready to "play up" a new idea,
to stimulate controversy, and to foster at-
tack and counter-attack between those for
and against a new undertaking, were
largely responsible for the hasty opinions
formed concerning Dr. Copeland's attempt
to cope with the narcotic drug problem.
These and other busy bodies made the sit-
uation more and more difficult for those en-
gaged in the enterprise. Instead of helping,
the tale bearers and trouble makers created
antagonisms and ill feelings in the minds
of Dr. Copeland and those who could have
aided him. Statements were made that were
not of a character to add to the entente
cordiale. Personalities crept in and the
creditable features of the enterprise have
been obscured by acrimonious discussion.
Many medical men of the highest standing
have been estranged by statements at-
tributed to the Commissioner. Many have
objected to the sensational publicity features
of the movement, forgetful that the press
was largely if not entirely to blame for
this. Early in the carrying out of the move-
ment. Dr. Copeland found that certain
crooks and dishonest addicts were resorting
to all manner of tricks and schemes to get
large quantities of narcotics. The use of
false names and visits to diflferent doctors as
well as to the clinic often enabled these peo-
ple to accumulate very considerable amounts
which they promptly adulterated and resold
at double or quadruple prices to addicts
who would not resort to such practices.
Recognizing the difficulty of controlling this
particular phase of the evil, Dr. Copeland
came forward with suggestions for estab-
lishing the identity of addicts. The idea was
even advanced of branding them with ni-
trate of silver, of taking their finger prints,
and so on. All of these suggestions were so
repugnant to the public at large that Dr.
Copeland soon found that he had stirred up
a veritable hornets* nest. The branding idea
was dropped, but in view of his knowledge
of the abuses that seemed to be inevitable
he insisted that some clearly defined system
of registration with identification cards,
photographs of the addicts, etc., was neces-
sary. So far as we know no system of regis-
tration and identification has been adopted
as yet, and Dr. Copeland has been quoted as
saying that the question is one that the State
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MEN AND THINGS
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191
Narcotic Drug Commission must work out.
Reviewing the events of the past month,
we feel that while Dr. Copeland has made
certain mistakes — probably he would be the
first to admit them — on the whole he de-
serves real credit for (1) his effort to help
solve a grave problem, (2) the emphasis
he has given to the fact that drug addiction
per se is not a form of moral delinquency
or obliquity to be penalized, but that it is
a disease to be intelligently studied and
treated ; and (3) the effort he has expended
in urging honest medical men to study nar-
cotic drug disease and treat its victims
with the same fidelity and intelligence given
to other diseases. We want to be big
enough and fair enough in expressing any
ideas we may have on this subject of drug
addiction, or criticisms we may feel inclined
to offer of the policies or acts of the Health
Commissioner to never fail to credit him
with as honest and honorable motives as we
ask him to ascribe to us when we cannot ac-
cept his viewpoint.
^ The great fundamental need in connec-
tion with the problem of narcotic Acug
addiction is a better understanding of the
conditions that are created in the human
body by the long continued use of opium
and its derivatives. A recent paper by
Du Mez (Jour. A. M. A,, April 12, 1919)
shows the diversity of scientific opinion
that exists concerning the mechanism of the
increased tolerance of the system for these
drugs and the cause of the symptoms that
follow their withdrawal., Incidentally, in
his scholarly review of the literature on the
subject, Du Mez shows how few American
physicians have made any noteworthy con-
tributions to the study of narcotic drug
addiction. In fact. Dr. Bishop and Dr. Pettey
seem to be the only American medical men
whose opinions are of sufficient scientific
importance to warrant serious considera-
tion. This confirms the statement we have
made in regard to the comparative indif-
ference of physicians in this country to
narcotic drug disease. It is a shame that
a subject so serious in many of its aspects
and so far-reaching in its possibilities for
evil, has been so neglected. With the ex-
ception of the few men whose work has
been referred to, the physicians of this
country have shirked their responsibilities
in regard to drug addiction and its effective
treatment. Conscientious medical men can-
not allow this state of affairs to continue,
for the control of a situation that is daily
growing more menacing lies in the success-
ful treatment and cure of the individual
case. Restrictive laws and regulative meas-
ures have their place and medical men
should uphold and support all rational and
humane efforts in this direction. But it is
thru the ability of the general practitioner to
afford prompt relief to the sufferer from
drug addiction, and in due course to re-
store him to a normal state of health, that
the control and conquest of narcotic drug
addiction will be accomplished. Those who
have had any experience whatsoever with
drug addicts know that one of the chief
obstacles to the successful solution of the
problem presented, is the attitude of the
average addict towards treatment. If his
addiction covers several years, he has
usually tried all or most all of the so-called
"treatments,'* has sojourned in many institu-
tions, public and private, and has sought
help from every good, bad or indifferent
doctor he could get to take up his case. He
has very vivid recollections of all he has
gpne thru, and as a result of his experi-
ences, he is under no delusions as to the
ability of the general practitioner to cure
him. He is fearful to a marked degree of
the suffering any curative treatment will
force him to undergo, and highly pessimistic
naturally, as to the probability of any per-
manent cure of his trouble. The hearing
of the Whitney Commission brought out
many of these facts and showed, not only the
lack of confidence of drug addicts in cura-
tive treatment, but the horror these unfor-
tunates have of being forced to undergo the
suffering which, in the light of their experi-
ences, they believe to be inseparable from
any at present known treatment. It is fairly
evident from the foregoing that the great
majority of those who suffer from narcotic
drug addiction have come to look on their
condition, with all that it entails in physical
distress and worry, as the lesser of two
evils.
The earnest, thoughtful observer is bound,
therefore, to reach the conclusion that any
successful control of narcotic drug addic-
tion must start with a better understanding
of the character of the disease and more
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painstaking and comprehensive methods of
treatment. The duty of the medical profes-
sion is clear and we can no longer dodge
the issue and be true to ourselves and our
calling. The work may not be to our liking.
The same may be said of other diseases we
are called upon to treat. But for humanity's
sake we must give our best and most faith-
ful thought and attention to those suf-
fering from narcotic drug addiction.
No physician has the right to plead that
a fear of coming in conflict with the laws
deters him from having anything to do with
the treatment of drug addicts. Every physi-
cian must conform to the laws to be sure,
but as we have stated on many former oc-
casions, no honest medical man has any-
thing to apprehend from the Federal or
local authorities. As a matter of fact, the
Revenue officials have performed their du-
ties in ways that have won the unqualified
respect and admiration of every honest phy-
sician with whom they have come in contact.
It is very apparent from numerous facts
brought to our attention that medical men
may count on the utmost courtesy and con-
sideration from the gentlemen connected
with the Revenue department. The state and
local authorities will doubtless follow simi-
lar methods. The physician who practices his
profession honestly and with conscientious
regard for the requirements of the laws reg-
ulating the use of narcotic drugs may be
sure that he will have no trouble, nor suf-
fer any interference with his legitimate
work. Dr. Copeland, speaking for the local
authorities, not only has given repeated as-
surances in this direction, but has urged
every physician to give his best thought and
eflFort to the treatment of drug addiction.
It is to be hoped that the medical pro-
fession will respond to this call, as it has to
so many others in the past. Wide differences
of opinion are bound to arise in regard to
various phases of the question, but differ-
ences of opinion should not keep honest men
from combining their strength to accom-
plish a result earnestly desired by all.
The active cooperation of every person^ho
is interested in the subject should be en-
listed, and no stone left unturned to bring
narcotic drug disease under the mastery of
medical science.
Above all it should be constantly borne
in mind that the narcotic drug addict is
a sick person who, in the great majority of
cases, has stronger claims on our sympathy,
consideration and humanity than the suf-
ferer from many other diseases.
The Profession and the Victory Liberty
Loan. — ^The courage and sacrifices of
members of the medical profession in the
Army and Navy in the war will forever be
remembered. Hundreds of physicians have
been awarded decorations for gallant con-
duct and thousands have given untiringly
the best in them to allay the sufferings of
soldiers and sailors. Many of these physi-
cians are still in service. The Government
is faced with the task of caring for boys
incapacitated for p/ofessional or industrial
work. The physicians have a job to finish
and still are giving gladly of their skill and
knowledge, that no youth may return to civil
life without first having been accorded the
best attention the profession has to offer.
To the medical profession the Victory
Liberty Loan has a special appeal. Its flota-
tion is partly necessary because of the ex-
pense to the Government to treat the sick
and wounded.
When the United States entered the war,
it was the last of the wealthy nations to be-
come involved. With a great surplus of in-
dustrial and financial resources there was no
necessity for external loans. The response
by the people to the Government's appeal to
lend money, had its immediate result. De-
feat loomed for the Central Powers as the
balance of money power shifted to the
Allies.
Just as the successful belligerents were
those that had financial resources to prose-
cute war, so will those nations be able to
cope with the problems of reconstruction
satisfactorily whose people continue to lend.
The campaign for the restoration of a
country to a peacetime basis must be rigor-
ous. The clash of arms is no more a stim-
ulant to patriotic sacrifices. To be a rigor-
ous campaign, those engaged must have the
courage of their convictions. No member of
the medical profession is ignorant of the
financial burdens of the Government in
maintaining large hospitals here and abroad.
The Government has many other such bur-
dens and the medical profession will help
lift them by buying Liberty Notes.
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ORIOINAIi ARTICLB8
April, 1919
193
ORIGINAL
TICLES*^^
THE PHYSICS OF THE CHEST AND
THEIR RELATION TO DISEASES
AND INJURIES OF THE THORACIC
ORGANS.'
BY
LIEUT.-COL. SIR JAMES BARR, M. D., LL. D.,
F. R. C. P.. F. R. S. B.,
Liverpool, Eng.
In this introductory lecture I do not pro-
pose to deal with soft platitudes, and tell
you of the wonderful achievements — in
which you have all taken your part— of
medicine and surgery during this war. No
doubt wonderful results have been obtained
in the prevention and treatment of disease
and injury. This war has afforded ample
scope for the application of skill and of well
known discoveries, rather than the evolu-
tion of new ideas. The evolution has been
more apparent in the development of
destructive and preventive measures than
in curative methods. All our wonder-
working miracles have resulted from carry-
ing out well recognized principles on that
marvelously adaptive and self-repairing ma-
chine— ^the healthy human body.
Today I propose to deal with the physics
of the chest, and their relatipn to the dis-
eases and injuries of the thoracic organs.
This is a subject equally important to the
physician and the surgeon and, it seems to
me, often one of vital importance to the pa-
> Delivered at the Liverpool Royal Infirmary,
February 4, 1919.
tient. Excellent surgery in severe chest
wounds was carried out by many surgeons
in casualty clearing stations, whereby many
lives were saved. They quickly removed as
far as practicable all foreign bodies, dead
tissues, blood clots and every possible source
of sepsis ; and then closed the chest wounds,
thus restoring the function of the injured
lung. During the operation, collapse of the
lung was prevented as far as possible. A
moderate amount of air left in the pleural
cavity does not matter much, as it gets soon
absorbed when the chest is closed.
In British Medicine in the War th^re is a
descriptive but slovenly written article on
gunshot injuries of the chest with special
reference to hemothorax. There is here an
almost complete failure to rec<^^ize the
physical principles which are so important
in such injuries. It is only from a clear ap-
preciation of basic principles that real ad-
vancement can take place.
In my Bradshaw lecture^ on the pleura,
pleural effusion and its treatment I dealt
fully with the physics of the chest, and in
the course of this lecture I shall refer to
many of the experiments which I then con-
ducted. If you wish to see a good schema
of the physical working of the chest I can-
not do better than refer you to Sir Douglas
Powell's work on diseases of the lungs. Sir
Douglas Powell aptly says: *Tt would be
impossible truly to comprehend the mani-
* British Medical Journal, Novemiyer 9, 1907.
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fold incidents and conditions of asthma,
emphysema, pleuritic effusion and pneumo-
thorax without a working knowledge of
these statical and dynamical conditions of
respiration in health."
Within the thoracic cavity there are two
pleural cavities and the pericardium which
in health are potential rather than real cavi-
ties : the blood-vascular cavity which is con-
stantly varying in capacity and in the
amount and distribution of its contents ; the
gullet, nerves and lymphatic spaces; and
lastly the aerial cavity within the lungs
which is the only one in health in direct
communication with the atmosphere.
The intrathoracic pressure in health is
usually negative, i. e,, less than the atmos-
phere, tho under varying conditions it may
and often does become positive, i. e., greater
than the atmosphere. In carrying out
the Valsalva experiment, I have often
raised my intrathoracic pressure 100 mm.
of mercury above that of the atmos-
phere. This is sufficient to shut out
all blood from entering the chest, and
of course if the chest were laid freely open
under such conditions the lung would bulge
thru the opening. However it is not likely
that under such conditions the victim would
be thinking of the Valsalva experiment.
After a few beats the pulse disappears in
all the superficial arteries, altho the vessels
remain full, and it is very interesting to
watch thru the X-ray screen the reduction
in the size of the heart until finally it does
not appear half its former size. Some have
thought that this is a very risky experiment
lest you should stop the heart, altogether,
but I can assure you that there is not the
slightest danger as no one could keep up
the pressure long enough to do so. More-
over only those with good vital capacity can
successfully carry out this experiment.
In order to keep up a positive pressure,
within the thorax while operating on the
pleura, an American surgeon many years
ago devised a cabinet in which he could
vary the pressure. He and the patient's
body were in the cabinet under negative
pressure, while the patient's head was in
communication with the external aitmos-
phere. This ingenious device was too ex-
pensive and troublesome to catch on, hence
it never became popular. A more simple
method is to supply the patient thru a
closely fitting facial apparatus with air or
oxygen under moderate pressure above that
of the atmosphere.
The negative pressure within the thorax
is due to the elasticity of the lungs and to
the slight tendency of the chest walls to re-
coil beyond that of their greatest capacity-
in inspiration. The intrapleural tension, with
which I shall deal later on, is equivalent to
the intrathoracic and due to the same causes.
This negative pressure under normal con-
ditions is slight, constantly varying in
amount, and always sufficient to act as a
respiratory pump which not only aids in
the gaseous changes within the lungs but
renders great assistance in carrying on the
pulmonic circulation. The lungs even in ex-
piration are in a state of elastic tension, so
that during quiet respiration the respira-
tory pump is more or less constantly in ac-
tion.
The amount of the elastic force of the
lungs has been determined by connecting
a mercurial manometer with the trachea in
the cadaver, and then puncturing the thorax
so as to allow air to enter the pleura and
cause the lung to collapse. This only gives a
record of 2 to 5 mm. of mercury, but this
procedure does not allow for the elastic
recoil of the thoracic walls, and, moreover, '
in the cadaver the lungs have lost a great
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deal of their elasticity. Bonders calculated
that in health the elastic pull of the lungs
in the expiratory period was 7.5 mm. of mer-
cury. After an ordinary inspiration the
negative tension is increased to 9 mm. of
Hg., and after the deepest possible inspira-
tion to 30 mm.
In Miiller's experiment I have often raised
the n^ative pressure within my thorax to
over — 80 mm. of Hg.
The intrathoracic pressure is constantly
varying during the phases^ and the differ-
ence in individuals is often very great, so
that experiments on the dead body are not
of much value except for the establishment
of general principles. So unsatisfactory
did I consider these experiments that in
1907 when I was writing my Bradshaw lec-
ture I conducted a large number of experi-
ments on myself and healthy friends. It is
needless to say that I did not carry out the
experiments with mercurial manometers
tied in our tracheae. Even in the cadaver
the manometer has the very serious fault
that with the collapse, of the lung the pres-
sure of air in the trachea is raised, which
•of course raises the column of mercury, but
at the same time prevents further collapse
of the lung.
The method which I adopted can be prac-
ticed by anyone on himself. What is re-
quired is a little intelligent practice so as
to convert the mouth, the nares, the larynx,
the trachea and the intrapulmonary cavity
into one aerial space having as nearly as
possible the same pressure thruout. When
taking the pressure in this cavity during
oral breathing the mouth is open and the
shut nares connected with a manometer.
When the pressure is taken during nasal
breathing, one or both nostrils are open, and
the tube of the manometer lies in the shut
mouth. In these observations it is absolutely
essential that all respiratory movements be
performed by the thorax alone, and that the
mouth and nares be held in absolute repose.
Any sucking or other movement of the
mouth or nares destroys the uniformity of
the cavity ; of course there is a second line
of obstruction at the glottis, and the varia-
tions in pressure must be greater beyond
the obstruction than in the mouth and nares.
This obstruction cannot readily be removed
in the human subject, but with the avoid-
ance of all excitement the obstruction is re-
duced to a minimum.
I give you the following observations
made on myself, because I can vouch for
their accuracy, and I think my lungs and
thoracic walls are still fairly elastic. I know
many who would give a better record, and
many who would give a worse. These, how-
ever, will suffice for the object I have in
view. The lower pressures were made with
a water manometer, and the higher with a
mercurial; as mercury is 13.6 heavier than
water, it is easy to convert the readings
into water or mercury as you prefer.
Millimetres of Water.
1. Quiet oral breathing: Insp. — 5 to —
8 ; exp. + 3 to 4- 5.
2. Deep oral breathing: Insp. — 24 to
— 34; exp. + 20 to +30.
3. Quiet nasal breathing, 2 nostrils:
Insp. — 10 to — 16; exp. + 6 to + 10.
4. Quiet nasal breathing, 1 nostril:
Insp. —16 to —22; exp. + 12 to -f 16.
5. Deep nasal breathing, 2 nostrils:
Insp. — 40 to — 60 ; exp. + 30 to + 40.
6. Deep nasal breathing, 1 nostril:
Insp. — 180 to — 200 ; exp. + 160 to + 180.
Miiller experiment. After deep expira-
tion expanding the chest with the mouth
and nostrils closed, — 80 mm. of mercury.
Valsalva's experiment. After deep in-
spiration forcible compression of the chest
with the mouth and nostrils closed, 100 mm.
of mercury.
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These experiments show the great varia-
tions in intrapulmonary pressure which
take place, and the more active the respira-
tory pump, the greater the variations. For
the maintenance of health it is important
that this pump should be kept in good
working order, as will become very apparent
when we come to deal with injuries and
diseases of the chest.
All these observations on the thoracic
cavity are equally applicable to the healthy
pleural cavities, but if you follow the teach-
ing of most text books which deal with
this subject you may infer that the elas-
ticity of the lungs and the recoil of the chest
walls were constant dragging forces trying
to separate the two layers of the pleura.
If such dragging were the result of these
forces we ought to find some evidence of
its existence. As a matter of fact there is
no traction but perfect equilibrium, as the
elasticity of the lungs is counterbalanced by
the intrapleural tension, which is equal in
force and opposite in direction, as the for-
mer is positive and the latter negative. The
elasticity of the lungs tends to separate tfie
pleural surfaces, and the intrapleural ten-
sion, which depends on the elasticity and to
a much less extent on the tendency to re-
coil of the chest walls, holds the surface to-
gether. When the lungs are stretched in in-
spiration the elasticity of the lungs is in-
creased, and so also is the intrapleural nega-
tive tension by an equal amount.
Sir Douglas Powell has shown "that in
quiet inspiration there is no inertia or elas-
tic resistance of the chest walls to be over-
come, but that on the contrary the thoracic
elasticity is a reserve force of appreciable
power constantly tending to enlarge the
thorax, and therefore acting in favor of in-
spiration."
In cases of great emphysema of both
lungs the chest enlarges to its greatest pos-
sible extent and becomes barrel shaped, con-
sequently this elasticity is abolished. Even
without enlargement of the chest a similar
condition appertains in advancing years
when the costal cartilages become calcified.
I have seen such calcification in a young
woman of 26, induced by the chest being
long fixed with a spinal support pr saddle.
Of course you can decalcify the costal car-
tilages but this is a troublesome process, in
the living subject, and prevention is better
than cure.
For the maintenance of a healthy chest
it is absolutely essential to keep the respira-
tory pump in constant action, and this can
only be satisfactorily done by practising
thoracic rather than diaphragmatic breath-
ing, and preventing calcification of the cos-
tal cartilages.
Regarding the intrapleural tension, which
we have seen is equivalent to the intra-
thoracic, the external surface of the pleura
is protected from the atmospheric pressure
by the comparative rigidity of the chest
walls and the tensioa of the diaphragm — it
is like a membrane lining the inner surface
of a metal ball, consequently the two sur-
faces of the pleura are pressed together,
and both layers are pressed against the in-
terior surface of the thoracic walls by the at-
mospheric pressure within the lungs.
The elasticity of the lungs and the elastic
tension or recoil of the chest walls main-
tain a negative pressure withip the pleura,
or an intrapleural tension, equal in amount
and opposite in sigh or direction to that
of the elasticity of the lungs, so long as
there is no fluid in the pleura sufficient to
overcome the elasticity, or as long as the
pressure within the lungs, minus their elas-
ticity, does not exceed the pressure of the
atmosphere. When the intrapulmonary
pressure exceeds that of the atmosphere the
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lung elasticity remains a protective but not
an active force.
If we take Donders' figures of 7.5 mm. of
mercur>' or 102 mm. of water as equivalent
to the elastic pull of the lungs during the ex-
piratory period, then it would require a
fluid pressure of 102 mm. of water all
around the lung to abolish the negative ten-
sion.
In pleural effusion gravitation carries the
liquid to the most dependent part of the
sacs and as the pressure of a liquid is as
its depth, the lower and posterior part of
the lung collapses first and the non-col-
lapsed portion is pushed upwards and to
the front.
On the other hand in cases of pneumo-
thorax the pressure is fairly equal at all
points, and the pressure rarely rises so high
as to cause complete collapse. When the
general intrapleural tension becomes posi-
tive, that is higher than the atmosphere,
the lung must collapse. On the other hand,
if the intrapulmonary pressure exceeds that
of the atmosphere by 102 mm. of water — ^a
condition which exists in my chest during
expiration thru one nostril — then the
intrapleural negative tension is abolished
during expiration, and any further rise in
the intrapulmonary pressure would keep the
pleural surface closely glued together so that
the external layer of the pleura might be
laid freely open without any risk of air
entering the sac. We have seen that great
intrapulmonary pressure only occurs when
there is some obstruction to forcible ex-.
piration, such as using only one nostril or
in Valsalva's experiment. It therefore fol-
lows that the best way to expand a collapsed
lung is to increase the intrapulmonary pres-
sure until you have restored the elasticity
of the lung, and then, and not till then, in-
crease the intrapleural negative tension.
Owing to these marvelous provisions of
Nature the two lubricated pleural surfaces
can move freely over one another, but any
force which separates them must be greater
than the atmospheric pressure in the lungs ;
during inspiration this is less than the ex-
ternal atmosphere, and during expiration
rather more. Moreover the warming of the
air in the lungs from 57 ^^ to 98** F. would
make it expand about one-twelfth of its
bulk, and this would increase the pressure
in the alveoli. It thus takes at least an at-
mosphere (about 760 mm. of mercury) to
separate the two pleural surfaces, and when
the surfaces are separated by fluid it must
have been secreted at a greater pressure
than the atmosphere. Thus any traction
from the elasticity of the lungs can have
no effect in separating the two pleural sur-
faces, but any such effect is transferred to
the walls of the thorax, seeing that there is
often a difference of pressure on the two
sides of the thorax. In the intact chest you
never could lower the intrapulmonary pres-
sure sufficiently to separate the two pleural
surfaces, but in Miiller's experiment you
can lower the intrapulmonary pressure suf-
ficiently to make its dragging effect readily
felt on the walls of the thorax.
If you attach the smooth surface of a
sixpence with a little vaseline to the bot-
tom of the metal piston of a syriAge the six-
pence can be easily moved about over the
flat surface of the piston, but even when
the nozzle is down and the sixpence only
suspended by the lubricant (the object of
which is to get rid of the air between the
piston and the sixpence), you can draw the
piston up to the top of the syringe with the
nozzle blocked, and thus make a large, tho
imperfect, vacuum without detaching the
sixpence. You can thus see that the elas-
ticity of the lungs and the atmospheric
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pressure are Nature's method for keeping
the two lubricated surfaces together and
enabling them to mov^ freely over one an-
other, and not for separating them as is
often supposed.
A very distinguished surgeon and Fellow
of the Royal Society has asserted that the
force holding the pleural surfaces together
is molecular cohesion, and has nothing what-
ever to do with atmospheric pressure. It
will not be difficult to show that this asser-
tion— of which I would take no notice were
it made by a less exalted personage — evinces
a lack of knowledge of molecular cohesion
and of the force of atmospheric pressure.
Fellows of the Royal Society are not, as
^ rule, more ignorant than other people, but
when you find them tripping, as you oc-
casionally do, their delinquencies become
more apparent, because less expected. The
first essential for molecular cohesion is that
the molecules must be in contact, and it is
absolutely impossible for such contact to
take place between two surfaces which are
separated by a thin layer of fluid even if that
layer be only a ten thousandth part of an
inch in thickness. Chemists and physicists
may tell us that molecules are free to move
about among one another, but in solid bodies
they cannot move very far and contact is
absolutely necessary for cohesion. In the
case of the pleura the surfaces glide over
one another very easily. The only difficulty
is in the separation of the surfaces, but if
there were molecular cohesion it would be
much more easy to tear the membrane than
to move the surfaces.
Professor Donnan once told me that the
surfaces of two pieces of steel have been
cut so true that when they were brought into
perfect apposition a much greater force
than would be accounted for by atmospheric
pressure was required to separate them.
This is molecular cohesion; nothing like it
occurs between any surfaces in the body. If
you had molecular cohesion over such a
large surface as the hip joint, the junction
would be so perfect that it would be much
easier to smash the shaft than move the
head of the bone the hundredth part of an
inch. This at once disposes of molecular co-
hesion as the force which holds the pleural
surfaces together, and it is unnecessary to
further multiply arguments.
Another force which some have imagined
to play an important part in this direction
is surface tension; this is a force which
has engaged a great deal of attention in
recent years but in this connection it proves
a very insignificant force.
I have made many experiments on this
subject, but the following should suffice:
The surface tension of a serous effusion
having a specific gravity 1025 will support
about 6 grains to the square inch ; a transu-
date of a sp. gr. of 1010 will support about
3 grains to the square inch, while the nor-
mal thin serous fluid of the pleural cavity
may be an excellent lubricating material,
its surface tension will not support more
than 2 grains to the square inch ; therefore
as a force in holding the two pleural sur-
faces together it is scarcely worth com-
puting.
I now wish to show you some experi-
ments of the force of the atmosphere in
holding surfaces together. I have shown
you the experiment with the sixpence at-
tached with a little vaseline to the bottom
of a metal piston of a syringe ; much heavier
metals can be suspended, but when the in-
fluence of gravity exceeds the atmospheric
pressure plus the surface tension in the par-
tial vacuum the weight drops off. In the
open air very heavy weights such as 56 lbs.
can be suspended from a smooth book shelf
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with only a thin layer of vaseline inter-
vening. No one could imagine that there
was any molecular cohesion between the
metal weight and the polished book-shelf,
or that the surface tension of vaseline
would support 56 lbs. On the other hand the
atmospheric pressure is about 15 lbs. to the
square inch, and the attached surface of the
metal is about 36 square inches, therefore
the atmosphere would support a much
greater weight with the same surface. The
use of the vaseline is to prevent the air
entering between the metal and the board;
it allows the board to be moved freely over
the metal, but so long as no air enters be-
tween the surfaces when the board is raised
the weight follows it.
In the intact chest no air can get be-
tween the chest wall and the external layer
of the pleura, consequently the two layers
of the pleura are pressed together by the
atmospheric pressure within the lungs. Even
in MuUer's experiment there is a pressure
of over 13 lbs. to the square inch press-
ing the two layers together.
In most conditions it takes mor« than the
pressure of an atmosphere to separate them,
it is therefore no wonder that they often
remain glued together even in punctured
wounds of the lung.
It is very easy to raise the intrapulmon-
ary pressure above that of the atmosphere,
and under such conditions there would be
a tendency to bulging of the lung thru the
external opening rather than separation of
the pleural layers.
Sir John Rose Bradford says: "Hemo-
thorax is the most common result of a chest
wound ; both pneumohemothorax and pneu-
mothorax are relatively rare, and in a series
of 328 cases of gunshot wounds of the chest
only 8 cases of the former and 4 cases of
the latter were observed." This statement
gives no indication of the relative number
of cases of simple hemothorax. In dealing
with infection he says: "In a series of 450
cases observed by Bradford and Elliott, in-
fection was present in 117 — that is to say,
roughly, in 25 per cent.; and Captain H.
Henry, who carried out the bacteriologic
investigation, found that lung organisms,
such as the pneumococcus, B, influenza and
M. tetragenous, were present in some 20
per cent, of the infected cases, and that in
the remaining 80 per cent, streptococci,
staphylococci and anaerobic gas- forming
bacilli were found."
Whatever be the relative proportion of
cases of hemothorax in wounds of the
chest, we will now deal with the physics of
the condition when it exists. In the vast
majority of cases the hemorrhage comes
from the lungs and naturally gravitates to'
the most dependent part of the pleural cav-
ity, and this pressure first causes collapse
of the lower part of the lung. If the wound
be low in the chest the collapse of the
wounded portion of the lung may quickly
arrest the hemorrhage so that the negative
tension is not abolished, but even increased
on account of the collapsed lung leaving
a potential or actual cavity which is filled
up by the effused blood, elevation of the
diaphragm, collapse of the lower part of the
chest walls and emphysematous expansion
of the non-collapsed portion of the lung.
The negative pressure may be so great as
to draw over the mediastinum — including
the heart — to the affected side. When the
wound is in the upper lobe the hemorrhage
is likely to continue until the intrapleural
tension becomes positive and you get col-
lapse of the greater portion of the lung.
When the external wound closes, as it as
a rule quickly does in cases of gunshot
wounds, and the wounded lung collapses, no
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more blood or air can get into the pleural
sac, and the air is quickly absorbed so the
negative tension is maintained or even in-
creased. You can easily form an estimate of
the amount of blood effused by the evidence
of the tension, negative or otherwise. When
the diaphragm is very high and immobile,
chest flattened in the lower part, you read-
ily perceive that the amount of blood is
slight and can be left alone if there be no
evidence of infection.
In my Bradshaw lecture delivered in
1907, I rather forestalled many of the ob-
servations on the chest wounds in the pres-
ent war. Inter alia, I said: "With care
atelectasis is easily differentiated from
pleural effusion even when the dull percus-
sion is absolute and the respiratory and
vocal phenomena absent. In atelectasis of
bne lung the affected side is smaller than
the other, the ribs are closer together and
more sloping, the costal angle more acute,
the diaphragm raised, the dull percussion
barely reaches the middle line in front,
while the sound lung passes beyond the
mesial line, the heart is either not displaced
or slightly pushed over by the sound lung."
In pleurisy there is no sudden arrest of
the effusion as in hemothorax but it grad-
ually accumulates and as the pressure be-
comes positive you get collapse from be-
low upwards, but there can be no general
collapse of the lung until the intrapleural
tension becomes sufficiently positive to over-
come the intrapulmonary pressure minus the
elasticity of the lung. Even before there is
any general p>ositive pressure, if there be
a difference of pressure in the two pleurae
the heart may be pushed or drawn over to
the side where the negative tension is the
greatest. As the effusion increases the ten-
sion becomes more and more positive, and
eventually there is not only complete col-
lapse of the lung, but the heart and neigh-
boring organs get much displaced, and the
diaphragm pushed down so as to depress
the abdominal organs. If you withdraw
the effusion and substitute fluid air for the
liquid you can now easily r^^late the pres-
sure, which then becomes equal all around
the lung and not according to the depth of
the liquid. If you are careful to leave a
pressure in the pleura less than that of the
atmosphere in the intrapulmonary air sacs
you encourage the gradual expansion of
the lung and the restoration of its elasticity.
On the contrary ih hemothorax the tension
rarely, if ever, becomes positive hence you
get sinking in of* the chest walls and a rise
in the diaphragm which becomes fixed in
its elevated position. Owing to the com-
plete collapse of the lower lobe there is
no intrapulmonary pressure to assist in the
expansion of the collapsed lobe. In em-
pyema the pressure is frequently higher
than in serous effusion, and when the ten-
sion is very high there is not only complete
collapse of the lung but you may have the
pulsations«of the heart communicated to the
liquid, giving rise to a pulsating empyema.
The lung is kept expanded by the nega-
tive tension within the pleura, and the
greater and more active the inspiration the
greater the negative tension, but not un-
frequently, especially in many wasting dis-
eases where the demand for oxygen is not
great, this negative pressure may fall to a
very low ebb or may disappear, especially
at the bases and posterior surfaces of one
or both lungs, the inspiratory movements
being confined to the upper part of the
thorax. In such cases partial atelectasis is
of one or both lungs, or almost complete
atelectasis of the lung of the side on which
the patient has mostly lain is not at all un-
common. Massive collapse mostly occurs
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in the lower lobes, and is especially apt to
occur in young flat-chested individuals with
pliant chest walls.
I have seen a greater number of these
cases than has fallen to the lot of most men
for the simple reason that I have been on
the lookout for them for many years. These
cases are frequently overlooked because
there is usually a negation of subjective
chest S)anptoms, and so the lung is often al-
lowed to remain so long collapsed that it
never completely expands, and afterwards
the deficient expansion of one side of the
chest is ascribed to some old pleural eflfu-
sion of which the p?itient has no recollec-
tion. When these cases are discovered in
the early stages they are frequently mis-
taken for pleural effusion — ^an error which
is apt to remain uncorrected if an explor-
ing needle be not inserted into the chest.
The careful physician should avoid explora-
tory operation until all other methods of
diagnosis have failed him. In massive col-
lapse the signs which I have before pointed
out should clear up the case. I have seen
cases where after tapping with negative
results the physician in charge had diag-
nosed sarcoma of the lung, unresolved
pneumonia, etc. My opinion that the con-
ditions were simply due to atelectasis which
could be removed by respiratory gymnas-
tics was at first received with credulity, but
the subsequent improvement in the cases,
and the non-fulfilment of the grave prog-
nostications proved the correctness of my
views.
In the early stages the diagnosis is at
once cleared up by the excitation of the
lung reflexes of Albert Abrams. If you rub
the affected side briskly with the hand the
collapsed lobe expands, the percussion note
clears, you can hear the air entering the
alveoli accompanied with some dry fine
crepitations. If you keep up this friction
for a length of time the collapsed lobe may
almost attain its former dimensions, and
the edges of the enlarging lung find their
way between the arch of the diaphragm and
the thoracic walls. When the lobe is ex-
panded if you strike the chest firmly sev-
eral times with the ulnar side of the closed
fist the lobe collapses again.
The lung reflexes are largely responsible
for the contralateral collapse which fre-
quently occurs in gunshot wounds or
other injuries of the chest. These lung re-
flexes also differentiate collapse from hypo-
static congestion. In these cases respira-
tory gymnastics should be practiced and
the patient told to frequently change his po-
sition, and to lie on the sound side.
In advanced cases of mitral stenosis col-
lapse of numerous lobules on the pos-
terior surface of both lungs is a matter of
frequent occurrence. In these cases the
oxygenating surface is greater than that
defhanded by the small quantity of blood
passing thru the lungs. These cases usually
pass on to more or less permanent collapse
with brown induration of the lungs. Apart
from cases associated with mitral stenosis,
atelectasis, partial or complete, when early
recognized is very amenable to treatment;
but when long n^lected permanent damage
to the lung results.
I saw such a neglected case ten years
ago where I effected considerable improve-
ment. He has since carried on hard labori-
ous work without further medical advice
until he consulted me a few days ago. There
is still considerable deformity, but his vital
capacity is sufficient.
Fluid in the pleura, as we have before
seen, lessens and finally abolishes the intra-
pleural negative tension, but so long as it
is not sufficient to 9ause collapse of the
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lung and displacement of other organs,
often gets rapidly absorbed after the febrile
stage has passed without any special medi-
cation. The effusion is a natural process
which, if it continue till after the inflamma-
tion has subsided, lessens the risk of pleu-
ritic adhesions; it also keeps the more or
less collapsed lung quiet, which is very de-
sirable if there be any active tuberculosis in
the lung. A very large proportion of cases
of pleurisy are tuberculous, and the early
withdrawal of the fluid causes vascular tur-
gescence of the lung, often hastens the dis-
semination of the tubercle bacilli, and kills
the patient. Before I began the substitu-
tion of one fluid for another by the intro-
duction of filtered air into the pleural cav-
ity, I was much more chary of early tapping
than I am at present. I can now remove
the whole of the effusion, even in tuber-
culous cases, at an early stage with perfect
impunity.
A considerable number of deaths have
followed the complete withdrawal of the
effusion in elderly persons with rigid chest
walls. The danger in such cases arises from
establishing too great a negative pressure
which leads to hyperemia and edema of
both lungs; this can be obviated by the
introduction of air. I prefer air to oxygen as
nitrogen is not quickly absorbed.
When you remove say three to five pints
of serous fluid from a pleural sac there is
a potential or actual cavity which cannot
be easily filled. Such a cavity cannot exist
in the human body with a surrounding at-
mospheric pressure of 15 lbs. to the square
inch. It is filled by : (a) the carbonic acid gas
which escapes from the serous fluid as the
pressure is lowered; (b) by the more or
less expansion of the collapsed lung; (c)
by the return of the mediastinal contents,
which were pushed to 9ne side, and the fur-
ther expansion of the other lung; (d) by
increased quantity of blood in the chest;
(e) by elevation of the diaphragm; and (f)
by falling in of the chest wall. All these
events may not suffice to fill the cavity if the
amount of fluid withdrawn has been very
great and the lung so collapsed and bound
down that it cannot expand. The great dan-
ger arises from the collateral congestion and
edema not only of the expanding lung but
also of the healthy one.
The best way to lessen this extreme nega-
tive pressure is to substitute filtered air
for the fluid withdrawn. I recommend the
the complete withdrawal of the effusion in
all cases where tapping is considered neces-
sary, but before any great negative pres-
sure is established, and before the patient
feels any discomfort, I stop the siphon and
introduce about an equal quantity of air to
the amount of fluid which I have with-
drawn. I then reestablish the siphon and
complete the removal of the effusion. When
all the liquid is withdrawn I inject 4 cm.
of adrenalin solution (1 to 1000) diluted
with 8 or 10 c. cm. of sterile normal saline ;
and, if I think it necessary, I introduce
more sterHe air so as to make the total
amount equal to half or three-fourths of
the bulk of the fluid removed; the larger
quantity of air is introduced in tuberculous
cases. By this method the patient suffers
no discomfort except from the thrust of
the trocar, and runs no risk. I prefer the
siphon to the aspirator because you can
readily regulate the force of the suction,
and as your tube can only reach to a re-
ceptacle on the floor practically your suc-
tion never exceeds 1 pound to the square
inch; this force is greatly exceeded by the
aspirator, and the greater the negative pres-
sure the greater the risk of hyperemia and
edema.
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When introducing the air into the pleura
it may be an advantage to place a mano-
meter in the circuit so as to obviate any
risk of the production of a positive pres-
sure in the pleura, but when the operation
is intelligently carried out such refinements
are scarcely necessary.
The pleura is a very vascular membrane,
the blood vessels of which belong to the
systemic ^system, and are innervated by the
sympathetic, hence the adrenalin solution
causes them to contract and lessens any
further secretion. When the use of adren-
alin is supplemented by the introduction of
air the negative pressure is lessened or
abolished but rarely becomes so positive as
to cause much collapse of the lung; as the
air gets absorbed the lung gradually ex-
pands and the negative pressure is reestab-
lished. By this combined method you can
operate easily in any case, even* during the
febrile stage (tho as a rule I prefer to let
that stage pass), and under no circumstances
should you allow the fluid to accumulate to
such an extent as to completely collapse
the lung you should tap before the patient
suffers any respiratory distress. By removal
of the effusion you often remove numerous
microorganisms, and by the introduction of
sterile air you substitute a light innocuous
fluid for a heavy deleterious one. I now
show you my apparatus for carrying out
this procedure. The history of the intro-
duction of air into the pleural cavity, in
which I took a prominent part, is recorded
in my Bradshaw lecture.
I rather hesitate to say anything about
drugs in this lecture, but as surgeons as a
rule know very little about physic and less
about physics, while every fool in the coun-
try, from which category surgeons are not
exempt, considers himself a physician I
mav venture on a few observations which
may contribute to the restoration of the
function of the damaged lung. There is
one drug, common salt, which you should as
far as possible eliminate from the diet, es-
pecially in cases of sero-fibrinous pleurisy
on account of its high asmotic equivalent.
When there is a large quantity of effused
fibrin, such as occurs in pneumococcal
pleurisy, dacalcifying agents such as
lemons, citric acid, the citrates of ammo-
nium, potassium and sodium may be used.
However it will be well to reserve their use
until the acute stage of the accompanying
pneumonia has passed, as the lime salts are
the most important drugs in the treatment-
of that disease.
In order to hasten the solution and ab-
sorption of the effused fibrin there is no
objection to the introduction of a small
amount of trypsin into the pleural cavity.
The injection of a few ounces of sterile
liquid paraffin, which has a lower specific
gravity but a higher surface tension than
the normal lubricating fluid, lessens the lia-
bility to pleural adhesions.
When the pleurisy is practically cured you
will find plenty of scope for ingenuity in
trying to restore the function of the lung
to its pristine vigor. For such purposes you
can study the conditions of the intrapul-
monary pressure in the various phases of
respiration, and there are numerous respira-
tory exercises which can be brought into
play.
Empyema. — This is one of those numer-
ous diseases which the surgeons have taken
under their own special care, but have done
very little to advance its treatment. In the
case of a child with elastic chest walls you
could not easily mismanage a case of empy-
ema. A considerable number of cases get
well in spite of the treatment to which they
are subjected. When a surgeon has to deal
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with a purulent effusion in the chest, about
the only idea which he can get into his
head is free drainage, and forthwith out
comes a piece of rib and in goes a large
drainage tube ; he expects it to suck up the
liquid from the most to perhaps the least
dependent part of the cavity, utterly reck-
less as to whether the collapsed lung ever
expands or not.
In empyema the lung is always more or
less collapsed and in any operation the ob-
ject should be to avoid any further col-
lapse and to make the lung expand so as
to drive the purulent fluid out of the chest.
A local anesthetic should be used, but if,
in any particular case, a general anesthetic
is deemed necessary the anesthesia should
be very light, as pointed out by Mr. Aryher
Edmunds, so as not to abolish the pleuro-
laryngeal reflex, and thus the vocal cords
are enabled to play their part in maintain-
ing the pressure within the lungs.
A free incision shoujd be made in a very
dependent spot, about the eighth intercostal
space, in a line with the lower angle of the
scapula. If the ribs be close together it
would be well to take out a long piece of
one rib and then make a very free incision
into the pleura. An assistant should firmly
compress the side so as to drive the puru-
lent matter out and allow as little air as
possible to enter the pleura. A strip of
gauze may be inserted into the wound to
prevent it closing, but no tube should be in-
troduced ; then apply a large piece of sterile
oiled silk over the wound to act as a valve,
so as to allow the discharge to escape and
no air to enter. Large aseptic dressings
should be applied over the valve, the af-
fected side may be well strapped to pre-
vent movement. The patient should lie on
or towards the affected side so as to lessen
movement and encourage drainage; he
sh6uld avoid deep inspirations, and make
deep nasal expirations, so as to expand the
affected lung and drive the purulent matter
out of the pleural cavity. He should be in-
structed to inspire thru the mouth and ex-
pire thru the nose. He should also fre-
quently practice the Valsalva method, or
blow thru a small tube. If the pus be very
offensive or not draining well, the patient
can be treated in a continuous saline bath
and then no dressings will be required, not*
unfrequently the surgical wound becomes
infected and then a previous afebrile tem-
perature becomes very febrile ; the surgeon
often ascribes this to the retention of mat-
ter in the chest, oblivious of the dry con-
dition of the wound which he inflicted, the
wound is enlarged or a counter opening
made and in goes a large tube ; the surgeon,
like a plumber, making a further job for
himself. The best treatment for such cases
is to keep the patient in a warm saline bath
for four or five hours daily, as long as re-
quired, during the febrile period which is
usually the afternoon.
In empyema the pus is usually fairly
liquid, is neutral or may be even slightly
acid in reaction, contains some peptone and
a ferment which seems to have the power
of digesting fibrin, and thus the lung is not
likely to be irreparably collapsed or bound
down by adhesions; there is, therefore, a
good chance of success if the operation be
adopted early, and the after-treatment be
intelligently carried out.
An appropriate vaccine is often very use-
ful. Tuberculous cases are the most trouble-
some, and usually when the fluid becomes
purulent there is a mixed infection. Cases
of pyopneumothorax are best treated by
drawing off the liquid and filling the cavity
with sterile air or oxygen. When the empy-
ema is located the surgeon may remove
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205
a piece of rib and insert a drainage tube if
he choose; he cannot do much harm. Un-
fortunately, Estlander's operation is often
necessary, partly owing to early misman-
agement of the case. There should be some
effort to place the treatment of this disease
on a more scientific basis than that on which
it has hitherto rested.
Pneumothorax. — When the air enters
the pleural cavity from the lung the exit is
usually not so free as the inlet, so the in-
trapleural tension both in inspiration and
expiration becomes positive; then the lung
collapses, and does not get a chance of ex-
panding again unless the perforation heals
and the air becomes absorbed. In these
cases if there be much respiratory distress
part of the air should be withdrawn.
Visual Hernia into the Thoracic Cavity.
— In case of hernia of the whole stomach
into the left thoracic cavity. Captain Ar-
thur Evans made an incision into the
diaphragm, and the patient made an unin-
terrupted recovery. This shows what good
surgery can accomplish.
Emphysema. — In emphysema the chest
becomes barrel-shaped (except in the senile
type), and the costal cartilages rigid; so
the chest walls assume their largest possible
dimensions, the Itmgs lose their elasticity,
the recoil of the chest walls and the intra-
pleura negative tension disappear. Conse-
quently the only part of the respiratory
pump which remains in action is the dia-
phragm, which is a very poor affair com-
pared with the movement of the pliant chest
walls; thus the vital capacity is much di-
minished. If the pump action be completely
abolished the blood can only enter the chest
under positive pressure. The veins of the
neck remain full and tense even in inspira-
tion, and the right side of the heart does
not receive any respiratory assistance.
Recently I drew the attention of a medi-
cal man to the fulness of the veins of his
neck and wished to know what had become
of the negative pressure within his thorax.
He seemed to think, tho he was too polite
to say, that I did not know what I was talk-
ing about, as he never felt better in his life
and the swelling must have been due to a
tight collar. Of course I was glad to hear
it, and if he were satisfied there was no
reason why I should be otherwise. It was
no business of mine, but if the veins of my
neck were prominent I would quickly get
rid of tight collars, and as soon as pos-
sible I would reestablish the negative pres-
sure within my thorax even if it should cost
me a visit to the Alps.
If you wish to retain a healthy chest, you
must maintain a good vital capacity for
which purpose pliant chest walls are es-
sential; you must not allow any calcifica-
tion of your costal cartilages to take place.
In the respiratory pump action which main-
tains the vital capacity the movements of
the chest walls are equivalent to more than
double that of the diaphragm. Everyone
should be taught chest breathing and leave
the diaphragm to look after itself ; it is an
adventitious agent which will naturally
come into play when required. In emphy-
sema the difficulty is not so much in getting
air into the chest as in driving it out, hence
an elastic band worn moderately tight
around the chest assists expiration and gives
more work on inspiration which helps to re-
establish a negative pressure within the
chest.
Asthma. — In asthma there is a tempo-
rary emphysema of the air cells, and even
violent expiratory efforts cannot expel the
air thru the contracted bronchi, but once
the spasm is relaxed the normal function
of the lungs is restored. In these cases there
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is always an excess of lime in the system,
hence decalcifying agents should be used,
and the intake in the diet diminished.
Bronchitis^ — Bronchitis is usually the
forerunner of emphysema, the vital capac-
ity diminished, and the respiratory pump
thrown out of gear. A dry atmosphere to
get rid of the moisture in the lungs is es-
sential, alkaline treatment is necessary
while decalcifying agents are only requisite
in the dry spasmodic type. When the ex-
pectoration is profuse, lime, adrenalin and
atropine are beneficial.
Pneumonia^ — On the affected side the
movements are diminished, the negative
pressure is lessened and gradually becomes
positive, but not to such an extent as to
cause displacement of the heart and other
organs. At first the loss of elasticity of the
lung may be greater than that of the chest
expansion so that the intercostal spaces are
depressed in inspiration. However the af-
fected lung may become so large as to
abolish the recoil of the chest wall and the
lung be marked by the pressure of the ribs.
When the lower lobe only is affected it
may become so enlarged as to compress the
upper lobe to half its size, and depress the
diaphragm. The blood is often badly oxy-
genated, but this is rarely, if ever, a cause
of death, while on the other hand the great-
er percentage of carbonic acid in the blood
stimulates the respiratory center and keeps
up the pump action.
Iiifliieiisa*^Some of the most prom-
inent features of the late epidemic of in-
fluenza, especially in those cases accom-
panied by bronchopneumonia, were extreme
nervous prostration, loss of the knee jerks
and a paretic condition of the chest walls
so that the patients became very livid with-
out much respiratory distress. The best re-
sults were attained by respiratory stimu-
lants such as strychnine and atropine, and
the lime salts.
Lamygeal Diphtheria and CroiqK —
When there is any acute obstruction to the
entrance of air to the chest the negative
pressure becomes so great that the pliant
chest walls are driven in, the diaphragm
raised, and the lower end of the sternum
caved in.
Adenoids^— In this case the obstruction
is a slowly increasing process which leads
to defective development of the chest, high
palate and narrow throat.
Whoo|Hng Cough. — ^This resembles the
Valsalva experiment carried out in spas-
modic efforts, and when the spasm is over
the long crowing inspiration to fill the ex-
panding chest represents a modified Miil-
ler's experiment. The result is that the low-
er part of the chest is pulled in during the
expiratory phase and driven in during in-
spiration— in the pliant chest walls of chil-
dren we may thus get permanent deformity.
Mediastinitis^ — In this condition we get
a modified Miiller's experiment, with a
diminution in the volume of the pulse at
the wrist during inspiration — ^the so-called
pulsus paradexus. When the chest is ex-
panding the adherent lungs cannot fill up
the vacant space in the mediastinum, hence
it is filled by the blood being retained in the
great veins, the right side of the heart and
the lungs, and the amount passing thru the
left side of the heart is temporarily dimin-
ished. I dealt very fully with this subject in
the British Medical Journal of April 20,
1907,
Gonorrhea^ — The use of astringents on
acute gonorrhea and discharge of cases
when symptoms disappear are responsible
for the infection of thousands of women. —
Hall, So, Practitioner,
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207
CHOREA.
BY
GEORGE T. STEVENS. M. D., Ph. D.. F. A.
C. S.,
New York City.
In the beginning permit me to state my
objection to the characterization usually
given to the common form of the affection
which is best known as chorea, namely,
that of "infectious chorea."
It is true that in a limited number of
cases in which death has quickly supervened
upon an attack in which choreiform symp-
toms have been conspicuous, certain organ-
isms have been observed, but these have
been of different kinds in different cases and
it cannot be said that any specific form or
any definite group of organisms of a bac-
terial nature is characteristic of the various
cases.
Moreover, the rapid course and speedy
lethal termination of these cases, which have
usually resulted fatally within a week or
ten days, separate them widely from the
typical form of chorea.
It is much more probable that some so
far undefined affections are accompanied by
choreiform manifestations than that these
suddenly and fatally terminating cases
should be representatives of typical cases of
chorea.
This remark may also apply perhaps to
such manifestations as those of chorea
gravidarum and some other special affec-
tions characterized by choreic movements.
So considerable a proportion of acute
cases of sickness is of bacterial origin that
there is an unwarranted tendency to as-
sume that every case of disturbed nervous
function is a case of microbic infection.
In any case, until an infectious origin is
specifically determined for the common
form of chorea, the term **infectious chorea"
should be abandoned.
Also, in respect to the designation of
"chorea minor" and "chorea major" there
are objections, for in fact the principal dif-
ference between one and the other is the
difference in severity between attacks of the
same affection.
The objection holds good in respect to
the characterization of the most ordinary
form of chorea as "acute chorea," for in
many cases the affection continues for an
indefinite time and is as "acute" after two
or three years as after a few days.
It is therefore more satisfactory to speak
of chorea as a general term and to char-
acterize the various manifestations as
varieties and not as species of the disease.
Let us consider some of the principal
features of chorea.
1. There is always a disturbance of mo-
tility.
2. The affection chiefly attacks children
between the ages of five and fifteen, tho it
may continue for many years or for a life-
time.
3. The motile disturbances are spon-
taneous or of coordination.
4. These motile disturbances are most
commonly manifested either as movements
of the upper extremities or of the head or
face.
Disturbances in the severe cases extend
to the trunk and to the lower extremities.
In sleep the movements are generally, not
always, quieted. In some cases the motile
affection is confined to one side of the body.
Loss of muscular p>ower sometimes de-
velops and speech is sometimes affected.
The patient is, in some instances, affected
mentally even to delirium, delusions or at-
tacks of mania. Other complications are
associated with the functions of nutrition.
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What interpretation can we place upon
these phenomena?
They constitute a series of manifestations
which arise from a definite cause or from
several causes.
In the first place it will be observed that
the parts of the body usually first affected
and principally involved are the head, face
and superior extremities. It is true that in
many cases the lower extremities are in-
volved and in exceptional instances mental
affections are added to the motile irregulari-
ties, but these are manifestations usually
of a stage in which a certain degree of
progress has occurred. It is to be remem-
bered that the attacks commence very early
in life.
A very important consideration is th.it the
initial phenomena are located in the head
and in the upper extremities.
Another very important consideration is
that, in the majority of cases, the duration
of the disease is limited to a few weeks,
tho individual cases continue indefinitely.
These last constitute a most unfortunate
class of sufferers.
A bacterial cause would, according to
usual experience, scarcely account for the
conditions mentioned.
Some other originating influence should
be found.
In the search for a predisposing cause I
suggest the following hypothesis:
The principal predisposing cause of the
typical form of chorea is found in the un-
symmetrical development of different parts
of the cerebrum and an absence of exact
conformity of growth of the cranium, es-
pecially at its anterior portion, inducing a
slight pressure upon the cerebrum at a point
or at points controlling the movements
which are involved in the choreic disturb-
ances.
Let us examine the evidence which leads
to this conclusion.
It is known that during the period of
growth of the body, the period during which
attacks usually occur, there are noticeable
irregularities in the development of the cere-
brum, depending upon the comparative use
of individual parts of the body.
The location of the brain center for the
adjustments of the eyes is situated in the
anterior part of the frontal lobe of each
cerebral hemisphere, and behind this are sit-
uated the centers for the motility of the
face, arms and hands with, a little further
removed, the centers for other muscle
groups.
Many affections may have a predisposing
and an immediate cause. The first may be
insufficient without the other to induce the
full manifestations of the disease.
This, I assume, is the case in respect to
chorea.
Many years ago I affirmed that chorea is
the result of faulty adjustment of the eyes.
Altho there was much to justify the propo-
sition I would, at the present time, modify
it to conform to observations of a later
date. Indeed I would place another con-
dition in the front line without surrender-
ing the conception of the great influence of
the adjustments of the eyes in the etiology
of the disease. The practical results of treat-
ment directed to the correction of the de-
fects of such adjustments have abundantly
confirmed the proposition ; yet I would as-
sign, with my present information, the po-
sition of immediate cause to the faulty ad-
justment of the eyes with probably a share
in the predisposing cause of the disease.
Examining first the initial or predisposing
cause, we may well consider an enlargement
of the frontal zone of the cerebrum, which
may result from excess of efforts by the ad-
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209
justing apparatus of the eyes, a cause of
pressure of the cerebrum against the
wall of the cranium induced by the more
rapid development of the former than of
the latter ; it might readily give rise to move-
ments of the face, arms and other portions
of the upper parts of the body, depending
upon the degree of pressure of such an ad-
vance in the development of the frontal lobe
as has been assumed, and the slight pressure
could well stimulate irregular muscular re-
sponses.
To the doubt which might be expressed
whether such excess of function would in-
duce the increase in volume of the anterior
lobe we may adduce as an example in illus-
tration of such an increase in the develop-
ment of the neighboring region of the cere-
brum the anterior lateral portion of the
left hemisphere of the cerebrum as a result
of the greater use of the right hand over
that of the left.
It is true that the bony walls of the
cranium usually keep pace with the growth
of their contained material and it is also
true that by far the greater number of
children are not affected by any such sup-
posed pressure as I have suggested.
Nevertheless, a combination of circum-
stances might well induce the indications
of pressure.
For the completion of the vicious circle
we may well suppose that the ocular con-
ditions which I have assumed as the imme-
diate cause, the state of refraction or of ad-
justments of the eye, will add to the state
of local pressure.
Especially is this to be presumed since
the center for the movements of the eyes is
situated in the anterior lobe of the cere-
brum and a condition of refraction or of
adjustment which demands an increase in
the nervous efforts to effect their object
may and does induce an increase in the
growth of that part of the cerebrum.
This may, in addition to the increase in
the development of some part of the cere-
brum as the result of other causes, aid in
the process of an unequal development be-
tween the skull and its enclosure.
Beyond the contingency of an increase in
the growth of parts of the brain, there is to
be considered a state of a greater than ordi-
nary hyperemia of the part of the cerebrum
controlling the adjustments of the eyes, thus
intensifying the effect of the slight pressure
from unequal growth.
This view is strengthened when we con-
sider that in cases of hypermetropia, which
is a prominent feature in the majority of
subjects of chorea, the frontar region of the
cranium is prominent, the orbits are short
and, in case of the unequal development of
the two sides of the cerebrum, there is like-
ly to be the condition known as declina-
tion, which in many cases is a cause of
much irritation and of fatigue to the eyes
and their surroundings.
Thus there is a combination of slight
pressure upon the anterior portion of the
cerebrum with a condition of irritation of
that portion of the brain.
Perhaps neither of these conditions acting
alone would induce the phenomena of
chorea, which is sometimes intermittent for
days together. In the very common chronic
form of chorea called tic there is evidently
a spasmodic effort to correct faulty adjust-
ments of the eyes.
Thus we have all the conditions neces-
sary for the origin and development of
choreic movements in slight pressure upon
certain parts of the brain with a source of
nervous disturbance in the region of the
eyes.
The development of the cranium is so
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uniformly in proportion to its contents
that, ordinarily, there is no manifestation
of irregular motile actions.
This is the case even when there is irrita-
tion from refractive or irregular muscular"
action. But when there is combined dis-
parity between the development of the cra-
nium and cerebrum with irritation from
ocular adjustments there is sufficient pro-
vocation to induce the phenomena of chorea.
We are then led to inquire why the pres-
sure effects should continue only, as a rule,
for a limited time and why relief to the
adjustments of the eyes should shorten
the process of the affection?
To the first question we might legitimate-
ly assume that the difference between the
growth of the cephalic and the cranial ex-
pansions would adjust themselves, as a rule,
after a few weeks. On the other hand, a
relief to the adjustments of the eyes serves
as an amelioration to the pressure which
is the cause of the trouble.
The considerations which I have pre-
sented would account for the peculiarities of
disturbance in the motile functions, for the
mental manifestations, for the difference
in the length of duration of the various
cases and for the relief afforded by treat-
ment of the eyes.
The rational treatment of chorea would,
in view of this hypothesis, consist prin-
cipally of measures directed to the correc-
tion of the anomalous conditions of the
eyes, since the development of the cerebrum
cannot so well be controlled and the treat-
ment of the unfavorable states of the eyes
is usually practicable.
Of course, when it can be assumed that
the greater use of the right (or left) hand
predisposes to the pressure upon one or
other part of the cerebrum, as the case
may be, advantage may follow a change in
the habitual use of the hands. Other meth-
ods tending to an equalization of the growth
of the brain may suggest themselves, but
these indications are obscure.
A majority of cases will recover under
almost any form of treatment but even in
any case adequate treatment directed to the
ocular conditions will materially hasten a
return to the normal condition, while in that
unfortunate proportion of cases, in which
the motile disturbances persist, the attention
to the eyes becomes absolutely necessary.
The simplest indications are directed to
the refraction but, unfortunately, for these
simple indications in the more persistent
cases, the disturbing immediate cause is
often found in the condition known as
declination.
It is, in these persistent cases, often ab-
solutely necessary to correct this condition-
and, as a rule, these most obstinate forms
of cases of common chorea will yield to
such correction.
40 East 41st Street.
PULMONARY TUBERCULOSIS CASES
TREATED WITH ULTRAVIOLET
LIGHT, '
(A Casuistic Contribution Second Paper)
BT
ERNEST ZUEBLIN, M. D., P. A. C. O. P.,
Associate Professor of Medicine, University of
Cincinnati,
Cincinnati, O.
Encouraged by previous observations on
the therapeutic action of highfrequency
waves on tubercular patients^^ a trial with a
less powerful machine applied to medium
or even far advanced cases of that disease
was at least of interest. In the case of
giving treatments the question arises as to
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ORIGINAL. ARTICLES
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211
the expense of the equipment, the accessi-
bility of the mode of treatment to the gen-
eral practitioner and to the patient as well.
The present portable highfrequency outfits,
available for the practitioner, furnish
enough energy and current ; doubt only pre-
vails whether this energy produced is suf-
ficient to benefit the patient. Experimental
work must necessarily support the clinical
results' and many cases must be subjected to
careful examination and supervision before
any definite conclusions can be drawn. The
present study shall not attempt a definite
conclusion, as a contributory addition to the
papers of other authors, however it appears
of practical and scientific interest.
The apparatus attached to an A. C. cur-
rent with 110 volts tension, and connected
with one flat low vacuum tube, the latter
was applied from 2-5 minutes upon the skin
of the patient, so that all aflFected parts of
the lungs would be placed under the action
of the current so introduced. The spark
gap at the beginning of the treatment did
not exceed one-half inch, only later, when
the patient had become accustomed to the
procedure, the distance of the two terminals
was gradually increased until the appear-
ance of a slight spark on the p>oint of con-
tact with the skin.
In a former paper* of mine I reported on
the radioscopic measurements of air thru
which the highfrequency current was al-
lowed to pass for one minute. The curve
so obtained during an observation period
of one-half hour shows that there is a radi-
ation present which, besides the alpha rays,
contains other rays of deeper penetration.
Today it is not possible to enter upon a dis-
cussion of the various eflFects produced by
ultraviolet light. From numerous papers on
the subject however, we must admit that ac-
cording to the dose of energy applied, we
exert either a stimulating or an inhibitory
effect by such means.^» *
The following cases, while under ambula-
tory treatment, were subjected to highfre-
quency application and in giving \the case
history the physical findings will be found
in abstract.
Case I, — Mr. B. Age 30, married, rail-
road employee, myasthenia for the past
eight months, subject to frequent colds,
tonsillitis, pains between the shoulder
blades, anorexia, general weakness and
slight cough. The patient was referred to
me by a medical friend, whose examination
aroused the suspicion of a tubercular in-
volvement. The physical findings on this
case were as follows :
Right Apex, ant. — Marked impaired per-
cussion sound over the apex as far as the
first interspace, with granular inspiration,
harsh tubular expiration, many moist mu-
cous rales and bronchophony.
Posteriorly. — Impaired percussion sound
extending from the apex to the sixth* spi-
nous process, impaired resistance on palpa-
tory percussion, granular inspiration, harsh
prolonged tubular expiration, many crepi-
tant rales, extending to the fifth interspin-
ous process.
Left Apex, ant. — Marked retarded
respiratory expansion and impaired percus-
sion sound, extending to the upper border
of the second rib, granular inspiration and
prolonged, extending to the first interspace,
abundant mucous and crepitant rales, with
bronchophony extending to the same level.
Posteriorly. — Marked retraction of the
left apex, impaired percussion note from
apex to sixth interspinous notch, granuhr
inspiration, harsh, markedly prolonged ex-
piration, diffuse crepitant rales and bron-
chophony extending from apex to sixth spi-
nous dorsal process.
These findings expressed in shorter and
abbreviated terms, as suggested in one of
my former papers, (5) read as follows:
R. L. Ap. ant.— P.-3 a. f . a. 1 Isp.
Insp. gr. Exp. h. t.
Rl. ++4- m. m. cr. r. Bph.
Post.— P.-2 a. f. a. spp. 6, Pp.-2
Insp. gr. Exp. prol. h. t.
Rl cr.++a. f. a. 5. Spp.
Rex. — Bph. a. f . a. 6. spp.
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L. L. Ap. ant. — P.-l. Isp. Pp.-l a. f. a. u ii.
Rb.
Insp. gr. Exp.-h. prol. a. f.
a. 1. Isp.
Rl m. m. mcr. 4-++Bph.
a. f. a. 1. Isp.
Post.— Scf. Retr. Rex.-
P.-l a. f. a. 6. Spd. pr.
Insp. gr. Exp. prol. h.
Rl. cr. diff. a. f. a. 6. Spd.
pr.
Bph. a. f. a. 6. Spd. j)r.
Diagnosis. — Moderately advanced Tbc.
Turban II B. involving both vertebral
and 1/11 interspace trunks on either side.
The emaciated patient reacted on tuber-
culin O. T. positively, locally and focally
after a dose of 0,0005. O. T. with an area
of redness extending over 3j4". The pa-
tient was treated every two weeks by an in-
jection of 0,0002 O. T. A physical examina-
tion after ambulatory treatment revealed no
marked improvement of the chest findings,
so it was decided to resort to the applica-
tion of highfrequency current for 2' twice
a w^ek. Digestive complaints suggested a
test meal with the following results : Free
HCL 60%, total acidity 95%, one hour
after test breakfast. The patient's weight
on 3/23 was* found 123 J4 lbs., with the
start of tuberculin treatment it rose to
142 lbs; when seen for the last time on
7/14, a difference and gain of 18 lbs. in 16
weeks could be recorded. The sputum was
at first quite copious, 6 oz. a day, mucoid
and frothy, but negative as to Tb. bacilli,
occasionally hemorrhagic in aspect. The
highfrequency lamp was applied to the
bared skin over the involved pulmonary
areas for 2' on the following dates and for
several minutes, on 5/1, 2', 5/4, 5' and with
the same length of treatment on the 5/17,
19, 26, on 6/5, 24, total amounts of treat-
ments 32'. Of course in judging the results
of any treatment, the objective and sub-
p. z= percussion, a. f a. = as far as, Isp. =
Interspace, Insp. = inspiration, gr. = granular,
exp. = expiration, h. = harsh, t. ^ tubular,
Rl. = rales, ++-I- = many, m.m. =r moist,
mucous, cr. r. := crepitant rales, bph. = 'bron-
chophony, P.-2 = marked impaired percussion
sound, spp. 6 = sixth spinous process, pp. =
palpatory percussion, prol. = prolonged, rex. =
respiratory expansion diminished, u. = upper,
II rb. = second rib, scf. = suprascapular form,
rctr. = retraction, spd. pr. = spinous dorsal
process.
jective changes must be taken into account.
Rapidly the patient's sputum was lessened
in amount, finally disappeared entirely and
no more blood was encountered in the ex-
pectoration. The acute sensation of pain in
the chest, as well as the tired feeling,
vanished and the formerly marked ex-
haustion, after the least exertion, sub-
sided, so that eight miles of walk
was no more followed by any systemic
reaction at all. Altho in tubercular patients
a physical examination may give varying
results, if practiced from day to day, with-
out any special treatment being applied,- it
was of interest to control the changes occur-
ring after treatment, provided the examina-
tion was made immediately preceding the
highfrequency application. Without at-
tempting to draw any conclusions from the
physical findings, it is of interest to mention
the regress of the dull areas of percussion,
for one or more inches, further, the lessen-
ing of crackles and moist rales. The con-
stancy of these changes encountered in
many cases without exception, suggests at
least some immediate action of the electric
waves. A physical examination made 7
weeks later, on 6/20, deserves some atten-
tion :
R. L. A. P. n. — Insp. gr. (-}-) Exp. n.
Rl. cr. + Bph. O.
R. L. post.— P. -I- Pp.+
Insp. gr. Exp. si. prol.
Rl. cr. 4- Bph. O.
L. L. A. ant.— P. n. Pp. n.
Resp. n.
Rl. O. Bph. O.
L. L. post. — P. n. Pp. n.
Insp. gr. ( + ) Exp. n.
Rl. O. Bph. O.
A glance at the former findings, occupy-
ing much more space, will show the diflFer-
ence. Another point of interest is the pa-
tient's susceptibility to tuberculin. Before
the starting of the electric treatment, the
local skin reaction in 48 hours, after 0,0002
grams O. T. amounted to a hyperemic area
of 2, 5/8" by 3, 1/8" and an area of tender-
ness of 1" by 7/8".
One week after the start of the electric
treatment the patient, after the identical
dose of 0,0002 grams O. T. 48 hours after-
n. = normal, si. = slightly, O. = none —
absent.
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213
wards, presented a redness of 6, J^" by 3,
5/8".
A tenderness of 1^" by J^", which un-
expected reaction was attended by consid-
erable tiredness and malaise, symptoms per-
sisting for more than four days, the pa-
tient performed just the same amount of
work and exercise as previously. The sus-
picion of a sensitization was entertained
and on the next tuberculin treatment the
dose was reduced to 0,0001. The follow-
ing reaction resulted in 48 hours, i. e., on
5/31, redness measuring 3j4" by 2".
Tenderness 1" by 1, 1/8'', swelling still
noticeable.
Such an observation recalls the observa-
tion on incipient tuberculosis patients,
where a very small dose of tuberculin is
required for obtainirig a positive reaction.
Further investigation along such a line is
on the way and will be reported later. Up
to date, five months later when the patient
was interviewed, he was able to work 8-9
hours a day in a machine shop without the
slightest disturbance of his health. Of
course one is not forgetful of the difficulty
of ascertaining the anactive process by
physical signs alone, the question when a pa-
tient is healed or arrested always remains
more or less doubtful.
Case //.—Mr. F. L. J., 29 years old,
chauffeur has had pulmonary Tbc. for the
past 3 years, was interned for 18* months in
a state sanatorium, leaving from there
apparently as an arrested case. In March,
1915. patient resumed his work, his health
failing rapidly, particularly after a severe
attack of whooping cough in January, 1916.
Was unable to recover. Sputum was
green, early vomiting in the morning,
anorexia very marked, general exhaustion
and toxemia. Considerable pain in his left
chest, exacerbated with deeper breathing.
Former weight was 161 lbs., present weight
133 lbs. Height of patient, 5' lO^"-
Physical findings of the much emaciated
patient, looking very hectic :
R. L. ant.— Rex.-2 A..retr. T. 3 a. f. a. 1.
isp.
P-1 a. f. a. Scl. f . Pp. -2. a. f . a.
u. Rb. 11.
Insp. cw- Exp. t. a. f. a. 1. Isp.
Rl. cr. + 3- Bph. + a. f. a. u.
Rb. 11.
R. L. post. — Rex.-2. T. a. f . a. Scpf .
P-2 a. f. a. 7. Spdp. Pp.-2
a. f. a. 9. Spdp.
Insp. cw. Exp. prol. t. a. f. a. 9.
Spdp.
Rl. cr. diff. 3 a. f. a. 9. Spdp.
Bph. +
L. L. ant. — Rex.-l A. retr. T. a. f . a. 1 — isp.
P.-l a. f. a. Scl. f. Pp.-2 a. f. a.
1. Isp.
Insp. cw. a. f. a. 1. Isp. Exp.
prol. h.
Rl. cr. 4- 2. Bph. ++ 1 Isp.
L. L. post. — Rex.-2 a. f . a. Scpf. T. a. f . a.
Scpf. a. f. a. 5 Spd. p.
P.-2 a. f . a. 5. Spdp. Pp.-3 a. f.
a. 7. Spdp.
Insp.. Prol. h. a. f. a. 5-Spdp.
Exp. ht-5 Spdp.
Rl. cr. + ms. diff. 3, Iw. Ang.
Scap.
Bph. -f -f- 7 Spdp.
Physical Diagnosis. — Involvement of
both upper lobes. Turban 11/111 verte-
bral, both interspace trunks possibly of
apices of both lower lobes posteriorly.
Displacement of the heart to the left
about yi" ^outside of the midclavicular line,
heart sounds indistinct and weak. Sputum
examination for Tbc. bacilli negative.
Patient was very much in a hurry to get
better and stayed in the city only ten days.
Three highfrequency treatments, each of
five minutes duration, were given every
other day, directly over the involved areas.
The subjective report of the patient after
that time was: Temperature about 99.
Less tiredness and exhaustion and coughs
much less during the night. Daily amount
of expectoration considerably reduced,
better appetite, tenderness of the chest
anteriorly and posteriorly disappeared.
Objectively the physical examination on
3/27/16, ten days later:
R. L. ant.— A. P. + Pp. —1 a. f . a. Self.
Insp. prol. Exp. h.
Rl. crp. (+). Bph. (+)
T. = tenderness on touch, Scl. f. = Supra-
clavicular form, cw. = cogwheel, uRbii = upper
border of second rib. P.- = diminished, im-
paired percussion, figures 1-2-3 meaning intens-
ity, 1 = slight, 2 = marked, 3 ^ very marked
diminution.
Ht. = harsh tubular, Iw. Ang. Scap. = lower
angle of scapula.
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R. L. post.— A. P. + Pp. — a. f . a. 3. Sppd.
Insp. gr. Exp. h. prol.
Re. crp. + Bph. + a. f. a. 3.
Sppd.
L. L. ant.— P. & Pp. + 1 a. f . a. A. a. f . a.
Self.
Insp. prol. Exp. prol. h.
Rl. cr. (+) a. f. a. A.
L. L. post.— A. P. & Pp. -1. a. f. a. 3. Sppd.
. Insp. gr. Exp. prol.
Rl. cr. (+) Bph. a. f. a. 3.
Sppd.
These findings compared with those 10
days before, show at a glance an improve-
ment, namely: Regress of the dull areas
on ordinary and palpatory percussion, less
extensively impaired breathing and only
scanty, indistinctly noticeable crepitant
rales and less bronchophony. An inquiry in-
to this patient's condition 9 months later
gives the following results : Patient is feel-
ing well, coughs very little and is able to at-
tend to his work several hours a day, with-
out any disturbance to his health.
Case IIL—Mv, L. A. G. L., 25 years
Seminarian. F. H. has no relation to the
disease present. P. H. — Measles and pneu-
monia in childhood. Consulted me in
January, 1915, for gastritis, on which oc-
casion physical examination revealed
chronic catarrh of both lungs, involving
right upper and part of middle lobe, and
left upper lobe. After Leube-Riegel test
meal free H. C. L. — 22%, total acidity
66% ; faint trace of albumen in urine and
no casts. Pulse rale 78, systolic 126 mm.,
diastolic 66 mm. (Tycos) pulse pressure 60
mm. cardiac activity for one minute. 14976
mm. Hg. Height 5 ft. 7 in. Weight 135
lbs., from 10-15 lbs. below the patient's
average. Normal temperature. Focal and
local reaction after .001 O. T., 48 hours on
3/5/15, area of (R) measured 4" x 4".
Area of (T) Ij^" x VA^ Moderate Sw.
Patient received every two weeks a thera-
peutic dose of O. T. .00025 up to 5/21/15,
which injection in 48 hours gave the follow-
ing reaction: R— 1" x: 1^" T.— 1^4" x
1J4". Marked Sw. Temp. 99.4 on the 5/20.
The patient's lung condition up to that time
showed considerable improvement ; the
lesions being restricted to both apices with
moderate Pp.-l. Exp. prol. h. Rl. cr. (-f-)
Bph. (+). Gain in weight after an initial
P.-h = hyperresonance on percussion.
loss of 2 lbs. in first week, during O. T.
treatment, 12 lbs. in 14 weeks without re-
quiring interruption of patient's studies.
Patient was seen no more until 1/5/16,
then complaining of a protracted cold and
dyspeptic symptoms ; moderate rise in tem-
perature 99, weight 134 lbs., considerable
mucoid sputum, with no Tbc. bacilli. Pulse
87.
Lung examination as follows :
R. L. ant.— Retract) + a. f. a. 1 Isp.
Rex. JT. a. f . a. 1 Isp.
P.-l a. f. a. A.
Pp.-2 a. f . a. 1 Isp.
Insp. gr. a. f. a. 1 Isp.
Exp. prol. t.
Rl. cr. + 3. Diflf. a. f. a. Isp.
Bph. + 2 a. f . a. 1 Isp.
R. L. post.-R^e^ract|[ + ^ ^ f ^ g^^j _^ ^
P.-2*. a. f. a. 5 Sppd.
Pp.-2. a. f. a. 7 Sppd. d.
Insp. gr. cw. a. f. a. 7 Sppd.
Esp. prol. h. (t) a. f. a. 5 Sppd.
Rl. cr. + (2) diflf. a. f. a. 7
Sppd.
Bph. + 2 a. f. a. 7 Sppd.
L. L. ant. — Retract)-}-
Rex. ]— Ap.
P.-l a. f. a. Self.
Pp. -2 a. f. a. Self.
Insp. gr. cw. a. f. a. A.
Exp. prol. h. a. f. a. A.
Rl.cr. + 2diflf. Self.
Bph. + 1 a. f. a. 1 Self.
L. L. post. — Retract) . c r t- i •
Rex. { ^' *• ^- Ssef . T. ++
P.-2 A. a. f. a. 3 Sppd.
Pp. -2 A. a. f. a. 4 Sppd.
Insp. gr. cw. Exp. prol. h. a. f.
a. 3 Sppd.
Bph. + 1 a. f . a. 4 Sp. d. pr.
The interpretation of these physical signs
would suggest an active case of pulmonary
involvement Turban 11/111 B. affecting up-
per and apex of right lower lobe; on left
side vertebral and first interspace trunks,
possibly also second .interspace trunk.
Early in February, patient was treated
with O. T. .002 showing R— 1^" x 1>4",
T— 5^" X ^", and moderate Sw. after 48
hours. Every two weeks, up to .004 O. T.
R. = redness, T.
swelling.
tenderness, Sw. r=
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215
were given as on 3/24. Third injection was
followed in 48 hours by the local reaction
R— ^" X j4\ T— J^" X ^", Sw. moder-
ate. The physical examination revealed,
4/5/16, 11 weeks after the first overhauling
of the chest :
R. L. ant.— A. Self. P.-Pp.-l
T.+ Self.
Insp. n. Exp. prol. h.
. Rl. cr. + Bph. +
R. L. post— P.-l a. f . a. 3 Spdp.
Pp.-l a. f. a. 5 Spdp. + T.
Insp. h. Exp. prol. h.
Rl. cr. + 2. Bph. a. f. a. 5
Spdp.
L. L: ant— Self. P. & + Pp. -1.
Insp. n. Exp. prol. h.
Rl. cr. + Bph. +
L. L. post. — P. + 1 a. f . a. 2 Spdp.
Pp. + 1 a. f. a. 3 Spdp.
Insp. h. Exp. prol. h.
Rl. cr. + 2 a. f . a. 3 Spdp.
Bph. a. f . a. 3 Spdp.
4/16 the same dose as on 3/24, freshly
prepared solution being used with .004 O. T.
local reaction in 48 hours :
R. I"xlj4"
T.lj4"xJ^"
Sw. 1" X 1"
On 4/4/16 the patient for the first time
had been given local highfrequency current,
for 2" on each apex, and reported on 4/12
considerable relief from pain and tiredness
lessened, hardly noticeable cough and in-
significant expectoration.
The same treatment was repeated on
4/19/16, for the same length of time. The
patient's observations are of interest, since
he left well stimulated. Digestive com-
plaints, cough and expectoration were strik-
ingly diminished. With a smaller dose of
.003 O. T. on the 4/26 the local reaction,
amounted in 48 hours to R. 1" x J4"
T. l"x^''
Sw. l"x%"
Two weeks later the patient having in-
jected .0025 O. T. made quite a marked
and more extensive reaction in 48 hours,
but, while before the cough was always
more pronounced, this time nothing ab-
normal along this line could be observed.
In 16 weeks the patient's weight had in-
creased 12 lbs. and he felt perfectly well.
On 9/16 without any further treament,
except two sittings — of 2' duration, each —
of highfrequency applications showed the
following chest findings :
R. L. ant.— P.+ Pp. n.
Resp. n.
Rl. cr. (+) Bph. O.
R. L. post.— A. P. + Pp. — a. f . a. 3 Spdp.
Exp. (prol.) Rl.
Bph. O.
L. L. ant.— P.-i- Pp.— (,1)
Insp. -f- gr. Exp. prol. h.
Rl. cr. + (few) Bph. + (1)
R. L. post. — A. P.-l a. f . a. 3 Spdp.
Exp. prol. h.
Rl. cr. -f 1 a. f . a. 3 Spdp. +
Bph.-f.
If we compare the physical findings of
this case, as revealed on 1/15 with those
noted on 4/15 and 9/16, we see a consider-
able difference suggesting a marked im-
provement. Also as mentioned in case I, we
cannot neglect the higher sensibility to
tuberculin, which followed the highfre-
quency treatment, nor is it permissible to
overlook the subjective improvement ob-
served by the skeptic patient.
In the present casuistic study, altho
limited to a few cases, with all respects
toward a critical reserve, we may recapitu-
late the following points :
Case I. — On pnmary examination listed
under Turban II, B. with physical changes
in the vertebral, and at least the 1st possibly
also, of the 2nd interspace trunks and
marked activity, was transformed into a
case with considerably lessened physical
signs, which changes were substantiated by
the patient's subjective improvement.
Case II, — ^A very active 3rd stage, pa-
tient offering a very doubtful prognosis.
On last examination, suggested less active
lesion apparently not exceeding the phys-
ical signs expected in a second stage case.
Subjectively improved. Sputum, daily
amount considerably lessened, regained his
appetite and became less toxic.
Case III, — Corresponding to lesions
classified as Turban 11/111 B. both upper
lobes being affected and suggestive changes
in apex of right lower lobe was trans-
formed into a case with the lesions pointing
towards Turban 2nd.,, namely, physical
changes in both vertebral and both inter-
space trunks on the right, physical changes
unlikely exceeding the areas of both verte-
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bral trunks. Subjective improvement as re-
gards the symptoms and general condition
including the weight.
Case IV. — More extensive lesions, an-
swering to Turban 11/111, more likely the
latter with involved vertebral, 1/11 inter-
space trunks, complicated by lesions in the
apex of right lower lobe, of vertebral and
first interspace trunks on the left side ; ex-
perienced temporary relief of intense pleu-
ritic pains, marked cough, lessened amount
of mucopurulent expectoration. This latter
case points very emphatically to the fate of
irresponsible weaklings affected with the
disease, wherein the desire to preserve life
and fight the infection by all cooperation
with medical advisors, sooner or later fails,
and so the patient surrenders his hopes to
the fatal disintegrating action of the deter-
mined bacterial invader.
REFERENCES
1— E. Zueblik: American Medicine, May, 1916,
Vol. XI, pp. 29-77.
2 — E. Zueblin: Medical Review of Reviews,
Jan., 1918, Vol. XXIV, p. 17.
3 — E. Zueblin: Maryland Medical Journal,
Feb., 1918, Vol. XLI, No. 11.
4— E. Zuebun: Medical Review of Reviews,
1918, Vol. XXIV, p. 147.
5. — E. Zueblin: Archives for Diagnosis, Vol.
X, No. 4, p. 374, 1917.
THE PREVENTION OF GOITRE.
BY
ISRAEL BRAM, M. D.,
Instructor in Clinical Medicine, Jefferson Medi-
cal College, Philadelphia, Pa.
It would not be presumptuous to claim
that the prophylaxis of goitre, if earnestly
attempted, would succeed in its purpose in
from 30 to 50% of instances. Deducting
the percentage of cases of hereditary and
"idiopathic" etiology, the attributed causes
of thyroid enlargements are eradicable, all
things being equal. This is attested by ex-
perimental evidences not only in goitrigen-
ous districts of Switzerland. France, Italy,
India and elsewhere, but in regions where
goitre is not at all endemic. Marine and Kim-
ball,^ after extensive experiments in this
work, conclude that simple goitre is prob-
ably the easiest of all known diseases to
prevent.
With respect to the causation of goitre,
McCarrison^ thus sums up the question:
"The problem of the causation of goitre is
one which has exercised the minds of ob-
servers since the earliest days of medical
history. There are, indeed, few diseases
about which so much has been written and
so many diverse views propounded.' The
association of goitre with mountains has
led to the promulgation of many of these
views. A causal influence has been attributed
to the configuration of the soil, to waters
derived from certain soils and charged with
certain chemical ingredients, to altitude, to
the rarity of the atmosphere, to cold and dry
air, to air holding too little oxygen
and to air holding too much, to air
laden with sulphurous vajjors, to the
action of cold air on the neck, to a want
of iodin in the air, to air charged with
electricity, and to some half hundred other
such causes. One is apt to dismiss with
scant ceremony the observations of earlier
observers in this field of research, but if we
consider some of their views in the light
of our modern knowledge of the thyroid
function, we shall realize the truth that is in
many of them. The effect of altitude and
of rarified atmosphere falls into place with
the gland's function of regulating the re-
spiratory changes and of maintaining the
red blood corpuscles and the hemoglobin at
a level proper to the altitude. The lack of
iodin in the air at altitudes above 1,000 feet
will indirectly influence the thyroid toward
hyperplasia by its lack in the food. The
ingestion of waters charged with an excess
of lime adds to the burden of the thyroid's
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numerous duties. IJven configuration of the
soil, by favoring the entry of surface drain-
age into unprotected water supplies, is not
without considerable influence in the gene-
sis of the disease."
. Let us discuss briefly a few of the most
plausible views in etiology and prophylaxis
of this affection.
Heredity plays an important role in the
occurrence of goitre, the percentage of cases
so influenced varying widely in the opinions
of observers. Female offspring are more
influenced by hereditary goitre than male.
Moving away to nongoitrous districts tends
to cause a gradual diminution of the heredi-
tar\' predisposition. Billiet, writing in 1835,
(quoted by Crotti,') remarks that "after
emigration from endemic territory the
hereditary tendency slowly disappears, a
complete cure being effected only in the
third generation." It can be surmised, then,
that a mother with a goitre may give birth
to a child with thyroid derangement, es-
pecially if the offspring be a female ; also,
that the child, tho born with an apparently
normal thyroid, is more susceptible to thy-
roid disease than one whose parent's thyroid
was normal. The various causes of goitre
operating on the mother during pregnancy
may similarly affect the infant.
Despite certain recent views to the con-
trary-, the opinion that goitre can be pro-
duced by water is based upon more than
mere theoretical speculation. From the days
of antiquity to the present time, proof is
not lacking in order to convince the most
skeptical of the causal relationship between
certain kinds of water and the incidence of
goitre. To pass on from the allusions made
on this subject by Hippocrates, Aristotle,
Pliny, and others, Lombroso, quoted by
Andre Crotti*, alludes to the wells in Cava-
curta in Lombardy as : "The goitre fountain
which is visited by youths at the time of
conscription in order to acquire this infirm-
ity in two weeks, and thus avoid military
service." Many are the instances which
could be cited of visitors to goitre districts,
who, having developed an enlarged thyroid,
were cured shortly after leaving that local-
ity. This need not be necessary, however,
as experiments of competent observers
prove that the boiling of water is a suf-
ficient safeguard against goitre, the excit-
ing cause being microorganismal in nature.
Bernhard* states that a feature of prophy-
laxis is the presence of a "healthy" well near
every schoolhouse. The water may also be
purified by ultraviolet rays or addition of
iodin or boiling. However, natural sunlight
is the best disinfectant and combined with
exercise in free air is also a prophylactic
for the child. A survey of shade dwellers
and sun dwellers on the slopes of mountain
valleys shows marked differences in con-
stitution, the former being more dumpy in
build and phlegmatic, while the latter are
slender, lean and lively. Bernhard believes
that the favorable influence of solar light
in the prophylaxis of goitre has never yet
been duly honored. He points out that the
intuition of a gifted layman has proved to
be superior to the scientific knowledge of
his day, and many years ago Balzac saw in
absence of sunlight and free air the cause
of cretinism. Tourists and those who take
cures in Switzerland almost never become
goitrous as they naturally visit the country
only in the summer or sunny months.
Kocher*^ also advocates modifying the
drinking water by addition of a minute
amount of iodin. In the endemic foci the
children first show signs of goitre after a
few months in school; the confinement in
school predisposes them to feel the effects
of the unknown substance that causes goitre.
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On the other hand, army service is liable
to cause the retrogression of established
goitre. Guttinger** reported that in one group
of 417 young recruits — ^all just 20 years
old — 331 showed goitre at the beginning of
their military service, but no signs of goitre
could be discovered in 146 of them at the
close of their service. Of seventy-six visible
goitres all have retrogressed except 21 per
cent., and of 138 goitres evident on palpa-
tion, only 58 per cent, could still be felt by
the end of their term of service. These
facts confirm the importance of hygiene
and outdoor life in warding oflS goitre.
Kocher*' cited experiences which demon-
strate the favorable action of iodin in the
earliest phases of endemic goitre, and also
the experiences with fishes which developed
goitre in certain ponds and the goitres
retrogressed when a minimal amount oi
iodin was added to the water. He therefore
suggests that in endemic foci of goitre the
younger school children should be encour-
aged to drink freely of water prepared with
a minute amount of iodin. This in connec-
tion with ventilation, clothing that does not
bind anywhere, regular bowel movements,
and plenty of exercise in fresh air will tend
to ward off the development of goitre. That
good drinking water not only prevents goitre
but aids in the retrogression of old goitres
was proved by his experience with Lauter-
brunnen water supplied to 75,000 school
children in the Bern district. He urges that
this water should be barreled for the school
children.
McCarrison^ has carried out a large
amount of experimental and epidemiologic
research which proves that the prime cause
of endemic goitre is a living organism. He
bases the above conclusion on the following
facts :
(1) In goitrous villages situated one
above the other on an^ unprotected water
supply, the incidence oif goitre steadily in-
creases from above downward, depending
upon the increased impurity of the water.
(2) Goitre has been produced in the hu-
man subject by the ingestion of the residue
left on the candle of a Berkefeld filter after
filtration of goitrigenous water. This resi-
due when boiled does not cause the disease.
(3) The administration of intestinal anti-
septics, e. g., beta-naphthol or thymol, causes
the disappearance of recent goitres in young
subjects. Lactic acid bacillus administered
daily to recent cases of goitre may cause
the complete disappearance of the swelling.
(4) The cure of chronic constipation and
intestinal stasis associated with goitre, as
by the operation of short circuiting or co-
lectomy, causes the disappearance or marked
reduction in the size of the goitre. (Lane.)
This proves intestinal toxemia as the causal
agent.
(5) Fish confined in tanks situated one
above the other on a single water supply,
show an increasing proportion of thyroid
hyperplasias from above downward. The
addition of iodin or the like has a prophy-
lactic or a curative influence upon the hyper-
plasia.
(6) The administration to rats and dogs
of the scraped deposit, found j)n the inner
surface of ^he water-soaked wooden tanks
in which the fish are confined, produces
thyroid hyperplasia and goitre. This sub-
stance is rendered inocuous by boiling.
(Gay lord.)
(7) Rats, goats and other animals are
rendered goitrous by being fed on fecal
material from goitrous and even nongoit-
rous subjects.
3»e 3»e ♦ 4e 4c 4e
(10) Vaccines prepared from intestinal
organisms are capable of causing a disap-
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pearance of recent cases of goitre when in-
jected in appropriate doses at weekly in-
tervals.
McCarrison^ concludes from these facts
that the causal agents of goitre are micro-
organisms inhabiting the alimentary caiial of
sufferers from this disease, and often of
other persons whose thyroids show no ac-
tual enlargement, but which, nevertheless,
may be in a hyperplastic state. These reach
the alimentary tract thru infected soil or
water, and such an infected individual may
become the "carrier" of the infecting agents.
The marked influence of diet upon the
size and activity of the thyroid gland has
been known for some time and been ex-
perimentally proved by Watson^ and others.
A dietary deficient in iodin is capable of
enhancing the occurrence of simple goitre;
food rich in animal proteids or a dietary
rich in fleshy substances increases the ac-
tivity of the thyroid gland with con-
comitant loss of stored up thyroid secretion
which is thrown in excessive quantities into
the blood. It is for this reason that a dietary
containing a minimum of flesh or, what is
best, an absence of animal foods is the ideal
regimen for subjects susceptible to or suffer-
ing from goitre.
It has been emphasized by many ob-
servers that lodin, the extract of thyroid
gland, or both, administered at the right
time in proper dosage, is capable of pre-
venting the formation of simple goitre, es-
pecially during adolescence. It is without
danger if carefully administered. Roux sug-
gests that it would be useful to have an
open jar with a few crystals of iodin placed
in each schoolroom, the crystals renewed ias
they evaporate. The amount of iodin thus
inhaled would be infinitesimal and harmless,
while during the school year it might act as
effectually as the iodin inhaled at the sea-
shore which generally suffices. At the hos-
pital and polyclinic in his charge he dis-
tributes on every occasion small boxwood
medallions containing a crystal of iodin in
waxed paper.
Marine and Kimball^ state that from the
practical standpoint the first instance of
preventing goitre on a large scale was ac-
cidental and in connection with the sheep-
raising industry of Michigan. Prior to the
discovery of salt deposits around the Great
Lakes, the future of the industry seemed
hopeless; but with the development of the
salt industry and its use by the sheep grow-
ers, goitre rapidly decreased. The explana-
tion as furnished by Marine* is that salt
contains appreciable quantities of both bro-
min and iodin,^and in places these elements
are extracted commercially. The second in-
stance of. goitre prevention on a large scale
was in brook trout, and the disease was
averted in the hatcheries by the use of tinc-
ture of iodin added to the water. In a cen-
sus taken by Marine and Kimball^ of the
condition of the thyroid in the girls from
the fifth to twelfth grades of the school
population of a large community in the
Great Lakes goitre district, it was found
than 1,688 or 43.59 per cent, had normal
thyroid; 2,184 or 56.41 per cent, had en-
larged thyroids; and 594 or 13.4 per cent,
had well defined, persistent thyroglossal
stalks. The district lies near the soythem
edge of the goitre area, and it is suggested
that communities near the lakes would show
a larger incidence. For the prophylactic
treatment the authors selected sodium iodid
on the grounds of economy and ease of ad-
ministration. In all their dispensary experi-
ments with children the authors used either
syrup of hydriodic acid or syrup of ferrous
lodid, in 1 c. c. doses, daily for two or three
weeks, repeated twice yearly. They arbi-
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trarily selected to use 2 gm. sodium iodid,
given in 0.2 gm. doses each school day, for
each pupil in fifth, sixth, seventh and eighth
grades; and 4 gm. given in 0.4 gm. doses
each school day for each pupil in the ninth,
tenth, eleventh and twelfth grades. These
amounts may be given twice annually about
the first of May and December, at the
schools, by the teachers or nurses. These
amounts of sodium iodid provide approxi-
mately 1,700 mg. of iodin for each pupil of
the fifth, sixth, seventh and eighth grades
and approximately 3,400 mg. for the ninth,
tenth, eleventh and twelfth grades. The
summarized results of reexamination by
these observers, made six months later, of
all girls from the fifth to the twelfth grades,
show that not a single pupij in whom the
thyroid was normal at first and who was
given iodin showed any enlargement, while
of those not taking iodin, 26 per cent,
showed definitely enlarged thyroids, and
some, moderately large goitres. The treat-
ment, in addition, proved of curative value.
One-third of the goitres marked "small
goitres" disappeared ; and one-third of those
marked "moderate goitres" showed a de-
crease of 2 cm. or more. Accordingly, the
investigators properly remark, a distinct
therapeutic effect is clearly demonstrated.
Commenting upon these experiments, an
editorial in the Jour, A. M. A,^ suggests
that tbese statistical findings are the more
conclusive because they represent not
dozens but hundreds of carefully examined
cases. More than a thousand girls took the
full treatment, the latter being restricted
for the present to this sex because during
the adolescent period simple goitre occurs
more frequently in girls than in boys. The
iodid rash prophesied by some critics failed
to materialize in any noticeable way in
more than five girls, in whom it was transi-
tory and uneventful, promptly clearing up
when the treatment was stopped. The inves-
tigators also now give assurance that there
is no danger of producing a toxic condition
like exophthalmic goitre under this prophy-
lactic regime, as not a single symptom of
this alleged danger from the use of iodids
was encountered. Nor was anything dif-
ferent to be expected; for, as Marine and
Kimball^ reminds us, the risk of inducing
manifestations of exophthalmic goitre from
the use of iodin in physiologic doses is ex-
ceedingly small, even in those cases in which
there were large hyperplastic thyroids, that
is, the kind of thyroid enlargement that
would permit of the most rapid formation
and excretion of the iodin-containing hor-
mone. The extent to which iodids are used
in general medicine and surgery and the
rarity of the development of signs of exoph-
thalmic goitre is the best index of the dan-
ger or its absence. Iodin is usually employed
in immensely large doses; from 0.2 to 0.4
gm. of sodium iodid daily for two weeks
would offer a great excess over the amounts
necessary to saturate even the largest thy-
roids, and probably much smaller amounts
would suffice in man, as it has been proved
to do in the lower animals.
P. Klinger'® advocates that at least 2 or
4 mg. of iodin should be given to each per-
son daily in experiments in the prophylaxis
of goitre. Any amount less than this is
futile.
Hunziker^^ concludes his long study of
the prevalence of goitre in different regions
and altitudes of Switzerland by sustaining
his theory that goitre is a functional hyper-
trophy of the thyroid caused by the effort
of the organism to make up a deficit in the
iodin supply. As the iodin naturally is sup-
plied in the food, goitre is prevalent in re-
gions where the vegetation lacks the stand-
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ard proportion of iodin. lodih-containing
manure in the regions where goitre is en-
demic might supply the vegetables with the
needed iodin, and thus exterminate goitre.
Hunziker therefore concludes that the iodin-
poor vegetables are what connect goitre with
climate and geologic formations. The
simplest way to remedy the poverty in
iodin would be to have salt made with a
small admixture of iodin. A year of such
"fertilizing" of human beings on a large
scale would go far toward solving the prob-
lem.
Kjlstad*^ states that goitre is extremely
prevalent in the Telemarken district in
southern Norway, southwest of Christiania.
In one school at Lunde 80 per cent, of the
children have goitre. Most of the goitres
are of the atoxic type, and they nearly al-
ways subside under iodin. He never noted
any symptoms of intolerance in children,
but several adults developed symptoms of
thyrotoxic action, and one girl of 15 seemed
to have had her simple goitre transformed
by the iodin into exophthalmic goitre, altho
the medication had been moderate and the
intermissions long. The iodin seems to act
on the hyperplasia of the parenchyma ; col-
loidal nodules and cysts are comparatively
little affected by it. The parents must be
warned that iodin treatment of goitre takes
a long time ; too vigorous treatment he re-
gards as dangerous. The dosage he prefers
with colloidal goitres is 0.10 gm. potassium
iodid every other day for two weeks, and
then suspension for three weeks and re-
sumption for two weeks, and so on. With
merely parenchymatous goitres, he follows
the Kocher method of anointing the goitre
with an iodin-potassium iodid salve, using
from 1 to 3 gm. daily for two weeks at a
time, then suspension for three-week
periods. Salve is better than the tincture.
as it spares the skin. No other treatment
or drugs have proved effectual in his
experience. According to Kjlstad, Roentgen
treatment is liable to injure the still intact
portions of the gland. With symptoms of
exophthalmic goitre or other signs of ex-
cessive functioning of the thyroid, sodium
phosphate in a 5 per, cent, solution seems
to give good results — a tablespoonful four
times a day, in milk. The basis for this
treatment is the antagonism between iodin
and phosphorus in the action of the thyroid
gland. (A. Kocher.) He has often seen the
goitre subside under this treatment, es-
pecially when the patients gave up work and
went to the hospital.
One often meets cases of goitre in young,
sallow-complexioned girls. These are the
cases which McCarrison* has designated as
instances of toxemic goitre in which he
indicates the pathogenesis of the affection.
A combination of causes conspires to bring
about an enlargement of the thyroid in these
instances. The establishment of menstrua-
tion with its profuse, painful periods; the
coexistence of a degree of chloro-anemia ;
the stubborn constipation with its autoin-
toxication, especially by the bacillus coli
communis and its products, and according
to McCarrison*, a "controlling appendix,"
I. e., an appendix which by its adhesion to
neighboring parts c9ntrols the onward flow
of ileal contents into the large bowel, pro-
ducing intestinal stasis, may here be asso-
ciated. A predisposing hereditary taint, that
is, the presence of goitre in the mother, fre-
quently renders the child more liable to
thyroid enlargement.
The treatment in these cases is the avoid-
ance of the probable cause or causes. The
administration of iodin or the iodides,
guarded doses of thyroid extract, proper
attention to diet and gastrointestinal tract,
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complete rest during the menstrual period,
and if necessary, the elimination of a dis-
eased appendix or other causes of intestinal
intoxication or stasis, are here indicated.
A diseased state of the tonsils and ade-
noids, because of their contained bacterial
and toxic deposits, is strongly potent in the
production of goitre, both simple and toxic.
In every instance of goitre where such dis-
eased lymphatic structures exist, their
prompt removal should be considered of
primary importance in the treatment. Often
surprisingly prompt results are obtainable.
A case of mine recently, a woman of 26,
presenting a medium sized nontoxic goitre
of four years' duration, was advised to per-
mit the removal of her diseased tonsils.
Within six weeks following the tonsillec-
tomy, the patient's improvement in health
was so marked and the size of her neck so
greatly reduced as to appear almost normal.
A few weeks later she was discharged cured,
the thyroid became normal, and there was a
considerable increase in weight and strength.
On the other hand, Leonard Williams*'
warns us that enlarged tonsils and adenoids
are evidences of thyroid deficiency in some
children. Says Williams: "Adenoids and
enlarged tonsils occur in children who have
an inadequate supply of thyroid secretion.
The hypertrophic condition in each case is
apparently an endeavor, on the part of the
organism to supply an internal secretion
as nearly allied as possible to the one which
is lacking. If the hypertrophy is not very
pronounced, and if it has not been very
long in evidence — ^great enough and pro-
tracted enough, i, e,, to produce complica-
tions, such as disease in the tonsils them-
selves or in the ears — then the exhibition
of thyroid extract will cause the regres-
sion." It is advocated that cases of so-called
mental deficiency in children should not lead
to an incrimination of the size of the tonsils
and adenoids unless the latter be diseased.
Williams asserts that this mental deficiency
is probably due to the presence of an in-
efficient thyroid gland, the coexisting hyper-
trophy of the tonsil and adenoid tissue ex-
isting merely to compensate for thyroid de-
ficiency. These lymphatic structures should
not be removed until after the administra-
tion of thyroid extract for a reasonable
length of time has not produced a shrinking
of those tonsils and adenoids and an im-
provement in the mental condition of the
child.
During menstruation and pregnancy the
thyroid gland swells, in some to an imper-
ceptible degree, in others to the extent of
goitre formation. Frequently repeated preg-
nancies, thru repeated stimulation of the
thyroid gland, may lead to permanent en-
largement of the organ, until, in the course
of years, a goitre is formed. Shock and
emotional excitement during menstruation
and pregnancy render the subjects more
liable to goitre formation. In these cases,
the judicious administration of thyroid
gland, alone or combined with potassium or
sodium iodid, and an endeavor to tran-
quilize the patient's environments will
usually succeed in avoiding the excessive
drain upon the thyroid gland and averting
goitre.
In the prophylaxis of exophthalmic goitre
it may be said that since many etiologic
factors are common to both the simple and
the hyperplastic types of goitre, the avoid-
ance of the known causal factors will serve
to prevent hyperthyroidism. It must be re-
membered that tho a cause or set of causes
are known to excite a mere increase in the
size of the thyroid gland, as for example,
infections from the mouth or intestines, the
changes incident to puberty, pregnancy, etc.,
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this thyroid disturbance often takes the
form of an aberration of function, i. e,, di-
minished or increased, or more rarely, a
combination of the two. Moreover, a pre-
viously existing simple goitre may become
toxic and give rise to the Basedowian syn-
drome. The foregoing suggestions calculated
to overcome the etiologic factors common to
both simple and exophthalmic goitre must
be carried out in the latter disease. Due
emphasis must be placed upon the im-
portance of eliminating tonsillar and nasal
infections, pyorrhea alveolaris, decayed
teeth, and autointoxication from the intes-
tinal tract; susceptible individuals should
be ordered to avail themselves of the maxi-
mum of physical and mental repose during
menstruation and pr^^nancy; all forms of
worry, excitement, shock, and the like, must
be avoided. It has been proved clinically
that an excessive meat diet predisposes to
autointoxication, and this, in turn may en-
gender hyperthyroidism. It is therefore sug-
gested that the diet be almost, if not en-
tirely, of vegetarian characteristics. The
strenuous life of today with its complex
problems — its hustle and bustle, its high
tension, restless sleep and hurried meals —
conduces to nervous dyspepsia and neuras-
thenia, and is strongly provocative of h)^er-
thyroidism. The prophylactic treatment of
this class of cases is obvious.
Last, but not least, must be mentioned
that state of nervous tension with its neces-
sary accompaniment of thyroid instability
which is associated with the undue post-
ponement of the married state. Prolonged
engagements, especially, are highly potent
in the production of a varjring degree of
hyperthyroidism. The author has met with
an example of a most extreme case of hyper-
thyroidism in a girl who developed these
symptoms three years, after the announce-
ment of her engagement. A heart to heart
talk with the couple which resulted in their
consent to see each other less frequently
and to keep good hours, plus the institu-
tion of dietetic, hygienic and medicinal
measures, yielded marked benefit within
four months. They were then advised to
marry. This was followed by complete cure
within six months, and they bid fair to
"live happily ever afterwards."
Conclusions.
1. Goitre is largely a preventable con-
dition.
2. The chief preventable means are the
boiling of water in regions where goitre is
endemic, the favoring of. a less fleshy and
more iodin-containing diet, and the removal
of focal infections, especially of the mouth
and intestines.
3. School children may be protected
against goitre by the administration, under
careful supervision, of iodin or the iodides.
4. During adolescence and pregnancy,
thyroid disturbances may be overcome by
the judicious administration of thyroid ex-
tract, the iodides, or both. Physical and
mental repose are essential requirements.
5. The prevention of exophthalmic
goitre is intimately related to the prophy-
laxis of simple goitre, since (a) etiologic
factors common to both toxic and nontoxic
goitre may lead to primary Graves' disease,
and (b) a simple goitre may become toxic
during the course of its existence, leading
to a secondary Basedowian syndrome.
6. The relaxation in the strenuosity of
modem life, in favor of the simple mode of
living, the reversion to the old-fashioned
short engagement and early marriages,
would tend to reduce the number of cases
of Graves' disease to a minimum.
7. Exophthalmic goitre being primarily
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a functional disturbance of the endocrine
organs, in which the thyroid gland is made
to saturate the blood with its secretion, re-
sulting in a turbulency of the nervous, cir-
culatory, and other functions, is not only
largely preventable thru the suggested
prophylaxis but is also nonsurgically cur-
able^* by the institution of the proper cor-
rective, dietetic, hygienic and medicinal
measures. The author has succeeded in cur-
ing every primary case of Graves' disease
that came to his attention, some of these
patients having previously undergone thy-
roidectomy without benefit.
Bibliography.
1. Marine and KimbaH: Jour, Lab, and Clin.
Med,, 1917, 3. 40.
2. McCarrison. Robert: "The Thyroid Gland in
Health and Disease."
3. Crottl, Andre: "The Thyroid and Thymus."
4. Bernhard: Correspondenz-Blatt fiir 8ch-
weizer Aerzte, Jan. 19, 1918.
5. Kocher: Archifur Klin. Chir,, 1908.
6 Gdttlnger: Jour, A. M. A., (abstract,) Jan.
26, 1918.
7. Watson, Leigh F.: Jour, A, M, A,, Sept. 14,
1918.
8. Marine and Lenhart: Jour. Exper. Med.
1919. 12, 311.
9. Jour A, M. A., Editorial— Dec. 26, 1918.
10. Klinger, P.: Correspondenz-Blatt fiir Sch-
weitzer 4erzte, Basel, April 27. 1918.
11. Hunziker. H.: Correspondenz-Blatt fiir Sch-
weitzer Aerzte, Basel. Feb. 9, 1918.
12. KJlstad. S.: Norsk Magazin for Laegevi-
denskahen, Christiania. March, 1918.
13. Williams, Leonard: Encyclopedia of Medi-
cine and Surgery, London. 1912.
14. Bram. L: "Successful Therapy of Exoph-
thalmic Goitre." N. Y. Med. Jour., Feb. 22,
1919.
1714 North Seventh Street.
Two Cases of Dermatitis from Salvar-
san. — Goldfarb {Dermatologische Zeitsch-
rift, April, 1918) states that in both cases
the process began with the appearance of
small red punctiform spots which later be-
came confluent. Soon afterward, there de-
veloped a rather severe moist necrosis with
scab formation and thick crusts and finally
scales of various sizes appeared. A cure
oi the cutaneous process resulted in about
three months' time.
A PLAN FOR THE ERADICATION OF
VENEREAL DISEASES IN
LOCALITIES.
EDMOND SOUCHON. M. D., F. A. C. S..
New Orleans, La.
Professor Emeritus of Anatomy and Clinical
Surgery, Tulane School of Medicine; For-
mer President Louisiana State Board
of Health.
Strenuous efforts are being revived in
this country to suppress public immoral
houses and prostitution. All such attempts
have failed in the old country, the result
having been to drive all public women into
the more dangerous clandestine class. The
city of Paris runs the public house system
with more or less perfunctory sanitation.
In view of these stem facts it is my deep
conviction after long thought and medita-
tion that the next best thing is to subject all
immoral women to rigid sanitation.
I earnestly believe the spread of venereal
diseases could be reduced by about eighty
per cent, by the enforcement of some such
regulations as follows:
Public immoral women should live in
houses registered at the Board of Health
by the keeper of the house.
The keeper shall see that every woman
who has had sexual connection with a man
shall be administered an antiseptic douche
by a trained nurse stationed in the house
by the Board of Health. This shall be done
before the woman has sexual connection
with another man or before she leaves the
house. The nurse will represent the Board
of Health with all its prestige and author-
ity.
The keeper shall provide the trained
nurse with a suitable room for douching
and sleeping in.
The keeper shall provide the nurse with
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three acceptable meals a day sent to her
room.
The keeper shall pay monthly or weekly
to the Board of Health a sum fixed by the
board sufficient to pay the salary and ex-
penses of the nurse and of the system.
Clandestine women also shall pay a high li-
cense.
Men shall not remain in the house after
one o'clock a. m.
In case of violation of the regulations
the house shall be closed by the Board of
Health.
Clandestine immoral women are more
numerous, more dangerous and more
troublesome because of the difficulty of lo-
cating and keeping track of them.
Boards of Health shall have a corps of
female sanitary, inspectors to locate and at-
tend specially to the clandestine immoral
women.
They shall have police powers to make ar-
rests for the violation of the regulations.
They shall have the power to search
premises without warrant for violations of
the regulations.
They shall be trained in douching prop-
erly and detecting venereal diseases in the
female.
Large cities shall be divided into sections
with inspectors assigned to each.
The inspectors shall locate the immoral
women by interviewing confidentially the
physicians of their section, the druggists,
the grocers, a female resident in each block.
An immoral woman is one who has sexual
connection with diflferent men, two or more.
To convict a woman of being immoral,
the inspector shall send two men or more
to make propositions to the woman. If she
accepts, it is sufficient proof. There need
not be actual sexual connection. The men
shall make a sworn affidavit of it before a
notary or before the chief sanitary inspec-
tor.
When located, the inspector shall make
the woman register at the Board of Health.
The thumb print shall be taken, also the
photograph with date affixed.
She shall examine her for venereal dis-
eases.
She shall see that she is given an antisep-
tic douche.
She shall teach her how to douche her-
self properly after each sexual connection.
She shall teach her how to detect venereal
disease in the male; chancres, buboes, dis-
charge from the urethra, stained shirt.
In case of refusal on her part to submit
to these regulations, the inspector shall ar-
rest the woman and bring her to the chief
inspector who shall sentence her to one
week's imprisonment.
The inspectors shall examine the immoral
women of their section once a week or
oftener.
When found diseased they shall be con-
fined in a hospital or in jail until thoro-
ly cured.
Inspectors shall report to the chief in-
spector and obey his orders.
Men suspecting of having been infected
by an immoral woman shall report her to
the chief inspector of the Board of Health.
Boards of health shall have a department
or committee on immoral houses and
women.
There shall be a chief sanitary inspector,
a man of character, standing and fitness,
of the type of a judge.
He will have the power of a judge or
recorder to enforce and impose sentences
for violations of the regulations, one week
of imprisonment for each offense.
He shall have the power to draw up affi-
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davits, like a notary, and to administer
oaths.
His office hours at the Board of Health
shall be from 9 a. m. to 1 p. m. and from
2 p. m. to 5 p. m.
He shall decide if a woman is immSral
or not.
Any violation of the regulations shall be
punished by imprisonment, not fines.
Some of these regulations may be dras-
tic, but we must bear in mind that the evil
is great and the powers to fight it must
be great and not sentimental.
Boards of health shall enforce these reg-
ulations.
Here again, the curbing of venereal dis-
eases is a question of organization, money,
and determination.
Tulane University, St. Charles Ave.
(From our Regular Correspondent.)
THE MINISTRY OF HEALTH BILL.
This important bill, having been read for the
first time in the House of Commons without
challenging any opposition, is now before a
standing committee, whose amendments will be
received in the form of a report to the House.
One of these amendments has already gone to
the heart of the bill, for the standing commit-
tee, without going to division, has recom-
mended that all the functions of the Board of
Education in respect of the medical inspection
and treatment of children of school age should
be at once transferred to the new Ministry of
Health. The amendment is perfectly logical,
because the Ministry of Health is being created
in reply to a demand for a concentration of all
the medical activities of the existing bureau
into the scope of one department, but it was
resisted by the President of the local Govern-
ment Board, Dr, Addison, and the President of
the Board of Education, Mr. H. A. L. Fisher,
on the grounds of expediency. The bill is
drafted in a distinct manner to do some things
now and some things later, because those hav-
ing charge of the measure considered that to
saddle a new department at once with the
charge of all the existing state medical activi-
ties would be to court an early breakdown of
the young institution. The standing committee
considered, however, that the health of the
children of school age was a prime charge upon
the state, and its care could not possibly be
relegated to some undefined future amending
act of Parliament, and in their view the com-
mittee has received both public and medical
support. No one has anything that is not
actually complimentary to say of the way in
which the Board of Education has administered
the medical responsibilities in regard to its
young charges. The work of the board has been
intelligent, progressive and sympathetic, but
there can be no reason why the same virtues
should not be displayed in this administration
of the new Ministry of Health.
THE STATE SUPPORT OF MEDICAL
EDUCATION.
.The medical profession is on the whole ill-
paid in Great Britain. The Institution of State
Insurance created a certain security of in-
come for general practitioners, but the service
carries no promotion, and the salaries are not
comparable to those earned by the state serv-
ants who follow law or theolo'gy, for example,
while the engineer is always more highly paid
than the doctor when the State employs their
joint services. For this reason it is submitted that
the question of what, if any, pecuniary support
should be given by the State to medical educa-
tion deserves the prominence which it has come
into owing to the publication verbatim of the
addresses of a group of distinguished men who
recently urged upon the Government that in
so many words higher education in England
was still starving. The arguments put forward
for state help in medical education were very
strong. There Is no medical man who gets an
official salary more than half the size of the
stipend of a bishop of the established church,
who, moreover, succeeds in rota to a seat in the
House of Lords and as such becomes a legis-
lator. The official head of state medicine in
England, the principal medical officer of health,
receives a tenth of the salary paid to the head
of the bar, who is ipso facto also the chairman
of the House of Lords.
Yet this badly paid profession exacts five or
six years at least of strenuous work from those
who would enter it, and the cost is expensive,
not less than $5,000. The Lancet has estimated
the figure as now being greater; and certainly
it will become greater in the near future, for
the mere material cost of medical education is
advancing pari passu with the elaboration of
scientific methods, the invention of new instrik
ments, the introduction into clinical medicine
and clinical surgery of a world of elaborate
mechanism like that connected with radiology
or with electrical treatment.
But this expensive profession is largely re-
cruited by the sons of middleclass men who
succeed to no private means, and whose parents
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227
are often sorely tried to find the money to sup-
port their children thru a long and expen-
sive curriculum. There is room here for State
subsidy and of a more generous kind than the
mere recognition by the Board of Education of
medical schools as institutions for technical
instruction.
Medical education is controlled by the Gen-
eral Medical Council, a statutory body acting
under the Privy Council, which has the duty of
regulating the examinations by which medical
students are admitted to the Medical Register.
The work done by the council in this as well
as in other directions is delicate and arduous
and it is carried on in the public behalf and in
no sense for the protection of the profession of
medicine. The council works under the Medical
Acts, which are definitely designed to see that
the medical profession is properly conducted
and managed, so as to supply the public with
adequate medical assistance. Yet this coun-
cil receives no grant from the Crown. The
whole of its work is paid for by medical
men who, after their examinations, proceed to
registration by payment of a capitation fee.
The income from these capitation fees supports
the council. It is an injustice that a body
existing for the public good and for the pro-
tection of public health should be supported
by medical men's money. On these grounds
medical men feel strongly that the time has
come when an endeavor should be made to
get from the Government some endowment of
medical education commensurate with the value
to the State of a well instructed medical pro-
fession. The Board of Education makes grants
to certain medical schools, regarding them as
institutions of technical instruction, but this is
a drop in the bucket in comparison with the
fluid cash that is required. The strong hope of
the medical profession is that in the debates in
committee, which will now follow upon the
first reading of the Ministry of Health Bill,
some of these questions will be thoroly
thrashed out Money will have to be found for
medical education. The London Hospital, the
largest of the metropolitan medical charities, has
just decided to appoint, instead of the usual
honorary members of the medical staff, salaried
directors of medical studies, who shall also be
physicians in the wards, giving their whole
time to the service of the hospital and the med-
ical school. This is an advisable and progres-
sive move towards bringing the clinical practice
of the hospital into touch alike with medical
education and medical research; but unless
public subsidies are acquired, it is difficult to
see where the adequate salaries are to be ob-
tained, and if the pay is hopelessly small why
should the right people compete for it.
THE ACTIVITT OF THE NATIONAL COUNCIL
FOR THE PREVENTION OF VENEREAL
DISEASES.
The activity of the National Council for the
Prevention of Venereal Diseases has been par-
ticularly manifested since the demobilization of
the conscript British Army has begun to be
extensive. And it is well that this should be so
for undoubtedly, and as I have often fore-
shadowed in these letters, the incidence of
gonorrhea remains heavy upon the troops. The
Executive Committee of the National Council
has collected and considered the expressed
opinions of medical officers of health in regard
to the immediate institution of facilities for
early and continuous preventive treatment and
as a result has formulated the following pro-
posals among others:
That in large towns and densely populated
districts the centers for such treatment should
be under direct medical supervision and con-
trol. Such centers should be established in as
many as possible of the following institutions:
General hospitals, subsidiary clinics, such other
places as may seem desirable to the local
authority and in doctors' surgeries.
That in case early preventive treatment (first
aid) has been rendered by a nurse or orderly,
on an emergency, the patient should be referred
to the medical officer of the center (clinic),
and under no circumstances whatever should
further treatment of any sort be given for the
same risk of infection by such nurse or orderly.
This latter is a wise provision to ensure that
no cases escape proper medical supervision, a
danger which must always occur when venereal
diseases are in question. The temptation of
the nurses or orderlies to believe that the treat-
ment of venereal diseases consists, and consists
only, of their particular piece of technic is
certain to be very strong.
The executive committee has wisely recog-
nized that in the case of small towns, villages,
rural and sparsely populated districts, such
centers under medical supervision can only be
arranged with difficulty and they suggest that
failing the possibility of securing accessibility
and privacy, general practitioners should be
aided financially and encouraged to undertake
such treatment at their own surgeries, so that
means for efficient, early and continuous treat-
ment under conditions of secrecy and medical
control may be placed within the reach of
every person. This is a most practical attitude
to take up, for anyone with any experience,
medical man and layman, knows that it is the
fear of publicity which drives the infected
young man into the net of the dangerous quack,
equally dangerous, whether he practices or
merely advertises. In this country advertise-
ment has now become dangerous, so hedged
about is it by legal restrictions, but unqualified
practice still has its exponents, and they remain,
as ever, predatory and ignorant rascals.
The Medical Committee of the National Coun-
cil has issued a circular letter to all medical
officers of health of counties and county
boroughs in England and Wales, and to all med-
ical practitioners in charge of venereal clinics
in order to secure their views as to the most
practical ways of bringing the facilities for
treatment within immediate reach of the civi-
lian population. From the answers received it
would seem that the opinion of the medical
committee was very fully endorsed by those
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RATIONAL ORGANOTHERAPY
AMBEICAN liXDIClNB
with practical experience of administration.
The problem is very different as it is manifested
in industrial centers or in country districts. In
respect of industrial centers, the majority
recommend that so long as the early preventive
treatment is given under general medical super-
vision, the facilities should be available at as
many centers as possible: — (1) At the hospital
clinics. (2) At subsidiary clinics under the
supervision of a medical officer, but in the con-
tinuous charge of trained members of his staff,
orderlies and nurses. (3) At any ad hoc
treatment clinic (4) Such other places as
may seem desirable to the local authority. (5)
In doctors' surgeries (the similarity between
this recommendation and the proposal of the
exeeutive committee is marked).
Very few consider It advisable to provide
facilities for early preventive treatment without
medical supervision, by the establishment of
slot machines from which prophylactic "out-
fits" could be obtained in public conveniences
or elsewhere.
The Ductless Glands and Development
of Bones* — Hutinel concludes his article
in the Archives de Medicine des Enfants,
(Dec., 1918) on the endocrine glands and
bone affections with the statement that or-
ganotherapy does not seem to Tiave fulfilled
its promises but he believes that this is
because we have been asking too much of
it. We cannot expect it to cure incurable
infirmities and deformities. If we dis-
tinguish the cases in which it will prove
actually useful and reliable, and we are
content to wait for the benefit to become ap-
parent and not expect it immediately, ef-
fectual and durable results can be counted
on. It is evident that notwithstanding the
abundant literature on the subject, we are
still in the tentative stage. It is only by
pursuing the investigations, keeping up ob-
servations for years, and supplementing
them by animal experimentation, that the
profession can hope to obtain a decisive
judgment on this great question of the or-
ganotherapy of dystrophies.
Outdoor life, hygiene, regulation of the
diet, tonics, etc., are indispensable adju-
vants to organotherapy and as there is
usually more than one endocrine gland in-
volved, it is important to determine which
ones. Tentative treatment and occasional
failures are inevitable but experience will
gradually clear away the uncertainty. It
is wise to begin with small doses, as exag-
gerated susceptibility is not infrequent.
Rachitis in infants develops under the in-
fluence of defective feeding and digestive
disturbance with superposed damage from
acute or chronic infections. All of the or-
gans may have suffered more or less in their
development, including the endocrinous
glands, and their functional upset may add
to the clinical picture. An organic extract
might help but again it might not. The
main reliance is on diet, cod liver oil, phos-
phorus, etc. But with rachitis in adolescents,
supplementary to general hygiene, a trip to
the seashore or mountains, rest for body
and mind, with ample regulated exercise,
thyroid, pituitary, ovary, testicle, even
suprarenal extract may have a decidedly
favorable influence. We must bear in mind,
however, that rachitis at this age is transient
and subsides spontaneously; this is another
reason for combating it so that it need not
leave deforming traces. In osteomalacia the
most brilliant results have been realized with
suprarenal treatment, sometimes associated
with pituitary and thyroid treatment. In
two such cases the inherited syphilis had
beforehand been given prolonged intra-
muscular mercurial treatment with the ben-
zoate. In chronic rheumatism, organo-
therapy gives the best results when the
lesions are of recent development. Thyroid,
supplemented with epinephrin or suprarenal
capsule or pituitary is generally ordered;
ovarian treatment for older girls. In adults
there is not much encouragement for organo-
therapy of chronic rheumatism, except pos-
sibly with thyroid and ovarian extract for
women, given early. Later, they are only
possibly useful adjuvants. To be effectual
they must be begun at the start and be long
kept up.
If a child remains small, backward in
developing, infantile, and there is reason
to assume deficient thyroid functioning, thy-
roid treatment is absolutely indicated. It
should be with large doses, long kept up. It
may sometimes be useful to add ovary, tes-
ticle, pituitary or suprarenal treatment in
addition to the cod liver oil, iron, arsenic or
other measures that may be needed. With
giant growth and acromegaly there are
usually several glands involved, and pitui-
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229
tary treatment is generally futile as the
lesions are irreparable. In the obese, and
with deformed bones, thyroid treatment
is the chief indication at first, and later
pituitary. Ovarian or testicle treatment
should be added if the genital organs
are backward in developing, plus cal-
cium and iron, and hygienic environ-
ment. It is wise to weigh frequently and not
to tr>' to reduce the weight too fast. In chil-
dren that are thin and look consiunptive,
with nutritional disturbances in bones and
skin, suprarenal capsule, associated some-
times with pituitary and always with im-
proved hygiene, has given good results. This
is due probably to the fact that there is a
certain degree of suprarenal insufficiency.
Thyroid Hormone and Its Relation to
Otlier Ducdess Glands. — According to
Kendall (Endocrinology, April-June, 1918)
the active substance of the thyroid has
been isolated and analyzed, its empirical
and structural formulae determined, its syn-
thesis completed, and its physiologic action
studied in a large number of patients at
the Mayo Qinic. In considering the role of
the other ductless glands of the body, Ken-
dall states that they assume positions sec-
ondary in importance to the thyroid, and
that their part may be preparing the vari-
ous metabolites for their final action with
thyroxin (the active constituent of the
thyroid), the production of energy. In
addition to this duty the task of taking
care of by-products and elaborating other
substances must be accomplished by some
agent in the body, possibly the parathyroids
and others of the ductless glands. A de-
tailed description of the structural formula
of thyroxin is given. It contains an indol
group with the iodines attached to the ben-
zene ring, and on the carbon atom adjacent
to the amino group of the indol ring there
is an oxygen atom. The physiologic activity
of the substance is produced by the CO.NH
groups. In explaining the action of iodine
in the compound, the theory is presented
that it renders the active groups more re-
active.
Organotherapy in Wounds. — Serge
Voronoff and Evelyn Bostwick (Press
Medically, September 9, 1918) report that,
after much experimentation at the College
de France, they were able to cause healing
of extensive and deep wounds in a few
days, by applying locally the pulp of sex
glands procured by castrating young ani-
mals. The cells of these glands, thru
the secretion they contain and which
is absorbed by the wound, exert an
intense accelerating action on the process
of granulation. The organ found most
eflfectual in these experiments would,
a priori, have been considered that most
suitable, owing to its especial vital energy.
Animals deprived of these organs are known
to accumulate fat at the expense of their
muscles and to become apathetic and passive.
In the wounds treated with this material,
its use often had to be discontinued after a
few days in order not to exceed the results
sought and cause projection of new tissue
beyond the level of the wound cavity by
reason of a too intensive development of
granulations. With the aid of this treatment
its sponsors hope to spare the wounded
long months of suflfering and considerably
shorten their stay in hospitals. This method
is being tried at Carrel's hospital.
Effect of Gland ExtracU on BUe Secre-
tion.— Downs and Eddy (Amer. Jour, of
Physiology, Mar. 1, 1919) found that the
amount of bile secreted is increased by
secretin, and decreased by epinephrin and
by mammary, orchic, ovarian, pancreatic
and thymic gland substances. The bile se-
cretion is not affected in a constant or def-
inite manner by the substance of the spleen
and thyroid.
Hjrperthyroidisni. — Hyperthyroidism
is, according to Kuh (///. Med. Jour., April
1919) an exceedingly common disease,
more frequent in women, undoubtedly, than
in men, but far from rare in the latter sex.
It is found as a complication in innumer-
able cases of the so-called functional neu-
rosis, and very often overlooked, because
of the tendency to waste little time in the
examination of a "neuro." Formes frustes
are undoubtedly very much more commor
than the classical syndrome first describes,
by Graves and Basedow. The disease often
has a very insidious onset and Kuh say>
he has no doubt that many of those who
suffer from it go thru life without ever ke-
coming conscious of its existence.
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April, 1919
PHYSICAX. THERAPY
AMERICAN MaOICINB
Under the Editorial Direction of Albert C.
Geyser, M. D., New York.
The Physiologic Treatment of Catarrhal
Deafness.
There is hardly another condition about
which the prognosis is usually so gloomy
from the average aurist's point of view as
deafness due to or the result of chronic
nasal catarrh.
The question arises *'\Vhy is it that these
cases receive such a hopeless prognosis at
the hands of the aural specialists, and yet
these same cases make most brilliant re-
coveries when treated by physiologic
therapeutics ?"
The answer is this: The aural special-
ist treats this affection from a pathologic
view point, he recognizes the impossibility
of restoring the normal physiologic con-
dition of the parts, either with drugs or
yet with surgical operations. Other meas-
ures, such as heat, vibration or electricity
are either too complicated or seem to sug-
gest "the quack" to him and therefore be-
neath his dignity to inquire into.
It will be my -privilege to call your atten-
tion to the physiologic methods of treating
these cases.
The Physiology of the Nose. — The
physiology of any part is always dependent
upon the anatomy of the same.
Certain tissues and cells have a certain
physiologic function to perform, they must
perform that function and no other should
be expected of them.
The formation of the mucous membrane
over the turbinates is there for the purpose
of increasing the radiating sijirface of it.
The turbinates are so arranged that the
air current from the outside enters their
funnel-shaped openings and is then broken
up into several streams.
When all of these broken air streams have
passed over the large area of this intensely
vascular membrane, it has been filtered of
its impurities which have lodged upon the
filtering passages; it has been warmed or
cooled as the case may be, so as to arrive
in the lungs at body temperature or nearly
so.
The intake force of the stream has been
properly retarded to prevent Injury to the
distending air cells. The impurities of the
inspired air have lodged upon the mucous
membrane which is supplied with mucous
glands and ciliated epithelium. This ciliated
epithelium possesses the faculty of always
waving everything in an outward direction.
Whatever causes an irritation to this mu-
cous membrane causes an increase in the
performance of its physiologic function
which is an extra excretion of mucus and
an overactivity of the ciliae.
The sudden change of temperature from
a hot room to the cold outside air imme-
diately causes an increase of the flow of
mucus; the deposit of dust, irritating sub-
stances, odors and bacteria cause the same
phenomenon.
This is spoken of as "catching cold'* what-
ever that means, when in reality it is an
attempt upon the part of the economy to
prevent something injurious from happen-
ing.
From the anatomical nerve supply we
see that the nose or at least the upper part
of it serves another physiologic purpose.
Thus the branches of the olfactory nerve are
distributed in this upper, "out-of-harms-
way" place to receive the sensations which
are to be carried to the olfactory center.
While the development of this special
sense. of smell is in every way desirable, in
the human being it is not a necessity.
Nature abhores anything that is not neces-
sary or useful and so the sense of smell in
the human being has been more or less ob-
tunded. If, however, the noxiousness of any-
thing is great enough, we receive certain
warnings that such substances are not de-
sirable for the lung or the intestinal
tract.
It is for that reason that we find a branch
of the sympathetic ganglion emerging from
between the eighth and ninth vertebrae con-
necting directly with the Schneiderian mem-
brane. It is there to warn us by the sense
of smell that whatever is not good for the
intestinal tract should not pass further than
the nose.
Another physiologic function, and this
includes the entire nose, is to act as a sound-
ing chamber to give resonance to the voice.
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PHYSICAL. THERAPY
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231
For this purpose the nasal chambers must
be free so as to emit the voice without
hindrance.
One frequently hears the remark that so
and so talks thru his nose. Whenever that
remark is made, it is a sure sign that so
and so does not talk thru his nose, for that
is just what we all should do, but many of
us cannot.
There may be other functions, but for our
purpose interference with these enumerated
ones will be all sufficient.
The mucous membrane lining the nasal
fossae is called the Schneiderian membrane.
Schneider pointed out the fact that the se-
cretions of the nose proceeded from the mu-
cous glands and not from the brain.
The mucous membrane is continuous with
the mucous membrane of the eye thru the
nasal and lachrymal duct, with the mem-
brane of the tympanum and the mastoid
cells thru the Eustachian tube. It is further
connected with the frontal, ethmoidal,
sphenoidal and the antrum of Highmore
thru the several openings in the meatuses.
It is a continuation of the mucous mem-
brane of the bronchial tube and thru the
esophagus with the gastrointestinal tract.
The mucous membrane is thickest and
most vascular over the turbinated bones,
fairly thick over the septum but thin be-
tween these and the floor of. the fossae.
Near the orifice, where common sensation
is chiefly required, the epithelium is of the
pavement variety, but in the rest of the nose,
all that portion of it engaged in the func-
tion of respiration, the mucous membrane
is covered by columnar ciliated epithelium;
this applies also to the passages leading to
the various sinuses.
In the olfactory region the epithelium
is columnar but not ciliated.
The mucous glands, while diflfering in size,
according to the location, are evenly dis-
tributed thruout the membrane.
The nerves are the olfactory, the nasal
branch of the ophthalmic, anterior dental,
superior maxillary, the Vidian, nasal pala-
tine or nasal branches from Meckel's gang-
lion.
The sphenopalatine or Meckel's ganglion
is the largest of the cranial ganglia. Like
other ganglia it possesses a motor, sensory
and sympathetic root.
Meckel's ganglion communicates by two
ascending branches with the superior max-
illary branch of the fifth or trifacial, which
comes from the Gasserian ganglion.
Etiology — Pathology^ — ^As the physi-
ology is the result of anatomical structure, so
is the pathology the result of interference
with physiologic function or due to struc-
tural anatomical changes.
Our principal pathologic condition to be
considered is inflammation of the mucous
membrane of the nose and pharynx, in other
words catarrh of the nose.
Morell Mackenzie considers two principal
causes for this affection : first, foreign mat-
ter, such as dust and bacteria lodging upon
a mucous membrane; second, the habit of
fast eating and drinking.
Dr. Freudenthal, on the other hand, con-
siders only dry, overheated, badly-ventilated
rooms.
From the anatomy and the subsequent
physiology it must be apparent that both
of these writers are correct.
We will therefore say that anything that
is capable of acting as a long continued or
oft repeated irritation to the Schneiderian
membrane must eventually cause thru over-
activity a hypertrophy.
Neither is it necessary that this irritation
affects primarily the mucous membrane of
the nose; chronic constipation will sooner
or later cause a colitis, this by direct con-
tiguity as well as thru the sympathetic fibrp«
from the ninth dorsal interspace connectinpr
with the Otic and Gasserian ganglion win
produce a similar condition in the mucous
membrane of the nose.
Pulmonary tuberculosis usually causes an
overactivity of the respiratory tract by di-
rect extension of the inflammation or thru
the sympathetic fibres reflexly.
Any one of these or all of them acting in
concert produce a hypertrophy of the mu-
cous membrane. At first, as a direct result
of the enormous increase in the vascularity
we have a pouring out of mucus in abund-
ance and the patient complains of nothing
worse than a running nose.
If this process is long continued there is
a gradual extension in all directions. The
discharge, instead of finding its way out by
the natural channels, now drops into the
nasopharynx; it accumulates in the upper
and posterior portion of the nose, invades
sinuses and the patient complains of frontal
headaches.
When this pain is located at the brow
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April, 1919
PHYSICAX. THERAPY
American BIedicinb
and bridge of the nose it is almost pathog-
nomonic that it is due to gastrointestinal and
secondary nose involvement.
The accumulation of mucus laden with
bacteria and detritus is especially marked
upon awakening in the morning and is al-
ways worse if the patient has been imbibing
in spirituous liquors the night before.
By gradual extension of the process the
entire nasopharynx becomes involved and
the Eustachian tube shares in this process.
Either the opening of the tube becomes
filled with mucus or thru swelling of the
parts become3 occluded.
At this time the patient complains of
noises or ringing in one or the other ear.
These noises may be relieved by forcibly
blowing the nose, only to return again soon
after. If this forcible blowing of the nose
is persisted in or if Valsalva's method of in-
flation is practiced, there is every possibility
of forcing some of the gc;rm-laden mucus
into the stenosed Eustachian tube and there-
by lay a foundation for a future otitis media.
Assuming that this does not occur on ac-
count of complete closure of the tube, then
the air contained within the same is grad-
ually absorbed, the tube collapses thruout
its entire length with the result that we have
a more or less of a vacuum on one side of
the membrana tympani and the air pressure
of fifteen pounds maintained on the other
side. The changes are self-evident. The ear
drum is bound to bulge inward from the ex-
ternal air pressure and the decreased resist-
ance on the inside.
This bulging drives before it the ossicles
which finally communicate thru the stapes
with the fenestrum ovale. Not only have we
now the extension of the inflammatory
process from within, but the added factor
of pressure in all of the articulations of the
chain of ossicles.
It is true these bones and joints are very
small, nevertheless they are articulations and
obey the laws of pressure as much as the
knee or the elbow joint.
A very little pressure, but long continued,
sets up an interarticular inflammation which
causes adhesions and stiflFness.
At this time the patient complains of
acute hearing, in fact slight noises and
sounds inaudible to other people are not
only magnified, but are distorted.
With a susceptible person these sounds
are interpreted as "some one calling them,
or as some one talking about them."
The rest of this story does not concern
us here, but I am satisfied from my contact
with patients in the Manhattan State Hos-
pital that only too many started on their
way across the river, thru nothing more
than an unrecognized nasal catarrh.
If the progress continues retrogression
takes place. Nature abhors anything that
is useless. A tympanic membrane that does
not vibrate, a chain of ossicles that do not
move, require little or no blood supply.
Atrophy causes a drying and blanching of
the ear drum and instead of giving that
shiny, mother of pearl appearance, we see a
bony, lusterless or chalky membrane. At the
same time we have an atrophic mucous mem-
brane in the anterior portion of the nose
while in the posterior we have a hyper-
trophic rhinitis with more or less loss of
hearing in one or both ears.
Such is the clinical pathology of a case
of catarrhal deafness.
Treatment. — Physiologic function is
based upon anatomic construction. Path-
ology IS the deviation from the normal of
either one of these, while treatment has for
its object the removal of the cause and the
restoration of physiologic function and
anatomic structure.
Pathologically we are confronted with
an atrophic or hypertrophic mucous mem-
brane functionating abnormally, a chain
of bony articulations having become
ankylosed as a result of pressure ; the pres-
sure due to a relaxed ear drum with a posi-
tive pressure on the outside and a negative
pressure on the inside the membrana
tympani is atrophied and non- vascular ; the
Eustachian tube may be either open, nar-
rowed or closed.
In enumerating the treatment I shall con-
fine myself to personal experience only.
There is no doubt that all of this treat-
ment has been advocated by others either
fragmentary or in whole; neither is this
treatment a fixed one, but must be varied as
the circumstances demand.
I shall also assume that the case is one
which falls into this category, thereby bar-
ring complications or unsuitable cases.
The normal discharge from the nose is
alkaline. Any kind of an alkaline solution
as a ten to twenty per cent, solution of
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PHYSICAL THERAPY
April, 1919
233
bicarbonate of soda will dissolve the mucus
whether thin, viscid or even crusts.
An ordinary nose spray is used, the pa-
tient vigorously uses the handkerchief or
a good sized piece of cheesecloth. I have
no cuspidors in my office, they are unclean,
disgusting and unnecessary.
As soon as all the mucus has thus been
removed, if there is atrophy present an
oily solution of iodine is then blown into
the parts from a vaporizer. If hypertrophy
predominates an oily solution of acetozone
is in the same manner vaporized. The iodine
irritates and stimulates tissue increase and
is a good germicide. The acetozone is a
sedative to the mucous membrane, at the
same time a germicide and antiseptic ano-
dyne emollient.
When the nasal mucous membrane has
thus been prepared the patient is treated
electrically.
If atrophy is present, the stimulating ac-
tion of the vacuum high-frequency tube is
used : if hypertrophy prevails, then the heat-
ing tissue contracting-effect of the diather-
mic current is indicated.
Assuming that the hypertrophy has so
occluded the nasal fossae that these elec-
trodes will not enter, we have resource to
electrolysis. Two, three or more fine cam-
bric needles are attached to the negative
pole of the galvanic current and inserted in-
to the hypertrophic tissue. The electrolysis
takes place between the cartilage and the
mucous membrane; immediate shrinking is
the result.
It will be noted that in all of these pro-
cedures the physiologic integrity of the parts
is strictly preserved, so that the mucous
membrane of the nose and pharynx is in a
condition to perform a normal physiologic
act.
Having cleared the nasopharynx we can
give our attention to the ankylosis of the
ossicles. An ankylosis is a certain condition
of bony joints, no matter where situated.
We treat this ankylosis the same as an an-
kylosis of the elbow. Our agents in either
case are dry heat and passive motion.
From an instrument devised for this pur-
pose, a stream of dry, hot air is forced
against the drum membrane and the adja-
cent parts. The instrument must fit snugly
into the external auditory canal and by a
vacuum pump arrangement this hot air is
blown into the canal, then again withdrawn
to the point of forming a vacuum.
In this manner the ear drum is made to
vibrate and thru its attachments with the
ossicles they are loosened up, thus returning
the parts to their normal anatomic and
physiologic condition.
The membrana tympani is next treated.
The external canal is freed from all fats
by a thoro washing with a warm alkaline
soap-water solution. The patient is placed
in a horizontal position and the ear filled
with a warm, clean alkaline solution. A
small piece of rubber tubing is inserted into
the external canal almost up to the ear
drum. The negative pole of the galvanic
current is placed into this rubber tube. The
contact with the ear drum is made thru the
water.
The positive pole is placed in the nape of
the neck. The current is turned on slowly
up to one half of a milliampere; gradually
as tolerance has been established it is in-
creased to one or even two milliamperes for
at least fifteen minutes.
This procedure has the effect of softening
and again revascularizing the membrane.
During this treatment, which lasts from
three to six weeks, the patients frequently
complain of increasing deafness due to the
softening of the membrane; this regulates
itself as soon as normal and efficient circula-
tion has been re-established.
The Eustachian tube is the last to receive
direct attention, for frequently this is made
unnecessary by the treatment of the adja-
cent parts'.
The most common condition is stenosis
of the tube. A Eustachian catheter at-
tached to the negative pole, and under the
guidance of the operator's eye, is inserted in-
to the opening in the pharynx. One quarter
to one half of a milliampere is allowed to
flow for five minutes. This procedure is con-
tinued until the canal is entirely patulous. All
the parts are now anatomically and physi-
ologically again intact. Patients that could
not hear an alarm clock tick one inch from
the external meatus, frequently, after such
treatment, can hear a watch tick six to
twelve inches from, the affected ear.
Papinoma, WarU, Verruca.— Struc-
turally all warts are practically the same.
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April^ 1919
PHYSICAl, THERAPY
AlfKRICAN MBDICINS
tho they may differ in shape and location;
they are essentially an affection of both
sexes, rather more frequent during early
youth or up to puberty and again in ad-
vanced age as after 60. When these warts
appear during early youth, they frequently
disappear again without treatment, but if
they remain or are a disfigurement, or when
they make their appearance late in life as
senile keratosis, then they should be re-
moved.
Treatment. — The positive pole of a gal-
vanic current is attached to a properly
moistened pad and applied in the immediate
neighborhood of the wart. The negative
pole is attached to a terminal possessing
several bifurcations, ' each of which is
armed with a fine cambric needle. When
everything is in readiness a piece of paper,
which has been perforated to just enclose
the wart, is placed over the growth in such
a manner that the wart projects thru the
opening in the paper. One needle is then
passed thru the base of the wart transfixing
it and resting upon the paper, then as many
needles as the base of the growth will per-
mit are now inserted, all upon the same
level and close down upon the paper. When
a sufficient number, three to five needles,
are in position, the current is gradually
turned on up to the point of tolerance
which will be about one and one-half or two
milliamperes. This strength should be main-
tained for about thirty seconds and the cur-
rent gradually reduced to zero. The needles
can now be removed very readily on ac-
count of the negative electrolitic decompo-
sition that has been going on. The top of
the wart will dry up, form a scab and in
the course of a week drop off, leaving a
perfectly smooth surface with seldom a re-
turn of the original.
Accessory Treatment. — ^The high-fre-
quency current, the D'Arsonval or the
Oudin type may be successfully used for
the destruction of warts, nevi and other
superficial growths.
An instrument devised by the author
known as the Geyser Fulguration electrode
consists of a thin copper wire about 5
inches long concealed within a glass tube,
ending on one end with a glass ring thru
which the index finger of the right hand
is passed, the thumb and middle finger of
the same hand holding a glass tube thru
which the first tube containing the wire is
passed. This instrument acts on the prin-
ciple of a piston and cylinder and so ar-
ranged that when the outer cylinder is
placed over a wart or similar growth, the
inner piston carrying the wire is plunged
up and down as required by a movement
of the index finger thru the ring of the pis-
ton. To one pole of the D'Arsonval current
the wire of the instrument is attached. The
outer glass shell or cylinder is now placed
over the area to be treated, the inner piston
is raised so that no sparking occurs. The
spark gap on the coil should not be more
than J4 of an inch apart. Gradually allow
the wire to approach the skin so that a few
fine sparks fall now and then upon the area.
In the course of J^ a minute the part will
be almost anesthetic when the wire may
be lowered to its full length. This is
so arranged that a collar on the cylinder
allows the piston to descend to within 1/16
of an inch upon the skin surface. Thru
this 1/16 of an inch a very hot spark passes
which at once destroys the tissues beneath
it and, strange as it may seem, with very
little pain to the patient. A successive num-
ber of such contacts should be made, each
contact lasting not more than ^ to J4 sec-
ond each. The wart or growth will at once
become blanched, form a blister, which when
it heals leaves a smooth scar. With larg-
er or deeper growths this fulguration may
have to be repeated at weekly intervals.
Freezing with C02 of carbon dioxide is
less painful and when convenient may be
substituted. A solid stock of C02 is made,
about the size in diameter of a twenty-
five cent piece and three or four inches long.
The end is then shaped to the size of the
lesion to be treated and moderate pressure
is made for about 30 to 60 seconds. Upon
removal of the contact the parts beneath
will be frozen hard ; in a few minutes, say
30, a blister will form with much the same
subsequent results as the high-frequency
current application. In certain superficial
lesions, among them lupus erythematosus,
the results from the C02 contact are very
encouraging, and not quite as painful as
the fulguration methods. The application of
caustics or strong acids should only be
mentioned to be condemned.
Rheumatism. — Bromide of ammonia
stands in high repute for acute rheumatism,
and the chloride for myalgia. — Med. Sum-
mary.
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AMERICAN MEDICINB
AMONG TH£ BOOKS
April, 1919
235
AMONG
THE
BOOKS
f
Hygiene of the Eje.— None of the special
senses of the body is more greatly missed than
that of sight and therefore on account of its
preciousness it should be conserved in every
way possible. However, not only is sight neg-
lected and abused but the hygiene of the eye is
not properly understood by, perhaps, the ma-
jority of medical practitioners. While to ac-
quire a thoro knowledge of the eye, its diseases,
abnormalities and so on, requires very close and
assiduous study, and while ophthalmology is one
of the most difficult of the specialties, never-
theless, it behooves the general practitioner
to know something about the eye and its com-
mon diseases. Hygiene o/ the Eye, by Wm.
Campbell Posey, A. M., M. D. (J. B. Lippincott
Company, Philadelphia) , is written with the idea
of imparting information concerning the more
frequent affections of the eye, as well as to
describe the manner in which the general health
affects the eye, and also how the health may be
Influenced by eye-strain. A considerable part
of the book can be read and understood by
teachers and parents, and hints gathered there-
from with respect to the best means of safe-
guarding the eyes of scholars and children. In
addition, the whole question of blindness and
disease and conditions leading thereto are ex-
haustively discussed by Dr. Posey. Moreover,
the movements that are being made for the
prevention of blindness, which after all is the
most important phase of the subject, are amply
dealt with. Particular attention is paid to in-
dustrial blindness, and to measures for its pre-
vention. This is timely. In view of the ever-in-
creasing number of injuries to the eye which
occur in foundries, factories and elsewhere.
Four chapters of the book are written by well-
known ophthalmologists and these will appeal to
those with special knowledge. The bulk of the
book, however, is devoted to the hygiene of
the eye purely and simply and of course is es-
pecially concerned with means of prevention.
The work is eminently practical and because
of its common sense is well calculated to effect
the object of its author in writing it, namely, to
Instruct general practitioners and to a less ex-
tent parents and teachers in the most satis-
factory methods of conserving eyesight and in
warding off the most common disease of the eye.
The illustrations are numerous and good.
ments have not kept pace with dietetic ad-
vances. E. V. McCollum, in The Newer Knowl-
edge of Nutrition (The Macmillan Company,
price 11.50), presents the results of studies
covering many years, in which the biologic test
of food has been given gn*eater value than
mere chemistry. The studies of McCollum and
his coworkers indicate the importance of at
least two unknown dietetic factors termed by
him "fat soluble A," and "water soluble B,"
because of their solubility in fats and in water
respectively. The description of the dietetic ex-
periments, together with the analysis of the
nutritive values of various types of foods such
as the seeds, leaves, fruits, roots, tubers, as
well as meats, eggs and milk, point out the
recognized variations in the quality of protein
as affecting nutrition, and indicate the neces-
sity of utilizing milk and the leaves of plants
as protectlves of nutrition.
His emphasis upon milk, eggs and the leafy
plants as protective foods stresses the necessity
of a dietary regime which cannot be satisfied
by merely ingesting seed products, tubers, roots
and meat.
It is important to note the high value which
he places upon the use of milk in the dietary,
and his belief in moderate prices of this com-
modity in order to insure the proper nutrition
of the people. The main contribution, however,
is the appreciation for which he pleads of the
biologic properties of foodstuffs as over against
the mere understanding of their chemistry. He
is more concerned in what part food actually
plays in nutrition than in its theoretic chemical
composition and the deductions following there-
from as to its place in metabolism.
Natritlon« — Rapid advances have been made
in the development of nutrition, and those who
persist in applying the theory of calories and
distribution of proteins, fat and car^bbhydrates
/n the dietary without reference to other ele-
Obstetrics.— The history of this colossal work
on obstetrics is interesting and again points the
moral that great things often have small begin-
nings. This, the third edition of the PHnciplea
an6r Practice of Obstetrics by Joseph B. De Lee,
A. M., M. D. (W. B. Saunders Company, Phila-
delphia), is the outgrowth of a volume entitled
Notes on Obstetrics, and used for fourteen years
as a text-book by the junior and senior classes
at the Northwestern University Medical School.
In the compilation of the book, two main ob-
jects have been always kept in view: first, the
needs of the general practitioner and, second,
the needs of the student, and while purely
scientific subjects are adequately dealt with,
their direct bearing on daily practice is the
point which is clearly emphasized. In accord-
ance with the scheme of rendering the book
first and before all of practical value, diagnosis
has been made a particular feature, and the
relations of obstetric conditions and accidents
to general medicine, surgery and the specialties
have been fully brought out. However, as this
is a third edition it is somewhat superfluous to
dwell upon the scheme of the book, and it will
be more in order to consider briefly the re-
visions, amplifications and elaboration of the
present volume. The war had the effect of hin-
dering in some degree the progress of obstet-
rical knowledge. But as Dr. De Lee points out in
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April, 1919
ETIOLOGY AND DIAGNOSIS
Ambrxcan Mbdicinb
the preface this has not been an unmixed evil,
because thereby the opportunity has been af-
forded not only to test the recent contributions
to science, but for experience to prove the good
and to eliminate the worthless.
Most of these contributions have stood the
test, while some of them have acquired new
valuations. Many of the subjects have been
amplified and in the treatment of eclampsia,
greater attention is paid to conservative meth-
ods. Dr. De Lee was fortunate in one important
direction; thru the kindness of Mrs. Ira Nelson
Morris, wife of the United States Ambassador to
Sweden, Dr. Erik Ahlstrom of Stockholm and
Privat-docent Dr. Paul Hussy of Basel, Switzer-
land, he was enabled to procure practically all
of the continental obstetric literature which,
otherwise, owing to the war would have been
inaccessible.
The illustrations are graphic and artistic and'
the book reflects the greatest credit upon the
author and publisher.
Home and Community Hygiene*— In the de-
sire to enlighten young and old in the purposes
and methods of personal hygiene and public
sanitation, numerous authors have sought to
produce in popular note a general text-book.
Among the volumes which may be regarded as
having approached the problem most success-
fully, none is superior to Home and Comr
munity Hygiene, by Jean Broadhurst (J. B.
Lippincott Company, price |2.00 net). With a
comparative freedom from technical terms, the
entire gamut of public health problems is cov-
ered with unusual brevity and accuracy. The
relation of individual health to public welfare
is carefully presented in its most practical as-
pects and without redundancy or deadliness in
exposition. The author, being a biologist, at-
tacks her su'bUect with all the care and precision
of a scientist, but her efforts are strengthened
by the evidence of a profound pedagogical sense
which has enabled her to present a volume that
will be most helpful to teachers, while at the
same time meriting a valuable place in the
reference library of any home.
ETFOLOGY
Two Signs in Chronic Appendicitls^r-Morris
in the N. Y. Med. Jour., Feb. 15, 1919, stated
that two signs belonging to the sympathetic
and autonomic nervous systems were of prime
importance in making a differential diagnosis
between chronic appendicitis and other affec-
tions of the abdomen and pelvis. These two
signs did not belong to acute appendicitis. As
a result of the chronic irritation of the appen-
dix, impulses were registered upon the second
and third right sympathetic lumbar ganglia
known as the fused ganglion, in such a way that
it became hyperesthetic. Deep pressure upon
the abdomen about an inch and a half to the
right of the navel and a trifle below brought
out this hyperesthetic point which constituted
one diagnostic sign of importance in differential
diagnosis. The other sign consisted in perma-
nent distention of the ascending colon. It was
what he called the cider barrel sign. Percus-
sion upon the normal left side of the abdomen
brought out a note suggestive of the cider bar-
rel in October and percussion over the right
side of the distended ascending colon brought
out a percussion note suggestive of a cider
barrel in March. This chronic disturbance of
the ascending colon was apparently caused by
exhaustion of its sympathetic innervation due
to chronic nagging from the irritated appendix.
GaU-st<»ne Disease Complicating Pregnancy.
— The cause of gall-stone disease is not defi-
nitely known. Heineck (Med. Times, Feb..
1919) states that numerous theories have been
advanced; not one has, as yet. been found
worthy of general acceptance. The following
three factors, owing to their frequency previous
to or during the existence of gall-stone disease,
impress one forcibly as being important predis-
posing causes. In the individual case, one, two.
or all of these three favoring influences may be
operative:
a. Conditions associated with, favoring, or
causing biliary stasis.
b. Inflammatory states of the biliary tract,
primary or secondary to local disease, or to
some general febrile state.
c. Regimens or diatheses favoring or caus-
ing hypercholesterinaemia.
Cholesterin, the principal component of gall-
stones, is derived from the bile. Simple bile-
stasis can, thru the precipitation of cholesterin,
lead to cholesterinstone formation. Precipita-
tion is prone to occur in inspissated bile, and
the elements thrown down may lead to stone
formation. In the later months of pregnancy,
the abdominal muscles and the diaphragm con-
tract feebly, and the bile, being inefficiently ex-
pelled, stagnates in the gall-bladder.
Stasis, in addition to separating out the es-
sential constituents of gall-stones from .the bile,
favors the growth of bacteria in the residual
fluid. According to Sherrington, bacteria can-
not enter the bile ducts, as long as the bile is
expelled at regular intervals. Bile is not an
antiseptic; it does not prevent the development
of bacteria; left exposed to bacterial contamina-
tion, it undergoes putrefaction. Obstruction to
the bile outflow may be due to foreign bodies
present in the gall-bladder or, in the larger bile
ducts, may be determined by inflammatory or
other degenerative changes involving the gall-
bladder or the bile ducts, or may result from
such pathologic states of contiguous organs
as lead to impingement of one or more of the
latter upon the bile ducts. Obesity, sedentary
life, constipation, tight clothing, such as ill-
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AMBUCAN MXDICIKB
TREATMENT
April, 1919
237
fitting and improper corsets, etc., are held by
some to be predisposing factors. Miyake be-
lieves that the non-wearing of corsets by Japan-
ese women is one of the principal reasons why
gall-stones are so infrequent among them.
Bacterial organisms are said to be the most
essential cause in the majority of cases of gall-
stones. In this connection one should not
ignore the relation of mouth and teeth infec-
tions to appendicitis and cholecystitis. In
some cases, supplementing the noxious influ-
ence of bile-statis, in others acting independ-
ently, in many acting conjointly, there is present
a bacterial inflammation of the mucous mem-
brane of the gall-bladder, of the bile ducts, or
of both. If the stone be of aseptic origin, the
abnormal element lies in the composition of the
bile; if tne stone be of inflammatory origin, the
pathologic condition is the cholecystitis or
catarrh of the gall-bladder.
The Etiology of Trigeminal Neuralgias-
According to an editorial writer in the New
York Med, Jour, (July 13, 1918), modern
medicine tends more and more to limit the rOle
of symptomatic treatment and to increase that
of the etiologic, and, since both means are re-
sorted to for the cure of trigeminal neuralgia,
it is evident that there are both known and
unknown causes of this dire affection.
Amons the general causes, by far the most
important, because the most frequent, is luetic
infection, which should always be looked for in
every case of neuralgia of the seventh cranial
nerve.
In cases where doubt exists, there is a quite
constant characteristic ofTered by syphilis,
namely, an increase in the intensity of the pain
during the early hours of the night, while if
the neuralgia is bilateral it is probably due
to a specific lesion at the base of the brain.
Malaria is a potent source of facial neuralgia,
but unfortunately far more obstinate to treat-
ment than when syphilis is in play. It might
seem as if the symptoms, when having a ma-
larial basis, should ofTer an intermittent char-
acter in the majority of cases, but such is not
the case. The pain is quite as much continued
as paroxysmal, altho we have a series of
phenomena which will, perchance, facilitate the
etiologic diagnosis. We refer to the vasomotor
disturbances, conjunctivitis and epiphora.
Of chlorosis, the various neuroses, and diabe-
tes, as etiologic factors of facial neuralgia, lit-
tle mention need be made, as the subject is
generally falrlv well known, and the same ap-
plies to gout, rheumatism, and various intoxi-
cations, particularly from nicotine and carbon
oxide. Alcohol does not appear to be a direct
factor in the causation of trigeminal neuralsia,
but is undoubtedly often an adjuvant cause.
The local causes are numerous, but to dimin-
ish their Influence all that is necessary is to
place the patient in suitable hy&rienic surround-
ines. after which the local etiologic factors are
to be r^onsidered. After removal of teeth, the
condensing periostitis arising In the empty
alveoli may include the nerve endings, and this
neuralgia of edentates is rapidly done away
with by resection of the alveolar borders. A
badly fitting plate of teeth or a tooth with
an exposed pulp, a badly fitting artificial eye
in contact with the inflamed and painful
ocular stump, and the various otitides are all
causal factors which should never be ignored
In other cases the causes will be more direct.
Among them may be mentioned periostitis, or
osteitis of the osseous canals existing along
the track of the nerve, resulting in compres-
sion of the trunk. Neoplasms and sinusitis oc-
cupy an important place in this respect, while
less frequently the casual factor may be an ir-
ritation of Gasser's ganglion by an aneurysm
of the internal carotid or a neoplasm at the
cranial base.
REATMENT
Severe Chronic Diarrhea*— Dflring iCorre-
spondenZ'Blatt fiir 8chweizer Aerzte,) Dec. 21,
1918) describes cases, in a girl of 10 and three
adults, which in many points resemble the se-
vere alimentary diarrhea of infants. One man
of 44, a prisoner of war in Germany, developed
severe chronic diarrhea with great depression,
but no pains or fever. No beneflt was derived
from tannin or opium preparations or charcoal.
A bleeding bunch in the rectum was assumed
to be cancer and the man was sent to Switzer-
land to be interned, where the rectal lesion sub-
sided under silver nitrate. In all the cases in
this group there was a history from youth of
substandard digestive functioning, and the pa-
tients showed a tendency to anemia, meteorism
in the upper abdomen, and a gray tint of the
skin. The stools in each case showed defective
digestion of carbohydrates, the high acidity tes-
tifying to abnormal fermentation, which was
responsible for the meteorism and the excessive
peristalsis. The correctness of this assumption
was demonstrated in each case by the beneflt
from dietetic restrictions, avoiding carbohy-
drates. Any meal of potatoes or tapioca was
liable to bring back the diarrhea. Carbohydrates
have to be banished as completely as from the
diet of diabetics. Further all cellulose-contain-
ing foods have to be scrupulously avoided. Lean
meat, flsh, eggs, cheese and cane sugar have to
be the sole reliance. CofTee and tea with cream
can be allowed, but no milk on account of its
lactic acid content. Keflr is very useful. It is
better to warm it. In the very severe cases, al-
bumin milk may have to be resorted to.
He begins treatment with a purge, allowing
only black tea, and for two or three days only
fluid food. He warns expressly against gruels.
The fluid stools soon stop and meat and eggs
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APRIL, 1919
TREIATMBNT
American BIedicikk
soon bring putrefaction bacteria to predominate.
In a few days tbe stools become formed and
alkaline. In obstinate cases, calcium chlorid may
hasten this transformation of the reaction. The
amounts of the foods allowed can be rapidly in-
creased and after a few weeks, zwieback and
flour dishes may be cautiously allowed under
constant supervision. Noodles, grits and rice may
be taken without harm in time, but the intol-
erance for potato long persists, and it may bring
on the gravest relapses. Institutional treatment
is almost indispensable, even more so than for
the graver cases of diabetes. Medicinal treat-
ment is of little use except that opium may aid
at first in checking the exaggerated peristalsis.
With ulcerative colitis it can be given with
belladonna 'by the rectum. Morphin may be use-
ful to quiet the excited patient. After recovery,
the patients long have to beware of foods con-
taining cellulose. A limit of tolerance is finally
reached, and keeping within this they have no
further trouble. His patients in this group have
been free from all disturbances for months.
Acne Ynlgaris*— It is a well known fact that
this is a very obstinate disease to treat in many
instances, and Miller (Urologic and Cutaneous
Review, July, 1918) recommends that the
scalps of these patients be examined very care-
fully. When the scalp shows seborrhea a pre-
liminary shampoo of a solution of potassium
carbonate (14.2 grams to the litre), followed by
the use of green soap tincture once a week and
the daily use of a sulphur pomade, should be
employed. The following is a good formula:
Sulphur precip dr. i;
Sodii bibor dr. v :
Aquae rosae dr. iii ;
Cerate alba dr. 1 ;
Petrolatum dr. v.
All comedones are to be carefully expressed.
Before expressing them it may be well to ap-
ply a hot towel to the face for a period of ten
minutes. Pustules must be opened and drained,
best done with a von Graefe cataract knife. The
hyperkeratotic layer must be removed by sul-
phur. One of the best preparations is lotio alba.
When stimulation is evidenced by a mild der-
matitis, cold cream or calamine lotion should
be substituted. Vaccine treatment Is used at
times. If the acne vaccine imcombined does
not ?ive results, the staphylococcus vaccine
may have to be added. The Initial dose should
be five million of the acne vaccine, which is in-
creased to one hundred million. The Initial
dose of the staphylococcus vaccine is one hun-
dred million, which is increased to a billion or
more. For arne indurata or blind boll. Bier's
suction cup should be used. The diet should be
carefully restricted. Plenty of water shouH be
taken between meals. Exceptionally the X-rays
or tbe Kromayer lamp may have to be em-
ployed.
curious how an expedient that one has used
for years will suddenly become a matter of
great interest to several men at the same time.
The matter is so very simple that it was never
put upon paper until now, tho the patients
that have been helped by it were many. When
the walls of the veins become a little dilated, if
they are rested they may regain some of their
tone; but since only too often they are never
rested, dilatation is slowly progressive. If one
has rather large veins upon the back of his
hand, if he lets that hand hang down those
veins dilate, and if he raises his hand slowly to
a horizontal position or in line with his
shoulder those veins do not rest, but remain
dilated, if one holds his hand vertically, or
with straight arm toward the ceiling of a room,
the veins will empty in a few minutes, and
when the hand is brought down to the aforesaid
position the veins remain empty and their walls
rest.
When a person with a varicose leg goes to
bed he usually sits upon the bed and draws his
leg in after him. The veins of that leg are
dilated and remain more or less so for hours,
therefore the vein walls do not rest.
Let that person go to bed, hoist his feet up in
the air, the higher the better, let him keep
them there for five minutes and let him lower
them slowly to the recumbent position. The
veins are empty and the vein walls rest.
After a few weeks of this exercise many pa-
tients declare that their whole sleep is more
restful.
The great value of the maneuver is shown
after an operation for a varicose vein.
Restlnir t»»e Veins, A Sfmnle ETned»ent— \
writer in the March Med, Council says it is
A New Incision for Appendectomy. — The
number of incisions that have been brought for-
ward for appendectomy from time to time, says
Watson (Annals of Surgery, Oct, 1918), show
that no one incision is adapted to all cases.
Many writers have noted that in the cadaver
the base of the appendix is found at McBurney's
point, while in the living subject it is below
this point, usually on a level with the center of
Poupart's ligament. A number of operators
have called attention to the ease with which
the appendix can be removed when operating
for right inguinal hernia. Since 1910, I have
used a new incision, with its center over the
base of the appendix, and believe that in many
cases it is an improvement over those in general
use.
Incision: A point one and one-half inches
from the right anterior superior spine, on a
level with a line connecting the two superior
spines, is selected for the beginning of a vert-
ical incision which extends directly downward
for two to three inches to a point just above,
and to the inner side of the internal abdominal
ring.
Advantages: Traction to expose the appen-
dix is avoided because this incision, in the ex-
ternal oblique and its aponeurosis, the most
resistant structures, is directly over the base
of the appendix. It can be enlarged without
weakening the abdominal wall. The ilio-hypo-
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AMERICAN Medicine
NOTES AND ANNOUNCEMENTS
April, 1919
239
gastric and ilio-inguinal nerves are not injured
because the incision lies between them. Be-
cause this incision is made over the cecum, the
small intestines do not crowd Into the wound
as they do when the McBurney and lateral
rectus incisions are used.
Treatment of Tetanus. — The success of treat-
ment lies in an early diagnosis. Twigg in
Therapeutic Gazette, Jan. 15, 1919 says don't
wait until lock^w has developed before giving
serum — 5,000 units given early in a case is more
efficient than 50,000 later when the symptoms
have become general.
Four methods are commonly used for giving
the antitetanus serum, namely, subcutaneous,
intramuscular, intravenous and intrathecal.
The War Office Cfommittee for the Study of
Tetanus reports that in cases of acute general
tetanus the best method is to give large doses
of antitoxic serum intrathecally, repeated in
two, three, or four days in succession and com-
bined with intramuscular injections.
Very large doses of serum should be given;
50,000 to 100,000 units may be administered
during the first few days of treatment.
For the intrathecal injections it is advisable
to withdraw 20 c. c. of cerebrospinal fluid and
then to run in the serum. In no case is it to ex-
ceed 20 c. c. in amount; 16,000 units is the ade-
quate single dose for the intrathecal injection.
We should repeat the intrathecal dose daily for
four days, at the same time giving supplemen-
tary doses, intramuscularly, of 8,000 units.
Treatment with magnesium sulphate is not
advised, as some risk attends its use, and it is
doubtful if it has any advantage whatever.
Treatment of Malaria with Quinin Hydro-
chlorid. — For twenty years Howard {Jour, of
Tropical Med. and Hygiene, Jan. 1, 1919) has
ufeed the hydrochlorid and bihydrochlorid of
quinin in the treatment of malaria. For routine
prophylaxis he uses the hydrochlorid, either in
tablet form or in solution, in which case he
usually adds 1 minim of dilute hydrochloric acid
to each grain of quinin to convert it into the
bihydrochlorid. For the treatment of definite
malarial pyrexia, he uses the bihydrochlorid.
If a patient is Y^ry susceptible to quinin and
complains much of tinnitus, this may sometimes
be decreased by giving a few minims of dilute
hydrobromic acid at the same time as the
quinin. In the treatment of native infants with
malaria, the tannate of quinin, given as a pow-
der, in relatively large doses, has proved satis-
factory.
Treatment of Chorea* — Odriozola {La Cronica
Medica de Lima; Oct., 1918) still has great faith
in Fowler's solution in doses up to physiologic
effect. Attention is given to the intestinal tract;
chloral for exaggerated movements up to thirty
centigrams every four hours for a child of six
years, and the salicylates, preferably aspirin,
up to five or seven grams daily. Rest is of im-
portance, especially absence from school, until
all traces of the condition have disappeared.
NEWS NOTES "«>
ANNOUNCEMENTf
American Delegates to the Bed Cross Confer-
ence at Cannes. — The following men have been
invited to represent the United States at the
Red Cross conference at Cannes, France:
Dr. William H. Welch, director. School oU
Hygiene and Public Health, Johns Hopkins Uni-
versity; Dr. Simon F^exner. director. Labora-
tories of Rockefeller Institute for Medical Re-
search, New York; Dr. Herman M. Biggs, Health
Commissioner, New York State; Dr. EM ward R.
Baldwin, director of Edward L. Trudeau Foun-
dation for Tuberculosis, New York; Dr. Theobald
Smith, director of Animal Pathology, Rocke-
feller Institute for Medical Research; Dr. Wick-
liffe Rose, director general. International Health
Board Rockefeller Foundation; Colonel George
Walker, U. S. Army, in charge of venereal dis-
eases, A. K F.; Colonel Homer Swift, U. S.
Army, consultant in medicine, A. E. F.; Colonel
William F. Snow, U. S. Army, President of As-
sociation of State and Provincial Boards of
Health of North America; Dr. L. ESmmet Holt,
professor of diseases of children. College of
Physicians and Surgeons, New York; Dr. Sam-
uel McC. Hamill, professor of diseases of chil-
dren, Philadelphia Polyclinic and College for
Graduates in Medicine; Dr. Fritz Talbot, chief
of Children's Medical Department, Massachu-
setts General Hospital, Boston; Dr. Livingston
Farrand, director general, American National
Red Cross; Major A. M. Garvin, chief. Bureau
of Tuberculosis, A. R. C, France; Major Wil-
liam Palmer Lucas, professor of pediatrics. Uni-
versity of California; Colonel Richard P. Strong,
U. S. Army, professor of tropical diseases. Har-
vard University Medical School; Assistant
Surgeon General N. S. Cummins, U. S. Public
Health Service; Colonel F. F. Russell, U. S.
Army; Lieutenant-Colonel Lindsay R. Williams,
U. S. Army.
Miss Delano Dies.— Miss Jane A. Delano, who
died April 15, aged 56, at Base Hospital No. 8,
at Sauvigny, France, was one of the foremost
figures of the nursing world. Under her di-
rection more than 30,000 nurses were recruited
thru the American Red Cross for service with
the Army and Navy after the United States en-
tered the great conflict. Miss Delano graduated
from Bellevue Hospital, New York, in 1886, and
two years later volunteered to nurse yellow
fever victims in Jacksonville, Fla. Altho at
that time medical science had not decided that
the mosquito was a yellow fever carrier, Miss
Delano had reached that conclusion, and had
insisted on the use of mosquito netting by her
nurses with the most satisfactory results. In
1891 she was made superintendent of the nurses'
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240
April, 1919
NOTES AND ANNOUNCEMENTS
American Mbdicinb
training school of the University of Pennsyl-
vania, a position she held for five years, and in
1900 she returned to Bellevue Hospital to direct
the nurses' training school there, continuing in
the capacity until 1905. Wlien the American
Red Cross, following the final reorganization
in 1906, entered into an agreement with the
American Nurses' Association for the purpose
of developing a nursing reserve for the Army
Nurses Corps, Miss Delano was appointed chair-
man of the committee in charge of the work.
She was also named as superintendent of the
Army Nurse Corps by the Surgeon-Oeneral, in
which capacity she visited the Philippine
Islands, China, Japan and Hawaii.
Medical Reserve Coips Commissions*— -Com-
missions in the Medical Reserve Corps are be-
ing offered to officers of the Medical Department
who have been discharged from the service upon
completion of their duties connected with the
emergency. Under the law they cannot be re-
turned to the inactive list of the Medical Re-
serve Corps, but must be discharged and reap-
pointed in the reserve in order to continue their
connection with the Medical Department. It is
planned to build up a large Medical Reserve
Corps and include all members of the medical
profession who served creditably during the
war. It is said that the policy governing these
appointments is such as to insure that within
the limitations prescribed by law every officer
so appointed will receive rank at least equal
to that held by him at the time of discharge.
GoTernment Surrey of Drug Addiction.— A
special committee, composed of G. C. Keith,
deputy commissioner in charge of narcotics of
the Internal Revenue Bureau at Washington,
Professor Reed Hunt of the Harvard Medical
College, Dr. A. G. du Maz of the Public Health
Service, Lleut.-Col. Pearce Bailey of the United
States Army Medical Corps, and Representative
H. T. Rainey of Illinois, appointed by the Secre-
tary of the Treasury to make a national investi-
gation of the drug habit, have recently sub-
mitted a survey. This report seems to show
that native born Americans are more prone to
the drug habit than other white races, and that
the drug habit is more widespread in the United
States than anywhere else on earth. In some
parts of the country, notably in large cities like
New York, Philadelphia and Pittsburgh, the
liquor and drug habits were found to be gain-
ing more victims side by side, while in other
parts of the country, where prohibition had
gone into effect, extensive use of paregoric and
similar compounds containing morphine was
discovered. In Jacksonville, Fla., 800 drug
victims were found out of a population of
7,000. The number of drug victims in the
United States is estimated at not less than
1,500,00. There is no part of the country
without them and no State where the grow-
ing evil has not been a problem. The ex-
perience of the war shows that excitement and
overstimulation are responsible to some extent
for the increase in the use of drugs. The re-
port points out that if drug addiction is to be
controlled the individual States will have to
pass supplementary legislation, and thus far
only three States have done this, namely. New
York, Massachusetts and Tennessee. In seek-
ing to prevent the drug evil from extending Its
grip when prohibition goes into effect the
authorities at Washington propose to seek the
closer cooperation of physicians.
The Drag Campaign. — Health Commissioner
Copeland has made a formal protest to the
prison commission that convicts in state insti-
tutions are receiving an uninterrupted supply
of narcotic drugs. Another serious matter
brought to the attention of the health commis-
sioner is that a considerable number of trans-
portation employees are drug addicts. Commis-
sioner Copeland has offered the narcotic drug
commission, offices and clerks in the department
of health building, as no appropriation was
made for offices for the State Narcotic Commis-
sion in this city. The announcement is made
that no more clinics for the treatment of drug
addicts will be opened by the health department
at present and that the work will be confined to
that of the Worth Street Clinic. Dr. Copeland
emphasizes the necessity for physicians to con-
tinue prescribing for drug addicts with a view
of effecting a cure. Walter R. Herrick has been
appointed chairman of the State Narcotic Drug
Commission. Statistics based on the histories
taken from 214 drug addicts coming to the
clinic show that most of them are unskilled
workers. Thirty-four different pursuits are
represented. At least 20 per cent, of the ad-
dicts are engaged in transportation work.
Among this number were four physicians, one
newspaper man and a school teacher.
A Creditable Course.— The U. S. Public
Health Service is putting forth the most strenu-
ous efforts to lessen venereal disease, and is
enlisting the assistance of all physicians and
druggists. The various state boards are cooperat-
ing most actively. The New York State Board
of Health, for example, has established venereal
clinics in the larger cities and towns and is
conducting post-graduate courses in New York
for the training of medical men to handle the
work in these clinics.
In the belief that the syphilis situation could
be handled better if treatment for the general
public were made possible, Col. H. A. Metz, of
the H. A. Metz Laboratories, Inc., New York, is
offering to the government and to the institu-
tions cooperating with the U. S. Public Health
Service salvarsan and neosalvarsan at prac-
tically cost. Believing, as he does, in humani-
tarianism in business, he has extended these
same low prices to all state and municipal in-
stitutions treating the general public, so that
there may be no further excuse why the poor
should not get the benefit of the best methods
in the treatment of syphilis.
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BMERlfflNHEDICINE
PUBI^ISHBB MONTHLT
Bdltorlal OiiiMsi 18 Bast 41st St.. N«w Tork Giir. Pnblleatfon Oflie«si 189 CoU«««'St., BnrUnAton. Vt.
Complete Swlef, YoL XXY. No. 6
New^Serias, Yd. XIY. No. 6
MAY, 1919
$2.00 "*^^
In Advaaoe
CONTENTS
EDITORIAJb COMnmifT
MBN AlVD THINGS
ORIGUTAIi ARTICUSS
LONI>ON USTTBR
PHYSICAL THBRAFT
RATIONAIi ORGANOTHVRAFY
CORIUBSPOHDBNCTB
ETIOI.OOT AND DIAGNOSIS
TRB3ATMBNT
NirWS IfOTESS AND ANNOVNCJBMBNTS .
AMONG THBS BOOKS
241
251
257
206
299
802
(Continaed on pavo 6)
CONTRIBUTORS
B. S. TAI^BY, M. D., New York City.
D. Y. lOSITH, M. IK, LouiSvlUe, Ky.
J. P. KBITH, M. n^ LouiBviUe, Ky.
CARIi SCHBFFBIi. Ph. B., M. D^ Boston, Mass.
ALBERT C. GEYSBR, M. 1>^ New York City.
CHRISTIAN F. J. LAASB, M. D^ New York City.
B. BARRYMOIUS BIARCO, D. D. 8^ New York
City.
Snlend m sewmd-olMg matter January 28, 1006, al the PosI OflSce at Borlincton, Yt, oader Ael of Concresa, Mardi 8, 1870.
Headache
and Neuralgia
are relieved by the rubbing in
of
K-Y ANALGESIC
^^The Greaseless Anodyne''
Repeat when necessary, washing off
the previous application.
^^A safe J harmless way that
works most of the time/*
Nonrgreasy; water-soluble; effective. Collapsible tubes, druggists, 50c.
M f fT <Q A
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ForEy^Ear,No8^Throat and
Genito-Urinary Oi^ans
r*iE9«.
18 a germicide of marked power
and efficacy. It ia non-tozie and non-irri-
_ h ia aerviceable in any condition in which a ailver
•ah ia indicated. Anthoiitiea nare pronounced SiKrol the
moat eatiifacfocy pioteid-ailver compound that haa been
offered to the medlca! piofeaaiatt. Hie product ia aupplied
in a variety of useful format
SILVOL POWDER (Granular): Aqueous
aolutiona may be prepared in any atrength deaired. They
may be applied to any inflamed mucoua membrane 1^
•pray, irrigation, injection or enema. They do not coagulate
albumin or precipitate the chlorides. Bottlea of one ounce.
SILVOL CAPSULES (6-grain): Convenient
for the estemporaneoua preparation of aolutiona of definite
strength. The contents of two capsulea make one-fourth
ounce of a lO-per-cent. solution. . Bottles of 100L
SILVOL OINTMENT (5%): Forsimpleand
MMMofic conjunctivitia, trachoma, corneal ulcer, blepharitis,
rhinitis, ulcer of the septum, tonsillitiib phaxyngitiab etc
Collapsible tubes, two i '
SILVOL SUPPOSrrORIESCVagmaDCS^):
For vaginitis (simple or gonorrheal) and cervical eroaiona.
Boxes of one doeen auppositories, each in a metal capsule.
SILVOL BOUGIES (5^): For specific and
non-specific inflammations of the male urethra. Boxes of
25 and 100 bougies, each wrapped in waxed paper. An
introducer ia supplied with each package.
Parke, Davis & CompaBy
DCTRorr
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American Medicine
H. EDWDI LEWIS, M. D., Managing Editor
IRA 8. WILE, Associate Editor
PUBUSHBD MONTHLT BT TBI AXBBIGAn MXDICAL PDBU8HII16 COMPANY
CopTTiffhted by the Amerfean Medical Pnblishlnff Co., 1910
Complete Series, Vol. XXV, No. 6
New Seriee, Vol. XIV. No. 6
MAY. 1919
to 0£\ YEARLY
^C.Xni In Advance
Aimiial Meetings^ — The month of June
approaches, which, eugenically speaking,
may be of interest because of the higher
incidence of marriages but, which, medi-
cally speaking, possesses two marked ad-
vantages. It is the month of medical meet-
ings ; not merely the annual meeting of the
American Medical Association and the
meeting of the American Academy of Medi-
cine, and the American Medical Editors'
Association, and at least 15 other medical
and surgical organizations, but various other
organizations whose interests lie along eco-
nomic and social branches indirectly re-
lated to medical practice. A second reason
that June is of significance to the medical
profession is to be found in the fact that
June is the most healthful month in the
year. Its mortality figures during 1916, for
example, were 3,000 lower than the next
lowest month, October.
There seems to be, therefore, a certain
excuse for the doctor to arrange for a holi-
day during that period of the year when
the public health appears to be in its most
flourishing condition. Whether one lives in
rural or urban sections, the month of June
is alike favorable and should stimulate
men's minds to thinking of self -improve-
ment thru rest, recreation, genial compan-
ionship, and the interchange of professional
views and opinion, either in halls of formal
meetings, or around festive tables where
companionable groups interchange experi-
ences and discuss theories of prevention or
treatment of disease.
Annual conventions are to be considered
as more than recurrent excuses for getting
away from the trials and pressures of medi-
cal practice. In theory, at least, they should
form part of the educational machinery of
the profession. The programs do not always
indicate that thought expansion is of the
utmost moment. All too frequently, there
is repetition of age-old topics to which prac-
tically nothing has been added during the
year past. Nor is it, indeed, strange to find
upon programs communications from those
whose opportunities have been so narrow
as to aflford little basis for the type of com-
munication for which a hearing has been
asked. Still, all this occurs in the month
of June, when sunshine and flowers, long
days, and nearly cool nights give men a
feeling of tolerance and aid and abet their
willingness to endure many things far from
their ordinary habitations and friends.
The medical convention is an occasion
for renewing medical vitality, for perfect-
ing old friendships and gaining new ones,
for whole-souled living in the spirit of
fraternity. The formal papers are on the
programs; a few are heard by many, and
many are heard by a few, but when the last
ripple of applause has died on the day of
adjournment, the success of the meeting
is felt. It is known by that greater thrill of
pleasure which each man feels as he takes
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242
May, 1919
EDITORIAL COMMENT
American Mbdicinb
away with him the pleasant memories of
a few days of recreation, companionship,
cordiality, and a sense of self -betterment,
not born of isolated experience, but from
a permeation of the mind with a greater ap-
preciation of the meaning, the power, and
the possibilities of the medical profession.
Losses from Preventable Diseases. —
While various attempts are being made to
raise large sums of money to satisfy and
maintain the government's honor by meet-
ing the expenditures required by war, de-
mobilization, and the consequent drains
upon the Federal treasury, it is not per-
haps unnatural to call attention to the yearly
drains of the assets of the Nation thru com-
municable diseases. The Illinois Health
News, of January, 1919, contains a most
excellent estimate of the cost of illness and
death from communicable diseases in that
state. According to the estimates pro-
vided, illness and death from com-
municable diseases entailed a cost of $24.67
per capita for each man, woman and child
in Illinois. The general death rate was low,
only 14.2, and the total loss from the prin-
cipal preventable diseases amounted to $15,-
881,685, or 6.01 per cent, of the total prop-
erty value of the State. If this ratio of
per capita cost were to apply for the entire
United States, the loss during 1918 would
amount to more than two and one-half bil-
lions of dollars. The Illinois figures, how-
ever, merely considered the cost of the
following communicable diseases: typhoid,
malaria, smallpox, measles, scarlet fever,
whooping cough, diphtheria, meningitis,
poliomyelitis, tuberculosis and pneumonia.
In computing the financial cost, four items
were involved: (1) The cost of funerals
based at $100 for adults and $50 for chil-
dren; (2) the value of life lost at $3,000
for an adult, and $500 for a child; (3) the
cost of care of those who recover includ-
ing medical service for adults. Utilizing
the same figures for the few above named
diseases in a computation on the basis of
the United States mortality figures for 1916,
the death losses from these ten diseases
(poliomyelitis not included) amounted to
approximately 570,000,000 and the losses
due to medical care and wAges to approxi-
mately $1,087,000.
The recent epidemic of influenza involved
at least ten million persons, with a mortality
of approximately 400,000. Assuming that
each case of illness involved only $25 for
medical care, the cost would be 250 million
dollars. Inasmuch as the mortality from in-
fluenza involved approximately three per-
sons of working age to one child, one may
consider the average loss by death equiva-
lent to $2,400, and the funeral expenses at
$90, giving thus a total economic loss in
vital assets of approximately one billion dol-
lars. These figures, large as they are, take
no account of the losses in production due
to the pestilence, nor, indeed, of the cost
of labor turnover due to the mortality of
industrial workers.
These tremendous costs of communicable
diseases may be regarded in part as an in-
dex of the economic efficiency of communi-
ties. It certainly does not reflect great in-
terest or care in the conservation of the as-
sets of the community to note the astonish-
ing destruction of resources due to prevent-
able communicable diseases. It is probably
a shock to the conservative thinker about
economic wastefulness to realize that the
number of industrial accidents reported to
the New York State Industrial Commission
for the year 1917-1918 was 286,871, a num-
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EDITORIAL COMMENT
May, 1919
243
ber larger than the total casualties of our
American Army, occupied in the strenuous
work of conquering a pitiless foe. It is of
the utmost significance that war, with all its
atrocities, is probably responsible for little
greater disease and disability during the
period of greatest industrial activity than
occurred during the ordinary years of con-
ditions reflecting normal industrial activity.
Health must be estimated in terms of
dollars and cents, in terms of productivity
in order to reach the conscience of the aver-
age taxpayer, who must be called upon to
defray the expenses of health departments
and to meet the increased costs laid upon
industry by virtue of the economic losses
entailed thru sickness and death. The eco-
nomic value merits greater attention, par-
ticularly at this time, when every effort is
being made to secure the rehabilitation of
the wounded and to increase the vigor and
potential powers of those who have suffered
from disease while pursuing their course
as part of the military or naval forces of
the nation. It must not be forgotten, how-
ever, that similar problems are of equal im-
portance in connection with the every-day
living of the growing nation, now bent upon
renewing national prosperity and raising
the standards of health, comfort and pros-
perity for all the types of citizens which
comprise the nation.
Hospitals as Educational Forces. — Hos-
pitals are no longer regarded as merely in-
stitutions for the care of the sick. Their
potentials for education have been extended
gradually so that they are now available for
the training of internes, the education of
nurses, for the rehabilitation of patients,
for the training of various type of tech-
nical workers such as dietitians, anesthet-
ists and laboratory workers. Some hos-
pitals aim to develop a corps of persons
able to do service in the community with
social work, to offer personal nursing care
of children, to act as aids in the guidance
of the tuberculous, and to serve as assistants
in the management of psychiatric cases.
With this large program constantly ex-
panding under the urge of sociologic
progress, it is patent that hospital standard-
ization possesses many difficulties, as pointed
out by A. R. Warner, Journal of the Ameri-
can Medical Association, March 29, 1919.
He presents the obvious and important con-
clusion that some disinterested and impar-
tial agency or organized group of agencies
should be developed to accomplish hospital
standardization so as to harmonize the in-
terests and welfare of all groups of work-
ers in hospitals such as the medical pro-
fession, the nurses, the dietitians, the so-
cial service workers, the dispensary staff
and the internes. It is obvious that any
scheme of standardization which is limited
to a consideration of the problems of a
single group of hospital workers will be
entirely inadequate to satisfy all the needs
for a high standard of hospital administra-
tion.
Dr. Warner stresses particularly the re-
sponsibility of hospitals along educational
lines. The utilization of hospital facilities
for the training of medical students, utiliz-
ing them as clinical clerks, the obligation to
offer experience of a post-graduate charac-
ter to graduates holding interneships, and
the provision of graduate medical instruc-
tion of various forms and degrees for all
physicians represent the crystallization of
the opinion that hospitals are not fulfilling
their obligations to the community unless
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May, 1919
EDITORIAL COMMENT
Ambrican Mbdicinb
they are, in a greater or lesser degree,
teaching institutions.
Hospitals are increasing in number, while,
for the time being, the number of medical
graduates is decreasing. It is very ques-
tionable whether the growth in the number
of medical licentiates can possibly keep
pace with the demand for internes in suffi-
cient number to satisfy all the demands of
modernized hospital administration. It is
apparent that the intemeship is destined
to undergo numerous alterations. The de-
sire for greater knowledge will lead recent
graduates to elect to enter institutions
affording them the widest experience, with
the minimum of routine involving little edu-
cational progress beyond an opportunity to
perfect various types of techhic. The evi-
dence in this direction is further accentuated
by the training of non-medical anesthetists
and laboratory technicians who already are
beginning to relieve internes of much of
their routine work. From the standpoint
of the patients it may be said that such
innovations are to their advantage. No one
will question the fact that a trained non-
medical anesthetist, who is working under
the direction of an attending physician, is
more capable than the average hospital in-
terne who, because of rotation in service,
is obliged to perform the service of an
anesthetist regardless of interest, inclina-
tion, or previous experience.
There is vital importance in considering
whether it is desirable for graduates to
immediately accept highly specialized serv-
ices in hospitals. In all probability, a year
spent in a general or rotating clinical hos-
pital service possesses many advantages
which will react to the benefit of the com-
innmty as compared with an immediate
plunge into a distinctly surgical or path-
ologic service. If it were possible to facili-
tate the arrangement of interneships in
small hospitals so as to permit a one year
service of the general type, and then pro-
vide opportunities for specialization in a
certain number of larger hospitals admitting
of particularization in services, there would
be a distinct educational benefit on the one
hand and, in all probability, an improvement
in the character of the training offered to
the internes in both the large and the small
hospital.
Clinical interneships are not substitutes
for interneships, and the state of mental
development of the average fourth year stu-
dent is not sufficient to enable him to secure
the maximum benefits from an interneship.
Unless there is ample supervision, his inter-
pretation of the results of his clerkship does
not suffice to advance his medical knowl-
edge in the large, tho, of course, it is of
most estimable assistance in perfecting his
professional bearing, his powers of analysis,
his ideas of pathology, and his ability to
develop a coherent idea of the nature, course
and treatment of the specific diseases as-
signed to him for investigation.
A Fifth Year in Medicine. — From the
standpoint of practicality, it would probably
be advantageous to demand a fifth year in
medicine with the last year spent in a gen-
eral or rotating interneship in an institu-
tion under the guidance ^nd advice of some
sponsoring medical institution. The general
attitude of hospitals towards internes would
be greatly improved if there were a greater
appreciation of their capabilities and re-
sponsibilities along educational lines. The
stimulation of medical progress which
would result from a plan of this character
should be manifest in greater care in the
selection of hospital personnel, in improve-
ment of equipment, in the establishment of
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EDITORIAL COMMENT
Mat. 191d
24b
laboratories of various kinds necessary to
modern medical practice. The interne
would remain a student, subject to the
criticisms, markings, correction and dis-
cipline customary in institutions of learn-
ing. The professional staff of the hospital
would assume a new dignity in the recog-
nition of their position as acknowledged
teachers. The entire plane of hospital man-
agement would be raised, because of the
closer touch with the sponsoring medical
college. Some program of this character
will undoubtedly be required in order to
make ample provision for satisfying the
needs of hospitals within the next few years.
The medical colleges are awakening to
the importance of raising the standards of
medical practice and are keen to have their,
graduates secure positions in hospitals, tho
it is impossible for them to make adequate
provisions of their own initiative for all
their graduates. Nor is it now regarded as
part of their function to assist or guide
men in discriminating among the various
hospital positions open to the medical
neophyte. If some large institution, or group
of medical colleges were to undertake to
extend their teaching power and to offer
their facilities, advisory and supervisory,
to a number of small hospitals with a view
to constituting them as the laboratory for
hospital training, there would be a marked
growth and improvement in the system of
hospital training now available. There is
little reason to believe that small hospitals
would refuse such an opportunity to raise
their educational standards.
When hospital standardization is finally
effected, there will be a weakness in the
program unless provision is made for a
minimum standard of educational facilities
to be available for students in every line
of medical, nursing, laboratory or adminis-
trative branch involved in medical practice
or hospital organization. Hospitals are not
merely places where operations are per-
formed or children are brought into the
world, or where those afflicted with chronic
diseases may have shelter until relief comes.
The hospital of the future is to be a vital
educational force, reflecting its interest in
patients, in families and in communities
which they aim to serve. One of its strong-
est levers for activating communities into
better health lies in a higher standard of
educational qualification and educational
practice.
One Piece of War Service. — In con-
templating the resourcefulness of America
during the recent conflict, it is helpful
to assess the value of performances
by specific institutions which promptly di-
verted their personnel and equipment from
civil to military problems. In this connec-
tion, the activities of the Rockefeller Insti-
tute present a striking example of adapta-
bility and capability. Founded for the pur-
pose of promoting medical discovery thru
research, it readjusted its numerous activi-
ties and placed all of its facilites on a war
basis. The character of the work which
it performed is most estimable and served
to make the horrors of war less continuous
and less devastating.
The curative serums for epidemic menin-
gitis and one of the forms of pneumonia
were continuously produced, while an anti-
dysenteric serum was manufactured in
quantity. The most important development,
however, was the discovery and production
of the antigaseous gangrene serum for the
prevention of B. welchii infection, which
was made possible by the researches of
Major Carrol G. Bull of the Institute staff.
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EDITORIAL COMMENT
Amkeican Mbdicimx
The protective properties of this serum have
been thoroly demonstrated, and thus another
link has been forged in the armor of pre-
ventive medicine.
Studies have been made concerning the
efficacy of prophylactic vaccination against
pneumonia and experiments would indicate
that such vaccination may be effective
against infection with pneumococci, types
1. II, III.
A new drug for the treatment of syphilis
has been perfected and tests of its action
and the best method of administration are
now being carried »out. If this chances to
prove successful we shall have an Ameri-
can drug which may supplant salvarsan in
this country.
Laboratory studies, begun before the war,
have sought to combat hemorrhage, and to-
day there are available the injections of
sterile solutions of gum arabic or the in-
jection of citrated blood corpuscles as a
means of combating both shock and hemor-
rhage.
Acetone plays a small part in the technic
of pathology, but was extensively used as a
solvent in aircraft production. The sources
of supply have been grossly inadequate,
and there was obvious necessity of perfect-
ing a method of acetone production which
would solve American difficulties. Dr. J. H.
Northrup secured from potatoes a bacterium,
which acts upon starch with the resultant
formation of a high percentage of acetone.
Fortunately, ethyl alcohol is formed as a by-
product, and thus, two valuable commod-
ities have been made available for scien-
tific and industrial purposes. This contri-
bution is by no means of insignificant pro-
portions.
Every one is familiar with the Carrel
method of treatment with the Dakin solu-
tion, but it is not generally known that the
work of Dr. Carrel had the support of the
Rockefeller Foundation. The treatment of
war wounds by the use of his technic and
Dakin's antiseptic, followed by methods of
bacteriologic control, have been of im-
mense value in reducing mortality and in
saving limbs which otherwise might have
been lost.
The War Demoii8trati<m Hospital
of the Rockefdler Institute, originally
planned as a school in which to teach mili-
tary surgeons the method of applying the
Carrel-Dakin treatment, came to play an
important part in the scheme of military
instruction for medical officers of the Army
and Navy, as well as for civil surgeons and
nurses. The bacteriologic and chemical lab-
oratories of the hospital have been study-
ing numerous problems bearing on the sur-
gical treatment of wounds, but have also
been employed for the purpose of giving in-
struction in bacteriology, serology and med-
ical chemistry.
This brief resume of the activities of a
single institution, highly endowed not mere-
ly with money, but with brains and patriot-
ism, is merely illustrative of the general
spirit of all our American institutions for
research, our hospitals, and the medical
profession. Every ounce of enthusiasm was
devoted towards constructive work upon
serious problems involving the physical
health and welfare of the civil as well as
the military and naval populations. The
number of discoveries which resulted may
not be numerically great, but their signifi-
cance in terms of human life is tremendous.
The gains from researches made neces-
sary for the conduct of military medicine
are now available for the management and
treatment of accidents and diseases among
the general population now redirecting their
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AMBUCAN MXDICINS
EDITORIAL COMMENT
May, 1919
247
efforts towards normalizing civil and indus-
trial activities. Out of the red cauldron of
war have bubbled many soothing, helpful
balms, to find a greater usefulness in the
quieter channels along which will flow
streams of peace-loving humanity.
A Federal Social Hygiene Board.—
The determination of the government to
attack the problem of venereal diseases
from every angle merits warmest appro-
bation. There is a determined effort to
break down the traditional taboo regarding
gonorrhea and syphilis, so that a knowledge
concerning their devastations and racial
hazards may be widely disseminated. It
requires the force and urge of governmental
action to overcome the hypocrisy, false
modesty, and vicious traditions which have
been evidenced for centuries in our atti-
tude towards these afflictions.
The most significant feature in the gov-
ernmental program is the leverage upon
public opinion which is being sought thru
the medium of publicity and educational
methods. The most recent development is
the organization of the United States In-
terdepartmental Social Hygiene Board,
which at present consists of Carter Glass,
Secretary of the Treasury ; Newton D.Baker,
Secretary of War ; Josephus Daniels, Secre-
tary of the Navy ; Lieutenant-Colonel W. F.
Snow, Medical Corps, U. S. A. ; Lieutenant-
Commander J. R. Phelps, Medical Corps, U.
S. N. ; and Assistant Surgeon-General C. C.
Pierce, United States Public Health Serv-
ice. This board is devising rules and reg-
ulations to govern grants of Federal funds,
to aid research and the development of
new methods of preventing venereal disease.
The sum of $300,000 is available for dis-
tribution to such universities, colleges, or
other institutions or organizations which
are qualified, in the judgment of the In-
terdepartmental Social Hygiene Board, to
attempt scientific research, and to develop
"more effective educational measures in the
prevention of venereal diseases and for the
purpose of sociologic and psychologic re-
search related thereto."
According to Schooi Life, educational
methods that combine instruction and train-
ing along other intimate and nearly related
lines of hygiene ought to merit the highest
approval. This endeavor to awaken educa-
tional institutions to their obligations and
responsibilities is noteworthy. The curric-
ula of training schools for teachers have
been notoriously deficient in anything of
pragmatic value related to the fundamental
verities of rational sex life, reproduction
and eugenics. The age-old reticence of com-
munities has been reflected in the blindness
of the courses of training for teachers ; and
in consequence, educational institutions have
been weak in their understanding of the
content or methods of imparting even the
simplest phases of sex education.
It is obvious that sex facts are not to be
isolated, but should be presented in their
proper relations to the ordinary subjects
contained in the curriculum. Particular un-
derstanding of the problems as related to in-
struction in hygiene is requisite. It is de-
signed to establish a modem department
of hygiene in state training schools for
teachers. Financial assistance will be made
available for the necessary personal serv-
ices when the general rules and regulations
of the board are accepted and there is proof
of willingness and ability to adopt satisfac-
tory standards of educational effectiveness
and the maintenance of scientific standards
that will not depend on the support of the
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EDITORIAL COMMENT
AlfBRICAN MSDICINB
hygiene board for their continuity.
The projected form of organization of a
department of hygiene involves a division
of informational hygiene, a division of ap-
plied hygiene, and a division of research,
while there are definite provisions made for
the personnel, requisite for the conduct of
such a department. There is a suggestion
that there should be close coordination be-
tween the department of hygiene in the
teaching institution and other community
agencies like the department of health that
are directly or indirectly concerned with
the problems of public hygiene.
The general plan, as contemplated, is
another evidence of the benefits of federal
assistance to educational developments, par-
ticularly along lines that affect national
welfare. One of the main elements respon-
sible for rapid changes in the educational
interests of other countries lies in a gen-
eral plan of centralization. In the United
States it is difficult to secure the adoption
of any particular program because of the
difference in educational vision existent in
the various states of the Union. There are,
however, numerous advantages in the di-
versification of educational methods owing
to the particular problems to be solved in
specific states, but there can be no ques-
tion about the desirability of establishing
a program of minimum standards of con-
tent in education which are essential for
healthful citizenship. The standards of
hygiene as projected by the United States
Interdepartmental Social Hygiene Board
should appeal to educators as having un-
usual force, having grown out of the ex-
perience of the Nation with venereal dis-
eases, physical training, periodic health ex-
aminations and a general knowledge of in-
dividual and group hygiene and sanitation
as evidenced in the products of school sys-
tems performing service in the Army, Nav>'
and Marine Corps.
The financial assistance which the govern-
ment is to give will serve as a ferment to
leaven some of our standards of education
in hygiene. It is to be hoped that, under
the guidance of this new interdepartmental
board, instruction in hygiene will be made
eflFective in our state institutions for the
training of teachers, and, in time, will be
manifested in the improved instruction
available for the growing generation. The
experiment is worth a trial, and will be
watched with eagerness by those interested
in the rational instruction of the growing
generation in the science and art of right
living.
Trench Fever.— The fact that trench
fever is spread by means of pediculi is now
well known. Major W. Byam calls attention
to the fact, in an excellent little book by
Lieutenant Lloyd on **Lice and Their Men-
ace to Man," that there is a possibility that
trench fever may be introduced into com-
munities to which discharged soldiers go.
The danger from men still capable of infect-
ing lice, on returning to their home
communities, makes it of particular im-
portance that there be a wider understand-
ing of the symptomatology of trench fever,
sometimes called "five day fever." It is
recognized that verminous conditions exist
in many portions of the country, and par-
ticularly in poorer districts and places where
facilities for cleanliness are limited. Having,
therefore, a sufferer with latent trench
fever and pediculi at hand, the possibility
of outbreaks of the disease is not remote.
Trench fever bears some symptoms in
common with influenza, and it is for this
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EDITORIAL COMMENT
May, 1919
249
reason that greater care is required in the
diagnosis of febrile conditions involving
pains in the muscles of the limbs and back,
around the joints, and in the shins in par-
ticular. The germs of trench fever may
continue for a considerable time in the
bodies of those who have had the affliction,
and the disease may flare up from
time to time with pains and depression
which may possibly be mistaken for attacks
of influenza, or rheumatism.
In its symptomatology, trench fever pre-
sents a sudden onset accompanied by severe
postocular headache, giddiness, weakness of
the legs, and pains all over. Occasionally,
there is a prodromal period when the patient
feels "out of sorts" and complains of head-
aches for a day or two. The pains involve
the back and limbs, the temperature mounts
to 103 "^ or 104 '^ or higher, with general dis-
comfort, greatest toward the evening when
insomnia and delirium may occur. After
a period of perspiration, the pains ease to-
ward morning, but with the approach of
night, fever returns and the pains appear
to seize upon the forehead, the back, the
legs, and especially the shins. Sweating
again occurs, and may be profuse, but with
it usually comes a certain measure of relief.
The fever reappears on the third evening,
but with less severity, and after that, the
recovery is usually rapid, tho some con-
tinue to have fever after the third day. More
victims have relapses towards the end of
a week and pass thru the experience above
described. After an illness of three weeks,
most sufferers from trench fever are suf-
ficiently recovered to return to their duties,
but others appear to develop a condition
of chronic aches and pains with occasional
outbursts of fever. These late fever curves
are usually short, but they may return at
regular intervals, as for example, every
fifth day.
Trench fever is due to infection by the
droppings of lice which have fed upon pa-
tients suflFering with trench fever. It is not
the biting of the louse that conveys the dis-
ease. The scratching of the person bitten
and the rubbing of the droppings into the
abrasions serve to begin the infection. It
is of importance, therefore, that clothes
and blankets be freed entirely from drop-
pings, as they may, perchance, serve as con-
veyers of potential infections to unsuspect-
ing persons making use of them for cover-
ing. Incidentally, infections may occur thru
small skin wounds or thru the delicate con»
junctiva.
The careful efforts at delousing which are
being practiced before embarking for home
from foreign shores, and the practices lead-
ing to disinfestation in this country pro-
vide a reasonable security of the popula-
tion against the danger of infection from
lice or their droppings, borne upon the per-
son, the clothing, or the equipment of re-
turning soldiers. Despite every care which
governmental ingenuity may provide, there
still remains the possibility that trench fever
may infest itself when proper conditions ex-
ist. It is, therefore, of particular importance
that this contingency be recognized. Health
officers and other physicians must be awake
to the importance of recognizing trench
fever with a symptomatology which might
ordinarily be regarded as evidence of in-
fluenza or rheumatism.
• The term trench fever is unfortunate
as it disguises the fact that the disease is
dependent upon vermin wherever existent,
and is only related thru war to trench life.
The control of lousiness is the essential fac-
tor in wiping out this unpleasant and un-
necessarv affliction.
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EDITORIAL COMMENT
AlfSRJCAN MBDICIMX
Health Almanacs.— For many years
the Health Almanac has had its place by
the fireside or kitchen side of innumerable
homes thruout the country. Its usual source
has been the establishment purveying reme-
dies to be taken as "blood purifiers," ^'spring
tonics," and panaceas for a large variety
of disorders of specific bodily sys-
tems. Recognizing the publicity value of
such almanacs, organized publicity depart-
ments dealing with matters of health have
sought to take advantage of them in order
to present authoritative facts, hygienic ad-
vice, and general good cheer to the readers
of such publications.
It is one thing to issue a Health Almanac
and another to make it readable. By way
of illustration, one notes the Health Al-
manac for 1919, Public Health Bulletin
Number 98, compiled by R. C. Williams,
and the Almanac of the Louisiana State
Board of Health for 1919. From the stand-
point of value to the average reader the
State of Louisiana has been more success-
ful thaji the United States Public Health
Service. With illustrations that are popular,
type that is easily readable, with subject
matter well adapted to the intelligence and
general psychology of average minds, it ap-
pears to approach more nearly the type
which has had the place of honor for many
years. From the standpoint of variety of
subjects discussed, accuracy of statements,
and wisdom of direction, there is very little
to diflferentiate one from the other. In the
form of presentation, however, the
simplicity of diction of the state publica-
tion, the paragraph arrangement and gen-
eral typography are distinctly more appeal-
ing for widespread use than the one pre-
sented by the United States Public Health
Service.
The value of an almanac as a means of
publicity is not to be denied, but it is ab-
solutely essential that the subject matter
be presented with a full recognition of the
psychology of the reading public to whom
the messages of hygiene are to be delivered.
If one assumes that health officers may be
inspired by the National Health Almanac,
there is an excuse for its present form,
which obviously could not have been in-
tended for common usage. The almanac
of Louisiana, like similar publications that
have been issued by other states, as for ex-
ample, Virginia, affords a more practical
example of how almanacs should be de-
veloped to prove of greater service to health
officials thruout the country.
Public health education is more than
mere publicity. It requires more than the
publication of articles, multigraphs, bulle-
tins, posters, pamphlets and almanacs. The
essence of the education depends upon at-
tractiveness, simplicity of diction, forceful-
ness in illustration, directness of appeal
and an appealing form of publication that
attracts attention, holds the interest, stim-
ulates imagination and invites thoughtful
reactions. The entire success of public health
education depends upon a thoro understand-
ing and appreciation of the educational
levels of communities, their habits of
thought, their psychology and susceptibility
to suggestion, appeal and direction. The
newness of this field of hygienic endeavor
warrants more attention being pikced upon
method. Subject matter is adequate and the
public mind is open to inky arguments,
logically developed and rationally pre-
sented. The two almanacs above referred
to present an interesting study in method,
and both are to be recommended to the at-
tention of all those interested in advancing
public health education.
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AMERICAN Medicine
MEN AND THINGS
May, 1919
251
■M:^
N AND THIN
Science and AlcohoL — It is gratifying
in the extreme to the editors of American
Medicine to find their views on prohibition,
frankly recorded in these columns during
the last few months, so strongly fortified
by the opinions of men as high in the es-
teem of the public and the profession as
Drs. A. A. Brill, Joseph Byrne, L. Pierce
Clark, Smith Ely Jelliffe, C. P. Sherwin,
E. E. Southard and a score of other well
known specialists. At a recent meeting of
the New York Academy of Medicine, a dis-
cussion was arranged by the Section on
Neurology and Psychiatry and the authori-
ties named expressed their frank views on
the dangers that will menace the social
fabric when prohibition comes into effect.
With amazing unanimity, they agreed that
the evils resulting therefrom will far out-
weigh any little good that may come of it.
Whatever the anti-alcohol forces may have
to say about such an opinion (and they
will surely feel constrained to answer such
serious criticism) they cannot attack the
authenticity of the judgment given at this
meeting. It was not a sentimental pronounce-
ment emanating from hysterical reformers,
nor was it a campaign maneuver on the
part of defiant reactionaries. These special-
ists have no axe to grind, they are the serv-
ants of no special interests. They met as
scientists, and as scientists they came to a
cool, unbiased, honest decision. And the de-
cision was against prohibition, on the ground
that it constituted an invitation to substitute
habits which will be much more dangerous
than drink to the common welfare. In ex-
pressing this view, they drew both upon
their experience in the past and their equip-
ment to judge the future. Surely, it would
be hard to find a body of men better fitted
to give an expert opinion on this subject.
What was said at this meeting of the
Academy of Medicine has been repeatedly
stated in these columns, and it is per-
haps of interest to note here that the edi-
torials have been written by men who are
absolute teetotalers or practically so. The
value of these opinions, then, has been
that of the testimony of a disinterested wit-
ness whose sole concern is the unperturbed
pursuit of the truth. Tho it was unhesi-
tatingly admitted that, at the base of the
prohibition movement, there was a fine and
worthy motive, attention was directed to
the fact that the whole movement was pure-
ly a negative one. It was destructive only —
elaborately conceived on its destructive side,
utterly undeveloped and poorly informed on
the constructive side. Alcohol was to be
definitely eliminated, but what was to
take the place of a habit that had taken
such deep root in the life of the average in-
dividual was not stated; or, if stated, was
so scantily referred to as to offer little help.
There was only one speaker at the Academy
meeting who had even a good word for pro-
hibition; and, tho he admitted that "the
reign of King Alcohol had been a disastrous
one," he asserted that his abdication could
be made of benefit to humanity only by
carrying out a most elaborate and costly ^
plan for amusements, recreations, and social
opportunities as an adequate substitute.
Such a plan, admittedly, has not been
worked out by the anti-alcohol forces ; and
prohibition threatens to come upon us be-
fore a substitute has been provided. One
knows from past experience the dangers
that would face the community in such an
event: the increased use of drugs, the ac-
centuation of social unrest, ruinous experi-
ment with new stimulants, and, strangely
enough, even the increase of the consump-
tion of alcohol in the guise of medicinal
preparations.
These dangers have been repeatedly em-
phasized here and they were emphasized,
in almost the self-same language, at the
meeting referred to. In particular, stress
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MEN AND THINGS
American BisDiciNB
was laid upon the danger of social unrest
and the lapse of the individual into various
degrees of neurosis. There are few men in
this country who understand better than
Dr. Smith Ely JelHffe the condition of strain
imposed on modern humans by the highly
artificial and trying standards which our
so-called civilized form of life demands. Dr.
Jelliffe made it clear that drink was more
of a blessing than a curse, in that it stayed
the evil effects that such trying conditions
might induce and soothed into quiescence
more vicious and more dangerously anti-
social reactions. Drinking might be a great
evil, but the evils it prevented were far
worse. Likewise, Dr. A. A. Brill pointed
out that drunkards were men and women
predisposed by inheritance or acquirement
to crime and vicious practices and that al-
cohol saves them from following the more
violent bent of their natures. Without drink,
these people would inevitably yield to temp-
tations of a more menacing type. Inciden-
tally, he brought out the fact that in his
practice men and women who had abused
the use of alcohol and were deprived of it
often acquired other excesses — notably that
of over-eating. The "food jag" took the
place of the "alcohol jag" — ^a type of excess
which, in its individual aspect, is not less
harmful than the excess it displaced.
These facts were not brought out at the
Academy meeting because of any prejudiced
hostility to the prohibition movement, and
they are not repeated here with a view to
cast discredit on the motives of its leaders.
These are admittedly of the very humanest.
But, at the same time, one must call atten-
* tion to the short-sighted philosophy of those
who permit the promise of vague benefits to
blind them to the hazards of the future
threat. And that this threat is a grave one,
few will doubt. It is as tho drugs having
done a considerable amount of mischief, a
movement were set afoot to abolish entirely
the use of drugs. It is easy to perceive the
absurdity of such an attempt. Drugs serve
a very useful and very necessary purpose,
and tho there is at the present moment be-
ing conducted a campaign against drugs, it
is directed entirely (and wisely) against
those narcotics which bring harm without
any commensurate good. It is hard to un-
derstand why the prohibition movement has
not taken this form — attacking the vicious
use of alcohol and preserving its harmless
employment. Such a plan would arouse lit-
tle hostility. It would find friends among
all classes. An indication of how even the
sanest leaders of society feel is offered by
President Wilson's wise suggestion that
beer and light wines be retained. Whether
Congress will see fit to act on his sugges-
tion, it is too early to say; but it is safe
to assert that President Wilson, in making
his recommendation, was well aware of the
preference of the vast majority of citizens.
The prohibition forces, aroused by this step,
are preparing to fight the issue with all
the influence they command. One can only
regret the stubbornness and lack of vision
which their persistence shows.
Savinflr the Saloon* — The revived Salva-
tion Army, with a brilliant record of war
service such as no other organization can
boast and held in the highest esteem by
every man with a gold stripe on his left
arm, is planning to plant itself even more
securely in the hearts of its friends. No
longer regarded by the public as an organ-
ization meriting sympathy rather than ad-
miration and, confident of its mission to
bring happiness to the multitude, a mission
to which Its war record has given a power-
ful impetus, the Salvation Army is dis-
posed to take over the abandoned saloons
when prohibition comes into force and save
them from passing into history. This organ-
ization, having proved its humaneness, now
demonstrates its wisdom. It is easy to
shock the corrupt. It is much more difficult
to shock the virtuous. The Salvation Army,
as well aware as any one of the evils of the
saloon, is not shocked to such an extent that
it does not realize what an important insti-
tution it has become and what a vital role
it has played in satisfying the instinct for
companionship, recreation and diversion
sought by the hard worker after the day's
toil. The saloon is a drinking place, but it
is at the same time a clubroom, a social
circle, a man's refuge from dull care, a place
where he can find relief and solace when he
is most in need of them. To innumerable
men to whom drink is not an absolute neces-
sity, the saloon, because of the attractions
it offers, has become an indispensable rally-
ing-place. It has assumed sentimental asso-
ciations. The bar, the brass rail, the sticky
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wooden tables have become familiar objects.
It is a club where no dues are required,
where every man meets his neighbor, what-
ever his station, on a footing of equality.
It is a symbol of social democracy. The
Salvation Army, recognizing this and aware
that its disappearance will leave a void in
the spirit of many men, is planning to take
over the idle saloon, bar, brass rail, and all
the trappings that have made the saloon such
a familiar and restful place and run it on
exactly the same lines that it has been run
before. Instead of liquor, soft drinks and
refreshments will be served. Otherwise,
nothing will be altered.
The appeal of the Salvation Army has
always been to the large masses. They have
understood them well. And, in deciding to
take over the saloon and retain its physical
aspects, it demonstrates anew that it is
familiar with the psychology of the type
which frequents saloons. The man who has
been in the habit of taking his cocktail or
his beer before a bar, with his foot ex-
travagantly poised on a glittering rail, will
hardly find much attraction in an uncon-
genial soft drink establishment where these
luxuries are lacking. The difference is too
c^reat. But he will, out of sheer habit, be
drawn to the old haunt, unaltered as it is
and offering the opportunities of companion-
ship and sociability, even tho the stuff that
is passed across the bar is not as strong as
it used to be. After all, he went there as
much for the amiable atmosphere as for
the liquor, and it is for the amiable atmos-
phere that he will return. And in time he
will learn to quaff his soft drink with a
measure of satisfaction. Certainly, the Sal-
vation Army plan offers an easy transition
to a state of affairs that will for a long
time be very trying. There is a type of man
who simply will not go directly home after
his day's work. If he cannot go to a saloon,
he will go to the next best place — which is
probably the next worse place. But, with
the environment of the saloon unchanged,
he will have one good reason less for going
to the worse place. It will help reduce the
capacity for mischief which a dry r^ime
at first generally encourages. It will di-
minish the hardship which otherwise might
drive the man deprived of the stimulant he
has become so dependent upon to more
vicious practices. There is no doubt that,
once prohibition is in force, numerous
greedy agencies will crop up everywhere
to attract the former drinking man; and
these agencies will not be of the most con-
scientious type. The unimaginative plan to
establish social centers will not meet this
danger adequately. The saloon alone will
be able to compete with any chance of suc-
cess, and that it will do so in the hands
of the Salvation Army is as certain as such
things can be. The prestige of the Salva-
tion Army has been enormously increased
in the last few years. They have shown the
world that they are not bigoted, that they
have infinite patience with habits of which
they themselves are free, that they are not
indignant censors but helpful companions;
and they will invite patronage where other
organizations would invite only suspicion
and timidity. They have the best wishes
of their numerous friends for the success
of their enterprise.
*Thc Vener^l PcriL''— Recently there
appeared in the morning papers of New
York City an advertisement, jointly pub-
lished thru the United States Public Health
Service and the New York City Depart-
ment of Health, which must have astounded
every reader and gratified every intelligent
person. This advertisement marks an epoch
in the altered attitude of officials to a com-
munity menace which it has in the past al-
ways approached timidly — ^the menace of
venereal disease. At last the issue is faced
squarely and frankly. A spade is called a
spade. No longer are the highly sensitive
feelings of the Puritanical spinster lady con-
sidered. The authorities, at last convinced
that vigorous measures have become neces-
sary, have rolled up their sleeves and un-
dauntedly taken up the fight. In the ad-
vertisement mentioned they go straight at
the issue. There is no meticulous and shy
reference to vague **social disease.*' There
is no effort to spare the prudes. The open-
ing phrases are worth recording as an
achievement in frankness which is welcome
tho belated:
"Conditions existing in many cities make
it necessary to resort to heroic measures to
check the spread of certain dangerous dis-
eases. Thru ignorance many persons, inno-
cently and accidentally, are exposed to a
peril which spares neither infant nor adult.
That peril is the venereal peril.
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*The exigencies of .war forced this gov-
ernment to face the problems frankly and
courageously, and, as a result, the venereal
rate in the American Army was lower than
in any army in the history of the world.
Yet, from the time America entered the
war, April, 1917, to September, 1918,
2,295,000 days^ of service were lost to the
American Army thru venereal disease,
. ... In New York State alone at least
270,000 men who registered in the first
draft and were not called were suffering
from venereal disease." The announcement
paints a rapid and vigorous picture of the
serious situation, adding: "The conditions
indicate that the vitality of the nation is
imperiled." And it concludes, with com-
mendable frankness: "The way to protect
them is to look the evil squarely in the face
and to attack it openly."
The purpose and the wording of the an-
nouncement are admirable. There is noth-
ing new stated, but the public appeal thru
the medium of the press is something dis-
tinctly new in American methods. It is
hard to exaggerate the gratification felt in
authoritative circles by the measures taken
at last to trv to wipe out or at least check
the venereal peril. It has always been an
Anglo-Saxon trait to wink at conditions,
however serious, if they seemed to involve
an indelicate admission of knowledge of
their existence. Tho it was well known that
venereal disease was as prevalent in this
country as it was abroad, it was always
hard to persuade the authorities to acknowl-
edge the situation frankly and take steps
toward the alleviation of this condition. To
the Anglo-Saxon mind, with its Puritanical
tradition, such steps would seem too much
like an acknowledgment of depravity, and
the penalty has been an increase in the
spread of the disease — particularly among
the innocent and uninformed. It is small
wonder that foreigners, visiting in this
country and witnessing our inactivity, left
with the impression that we were a nation
of hypocrites and prudes. Our whole atti-
tude toward social disease in the past has
been an evasion. In our effort to avoid the
issue, we were inclined to assume, or let it
be assumed, that the evils did not exist.
Prostitution? We shrugged our shoulders
and disclaimed any knowledge of that vice.
Venereal disease? Why, we were admit-
tedly a vigorous and healthy race. And
meanwhile the evils continued and spread.
To acknowledge their existence, seemed to
involve an admission of moral inferiority
which we were loath to yield. In spite of
the strenuous efforts of the finest scientific
minds, we persisted in this attitude. But
now it would appear that the authorities
have at last undergone a change of heart.
Unyielding before the persuasion of con-
scientious experts, they have succumbed to
the menace of multiplied danger. They
have decided to take the bull by the horns
and fight the issue to a bold conclusion. In
the announcement quoted, an intelligent
program is promised; first, the enlighten-
ment of the public as to the seriousness of
venereal infections ; second, immediate
measures to provide prompt and effective
treatment for those afflicted. Clinics have
been established all over the city, and the
addresses of these have been published in
the papers. This enlightened policy should
go far toward correcting the error of silence
and neglect which has been such a blemish
on the record of our health departments in
the past. We congratulate the authorities
on their courage and vision.
Wombless Motherhood. — ^The day of
Homunculus is perhaps near at hand, and
Faust's fanciful effort to produce a man
chemically in a test tube may not be as im-
possible an adventure as it appears. The
trend of man-made evolution has been in
that direction in the last few decades. What
with horseless carriages, motherless chick-
ens and seedless fruit, the conventional
routine of nature has been defeated by
science, and it would seem that we are on
the threshold of an era when mothers will
be dispensed with in the involved process
of propagation. Motherless infants! That
is the next step. At any rate, it is an easy
advance to motherless infants from an
amazing phenomenon which Dr. William F.
Grigg, of Richmond, Va., reports. This re-
port, which Dr. Grigg read before the Rich-
mond Academy of Medicine and Surgery,
is so curious and melodramatic that it is
reproduced without any change:
"Case No. 105. Female, referred to me
September, 1917, with a history of bleeding
between her periods. On examination, I
found an enlarged boggy uterus with pos-
sible uterine fibroid and advised operation,
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which was done September 21, 1917.
Operation consisted of a median incision
thru which the uterus and both tubes were
removed. Multiple fibroids of small size
were found in body of uterus. All the
cervix and both ovaries (which were in
good condition) were left in place. The
patient made an uneventful recovery and
was out of the hospital in thirteen days. I
kept her under observation for six months,
after which time I lost sight of her until
about February 20, 1919, when I met her
in the market and she told me she had had
a baby born to her December 30, 1918. I
told her it was impossible and went to her
home the next day to see her baby. She
swore it was her child.. I then went to see
the midwife, who said the case was as
nearly a normal delivery as she had ever
seen. I then told her that the mother had
no womb. She said she did not know
about that, but one thing she did know and
that' was that she delivered her of the child
and was with her all during her labor."
Dr. Grigg's amazement at this phenom-
enon is quite natural. Amazement is the
first step in discovery, which is presently
followed by study and terminates in inven-
tion. The modem locomotive began with
amazement that the lid of a steaming kettle
should be lifted by an unseen hand when
the water reaches a certain temperature.
The law of gravity was discovered with
amazement that an apple should fall to the
ground from a tree. We do not doubt that
Dr. Grigg's amazement will be capitalized
in the near future, not by himself perhaps,
for he may be too wary and timid a scientist,
but by bolder experimenters. And it may
come about that nature will be found to be
as wasteful and involved as she usually is
even in the matter of propagation; that
parenthood is an unnecessary and super-
fluous accompaniment of birth; or at least
that one parent, the female, can be easily
dispensed with. Such a discovery would
be in contradiction of all our conventional
beliefs, but then discovery is always a con-
tradiction of some old-fashioned notion.
Timid philosophers have believed that both
parents are essential to propagation, and
even the most radical insisted that at least
the mother was indispensable. Soon it may
be a commonplace event, however, to pro-
duce vigorous, normal infants with an utter
disregard of the parents. The future holds
forth a brilliant promise. What a simple
thing child-bearing will become. There
will be little danger of race suicide when a
honeymooning couple in Europe, suddenly
possessed of the desire for a child, can satis-
fy their wish by cabling home specifications
of the sort of infant they want and will
find that infant awaiting them on their re-
tum. There is only one drawback to such
a delightful innovation — it will ruin one of
the oldest and most estimable jokes in the
language. What is to become of the ever-
amusing quip about being bom in the ab-
sence of one's mother? It will have no
meaning in the new era, for being bom in
the absence of one's mother will be an
every-day event. But progress is always
purchased at a heavy price, and one must
resign one's self philosophically to th^ sad
deprivation of a time-honored and beloved
joke !
In seeking to control nlurcotic drag
addiction, the treatment of the afflicted
individual is the most important problem
confronting the medical profession, and
few who realize the lack of knowledge of
the average practitioner concerning the na-
ture of this disease will deny that this phase
of the question should logically and as a
matter of common humanity, be given
precedence over restrictive measures.
It would seem that the Federal govern-
ment, which is responsible for the laws that
are designed to prevent the continuance of
drug addiction, should long before this have
recognized its responsibility and obligation
to take steps for the establishment and
maintenance (1) of institutions in which
those suffering from drug addiction may be
treated thru the withdrawal period, and (2)
of suitable places for the upbuilding
process which in the majority of cases is
so urgently required after the drug has been
completely withdrawn, to fit the patient to
meet the conditions of every-day life. From
the knowledge at present available there are
excellent grounds for believing that there is
a certain proportion of cases in which, thru
the presence of some physiologic deficiency,
or psychologic defect, a permanent cure is
extremely difficult if not impossible. These
patients may, of course, be permanently de-
prived of narcotics, but such deprivation
renders them unable to meet the competitive
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conditions of life and throws them into the
class of the unfit or dependable. Some suit-
able provision should be made for the study
of these cases, particularly today when every
worker is needed as never before. The large
number of cases of drug addiction that will
be brought to light by the enforcement of
prohibition, will also call for special atten-
tion. As we have said, it is a miatter of deep
regret that the humanitarian, medical and
economic obligations due to drug addicts
were not recognized long ago, but it is not
now too late, and we sincerely hope that
some action may be taken during the pres-
ent session of Congress to fulfil the govern-
ment's plain duty to these unfortunate per-
sons and to the communities in which they
will be obliged to live. In the meantime
these communities should also do their part.
It is particularly appropriate that a city like
New York, whose Health Commissioner has
been so vigorous in his efforts to have some
constructive measure adopted, should be at
least as willing to provide means for cure
as to provide legislation to make cure com-
pulsory. In so far as Dr. Copeland's efforts
have been directed to the obtaining of funds
and facilities for the hospital treatment and
after-care of drug addicts, he has our hearty
support, and we wish him the fullest meas-
ure of success. We hope his success in this
direction will be so prompt and substantial
that it will make quite unnecessary certain
of the other plans he has been quoted as in-
tending to put into effect.
In our April issue we referred to the
necessity for a better scientific understand-
ing of the phenomena of drug addiction, as
a basis for more comprehensive and effect-
ive methods of treatment. Those who have
studied the subject realize the many un-
solved medical problems which it presents,
and which can only be cleared up satisfac-
torily by laboratory experimentation and
scientific clinical study. Dr. Du Mez's
paper, to which we referred, was very
timely in its exposition of these problems,
and of the diversity of results in the experi-
mental work that has already been done. In
reading his paper, which was a comprehen-
sive review of the laboratory work done
to date, one is struck by the fact that al-
most all of it, with one or two important
exceptions, was done abroad. In view of
the fact that the recent report of the Rainey
Committee, appointed by the Secretary of
the Treasury to gather data on drug addic-
tion, showed the drug habit to be more
prevalent in this country than in any other,
it is certainly an anomaly that there has
been no scientific work done t^y any labora-
tory or institution in America on the action
and effects of habit-forming drugs.
It would seem to be clearly in or-
der, at this time, for the Public Health
Service, which has a well equipped labora-
tory, to take this up and carry it thru in
a manner which will enable it to obtain
authoritative results upon the various dis-
puted points, and thus lay the foundation
for lines of treatment which will give the
medical profession new confidence in coping
with the conditions presented by narcotic
drug addiction. No doubt this work will re-
quire funds, but this, also, is an obligation
that ought to be recognized by Congress,
and it is not irrelevant to point out that the
present time offers an excellent opportunity
for America to acquire the scientific
prestige and authority which, in the Held
of biologic and medical research, has here-
tofore been in too large degree conceded to
Germany.
The medical profession in particular has
a very definite duty, as we have before
pointed out, to do all in its power to en-
courage such research work, and at the
same time to give the clinical aspects of
the problem more painstaking study and in-
vestigation. To continue to ignore these
increasingly insistent obligations will sure-
ly not only reflect seriously on both the
scientific interest and humanitarian spirit
of the profession, but for the first and only
time in its history will lay it open to the
indictment of remaining indifferent to hu-
man suffering and distress.
Announcement. — Owing to unavoidable
conditions and the delays occasioned in the
transmission thru the mails of material,
proofs, etc., especially from overseas, it has
been decided to make our June issue the
Special War Number rather than May, as
originally announced. The plans for this
Special War Number of American Medi-
cine, aside from unavoidable delays, have
worked out more satisfactorily even than
expected and this forthcoming memorial
issue promises to be a notable contribution
to the literature of the World War. It will
be one of the most remarkable numbers
American Medicine or any other medical
journal has ever brought out.
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ORIGINAL ARTICLES.
May, 1919
257
ORIGINAL
RTI C LE S *^^
THE PSYCHOLOGY OF THE UNCON-
SCIOUS AND MODERN DREAM-
INTERPRETATION.
BY
B. S. TALMEY, M.
New York City.
D.,
'^Est modus in rebus, sunt certi dcnique
fines J*
"Quos ultra citraque nequit consistere rec-
tum!'
"There is a mean in things, there are cer-
tain boundaries, on either side of
which moral rectitude cannot exist."^
— Horace, Satires I, 1, 106.
Exaggeration is not seldom the curse of
the greatest discoveries. It exposes the
siiblimest to ridicule and banishes great
values to the realms of oblivion. The new
psychology of the unconscious is in great
danger to reap the harvest of lack of appre-
ciation thru the exaggeration of its very
votaries.
The first great impetus to the study of
this psychology was given thru the publica-
tion of an essay, "Studies in Hysteria," by
Breuer and Freud in 1895. The authors had
the occasion to study the etiology and symp-
tomatology of hysterical patients. In their
^ In this article the writer wishes to show
nothing more than that while the modern
psychology of the unconscious has been a great
gain to the study of psychology in general, the
doctrine of infantile sexuality and the sexuality
in dream-interpretation is an un proven theory,
contrary to all human experience.
studies they found that hysterical symptoms
depend largely upon impressive but forgot-
ten scenes in the life of the patient. Every
symptom has its origin in a psychic trauma
which acts like a foreign body in conscious-
ness, the trauma being effected thru the re-
pression of eventful concepts beyond the
limit of memory. Such concepts^ are no
longer subject to the laws of reason, judg-
ment or will. Still they give rise to certain
emotions, since emotions are not subject to
conscious reasoning or to will power.
The new doctrine of the origin of the
hysterical symptoms led to the introduction
of six new conceptions in the study of
psychology.
I. The first role is played by the basic
etfent. A certain event in the life of the in-
dividual gives rise to aflfects out of har-
mony with the ethical, moral, religious, so-
cial or educational ideas of this person.
II. These eflfects cause a conflict in the
psyche of the individual, a conflict between
his anti-social impulses and ethical restraint.
III. If an immediate abreaction or dis-
charge by conversion is not eflFected, if the
aflfects have pot found an adequate release,
if the emotional tone has not found a prop-
er outlet by being converted, e, g., into cry-
^ A concept is a mental picture of a sensation;
memory is the faculty of recalling concepts;
reason is the power to recognize the source of
concepts; Judgment is the power to arrange
concepts for definite ends; will is the power to
select and regulate concepts; and emotion is the
condition when marked concepts overcome the
power of will.
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ing, scolding, rage or punishment of the
offender, if the emotionally accentuated af-
fect has not been worked off — then a strang-
ulation of the emotion takes place. The af-
fective toned event is automatically or vo-
litionally put beyond the limit of memory.
The conflict causes a certain repression. All
painful events, unfulfilled wishes, remorses,
cares or all emotions which come in con-
flict with cultural qualities and cause psychic
pain, are placed in the secret recesses of
the mind or are expelled from consciousness.
Any event incompatible with conscious-
ness is rendered innocuous by repression.
The disagreeable, or that which is harmful
to the individual or to the race, is avoided ;
the agreeable, which is helpful to the in-
dividual or to the race, is sought for. Con-
sciousness admits the affects of beneficent
ideas and inhibits the entrance of harmful
conceptions. When a pathogenic idea of a
painful nature is incompatible with the ego
a repression takes place. A certain psychic
force opposes the pathogenic idea from be-
coming conscious.
Every conflict between conscience and de-
sire being the cause of psychic pain is re-
pressed, in this way guarding the mind
against inimical influences. All ideas, tenden-
cies, inclinations, fears and disappointments
that bring mental reactions leading to con-
flicts are repressed. All highly emotional
events which did not find an immediate re-
lease, an abreaction, or catharsis, at the
time of the occurrence, by action or speech
are repressed.
IV. The repressed idea is crowded out
from consciousness and placed below the-
zone of conscious thought where mental and
nervous activities or subliminal processes are
shut off from the observation of the ego.^
The repressed affects form a nucleus for an
entire constellation of ideas in the subcon-
sciousness. One fixed idea associates itself
with another idea until a group of ideas is
formed, an idea-system, or complex. Every
idea with its emotions removed from aware-
ness forms a complex. The complex desig-
nates a group of ideas centered or constel-
lated about a central event which had a
large content of painful, emotional color-
ing. The isolated idea of the event which
conditioned the painful emotional state
forms the point of crystallization around
which all other corresponding ideas gather
and cluster. The complex is thus a system of
connected ideas all having a strong emo-
tional tone.
The complex is a quasi-parasite of the
psyche, the associative connection between
it and the rest of the psyche being disturbed.
The complex being dissociated falls out of
association with the other facts of mental
life, and a reaction amnesia is produced.
The volitional memory being withdrawn,
the amnesia makes it impossible for the
piled up emotions to be discharged. The
idea can only be recalled in the abnormal
states of consciousness, such as in the hyp-
noid or somnolent condition.
' It has always been known among psychol-
ogists that man possesses two personalities,
conscious and unconscious; that the mind con-
sists of two selves, the subliminal that never
sleeps and never forgets and the supraliminal
self that does. Metabolism, digestion, circulation,
secretion and excretion are not controlled by
the conscious ego; these functions dwell out-
side the field of awareness. The autonomic sys-
tems of the vagus and the sympathetic nerves
have their centers in the subliminal psyche and
their seats outside of the realm of conscious-
ness. The coordination of the bodily functions,
such as the relaxation of the extensors at the
moment of the contraction of the flexors in
the act of walking, or the relaxation of the
sphincter at the instant of the contraction of
the detrusor in emptying of rectum and 'blad-
der, lies below the threshold of consciousness
as long as the balance is well regulated in the
healthy organism. What the Freudian school
has added is the doctrine that subconscious-
ness is responsible for many a character trait
of a person. This addition will remain of last-
ing importance for the discipline of psychology.
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V. The accumulated energy finds no
channels of^exit. The unrequited affects
being ready to come to light, the complex
has the tendency to produce actions of a
certain character. Especially dynamogenic
are complexes with a large emotional con-
tent. They will not stay repressed because
of their dynamic potency. When sufficient
energy has been accumulated to overcome
resistance, they begin to flash a series of
neurograms, and certain reminiscences ap-
pear which must find expression somehow.
Especially in the neurotic the repression is
not always complete, and the affect has to
be expressed in some other way. The pain-
ful experience, e. g., an attempt of rape, is
forgotten but a symbolical reminiscence is
retained. These emotional ideas are con-
stantly seeking a reentry into consciousness.
VI. These irradiations from the psychic
complex give rise to a certain restlessness
of the individual, and he finds a defense in
the conversion or substitution of the rem-
iniscent energy or psychic impulse into hys-
teria, compulsion neurosis, or obsessions.
The hysterical attack is thus equivalent to
an emotional discharge. The impulse spends
itself in the attack.
The psychic determination of the symp-
tom is the intentional repression from con-
sciousness of an idea of a painful nature.
A certain psychic force strives hard to
crowd it out of the mind — to eliminate it
from consciousness. The idea or the verbal
element is then repressed but the emotion
is free to associate itself with any appro-
priate substitute idea. The individual hence
invents certain defense-reactions against
these reminiscences.
The defenses are compensatory in char-
acter. In everyday life, to forget trials,
tribulations, blasted hopes and disappoint-
ments the individual plunges into a strenu-
ous life of business, into the service of re-
ligion, into social service. Sometimes the in-
dividual embraces a fad, or he takes to
drugs, alcohol or opium. Others find their
wishfulfilments in dreams, reveries, deliria,
phantasies and hopes. Other defense reac-
tions consist in moods or character-traits
which find expression in witticisms, jokes,
puns, cynicism, nagging, faultfinding, scold-
ing and scandal-mongering. These are all
means of side-tracking painful reminis-
cences.
One of the most important defense reac-
tions is the hysterical conversion. The
energy quantity of the affective-toned idea
within the complex is converted into a mo-
tor or sensory innervation which is some-
what related to the trauniatic event,* as the
following case may illustrate.
Miss S., 26 vears of age, when nine years
old, had a girl friend with whom she slept
in one bed and who practiced masturbation
on her, but she never herself repeated the
practice. She began to menstruate when 14
years old. From this time until four years
ago she enjoyed being occasionally caressed
by boys, and altho very passionate, she
never found anything abnormal in her be-
havior. Four years ago she got engaged and
in her sensual excitement she allowed her
lover to try intercourse, but he never suc-
ceeded entrance. As soon as he came near
the vaginal orifice, she immediately got a
severe pain in the sphincter cunni, the ab-
dominal muscles contracted and became
rigid and painful, the pains radiating to the
legs as far down as the knee. The cramps
in the uterus resembled the pains at men-
struation. With the moment of the onset of
the attack she became frigid and refused
to allow any farther attempts of intercourse.
These attacks repeated every time such at-
tempts were made. For this reason she broke
off her engagement.
*In an article "Vicarious Vaginismus" (Am.
Med., December, 1916, p. 834) the writer de-
scribed a case of vicarious vaginism where the
convulsions formed the defense reaction against
conjugal Incompatibility.
In the present case fear of the pain at de-
floration is the basis for the defense reaction.
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At present she is engaged to another man.
But nowadays the same attacks take place
when she becomes passionate by ordinary
caresses, such as kissing or hugging. She is
therefore afraid to get married and is look-
ing for medical advice.
The gynecologic examination revealed
some ecchymoses at the vaginal orifice and
a hard prolapsed left ovary. During this ex-
amination she had no attacks, as usually
found in genuine vaginism.
The anamnestic inquiry elicited the con-
fession that her girl friends have painted
to her the pains at defloration in the black-
est colors. The original attacks at the at-
tempted coitions were hence the defense
reaction against the realization of the at-
tempts. At present the defense reaction is
directed already against simple caresses
which may lead to an attempt. During the
gynecologic examination when such a fear
was absent, even the stretching of the
sphincter cunni with two fingers did not
elicit any convulsions.
The hysterical symptom represents a cer-
tain process of conversion of affects. The
struggle between the wish to forget and the
striving of the idea to come to the surface
results in a compromise. The transmutation
of the affects in the motor realm is mani-
fested in hysterical paralytic conditions or
in convulsions. In the mental realm such
transmutation creates the anxiety-neurosis
and is expressed in irritability, conscience-
fear, in being suddenly startled, vertigo, in
ravenous hunger, diarrhea, panting respira-
tion, sudden perspiration, palpitation of the
heart and so forth. The neurotic anxiety
corresponds to a force diverted from its
destined unused up goal, it corresponds to
the undischarged sum of excitement. The
hysterical symptom represents thus the ex-
pression of a wish fulfilment. The emotional
tone of the conflict, the intensity of the feel-
ing-tone, determines the nature and inten-
sity of the symptom. Where the conversion
or the transference of the affects upon in-
different conceptions is impossible, the idea
is dislocated into an obsession.
The discovery that the sources of the
hysterical symptom are the psychic over-
tones, emanating from repressed emotions,
that the neuroses are based upon certain
affective-toned events in the life of the pa-
tient, that these affections represent the dis-
placement of the affective energies not im-
mediately discharged at the time of the
event^ led to a new mode of treatment con-
sisting in a later discharge of these emo-
.tions. It was found that in many of these
affections, if a free outlet is given to the
symbolical reminiscence by the aid of the
physician, if the experience, long forgotten,
is reproduced in a hypnotic or somnolent
state of consciousness, the symptoms not
seldom disappear. Upon this phenomenon
rests the so-called cathartic treatment. The
event is recalled to memory and a late dis-
charge of the affects is effected. The abre-
action consists in working off something
by living thru it again. It is a catharsis thru
speech.
The doctrine of the neurotic symptom be-
ing produced by the antagonism of incom-
patible emotional trends, this principle of
the dissociation of consciousness which led
to a new mode of treatment by catharsis be-
came at the same time the starting point of
the new psychology of the unconscious
based upon the above described six cardinal
points: (1) the affective-toned event, (2)
the conflict, (3) the repression, (4) the
complex, (5) the reminiscence, (6) the de-
fense reaction by the substitution or trans-
ference of the original affects of painful
experiences upon other less disagreeable
actions.
^ Such an immediate discharge would be the
destruction of innocent objects in rage, the
harming of the messenger of bad news, or the
killing of the offender in a case of rape.
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With the aid of this branch of psychology
many a fad^ or exaggerated tendency
hitherto unexplainable is now amenable to
interpretation. Every emotionally accentu-
ated idea or activity is the emanation of a
complex, the emotion of which is ambiv-
alent. Repressed love is thus not seldom re-
placed by manifest exaggerated hatred and
and repressed hatred by manifest exagger-
ated love. Repressed desire is replaced by
manifest aversion. An intense repugnance is
converted into extreme solicitude. It is the
attempt on the individual's part to guard
himself against the repressed affect and to
rehabilitate himself in his own self-esteem.
In this way there may not seldom exist a
wish to love and at the same time to destroy
a person. A piece of art* may thus be only
a compromise by which the artist liberates
himself from the reminiscence of his com-
plex, the artistic creation representing the
compromise.
The psychology of the unconscious would
no doubt have been accepted by the majority
of psychologists and would have changed
the entire conception of psychology in gen-
eral but for the preposterous proposition
»In an article "The Psychology of the Fad-
dist" (N. Y. Med. Jour., Oct. 7. 1917), the writer
tried to trace to their respective complexes a
few conspicuous fads, such as the obscenity
complex of the purist, the prostitution complex
of the morality hunter, the clinging complex
of the feminist, the drink complex of the pro-
hibitionist, the cruelty complex of the anti-
ylTisectionist, the Shylock complex of the anti-
semite, the individualistic complex of the so-
cialist, the oppression complex of the anarchist
or Bolshevist, the sadistic complex of the phil-
anthropist Even some vocations could be traced
to complexes, e. g., the criminality complex of
the criminalistic Jurist
' The artist is usually a person who Is not In
sympathy with the world of reality, which de-
mands that hedonic desires should often >b^ re-
nounced. Art is then the substitute of an
equivalent pleasure to an esthetic sort. The
pleasure-urge is thus diverted from the purely
physical and furnishes the motive power for
artistic production. The tragic incompleteness
of the artist's life thus becomes the spring of
art in literature, painting, sculpture and archi-
tecture.
that the sex instinct in its various disguises
is the only dynamic force at the basis of
subconsciousness. As the outgrow of the
Freudian doctrine, appeared the dogma of
infantile sexuality which has become the
pivot around which the pansexualistic
psychology is turning. A school grew up
around the Freudian theories which exposes
the entire discipline to ridicule thru the ex-
aggerated emphasis of infantile sexuality
and the queer interpretation of dreams on
the exclusive basis of sex.
The doctrine of the pent up sexual
energy being the source of all human ac-
tivity and endeavor is entirely out of har-
mony with the moral, ethical and logical
conception not only of the man of the street
but also of the scientist. The conclusion that,
because the complexes of hysterics may
often be traced back to sexually toned events
of childhood, every child is polymorphous-
perverse is neither logical nor scien-
tific. Because some hysterical attacks rep-
resent the equivalent of orgastic gratifica-
tion does not prove that every normal or
even abnormal phenomenon of life should
be traced back to sexuality and that sex in
the generic pervades all manifestations of
life. Because infantile sexual memories have
been found in hysteria and anxiety-neurosis
of the adult does not prove that every
habit and behavior must be retraced to
infantile sex life, that all pleasurable feel-
ings, bodily or psychical, all emotion or
affection, intrafamilial or extrafamilial
must be classified as sexual, that the play
instinct of child and adult, the desire for
knowledge, the impulse for investigation
should all be attributed to sexuality in the
usual gross sense.^
The fantastical extravagant doctrine of
'This is what the pansexualist could mean
when he speaks of infantile incest, infantile
homosexuality, exhibitionism, mixoscopy, sad-
ism, masochism, etc.
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infantile sexuality starts from the propo-
sition that every new-born infant brings
along sexual inclination, that every infant
is composed of nothing but sex. This is
surely not a self-evident proposition and
requires to be proven; yet no adequate
proof is brought forth. The pansexualist de-
mands that this proposition should be taken
for granted. For him it is an axiomatic
truth that must not be doubted, but since
this dogma runs counter to all experiences
of mankind, we are told that by infantile
sexuality the Vienna school understands
infantile libido or infantile pleasure goal.
But if infantile libido is something dif-
ferent from adult sexuality it should not be
called by the same name.
We cannot employ the same term for
two entirely different conceptions. A libido
embracing all positive strivings such as de-
*The term "libido" is often used indiscrim-
inately even by non-Freudians for two different
conceptions, for the sex-urge, or the desire for
union, and for the material pleasure, experi-
enced at the moment of the gratification of the
desire. Still the former is an impulse and the
latter an affective experience. The pleasure
which is synchronous with an act has nothing
to do with the will to act. No sensible man
would ever think of calling "hunger" for food
and the pleasure derived while eating by one
and the same term. Still just this is done when
sex-ardor and orgastic delight are called by one
and the same term libido. The writer always
calls the sex desire "voluptas" and reserves the
term "libido" to designate the orgastic experi-
ence. Voluptas is an impulse, libido an experi-
ence, an agreeable excitation of the nerves, an
enjoyable sensation, a self-feeling, not compar-
able with emotional pleasure, experienced, e. g.,
in the anticipation of a show, dance, or ban-
quet, or the Joy of a parent derived from the
success of a child, or the delight at the con-
templation of a beautiful landscape, or the
felicity attached to achievement. Orgastic
libido is a state of the body 8ui generis, an
ecstacy, rapture, or bliss unique in its content.
It is not to be compared with the negative lust-
feelings felt at the removal of pain, such as
the removal of hunger by eating; of the pres-
sure of bladder by micturition; of pressure of
rectum by defecation; of the itching of the skin
by scratching. Because of the uniqueness of the
positive sexual lust-feeling the early sexologists
had to look for a new term for this feeling, and
they called the reflex-condition or the state of
the body during ejaculation by the term or-
sire for food, defecation, micturition and so
forth, is a misnomer, it is not sexual libido.
All kinds of sensuous pleasure and desires
cannot be designated by the same term —
libido. The first sexologists used the term
libido to designate orgastic pleasure, hence it
ought to be reserved for this exclusive use.
In common speech such an equivocal mode
of expression would bring confusion, and
it was bound to bring confusion in
psychology*. The use of equivocal terms
for the purpose of supporting some precon-
ceived system does not become the honest
scientist. By adult sexuality is commonly
meant the gross sexual act with all its pre-
liminaries and associated activities which
lead to it or follow the same. Such a sex-
uality does not exist in the normal child.
Normal infants and non-seduced children
up to the age of 8 to 12 have no conception
gasm, while to the experience, or to the con-
scious condition they gave the name libido. To
call the desire for this experience also iby the
term libido is to bring confusion into the study
of sexuality. The desire for a positive lust-feel-
ing and the feeling itself are not one and the
same thing. If this proposition needed any fur-
ther proof at all, pathology proves it to con-
clusion. In some patients the sex-urge or the
potency of voluptas is greatly enhanced; they
get excited by every petticoat; still union is
accomplished with scarcely a trace of pleasure.
They are impotent of libido. In other patients,
the so-called woman haters, the sex-urge is on
the zero-point; yet when they happen to have
intercourse they experience normal pleasure,
the potency of libido is intact. Still a good
many sexologists continue to use the same term
libido interchangeably for the experience and
the desire. Now coine the Freudians and com-
plicate matters still farther by calling not only
sex desire but all other desires, such as the de-
sire of food, for defecation, micturition, or
for scratching by the same term libido. Then
after having borrowed a sex term for non-sex-
ual desires, they turn around and call all these
desires sexual. They constantly speak of lip,
anal, urethral or skin erotism. Thus one sin
brings in its train another sin, as Ben AJaj
used to say (Aboth IV. 2). To give to this ar-
bitrary play with terms a metaphysical cover-
let, this school regards the multiplicity of in-
stincts as issuing from a relative unity, the
primal libido. Since the most intelligible ar-
ticulation of this primal libido is sex attraction,
the pansexualist attributes all desires to this
sex attraction.
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of the sexual act. Every thinking parent is
enough of a psychologist to observe his or
her own child and he finds that his child
is not polymorphous-perverse.
If the Freudian means by infantile libido
something different from adult sexuality he
fails to show it by his reasoning. "Who-
ever observes," says Freud himself, "how
the infant satisfied at the mother's breast
falls back with flushed cheeks and happy
smile will admit that this picture is the
standard for the expression of sexual satis-
faction in later life." If this passage of
Freud means anything it means that the in-
fant had enjoyed orgastic libido such as the
adult in later life. It is not the satisfaction
of hunger but that of sex that gave him the
pleasure. Nobody in the full command of
his senses would dream to call the satisfac-
tion the adult experiences at the relief of
pressure by defecation or micturition sex-
ual, but the infant's satisfaction at such re-
lief is attributed by the pansexualist to sex-
ual libido^ If an adult, when alone should
relieve himself of his clothes, he could not
be called an exhibitionist, because in exhi-
bitionism an observer is a condition sine
qua non. Mere nudity is not exhibitionism
nor narcissism. But if the infant, whether
alone or in presence of his mother or nurse,
pushes off his covering the action is at-
tributed to sexual exhibitionism, not to the
pleasant sensation of freedom from clothes.
The curiosity of children is proverbial. The
small child wishes to see everything, to hear
everything, to know everything. Qiildren
will break and destroy any plaything for the
sake of exploring the mechanism. But when
a child observes with curiosity the genitals
^Thls pleasure, the pansexualist claims, is
different from that derived from the natural
relief from tension. And he finds this difference
in the michievous expression of the infant's
face. Upon such shaky evidence is built this
wonderful doctrine.
of another child of the opposite sex, this
instinct of curiosity, this emotion of wonder ;
is denounced as mixoscopy.' The curiosity
defecation produces in the child is copro-
philia in the eyes of the pansexualist. The
cruelty of the child towards animals, in his
ignorance of the caiJse and effect of pain,
is denounced as sadism. If the child mal-
treats the teacher by his naughtiness he is
a sadist. If he knows that he will be
punished and still does it he is a masochist,
and if he screams while punished he is a
malingerer. If a boy loves his mother, the
love is attributed to sexual desire, and if
he loves his father, he is a homosexualist.
The girl's love of her father has a sexual
component, and her love for her mother is
a sure sign of bisexuality. The pleasure of
sucking at the mother's breast is sexual
libido, and the lust at sucking from the bot-
tle or of the finger is attributed to lip erot-
ism. In the opinion of the pansexualist, the
infant has no need of food, only of sex.
Because the three body openings happen
to be erogenous in some degenerate adults,
the labial, anal, and urethral erotism of the
child has become a common by- word of the
pansexual school. The fascination of being
rocked is due to sexual excitement. The
pleasure of being tossed in the air has a
sexual undertone. When the child enjoys his
bath the enjoyment is attributed to the
erotic functions of the skin, not to its simple
stimulation. When the child makes its body
rigid, it is not an expression of angry ob-
stinacy— this would be common sense which
does not exist in the eyes of the pansex-
ualist— but muscle erotism. The child is not
only polymorphous-perverse but a common
criminal, as shown in his plays and games.
When he plays the soldier, he is a mur-
derer; when he plays with matches, he is
inclined to arson.
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It is not only the hysterical patient who
harbors the Oedipus complex or the Electra
complex. In the eyes of the pansexualist, one
of these complexes dwells in every normal
man or woman. The sexual emotions of the
adult only associate and assimilate the orig-
inal affection the boy has for his mother
and the girl for her father. Every love is
merely a repetition of the first love of the
mother or, respectively, for the father. The
mate is always a mother or father image.
The love of God is the sublimation of the
gross love of father. The father complex is
the prototype for all kind of reverence. The
struggle between the infantile constellation
and the cultural incest-taboo forms the
parents complex, and the sublimation of the
sex reminiscences of this complex gains
components for cultural effects, such as dis-
gust, shame, morality and so forth.
Such a strange proposition as infantile
sexuality would naturally require an irre-
futable proof, and the only proof the school
has is Freud's word which must be accepted
as final or one lacks scientific attainments.
The infantile sexual factor in man's life is
taught as if it were the positive, untarnished,
absolutely proven truth. Infantile sexuality
forms the cornerstone of the entire Freudian
edifice, yet no genuine evidence is presented
of its existence in the normal child. The
direct observation of normal children by
unbiased observers does not show any sex
motive in the infant's life. The study of
normal babies shows them to be without any
sex consciousness. The evidence brought
forward by tTie Freudian sect emanates
mostly from the reminiscences of neurotic
adults or is based upon the observation of
neurotic children. The striking and excep-
tional is then extended to cover the normal.
There is no positive, clear-cut proof of the
existence of any infantile sexual desire. In-
fantile sexuality is nothing short of the aber-
ration of the spirit. Unless all feeling, affec-
tivity, yearning, all human energy are called
sexual, such a thing as infantile sexuality,
analogous to that of the adult, does not ex-
ist. There is no sexual factor in the life of
the infant. The normal child has no copula-
tive desire for parents or anybody else. The
incest-complex is a terminologic absurdity.
The greater attraction the parent of the
opposite sex may have for the child or the
child for the parent has no conscious sexual
coloring in the sense of adult sexuality. This
attraction is based upon the unconscious
biologic general attraction of the male and
female principles in all organic life. It is
the attraction of the pistil for the pollen. It
is a part of life's mystery, of the elan vital,
the "IVillc zum Lebenf* This attraction is
not synonymous with adult sexuality.
Neither is the satisfaction of all infantile
desires sexual libido. The term sexual for
all infantile pleasures is used by the
Freudians in a loose, confusing manner. The
entire doctrine is mere guesswork, based on
the vaguest sort of evidence. Probably the
followers of the cult are themselves suffer-
ing from a certain complex.
The interpretation given by the Freudians
to the innocent activities of their own or
of their friends' children would show that
they themselves are harboring the sensuality
complex in their make up. They find sex
where the normal man would look for it in
vain.
This sensuality complex would explain
the stand the pansexualist has taken in re-
gard to chastity. Only the sensualist claims
that chastity is impo.ssible. Normal men
in all walks of life, from the north pole ex-
plorer to the soldier in the trenches, know
by their own experience that chastity is pos-
sible. The pansexualist who, if not advocat-
ing, is at least condoning sexual license in
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265
men or women, is no doubt harboring a
sensual complex. In an essay on chastity
(Amcr. Jour, of Urology and Sexology,
May, 1918) such a Freudian claims that
total abstinence is impossible. He plays the
trick, well known to the student of logic,
by starting from the false premise that by
chastity is meant a chaste human being that
never felt the alluring breath of sexual
thought. Then he goes on to prove that such
a being has never existed. But supposing
the individual has felt the alluring breath
of sensual thought and did not yield to the
allurement, is not such a person also chaste ?
When we speak of an offense against chas-
tity we do not mean sensual thoughts. Sup-
posing that by chastity is meant the refrain-
ing from physical congress except with one's
permanent mate? Such a chastity is surely
not impossible and it fulfils all the require-
ments of the categorical imperative. This
social imperative is only concerned with sex
congress when a second person is in the
play. Masturbation, mental erotism, day-
dreaming may violate the rules of personal
hygiene, but they do not concern society.
Thinking unchaste thoughts does no one any
harm except the thinker, and he has to settle
his autoerotic practices with his own con-
ception of personal hygiene. The advocate
of sexual chastity is mostly concerned with
the categorical imperative which reads for
the woman: "Thou shalt not introduce
strange blood into your system and cause
blood chaos in your offspring and thou shalt
not jeopardize the economic life of your-
self and of your offspring" ; for the man it
reads: "Thou shalt not jeopardize the eco-
nomic welfare of your neighbor's wife and
children, thou shalt not introduce blood
chaos into his family and thou shalt not ex-
pose yourself to the pollution of the venereal
disease and thus jeopardize the health and
life of your wife and children" (Talmey,
Amer. Medicine, July, 1917).
The advocate of chastity claims that ab-
stinence is difficult for the hedonist, the
person with an ardent sensual disposition;
for the intellectual elite, the superman, the
great thinkers, the investigators, abstinence
is easy. The pansexualist continually con-
tradicts himself. In one breath he says that
the sexual impulse is intractable and un-
controllable and then he says : "If our youth
could marry at 20, they would be the first to
preach abstinence." Hence from puberty to
twenty, the period of storm and stress, when
most of the venereal diseases are contracted,
the youth would have to control their sex
urge. Why then could not they control it
after twenty? Suppose they are not abso-
lutely abstinent, suppose they do sometimes
think sensual thoughts, suppose they prac-
tice sometimes autoeroticism — the pansex-
ualists with Stekel at the top claim that
masturbation per se is harmless — if they
only be chaste, «. e., relative abstinence from
illicit congress, that would be a great gain
and the only thing the moralist is concerned
with. The moral categorical imperative is a
social imperative. When no other person is
in the play, man's behavior ceases to be
subject to the moral imperative and is only
controlled by right conduct.
The claim of the pansexualist that one
can no more live without sexual experi-
ences and not be harmed thereby than with-
out food is a palpable error. The individual
grows and thrives without sexual experience
before puberty arid after the climacterium
but needs food during these periods. The
pansexualist has gone mad on sex. To speak
of the erotic fantasies of a one-year-old
child is nothing but madness. The pansex-
ualist is defending a sex complex of the
first magnitude. Any psychologist who can
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say that "There is only one kind of love —
the erotic" — is a hopeless sensualist. Such
a dogma can only be the emanation of his
own complex.
The dogmatic attitude is even more em-
phasized in the dream interpretation of this
school. It has been known since time im-
memorial that many dreams represent wish-
fulfilments not realized in the waking state.
From this general observation the doctrine
was proclaimed that every dream represents
the fulfilment of repressed wishes, not of
ordinary every day wishes, but infantile
sex wishes.
This theory of the wishfulfilment of the
dream runs counter to everybody's experi-
ence when he happens to remember the
phantasmagoria of sleep which, far from al-
ways fulfilling a wish, not seldom produces
the most frightful oppressive emotions.
Hence a deus ex machina was created in
the psychic censor who, watching over the
woe and weal of the sleeper, distorts the
hidden dream content into the manifest
dream thought. The dream itself is pur-
posive, teleologic, providential, created no
doubt by a god, probably Morpheus, to se-
cure refreshing sleep. But in order that the
dream should not reveal too much of the
repressed infantile sex wish, the censor has
been placed on the threshold of conscious-
ness and his duty is not to allow any con-
tents he does not approve of to enter aware-
ness. This theory required three distinct
principles to be introduced into the mech-
anism of the dream.
(1) The latent dream content, non-re-
callable to memory, having its seat in sub-
consciousness.
(2) The manifest dream thought, re-
callable to memory, with its seat in con-
sciousness, and
(3) The censor with his seat at the point
of transition of the two psychic systems, or
on the threshold of recall.
The latent thought invariably contains the
fulfilment of a repressed infantile, sexual
wish. In order that the wish remain re-
pressed the censor watches at the threshold
and distorts the latent content so that the
fulfilment is not any longer recognizable in
the manifest thought. The aim of the entire
elaborate mechanism is not easy to grasp.
What is the purpose of a wishfulfilment that
does not reveal itself to the conscious ego?
What is the use of representing the wish as
fulfilled if the fulfilment does not enter
the wisher's awareness? How should such
a problematical wishfulfilment guard sleep?
A fulfilment that remains hidden to the con-
scious ego is not fulfilled as far as the ego
is concerned. The entire latent content ap-
pears aimless and purposeless. In the wak-
ing reveries the individual's wishes are ful-
filled, and he knows it. In his dream the re-
pressed wishes are also said to be fulfilled,
but the individual does not know it, he has
to go to a disciple of psycho-analysis to find
it out. Still, without telling the logical "why"
for the dream work, an edifice of phantastic
dream interpretation has been erected which
could rival the dream books of our g^eat
grandmothers.
In the first place several laws have been
laid down, the truth of which no one is al-
lowed to question under the penalty of be-
ing considered an ignorant heretic.
(1) Every dream deals egotistically of
the dreamer himself.
(2) Every dream is a wishfulfilment of
a sexual nature.
(3 The wishfulfilment is contained in
the latent content.
(4) The manifest content forms the
dream work ; it is the allegorical expression
of a dream thought.
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(5) The allegory is used by the psychic
censor to prevent the unconscious from be-
coming conscious.
In the waking condition the censor keeps
back the unconscious desires emanating
from the complex and does not allow them
to penetrate into consciousness at all.* In
sleep the censor allows the desire to enter
awareness but in disguise, in conversion,
distortion, so that the desire and its fulfil-
ment remain hidden to the sleeper.*
The means of distortion are :
(1) Fusion of words and events.
(2) Transformation of pictures.
(3) Indirect expression of things thru
symbols.
(4) Displacement or transformation of
affects.
(5) Condensation; one element rep-
resents several dream thoughts.
(6) Transference by dividing the
dreamer into his good and evil ego.
Besides the class of dreams, always
known to mankind since time immemorial,
the Freudians know of two more classes:
(1) The innocent wish is fulfilled in the
manifest dramatization. These are the sweet
dreams. The hungry receive all kind of
delicacies, the thirsty all kind of drinks, the
cold are warmed, and the abstinent enjoys
the company of the other sex. To this well
known class the Freudians add :
(2) The second class represents the ful-
filment of repressed wishes. But the censor
does not allow any trace of the latent sub-
conscious wish to enter consciousness.
Hence the dreams remain unknown to the
ego and are emotionless.*
^This conception is not new. The censor is
here nothing else but the system of inhibitions
between the impulse of gratifying instinctive
desires and cultural restraints.
* No adequate answer is given why the censor
allows the entrance at all, if the desire is to
remain hidden anyhow.
(3) The third class of dreams rep-
resents the realization of a repressed but
not sufficiently hidden wish. Such dreams
are accompanied by fear and distress. Be-
ing strongly affect-toned dreams they are
usually remembered.* When the affects are
so great that they arouse consciousness, the
dream is remembered.'
Three sources of the dream have always
been known to man: (1) recent events, (2)
somatic states, (3) affect-toned past events,
and to these Freudians add (4) infantile
sexual events.*
It was always known, even to primitive
man, that anxiety dreams usually have a
somatic source, a stomach full of indiges-
tible food, trouble in breathing, pressure on
the heart or on the great vessels and so
forth. In such dreams the sleeper often
passes thru the same anxieties he experi-
enced in the past in the waking state. The
incitement to indifferent dreams lies usually
in the events and experiences of the last
few days.
But the new school claims that the dream
work is marked by overdetermination. In
waking thought the tendency to side-asso-
ciation is inhibited by the thought direction.
When this direction is removed or weak-
ened, as in dreams, a condensation takes
place, or the dream thought is determined
from different sides by different associa-
tions. The dream is overdetermined, hence
"Under Freud's teleologic interpretation of
dreams the purpose of their presence is not
quite intelligible.
'Why the censor allows the commission of
incest, the greatest sin known to man, to enter
awareness is not easily seen.
* In the writer's limited experience the change
of position when awakening creates a complete
amnesia of his dream. If he remains in the same
position he occupied when he slept he remem-
bers his dream; if he turns on the other side
he forgets the most innocent dreams.
•The dream of nudity without regard to the
persons present is an infantile exhibition-dream,
the incest dream Is an infantile wishfulfilment
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its ambiguity. The affects reign, similitudes
have the value of indentities, and symbols
render thought-residues innocuous. The
symbols are the cause of the oneiric fusion
and aim to protect sleep.^
With the aid of dream-symbolism the
Freudian is in a position to put the sex
motive into the most innocent dream. The
enumeration of the sex symbols will easily
show that there can scarcely be any dream
in existence without having some sex sym-
bol in its content. The interpretation of the
material symbols by the new sect.* is simply
riotous. Everything that is tall, thin, long,
that grows or opens like an umbrella, shoots
like a gun, has a cryptic allusion to the male
sex organ, or the phallus. Things that
have the shape of a curve, or which enclose
a certain space,^ such as the box, case,
closet, stove, carriage, tunnel, cave, ring,
or shell represent the female sex organs,
or the yoni. A store means the vulva, an
apron the labia. If a man enters a store in
his dream or touches an apron, it is a wish-
fulfilment of intercourse. If unhappily a
woman dreams of a store or of an apron
then it is simply a homosexual infantile
wish.
Every twig, cigar, asparagus, tooth, tower,
* With the help of the symbol an abstract
thought is changed into a material picture. The
thought of love is pictured by a death scene,
the thought of the phallus by the symbol of a
screw driver and the thought of the vulva by
the picture of a plum. This doctrine of the
am'blguity and symbolism of dreams enables
the new school to give any meaning it chooses
to any dream. The most forced fantastic inter-
pretation may be defended with the help of this
pretended symbolism and ambiguity for the
existence of which no adequate clear-cut proof
has been given except the dreams of degen-
erates.
* The symbols are not even original with this
sect. Any student of ancient sex worship meets
time and again with the Freudian symbols in
the ancient cults. (Talmey, Amer. Medicine,
November, 1918.)
'They are said to recall the female curved
Mount Veneris and the enclosures of the vagina
and uterus.
peak, summit, sausage, or serpent repre-
sents the phallus. A copula means a testicle.
Opening an umbrella means erection. The
number three means the male genitals which
consist of three parts. The curve of the
moon means the yoni, but also erection be-
cause it grows. A sharp sword means erec-
tion. Every hole, screw-nut, pocket, pear,
plum, grave, female servant, or sister, means
the vagina. The triangle or the rose mean
the vulva. A coffin symbolizes the womb.
Fur is the symbol of the pubic hair. A ball
surrounded by a ring, like the Hindu lingam,
means sexual union. Telephoning means
copulation. Penetration into narrow spaces
is a birth phantasy. The opening of a locked
door, or of a letter means sex union. Mur-
der means defloration. The criminal, horses,
lions, tigers, biting dogs mean passion. The
stallion, steer, hare, buck, mean great po-
tency. A hand, a finger, or drawing, tearing
and milking mean masturbation. The auto-
mobile means autoeroticism. Playing piano
means copulation. A woman dreaming of a
bundle means non-satisfaction with one
man. Water in her dream means pregnancy.
To be poisoned means to become pregnant.
Going thru a narrow channel or seeing the
bank of a river is a birth recollection. The
transformation of one thing into another
means bisexuality, or vascillation between
a man and a woman. The dog means sex-
uality. Going thru the trial of examination
means sexual trial. A woman dreaming of
falling means yielding. A locked door means
fear of temptation. Not being understood
means sexually not satisfied. A draught-
horse means the husband, the watchman
means the wife, and the emperor means the
father.
Dreaming of being nude is an infantile
exhibition dream, dreaming of flying is an
infantile reminiscence of being carried by
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the mother. Flying also represents a death-
wish, to become a flying angel. Taking a
walk, departing, going home, leaving the
room, vanishing, all mean to die. Paleness
means death, and a small house means the
grave. Death of relatives with sorrow is
an infantile wish fulfilment. The death of
the father is a sign of the Oedipus complex.
The mother's death is a homosexual infan-
tile love for father. Dying means to live.
An old woman means death. A fall into
depth means a terrible crime. A crowd of
people means a secret. Affective dreams,
such as exertion, exhaustion, restlessness,
coming too late to a train mean moral loads.
Unrealizable, unfulfilled wishes change into
anxiety dreams.^
The mere enumeration of these fantastic
symbols, these wild, fanciful and capricious
interpretations, sufficiently explain why
most psychologists turn away entirely from
Freud's teachings. This doctrine of fixed
symbolism is inherently so improbable, un-
founded and unscientific; this obsession of
the pansexual sect that there must be some
suppressed sexual element in every dream;
this preconceived notion that some sex com-
plex is at the bottom of every dream — these
are responsible for the agnostic attitude of
the true scientist towards the teachings of
the Vienna school.
The theory that the kaleidoscopic bizarre-
ness and strangeness, the shifting scenes,
the changing of persons in the dream are all
purposive and the result of an intropsychic
struggle between repressed tendencies and
a censor has no solid foundation to stand
upon. The entire theory has no scientific
basis. There is no particle of proof for a
' The lengthy enumeration of these symbols
was necessary to show that there cannot pos-
sibly exist any dream without containing one
or the other of these sex symbols. Thus every
dream is eo ipso a sex dream, if we believe in
these symbols.
specific transformation of an antecedent
latent idea into a manifest content. There
is no proof of the employment of a special
symbolism, no proof of an introrpsychic
struggle in dreamland. Freud's censor re-
sembles the occult conception of a dream
god. The entire edifice of dream interpre-
tation is devoid of substance and the fan-
tastic outgrowth of a dreaming psychologist.
All we know of the dream is it to be a
fantastic imagery without law and order,
an hallucinatory delirium, occurring in a
state of dissociation and influenced by cer-
tain drugs, such as alcohol, opium, has-
heesh and so forth. The dreams which en-
ter our awareness and are remembered, and
only these dreams are subject to a scientific
analysis, do not show any motive. They
are disconnected ideas, coursed in a passive,
fleeting way thru the mind. Some conscious-
ness exists in sleep ; the senses are not en-
tirely out of play. Hence there must remain
some mental activity. This activity is at the
bottom of dream life. The dreams remem-
bered are, as a rule, hypnagnotic dreams,
/. e,, dreamt either before falling asleep or
just before awakening.
The sources of the dream material are
somatic sensations or residue sensations of
sound, sight, smell, touch and taste, and
pressure on the circulatory apparatus, on
the bladder, on bowels and so forth. The
dramatization of the dream is formed of
presleeping ideas, usually of the last days
before the respective dream, but it is also
incited by residue emotions emanating from
remote affect-toned events. The following
may show how somatic sensations and re-
cent presleeping ideas work together in the
composition of the dream.
I. At the fall-opening of school, a man,
not a teacher, dreams that he is opening a
school in the presence of his wife. He first
puts on the electric lights, then he tries to
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open all rooms on one side of the school,
which is built in the form of a triangle.
Each room opened is found to be a closet
only, with a sink and water running from
the faucet. When all the rooms on one side
of the triangle had been opened, the wife
refused to be present at the farther opening
of school rooms, because she is afraid of
the devil. So they both leave the school.
When the man tries to close the outer door,
three devils appear and do not let him. Tired
out trying he awakes.
For the pansexualist such a dream would
be a veritable mine of male and female sex
symbols. School, triangle, closet, faucet are
all yonic, and devil and the number three are
phallic symbols. For the Freudian such a
dream is a typical impotence-phantasy. The
fact is that at awakening the dreamer found
the room quite lighted by the early sun and
that water was running from a faucet out
of order. A few days before, the dreamer
met with a teacher who was going to open
a school which is built in the form of an
H. On a rainy day, a few days previously,
there was the question who should call for
the child, the dreamer or his wife. All these
sensations and ideas served as the dream
incitors. There is no proof that the dream
was overdetermined and that a sex-motive
was hidden behind the scene. The psycho-
analyst with his ipse dixi takes himself too
seriously.
As examples where dreams represent re-
membrances of strongly aflfective-toned
events in the dreamer's past life, entirely
remote from sex, may serve the following
histories: A young German student left
Lithuania for Germany. At the frontier
the Russian officials found some irregularity
in his passport and did not let him pass. He
had to return to the village and to stay in
a farmer's house, only a few feet away
from the frontier ditch. There he remained
hidden till darkness when the Russian sol-
diers are withdrawn from the immediate
line to a line farther inland. Thereupon he
jumped over the ditch and proceeded dur-
ing the night to the next German city to
board a train. This event made such an im-
pression on him that in his anxiety dreams
for the last 35 years he lives thru the same
experiences. Every time he wakes up from
this typical dream he finds himself lying
on the left side, pressing his heart.
Another example of remote emotions fur-
nishing the dream materials is the follow-
ing history: A boy of 15 years while sitting
on one of the open country-closets in the yard
slipped and fell in up to his knees in the
dirt. The disgust made such an impression
on him that since this disagreeable strongly-
affective experience he has typical dreams
where he passes thru the same or similar ex-
periences. At awakening he finds himself
pressed either for defecation or micturition.
Now these two histories explain themselves
in the most natural way. To put a sex-
motive behind these typical dreams would
be an arbitrary act of the oneirocritic.
That the supraliminal consciousness and
reasoning are not entirely extinct in sleep is
shown in the following dreams:
II. The writer had been operated upon for
gangrenous appendicitis nine years ago. His
condition was very grave. In the night of
the second to the third day he finds himself,
in his dream, in a public Russian-Turkish
bath of his native town. There he meets
with his parents. His old mother, dressed in
her usual street garb, says to him: "Why
do you want to suffer here, my child, come
with us." Thereupon he answers: "No I
cannot go now, I have a little girl, one and
a half years old. I shall wait till she is mar-
ried." Then his father turns to his mother
and says: "Leave him alone, he does not
want to go with us." Then they both dis-
appear.
Now, in his native small town the super-
stition prevailed that if one goes away in
his dream with a dead person the dreamer
will soon die. The writer's parents had been
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dead at the time of the dream. But in the
dream scene they both appear to be alive,
i. e,, the subliminal psyche perceives them
as being alive. Still there was a reminiscence
from the supraliminal psyche that they are
dead, hence he must not go with them until
his child is independent. Still this reminis-
cence was not strong enough to represent
them as dead in the dream dramatization.
We can only conclude from the logic of his
answer that some faint reminiscence of their
death remained present in his psyche.
In the following dream the reminiscence
was strong enough to enter awareness dur-
ing the dream :
III. About six months before the dream,
the writer's sister-in-law died thru an un-
fortunate accident. In his dream he meets
her in a house where he is observing the
children at their play. He is delighted to see
her looking so well. She is dressed in her
usual street costume, as if to go shopping.
Suddenly she takes her youngest girl by the
hand and tries to go away with her. The
writer gets terribly frightened, grabs the
child in his arms and exclaims: "Do not
go with her, she is dead."
Thus again the deceased appears alive
in the dream scene, hence a plain wishful-
filment. Still the irradiating reminiscences
from the supraliminal consciousness are
strong enough to make the dreamer aware
that she is dead and that he must not let
her take away her child. This shows that
there is a certain cleavage of awareness in
a supraliminal and subliminal psyche in
the dream just as in the waking state.
Sometimes the dream shows the presence
of three degrees of consciousness, the sub-
conscious, the fore-conscious and the con-
scious.
IV. After having read a great deal about
Freud's dream theories the writer dreamt he
saw three big watermelons and tried to
measure and weigh them. While handling
the melons he awakes and tries in this state
to analyze the dream, wondering what re-
lation the watermelons could have to sex
and comes to the conclusion that Freud's
dream theories do not always bear scrutiny.
After coming . to this final conclusion the
writer awakes and finds that the dream
analysis was itself made in a dream, like
Hamlet's show within a show.
The first awakening was not a real but a
dreamt awakening. The dream of the mel-
ons was thus the work in the subconscious
state, that of the analysis in the fore-con-
scious state, leading to the conscious state
at the real awakening.
That an innocent non-sexual wish may
furnish the material for the dream thought
shows the following dream:
V. The night before the operation of a
near relative which the writer wished to
escape from performing he dreams that he
had packed all his things to leave the city.
He hastens to the railroad station but is
often prevented from proceeding by one ob-
stacle and the other. When at last he ar-
rives at the station, the train had left and
he has to return home.
Here the basis for the dream wish to leave
the city is the wish to escape from operating
upon his relative. But both wishes remain
unfulfilled, the real wish and the dream
wish, contrary to the Freudian theory that
every dream expresses a wish fulfilment.
The entire theory about repressed unac-
ceptable ideas, censor, compromise, dis-
guise and so forth is incapable of sub-
stantiation. The modem oneirocritics have
no particle of proof that the dream is on
one hand teleologic and on the other hand
intended not to be understood.
But even granted that the theories about
infantile sexuality and about the sexual
meaning of dreams are grotesque phantasies
of a strongly imaginative psychologist, these
phantastic doctrines do not detract from
the merit and glory of the teacher who has
given to the world the new psychology of
the unconscious, many features of which
even Freud's opponents have absorbed.
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With the aid of this psychology we are
able to read the secret, unconscious wishes,
yearnings and longings of the individual.
This psychology also furnishes us the
means of fathoming the workings of the
racial psyche from prehistoric antiquity
down to the present high state of culture.
Whatever objection one may have to the
overemphasis of the sexual impulse in the
infant and in dream, whatever objection to
the intellectual monism of Freud who re-
duces all psychic manifestations to one pow-
erful dominating instinct/ even his op-
ponents will admit that his discovery of the
psychology of the unconscious forms one of
the conspicuous landmarks in medical
science.
171 W. 126th St.
RADIOTHERAPY: INDICATIONS AND
RESULTS OBTAINED WHEN
PROPERLY USED.'
BY
D. Y. KEITH, M. D.,
and
J. P. KEITH, M. D.,
Louisville, Kentucky.
The treatment of carcinoma is the largest
and most serious problem before the medi-
cal profession today. This article will not
burden its readers with statistics, detailed
report of cases, or the technic of treatment ;
but will as briefly as possible give certain
conclusions from personal experience in
' Freud's doctrine of the primal libido is a
metaphysical proposition and may better be
discussed by a philosopher. The writer is more
concerned with the outgrowth of Freud's the-
ories, or rather with the ravings of his less
philosophical disciples who are trying to outdo
their master in their emphasis of gross erotism
and pansexualism.
'Read by Dr. D. Y. Keith before the Society
of Physicians and Surgeons, of Louisville,
Kentucky.
radiotherapy and the trend of the literature
as we see it.
In superficial epithelioma we believe a
larger proportion can be cured by proper
application of the X-ray (which includes
proper filtering of the rays) than with the
knife, caustics and cautery combined. This
is especially true of epithelioma involving
the face, and the scarring is much less than
from other methods of removal. The pain
from surgery, caustics or cautery, ranges
from the mildest to the most severe ; where-
as under radiotherapy the patient remains
practically free from pain. Reaction in the
tumor and surrounding glandular area may
be so marked as to cause pain for twenty-
four to forty-eight hours, but it is usually
not severe.
In malignant tumors about the face
which by secondary involvement have
reached adjacent glandular areas, we are
positive more benefit can be obtained by
radiation, fulguration and surgery than by
the mutilating operative procedures hitherto
practiced. In our opinion removal of half
the jaw (either lower jaw or upper maxilla)
is of absolutely no benefit, that on the other
hand the patient is rendered more miserable
than if nothing had been done. Any treat-
ment which permanently increases suffer-
ing and undoubtedly shortens existence
should be condemned on every possible oc-
casion.
We have seen a large number of recur-
rent malignant tumors of the breast where
marked axillary glandular involvement had
occurred and was incompletely removed.
Partial or complete loss of usefulness of
the corresponding arm, which not infre-
quently follows such extensive surgical pro-
cedures, constitutes a most serious handi-
cap, and in many instances the occurrence
of edema involving the entire arm renders
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ORIGINAL ARTICLES
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273
the patient a pitiful and uncomfortable ob-
ject to deal with daily. It is our belief that
any patient, having a malignant tumor of
the mammary gland with secondary involve-
ment in the axilla, will be much more com-
fortable and live longer with persistent,
judicious application of radiotherapy to the
entire gland-bearing area of the affected
side than by immediate surgical removal.
Of course surgery may be later invoked if
it seems certain that benefit may be thereby
obtained. In other words, we believe sur-
gery of the breast will hereafter be almost
limited to removal of the breast after radio-
therapy, and be followed by radiation of
all the glandular areas.
Several surgeons are now referring to us
their patients after radical breast opera-
tions for radiotherapy as soon as they are
able to leave the hospital. A few years hence
complete statistics will be available showing
the results obtained by this method of treat-
ment- We believe fewer recurrences will
be reported than have been noted from
surgery alone. At present those who have
seen a goodly number of patients subjected
to radical operation for mammary carci-
noma are not especially optimistic about
surgery. Please recall in your experience
the number of patients who have been
operated upon for mammary carcinoma,
and who have remained well for five years
or more, where a positive diagnosis of
malignancy was made.
Should you have occasion to compare a
primary carcinoma with one that has re-
curred after operation, you will be impressed
with the marked resistance the recurring
type has to any form of treatment, whether
it be radiotherapy, fulguration or caustics.
This increased resistance has been explained
by Dr. Holding of New York (who re-
ported two thousand cases embracing nearly
every type of tumor) who made numbers
of microscopic sections of both primary and
recurring carcinomata. In the primary tu-
mor he found the blood supply was quite
limited, and that radiotherapy caused
strangulation by reduction in the blood sup-
ply. In the recurring type the blood supply
was greater than the tumor in development,
therefore it would seem impossible to
destroy the tumor mass by strangulation as
in primary neoplasms. We believe this ex-
plains the advantage of three or four series
of X-ray applications after operation, as
destruction of remaining cell nests can be
better accomplished early before a well es-
tablished blood supply has been formed. In
deep-seated malignant tumors, such as those
of the abdomen, chest etc., the principles
outlined will hold good so far as post-opera-
tive radiotherapy is concerned.
At present we have under observation
and treatment by radiotherapy several pa-
tients with uterine disorders, ranging in
age from thirty-one to forty-six years, and
thus far the results obtained have been satis-
factory. In three of these we are expected
to produce an artificial menopause, and
neither patient has menstruated more than
once since treatment was commenced six
months ago. In two others continuous bleed-
ing for more than one year has been con-
trolled within two weeks after treatment
was begun, the patients experiencing normal
menstruation two weeks later — excepting
that the flow was very profuse. We antici-
pate good results in these cases. In another
where menstruation was prolonged for a
period of two weeks, with great pain in the
pelvis and lower lumbar region, normal
menstruation with cessation of pain was ex-
perienced after two series of treatment.
Our greatest objection to radiotherapy
in uterine affections is the likelihood of
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mistaken diagnoses, and in such instances
our efforts might prove futile. In uterine
fibromata without complication of the ad-
nexa, or where surgery was contraindicated,
many brilliant results have been reported.
Since this report was written a total of
twenty-two patients has been rayed for
uterine hemorrhage. In a number of these
cases more than two years have elapsed with
no recurrence of uterine bleeding. Many of
the younger patients (under 30 years) have
had a return to normal menstruation.
Our results in goiter have been satisfac*
tory, tho only a few cases of this kind have
been treated. In our first cases treated four
years ago, the patients have remained well
without any other treatment. The first pa-
tients were treated by the old technic of
small doses given frequently, with very lit-
tle filtering of the rays. At present we are
using heavier doses with an increase in the
intervals between treatments. Many reports
in recent literature would lead one to be-
come very optimistic about the results, as
practically all cases respond to the later
technic of heavy doses. The improvement
of the patient is early noted, first showing
reduction in pulse rate and nervous phe-
nomena, the tumor being the last clinical evi-
dence to disappear.
The most rapid clinical improvement is
seen in the treatment of spleno-myelogen-
ous leukemia, the blood picture showing
a change within a few hours after raying
the long bones. The blood serum ot a pa-
tient so treated given to another individual
with spleno-myelogenous leukemia, who has
not been exposed to the rays, will produce
a change in the blood picture.
A middle-aged female recently came to
us presenting the following blood count:
Erythrocytes 3,800,000, leucocytes 120,000,
myelocytes 30%. Splenic enlargement
marked, the lower border being on a line
with the umbilicus. Her entire bony system
was given two series of treatment with the
X-ray about ten days apart, and at the end
of one month her blood picture showed:
Erythrocytes 4,000,000, leucocytes 4,800,
myelocytes 8%.
LOUISVILLE RESEARCH LABORATORY.
7ao Atherton Bldg., LouisviHe, Ky.
Examination of Bixx)d.
No. 1.
No.
For Dr. Keith. Patient Mrs. S. Date 4/4/17
Hemaglobin % 65
Blood pressure
Red Cells in Cu. Mm. 3,800,00
White Cells 120,000
Color index
Unstained
STAINED SPECIMEN.
Erythrocytes pale Lymphocytes
Megalo or Microcytes present . .Mononucli^nrs . . 8
Poikilocytes present. .Transitionals.. . 2
Polychromotrophilia present. .Neutrophiles. . .60
Erythroblasta present. .Eosinophiles
Megalo or Microblasts present. .Basophiles
Blood Platelets few
Myelocytes SO
Parasites, bacteria none found
Cultures
Wassermann Reaction
Widal Test
Remarks Spleno-myelogenous Leukemia
►
L. R. Laboratory. Signed
J. D. ALLEN.
No. 2
EXAMINATIOX OF BLOOD
No.
For Dr. Keith. Patient Mrs. S. Date 5/5/17
Hemaglobin %
Blood pressure
Red Cells in Cu. Mm 4,000,000
White Cells .* 4,800
Color index
Unstained
STAINED SPECIMEN.
Erythrocytes -^ale Lymphocytes
Megalo or Microcytes. present. . Mononuclear^. .20
Poikilocytes .present . . Transitionals. . . 2
Polychromotrophilia. iresent. .JNeutrophiles. . .68
Erythroblasts none Eosinophiles
Megalo or Microblasts none Basophiles 2
Blood Platelets few
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Myelocytes 8
Parasites, bacteria
Cultures
Wassermann Reaction
Widal Test
Remarks
L. R. Laboratory. Signed
J. D. ALLEN.
No. 3.
EXAUINATION OF BlOOD
No.
For Dr. Keith. Patient Mrs. S. Date 6/7/17
Hemaglobin %
Blood pressure
Red Cells in Cu. Mm
White Cells 5,000
Color index
Unstained
STAINED SPECIMEN.
Erythrocytes Lymphocytes
MegaloorMicrocytes Mononuclears 24
Poikllocytes Transitionals 2
Polychromotrophilia. . . .Neutrophiles 70
Erythroblasts Eosinophiles 2
Megalo or Microblasts Basophiles 2
Blood Platelets
Myelocytes 0
Parasites, bacteria
Cultures
Wassermann Reaction.
Widal Test
Remarks
L. R. Laboratory. Signed
J. D. ALLEN.
The improvement clinically was as rapid as
the changes in the blood. Within one week
the patient was attending to her household
duties, she gained in weight, her color im-
proved, and after two weeks she assured us
that she felt as well as she had for eighteen
months or longer. It is probable she had
been affected for at least a year before we
saw her, as the splenic enlargement had
been noted by her physician in a routine
examination during slow convalescence fol-
lowing an attack of la grippe.
All of the patients we have treated for
spleno-myelogenous leukemia have im-
proved rapidly and have remained comfort-
able under frequent applications of the
X-ray, some of them showing no indica-
tions for further treatment for six or eight
months. A blood examination is required at
least every four to six weeks to keep a prop-
er index in these cases. Blood changes are
noted from three to six months earlier
than clinical symptoms.
In eczema every patient treated by radio-
therapy has shown immediate improvement.
In a few cases the results obtained have
been brilliant and seem to be permanent.
One patient with palmar eczema that had
resisted medicinal applications for nearly
two years, and who had abstained from the
use of water on her hands during this time,
was completely cured under three applica-
tions of the X-ray and has remained well
for more than two years. Within three
weeks after treatment was begun she was
using soap and water and was attending
to her household duties without the use of
gloves which she had formerly worn. This
was one of the most pleasing results we
have ever observed.
There are many other skin lesions in
which definite results have been reported
but our observations have been too limited to
warrant conclusions from personal experi-
ence.
At present we have under treatment six
or seven patients with psoriasis, and hope
to give a detailed report with our conclu-
sions concerning these cases at a later date.
Pleurisy. — It is stated that iodoform one
part, with collodion fifteen parts, mixed and
applied night and morning, removes pleurisy
pains and chest pains of consumption.
CharcoaL — Fresh animal charcoal is
more efficient than wood charcoal, but char-
coal prepared from blood is the best. — Critic
and Guide.
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HEALTH AND HYGIENIC STAND-
ARDS OF INDUSTRIAL
WORKERS.
BT
CARL SCHEFFEL. Ph. B., M. D..
Boston, Mass.
The preservation of the health and limbs
of the industrial worker has been given
considerable attention in recent years by
medical and legislative bodies, so that to-
day communities, manufacturers and indi-
viduals have come to realize that to safe-
guard the health and limbs of the industrial
worker carries with it remuneration far in
in excess of the costs.
Industrial health and safety commissions
have been created, workmen's compensa-
tion laws have been enacted and compul-
sory health insurance is being much talked
and written about. All of these measures are
aimed at elevating the hygienic standards
of the industrial worker, safeguard him
from accident and care for him in time of
misfortime.
A study of numerous bulletins, pamphlets,
reports and announcements of some of
these various boards and commiseions
strikingly reveals the fact that extreme en-
deavors are being directed towards com-
pelling the manufaclurer to comply with in-
numerable laws, rules and regulations, and
forcing him to install much valuable equip-
ment for the purpose of safeguarding his
employees' health and limbs ; while compara-
tively little is being done to teach the work-
er himself to appreciate the value of sanita-
tion and accident prevention, and much less
to compel him to observe reasonable rules
and regulations to that effect.
As a student of industrial medical prob-
lems I may be permitted to take a broad
view of the situation and give some con-
sideration to the practical difficulties en-
countered in attempting to apply measures
aimed at health conservation and accident
prevention among industrial workers. It is
one thing for an industrial safety commis-
sion having mandatory powers to prescribe
these measures ; but it is quite another prob-
lem to carry them out. As matters now
stand it Is only too often the case that an
industrial establishment is compelled to
spend large sums of money for the installa-
tion of sanitary and safety devices only to
find that the employees will not avail them-
selves of them after they have been in-
stalled. For instance, respirators have been
prescribed for many dusty occupations, but
most reports seem to agree that only a few
workmen can be induced to wear them
where they are available. Much has been
written of the "kiss of death" and shuttle-
sucking practiced by weavers, but I dare
say that not one in a thousand weavers will
use the hook provided to do away with this
dangerous practice. Even the wearing of
caps to protect the hair, and the wearing
of tight sleeved garments among women
workers will not be voluntarily complied
with by the majority of them. These and
many other features intended to safeguard
the industrial worker are oftentimes viewed
by him as unwelcome innovations, intended
only to inconvenience him.
As a mass, industrial workers cannot as
yet understand and appreciate the value of
many measures instituted to safeguard their
health and limbs ; and if they happen to in-
terfere in the least with their acquired
habits or entail much inconvenience they
are apt to be condemned instead of appre-
ciated. To be sure, there are today many
thousands of industrial workers who appre-
ciate measures intended for their welfare;
but there are manv thousands more who
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277
look upon such measures with prejudice
and skepticism, and it is usually the latter
classes who need them most. Workmen who
have shown extreme intelligence in form-
ing trade-unions for their economic protec-
tion have shown animosity towards sani-
tary and safety movements thru the medium
of these very organizations. The value of
such measures as medical inspection and
examination of industrial workers and com-
pulsory health insurance has as yet failed
to be grasped by the great majority of
workers notwithstanding the fact that such
measures would result in benefitting them
the better to wage the battle for economic
existence.
In view of this attitude it becomes ap-
parent that the majority of industrial work-
ers need much education and enlighten-
ment along these lines. Under present con-
ditions the employer is constantly being
bombarded with ever new and more strin-
gent rules and r^^lations governing the
health and safety of his employees, and in
order to tarry them out he is obliged to re-
sort to compulsory measures because the
mass of the workers fails to appreciate their
value due to lack of education along these
lines. The outcome is that a measure pri-
marily intended to benefit the worker is
viewed by him as a burden forced upon
him by an exacting employer.
It is by no means my contention that
compulsory measures intended to safeguard
the health and limbs of the worker are of
no value — far be it from this — ^but what I
do contend is that the manner in which these
measures are applied is many times not
productive of the maximum results consid-
ering the time and money expended for
them. For instance, I believe the sanitary
standard existing in any industrial plant
which is not being governed by compulsory
sanitary rules clearly portrays in a most
striking manner the sanitary conditions pre-
vailing in the homes of the majority of its
workers. There is every reason for befiev-
ing that many industrial establishments
whose sanitary standards are poorest, and
whose number of infected cases subsequent
to industrial accidents are the highest, have
among their employees a preponderance of
those whose sanitary standards at home are
the poorest, and this entirely irrespective of
economic conditions. Soap, water and "el-
bow-grease" are so cheap that even the
poorest paid industrial worker is enabled to
make free use of them. All that is needed
for their employment is an appreciation of
their value.
It does not seem logical to expect -an em-
ployee to show much enthusiasm for health
and safety movements at an industrial es-
tablishment when his home surroundings
are the picture of uncleanliness and disor-
der. A worker who daily sees his sidewalk
littered with filth or whose backyard is
allowed to become the dumping-ground for
refuse, cannot be expected to easily comply
with strict sanitary rules during working
hours.
In many ways the average man is only a
grown up child. What he sees and does in
his own home he is apt to look upon as be-
ing acceptable outside. If the municipality
in which he resides permits unsanitary con-
ditions to exist in his home he cannot un-
derstand why similar conditions should not
be tolerated at his place of employment.
A workman who is allowed to spit on the
sidewalks of his town without interference
will spit on the floor at his place of employ-
ment and will resent those in authority if
they endeavor to prevent him from so do-
ing.
Assuming that there is a dearth of ap-
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preciation of sanitary and safety measures
on the part of the workers as a mass, how
are we to remedy these conditions? It is
my opinion that the industrial worker should
be educated outside as well as inside of
the factory. In fact he is apt to take more
kindly to educational endeavors undertaken
by outsiders than he is towards those un-
dertaken by his employer. There should be
a much closer cooperation among boards of
health, sanitary engineers and those en-
deavoring to improve the hygienic stand-
ards of the industrial worker. Teach the
worker how to live better from a hygienic
standpoint at his home and in public, and
he will then more readily cooperate with
those endeavoring to safeguard his health
and limbs at the workshop. If the many thou-
sands of minors employed in industry who
are now compelled to attend continuation
schools were taught such subjects as general
and personal hygiene and accident preven-
tion rather than some subjects for which
they neither care nor have use, I believe a
more enlightened industrial worker would
be produced in a few years from now. Es-
pecially is the value of such instruction com-
prehended when consideration is given to
the fact that most of these youths shall fol-
low an industrial career for the rest of their
working days.
As conditions now exist the industrial
worker receives almost his entire knowl-
edge of industrial sanitation, and accident
prevention measures from his employer.
With the present relationship of capital and
labor it is only natural to see the worker
view any and all measures inaugurated by
his employer as being for his employer's ben-
efit rather than for his own. If greater and
more rapid progress in the appreciation of
industrial hygienic measures and accident
prevention is desired on the part of the in-
dustrial worker there are two principal
means by which this may be accomplished.
First teach the worker how to live in a
sanitary manner at home and force him to
obey the sanitary code of his home town
to the letter; secondly, educate him in per-
sonal hygiene and accident prevention thru
the medium of public lectures, moving pic-
tures and the daily press, all of which are
at present hardly utilized.
1127 Commonwealth Ave.
THE TREATMENT OF EXOPHTHAL-
MIC GOITRE.
BY
ALBERT C. GEYSER, M. D.,
New York City.
In speaking of exophthalmic goitre, t shall
include, for the sake of brevity, diseases of
the parathyroids. From the surgical removal
of either of these glands much valuable clin-
ical data have been obtained. We know that
the functions of these two glands differ from
each other,* but in all probability their close
anatomical associationship is not without
reason. I shall therefore treat this subject
as tho the thyroids and the parathyroids
were directly dependent one upon the other.
For clinical and especially therapeutic rea-
sons this seems advisable.
In no department of medicine is the
etiology of a disease process of more im-
portance than in the practice of physical
therapy. The cause must be sought for
and such agents employed as will keep
the future activity of the same in abey-
ance.
In exophthalmic goitre we are not quite
sure of the exciting cause. Here, as in
many similar diseases, the pathology
throws but little light upon the actual
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279
conditions. The visible pathology is the
result of something which has preceded.
From laboratory experimentations we
are warranted in concluding that the
etiology of this disease is to be found in
a perverted metabolism. There is every
possibility that the enlargement of the
gland was in the first instance a physiologic
response on the part of that gland to en-
able it to increase the performance of its
function. Assuming that the enlargement of
this gland supplied the necessary element
in proper quantities to the system, then we
would have cases with a simple enlargement
of the gland and no other symptpms. This
is just what we do have in simple enlarge-
ment of the gland (simple goitre). Some-
times these glands grow to an enormous
size ; beyond pressure symptoms, which may
be present, these patients complain of no
other inconvenience. Another phenomenon,
worth noting, is the fact that in certain re-
gions (Swiss Alps) goitre is endemic.
Tourists visiting there frequently develop
an enlargement of the thyroid which quick-
ly subsides when they leaVe the region. We
have here a clear demonstration of the
physiologic response of a gland to a sudden
demand by the system. The therapeutic
lesson that is impressed upon us is this : the
enlargement of the gland is not the disease
of exophthalmic goitre ; again, our therapeu-
tic measure ought not to be something
which has for its prime purpose the reduc-
tion of la physiologic enlarged gland.
In exophthalmic goitre we are dealing with
something very different from the mere
enlargement of the gland. In this disease
we recognize four cardinal symptoms;
thyroid enlargement, exophthalmos, tachy-
cardia and tremor. Since we have considered
the gland enlargement as physiologic, we
have remaining exophthalmos, tachycardia
and tremor. Exophthalmos appears in other
conditions, such as aneurisms, inflammation
and tumor of the orbit, atheroma with dila-
tation of the arteries, chronic cyanosis of
the head and lead poisoning. In whatever
other diseases exophthalmos may appear, it
is a symptom-complex with tremor and
tachycardia. Either or all of these three
symptoms may be produced in any kind of
a toxemia. Neither does it matter whether
the toxic material is introduced from with-
out or whether it is formed within the body
(autotoxemia). As a matter of fact the
symptom complex, the exophthalmos, the
tachycardia and tremor, point strongly to
some- irritant, some toxic material of auto-
genous origin. More than that, it strongly
suggests suboxidation.
Physiologically speaking, our therapeutic
measures ought to consist of something that
would supply that which the thyroid gland,
even in its enlarged state, fails to furnish,
or assuming that the gland does provide an
adequate amount of the particular secretion,
but the system fails to make use of it, then
in such a case we would require some agent
capable of compelling more normal metab-
olism. In the first instance thyroid extract
is clearly indicated and clinical experience
has abundantly shown this to be a proper
therapeutic agent. Yet there are some cases,
which not only fail to improve under thy-
roid extract but promptly get worse. In
such cases, we are again dealing with two
possibilities: first, either the patient's thy-
roid extract is excessive or the system fails
to make proper use of it. Such a proposition
leads us to inquire : what is the function of
the thyroid secretion? Without too much
speculation, iodin seems to be the active
agent of this secretion. Of all the medicinal
agents that we have, iodin occupies the
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first place as a reducing or oxidizing agent
of animal tissue.
If then the system is adequately supplied
with such a powerful reducing agent as
iodin, yet fails to properly reduce its own
toxines, physiologic therapy would point to
some agent or agents capable of perform-
ing this function for it.
Diathermia is one of the most logical
treatments that suggests itself.
Technics — Exopthalmic goitre is a
constitutional disease; since it is an
open question as to whether the gland
is enlarged as the result of inadequacy
or whether the system as a whole
fails to make use of the enlarged
gland's activity, it behooves us to consider
feet of the patient rest upon a metallic; foot
plate or ankle electrodes may be used in-
stead of the foot plates. A bar electrode is
held with both hands or wrist electrodes
may be employed. A piece of flexible tin
foil is placed over the region of the thyroid
gland. These three electrodes are connected
in such a manner that they form one pole.
The amount of current must be controlled
by the sensation of the patient. As a general
rule about 800 to 1,000 milliamperes, as
registered by a Wappler hot wire M. A.
meter, is an average dose. Of equal im-
portance, with the amount of current pass-
ing is the time consumed. The treatment
should be repeated daily and must last for
at least one hour.
Diathermia from a High-frequency Appabatus.
One pole is connected to an auto-condensation chair, the other pole is tri-furcated, its elec-
trodes are distributed to the various parts of the body, feet, hands and throat.
both possibilities in our therapeutic meas-
ures. Let the patient be seated in an auto-
condensation chair, which is connected to
one pole of a high-frequency apparatus.
The other pole is so arranged that a foot
plate, a hand electrode and a throat electrode
are connected at the same time. The bare
The result of such a treatment is very
far reaching in its physiologic effects.
1. The entire body tissue is heated from
one-half to one degree above normal. Dur-
ing this heating process, to which the pa-
tient contributes no energy, hyperoxidation
takes place. If a patient's urine is tested for
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281
urea just prior to the treatment it may be
1.5 urea, while one hour later, immediately
after the treatment the urea output fre-
quently reads as high as 3.5. Such an in-
crease in urea can only be the result of
hyperoxidation.
2. - Since the output of urea has in-
creased at least for the time being, from
25% to 100% or more, it proves that the
system has reduced something. The mere
fact that the reduction took place has put
the system in the habit of again functionat-
ing in a more physiologic manner.
3. The throat electrode is placed over
the gland because, after all, there is a close
connection between the function, nonfunc-
tion or overfunction of the thyroid gland
and the general system. The sharing of this
gland, in the localized heating of itself and
the body as a whole, creates an important
connecting link in the reestablishment of
harmonious function.
4. Seated, as the patient is, in the auto-
condensation chair, the full length of the
spine is subjected to a gentle, nevertheless
efficient counter irritation. This irritation
acts as a stimulation to the terminal nerve
fibres in the skin. In this disease the sym-
pathetic nervous system is more at fault
than anything else in the entire economy.
That an impression is made upon the sym-
pathetic nervous system is shown by the
immediate slowing of the pulse, the result
of vessel dilatation. The whole body feels
hot and the cheeks are flushed. Visible per-
spiration is upon the forehead, tremor ceases
and the patient is at ease. Such symptoms
could not come about without the interven-
tion of the sympathetic nervous system.
The cardinal symptoms of the disease are
enlarged thyroid, exophthalmos, tachycardia
and tremor. The enlargement of the gland
per se should not be considered. The re-
maining three symptoms are the immediate
result of hypertension. Anything which is
capable of relieving the hypertension is
bound to modify these three remaining
symptoms.
Diathermia does not do this, as a dose of
morphine, bromide or chloral by depressing
the automatic centers, but rather by stim-
ulating all of the sympathetic functions into
producing relaxation of the entire circula-
tory apparatus in a perfectly physiologic
manner.
The moment that the sympathetic centers
again exercise control of function, from
that moment on the nervous system, the cir-
culatory apparatus and the metabolic func-
tion, operate physiologically.
It is therefore to be expected that the
exophthalmos, the tachycardia and the
tremors cease.
Since the after-effect of each treatment
lasts from two to six hours, it is easy to
see why the oftener the treatment is re-
peated, the better and the more lasting the
results.
General FaradixatioiK — ^Another valu-
able the much neglected physical agent
in abnormal metabolism is general
faradization. The reason for the neglect
of this agent is found in the fact that
the faradic current, like so many other
electric modalities, has been much abused.
Of course, strictly speaking, it was the pa-
tients who were abused. The faradic cur-
rent is the best means for causing physi-
ologic muscular contractions of the volun-
tary as well as the involuntary system.
Every time that a muscle contracts, provid-
ing that it is in contact with its trophic cen-
ter, it performs its physiologic function.
Such performance of physiologic function
means metabolic changes. The production
of urea, the end product of catabolism is
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materially increased by physical exercise,
rhythmic muscular contraction and relaxa-
tion.
A properly constructed faradic apparatus
with at least four separate poles will cause
rhythmic muscular contractions and relaxa-
tions. In general faradization in cases of
The Faradic Appabatus.
Thl8 apparatus has one universal or common
positive electrode and four negative ones. Each
negative forms with the common positive a
separate circuit. These four circuits produce
rhythmic muscle contractions, while one circuit
is operating the other three are resting. All of
these faradic currents are descending, from
the spine to the periphery; it is most unphysi-
ologic to cause muscle contractions with ascend-
ing currents.
goitre, the poles must be placed as in the
diagram.
It must be noted that four distinct sinu-
soidalized faradic currents are causing reg-
ular muscular contractions. Each group of
muscles, after slowly and gradually con-
tracting, relaxes in a similar manner, then
rests for ^ of a period while some
other muscle group undergoes a similar
process of physiologic function. Since each
one of the four current phases is controlled
by its own rheostat, the smaller muscle
groups receive a correspondingly smaller
amount of energy, the larger muscles vice
versa. In this manner all of the muscles
may be caused to undergo a rhythmical
muscular contraction and relaxation, ex-
actly the same as tho the patient was tak-
ing a course in physical exercises. A notable
difference is in the fact that in these con-
tractions the patient is not called upon for
the furnishing of his own energy, that is
conserved for recuperative power. Since
every muscular contraction is accompanied
by an increase in the urea output, it fol-
lows that general faradization is indicated
in all such conditions where suboxidation
seems to be a causative factor.
Disappearance of most of the symptoms
may be accomplished in from three months
to one year. The gland, during all of this
time, may remain more or less enlarged. If
rapid decrease in the size of the gland is
desirable for cosmetic reasons, it «iay be ac-
complished by employing the positive gal-
vanic current over the gland, while the nega-
tive pole rests over the three sympathetic
cervical ganglia. The galvanic current must
be used in rather large doses. A negative
spinal electrode 3 by 12 inches is placed over
the spine so as to include the cervical re-
gion. A smaller positive electrode 2-2 inches
is placed directly over the thyroid gland.
The positive or active pole attracts the
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283
electro-negative ions, acids, chlorine and
oxygen; these tend to contract, dry and
harden the local area. The use of potassium
iodid or other substances to affect the
gland structure is unphysiologic, unscien-
tific and unnecessary.
Some glands respond remarkably well
to X-ray exposures. When the X-ray is
used a filter for the softer rays is impera-
tive ; the parallel spark or the current back
up must be between 4 and 5 inches, with
10 milliamperes in the tube. Such a dosage
refers only to a Wappler transformer meas-
ured by a Wappler meter. The dose of every
X-ray apparatus depends upon what portion
of the inductive wave is utilized. As soon
as erythema is noticeable over the gland,
all treatment must cease until the complete
disappearance of the redness ; from ten days
to three weeks may be required.
Rdapsesw — Out of 14 cases on my
records prior to 1916, six have re-
mained cured and are well; 5 showed
some recurrence of tachycardia and
tremor in varying degrees, they again
responded to diathermia. In 2 cases nervous
symptoms manifested theinselves six months
and two years, respectively. The one case,
which showed such early recurrence went
on to hallucinations and was placed in a
sanitarium; whether this latter condition
had anything to do with the original disease
is not knowable. One case died of some in-
tercurrent disease.
The more careful the relapsing cases
were as to observance of diet, the easier
it was to influence them with diathermia,
the shorter was each relapse and the longer
the intervals. While 9 of the patients were
hyperacid, five were distinctly hypoacid. It
is on this account that no universal dietary
can be prescribed in exophthalmic goitre.
Out of 8 cases treated since 1916, five are
practically well. Three are under treatment.
The technic in these recent cases is the
same as in those prior to 1916. In addition
to the above outlined treatment, if a case
shows a tendency to prolonged anemia, iron
and arsenic intravenous solution (Loeser)
is used once per week for from four to six
weeks.
301 West 91st St.
NARCOTIC DRUG ADDICTION IN
THE NEW-BORN: REPORT OF
A CASE.
BY
CHRISTIAN F. J. LAA8B, M. D.,
New York City.
Associate Surgeon, Saint Mark's Hospital, As-
sistant Visiting Physician, Saint Joseph's
Hospital for Tuberculous Patients.
In view of the present wide publicity and
awakening interest in the matter of narcotic
drug addictions, the case I am reporting
should be of interest to the medical profes-
sion, and should open up for discussion and
scientific consideration many points of clin-
ical and therapeutic value.
Insofar as I know, but few such cases
have been medically reported. Several in-
stances have appeared in the new news-
papers, coming from such institutions as
the New York Tombs where addicted
women under arrest have been confined, but
such cases have been announced more as
curiositieis than as clinical problems for
scientific consideration.
Dr. Ernest S. Bishop of New York has
discussed a case seen by him in consultation
and observed for a time afterwards. Dr.
Charles E. Terry^ of Jacksonville has re-
ported several cases coming to his attention
as health officer of that city. The occurrence
is mentioned by several other writers with-
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out much discussion of its clinical or disease
problems.
The mother of my patient was a woman
of twenty-seven years, who had been ad-
dicted to opiates for over two years. Her
general and physical condition was good.
Her pregnancy was uncomplicated and un-
eventful. Its course was apparently un-
influenced by her addicted condition so
long as opiate drug was supplied to her in
the quantities necessary to maintain her free
from the symptoms of opiate drug with-
drawal, or body-need for opiate.
Labor was accomplished during insuffi-
cient supply of narcotic drug, practically in
a condition of withdrawal or drug-need. I
had explained to her the inhibitory action
of opiate, and she had concluded that the
opiate would slow her pains and prolong her
delivery and might jeopardize the child's
life. She, therefore, refused a normal sup-
ply of opiate during labor. She was in ;
highly excited state, when labor was finally
completed, very restless, suffering from the
usual distresses of opiate need, and just
before the final pains attempted to jump out
of the window to end the misery of com-
bined labor pains and opiate deprivation.
Labor pains were very energetic, and de-
livery was accomplished with little diffi-
culty.
The baby was a well-nourished, healthy
appearing child. From the moment of birth,
however, it was very restless. This restless-
ness is probably to be interpreted as early
opiate need, due to the insufficient amounts
of opiate taken by the mother just previous-
ly. The symptoms and signs of drug-need
developed in the infant identically with
those of its mother, in character and in se-
quence. The restlessness increased ; it began
to yawn and sneeze. Its face became pinched
and its color poor. It drew up its legs as if
in cramps, and cried out as if in pain. Its
pupils became widely dilated. The chin was
in a constant tremor reminding observer of
the chattering of an adult in a chill. Finally
diarrhea began, and the infant showed signs
of collapse, with general convulsions.
Nothing seemed to alleviate these symp-
toms, until finally a drop of paregoric in
water was given, using a small eye-dropper
to put the paregoric in the mouth. Five
drops of paregoric were given at intervals
of five to ten minutes, causing a progressive
subsidence of the symptoms and a return to
normal.
It is of interest to note that the progress
of symptom alleviation followed exactly the
progress stated by Bishop in adults, that is,
the symptoms disappeared in ratio to the
amount of drug administered, those last ap-
pearing going first, and the restlessness first
appearing being the last to disappear.
Following the administration of the final
dose of this first series of paregoric, the in-
fant became quiet and in every way acted
and seemed perfectly normal.
The mother was very anxious to avoid
continuing to give the opiate to the child,
and delayed its administration as long as
possible. The child would develop the above
symptoms, however, at intervals of about
eight hours after opiate administration, the
severity of the symptomatology varying ac-
cording to the length of time the mother
delayed in administering the opiate.
When lactation was fully established, the
necessity for paregoric administration
ceased. The infant apparently obtained its
narcotic supply thru the mother's milk. The
mother nursed the child at regular intervals.
Just before the time for nursing, the child
would display a restlessness unlike that seen
in normal children, which would subside im-
mediately after nursing.
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285
Following in strict accord with Bishop's^
observations upon adults, the intervals of
relief from withdrawal symptoms and the
severity of the withdrawal symptoms were
invariably in proportion and ratio to the
length of time between doses and also to
the amount of opiate secured thru the
mother's milk. The mother at times en-
deavored to reduce the amount of her own
opiate intake. This reduction was imme-
diately reflected not only in her own physi-
cal condition but in that of the nursing in-
fant.
When the mother went for a longer in-
terval before taking her own opiate, or
when she took it in diminished quantity,
the child displayed earlier onset and greater
severity of withdrawal symptomatology, it
being necessary at times to supplement the
opiate derived from the mother's milk with
a drop or two of paregoric. Apparently the
amount supplied to the child varied with
the amount present in the mother.
The picture of physical symptomatology,
and of suffering, in the child was identical
with the picture in the mother ; the various
symptoms occurring in the same sequence
and relative severity, and following the
same reactions to opiate administration, and
also yielding to nothing other than opiate
administration.
It seems to the writer, that cases such as
the above deserve closest consideration and
interpretation. They certainly upset the gen-
erally accepted theories of opiate addiction
expressed by the older writers. It seems
absurd and impossible to attempt to ex-
plain any of the phenomena displayed by
psychiatric or psychologic approach on the
old basis of sensuous enjoyment, of de-
liberate indulgence, morbid curiosity, vicious
or criminal instincts, etc.
The manifestations in this case were be-
yond all argument purely physical in their
origin and in the machinery of their produc-
tion. Something in that infant's body caused
the physical manifestations it exhibited.
This something was manufactured by the
body of the infant itself, and not merely
supplied to it thru the umbilical circulation
from its mother, otherwise it would not
have continued to manifest the symptoma-
tology after birth or after a reasonable time
following birth. The organs of the infant
while still in utero developed the function
of protective mechanism against opiate, and
carried on that function after birth.
A recent review of the scientific literature
of addiction, by Dr. DuMez* of the Public
Health Service, expresses the only explana-
tion at present logically tenable, based on
the clinical work of Bishop and on the lab-
oratory work of Hirschlaff*, Gioffredi' and
Valenti*^. Medical literature gives no other
satisfactory explanation of the clinical mani-
festations, physical phenomena and re-
actions of this case.
Bishop's* theory of antidotal toxic sub-
stance production within the body gives a
machinery of addiction-disease which ex-
plains every manifestation, phenomena and
reaction displayed by this infant. The ex-
periments of GioflFredi, Hirschlaff and
Valenti point to the same conclusions. The
condition in this infant is to my mind very
important for the appreciation of the med-
ical profession and of the laity, in the so-
lution of the narcotic drug problem.
Refebences.
(1) Terby, C. E. Drug Addiction in the
New-Born, American Medicine, new series
12, 807-808, 1917.
(2) Bishop, E. S. Narcotic Addiction, a Sys-
temic Disease Ck)ndition, Journal A, M. A.,
60, 431-434 (Feb. 8. 1913).
(3) GiOFTREDi, Cablo. L'immunite artificielle
par les alcaloides, Arch, ital, de biol., 28,
402-407, 1897.
(4) Hirschlaff, Leo. Ein .Heilserum ziir
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Bekampfung der Morphinsucht und ahn-
llcher Intoxlkationen. Berlin klin.
Wochenschr., 39, 1140-1162 and 1174-1177
1902.
(5) Valenti, Adbiano. Experimentalle Un-
tersuchungen u'hter den chronischen Mor-
phinismus, etc., Arch, f, exper. Path, u,
PharmakoU 75, 437-462, 1914.
(6) DuMez, a. G. Increased Tolerance and
Withdrawal Phenomena in Chronic Mor-
phinism, Jour. A. M, A., 72. 1069-1072.
THE ETIOLOGIC IMPORTANCE OF
DENTAL INFECTIONS.
BY
B. BARRYMORE MARCO, D. D. S.,
New York City.
The cooperation of physician and dentist
every day becomes more apparent since it
has been discovered that so many remote
diseases, which heretofore puzzled the
physician, have been caused by the teeth.
Notable among these are rheumatic fever,
neuritis, the heart, arthritis deformans,
nephritis, the nervous system, the lining of
the stomach and the intestines, the appen-
dix, the blood-forming organs, paralysis,
etc.
The mouth is a fine breeding spot for har-
boring the germs causative of most of the
virulent infectious diseases.
The writer has seen many diseases
traceable to apical infections or blind
abscesses. Some of these have been
strange, indeed, because they have caused
bodily ailments so far and remotely
removed from the teeth, that even the
most expert diagnostician would hardly
suspect their etiologic importance. On the
other hand, in many obscure cases, not a
few dentists have recently been too prone to
blame the teeth. While experience has
shown that these apical infections should
never be regarded lightly, judgment and
common sense require that the condition of
the teeth be studied carefully and examina-
tions be conducted with thoroness.
A remarkable case showing, however,
the menace of apical infections came to my
attention a short time ago. The patient, a
man about fifty had, some two years be-
fore, lost the sight of his right eye. It was
removed and he wore a glass substitute.
Sometime in September he had consider-
able trouble with his good eye, noticing a
gradual formation of dark, floating clouds,
which severely interfered with his vision
and threatened blindness. He visited a
prominent specialist who, after treating the
eye for a short period without success, sug-
gested X-rays of his teeth, which was done.
All of his teeth were found to be vital, ex-
cept the upper, right, canine root, which
carried a pivot. This root showed a well-
defined apical abscess. The root was ex-
tracted, dropped into a culture tube,
and taken immediately to a bacteriologist.
A culture was made, and a virulent growth
of streptococci was discovered. A vaccine
was then made, and this was given four
days apart, up to sixteen injections. Other
internal treatment was given by the physi-
cian, including hot compresses and the in-
evitable K. I.
The eye improved slowly but surely, and
now seems entirely well.
The vaccine seems to have effected a fur-
ther cure than the eye. It seems that the
patient, for many years, suffered severely
with his intestinal tract. To use his own
words, in particular: "A slow diminution
of pain in a certain spot of my intestines,
when and for a long time, suspected some
kind of trouble." (Periodical, small ulcers.)
This intestinal trouble seems now to have
left him, his general condition is better
than it ha? been for years, having gruned
considerable weight, and feels like a *dif-
terent man.
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LONDON LETTER
May. 1919
287
(From our Regular Correspondent.)
THE HOUSING QUESTION.
The British Government is obviously de-
termined to start at onoe upon a comprehensive
plan for the betterment of the housing of the
working classes and at the same time they will
promote and forward the objects of existing
schemes for the purpose. The movement is of
the utmost importance to the public health of
the nation for two reasons. The first and most
obvious one is that the three great scourges of
modern civilization, at any rate so far as their
part is played in this country, owe their ram-
pant growth and permanent mischief largely to
bad housing. Over and over again the medical
profession at large, those specially interested
in tuberculosis — like tuberculosis medical offi-
cers, school medical officers and the staffs of
consumption hospitals — have urged that bad
housing of the poor is the ground of the evil
with which they are attempting to deal. In the
overcrowded and ill- ventilated home a disease
like tuberculosis spreads; but not only has the
bad home this sinister influence on the well, it
is also the main factor in promoting the
progress of the disease in those already in-
fected. The early cases, diagnosed, removed
from the unwholesome environment, treated
medically and dietetically, would, if the future
offered a better home, have splendid chances of
permanent recovery — in the upper and middle
classes thousands of such fortunate issues are
chronicled in the case books of practitioners —
but the poor man has to go back to the evil sur-
roundings whence he emerged and his chances
of flrm restoration to health are, by doing so,
much minimized.
If tuberculosis is the principal scourge of our
population, the results of alcoholism and vene-
real diseases play nearly as sad a part in our
public health and vital statistics. Now the
connection of alcoholism with noisome domestic
conditions is very close. Within the walls of
the taudis, life is so depressing that those re-
sponsible for the upkeep of what is nicknamed
"home.'* feel a perpetual call both for stimulants
and for sojourn in more comfortable places.
Drink at home and drink abroad are conse-
quently taken to excess, and the morale of men
and women alike is sapped. Domestic duties
are neglected, their work is poor and employ-
ment is soon lost, disease and hunger follow,
while the children die like files.
The connection between venereal disease and
evil domestic environment is not so close. In
the class of society under consideration there is
no suggestion that either the man or the
woman escapes from the miseries of domesticity
to the charms of illicit connection — this is not
the sort of thing that occurs in the lower class
in any nation. But it is undoubted that the
filthy home, especially if it has already produced
in its inhabitants the evils of alcoholism, con-
duces to a lack of moral restraint. Those who
live like animals, and who are overcrowded in
garrets as rabbits may be overcrowded in bur-
rows, must lose their sense of modesty as well
as their powers of, or inclinations for, restraint,
while should disease follow indulgence, as in
these circles it usually does, there are no facil-
ities for the prevention of its spread. There-
fore, it is of the first importance to the public
health of this country that the present disgrace-
ful housing of the great bulk of the working
classes should be set in order immediately.
But there is a second reason for desiring this
reform to be expeditious, and it is this: The
sinister infiuence of bad housing in connection
with tuberculosis, venereal disease and al-
coholism causes those in charge of the health
of th^ people to find their efforts paralyzed
when they attempt the work of reform in other
directions. The tuberculosis officer reports to
his authority that the incidence of tuberculosis
upon the population of a town has now reached
the appalling figure of x and if unchecked may
go even to y or z, and he demands certain
measures for the improvement of notification,
for the institution of tuberculosis clinics or for
the coordination of his work to that of bis
brother practitioners. He demands improve-
ment in school buildings, and money for the
building and maintenance of special hospitals,
sanatoriums, rest-houses, playgrounds and
similar aids to convalescence. The supine
local authority always replies with a sympa-
thetic non poaaumus, taking the ground that as
long as the evils of housing, which they are
unable to counteract, are in full sway, it is a
waste of time and money to look elsewhere for
reform. This of course is perfect nonsense. If
a large number of patients on return to their
wretched homes do relapse, an equally large
number, also, on their return begin immediately
to institute domestic improvements. Recalling
the kind of environment in which their lives
have so materially improved, the tendency is to
attempt to obtain for themselves and their
families in their homes something of the stand-
ards of cleanliness, decency and order, the
benefits from which are so evident. A well
carried out regimen against tuberculosis is
a liberal education in domestic economy, and
this is a point to which sufficient attention has
not been drawn.
The Local Government Board has now issued
for official use a Memorandum on the prepara-
tion of State-Aided Housing Schemes; the pur-
pose, of course, is to assist local authorities to
meet the shortage of working class housing ac-
commodation, which is generally recognized as
one of the most serious problems facing us at
the conclusion of the war. In the Housing and
Town Planning Bill now before Parliament the
Government proposes that powet*s should be
given to the Local Government Board to relieve
schemes, approved by the Board, from the neces-
sity of complying with existing local Acts of
Parliament in regard to building, inasmuch a?
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the by-laws under many of these Acts make it
impossible to build houses 'to economic advan-
tage. At the same time, if housing schemes are
to be embarked upon with rapidity and to meet
the urgent need, it is essential that the schemes
of local authorities should contain the elements
of success. The houses to be built must be of
the kind where the present existing evils can
find no room. The Memorandum of the Local
Government Board contains indications of the
kind of scheme which should be embarked upon
if the assistance of the Board is to be obtained.
Elaborate arrangements have been made for
money grants to local authorities and "public
utility societies," while district ofDces have
been established by the Board in charge of Com-
missioners who will be ready to assist local
authorities with expert advice in regard to the
entire housing problem. These Commissioners
will advise authorities on the choice and lay-
out of sites, the best types of houses to be
erected, the methods for carrying out contracts
and obtaining the materials. Authorities who
follow the guidance of the Commissioners will
obtain approval of their schemes and grants in
aid of them. Many local authorities have al-
ready made a preliminary estimate of the num-
ber of houses immediately required in their
districts, and some have notified the Local
Qovemment Board as to the number of houses
they are prepared to build. It is certain that
the issue of the Memorandum of the Local Gov-
ernment Board will stimulate other communi-
ties to take the matter in hand at once. The
Memorandum contains full instruction for the
planning of a scheme with regard to site, roads,
fencing, planting and drainage, while in an in-
teresting appendix plans of actual houses are
given for general guidance, which are not in-
tended to hamper initiative, or to prevent full
expression being given to local cbstoms and
traditions, or the use of local building materials.
The general requirements which the Board con-
sider should be met are set out in full detail;
they provide for living-rooms of the most con-
venient and economical kind, for good bath
and scullery accommodations, and for larder
and cold storage; while precise Injunctions are
laid down for the avoidance of needless ex-
terior work, for the grouping of flues into a
few chimney-stacks and for placing those parts
of the house which will require plumbing and
attention to drainage as near as possible to-
gether. In other words, if anything should
go wrong the house will not have to be half
pulled down, as now occurs in tenant house
property.
The issue of this Memorandum ought to make
for expediency and economy in view of the
pressing urgency of the housing situation. The
preparation of their schemes by the local
authorities ought not to be postponed until the
Housing and Town Planning Bill has become
law. The schemes ought to be ready and as far
as possible approved by the time the Act is on
the statute books. Local authorities now have
guidance in drawing up the schemes, and the
medical officers of health of the various districts
may be trusted to keep the officials charged
with this splendid work "up to the scratch."
Under the Editorial Direction of Albert C.
Geyser, M. D., New York.
THE PHYSIOLOGIC USE OF ""NORMAL SALT
SOLUTION."
Unless a therapeutic measure has for its
object the restoration or at least the main-
tenance of normal physiologic functions, it
is of questionable value.
Simply because our ancestor, the seaur-
chin, was largely made up of and lived in
salt water is not really a good and logic
reason for believing that salt in any quan-
tity is still good for the human body.
Our organisms are no doubt habituated
to a certain amount of sodium chloride, in
fact, a normal physiologic amount is essen-
tial to our well being.
For a short time the system will even
bear a rather large amount, but unless
promptly eliminated such an excess will
soon produce toxic manifestations.
Before the present highly coniplicated
kidney existed, the only function allotted to
its predecessor was the regulation of the
inorganic composition of the blood or body
fluids.
Later these rudimentary organs were
called upon to eliminate the waste products
of metabolism.
Today we have a kidney, an organ of
complex character with duties to perform
that daily taxes its physiologic capabilities
more and more.
Our kidneys now regulate blood concen-
tration, proportioning the various ions, pre-
serving the acid base equilibrium and in ad-
dition to these primal functions the kid-
neys must now dispose of large amounts of
organic waste matter — ^toxic substances of
endogenous and exogenous origin.
While an excess of inorganic salts is detri-
mental, the toxic waste material of organic
compounds taxes the kidney function to its
limit.
Yet it is a fact that an organ or tissue
created primarily for a certain purpose will
always have a tendency to revert to the per-
formance of that function when opportunity
presents itself. / ^^ci\o
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If, for any reason then, the inorganic
balance in the blood is disturbed, that dis-
turbance receives the more or less exclusive
attention of the kidney, tho organic acids
and toxines may in consequence accumulate
in the blood stream.
We ought to appreciate the danger of
flooding the organism with inorganic salts
which demand prompt elimination.
This also explains the fact that an ex-
cess of sodium chloride may cause symp-
toms which vary in accordance with the
particular toxines which happen to be re-
tained.
The entire kidney function for the time
being is taken up with the elimination of the
excess of the sodium chloride.
As a rule, there is little danger of too
nfuch sodium chloride entering per os, altho
some individuals do consume an amount of
salt daily with their meals that borders
closely on excess.
Such patients show a prompt ameliora-
tion of their toxic symptoms the moment
physiologic rest is secured for the kidney
by withdrawing the excessive amount of
salt ingested.
It must not be assumed that the toxic
manifestations were due primarily to the
presence of excessive amjounts of the salt/
but rather to the fact that the kidney for
the time being reverted to its fundamental
function of regulating the inorganic com-
position of the body fluids and thereby
neglected the more important function of
ridding the body of organic waste material.
There is danger in an excess of sodium
chloride finding its way into the system by
the employment of what is known as a
"normal salt solution."
Personally, I have some objection to that
term. In the first place, altho it may com-
pare in Sp. Gr. to the blood plasma, yet
as far as the economy is concerned, it may
not be normal when introduced into the
circulation. Again it is not absolutely neces-
sary that a solution which is to be intro-
duced into the circulation must contain any
salt at all.
An isotonic solution of glucose, in many
instances, serves a much better purpose.
The "physiologic isotonic solution" would
be a more appropriate term. Under this
term the solution could contain any and
all of the salts normally found in the blood
plasma, or it might contain- none of them,
being made up of glucose, yet it would be
physiologic and isotonic.
Such solutions approach in similarity the
normal blood serum and under suitable cir-
cumstances may perform the physiologic
functions of the latter.
Such isotonic solutions are used for the
following purposes:
1. For increasing the volume of the
blood, as after severe hemorrhage.
2. For increasing the volume of the
blood ^yhen the watery elements have been
lost as in cholera, dysentery and gastro-
enteritis accompanied by large watery move-
ments.
3. To dilute and favor the removal of
toxines as after anesthetics, gas poisoning,
ptomaine poisoning, bichloride of mercury
poisoning, even in certain infectious or
toxic diseases.
4. For raising the blood pressure to
stimulate the action of the kidneys and
sudoriparous glands.
5. For counteracting the effect of shock.
6. For introducing necessary fluids into
the system by any other way than per os,
as after operations on the throat or stomach
or when the patient cannot for any reason
swallow, as during unconsciousness, spasm
and lockjaw.
In all of these enumerated conditions this
solution has a physiologic function to per-
form.
Neither a certain so-called "normal saline
solution" nor any other stereotyped solution
will answer in each one of these indications.
Even tho in a given case a certain solution
is indicated, that same solution, under simi-
lar circumstances, is contraindicated in an-
other patient.
The patient's condition, the physiologic
function desired and the solution required
must be in harmony.
These solutions may be introduced into
the system by the following routes:
1. Intravenously.
2. Hypodermatically — hypodermoclysis.
3. Colonic flushings — proctoclysis — en-
teroclysis.
It may seem strange, but it is a fact that
if a falsehood is repeated often enough, it
will sound like the truth.
As soon as it was discovered that certain
postoperative cases required and did well
upon an artificial increase in the blood
serum, every patient was ordered, as a
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routine measure, to be given a **nomial salt
solution" per rectum.
The enteroclysis was given to raise the
blood pressure. Sometimes it was needed,
sometimes it was not needed, but for fear
of missing one that might need it, every
postoperative case received it.
The only reason that I can ascribe to the
adding of salt to the solution is that some
laboratory specimens in zntro thrived bet-
ter in an isotonic solution than in ordinary
water.
It may also have originated from the
erroneous belief that plain water was an
irritant to the mucous membrane and for
that reason the salt was added.
There certainly does not exist any good
or valid reason why salt should be added
to a solution intended for proctoclysis.
The very fact that the solution is being
introduced per rectum shows that it must
have been intended only for the purpose of
feeding a patient water, who could not take
it per OS.
As no one ever thinks of feeding a pa-
tient salt water per mouth, there is no rea-
son why it should be administered per rec-
tum.
It is certainly a fact that ordinary plain
tap water will be absorbed in much less time
than any salt solution.
Doctor Trout has demonstrated by a
series of over two thousand cases that ordi-
nary hydrant water is better than any salt
solution. More water is absorbed, the post-
operative thirst is more promptly relieved
while the toxic effects of the salt are
avoided.
Simple and logic as this may seem the
average doctor still recommends "normal
salt solution'* per rectum.
The method of proctoclysis is only indi-
cated when the blood pressure remains un-
desirably low after the loss of fluids from
the body, or' in cases where the patient has
undergone an operation of the passages
leading to the stomach, or an operation upon
that organ itself.
In other words, this method is not indi-
cated unless thirst is the leading symptom
and the same fluid that is best calculated to
relieve thirst is also indicated in proctoc-
Ivsis, which is plain tap water at a tempera-
ture of about 100*' F.
If a small amount, say 5% of whiskey has
been added to this water there is reason
for believing that the absorption will be
hastened.
Technic* — ^The patient should be lying
down, a fountain syringe or similar con-
tainer should be suspended three or four
feet above.
To the end of a rubber hose is attached
a stopcock and a piece of glass tubing to
which a soft rubber rectal catheter is con-
nected.
The water is turned on so as to expel
the air in the tube, not that the entrance
of air in the rectum is dangerous but the
air in the tube is likely to interfere with the
flow and so cause an unnecessary, disturb-
ance of the patient later on.
The water is allowed to flow from thirty
to sixty drops per minute thru the glass
tube. Now the rectal catheter is inserted
with a gentle rotary motion, as otherwise
the catheter is liable to double upon itself
and instead of being high up, is really low
down, presenting a very small surface of
mucous membrane for the absorption of the
fluid.
When the catheter is in position, it is
attached to the still dripping end of the
glass. A few turns of adhesive tape will
fasten the catheter and hose in a suitable
position so that the patient need not be dis-
turbed for some time.
From two to four quarts or more of wa-
ter may, with this method, be introduced
into the circulation. In toxemias this
method may render good service but the
elimination of the water is of the utmost
importance.
Hypodermoclysis is the next most im-
portant method. The solution is introduced
beneath the skin into the areolar tissue. The
advantage of this method over proctoclysis
is the certainty of knowing that a certain
amount of fluid has really entered the sys-
tem.
The fluid so introduced is taken up by
the general or systemic circulation in much
shorter time, yet in not so short a time as
to embarrass the circulatory system.
Hypodermoclysis is indicated when the
tissues require the addition of water for
its solvent properties; this is so in toxic
states where it is desirable to dilute the
toxic material, in postoperative cases
where the pulse is soft and feeble, provid-
ing the feebleness is due to loss in volume,
or vessel-tone is lost as a result of toxemia,
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where the patient's condition will not allow
the introduction directly into the circulatory
system.
If it is our intention to reduce a tox-
emia, a hypotonic solution is indicated, be-
cause if we make use of an isotonic solu-
tion there is a probability that such a solu-
tion will not take up enough of the poison,
while if we make use of distilled water
there is danger of injuring the wandering
cells of the blood and a solution 9f a quan-
tity used for hypodermoclysis would be
dangerous to life.
The pulse and the general responsive con-
ditions of the patient should be our guide.
Above all else, the eliminative power of
the patient plays the most important part,
because this whole procedure is for the pur-
pose of elimination principally.
All of the instruments used, as well as
the field of operation, must be made and
kept sterile ; this can be easily accomplished
because as a rule there is no hurry.
A fountain syringe or similar container
is filled with a sterile solution, either
isotonic or hypotonic. To the end of the
rubber hose is attached a rather large cali-
bre hypodermic needle or a small cannula.
The water is allowed to flow in order to
expel the air, then the needle is introduced
into the cellular tissues well beneath the
surface of the skin. The small needle open-
ing and the approximation of the tissues
offer sufficient resistance to the flow of the
current.
As soon as the tissues become boggy or
water-laden, the needle must be withdrawn
and reinserted into a new area. If this pre-
caution is overlooked, the patient suffers un-
necessary discomfort and pain.
If a hypotonic solution has been used, the
patient must be supplied with additional
heat to encourage free perspiration. It is
assumed thrit the kidney function is normal.
The ir.ethod of hypodermoclysis is grad-
ually being displaced by the method of in-
travenous infusion.
Of all the methods of adding fluid
to the body in an artificial manner this is
certainly the most direct.
If there is physiologic response, it is al-
most immediate.
When we turn from enteroclysis to the
more scientific intravenous infusion, we
meet with new dangers, which certainly
have not as yet received proper considera-
tion. The fact that water has been freshly
sterilized or even distilled does not prove
that it is innocuous. It may contain many
harmful products of distillation or toxic
substances set free from killed bacteria.
It is true that in the administration of
salvarsan no untoward effects have been
recorded as a direct result of the intrave-
nous route.
The quantity of the one as compared
with the quantity used in the other is an
important factor. Again, when the intra-
venous method of adding volume to the
blood is indicated, we are dealing with a
patient who is exsanguinated or at least
suffering from shock or collapse.
Under suitable circumstances the benefi-
cent effects of directly increasing the bulk
of the blood serum by an isotonic solution-
in certain surgical cases are not doubted.
There are two* indications for the use
of an artificial serum, one where the bulk
of the blood has been suddenly diminished
to a danger point. Such a sudden diminish-
ing is always the result of hemorrhages.
For our purpose we must distinguish
between two kinds of hemorrhages, those
resulting from surgical intervention or
trauma, such as accidents and those appear-
ing de novo as secondary hemorrhages
from the lungs, stomach, intestines, rup-
tured tubal gestation, etc.
The difference between these is the fact
that in the one the hemorrhage is controll-
able while in the other it is not.
In a severe hemorrhage from the lungs
it would almost seem good theraf)eutic pro-
cedure to resort to blood letting in order
to reduce the blood pressure to the lowest,
while it would be short of criminal to re-
sort to an intravenous infusion of a salt
solution.
In the first place the blood pressure
would be increased and in the second place
the sodium chloride would keep the blood
in a fluid state and so prevent coagulation.
The second indication for intravenous in-
fusion is said to be in cases of shock or
collapse.
When water is used under such circum-
stances it is not our desire to materially
increase the volume, but we do wish to
add heat to the system. For this purpose
one pint of hot water at a temperature of
115° F., which is ntade isotonic bv the ad-
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PHYSICAL* THERAPY
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dition of glucose, has given satisfactory
results.
The technic for intravenous infusion
must be perfect in maintaining asepsis in
the field of operation as well as being sure
that the introduced fluid is free from all
toxic substances.
When a large amount of water is to be
introduced, as after a surgical hemorrhage,
the temperature should be about 100° F. to
105° F. When a smaller amount is to be
used, as in cases of shock, the temperature
should be from 110° F. to 120° F. and this
fluid must be introduced slowly and not ex-
ceed one quart in amount.
The solution must be at least isotonic,
^ while no harm results even from a hyper-
tonic solution, providing glucose is used in-
stead of sodium chloride.
A rather large hypodermic needle with a
blunt end is attached to the end of the hose
from the container; after all the air has
been expelled and the water still flowing,
it is inserted into the vein of the arm.
In the adult patient this is usually not
very difficult, but in children, or when the
veins are much collapsed, some difficulty
will be encountered.
Frequently a great loss of time occurs
as the result of looking for a suitable en-
trance into a vein. In all such cases time is
usually an important factor and it is good
practice to abandon at once the intravenous
method for the hypodermic one.
It is safer, usually more quickly per-
formed, about as effective but perhaps less
scientific.
A few practical case reports will show
the dangers attending the routine adminis-
tration of the "normal saline solution."
Case 1. To a patient with double pneu-
monia, in an extremely toxic condition but
with apparently a good heart action and
no evidence of edema of the lungs, an iso-
tonic intravenous salt infusion was ordered.
The interne who took the order was doing
double duty and did not get around to this
case for four or five hours. The patient then
showed signs of approaching edema of the
lung, with tracheal rales. The infusion,
however, was given without consulting the
visiting physician who gave the order and
the patient died promptly.
This case teaches several things: In the
first place the folly of routine work; sec-
ond, the danger of delaying an order;
third, the fact that this case was not treated
according to physiologic therapy.
There was no other indication except the
toxemia for the use of additional fluid. In
such cases it is the elimination and not the
administration of the fluid that should re-
ceive first consideration.
Case 2. A patient with advanced cardio-
vascular fibrosis, with a systolic pressure
of 220, was found by the physician whom
he consulted to have albumen and casts. A
flushing out of the kidneys was decided
upon and three quarts of water and three
quarts of milk were ordered to be taken in
each twenty-four hours. In about one week
the patient began to bleed from the nose,
and this bleeding continued for twelve days
off and on, necessitating repeated plugging
of the anterior and posterior nares. In this
case the profuse and continued hemorrhage
from the nose delayed the fatal results.
Case 3. A case was recently reported by
Brooks where one and one-half liters of
salt solution in three doses per rectum were
used, apparently without any particular in-
dications for its use.
A short and simple appendectomy had
been performed ; the patient had practically
lost no blood ; the pulse was perfect. The
giving of the normal saline solution was left
to the nurse who, either thru ignorance or
gross carelessness, made use of a stock
solution of nearly saturated sodium chloride.
This patient received almost nine ounces
of the pure salt with rapidly fatal results
from acute sodium chloride poisoning.
Case 4. A woman, age twenty-eight,
was operated upon by the Wertheim
method for the removal of a carcinomatous
uterus. After the operation normal saline
solution was ordered to be administered
by the Murphy method of proctoclysis.
Again a nurse administered five quarts of
the solution within the period of eight hours.
The kidneys failed to act, while the patient's
pulse rose to 148 per minute.
Pulse became irregular and weak and
patient went into stupor. Under the in-
fluence of external stimulation and mustard
to the precordia the alarming symptoms
subsided, the pulse dropping in two hours
to 118 per minute. In this case the solution
was of the proper kind, yet if the kidneys
failed to eliminate the added amount of
chlorine, poisoning was sure to occur, es-
pecially when the larger amount of increase
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in the circulating fluid embarrasses the car-
diac action.
Case 5. Sippel reports the following : A
patient suffering from eclamptic convul-
sions, which had kept up for thirty hours
after delivery, was relieved following the
decapsulation of one kidney.
Copious urination followed, coma com-
pletely subsided. Following this, three
quarts of normal salt solution were given
hypodermatically, with the result that a
complete anuria and coma returned, which
soon proved fatal.
In this case no solution of any kind was
indicated, but if after the kidney function
was restored, it seemed advisable to assist
in the further elimination of the toxemia a
glucose solution would have given better re-
sults.
In dextrose we have a substance which
has been recognized since the days of Claude
Bernard as in the highest d^ree non-toxic,
diuretic, nutritious and easily assimilated.
If introduced slowly, either by enteroc-
lysis or intravenous infusion, in isotonic or
hypertonic solutions, very large amounts
will be utilized by the organism without
the occurrence of glycosuria, or with the
loss thru glycosuria of only a negligible
percentage of the sugar administered.
Case 6. McKelvy reports a case from
the West Pennsylvania Hospital. Patient
suffering from bronchial asthma, with mod-
erate emphysema, but in a very emaciated
and poor physical condition.
Enteroclysis was given for a long period,
consisting of a 15% glucose solution. The
urine very seldom showed a sugar reaction,
but the patient gained in weight and a de-
cided improvement was noted in his physical
condition.
Recently a great deal of attention has
been paid in Europe, particularly in France,
to the use of h3rpertonic solutions of dex-
trose intravenously.
Enriquez reports the use of a 30% solu-
tion intravenously in more than fifty pa-
tients, giving from 250 to 300 c.c, repeated
three and four times in twenty-four hours.
The essential feature in the technic is
that the hypertonic dextrose solution enters
the blood stream very slowly, one hour be-
ing occupied for the infusion of from 250
to 300 c.c. ^
Omdasiont* — 1. The administration
of any artificial serum as routine post-
operative practice is questionable therapeu-
tics.
2. Too much water may fatally em-
barrass the heart.
3. Too much salt may fatally embarrass
the kidneys.
4. When fluids cannot be taken by
mouth, thirst may be relieved by tap wa-
ter or by isotonic dextrose solutions given
by enteroclysis. The dextrose solution is
preferable when there is danger of acidosis
and in all cases of inanition.
5. When there is a distinct indication
for an artificial addition to the amount of
the circulating blood-serum this may best
be accomplished by the use of dextrose so-
lutions: isotonic (5.1%) by enteroclysis;
isotonic, hypertonic (up to 30%), or hypo-
tonic (2%) by intravenous infusion.
6. There are no contraindications for
the use of dextrose, but often serious con-
traindications for the use of saline solu-
tions.
7. In all urgent cases the intravenous
method is preferable.
8. Greater care should be exercised to
see that all water used intravenously is
not only sterile but also non-toxic.
9. In medical practice artificial serums
should be more frequently employed: (1)
Isotonic or hypertonic after severe hemor-
rhage, exhausitive vomiting or diarrhea or
in cases of extreme inanition; (2) hyper-
tonic in toxemic cases including eclampsia
and uremia ; in cases of oliguria with threat-
ened uremia ; to combat acidosis, or if toxic
states, as after anesthetics, gas, morphine,
mercury poisoning, etc.
10. The old idea of "flushing out the
kidneys" cannot be too severely condemned.
Refebences.
Lawbence Litchfield: The Abuse of Normal
Salt Solution. N. Y. Medical Jour., June 6,
' 1914.
Macallum, a. B.: The Inorganic Composition
of the Blood. Its origin, Proc. Roy. Soc. B.,
1910, LXXXII. The ancient foundations of
heridity, Can. Med. Assn. Jour,, 1911.
Roessies: Giebt est Schadigungen dorch Koch-
sal tzinfusionen? Berl, klin. Wchnschr., Sept
18, 1907.
Blitms : Les dangers des injections intraveneuses
alcalines: efPet. toxiques du sodium, 8em. med.,
1911, xxxi abstr. J. A. M. A., Oct 21, 1911, p.
1408.
Geyser: The Use and Abuse of the Normal Salt
Solution. Am. Med., Jan., 1914, p. 57.
Christian: Experimental Nephritis, Boston
Med. and 8ur. Jour., 1908. CLVIII, 416.
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Lepine, J.: Hystery insufflsance renale, reten-
tion chlorine Rev. de med., Sept., 1911.
Jackson and Blting: Studies from the Bender
Hygienic Laboratory, 1908.
Burnett, T. C: On the production of glycosuria
in rabbits by the intravenous injection of sea
water made isotonic with the blood. Jour,
Biol. Chem., 1908, IV, 57.
GuTHBiE, C. C: The Effect on the Kidneys of
Temporary Anemia. Alone and accompanied
by perfusion. Arch. Inter. Med., March, 1910,
p. 232. Quart. Bull. Med. dep. Washington Uni-
versity, Dec., 1908, p. 47.
Bain, John: Excessive Ingestion of Salt Pro-
ducing Edema. Brit. Med. Jour., Dec. 28, 1912,
.p. 1749.
Tbout: Proctoclysis, J. A. M. A., May 4, 1912,
p. 1352. South, Med. Jour., 1913, No. 12, p.
791. Surg., Oynec. and Ohst., May, 1913, p. 560
Frogr. Med. Jour., 1914.
Borchabdt: Deutsch. Med. Wchnachr., 1912.
xxxviii, 1723.
Smith, R. M.: Recent Contributions to our
Knowledge of Nephritis. Am. Jour. Dis.
Child., May, 1914, p. 389.
Firhbr: Nephritis. 1911. Cartwright Prize
Essay, N. Y. John Wiley ft Son, 1912.
Hbndebbon, Palmes and NEWsitsoH: Jour,
Pharm. and Exper. Therap., 1914, v. No. 5.
Newburgh. Boston Med. Surg. Jour., 1913,
clxlx, 40.
MooBE, A. R.: Fisher's Theory of Nephritis. J.
A. M. A., Aug. 10, 1912, p. 423. Edema and
Nephritis, ibid. Feb. 1, 1913. A controverted
theory of Nephritis, ibid. June 20, 1914, p.
1971.
Sei.labd: The Essential Features of Acidosis,
Johns Hopkins Hosp. Bull., MtLy, 1914.
301 West 91st Street.
The Treatment of Asthma. — Beusaude
and Hallion (Med. Press and Circular,
Dec. 4, 1918) claim that very satisfactory
and immediate results can be obtained in
the treatment of the attack of asthma by
the subcutaneous injection of either adren-
alin or of pituitary extract, or, still better,
by a mixture of the two substances.
The solution with which the authors ob-
tained the results contained per c.c. half a
milligramme of hydrochloride of adrenalin
and an amount of dealbuminized total ex-
tract of pituitary body corresponding to 0.
gr. 25 centigrammes of the fresh gland.
This was employed at the rate of one c.c.
a day, but one of their patients, unknown
to them, made three injections in twelvie
hours without any untoward symptom.
The authors have employed the adren-
alino-pituitary mixture in 56 cases of
asthma, and also in a few cases of persistent
spasmodic cough. The youngest patient was
8 and the oldest 60 years of age. They have
given, in all, some 500 injections.
In almost every instance the treatment
determined subsidence of the asthmatic at-
tack. The effect usually made itself felt
within from two to five minutes after the
injection, and a single injection in most
instances sufficed to cause the attack to sub-
side. As a rule the relief is immediate and
complete. One of their patients, employed
at a neighboring railway station, when he
feels the attack coming on, runs around to
the hospital, gets his injection, and is able
to return to work in the course of a few
minutes. In most of these cases not only
does the attack cease, but complete quies-
cence takes place, so that when the attack
is by night refreshing sleep follows.
This abrupt passage from the state of
crisis to one of absolute well-being does
not obtain in every instance, the effect some-
times merely amounting to relief, short of
total subsidence. When patients have had to
be given injections several days following,
the results of the second and third injec-
tions have seemed more effectual than the
first. In any event a patient who reacts to
a given dose invariably remains sensitive to
that dose without any tendency to tolerance,
consequently we are not called upon to
increase the dose in order to obtain the
same effect. In one instance a patient has
been employing the remedy for the last four
years, and the effect has in no wise dimin-
ished.
Altho it is necessarily somewhat difficult
to estimate the efficacy of a remedy in such
a capricious disease as asthma, Beusaude
and Hallion believe they are entitled to con-
clude from their experience that not only
does it, in favorable cases, afford immediate
relief, but it seems to lengthen the interval
between subsequent attacks. This is also
Borchardt's opinion, and his view is that
this effect is due to the pituitary constituent.
Patients who have been obliged to have
recourse to morphine to obtain relief are
unanimous in preferring the adrenalino-
pituitary injection. Comparing the effect of
the morphine injection to that of this mix-
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ture, one of them said his impression was.
that morphine abolished his individuality
without acting on the attack, whereas our
injection seemed to act on the attack with-
out impinging upon his individuality.
As far as the authors* experience goes,
these injections do not seem to expose the
patient to any undesirable collateral conse-
quences. In the great majority of instances
the injection gives rise to no discomfort
whatever. Occasionally, after the first in-
jection, the patient complains of slight
tremors, the sensation of electric shocks,
of weakness in the legs, restlessness or
palpitation lasting at most a few minutes.
The symptoms, such as they are, are in
all probability due to the adrenalin, and
are, if anything, attenuated by the pituitary
extract.
Speaking generally, it may be undesirable
to employ this treatment in cases in which,
for any reason, hypertensor drugs are con-
traindicated. At the same time this is a
theoretical objection which is open to the
criticism that, in the dose recommended, ad-
ministered hypodermically, the authors have
never remarked any tendency to heightening
of the blood pressure.
Ductless Gland Therapy. — In observing,
from the clinical point of view, the action
cl the thyroid^gland, it is important to re-
member that neither its complete chemistry
nor its total functions have yet been satis-
factorily elucidated. Masterman-Wood
(Practitioner, May, 1919) states that re-
cently, however, certain American investi-
gators have produced synthetically a crys-
talline substance under the name of ''thy-
roxin," the administration of which, it is
stated, not only relieves all the symptoms
of myxedema, but if given in excessive
doses produces those signs which are asso-
ciated with hyper-thyroidism.
While it is evident that this aspect of the
subject demands further investigation and
proof, it is, nevertheless, axiomatic to state
that a normally functioning thyroid is an
essential for the complete physical and men-
tal development of the infant and for the
maintenance of health of the adult. That this
gland also is intimately connected with the
metabolism of the iodine and calcium in the
body seems now to be beyond dispute. Ac-
cording to Jolin the average amount of
iodine in the normal human thyroid is 8.5
m. g., and this increases to 15.6 m. g., un-
der iodine medication. It has further been
established that, altho the eviscerated gland
is capable of absorbing iodine, its living cel-
lular tissue is essential for the due elabora-
tion of its iodine-containing hormone.
The claim that has been made, that the
normal thyroid in virtue of its iodine-con-
tent supplies an antiseptic to the blood
stream, is based mainly upon the laboratory
findings of a greatly reduced amount of this
substance in the gland after acute illness.
One of its important properties is its ability
to store up iodine; but it is open to doubt
whether it can retain for transmission via
the blood-stream to the tissues of the body
at any given period sufficient iodine, in the
form of a "vital antiseptic,'' to restore the
balance from a septic to an aseptic state.
There is no doubt, however, that in all tox-
emias the thyroid plays a very active and
essential part, and that after severe illness
in many cases it often ceases to function
adequately. Qinically, many instances of
this may be observed in children who, pre-
vious to the onset of some acute infection,
have been normal in every respect, but who
subsequently exhibit in varying degrees signs
of failure of development and other stig-
mata of sub-thyroidism. Likewise, adults
under similar conditions show evidences
which point conclusively to a breaking-
down of the thyroid's efficiency, which may
be temporary or the incipient stage of
chronic benign myxedema. The truth of
this can soon be verified by the exhibition
of thyroid extract which, if used with care
and perseverance in such cases, not only
aids defervescence but greatly hastens con-
valescence. In the writer's opinion, the pre-
cise part which the thyroid plays in the
defense system of the body must be viewed
more from the aspect of its specific ability
to store up and elaborate iodine, and its in-
timate hormonic and chalonic relationship
with other members of the endocrine glands.
Skin Diseases. — In all skin diseases, the
first duty of the physician, according to the
Medical Press, is to treat the man that has
got the disease, and then the disease that
has got the man.
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ETIOLOGY AND DIAGNOSIS
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CORRESPONDENCJ
THE ADMINISTRATION OF
ARSPHENAMINE.
To the Editor,
American Medicine.
Sir:— It appears that there is a lamentable
want of care on the part of many physicians
who administer arsphenamine as to the con-
centration of the drug used and the time re-
quired for administration.
The Hygienic Laboratory receives many com-
plaints in regard to untoward results from the
administration of arsphenamine made by
various American producers. When careful in-
vestigation is made it is almost invariably
found that the drug has been used in a solution
that is too concentrated, and that It has been
administered too rapidly. We have reports of a
dose of 0.4 gm. being given in a volume of as
little as 25 c. c and injected within 30 seconds.
Such practice is abuse, not use, of a powerful
therapeutic agent.
If, in addition to the usual precautions as to
the use of perfect ampules and neutralization,
physicians would give the drug In concentration
of not more than 0.1 gm. to 30 c. c. of fluid and
allow a minimum of two minutes for the in-
travenous injection of each 0.1 gm. of the drug
(in 30 c. c. of solution), the number of reactions
would be very materially reduced. This would
necessitate from 90 c c. to 180 c. c. of the solu-
tion for the doses usually given and would re-
quire from six to twelve minutes for the in-
jection.
Any physician who fails to observe these pre-
cautions should be considered as directly re-
sponsible for serious results that follow the
improper use of the drug.
G. W. McCoy,
Director, Hygienic Laboratory,
U. S. Public Health Service.
Washington, D. C.
m
ETIOLOGY
AN9
lAQNOSI
Some Obserratlons on Astigmatism.— In order
to eliminate uncertainty as to what is meant
by astigmatism with the rule, against the rule,
and oblique. Green and Hardy (Amer, Jour, of
Ophthalmology/, Jan., 1919) propose the follow-
ing definitions:
"Astigmatism with the rule, or direct astig-
matism, shall include all cases with meridian
of greatest curvature at any point on the arc
from 46 to 134r
"Astigmatism against the rule, or inverse
astigmatism, shall include all cases with merid-
ian of greatest curvature at any point on the
arc from 0 to 44" and from 136 to 180**.
"Oblique astigmatism shall include all cases
of astigmatism with meridian of greatest curva-
ture exactly at 135 and 45^"
It is stated that inverse astigmatism is pro-
ductive of unusually annoying symptoms. Ref-
erence is made to a recent study by the same
authors, in which, in 1,024 eyes with regular
astigmatism, 283, or 27.7%, were inverse. This
is a larger percentage than is generally sur-
mised.
A photograph illustrates one reason for the
greater degree of asthenopia in eyes with indi-
rect astigmatism, c. g„ the greater interference
with the legibility of type.
Cycloplegic measurement is advocated in pres-
byopes who give conflicting answers when
tested without "drops."
One case reported illustrates that high uni-
lateral regular astigmatism may be due to a
birth injury.
An appropriate cylinder will often greatly Im-
prove vision and enhance the comfort of a pa-
tient whose cornea is deformed by antecedent
injury or disease.
An eye with irregular astigmatism due to in-
cipient cataract does not often tolerate a cylin-
der, as the lenticular astigmatism is constantly
changing with the progress of the opaciflcation.
Diagnosis of Smallpox*— Our Us points out 'h
his article in Medical Progress (June, 1918)
that in the diagnosis of mild smallpox, there
are three cardinal points. In the order of their
diagnostic value they are: (1) The initial fever
or mode of onset; (2) the distribution of the
skin lesions; (3) the morphology of the lesions.
The mistake is made. of putting the last point
first in Importance and perhaps relying on it
entirely.
The mode of onset of smallpox is peculiar
to it and not like that of any other eruptive
disease; its value Is enhanced by the fact that
to some degree it is manifest in even mild cases.
The disease begins with a moderate fever or
sense of malaise like that of an ordinary cold.
Headache and backache, which are commonly
present, increase gradually and continue for
the next two days. It is more than likely in a
mild case that the sense of illness will be
greater during these first three days than at
any subsequent period of the sickness. At the
end of the third day, or as soon after as the
eruption begins to appear, the sense of illness
will quite abruptly subside. A little reflection
will show a physician that no other eruptive
disease has such initial phenomena as these
It is very simple to draw out the subJecUve
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sensations from the patient and very often will
volunteer his history without questions being
asked. In every case the mode of onset should
be ascertained.
Another feature of smallpox, peculiar to it
and equally trustworthy for diagnosis, is the
site of the eruption. It will always appear first
and be most abundant on the face and hands.
If there are only a few lesions they will be
found in these locations. This is in contrast to
chickenpox where the lesions show preference
for the chest which is usually free in smallpox.
The face is the site of eruption by preference in
other simpler affections such as acne, but the
back of the hands will not be broken out; in
multiform erythema, the face and back of the
hands may both be affected along with febrile
symptoms, but the lesions will be macular.
As to the eruption itself, the tsrpe lesion of
smallpox is a papule, hard, red and firm to the
touch. It develops into a vesico-papule or later
a pustula^papule, and never loses its hard firm
base. All eruption will appear within two days
and all in a given region of the body almost
simultaneously. All adjacent lesions will be
of the same type. Aside from these points trust
lighUy to the lesion for diagnosis. In mild
forms of smallpox the eruption sometimes
aborts even before the vesicle forms and may
never become pustular, but whatever the lesion,
it will retain its papular quality and over a pro-
longed period.
No other eruptive disease has at onset a fever,
or possibly malaise only, which lasts for about
three days and then subsides as the eruption
appears; no other eruptive disease has a
papular eruption which comes first on the un-
covered skin — the face and hands; no other has
a papulo-vesicular eruption which develops in
its entirety within 24 or 48 hours, so that all
adjacent lesions are of the same age and state
of development.
Left Scapular Pain and Hyperalgesia In
Heart DIsemse*— The significance of symptoms
in the diagnosis of disease and in the estimation
of its degree is receiving exact study in many
departments of medicine, states an editorial
writer in The Lancet (Apr. 5, 1919). In pul-
monary tuberculosis it is practically impossible
to express an opinion as to the nature and stage
of the disease without careful correlation of the
symptoms with the physical signs observed. In
heart disease the symptoms afford a valuable
measure of the degree of the derangement of
function caused by the lesion Indicated by the
physicial signs and of the necessity for treat-
ment. That various cardiac conditions are as-
sociated with some degree of precordial pain
and tenderness has long been familiar, but the
extent, character and radiations of these pains
have perhaps not received the attention they
deserve except in the case of angina pectoris.
There appears in this same issue of The Lancet
an interesting and suggestive note by Dr. John
Parkinson upon a little-recognized form of
cardiac pain and tenderness, namely, that oc-
curring in the left scapular region. He has
made a careful study of 50 cases in which these
conditions were observed. The scapular pain
is usually referred to a spot just below or in-
ternal to the lower angle of the left scapula, tho
it is sometimes felt along the vertebral border
of the lower half of the scapula. It is appar-
ently always accompanied by submammary
pain, which is more generally recognized as of
cardiac origin. The scapular pain is usually a
later manifestation, tho in a few patients it ap-
peared to originate at the same time as the
submammary. The hyperalgesia was less fre-
quently present than the pain, and its extent
was variable, as shown in the record of 10 cases
given by Dr. Parkinson. The conditions in
which left submammary and scapular pain were
observed included valvular and myocardial dis-
ease, arteriosclerosis and renal disease with
cardiac embarrassment, especially when asso-
ciated with high blood pressure; also "funo-
tional" heart disease and conditions of general
ill health with inefficient action of the heart
As might be expected. Dr. Parkinson finds the
explanation of these symptoms in the well-
recognized principle of referred pain in visceral
disease, so ably elucidated by Dr. Henry Head
and Sir James Mackenzie. He finds that the
sixth thoracic segment alone or in combination
with the fifth supplies the submammary and
scapular regions to which the pain is usually
referred. The hyperalgesia corresponds to the
same segments, tho it may extend to a larger
area. He regards the development of hyperes-
thesia in cases of chronic heart disease or dis-
order, especicUly when it persists or recurs, as
indicating a new and more obstinate stage. In
his opinion the hyperesthesia induces and sup-
plements the pain since it may be started or
provoked by various movements disturbing the
hyperesthetic areas. Dr. Parkinson's note illus-
trates well the manner in which careful record
of symptoms may throw light upon disturbed
function in disease.
Diagnosis of Cerebrospinal Meningitis.—
This is the most important type of meningitis
in the young. Perry in 'the Southern Practi-
tioner (Aug., 1918). says that the diagnosis is
made on the following symptoms and lumbar
puncture. The onset is usually abrupt, violent
headache and vomiting being the first symptoms.
Soon the temperature rises to 104-105 degrees,
and prostration is marked. The pulse is rapid,
and the respiration Cheyne-Stokes in type. By
the third or fourth day after symptoms have
developed there is marked stiffness of the neck
with retraction of the head. The thighs be-
come fiexed on the abdomen, and the legs are
fiexed on the thighs. This causes the patient
to assume the "gun-hammer" position. If left
undisturbed in this position the patient seems
comfortable, but cries out when moved. The
legs cannot be extended on the thighs and we
get what is known as Kernig's sign. Photopho-
bia is a constant symptom. Ocular paralysis
does not occur frequently. The discs, however.
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May, 1919
ETIOLOGY AND DIAGNOSIS
AMBRICAN MSDICINB
may become choked and optic atrophy result
The middle ear occasionally becomes involved,
the pus showing the meningococcus. Central
deafness often results.
Punctate hemorrhagic skin lesions resem-
bling "flea bites" are* described in this disease.
In two cases Perry has seen these lesions.
Hyperesthesia is usually very marked. The
knee-jerks are exaggerated, and Brudzinski's
sign is present in most cases. Tache c^r^brale
and McE wen's sign are also present in this
type of meningitis. The urine usualy shows
albumen. The blood averages a total count of
30,000 with 90 per cent, polymorphonuclears.
The spinal fluid may be only cloudy or almost
pure ^us.
Complications and Sequelae, — Bronchopneu-
monia, acute otitis media, and central deafness,
choked discs followed by optic atrophy and
blindness. Various forms of paralysis, and the
development of chronic basilar meningitis. In
this latter condition the patient is in the *'gun-
hammer'* position with a spastic paralysis. The
head is hydrocephalic In type and there Is
usually blindness.
The spinal fluid in this type of meningitis is
always cloudy, and on microscopic examination
is found to consist of many cells, 30,000-40,000
per c m., and to be mostly of the polymorpho-
nuclear variety. Globulin is increased, sugar
decreased or absent. Smears stained by Gram's
method show negative, intracellular diplococci.
The organism grows best on Loeffler's blood
serum or glycerine-agar. In smear prepara-
tions made from the freshly drawn fluid the or-
ganisms may be hard to find, and patient
searching may be necessary before they are
discovered. In a purulent spinal fluid one
should not give up until the character of the
organism has been demonstrated. In all cases
where one suspects meningitis a lumbar punc-
ture should be done. It is a simple and, under
proper precautions, a harmless operation, and
it makes the diagnosis certain.
Prognosis, — In this type of meningitis, since
the introduction of the serum treatment, the
mortality has been reduced from 70 or 75 per
cent, to 25 per cent.
Prophylaxis. — Cases of cerebrospinal menin-
gitis should be kept isolated until the nose and
throat do not show any meningococci on culture.
Alkaline sprays and argyrol are useful in rid-
ding the mucous membrane of this germ.
Appendicitis in Children.— AppendiciUs in
children is not infrequently associated with
other infectious diseases: Influenza, measles,
acute rheumatism, enterocolitis, typhoid and
tonsillitis. Bower (N. Y. Med, Jour., Sept. 21,
1918) states that it is the opinion of many that
the excess of lymphoid tissue together with a
thinning of the submucous coat accounts for
the frequency of associated appendicular in-
flammation in these cases. 2. Abdominal in-
Jury predisposes to appendiceal inflammation
in the young adult, 2.5 per cent, of cases giving
such a history. 3. Fecal concretions are usually
larger and are more frequently found in early
life. 4. Intestinal parasites are uncommon but
are more frequently associated with appen-
dicitis in juveniles. 5. Foreign bodies are more
frequently found In appendices in children than
in adults. We have seen lemon and grape
seeds, toothbrush bristles, toothpicks, and,
more recently, a common pin. In this in-
stance the patient, two i^nd a half years of age.
entered the hospital with a history of lower
abdominal pain, nausea, vomiting, and frequent
urination, of four days' duration. At operation
we found a localized abscess with a rusty pin
well down in the pelvis. The tip of the ap-
pendix was markedly hypertrophied, the pin
undoubtedly having lodged in this portion of
the organ for some time prior to its passage
into the peritoneal cavity.
The direct causative factors are the bacillus
coll, staphylococcus, streptococcus, bacillus py-
ocyaneus, and the tubercle bacillus. This is the
order of frequeny with which the above men-
tioned germs attack the appendix. It must be
remembered, however, that tuberculosis of the
appendix in adults is invariably secondary to a
pulmonary lesion, while in young adults it
usually follows or accompanies a general ab-
dominal tuberculosis.
Clinical Aspects of Hematarla^— Hirsch
(Therap. Qnzette, November, 1918), in an in-
structive paper, recapitulates his observations
as follows: 1. A complete detailed history
and a careful physical examination should be an
invariable rule in every case of hematuria.
2. A positive diagnosis can be made in 99 per
cent, of all cases, by the Judicious use of the
cystoscope, ureteral catheter, urethroscope.
X-ray and laboratory. 3. The color or density
of blood in the urine, or the presence and char-
acter of clots, are in themselves not sufficient
criteria on which to base a diagnosis. 4. Too
much reliance must not be placed on iiie clinical
significance of Initial or terminal hematuria, as
indicating the origin of the bleeding. 5. Re-
peated cystoscopic, urethroscopic. X-ray and
laboratory studies may be necessary before giv-
ing a definite opinion. 6. Many so-called es-
sential, idiopathic or symptomless hematurias
are cases of bleeding arising from a renal varix,
angioma of the papilla, uretral papilloma, etc.,
conditions which are impossible of clinical
recognition. 7. The presence of excessive
urate, phosphate or oxalate crystals in the
urine may produce hematuria, hence careful
microscopic study should be made. Tubercle
bacilli casts, parasites or their larvae, and hooks
of the echinococcus should be sought for In all
hematurias of suspicious origin. 8. If blood is
of suspected vesical origin, cystoscopy should
be done during tne intervals, when there is
little or no hemorrhage. The origin of hemor-
rhage coming from the upper urinary tract is
best determined by seeing the blood as it issues
from the ureteral orifice. Ureteral catheteriza-
tion is rarely necessary in these cases, and
should only be resorted to either for functional
study or the collection of the separate urines
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299
from each kidney. Due allowance should be
made for blood-tinged urine coming from the
catheter, which might be due to instrumenta-
tion.
tion is simple and rarely takes more than nine
minutes, from the opening of the flap to the
closing of the flap and the end of the operation.
REATMENT
Intraeranial Treatment of Paresis.— Cotton
and Stevenson report in the Journal of Nervous
and Mental Diseases, April, 1918, that one of
the difficulties constantly met in the treatment
of this trouble is t6 determine the best method,
for it largely depends upon the type of case that
is being treated.
The writers do not believe that the intra-
venous administration of salvarsan alone is
sufficient to effect a remission, even if the
spinal fluid is drained, as advocated by some,
tho it is absolutely necessary. The cases that
have had the combined treatment, both intrar
venous and intraspinous or intracranial, cer-
tainly do much better than those who have had
no intravenous injections. One advantage of
the intracranial method is that one can give a
nluch larger dose of salvarsan, than by the In-
traspinal method, for in the latter, because of
the sensitiveness of the spinal cord and the
danger of producing serious damage, only a
very small dose of salvarsan can be given, and
only at two week intervals. On the other hand,
with the intracranial method, a very much
larger dose can be given and often once a week,
especially if the subdural route is used.
A general anesthetic is not given, but the
scalp cocainized with a 4 per cent, solution of
cocaine. An incision is made over the bregma,
either on the right or left side of the head and
about a flnger's breadth from the median line.
A semicircular flap is then made and the peri-
osteum is separated from the bone. For making
the ti^phine opening into the Bkull an Albee
electric drill with a Martel attachment is used
which prevents any injury to the dura. After
the dura is exposed a small incision is made
and care taken not to sever any dural vessel,
and then a modlfled Gushing brain cannula is
introduced thru the dura and then thru the
brain cortex, and when the ventricle is reached
the plunger is withdrawn and the fluid allowed
to flow out. During this stage of the operation
the head of the table is lowered to facilitate the
flow of the fluid. After sufficient fluid has
escaped the serum is then introduced thru the
cannula into the cortex, from a luer syringe and
then the cannula is withdrawn, and the scalp
flap is sutured. The patient is able to get up
from the table unassisted and walk out of the
room. He is told to lie down for a little while
if he feels any effects from his treatment, but
usually he has no after-effects. This opera-
Hoarseness^^Levbarg in yew York Medical
Journal, April 20, 1918, says that the most im-
portant problem confronting the laryngologist
is hoarseness, especially* that in singers, speak-
ers and those who depend for a livelihood solely
upon the use of their voice. It is important
before examining the patient to take a careful
history of the case. * It is essential to know the
habits of the individual, his customary diet,
etc.
Do not direct all the attention exclusively to
* the vocal cords, but search carefully the sur-
rounding tissues. Any pathologic condition
interfering with the action of the vocal cords
will cause hoarseness, but other things will
produce the same effect. Marked hypertrophy
of the lingual tonsil will cause a constant irrita-
tion, setting up severe congestion of the mu-
cous membrane around the laryngeal region.
Caseous tonsils have the same effect. Enlarged
and inflamed adenoids and chronic nasophar-
yngitis have been proved to cause hoarseness.
Great meat eaters will always have a severe
congestion of the mucous membrane of the
nose and throat, probably due to the increased
proteins in their blood.
The most important problem is the hoarseness
which comes on without apparent cause and
without history of exposure on the part of the
singer. It will frequently disappear almost as«
suddenly as it came. The patient fears to sing
a long aria; he dreads that his voice may break
during the course of his delivery of it. On ex-
amination invariably you will And in these pa-
tients a small nodule on one or both cords. This
condition is known as chorditis nodosa. Chor-
ditis nodosa accompanies chronic laryngitis in
those who use their voices in a faulty manner.
The treatment depends upon the cause. If
the method is faulty have the singer change in-
structors; if due to diet prescribe a different
one; if due to any pathologic condition treat it
accordingly. Diet, rest, relaxation, plenty of
air, exercise, and regular habits will gradually
eradicate the hoarseness which is the dread of
the singer and the public speaker.
Hay Fever and A 8thma«— Reporting the re-
sults of his investigations, with a view of select-
ing the most effective treatment, Scheppegrell
states in New York Medioai Journal (June 1,
1918): The treatment of the cases of this
series, during the active stage of the hay fever,
was limited to the hypodermic injection of
pollen extracts and bacterial vaccines. The
extract of the pollen was selected to which the
patient was found to be sensitive and to which
he was exposed as indicated by the polleno-
metric records. The pollen responsible for most
of the early hay fever cases (April to July)
was found to be from the grasses (Oraminea),
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May, 1919
TREATMENT
AjcmuOAN Mboicinb
which also include the cultivated varieties such
as rye, wheat, oats and corn. The fall hay
fever (August, September, October) was found
to be principally due (ninety-five per cent.) to
the ragweeds (Ambrosiacew) . The large size
of the com pollen (eighty microns) limits its
potential area to a short distance from the
plant.
In the spring hay fever cases the extract of
the grass pollen was uded. and In the fall cases
that of the ragweeds. In cases in which the
patient suffered from both forms of hay fever
(spring and fall) the grass pollen was injected
at first, and the ragweed* extract during the
fall season. Combined extracts should not be
used in these cases, either for prophylactic or
curative purposes. /The grass pollens predom-
inate in the early part of the season and the •
ragweed in the latter, and the pollen extracts
should therefore be adapted to each season. The
patient, moreover, is rarely equally sensitive
to both pollens, so that a combined extract, in
which equal parts of each pollen is used, is not
indicated.
If the patient applies for treatment during a
severe period, the pollen extracts are usually
ineffective and a vaccine should be used, these
being injected at intervals of one or two days
until the severity of the attack subsides. The
pollen extract is then used, the vaccine injec-
tions being resumed if a severe paroxysm de-
velops. The reason for using the vaccine dur-
ing the severe paroxysms is that at this time
the patient is suffering not only from the effects
of the pollen but also from the great increase
•in the pathogenic microorganisms resulting
from the lowered resistance of the respiratory
membranes. The use of vaccine therapy at
this stage is therefore logical, and has given
satisfactory results. In a few cases (5 per
cent of this series) the treatment of the suc-
cessful ones was limited to vaccine therapy
only. The question of autogenous and stock
vaccines has been carefully considered in this
series. The autogenous vaccines are preferable
provided they can be obtained of the proper
standard and purity. When there is any doubt
regarding this, the stock vaccines of unques-
tioned reliability should be given the pref-
erence.
The Ineffielent Use of Taeclnes«— Objections
to the use of vaccines in the treatment of acute
infections like pneumonia, broncho-pneumonia,
infiuenza, mastoiditis, sinusitis, colds, etc., says
a writer in the Bacterial Therapist (Mar., 1919),
arise only from those who have had no real ex-
perience with them in the treatment of such
cases, or from those who have used them In-
efllciently and improperly; used them differently
than those who obtain excellent results; and
curiously enough most of these objections come
from men high in authority on other thera-
peutic measures. Therapeutic agents are eflEL-
cient only when properly applied, hence the
greatest efficiency of a remedy can only be de-
termined by extensive clinical experience.
The objections to the use of bacterial vac-
cines in the treatment of extensive acute infec-
tions are purely theoretical. The contentions
are, that the toxic symptoms which prevail in
these acute Infections show that the patient is
suffering from an overload of bacteria and their
products; that to give vaccines under such con-
ditions is irrational because we thereby simply
add more bacterial toxins where it is clearly
evident that the patient is suffering from an
excessive amount of toxins; and that by giving
vaccines under such conditions we are liable
to thrust the patient into the so-called ''negative
phase'' and make matters worse.
Many of these objectors have heard of the
good results that are being obtained with vac-
cines in extensive acute infections, but as a
rule their theoretical prejudices are so strong
that they are unwilling to give them a trial and
if perchance they do try them, nine times out
of ten they allow their preconceived notions to
prevail; allow the thought, that by giviilg vac-
cines we make the patient more toxic, to dom-
inate, with the result that the patient receives
entirely too small doses at much too long' in-
tervals. Such trials would naturally result in
failure, and yet the contention from these
sources will carry more weight with many
otherwise well informed physicians, than state-
ments from general practitioners who have used
vaccines with success, because they use them in
. such a way that experience teaches them to be
most efficient. Most of the available literature
on vaccine therapy has been written by labora-
tory research workers who hold that vaccines
are contraindicated in extensive acute infec-
tions and that if vaccines are employed in such
cases, very small doses are recommended.
We find, however, that absolutely contrary
conditions prevail. We find that in subacute
and chronic infections, to obtain the best re-
sults, treatment must be started with a small
dose, usually 0.2 mil. of a standardized suspen-
sion, and the dose should then be gradually in-
creased to 1 mil. or more and inoculations made
at 4 to 7 day intervals. If in chronic infec-
tions treatment is started with a large dose un-
pleasant reactions are almost sure to follow
and if the injections are repeated ^t short in-
tervals the infection will not subside as rapidly
as if small doscfS are employed at long intervals.
In extensive acute infections, large doses — 1
mil. of a standard suspension given at the
earliest possible moment, repeated at daily in-
tervals— give decidedly the best results^ and in
extremely bad cases the vaccine may be given
twice a day to advantage. No appreciable reac-
tions follow the use of 1 mil. doses of vaccine,
when given during a high temperature and
other indications of a toxic infection, nor does
any material infiltration develop at the site of
injection. The rule should be that in the most
severe infections, the largest dose should be
given at the shortest interval and the less
severe cases should receive the smaller dose at
longer intervals. Unless this general rule is
followed, no satisfactory results will be obtained
from the use of bacterial vaccines.
As long as objectors to vaccine therapy re-
main obstinate, as long as they are unwilling
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AMERICAN MBDICXNB
TREATMENT
May. 1919
301
to give vaccines an efficient trial, we must ex-
pect the unfortunate victims of pneumonia and
similar infections to pay the penalty, but surely
this apathy cannot continue much longer. If
any dangerous or unpleasant symptoms would
follow the use of vaccines, there would be some
excuse for hesitation, but all available informa-
tion shows that the treatment is absolutely
harmless. The reason for the necessity of large
doses of vaccines at short intervals may be ex-
plained on the ground that in extensive acute
infections we have a large number of organisms
multiplying rapidly, to contend with and to de-
stroy these organisms there is required a large
amount of antibody. If the antibody that was
produced as the result of the first injection is
all consumed before all the infecting organisms
are destroyed, the infection may "light up"
again, but by repeating the inoculations at short
Intervals, the antibody producing process will
be continued until the infection is eliminated.
Thousands of doctors are employing this
method in the treatment of pneumonia and
other acute Infections and the results speak for
themselves. No one, to our knowledge, who has
ever given this treatment a fair and unbiased
trial, has discontinued it The only way you
can satisfy yourself as to the efficacy of bacterial
vaccines, is to give them a trial and use them
in the same way as others do who are obtaining
results.
Treatment of Iritis*— If the treatment of iritis
could be confined to one drug, that drug would
undoubtedly be atropia. Atropine, Andrew
{Long Island Med. Jour., Jan., 1919) claims
meets most of the local requirements. It dilates
the pupil narrowing the diameter of the iris,
squeezing the engorged vessels and reducing
the inflammation. It paralyzes the accommoda-
tion thus putting the eye at rest, and by draw-
ing the pupilary margin away from the ante-
rior surface of the lens prevents the formation
of adhesions or breaks up those which are
forming. It is of no value in occluded pupils.
Sometimes a granule of powdered atropine
placed in the conjunctival sac accomplishes the
purpose better than the solution. Cocaine
added to the atropine will occasionally increase
the effect. Atropia must be instilled sufficiently
often to keep the pupil dilated, and the tension
of the eye should be constantly watched during
its use. Dionin used with the atropine relieves
pain in some Instances, and by its lymphagogue
action assists in removing the products of in-
flammation.
An old and honorable way to deplete the en-
gorged vessels is by blood letting at the temple,
either by the use of leeches, or by the use of an
artiflclal leech. In this connection it may be
well to add that in the absence of leeches or the
usual artificial leech, a good substitute may be
improvised by scarifying the temple and apply-
ing an ordinary breast pump. It is sometimes
a matter of surprise to see how quickly atropine
will produce its maximum effect after a blood
letting.
The systematic treatment of iritis is the treat-
ment of its cause. In syphilis our sheet anchors
are salvarsan, mercury and after the inflamma-
tion has begun to subside the iodides.
When associated with myositis and arthritis
the salicylates and aspirin are indicated, even
tho the gonococcus is the causative factor. If
a focus of Infection can be found In the teeth,
the tonsils, the nasal sinuses, the prostate or
any other place it must be gotten rid of at once.
In many cases, in addition to lemovlng the
focus, the condition will be helped by the ad-
ministration of an autogenous vaccine. The
gonorrheal form is also frequently helped by a
gonorrheal vaccine.
Tuberculosis is tuberculosis whether found
in the lungs or the Iris, and the general rules
for its management are similar. The adminis-
tration of tuberculin is sometimes of consider-
able benefit. Some surgeons advocate the use
of a three per cent, gualacol ointment as an
inunction, or the subconjunctival injection of a
one or two per cent, solution of gualacol.
To be successful in the treatment of iritis the
surgeon must ever bear in mind its pathology,
and he must be prepared to discover the etiology
of each case, by using all those aids to modern
medicine, the X-ray, and particularly the patho-
logic laboratory for his bacteriologic and sero-
logic tests and for the preparation of his vac-
cines. With all the aid which modern medicine
offers us we find it necessary only too often in
the treatment of this most insidious disease, to
summon to our aid our last reserves of common
and diagnostic sense and therapeutic acumen.
Diet in Clrriiosls of Liver*- Terol (Revista
dos. Curaos, Apr., 1918) advises a milk diet in
the early stages of cirrhosis of liver. This
leaves the liver comparatively in repose while
promoting diuresis. He gives nothing but water
the first day except a purge. An adult should
take 3 liters of milk during the day, sipping a
small amount every one or two hours. The
milk should never be taken more than this at
a time, as this would distend the stomach, with
retention and fermentation with results in-
jurious for the liver cells, and digestive disturb-
ances which impel the abandoning of the milk
diet. The milk must never be taken raw. but
goat's or ass' milk may be substituted for
cow's milk. Fermented milk or condensed milk,
etc., should not be used except when the patient
wearies of the sterilized milk. This milk diet
should be kept up for a month. After this the
ordinary diet can be very slowly and gradually
resumed, keeping to smcUl meals of easily
digestible foods. He advises four meals, the two
latest at 5 and 9 p. m.. but they should never be
abundant. Weak mineral waters are useful,
avoiding all carbonated beverages as their gas
distends the stomach. Mastication should be
especially thoro, and the patient should give
both body and mind a rest after eating. Gen-
eral and tonic hygiene should be enforced. In
cirrhosis with hypertrophy there is excessive
functioning on the part of the liver, and the
diet should aim to reduce production of toxins,
being restricted to starchy foods and dry vege-
tables with little sugar or substances liable to
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NOTES AND ANNOUNCEMENTS
American Mbdicinb
putrefy. In cirrhosis with atrophy, meat should
be positively prohibited to ward off production
of toxins, and salt should be restricted to 6 gm.
a day to guard against ascites and edema.
victims as they are at present of the poorest
and cheapest form of contract medical service
supplied by the insurance companies.
NEWS NOTES "»
ANNOONCEMENTJ
lAUaria In the United States^-The United
States Public Health Service estimates that over
7,000,000 people in the United States are in-
fected with malaria. Estimates prepared by
the service indicate that in the South the rav-
ages of typhoid fever, tuberculosis, hookworm,
and pellagra all together are not as serious as
from malaria.
Workmen's Compensation Laws and the In-
surance Companies* — At a special meeting held
April 2, 1919, at 51 E. 100th Street of the ex-
ecutive committee of the Physicians' Protective
Association of New York, Dr. Eidward L. Spltzer
presiding, the following resolutions were intro-
duced by Dr. John P. Davin and were passed
unanimously :
Whereas, The Governor of the State in a
special message to the legislature has demanded
immediate revision of the Workman's Compen-
sation Law to prevent direct settlement between
injured employees and the insurance carriers,
suggesting that the legislators read the report
of Jeremiah F. Connor, showing that many in-
jured persons have been defrauded by the in-
surance companies, in some instances being
bilked of $2,000.00 or more.
A/nd Whereas, Governor Smith further says
that with these facts before the legislature. It
should forthwith amend the law and abolish di-
rect settlements or present some good reason for
not doing so which thinking men and women
will tolerate.
Resolved, That we respectfully call the atten-
tion of the Governor and the legislature to
an exactly similar condition relating to the
payment of physicians' fees by the insurance
companies, which has resulted in the denial of
the best medical service to the injured work-
men and working women of the State. This is
owing to the impotency of the medical pro-
visions of the Workman's Compensation Law
either to provide a proper fee for medical serv-
ice or to compel the payment of the fee
awarded by the commission against the insur-
ance companies.
Resolved, That the Governor include in his
proposed revision of the Workman's Compen-
sation Law to remedy this form of in-
justice to the medical profession, to the end
that the working men of this State will receive
the services of the best men in the medical
practice as they did before the passage of the
Workman's Compensation Law, and not be the
Dr. Abraliam Jaeobi's Eighty-ninth Birthday
was celebrated a few days ago. It is one of the
privileges of May time to offer felicitations to
Dr. Jacobi on this day each year, and we join
the Medical Record in looking forward with
pleasurable anticipation to the celebration,
eleven years hence, of his first centennial.
Spain Honors Mme. Cnrie. — King Alfonso has
signed a decree awarding the Great Cross of
the Civilian Order of Alfonso XIII to Mme.
Sklodowska Curie, the distinguished French
scientist, chief professor in the faculty of
sciences of the University of Paris. Mme. Cnrie
was the discoverer of polonium and co-discov-
erer with her husband of radium.
General Gorgas Heads Yellow Fever Com-
mission.— ^Major-General William C. Gorgas, re-
cently retired for age from the office of Surgeon-
General of the United States Army, has re-
sumed his position as chief, of the Rockefeller
Commission on Yellow Fever and will soon sail
for Central America to supervise the studies
that are being carried on there by the Rocke-
feller Commission.
The National Society for the Study and Cor-
rection of Speech Defects.— The National So-
ciety for the Study and Correction of Speech
Disorder will have its summer meeting in Mil-
waukee, on July 4, as one of the affiliated So-
cieties of the National Educational Association.
Members of the Society and invited guests of
prominence in the field of speech correction,
will address the Association. Anyone interested
to receive an advanced program may do so by
addressing the Secretary, Miss Marguerite
Franklin, 110 Bay State Rd.. Boston. Mass.
Don't Qait!
"You're sick of the game?" Well, now, that's
a shame;
You're young and you're brave and you're
bright.
"You've had a raw deal?" t know, but don't
squeal;
Buck up, do your damnedest and fight.
It's the plugging away that will win you the
day.
So don't be a piker, old pard.
Just draw on your grit; it's so easy to quit,
It's the keeping-your-chin-up that's hard.
— Anon.
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American Mkdicinb
AMONG THE BOOKS
May. 1919
303
It Can Be Done!
"Somebody said that It couldn't be done,
But he, with a chuckle, replied
That 'maybe it couldn't,' but he would be one
Who wouldn't say so till he'd tried.
So he buckled right in with the trace of a grin
On his face. If he worried he hid it.
He started to sing as he tackled the thing
That couldn't be done, and he did it.
"Somebody scoffed, 'Oh, you'll never do that,
At least no one ever has done it';
But he took off his coat and he took oft his hat,
And the first think he knew he'd begun it,
With the lift of his chin and a bit of a grin.
If any doubt rose he forbade it;
He started to sing as he tackled the thing
That couldn't be done, and he did it.
"There are thousands to tell you it couldn't be
done,
There are thousands to prophesy failure;
There are thousands to point out to you, one by
one.
The dangers that wait to assail you.
But Just buckle in with a bit of a grin.
Then take off your coat and go to it.
Just start in to sing as you tackle the thing
That cannot be done, and you'll do it."
—"Evelyn," in the N, 7. THbune.
top no matter how keen the competition." In
the same way it may be said that there is al-
ways room for a really good book, no matter
how many may have been written on the same
subject.
The Treatment of War Wounds by Dr. W. W.
Keen (W. B. Saunders Company, Philadelphia,
1918) is assuredly a work of this kind. It is
a compact and concise presentation of some of
the most important phases of war surgery. In
fact it is just such a work as might be expected
from such an acknowledged master of surgery
as Dr. Keen is known to be. This is a second
edition, the first having been issued only a
little over a year or so ago. However, this
latest edition is more than a simple revision,
as the rapid progress made in the treatment of
war wounds has rendered it necessary to prac-
tically rewrite the entire book. In this edition
is included the work on acriflavine, proflavine
and "brilliant green" mercurophen, as well as
the latest technic on the paraflin treatment of
burns as devised and perfected by the French
naval surgeon de Sandfort. Dr. Keen is a writer
whose forceful and interesting personality is
always reflected in his writings. As a con-
sequence, this contribution to the subject, in
addition to its practical scientific value, has a
quality and merit which those who know Dr.
Keen and his work will be quick to recognize
and appreciate.
God CUve Us Hen!
God give us men! A time like this demands
Strong minds, great hearts, true faith and
ready hands;
Men whom the love of office cannot kill;
Men whom the spoils of office cannot buy;
Men who possess opinions and a will;
Men who have known, men who will not lie;
Men who stand before a demagogue
And damn his treacherous fiatteries without
winking.
Tall men, sun-crowned, who live above the fog.
In public duty and in private thinking;
For while the rabble with their thumb-worn
creeds.
Their large professions and their little deeds.
Mingle in selfish strife, lo! Freedom weeps,
Wrong rules the land, and waiting justice
sleeps. — John S. Holland.'
AMONG
THE
BOOKS
0
The Treatment of War Wonndsr— It is a well
known adage that "there is always room at the
Electrotherapeutics. — Probably no branch of
therapeutics has made greater strides than
electricity, or has more surely within recent
years been lifted out of the slough of em-
piricism. While empiricism cannot be entirely
eliminated from the employment of any line of
treatment, it is perhaps more aggressively
evident in the domain of electrotherapeutics
than in any other field of medicine. Therefore
it is encouraging to note that the science of
medical electricity is at last duly and properly
coming into its own. A good deal of the em-
piricism, which has prejudiced the medical pro-
fession against the use of electricity for
therapeutic purposes, has been brought about
by reason of the way in which electricity has
been shrouded in mysticism. Obviously, the
more that simple methods of -electrical treat-
ment are employed the more quickly will the
whole subject be deprived of the mystic element
and the more comprehensive and effective will
become its application to diseased conditions.
Electricity in Medicine by George W. Jacoby,
M. D., and J. Ralph Jacoby, M. D. (P. Blakis-
ton's Son & Co., Philadelphia) serves admirably
to show what can be accomplished by electro-
therapy when thoroly understood. The book is
well written and contains all the necessary,
up-to-date information required to insure the
successful use of electricity in medicine. The
illustrations are numerous and aid greatly in
the interpretation and elucidation of the text.
We do not hesiUte to say that this is one of the
best and most satisfactory works on the sub-
ject that has ever been published. No man who
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May. 1919
AMONG THE BOOKS
Amebican Mboicins
uses electricity in any way in his practice
should fail to have it for frequent reference.
Surgical Nnrsingr— That nurses are absolutely
essential to the proper care of all patients,
but especially those forced to undergo surgical
treatment has received ample testimony, if
such testimony were needed, during the war.
It may seem heresy to say so in a medical
Journal but nurses are almost, if not quite, as
necessary in the management of surgical in-
juries as physicians and surgeons. When
nurses are thus referred to it must be under-
stood that thoroly skilled and competent nurses
are meant. In order to be skilled a nurse
must we well trained, and she cannot be well
trained unless she is well versed in the elemen-
tary principles of medicine and surgery. There-
fore, the Text-Book of Surgery for Student and
Graduate Nurses by Archibald Leete McDonald,
M. D. (J. B. Uppincott Company, Philadelphia)
is welcome. This manual deals with anatomy,
physiology and bacteriology in so far as these
directly relate to surgical conditions in addition
to the care and management of surgical pa-
tients. It is a book calculated to be of un-
limited value to nurses who are called on to
assist at surgical operations, as well as to carry
out the surgeon's instructions in regard to after
care.
X-Ray Therapy.— -Roentgenotherapy has made
great headway during recent years, despite the
fact that there has been a dearth of reliable
works on the subject from which the beginner
could obtain the necessary Information. With
the view of filling this want, Albert Franklin
Tyler, B. Sc, M. D., in Roentgenotherapy (C. V.
Mosby Co., St. Louis) has written a book the
terms of which are so simple that a veritable
novice can readily grasp the essential principles.
He has also furnished a brief description of
the apparatus necessary in roentgenotherapy;
this is so well and profusely illustrated that
the reader may, with minimum effort, become
familiarized with the requisite mechanical and
electrical details of the work. The book is
practical, and undoubtedly will prove extremely
helpful, not alone in clearing away obscure
points, but in rendering roentgenotherapy
easily intelligible to those who seek a working
knowledge of its effective application.
Tropical Medicine.— It never has been, and is
not now, generally realized that many tropical
diseases are indigenous to this country. In
fact, a considerable portion of the United States
lies in a sub-tropical region, in which unfor-
tunately flourish all such tropical alfections as
malaria, black water fever, amebic dysentery,
bacillary dysentery, liver abscess, pellagra and
hookworm disease. Consequently these mal-
adies possess for many American medical prac-
titioners much more than an academic Interest,
and not a few physicians have found It neces-
sary to study them in all their bearings. It is
not enough, moreover, to approach these dis-
eases from the laboratory viewpoint, but the
clinical phenomena of each and all of them
should be made the subject of careful investiga-
tion. Correct diagnosis obviously is essential
to proper treatment and the procuring of a
correct diagnosis is immensely aided by clinical
study of the sufferer. With a full apprecia-
tion of these facto, E. R. Stitt, A. B., Ph. G.,
M. D., LL. D., has written The Diagnosis and
Treatment of Tropical Diseases (P. Blakiston's
Son ft Co., Philadelphia) in which tropical dis-
eases are considered from the clinical stand-
point As this is a third edition it is unneces-
sary to deal with the book in detail, and it will
suffice to point out that as the second edition
was published less than a year ago, at which
time a very thoro revision was made, there has
seemed to be no need for material changes in
the present edition. The subject Of trench
fever has been brought up-to-date and a few
other somewhat immaterial alterations have
been made. The illustrations are numerous
and effective, and the book can be highly en-
dorsed as a commendable contribution to the
subject.
Beverages. — The matter of beverages is an
important one, and altho it seems probable
that alcohol beverages will not bulk large or,
at any rate, not so large, in this country in the
future, that fact affords no valid reason why
alcoholic beverages should not be considered.
Unfortunately, all beverages, and alcoholic
beverages are not exempt from this Implication,
are subject to adulteration. In Beverages and
Their Adulteration by Harvey W. Wiley, M. D.
(P. Blakiston's Son ft Co., Philadelphia) the
subject is dealt with by an acknowledged
authority. Indeed on this side of the Atlantic
there is perhaps no higher authority on the
question of diet than Dr. Wiley. The book be-
fore us is intended as a companion to the
volume on Food and Its Adulteration, which
the same author brought out not long ago, and
which met with so favorable a reception at the
hands of the medical profession and the public
alike. This book discusses the subject in de-
tail, and a feature of that part of it in which
alcohol is considered, is that medicines, so-
called, which consist chiefly of alcohol, and
which are held by the Bureau of Internal
Revenue as non-medicinal but alcoholic, are
fully described. Those drinks which are popu-
larly termed soft are given an exhaustive de-
scription, and water of all kinds, potable, min-
eral of the artificial and natural varieties, are
all considered at considerable length. With each
subject dealt with, the common adulterations
and misbrandings which may be practiced there-
with, are gone Into. The book is timely and
valuable, and by its publication Dr. Wiley has
given us a fitting companion to his volume on
Food and Its Adulterations.
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For Eye,Ear,Nose,Throat and
Genito-Urinary Organs
r«nwoL
18 a germicicle of marked power
dand «ffica^. It is non-toxic and non-irri-
tating. It is serviceable in any condition in which a silver
salt is indicated. Audiorities have pronounced Silvol the
most satisfactory proteid-silver compound that^ has been
offered to the medical profession. The product is supplied
in a variety of useful forms:
SILVOL POWDER (Granular): Aqueouo
solutions may be prepared in any strength desired. They
may be applied to any inflamed mucous membrane by
spray, irrigation, injection or enema. They do not coagulate
albumin or precipitate the chlorides. Bottles of one ounce.
SILVOL CAPSULES (6-grain): Convenient
for the extemporaneous preparation of solutions of definite
strength. The contents of two capsules make one-fourth
ounce of a 10-per-cent. solution. Botdes of 100.
SILVOL OINTMENT (5 ^^ ) : For simple and
specific conjunctivitis^ trachoma, corneal ulcer, blepharitis,
rhinitis, ulcer of the septum, tonsillitis, pharyngitii^ etc
Collapsible tubes, two i '
SILVOL SUPPOSITORIES (Vaginal) (5 %):
For vaginitis (simple or gonorrheal) and cervical erosions.
Boxes of one dozen suppositories, eac^h in a metal capsule.
SILVOL BOUGIES (5%): For specific and
non-specific inflammations of the male urethra. Boxes of
25 and 100 bougies, each wrapped in waxed paper. An
introducer is supplied with each package.
Parke, Davis Sc Company
DETROIT
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American Medicine
H. EDWIN LEWIS, M. D., Manmzing Editor
IBA 8. WILE, Associate Editor
PUBUBHID MOHTHLT BT THB AmRIOAR MBDICAL PUBUBHING COMFAlTr
Copyrighted by the American Medieal Pabliahing Co., 1919
Complete Series, Vol. XXV, No. 0
New Series, Vol. XIV, No. 0
JUNE, 1919
CO no YEARLY
^C.\n3 In Advance
Greetings. — ^The response of the medi-
cal professton to the demands of war was
in thoro accord with its highest traditions.
With war regarded as a type of pestilence,
it was natural to find those whose duty it
is to wrestle with the forces of disease and
destruction prepared to assume their duties
and obligations in staying the horrors of
modern warfare, at home, in camp, in
trench, or in the shell-pocked "No Man's
Land." It were needless redundancy to dwell
upon the loyalty, courage and devotion of
the physicians, who, with their wonted
spirit of service, were willing to sacrifice
every personal consideration in order to
participate in the cause of their country.
Fortunately, the number of deaths from
wound, accident, disease or direct hits was
not high. The actual ratio of mortality to
medical mobilization was no higher than
that general to all mobilized forces. The
good fortune was not merely accorded to
the individuals, but passed to the entire
American Expeditionary Force, which
thus was enabled to secure a higher degree
of medical efficiency and a more continuous
service from the front line trench to the
base hospital.
Practically one quarter of the actually
practicing physicians of the United States
were wearing the colors. In addition, many
thousands were called upon for service in
connection with the selective service draft,
various problems in industry, in hospital
organization, and in readjusting the agen-
cies for health administration, so severely
handicapped by reason of the enlistment of
the regular staflf. The medical colleges ral-
lied to the cause, and with wise judgment
were permitted to continue their important
function of developing a new class of
graduates to take the place of those so sadly
needed in various sections of the country, or
to replace those who had "gone West."
The entire history of the American med-
ical service will not be written for many
years to come. Chapters have been devel-
oped which transcend in value any that
have ever been written. The European
War brought out the finest qualities in all
men, and in the medical fraternity intensi-
fied the ever-present virtues which under-
lie medical service. In the crucible of suf-
fering was developed a more worthy pro-
fession. In the face of hardship, suffering,
and impending calamity, ideals crystallized,
and bases of greater accomplishment were
founded.
Whether as a medical officer, a general
or special surgeon, a sanitarian or an admin-
istrator; whether on service at a hospital
this side of the Atlantic, or on duty in
France, England, or Germany, there was
evidenced the same conscientious spirit, an
identical determination to work by night
and by day in the interests of mankind.
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306
JUNB, 1919
EDITORIAL. COMMENT
American Mbdicink
Duty was their only calland they strained
to listen for it.
Taken as a whole, the accomplishments
of the Medical Corps of the United States
Army and Navy merit highest appreciation.
They had a most difficult task to perform
for which training had been inadequate.
Despite the difficulties and limitations in
practical experience, which may be freely
acknowledged without shame, the profession
rose to the demands of the occasion and,
under capable leadership, guidance and di-
rection, evercame obstacles which, during
years of peace, might have given innumer-
able fears and discouragements to the same
group of workers. Weighing all the com-
plaints, the criticisms, the individual ob-
jections to this and to that, waiving aside
certain injustices that may have occurred,
throwing aside unfavorable comments that
may have arisen from jealousy or unful-
filled hopes, the work of the medical offi-
cers of the United States Medical Corps
deserves cordial recognition and highest ap-
proval.
While actually an instrument of an army
bent upon destroying human life, medicine
maintained its position as a constructive
force for conserving human life. All the
traditions of the profession, from the ages
that have passed, shone forth splendidly,
and emerged from the welter of blood, un-
stained.
To all our professional brethren, who
have gone thru the great consecration of
war, American Medicine gives greetings.
It sees no wound stripes; it sees no service
stripes ; it sees no gold or silver chevrons ;
it sees only the spirit of American manhood,
the patriotic self-sacrificing attributes that
have ever redounded to the greatness and
glory of American medicine.
War Casualties.^— According to the re-
cently published summary of the casualties
of the United States Army and Marine
Corps, 33,374 soldiers were killed in action,
13,571 died from wounds, 23,399 died of
disease, and 4,950 died from accidents and
other causes. The total number of wounded
was 211,302, of whom more than 85 per
cent, returned to duty. The casualties in ,the
Marine Corps totaled 6,061, and the com-
plete number of deaths in both branches
was only 76,027, with the total number of
casualties in both branches of 294,234.
Under ordinary circumstances, a casualty
list of this proportion would be regarded
as heavy. Fortunately, the war ended be-
fore all American troops were exposed to
the front line hazards. The official data
have not indicated the ratio of the casualties
to the number of men actually engaged in
direct action. Regardless of ratios, how-
ever, the cost in life, wounds, permanent
disability and chronic invalidism, large as
it may seem to those to whom the loss is
personal, constitutes but a negligible part
of the war casualties of the most frightful
war of carnage that has ever cursed or
blessed humankind.
It is well, at this time, when we are ac-
customed to think in terms of millions and
billions, to contemplate the war losses of
the Allies and of the Central Powers, with
a view to visualizing, if possible, the eflfects
that have been wrought upon this genera-
tion, and with a view to contemplating the
enormity of the wastage from which suc-
ceeding generations, too, must suffer. The
figures do not take account of the deaths
from starvation, from pestilence, from the
trials, the massacres, the brutalities suf-
fered by the non-combatant population.
They convey no idea of the decreased birth
rate, the increased infant mortality rate.
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Amkrican Medicins
EDITORIAL COMMENT
June, 1919
307
the insanities, the wanton atrocities visited
upon infants, children, old men and old
women, the girls and young women. The
Allies had a total mobilization of 39,676,-
864, of whom 4,869,478 were killed; 11,-
175,715 were wounded, and 4,956,233 were
taken prisoners or reported missing. The
four Central Powers had mobilized 19,500,-
000, of whom 2,912,000 were killed; 7,605,-
542 were wounded, and 2,124,347 were re-
ported among the missing or were prisoners.
Compared with these vast numbers, how
fortunately small are the losses of the
United States!
The real ratios are more startlingly ap-
preciated when it is recognized that the
number of killed of the United States forces
was approximately only one and one-half
per cent, of the mobilized forces, as com-
pared with the 18>^ per cent, of France;
the 9.2 per cent, of the British Empire, the
8.4 per cent, for Italy, the 45.5 per cent,
for Serbia, and the 26.7 per cent, for Rou-
mania. The wounded of the United States
was approximately five per cent, of the
mobilized forces, compared with 35.7 per
cent, of France; 41.3 per cent, of Russia;
27.2 per cent of the British Empire; 17.2
per cent, of Italy.
According to the Vocational Summary^
March, 1919, the total number of wounded
for the United States and its Allies is in
excess of 11,000,000, and for the Central
Powers of 7,600;000. Of this total
number of 18,600,000 wounded men, it
is estimated that thirty per cent, or
nearly six million are "permanent hu-
man wrecks." These appalling figures
are fraught with a significance that it
is difficult to comprehend. The problems
of reorganizing the world's humanity into
a semblance of normal activity are stupend-
ous. They demand an unshaken faith and
confidence in the essential principles of
brotherliness and cooperation. They call
for unswerving fidelity to the ideals fof
which the war was waged by those who
proclaimed themselves the champions of
civilization, the defenders of mankind. The
weight of America's arms was the final
factor in ending the struggle, and to that
extent, the United States emerges as a peace-
maker. Fortunately, the rich resources of
this country were not impaired, and its
brains and its brawn were not ruthlessly
sacrificed or crippled by engines of de-
truction either at home or abroad.
America's real opportunity lies before it,
as a most powerful agent for world recon-
struction, as a rehabilitator of the handi-
capped, an encourager of the disheartened,
a shield to the weakened, a purveyor of
food, clothing and shelter to the peoples
of all lands, a physician to heal and soothe
the frightful wounds and diseases war has
visited upon the nations of the world.
International Red Cross Activities. —
Among significant efforts at reorganizing
the instrumentalities for advancing human
welfare must be noted the recent meeting
of the Interallied League of Red Cross So-
cieties held at Cannes. Here were gathered
together such authoritative councellors as
Drs. Roux, Laveran, Calmette, Widal and
Rist, representing France ; Drs. Bastianelli,
Lafava, Golgi and Castellani, from Italy;
Sir Arthur Newsholme, Sir Ronald Ross,
Dr. K. Menzies and Dr. Truby King, rep-
resentatives of England. The United
States delegation included Drs. William H.
Welch, Dr. L. Emmett Holt, Dr. Samuel M.
Hamill, Dr. Livingston Farrand, Dr. Her-
mann M. Briggs, Dr. William P. Lucas,
Dr. Fritz Talbot and Dr. William F. Snow.
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308
JUNB^ 1919
EDITORIAL. COMMENT
American Mbdicins
In addition, there were delegates from the
Federal Children's Bureau, and from the
nursing organizations in charge of the
American Red Cross Forces overseas, and
the head of the Army Nursing Corps.
The program of the conference, accord-
ing to The Survey, May 31, 1919, "cen-
tered about the realization of article XXV
of the Covenant of the League of Nations,
under which members of the League agree
to encourage and promote the establishment
and cooperation of duly authorized volun-
tary national Red Cross Organizations,
having for their purpose the improvement
of health, the prevention of disease and
the mitigation of suffering." Among sug-.
gestions considered was the formation of
an International Bureau of Health, with a
director and an advisory council operating
principally thru national Red Cross soci-
eties, where such existed, but always in
full cooperation with govermental or other
bureaus and agencies interested in the prob-
lems of health and relief. The function
of the Red Cross will be principally to
lead the way in health experimentation and
in demonstration of methods of attaining
health and promoting education in sanita-
tion.
A movement of this character constitutes
a distinct advance in methods of ameliorat-
ing not merely conditions which have grown
out of war, but in attacking the numerous
health problems which existed previous to
the years of strife. The accomplishment
of international cooperation in the devel-
opment of standards of health and stand-
ards of methods is of no small significance.
It forms an essential part of the general
plan for promoting the security of civili-
zation. An appreciation and understanding
of the principles and practices requisite for
the maintenance and protection of health
and welfare are basic in determining future
progress, free from the ravages of prevent-
able diseases and disabilities, whose poten-
tial mortality or morbidity threatens to
cause unnecessary hardship and suffering
in the homes of all peoples of all lands.
It becomes of the utmost importance that
the forces of expert knowledge and opinion
should unite for cooperative effort in pro-
moting and fostering a wider understand-
ing of the health needs of communities, in
stimulating and aiding existent agencies in
the fuller performance of their special ac-
tivities. It is essential that the mass of
scientific knowledge available be dissem-
inated for the purpose of building up a
body of public opinion which shall refuse
any longer to countenance low standards of
health administration. Participation of
varied governments in the mutual task of
developing an international force possesses
high moral values, particularly for crea-
ting a deeper sentiment regarding human
worth and for winning the confidence of
all peoples in giving support to the pro-
mulgation of the measures necessary for
the improvement of human living, to the
end that needless sacrifices of * life and
health may be decreased.
The high standing which the Red Cross
organizations have achieved affords them
a remarkable opportunity for seizing the
leadership in this direction and for forcing
the medical and allied professions to greater
activity along public health lines. One of
the greatest difficulties of modern admin-
istration is the securing of a fuller measure
of cooperation on the part of existent agen-
cies and institutions, whose programs over-
lap and whose specific problems all form
part of the large plan for promoting human
welfare. As education to no small extent
is dependent upon schemes originating in
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Ambrican Mbdicinb
EDITORIAL. COMMENT
June, 1919
309
universities which filtered down to and thru
the elementary schools, so it is possible to
have the high principles worked out in in-
ternational cooperation, thru national agen-
cies, state and municipal institutions until
all citizens may be reached by the con-
tents of the program and recognize its true
and insistent worth. In this connection,
however, the multiple medical organiza-
tions of the country should be pronowncedly
active in stirring up their respective com-
munities to the importance of public
health principles and practices. In all prob-
ability, a large measure of dependence will
be placed upon medical activity, organized
in the interests of communal health.
The Red Cross movement will gain im-
measurably if the enthusiasm, knowledge
and the powers of medical organizations
can be linked with the other voluntary or-
ganizations of a lay membership, whose
specific interests lie in the field of public
health medicine and public health nursing.
International effort can only become eflfect-
ive thru the cooperation of national insti-
tutions ; and national capabilities are closely
interwoven with the successful cooperation
of all types of organizations seeking to
serve the citizenry. A League of Nations
can be no stronger than a League of Work-
ers, seeking to perfect the development of
humanitarian impulses and practices.
Indnstrud Health.— While war called
forth various new plans of organization for
the creation of a highly efficient army and
navy, other prog^ms concerning the wel-
fare of the industrial line of support were
equally under advisement. The most en-
couraging feature of America's participa-
tion lay in the fact that it had the oppor-
tunity of profiting by the experience of
its allies.
From an industrial standpoint, the most
noteworthy assistance was received from
the splendid investigations of the British
Health of Munition Workers' Committee.
With the title of 'Industrial Health and
Efficiency," the United States Department
of Labor, thru its Bureau of Labor Sta-
tistics, Bulletin Number 249, has issued
the final report of the British Health of
Munition Workers' Committee. The scope
of their investigations, the thoroness with
which specific industrial health problems
were studied, the frankness and soundness
of their views, made their report a most
notable contribution to the literature of in-
dustrial health as affected by war conditions.
At various places in the report there are
what would seem to be disgressions point-
ing out the intimate relations between in-
dustrial health and some of the larger so-
cial industrial problems. As an evidence
of their careful thought, we may quote the
following from their final report: ''First
and foremost, there is the fundamental ques-
tion of shorter hours of labor from a po-
litical and economic point of view (as well
as from a health point of view) ; the com-
mittee is convinced that this question lies
near the root of the whole labor problem.
Secondly, there is the far-reaching issue
of the social and economic conditions of
women's labor (over and above the issues
of health with which the present report
deals), a matter of vital importance to the
future of the British race, for the health
conditions of women are even more insep-
arable from the social condition than in
the case of men. Thirdly, there is the ques-
tion of the solidarity of industrial society,
the interdependence between employer and
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June. 1919
EDITORIAL. COMMENT
American Medicine
workman, which is closely related to the
whole issue of the status, health and physi-
cal equipment of the worker. And fourthly,
there is the title of the worker to an ef-
fective voice in regard to the conditions
under which he works. If industry be in-
deed a national service, the object of those
engaged in it is the good of the community
as a whole, and the worker should have a
fair and legitimate share in the responsi-
bility of the transaction. The committee
is convinced that these four problems
must be faced and solved if ever the State
is to lay sound foundations for the health
and physical efficiency of the industrial
worker."
It must be recalled that this committee
was organized "To consider and advise on
questions of industrial fatigue, hours of
labor and other matters affecting the per-
sonal health and physical efficiency of work-
ers in munition factories and workshops."
It is of significance to find the constant in-
sistence that industrial life be guided in
the future (1) "by the application of physi-
ologic science to the details of its man-
agement; (2) by a proper and practical
regard for the health and well being of our
work people in the form both of human-
izing industry, and improving the environ-
ment." These statements were not a priori
conclusions, but were based upon a thoro,
systematic and well balanced review and
study of conditions involved in the consid-
eration of such problems as hours of labor,
Sunday labor and night work, food and
canteens, industrial diseases, sanitary ac-
commodations, welfare supervision, within
and without the factory and the relation
of fatigue and ill health to industrial ef-
ficiency.
As the vital work of the Medical De-
partment of the Army was the care and
protection of the men who wfere to bear the
brunt of military work and battle shock,
so the home forces were held responsible
in a larger measure for the conservation
of the physical potentials of the industrial
workers. The principle involved is one
and the same. National efficiency in so-
cial and economic fields is to be achieved
only by a larger degree of interest in the
preservation of the general welfare of all
those who labor with brain or brawn. It
is particularly pertinent, with the Peace
Treaty rising above the horizon, to realize
the necessity of carrying into the days of
peace all the information or machinery
which was found helpful in waging war.
To promote prosperity, to advance human
contentment, to aid in the development of
a more vigorous race, it is imperative that
more emphasis be placed upon the needs
of those who constitute the overwhelming
majority of our population. The right of
workers to conditions of health becomes
intensified as public opinion is awakened to
the means of achieving health, and the cost-
liness and extravagance of neglecting to
make provisions for an environment con-
ducive to health ^d safety.
The British Health of Munition Workers'
Committee has shed much light upon def-
inite problems, and while some of its con-
clusions have already been adopted in
American industry, there is still ample room
for accepting, with such modifications as
American conditions require, those elements
which unquestionably promote both health
and efficiency. In the highest sense, the
word "health" should possess a connotation
of efficiency, and efficiency should reflect
an underlying meaning of soundness.
The next few years will involve much
discussion of problems relating to labor,
and it is of paramount importance that the
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ilMERICAN MBOICINB
EDITORIAL. COMMENT
JUNB., 1919
311
medical profession fully understand the
numerous problems ordinarily termed so-
cial, economic or political, insofar as they
are related to sanitation, hygiene, health
and preventive medicine. In one sense, the
industrial worker is seeking to secure ade-
quate health standards for himself and his
family, tho his agitation may take the form
of demanding shorter hours, higher pay
and a more sanitary environment.
Reporting OHnmunicaUe Diseases. —
The reporting of diseases by physicians is
frequently regarded as a useless task or
unnecessary burden. In fact, a few health
officers are still uninterested in the devel-
opment of their official statistics, relative to
the facts imparted by notification of the
presence of specific communicable diseases.
An editorial writer in the American Jour-
nal of Public Health, June, 1919, points
out the. following five reasons for urging
the reporting of diseases, despite the fact
that there may be difficulties in limiting or
controlling them in the light of our present
knowledge. The advantages urged are:
"1. To prevent the spread of the disease
by means of quarantine or isolation. This
is the most important motive and applies
in the case of most of the reportable dis-
eases. 2. To secure statistical data as a
basis of study. This applies especially to
diseases which are not yet fully understood,
such as influenza. 3. To induce the patient
to take proper treatment. This applies in
the case of pneumonia and syphilis. 4. To
urge proper after-care. With poliomye-
litis, for example, it is very important that
proper muscle training should be pursued
in order to restore the use of muscles. The
guarding against after-effects of measles
has already been referred to. 5. To guard
against confusion owing to mistaken diag-
nosis. For example, many health officers
think that every case of chicken-pox should
be investigated in order to differentiate it
from smallpox. Similarly, German measles
and scarlet fever are frequently confused."
No sane person would advocate the ac-
cumulation of reports and statistics for the
mere satisfaction of possessing them. Re-
ports and figures are to be regarded as
bases of judgment, points of departure for
investigation and the essential items in
building up well-founded systems of health
administration, or for indicating lines of in-
vestigation needed in the advance of pub-
lic health. It is impossible to conduct a
modern health department today without
making every effort to possess an under-
standing of local health conditions. Mere
questionings on the part of the administra-
tive officer are inadequate to secure a sat-
isfactory conception of disease states that
may be existent generally or in particular
localities or communities. The determina-
tion of the existence of an epidemic is prac-
tically dependent upon a knowledge of the
normal frequency of disease appearance
with which may be contrasted the number
of cases of each particular disease devel-
oped at any definite time or period in the
community. Obviously, information of this
character can be ascertained only by the
cooperation and support of the physicians
who are in daily contact with the sick. The
facts which may be supplied by notification
thru postal cards are of transcendent mean-
ing to the epidemiologist and health officials,
while they are regarded by most persons
as merely constituting a reason for the em-
ployment of a statistician capable of evolv-
ing weird and startling vital statistics.
Statistics, as such, to many, are regarded
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JUNB, 1911
EDITORIAL. COMMENT
American Mboicins
as dry, uninteresting and dead. It re-
quires the spark of human intelligence and
appreciation to set them aflame with life
and to convert them from passive figures
to active and dynamic facts, capable of aid-
ing and saving a multitude.
Under a properly organized and care-
ful system of notification communities
may possess a sensitive index of public
health at any time. The freedom from, or
prevalence of, particular diseases is readily
ascertained, and due and proper action may
be taken in accordance therewith. For-
tunately, the larger the city the more de-
tailed is the system of notification. While
state laws list numerous diseases as report-
able, there is a well grounded belief that
the success in carrying out state provisions
has not been as great as might be desired
or expected. Like many other laws, the
results depend upon the cooperation of cit-
izens. Fundamentally, notification acts re-
quire the warm support of the medical pro-
fession as well as of the community.
There may be a certain element of un-
fairness in placing full responsibility upon
physicians, particularly while there is no
provision that covers the notification of
disease by practitioners of various cults,
who deny their existence, or whose train-
ing fails to give the education requisite for
accurate diagnosis. Despite this shortcom-
ing of the law, the responsibility for mak-
ing known the presence of communicable
diseases rests upon physicians and should
be accepted by them as an evidence of con-
fidence in their capabilities and of belief
in their interest in the public weal. The
collation of facts and figures relative to
communicable diseases is essential in pub-
lic health work and should have the whole-
hearted assistance of medical men.
Health Care for Employees^ — ^The in-
tricacies of industrial organization have
been added to by the ever increasing inter-
est in the welfare work for employees.
While it may be assumed by some that the
purpose is distinctly philanthropic, it must
not be forgotten that welfare work pays
a legitimate return to industry in ways
other than the protection of the welfare of
the workers. Motives, however, do not
concern us. The point of interest lies in
the fact that there is a growing and health-
ful attitude of solicitude for the welfare
of human beings on the part of employers
thruout the country.
As pointed out in the Bulletin of the
United States Labor Statistics, No. 250,
methods of caring for the health of em-
ployees vary with the needs of diflFerent
industries and the individual ideas of em-
ployers. "These methods include work
along the lines of preventive and curative,
medicine and surgery, the safeguarding of
the health of all the employees thru the
physical examination upon entrance, the re-
lief from the strain of especially monot-
onous and fatiguing operations thru the
granting of rest periods or change of oc-
cupation, and the granting of vacations and
sick leave which give employees the oppor-
tunity to recuperate from long, periods of
work or of illness."
Under the stimulus of personal interest
and state laws, as well as the urge of spe-
cific organizations, many types of industries
have successfully developed various plans
of medical, hospital and surgical treatment
for their employees. The details of organ-
ization include a large number of items,
varying from simple first-aid cabinets to
elaborate and up-to-date emergency hospi-
tals, with dispensary plants, social service
workers, convalescent homes and similar
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American Mbdicinb
BDITORIAL. COMBIENT
June, 1919
313
modern agencies. A total of 375 establish-
ments reporting to the Government, em-
ploying over a million men and women, ac-
counted for 265 hospitals or emergency
rooms, while 110 offer only first-aid equip-
ment, 171 report their own physician, 181
their own nurse and 131 first-aid attend-
ants.
The significance of these figures is en-
hanced by an appreciation of the need for
preventive and curative work of this char-
acter. To illustrate : 261 establishments re-
porting the number of cases treated, em-
ploying in all 770,000 men and women,
stated the average number of individuals
treated for a month to be 196,772. In
other words, from statistics presented, 24
per cent, of the male employees undergo
treatment each month, and 27 per cent, of
the female employees.
Without inquiring into the nature of the
hazards of the various industries, or other
reasons accounting for the need for*
emergent or other treatment, practically 25
per cent, of the employees of these large
establishments covering fundamental in-
dustries actually receive treatment thru
first-aid or hospital care.
The next few years undoubtedly will re-
veal a rapid development of industrial hy-
giene, decreasing the hazards of industry,
but there will, nevertheless, grow up a
larger measure of carefully systematized
agencies in industry to meet the medical
and surgical needs growing out of occupa-
tion. The employment of doctors, nurses,
welfare workers, already under way, will
be stimulated by reason of the demands of
employees, the protective interest of em-
ployers, and the recognition by the public
of the necessity for industry to carry out
its responsibilities to the group of the com-
munity constituting the industrial workers.
The decrease in immigration, with a greater
dependence upon a mere stationary popu-
lation for future workers, increases the
need for conserving the industrial popula-
tion along lines in harmony with the higher
standards of health efficiency, not merely
the efficiency that arises from good health,
but the efficiency needed to secure and
maintain it.
The rational basis of medical and surgical
work in connection with industry is to be
found in an understanding of the fact that
each worker constitutes an asset, not only to
industry, but to the nation ; and no industry
should be permitted to avoid its responsi-
bility in protecting the welfare of national
assets. The emphasis in industry is being
placed upon men rather than machinery, as
the item of greatest consequence and sig-
nificance.
It is patent that in the future there will
be an increasing number of opportunities
for medical men to engage in a form of
practice which will have the backing of
corporations and intelligent business men,
who are alive to the important part that
health pays in production. Machines are
more readily secured and repaired than hu-
man beings. Industrial protection of work-
ers is essential, not merely because it pays,
but because it is fundamentally sound.
Creed of the Disabled. — Once more to
be useful — to see in the eyes of my friends
replaced with commendation — to work, pro-
duce, provide, and to feel that I ha,ve a
place in the world — seeking no favors and
given none — b, man among men in spite of
this physical handicap. — Carry On.
"Strengthened by the practical test of
war, and with an abiding faith in the Al-
niJghty, let us be steadfast in upholding the
integrity of our traditions as a guide to
future generations at home and a beacon
to all who are oppressed." — General Per-
shing.
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JUNE^ 1919
MEN AND THINGS
American Medicine
MEN AND
THINGS
A Po8t-War Opportunity.— The doc-
tor's calling, more than any other profes-
sion, is* preeminently a calling of service.
It is the one profession in which the reward
is only in the exceptional case at all com-
mensurate with the work done. One may
safely say that hardly one student in a hun-
dred chooses a medical career for the profit
that may be in it. In that respect he dif-
fers conspicuously from the lawyer, or the
engineer, or the business expert. To make
the choice of medicine as a profession re-
quires a generous measure of idealism
which ignores profit, and every student who
matriculates in a medical school bears the
stamp of an idealist who has deliberately
chosen a vocation the chieit emolument of
which is the gratification that comes from
humane service to one's fellowmen. Evi-
dence of this, if one requires evidence for
so patent a fact, is the unique consideration
that a lawyer will abandon his profession
for another if he finds it is unprofitable ; the
engineer will seek some other work if he
does not achieve the return he had counted
on ; but the doctor continues, never waver-
ing from his course, even when he finds
that he will have to content himself with
the barest necessities for the remainder of
his career. And it is only the ideal which
he has brought with him into his work that
permits him to survive financial disappoint-
ments. Granting this, one must grant that
the war has brought the doctor an oppor-
tunity such has not been offered to him be-
fore— an opportunity which will increase
his capacity for service and at the same
time perhaps add to his material reward.
The whole world is in a state of flux,
socially, morally, industrially. It is in the
making: again. It is being reborn. Out of
the debris of the war, a new structure is
rising. But it is chiefly among the large
masses, in the industrial centers, that the
situation is most tense and delicate. In the
largre cities of Europe strikes and even re-
bellion are prevalent, and in the industrial
sections of this country there are indica-
tions of a mood of unrest that is extremely
disquieting. The workers of the world,
having given their all for the establishment
of a new order, aroused to a consciousness
of their importance and power, are intent
upon making sure that this new order will
be established. Ignoring the Bolshevist
and Anarchist element, which represent
only a small minority in this country, the
demands of the masses, in view of the
sacrifices they have made, cannot be set
aside with vague promises, cannot be
hushed by the enactment of suppressive
laws' which only serve to stir impatience
and violence. The demands of labor must
be met generously, and they will be; and
when they are, a new era will set in, an era
of change and advance and understanding.
But how, it may be asked, does this aflfect
the doctors of the country ? In what man-
ner does this constitute an opportunity for
them?
The Doctoi^s Equi|Hnent for Leader-
ship.— ^The present unrest ampng the
masses of the world is due to the fact that
they have lost faith in their leaders and
^ everywhere there is a disposition to seek
* new ones. They feel that their representa-
tives have not understood theiji, in some in-
stances have misled them, and they have
grown cautious about putting their future
trust in men who have exhibited so inade-
quate an understanding of and sympathy
with their aims. The problem is, then, who
is to be their spokesmen, to whom will they
entrust the leadership which is so necessary
because of their unwieldy numbers? It is
impossible to predict so early, but one can
assert, without fear of contradiction, that
there is one class of men in whom the
masses have a faith of long standing, a
faith that has not been impaired by the ex-
periences of the war. That class is the med-
ical profession. The war has served to bring
the doctor in closer intimacy with the indi-
vidual and thru him with the family. From
the earliest times, the family doctor has en-
joyed the privilege of serving at once as
healer, friend, confidant, adviser and con-
fessor. He has always been in the closest
rapport with the individuals whose health
he guarded, and this rapport has been in-
tensified by his experiences in the war. The
returning soldiers have nothing but praise
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American Medicine
MEN AND THINGS
June, 1919
315
for the work of the Army Medical Corps.
They may have questioned the judgment of
their military leaders, they may have doubt-
ed the wisdom of their diplomats, they may
have lost faith in their government represen-
tatives, but they never held the doctors in
anything but the highest esteem. The doc-
tors who return to their practice, even
those who remained behind and served at
home, will find that the ties between them
and their patients have been intensified, the
faith that has always been reposed in them
has been strengthened. These intensified
ties and this strengthened faith impose an
obligation upon the doctor which is an op-
portunity, for it is these things that consti-
tute the elements of successful leadership.
Such leadership will not carry the doctor
far out of his chosen field, for the changes
that are about to take place in the industrial
world are intimately wrapped up with the
interests of the modern, conscientious phy-
sician. As an instance, one may take the
vital problem of industrial disablement, a
problem which is sure to command great
attention during the period of reconstruc-
tion which we face. Not only is the doc-
tor interested in this problem, but he is bet-
ter qualified than any other member of
society to act as leader and adviser in bring-
ing about legislation to meet the havoc of
industrial accidents and industrial disease.
The army reconstruction hospitals have
proved that no man need be lost to the
community thru wounds or injuries which
once placed him among the human discards,
and it is not likely that the lesson learned
in these splendid hospitals will be forgotten.
Indeed, there is a movement afoot to pre-
serve these hospitals, with their equipment
of material and experts, and to use them
for the reclamation of workers injured at
their tasks. Wherever possible, the war
cripple was restored ; and wherever pos-
sible, the peace cripple is to be restored to a
productive and honorable role in the com-
munity life. In this work the doctors are
destined to play a vital paxt. Furthermore,
the experience that the army doctors ac-
quired in caring for the health of the sol-
diers, in spreading the gospel of hygiene
and sanitation, will prove of inestimable
value in conducting a campaign, spoken of
in authoritative quarters lately, to educate
the masses of the whole country in sanita-
tion and the principles of health. It has
been suggested that a force of doctors,
equivalent to the Medical Corps in the
army, be organized to undertake responsi-
bility for the health of the population thru-
out the country. Whatever the course
finally pursued, it is evident that here again
the doctor's leadership will be called upon.
With the coming of prohibition and the
danger of evils which invariably attend the
change to a dry regime, the physician's re-
sponsibility will be increased. There will
be a need of intelligent cooperation, of sym-
pathetic effort. These are but a few of
the changes that are on the industrial and
social program, and in all of them the doc-
tor will find not only an opportunity for
enlarged usefulness but a distinct and
pressing need for his guidance, for both by
education and training he will be better
equipped than any other individual to di-
rect the course of change so that it may
truly merit the name of Progress. No one
who knows the American doctor can believe
for a moment that he will either evade the
obligation or reject the opportunity that the
new era offers.
The Nation's Debt to the Doctors.^For
the past few months the billboards thruout
the country have been covered with posters
admonishing citizens to acknowledge their
debt to our victorious army by hiring the
returned soldier or restoring him to his
former job. So intense and insistent has
been this campaign, that it succeeded in
arousing a consciousness of the obligation
we owe to the men who did their bit so
magnificently over there and who, it is
promised, will do their bit just as well over
here. "They Work the Way They Fight,"
"Hire a Fighter," " Now for a Job"— so
read these convincing signs. But nowhere
thruout this campaign has there been men-
tion made of a fighter who contributed
as much to victory and who sacrificed as
much for that victory as any soldier in the
service — the doctor in the A. E. F. Fighters
these men are, and splendid ones — they
fought an enemy which, in former days,
killed more men than bullets, disease and
epidemic. They fought this enemy so suc-
cessfully that the health record of the
American Army abroad is second to none.
Yet who has thought of doing anything for
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JUNB, 1910
MEN AND THINGS
American Medicins
the returning doctor?
A well known medical writer in discuss-
ing this matter has called attention to this
unfortunate situation, and his appeal will
find a prompt and ready response on the
part of all who realize the magnitude
of the service the army doctors rendered,
the seriousness of their problem on re-
turning to their abandoned practices. Thou-
sands of successful practitioners, many of
them with family and other weighty re-
sponsibilities, responded to the call of their
country without any consideration of them-
selves or of those dependent upon them,
mindful only of their duty to the ideal for
which they were eager to give their energies
and their lives. Many of these were above
the draft age, and they went without wait-
ing to be called, giving up their practices
built up after years of arduous labor, sever-
ing the closest of ties, throwing their own
interests to the. winds in their desire to
lighten the burden of the men in the service
of the national cause. And it is common
knowledge that a splendid record is theirs.
Now these men are returning, but they are
coming back, in numerous instances, to
vanished practices, to abandoned homes, to
scattered families. Some fortunate ones
will find things so little altered that they
will be able to pick up the thread of their
lives where they left it; but others, many
others, will face the distressing prospect of
trying to begin at the bottom again, to re-
cover the success which came to them only
after years of conscientious service. How
many of these will have the courage to face
such a trying prospect ; and how many, hav-
ing the courage, will be able to overcome
the enormous obstacles? There come to
mind instances in our personal knowledge
of young doctors who, meeting what seems
an almost impossible and altogether for-
bidding task on their return, seriously con-
template the choice of a new profession
rather than try to content themselves with
the meagre salvage of their old one. What
is being done to lighten the burden of these
returned fighters? What can be done?
The situation is indeed a serious one, but
fortunately it is an easy one to remedy.
And the remedy is a gratifying one because
it fulfils an obligation to the returned doc-
tor and at the same time fulfils an obliga-
tion, long neglected, to the community.
These men can be rewarded for their serv-
ice with profit to society as a whole, for
their education and their training can be
used to splendid advantage. The returning
doctors successfully guarded the health of
our soldiers and made our army the power-
ful instrument for victory that it proved.
Why cannot they be enlisted in the service
of workers and citizens, to guard their
health and wellbeing under the direction
of the proper authorities and make the
army of peaceful men and women and chil-
dren the soundest in the world ? In the pay
of the government, they served the soldiers ;
in the pay of the government, they can
serve the community as well. It is an easy
step from an Army Medical Corps to a
Community Medical Corps. During war,
it is a commonplace that the fitness of the
individual soldier is of the greatest im-
portance to the whole regiment or the whole
army. We have been altogether too slow
in realizing that in peace the fitness of the
individual citizen is of vital importance to
the whole community. There have been
sporadic and partially successful efforts to
guard community health in scattered sec-
tions of the country, but it is high time that
such efforts take on a national and official
character. As in the Army, there should
be a peace-time Surgeon-General, with a
large and efficient corps of assistants and
employees, whose duty it would be to keep
the population of the country in good
health, to educate the public in matters of
hygiene and sanitation, to guide the masses
in the observation of approved rules for
bodily and even mental wellbeing. Such a
department, nationally organized and co-
ordinated, can be subdivided into smaller
groups, so that every community will have
its own official health guardians. In to
such a plan, the returning doctors whose
practices have vanished in their absence
will fit splendidly. Their equipment and
talents will not be wasted and they can be
of inestimable service to the community
which they once served in a private capac-
ity ; and, in such a way, their value will be
increased rather than lost entirely. It
would be an unpardonable waste and ne|^-
lect to allow them to drift into work m
which their special fitness would count for
nothing. The government should avail it-
self of the opportunity to engage their
services in the interest of the national well-
being.
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'Duty is his watchword— the word rarest on his lips
—and most constantly illustrated in his daily life. "
— Braisted
'THE MEDICAL PROFESSION
SHOULD BE CONGRATULATED.''
NEWTON D. BAKER,
Secretary of War,
Washington, D. C.
The record of the medical service with
the forces of the United States is such that
no word of mine is necessary or can avail
to enhance the
brilliance of their
cooperation.
When the war
ended, more than
30,000 medical
officers, exclusive
of the Sanitary
Corps, Dental
Corps and Veter-
inary Corps, were
on duty with the
Army, and nearly
half of this num-
ber had gone overseas. In the last month
of fighting the number of patients cared for
by the Medical Corps overseas reached its
peak — about 190,000 cases. There is cause
for exultation in the knowledge that for
only two weeks did the number of patients
in overseas hospitals exceed the normal bed
capacity of the hospitals, and that even dur-
ing that time there was a substantial margin
of emergency capacity. I have been told
that more than three-quarters of the 230,000
men woimded in action in the A. E. F. were
able to return to duty, and that the annual
death rate from disease for all of our troops
in the present war will be less than 16 as
compared with 26 for the Spanish-
American War, 65 for the Civil War and
1 10 for the Mexican War.
As is generally known, a rather intensive
inquiry into venereal cases was conducted at
five camps covering a number of months.
The annual rate per thousand bjefore enlist-
ment was found to be 294.4; after enlist-
ment it was brought down to 10.17.
The medical profession should be con-
gratulated also I think on the practical
elimination of typhoid fever as a cause of
death in the Army. For the week show-
ing the highest incidence of typhoid fever
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the annual rate per thousand for new cases
was less than 4, as compared with 141 for
the entire period of the Spanish-American
War. The Surgeon-Generars Office is
confident that the rate for the entire period
of the present war will not exceed 0.5.
For the services rendered the American
Army and the American people none of us
can have other than the deepest gratitude
and I trust you will make plain to the pro-
fession that this Department feels the keen-
est appreciation for the work that has been
done.
''A NEW AND HIGHER STANDARD
TO MEDICAL EFFICIENCY.''
JOSEPHUS DANIELS,
Secretary of the Navy,
Washington, D. C.
The fighting strength of the Navy, as
every military organization, depends upon
the physical ability of the men engaged in
the conflict. We
have recognized
from the begin-
ning our depend-
ence upon the
very able and
skilful physicians
and surgeons in
the profession
then in the serv-
ice and those who
have come in
from civil life as
Reserves, and we
have urged them to accept for naval service
only men who were physically fit. They
did this work so well that the Navy's stand-
ard was kept high. After they were ad-
mitted into the service our medical officers
by good methods of sanitation and pre-
vention, and in treatment administered, have
given a new and higher standard to med-
ical efficiency. I cannot speak in terms of
high enough commendation of the skilled
medical men who have served, in the Navy
during this great war.
"TO THE NATION ALL THEY POS-
SESSED/'
M. W. IRELAND, M. D.,
Surgeon-General, U. S. Army.
In answer to the call on the civil profes-
sion, equarresponse was made by the young
and by the old, by the specialist and by the
general practi-
tioner. City and
country re-
sponded with
similar enthusi-
asm. Special
thanks are due to |
those officers
from civil life
who, long after
the excitement of
the actual war has
passed, must con-
tinue in the serv-
ice attending the needs of the wounded,
while many of their comrades, both in the
Medical Corps and in the line, are rapidly
returning to their homes and ordinary voca-
tions. In view of the enormous prepon-
derance in the army of physicians fresh
from civil life it may be said without reflec-
tion on the medical officers of the regular
army, that the great achievement of the
Medical Department in medicine, in surgery
and in sanitation is primarily the work of
the civil profession of the United States and
is due to the patriotism, fidelity and ability
of that great body of practitioners. It is to
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be hoped that one of the results of the great
war will be the closest sympathy between
the Medical Corps of the Army and the
medical profession of the country, resulting
in the development of a firm conviction in
the minds of all civilian practitioners that
preparedness for war conditions in the case
of each and every physician of military age
is a fundamental necessity for attainment
to the highest type of citizenship.
Great injustice would be done, did I omit
to call attention to the difficult task which
was so well and faithfully performed by
the physicians connected with the Draft, and
which forms another of the important con-
tributions made by the American medical
profession toward the winning of the World
War.
«IN EVERY PUBLIC CALAMITY
* * * * HE IS AMONG THE FIRST
TO VOLUNTEER.''
W. C. BRAISTED, M. D.,
Surgeon-Qeneral, U. S. Navy.
The physician always plays the game. In
every public calamity — railway accident,
fire, flood, famine or pestilence — he appears
on the scene and
quietly shoulders
the burden of the
moment, regard-
less of personal
inconvenience or
danger. In war,
the greatest of
public calamities,
he is among the
first to volunteer,
tho in the hospital
or the trench he
has little to gain
and as much as any man to lose. The
peculiar beauty of his service is this ab-
solute disregard of reward. It is proffered
automatically because in spite of the short-
comings, common to him as a mortal, he
has the habit of duty. Duty is his watch-
word— the word rarest on his lips — and
most- constantly illustrated in his daily life.
All honor to the unostentatious courage
of the American doctors who served in the
great war. Some have won a passing word
of praise because fortune brought them into
notice but all have deserved well of their
country, whether they laid down their lives
in the struggle or merely imposed added
anxiety and privation on their loved ones
and themselves faced the uncertainty of
war and the uncertainty of the days to fol-
low the war.
Every physician who today basks in the
light of heaven, breathes the upper air and
tastes the beauty of the forest, field and
stream should set up in his heart a shrine to
the memory of the brothers that did not
come back. There was Doctor John
McCrae, Lieutenant-Colonel in the Cana-
dian Forces, author of "In Flanders Fields,"
the most exquisite lyric of the war, who
died of pneumonia in France; there was
Surgeon L. C. Whiteside, U. S. N., who re-
ported to the captain that all the sick were
safe over the side in boat or oh raft and
went down with the torpedoed transport;
there was Dental Surgeon W. E. Osborne,
U. S. N., who having no chance to exercise
his specialty on the day of battle went
forward with the attacking wave to admin-
ister first aid and fell mortally wounded by
a German bullet; "and what shall I say
more for time would fail me to tell" of the
men of all services and all ranks whose
mission was to save life amid the universal
rivalry to multiply death !
To each of them we might quote the
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beautiful words of the Psalmist: "He asked
life of Thee and Thou gavest it him, even
length of days forever and ever"; to each
his CQuntrymen must accord here on earth
an immortality in grateful loving thoughts.
''NO CLASS OF PROFESSIONAL MEN
EVER SERVED TO BETTER
PURPOSE.''
JOHN J. PERSHING,
General Commanding American Expeditionary
Force,
Chaumont, France.
Every officer and man of the American
Expeditionary Forces will gladly join me
in appreciation of
the splendid work
that the American
physicians did for
us in France. No
class of profes-
sional men ever
served to better
purpose and none
have more fully
earned the grati-
tude of those
whom they
served.
The Heroism of Medical Officers. —
Never have the fighting troops manifested
finer courage than that shown by medical
officers everywhere — on the fighting line,
in rendering first-aid to the wounded, in
operating rooms, with Boche aeroplanes
bombing the hospitals in which they were
working and in the pneumonia and men-
ingitis wards of hospitals where, in admin-
istering to the needs of sick soldiers, they
have daily and nightly risked their own
lives. The casualties in the Medical Corps
were second only to those in the infantry. —
War Medicine,
-WITH CONSPICUOUS UNSELFISH-
NESS, LOYALTY AND
EFFICIENCY.''
LEONARD WOOD,
Major-General, U. S. Army,
Chicago, 111.
The excellent health conditions which ex-
isted in the Armies in France. Flanders and
elsewhere, were due principally to the work
of the medical
officers of the
various forces —
much of* it work
on the line of pre-
ventive medi-
cine. . This, to-
gether with the I
enforcement o f
sound sanitary
measures, made
i t possible t o
maintain a highly
efficient fighting
force under conditions and surroundings
which, in former years, would have de-
stroyed an army, or would have, rendered
it ineffective.
Among the medical officers of the various
nations, our Americans stood out conspicu-
ously, and to their intelligent, loyal and effi-
cient service the successful conduct of
operations is due in a large measure.
The problem of maintaining an army fit
to fight is one of the most, if not the most,
serious one in modern warfare, and the suc-
cess with which this was done during the
present war speaks volumes for the impor-
tance of the medical officer in war.
We can feel that our representatives did
their part with conspicuous unselfishness,
loyalty and efficiency.
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MOBILIZATION OF THE MEDICAL
PROFESSION OF THE UNITED
STATES FOR SERVICE IN THE
GREAT WAR
FRANKLIN MARTIN, M. D.,
Col. M. C, U. S. Army.
Chairman of Committee on Medicine and Sani-
tation of the Advisory Commission, and
Chairman of General Medical Board,
Council of National Defense.
I am filled with pride whenever I think of
the magnificent response that was made to
the request of our Federal Government
that the medical
profession b e
mobilized for
service in the
great war. It
was not only my
privilege to be
chairman of the
Committee o n
Medicine and
Sanitation of the
Advisory Com-
mission of the
Council of Na-
tional Defense, which latter body played
such an important part in the activities of
the war, but I was also privileged to act as
a member of the Committee of American
Physicians for Medical Preparedness, which
did such splendid work beginning one year
in advance of our actual declaration of hos-
tilities. It was generally conceded among
those who were planning for the war that
the medical profession in its mobilization
was at all times definitely ahead of the
game.
There were three distinct departments of
the Government which were interested in
securing medical men for active service dur-
ing the war : The War Department, under
Surgeon-General Gorgas ; the Navy Depart-
ment, under Surgeon-General Braisted ;
and the Public Health Service, under Sur-
geon-General Blue. In addition to this
there were several other organizations that
required the services of the best medical
men, namely, the American Red Cross, the
Young Men's Christian Association, and the
Knights of Columbus.
While being extremely interested in the
mobilization of medical men for the last
three activities, I will confine my remarks
here to the three distinctly governmental
departments, namely, the Army, the Navy,
and the Public Health Service. These
three departments, at the beginning of the
war, had between them less than 1,200 com-
missioned officers. Our first duty was to
obtain medical officers for the Army and
Navy from the civilian medical profession
in the proportion of about ten doctors for
each one thousand enlisted men. This was
accomplished thru organizations already in
existence, and thru the General Medical
Board of the Council of National Defense,
which established a large committee of med-
ical men in each State, known as the State
Committee, Medical Section, Council of Na-
tional Defense. In order to subdivide the
work and make it effective, finally county
organizations under the respective state or-
ganizations were effected in more than
4,000 counties of the United States.
Thru their own organizations, the Army,
the Navy, and the Public Health Service,
supplemented by the organizations under
the General Medical Board and a number
of the medical societies of the United
States, mobilized approximately thirty thou-
sand medical men for the Army, forty-five
hundred for the Navy, and one thousand
for the Public Health Service, to say noth-
ing of the medical volunteers in the Ameri-
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can Red Cross, the Young Men's Christian
Association, and the Knights of Columbus,
which brought up the number of medical
men at the disposition of the Government to
practically forty thousand. There was no
difficulty at any time in securing medical
men for service ; the only reluctance we ob-
served on the part of the doctors was to
blindly accept service without a definite as-
signment. In the first rush of organization
we were unable to properly classify physi-
cians so that they would be chosen with
reference to their special fitness and desire.
However, six months before the end of the
war a plan was devised which relieved this
uncertainty on the part of the candidates
for enrolment, and on the part of the de-
partment making the enrolments. This
was accomplished thru the organization of
the Volunteer Medical Service Corps, under
the presidency of Dr. Edward P. Davis of
Philadelphia.
This Corps was established after consulta-
tion with the Surgeons-General of the
Army, the Navy, and the Public Health
Service,, and the General Medical Board of
the Council of National Defense. It was
finally approved by the Council of National
Defense and the President of the United
States. Briefly, it consisted in asking the
ninety thousand medical men who were not
yet enrolled to agree to serve the Govern-
ment in any capacity, at any time, or in any
place, with the implied reservation, how-
ever, that they would be selected, so far as
practicable^ with reference to their prefer-
ence for service as indicated on their appli-
cation blanks. In spite of a subtle prop-
aganda, based on the alleged opposition to
men blindly signing an agreement for serv-
ice, 72,000 of these applications were signed
and made the basis of a classification that
would have been of inestimable value for
further mobilization for service in any of
the departments of the Government. These
applications were coded on the Hollerith
system of cards, which made it possible to
secure almost instantly a group of men
classified for any particular service under
specialties, in reference to states or com-
munities, age, languages spoken, etc.
To illustrate the working of this system,
we will take a hypothetical case: The Sur-
geon-General of the Army requires one
thousand additional medical officers to man
an additional one million enlisted men. He
asks the Volunteer Medical Service Corps
for these 1,000 men under forty-five years
of age, selected from all parts of the United
States — ^200 surgeons, 400 medical men, and
the balance divided among the various
specialties. The Volunteer Medical Serv-
ice Corps has upon its Hollerith code cards
72,000 volunteers. In twenty-four hours
a complete list, with an additional list of
1,000 for good measure, could be furnished
to the Surgeon-General, with every assur-
ance that the men upon these lists would
immediately accept service. A similar re-
quest from the Surgeon-General of the
Navy or of the Public Health Service could
be met.
A specific case in point is the prompt
compliance with the request for medical
men by Surgeon-General Blue of the Public
Health Service during* the influenza epi-
demic last October. On Saturday we were
asked to furnish a list of five hundred med-
ical men who would be willing to serve in
the Public Health Service anywhere in the
United States. On the following Monday
the list was furnished to the Surgeon-Gen-
eral, and he immediately telegraphed to
these men for aid. The response was im-
mediate. On Thursday of the same week
a request for 500 additional men was made.
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and 600 names were immediately furnished,
or in all more than 1,100 volunteers were
supplied by the Volunteer Medical Service
Corps. This tender of service succeeded in
more than supplying the demand, and
brought forth a letter of appreciation from
the Surgeon-General of the Public Health
Service.
Another practical proof of the perma-
nent value of the organization of the Volun-
teer Medical Service Corps is the fact that
the present Surgeon-General of the Army,
Major-General Merritte W. Ireland, has
asked the Council of National Defense to
complete its survey and make it a part of
the permanent records of the Library of the
Surgeon-General, and place at his disposal
one or two experts who will keep the
records up-to-date.
Thus may be summarized the story of the
mobilization of the medical profession of
the United States : First, creating national,
state and county organizations that aided in
the mobilization and classification of med-
ical men required for war service; and,
finally, the care of the home population and
industries by those who were not called to
active service. Mobilization of 40,000 civi-
lian medical men as officers in the Army,
the Navy, and the Public Health Service,
and 72,000 additional medical men and
women in the Volunteer Medical Service
Corps enrolled, classified and coded, mak-
ing a grand total of 112,000 out of a med-
ical population of approximately 140,000.
"The times demand of us clearness in
thought and firmness in action. The solid-
ity of our national institutions must be the
bulwark against insidious and destructive
tendencies.
"The glory of our independence must re-
main the leaven and our flag the emblem
of all that freemen love and cherish." —
General Pershing.
''NO CLASS OF MEN GAVE UP MORE
FOR THE SERVICE OF THEIR
COUNTRY."
W. J. MONOGHAN. M. D.,
Lieut.-Colonel, M. C, U. S. Army,
New York City. '
The general sanitary welfare of the na-
tion will gain tremendously in the general
health of the people and the cure and pre-
vention of dis-
ease as the result
of the past few
years of study
and practice in
the medical and
surgical branch
of the military
service. The
training in dis-
cipline for Ameri-
can doctors as the
result of their
army work in sys-
tematic methods and executive management
will be instrumental in developing the better
individual equipment of these professional
men when they go back to civilian life and
will enable them to give to their respective
communities the benefit of their studies in
the greatest clinic the world has ever known.
The same efficient mastery of unfamiliar
and unexpected problems will be continued
for the American people, the citizens of this
country, when these same capable and self-
sacrificing American doctors return to con-
tinue their labors in mufti. Few persons
realize that no class of men gave up more
for the service of their country than the
physicians and surgeons who joined the
medical and sanitary corps of the army.
Many of them abandoned practices which
had required years to build up, and in the
very nature of the case other men took their
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places and will naturally retain them. It is
not so easy for a doctor, even a specialist,
to come back. Often he must begin all over
again. The self-sacrificing and cheerful
elimination of personal interests that has
characterized* the men and officers of the
medical and sanitary corps will never be
fully known.
"NOT AT ALL SEEING WHAT WAS
TO COME AFTERWARDS."
WM. C. GORGAS. M. D.,
Surgeon-General (Retired), U. S. Army,
Panama.
I think about the most remarkable thing
in the organization of the Medical Depart-
ment of the Army for this great war thru
which we have
just passed i s
the extraordinary
way in which the
doctors responded
to the call of our
country. The
greatest men of
our profession
gave up their
large incomes and
great practices
and cheerfully en-
tered the service.
It impressed me greatly to see such great
men as Welch, Mayo and Billings sacrifice
all as they did when called upon for duty,
but what appealed to me most were the
thousands of young doctors who had just
made a start in life with a wife, one or two
children, and building a home, who just as
cheerfully responded to the call, not at all
seeing what was to come afterwards. Some
thirty thousand of these men volunteered
their services and were accepted.
""RENDERED AS FINE AND DIS-
TINGUISHED SERVICE AS ANY
OTHER BRANCH OF THE MILL
TARY.''
THEODORE ROOSEVELT,
Lieut-Colonel (Retired), U. S. Army,
New York City.
I am happy to tell you concerning the
medical officers who served with and around
me during the past war.
Capt. E. D.
Morgan of Clay
Center, Kansas,
was my Battalion
Medical Officer
during the greater
part of the war.
No finer service
could have been
rendered than his.
He worked with
his duties solely
in mind and con-
sidered no dan-
ger to himself.
Lieutenant Skilling was killed while on
duty with my regiment four days before the
finish of the war.
Major Kenner was always cool under
most trying circumstances, a constant in-
spiration to those who worked with him.
These are only a few of the numerous in-
stances that came under my personal ob-
servation. Indeed, as far as my experience
went the medical officers who served in the
war, especially those who served with the
front line troops, rendered as fine and as
distinguished service as any other branch
of the military.
"Never miss an opportunity to do some-
thing."— Major-Gen. Leonard Wood.
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ACTIVITIES OF THE MEDICAL DE-
PARTMENT OF THE UNITED
STATES ARMY DURING THE WAR.
BY
M. W. IRELAND, M. D.,
Surgeon-General, U. S. Army,
Washington, D. C.
The Medical Department of the United
States Army is charged with the duty of
investigating the sanitary conditions of the
army and making recommendations in ref-
erence thereto, of advising with reference
to the location of permanent camps and
posts, the adoption of systems of water sup-
ply and purification, and the disposal of
wastes, with the duty of caring for the
sick and wounded, making physical ex-
aminations of officers and enlisted men,
the management and control of military
hospitals, the recruitment, instruction
and control of the enlisted force of the
Medical Department and of the Nurse
Corps, and furnishing all medical and hos-
pital supplies, including those for public
animals. At the head of the Medical De-
partment is the Surgeon-General of the
Army. The Department includes the Med-
ical Corps (consisting of physicians),
Dental Corps, the Veterinary Corps, the
Sanitary Corps (consisting of sanitary en-
gineers, psychologists, food experts, X-ray
experts, chemists, administrative officers
and a variety of others with special attain-
ments), the Nurse Corps (consisting of
female nurses), the U. S. A. Ambulance
Service and the enlisted personnel.
The Medical Corps of the Regular Army
was, of course, entirely inadequate to ren-
der the professional care for the vast new
armies, but was peculiarly fitted by reason
of its experience and training to handle the
medico-military administrative problems and
to train the new medical officers, fresh from
civil life, in their duties as officers, sanita-
rians and administrators. Consequently,
nearly every regular officer was placed in
an administrative position. Those regular
officers particularly qualified were assem-
bled in the office of the Surgeon General,
and with them was associated the best
civilian talent of the country — not only
surgeons and internists, but also renowned
specialists in the eye, ear, nose, throat, in
dentistry, in oral-plastic surgery, in roent-
genology, in sanitary engineering, in psy-
chology, in epidemiolog}', in food and nu-
trition, in veterinary medicine, etc. Inval-
uable service has been rendered by these
efficient and enthusiastic advisers from
civil life.
At the height of its activity during the
war the office of the Surgeon-General was
organized in the following Divisions:
Division of Sanitation
Hospital Division
Personnel Division
Laboratory Division
Division of Physical Reconstniction
Division of Medicine
Division of Surgery
Finance and Supply Division
Library Division
Air Service Division
Gas Defense Service
Food Division
Overseas Division
Division of Head Surgery
Medical Officers Training Camp Division
Veterinary Division.
Most of the divisions were divided into
numerous sections. Of the above divisions
several have now been discontinued and
their activities embodied in other divisions
as sections thereof. Below is a brief de-
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scription of the work accomplished by these
divisions.
The largest division, and that primarily
concerned in the sanitation of camps and
the prevention of disease, from an admin-
istrative point of view, is the Division of
Sanitation.
The Division of Sanitation, which has
for many years been one of the three per-
manent divisions of the Surgeon-General's
office, has undergone great expansion dur-
ing the war, and its duties rapidly extended
to the handling of all questions relating to
the health and well-being of troops and the
sanitation of camps, cantonments, perma-
nent posts, hospitals, ports of embarkation,
transports, military trains and other mili-
tary stations. Its function includes the phys-
ical examination and selection of recruits
and registrants; the physical examination
of soldiers prior to demobilization; the se-
lection of camp and division surgeons,
camp and division sanitary inspectors,
epidemiologists, sanitary engineers and sur-
geons for recruit depots; the direction of
medico-military activities in . camps, can-
tonments and other stations in so far
as they relate to the Surgeon-General's
office; supervision of the hygiene and sani-
tation of camps ; advising the War Depart-
ment with reference to camp sites,
housing, air space, clothing, food, water
supplies, sewerage systems and garbage
disposal; the control of fly and mos-
quito breeding and the elimination of these
pests ; the destruction of lice and other dis-
ease-bearing insects; the search for and
quarantine of "carriers" of disease and
"contacts" with disease ; the design and con-
struction of quarantine and construction
camps; the administration of quarantine
and other measures necessary to prevent
the spread of communicable diseases, and
the inspection of camp, post, base and gen-
eral hospitals. In sum, the activities of the
Division of Sanitation include all the func-
tions of a health department in a civil com-
munity and many other duties in addition.
In this work the men from the civil pro-
fessions have rendered efficient aid as camp
sanitary inspectors, camp epidemiologists,
camp sanitary engineers, laboratory experts,
etc., and also in the capacity of supervisors
of special activities in the office of the Sur-
geon-General.
The Inspection Section of the Division
of Sanitation caused frequent inspections
of all military stations to be made by ex-
perienced sanitary inspectors. When san-
itary defects or deficiencies are brought to
the attention of the Surgeon-General's of-
fice immediate steps are taken to correct
them, either by instructions sent to the
Camp Surgeon, if the correction lies within
his power, or by correspondence with the
higher authorities of the War Department,
if this action is necessary. Ultimate re-
port as to action taken and results obtained
is received in this division and filed. Over
700 inspections have been made by this
section.
The Current Statistics Section received
and consolidated daily and weekly tele-
graphic reports of sick and wounded, and
prepared weekly reports of health condi-
tions which were given freely to the press.
The following figures indicate the enor-
mous reduction in deaths which has resulted
from the sanitary measures enforced dur-
ing the present war as compared with the
practice in vogue in the Civil War, the
Franco-Prussian War, the Spanish War,
and the Boer War. The figures indicate
the actual deaths which occurred during
the period between September 1, 1917, and
May 2, 1919, in our army, both in the
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United States and in France, which had an
average strength of 2,121,396, and the num-
ber of deaths which would have occurred
in an army of the same size for the same
period if the mean annual death rates for the
Civil War and for the Spanish War, respect-
ively, had prevailed during the present war.
The figures for the present war are based
upon current telegraphic reports and while
approximately accurate may be subject to
slight revision on completion of final sta-
tistics :
the service almost as soon as diagnosed and
so the deaths when they occurred were
credited not to the army but to the civil
community. In our present war nearly all
tuberculous soldiers are held in the army
for indefinite sanitarium treatment, and of
course a certain per cent, will die in the
service while the majority are being cured.
The number of deaths from pneumonia
is much greater than for the Spanish War
comparison. The Spanish War rates were
low because the war period was entirely in
Number of deaths that
Number of deaths
Number of deaths that
occurred in present
that would have oc-
would have occurred
war, Sept. 1, 1917-
•curred if the Civil
if the Spanish-Amer-
May 2, 1919. Average
War death rate had
ican War death rate
strength approximate-
obtained
had obtained
ly 2,121,396
Typhoid fever
213
51,133
68,164
Malaria
13
13,951c
11,317
Dysentery
42
63,898b
6,382b
Smallpox
5
9,536
37
Pneumonia
41,747a
38,962a
6,086
Scarlet fever
167
112
222
Diphtheria
100
1,188
149
Tuberculosis
1,220
9,574
631
Meningitis
2,137
3,859
4,081
Other diseases
3,768
34,881
15,587
Total of diseases
49,412
227,094
112,656
(a) Includes deaths listed from measles, influenza, empyema, inflammation of the lungs
and pleurisy, as well as pneumonia.
(b) Includes dysentery and diarrhea.
(c) Includes malaria and remittent and congestive fevers.
In the Franco-Prussian War the Germans
lost 9,000 men from typhoid fever. With
reference to the typhoid in the Boer War,
Colonel F. F. Russell quotes from Leish-
man, "Antityphoid Vaccination," Glasgow
Med. Jour., 1912, LXXVII, 406:
"We know in general that there were
57,684 cases of typhoid and 8,022 deaths
among 380,605 men."
The low death rate from tuberculosis in
the Spanish War is due to three causes:
First, that the war was of short duration;
second, that the war period was in the sum-
mer; third, and most important, that all
cases of tuberculosis were discharged from
warm weather when pneumonia is infre-
quent. The greatest cause of the high
pneumonia rate for the present war was
the pandemic of influenza, a factor which
occurs only about once in 30 years. Had
this epidemic not occurred the rate would
have been much lower than for the Civil
War and probably lower than for the Span-
ish War. Taken all in all, however, it
must be confessed that the secret of the
control of respiratory diseases, particularly
pneumonia, still remains undiscovered.
The duty of the Hospital Division is to
provide and operate all military hospitals
in the United States, — that is to say, to care
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for all sick and injured of the armies in
training in the United States and also for
the cases returned from overseas. This
plan comprehended some 600 separate lo-
cations of military medical activity. These
hospitals were designed, built, maintained
and administered in very much the same
way. The construction of new hospitals
especially was standardized as much as pos-
sible, since it was realized that this would
aid greatly in their operation and future
alteration. Camp and base hospitals were
constructed in each camp to care for the
sick of that camp. General hospitals were
constructed to care for overseas cases and
the most 'severe domestic cases. It was be-
lieved unwise to mix the maimed soldiers
from the American Expeditionary Force
with the raw recruits preparing to embark
overseas. The general hospitals were dis-
tributed thruout the United States so as to
allow the sick to be sent as near to their
homes as possible and were located with
reference to density of population, railroad
facilities and available convertible buildings.
The procurement of additional hospital
facilities for the greatly increased army in
the United States was accomplished in two
ways : First, by constructing new hospitals
with a total of 88,460 beds ; second, by con-
verting some army posts into hospitals and
by enlarging some post hospitals, together
giving a total capacity of 35,439 beds. The
army hospital capacity was increased 1850
per cent, within a period of twenty months.
A single base hospital, with a capacity of
2,000 beds, includes more than 90 separate
buildings and about two miles of covered
corridor.
In addition to the permanent staff at each
large hospital, a second complete adminis-
trative staff was formed to be used as a
nucleus in organizing new field units and
new hospitals to be opened up. The method
was for the commanding officer and
each administrative officer to have an
understudy who assisted him in all of his
duties and who was trained to either take
up the work of his chief when the latter was
relieved or to establish the same line of
work elsewhere. This scheme made pos-
sible the prompt establishment of new hos-
pitals whenever required. About 98% of
the medical officers in the hospitals were
freshly drawn from civil life.
From April 7, 1917, to April 30, 1919,
there were transferred to the interior hos-
pitals of the United States from New York
89,333 cases and from Newport News 32,-
246, making a total of 121,579. During the
same period there were 20,327 domestic
cases moved by the inter-hospital transfer
in the United States, making a total of
141,976 dispositions handled by this divi-
sion, and an equal number of patients moved
by train.
The statistics of this office show that dur-
ing the period of the emergency there were
operating on a monthly average 30 general
hospitals, 38 base hospitals and 131 miscel-
laneous hospitals for the care of the sick
in the United States. Each of these hos-
pitals had on duty an average of 33 medi-
cal officers, selected from the best person-
nel of the army and country at large, 88
trained nurses and 465 enlisted men of the
Medical Department. In round numbers
2,000,000 sick were treated in these hos-
pitals from the time of the first draft in
1917 to April 25, 1919. The total number
of medical officers, nurses and enlisted men
employed in the army hospitals during the
period of the war would furnish the en-
tire population for a city the size of Albany.
New York. At one time 150,000 beds were
set up for men in the army hospitals. If
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these beds were placed end to end they
would form an almost unbroken line from
New York to Washington.
On April 6, 1917, the Medical Depart-
ment had approximately 981 commissioned
officers, 403 female nurses, and 6,900 en-
listed men on active duty. On December
1, 1918, there were approximately 40,100
commissioned officers, 31,480 female nurses
and 264,000 enlisted men. The records of
these officers and their active duty status
were under the supervision of the Personnel
Division, which at the beginning of the war
consisted of one officer and ten clerks. On
December 1, 1918, the Personnel Division
had increased to fifteen officers and three
hundred and eleven clerks.
Upon declaration of war, it became im-
mediately necessary to call upon the medi-
cal profession of the country to augment
the Regular Medical Corps in order to pro-
vide adequate medical care and treatment
for the enormous armies which it was cer-
tain would be brought into the field. The
task of classifying, commissioning and as-
signing new medical officers was suddenly
thrown upon the Personnel Division of the
Surgeon-General's office. The statistical
Section indexed and classified all available
physicians of the country, the cards being
arranged alphabetically, by states and by
specialties. Since January 1st, officers have
been discharged from the Medical Depart-
ment at an average rate of nearly one thou-
sand per week.
On the day the United States declared
war with Germany there were in the Army
Nurse Corps 233 members of the Regular
Corps and 170 reserve nurses on active
duty because of the mobilization of troops
on the Border. The needs, both in this
country and in France, increased enormous-
ly and at the time of signing the armistice
there were approximately 21,500 nurses on
active duty, about 10,000 of them being
overseas. These 21,500 women were not
employees of the Red Cross, but were
nurses enrolled and paid by the United
States Government as an integral part of
its Medical Department. To supplement
the waning supply of graduate nurses the
Medical Department established the Army
School for Nurses. For this school 10,767
young women made application, 5,517 were
accepted and 1,600 were in training at 53
different hospitals when the armistice was
declared.
The duties of the Division of Laborato-
ries and Infectious Diseases may be termed,
broadly speaking, the control of communi-
cable diseases, more particularly from the
standpoint of laboratory methods; the di-
agnosis of these diseases by these same
methods; and the accumulation of mate-
rials, by research and by observation of the
individual cases, for the further study of
these conditions. In addition, the admin-
istration of the Surgeon-Generars program
for combating venereal diseases was as-
signed to this division, so that in this class
of diseases all methods of control were
combined unjer one head.
The problems presented to the Division
of Laboratories and Infectious Diseases
were both varied and extremely important
in their relation to the prevention of wa-
stage in troops. Developments in sanitation
and sanitary control and in specific pre-
ventive measures, such as vaccines, indi-
cated that the intestinal group diseases (ty-
phoid fever and dysentery), which have
wrought such havoc in the armies of the
past, would be controlled by the protection
given by typhoid and paratyphoid vaccine
and by adequate general sanitary measures.
The expectations in regard to this group of
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diseases have been confirmed. Typhoid
fever has occurred in the devastated and
extremely insanitary regions of the West-
ern front, but the incidence has been low,
and typhoid fever during the present war
has never been a serious menace.
Epidemic cerebro-spinal meningitis is al-
ways an important disease when troops are
mobilized. Infection in this disease is trans-
mitted by discharges from the mouth and
nose. Specific measures of control by
means of serum treatment were used thru-
out the service. The laboratories of the
army examined hundreds of thousands of
men to discover those who, tho not having
the disease, were yet capable, as healthy
^'carriers," of transmitting it to others. The
discovery of these so-called "carriers," and
their isolation and treatment to render them
harnlless to others, was one of the most
important tasks of the laboratories.
To handle the laboratory problem effi-
ciently it was necessary to practically con-
trol the production of medical laboratory
apparatus and supplies. Germany and Aus-
tria have produced in the past the large pro-
portion of the laboratory glassware and
chemicals used in this country, and it was
necessary to adopt standard types of ap-
paratus for the work of the laboratories of
the army and to stimulate the manufacture
of this apparatus and to initiate the produc-
tion in this country of certain indispensa-
ble chemicals. In this the Army was aided
greatly by the cooperation of the Medical
EHvision of the National Council of Re-
search.
To produce the necessary sera and vac-
cines for the prevention and treatment of
disease in the Army and Navy, the Army
Medical School increased its power of pro-
duction to a marked degree. Thousands of
gallons of typhoid and other vaccines were
produced and large quantities of special
serums made for diagnostic purposes.
The administration of the Surgeon-Gen-
eral's program for combating venereal dis-
eases constitutes perhaps one of the most
important sections of the work of the Di-
vision of Laboratories and Infectious Dis-
eases. The problem of the venereal dis-
eases has always been of vital interest to
all armies and the fight against this class
of infections has been carried on most ac-
tively and openly in the Army for many
years. With the passage of the draft act
it became evident that it would be neces-
sary to extend the fight to the civil popu-
lation, not only as the latter was a source
of infection to the Army, but also that
every effort might be made to diminish the
incidence of these diseases among men
drafted and about to be drafted. To ac-
complish this more effectively a section for
combating venereal diseases was added to
the War Department's Commission on
Training Camp Activities. This section
worked in close liaison with the office of
the Surgeon-General, more particularly as
the administration of this section and the
personnel for the work was furnished by
the Surgeon-General.
The activities of this program for com-
bating venereal disease were divided into
Educational, Law Enforcement and Early
Treatment Sections.
From incomplete statistics of the war it
is shown that of 225,000 cases of venereal
disease 200,000 were contracted before en-
listment, that is, before the men joined the
army. The record of the army for cases
contracted after enlistment has been good,
showing the eflfect of the combination of
the several measures included in the Sur-
geon-General's program.
In addition to these preventive measures
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adequate treatment has been provided for
every soldier infected with this class of
disease, and not only that but under pres-
ent regulations men so infected, whether
they brought the disease into the Army with
them or acquired it after entrance, are be-
ing retained in the service until they are
no longer infectious to others or a danger
to the community to which they go.
When war was declared there were
eighty-six commissioned dental officers in
the Regular Army of the United States.
There were approximately thirty dental of-
ficers in foreign service, viz., in the Philip-
pines, Hawaii and Panama, the remaining
officers being scattered thruout the United
States. On November 13, 1918, there were
6,254 dental officers commissioned, of whom
4,286 reserve officers and 224 regular
corps officers were in active service. There
were approximately 2,000 with the Amer-
ican Expeditionary Forces.
Schools were established in Philadelphia,
Chicago and St. Louis to give special train-
ing to officers who were to do oral and
plastic surgery, and dentists were assigned
to these schools for that training and have
been associated with the surgeons thruout
the war in this special work.
The policy of physical reconstruction of
disabled soldiers, later extended to disabled
sailors and marines, was formulated in the
office of the Surgeon-General in August,
1917; practically applied in seven hospitals
early in 1918; and the policy and program
were finally approved by the War Depart-
ment on July 29, 1918.
Physical reconstruction as applied in mil-
itary- hospitals is defined as continued
treatment, carried to the fullest degree of
maximum physical and functional restora-
tion consistent with the nature of the dis-
ability of the sick or injured soldier, by
the employment of all known measures of
modern medical and surgical management,
including physio-therapy, (thermo, electro,
hydro, and mechano-therapy, massage, cal-
isthenties, gymnastics, military drill and the
like), curative mental and manual work
(in wards, shops, schools, gardens and
fields) and sports and games in and out
of doors.
For administration the Division of Phys-
ical Reconstruction in the office of the Sur-
geon-General was organized with a per-
sonnel of a Director and assistant, with
sections on education (general, technical,
agricultural and psychologic) ; training the
blind; training the deaf and correction of
speech defects, and physio-therapy.
There are special facilities for training
the blind and nearly blind soldiers, sailors
and marines at U. S. Army General Hos-
pital No. 7 at Roland Park, Baltimore,
Maryland. The blind are trained to dress,
feed themselves and to get about inde-
pendently; to read Braille; and to use a
typewriter. Coincidently, occupations suit-
able for the blind are taught by a corps of
competent instructors.
The disabled soldiers who suffer from
speech defects, and from deafness are
trained to talk and to understand by lip
reading at U. S. Army General Hospital
No. 11, Camp May, New Jersey.
Curative work modified to meet the need
of the tuberculous soldiers is applied in a
most beneficial way at seven military tuber-
culosis sanatoria.
Before the armistice was signed, approx-
imately 10,000 disabled soldiers were re-
turned from the American Expeditionary
Force to the United States. These were
cared for in sixteen General Military Hos-
pitals, and those who needed it were given
the benefit of, the continued treatment
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known as physical reconstruction.
Following the armistice, the return of
the sick and injured from overseas was
expedited. From November 11, 1918, to
May 1, 1919, approximately 110,000 disa-
bled soldiers from the American Expedi-
tionary Force have been returned to Amer-
ica. This has required the Medical Depart-
ment of the Army to secure facilities for
the application of measures of physical re-
construction in additional general hospitals
and in fifteen base hospitals of the training
camps. At the height of the maximum de-
gree of hospitalization, since the armistice
was signed, forty-eight hospitals have func-
tioned in physical reconstruction. At the
present time, forty-four general and base
hospitals carry on this type of treatment.
Of a total number of reconstruction pa-
tients discharged for disability to April 1,
1919 (5,070), approximately 41 have been
designated as hopeless or institutional cases ;
510 have been reported as in need of fur-
ther training, while 4,519 were able to re-
sume their old occupation or were not in
need of retraining. Many disabled soldiers
have been so fully trained vocationally
while patients in the hospitals that they
have needed no further training after their
discharge.
The need was recognized for the educa-
tion of the public and of the disabled sol-
diers themselves as to the value of curative
work in the continued treatment of the
sick and wounded soldiers. In cooperation
with the Federal Board of Vocational Edu-
cation, the American Red Cross and the
public press, circulars, pamphlets, the mag-
azine ''Carry On/' and articles prepared for
popular monthly magazines and the daily
press have been circulated thruout the
country and in the hospitals.
The Division of Medicine consists of four
sections : Psychology, Neuro-psychiatry
(nervous and mental diseases), Tubercu-
losis and Internal Medicine (all diseases
not included in the above). The function
of the Section of Psychology is twofold:
First, to determine the mental capacity- of
the individual; second, to classify men so
that, as far as practicable, an individual's
previous training and mental development
will be given due consideration when the
specific assignment in the Army must be
made.
The activities of the other sections of
the Division of Medicine are concerned
with two functions: First, physical exam-
ination of men sent to the mobilization
camps and the final physical examination
upon demobilization in so far as medical
conditions are concerned. Second, care and
treatment of sick in the service.
The Medical Department convened cer-
tain boards, consisting of experts in their
respective branches, at mobilization camps
for the more complete examination of all
soldiers who had passed the preliminary
physical examination. The members of
these Special Boards were represented by
specialists in tuberculosis, in diseases of the
heart and arteries and in nervous and men-
tal diseases. Nearly 60,000 men were re-
jected on account of defective development
or diseases of the nervous system ; nearly
80,000 men were rejected on account of
various forms of tuberculosis; and about
50,000 men were rejected on account of
diseases of the heart and arteries.
The second function referred to above,
the care of the sick, has been handled by
the establishment in every important hos-
pital of medical services, presided over bv
experienced physicians who are not only
expert in diagnosis and treatment, but are
also administrators capable of organizing
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and supervising the extensive services
which, during epidemics, tax the abilities of
the most able men and equal in difficulty
the problem$ encountered by the surgical
staffs at hospitals near the front. In addi-
tion to the care and treatment given pa- .
tients in the hospitals at the mobilization
camps, a number of special hospitals have
been established at various places in the
country for the treatment of certain dis-
eases or groups of diseases. These hos-
pitals have been manned T^y the ablest men
in the profession and experts in their re-
spective spheres for a number of years.
It is the duty of the Medical Department
to care for soldiers who have incurred sick-
ness or disability incident to the service,
until they are cured, or the maximum
amount of improvement has been attained.
Finally, on discharge from the service a
careful physical examination is made of
each soldier in order to determine whether
any disability exists at the date of separa-
tion from the. Army, and, if so, to estimate
the degree and make it of record so that
future claims and rights of the individual
can be adjudicated with justice to the sol-
dier and the Government. This Division
provides the special personnel for the med-
ical portion of this examination. Special-
ists in all lines cooperate in this final exam-
«
ination.
The Division of Surgery developed pari
passu with the Division of Medicine. In
a short time the Surgeon-General appointed
a number of surgeons eminent in the civil
professions who were to act in an advisory
and executive capacity. Three distinct lines
of effort at once opened up. First, as the
concentration camps were established and
opened for the training of troops, the es-
tablishment of base hospitals in connection
therewith necessitated the organization of
a surgical personnel to look after the or*
dinary surgical ills of a large camp. Thru
the efforts of the Red Cross fifty base hos-
pitals and a few other hospital units had
been raised and equipped from the great
medical centers and some other places.
Some of the best of the surgical profession
were included in these groups. It was
evident that many more units would be
needed and it was the second task of the
Surgical Division to arrange for the organ-
ization of the surgical side of these units.
Thirdly, many of the most important sur-
gical instruments, needles, etc., had previ-
ously been imported from England and
Germany. There was no standardization
in civil life, the surgeon using that which
from experience or fancy had seemed to
him the best. The committee of surgeons
met and standardized these instruments so
that the equipment of every base hospital,
or of every hospital unit sent abroad, would
be identical, thus assuring an ample supply
of the most modern and efficient types.
The rotating consulting surgeons working
with the Surgeon-General could not know
more than a few oi the experienced sur-
geons of the country, or the active, prom-
ising young men of the profession ; conse-
quently a scheme was devised whereby the
qualifications of every civil surgeon were
placed on cards, which were sorted and re-
sorted until the relative standing of each
man was known. Additional information
with regard to the qualification of surgeons
was secured in many ways, one of the most
important being the local organizations of
the Medical Section of the Council of
National defense.
As a result of the study of these qual-
ification cards it was found that the actual
number of physicians capable of doing the
special work required by reason of the casur
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alties of war was limited. Accordingly,
schools of instruction were established in
general surgery including fractures, in
neurologic surgery, in plastic and oral sur-
gery, in orthopedic surgery, etc. These
schools were located in well known centers
such as New York, Philadelphia, Chicago,
Rochester, San Francisco and New Or-
leans, and were under the charge of ex-
perienced surgeons and teachers. The suc-
cessful method of Carrel at Compiegne was
established at the hospital of the Rockefel-
ler Institute, and a continual stream of med-
ical officers passed thru this institution
studying this method of treatment.
By November, 1917, the work of organ-
izing base and evacuation hospitals was well
under way and a little later the organiza-
tion of Mobile Units was begun. From
then on until the armistice, one hospital
after another, unit after unit, was organ-
ized, mobilized, equipped and sent abroad.
This necessitated a constant shifting of the
surgical personnel of the camp and canton-
ment hospitals, and it was found necessary
to gradually work into places on the per-
manent staff the older and less active, but
nevertheless competent surgeons in order
to set free the younger and more active ones
for overseas service.
Many hundreds of complete X-ray equip-
ments were purchased and supplied to the
troops overseas and all the military hos-
pitals in this country were completely
equipped with everything that could be de-
sired for X-ray work. One of the most
important developments of the war is a
portable X-ray apparatus which was to be
found scattered over the front wherever
needed.
A literary program was an important
part of the surgical organization. Special
tK)oks were written with wonderful speed;
the experience of French, English and even
German surgeons was collected and ab-
stracted and distributed to our medical of-
ficers; a review of the war literature was
issued monthly. Lantern slides and mov-
ing picture films were made and used for
instruction. Finally, during the summer of
1918 a large surgical school was established
as a branch of the Medical Officers* Train-
ing Camp, at Fort Oglethorpe, Georgia, a
faculty formed, a systematic course of in-
struction begun and carried on to the time
of the armistice.
The enormous number of men located in
camps in this country required a large force
of skilled surgeons and assistants and by
July, 1918, a complete survey of the char-
acter of the surgical work was made, and
a system established by which it was pos-
sible in Washington to check over all op-
erations and determine if the highest class
of work was being done. When the pneu-
monia epidemic swept the camps it was fol-
lowed by a wave of empyemji which, ow-
ing to its severity and unusual nature,
temporarily baffled the surgeons. An Em-
pyema Commission was appointed which
w"ent from camp to camp studying the sur-
gical aspects of this disease, and thru its
suggestions and directions much good was
done. After the armistice was signed the
reconstruction era began and it was now
the duty of the Division of Surgery to pre-
pare for the care of the stream of wounded
returning from the overseas hospitals.
These were classified in certain large groups
of which compound fractures, peripheral
nerve injuries, stiff joints and amputations
constituted the most important. With some
fifty hospitals receiving patients, and with
the personnel thereof everywhere greatly
depleted of specialists in order to supply
the services abroad, it was soon realized
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it would be necessary to concentrate the
injuries most difficult of treatment into spe-
cial hospitals where a sufficient personnel
and equipment could be gathered to meet
the various indications of treatment. This
was particularly true of the peripheral nerve
injuries. Centers also were established to
which cases of amputations were to be sent
and preparations made for the application
of provisional limbs during the long peroid
in which such cases must wait for the appli-
cation of permanent limbs. The matter of
artificial limbs was thoroly investigated and
a standard provisional and a standard per-
manent limb adopted and given to the sol-
diers.
At the outbreak of the war with Ger-
many the Division of Finance and Supply
of the Medical Department ' had its need
for supplies computed in such a manner
as to permit its ready adaptation to any
size army it might be called upon to equip.
In cooperation with the Medical Section
of the Council of National Defense, it held
conferences with representative committees
of manufacturers of surgical instruments,
pharmaceuticals, laboratory supplies, sur-
gical dressings, hospital equipment, etc.,
and succeeded in getting these industries
lined up for full, complete and enthusi-
astic support of the Medical Departments
of the Army and Navy. New sources of
supply were developed as rapidly as it be-
came evident that existing sources would
prove inadequate.
The equipment needed for each individ-
ual camp was carefully computed and the
supplies ordered shipped considerably in
advance of the day the first troops were
scheduled to arrive. Unit equipment was
devised for base hospitals, camp infirma-
ries and the various other organizations.
Sufficient equipment for the establishment
of a base hospital of 500 beds was sent to
ever}' camp before the arrival of troops,
and ambulances were also provided for the
transportation of the sick. By the end of
September, 1917, at least 14 standard am-
bulances had been delivered to every camp.
In one instance, at the establishment of a
large hospital at Newport News, the first
carload of supplies for the hospital actually
arrived six days after the request for the
equipment had been 'phoned in to the Sur-
geon-General's Office.
Great quantities of surgical dressings
w ere purchased. The quantity reached such
magnitude by the end of ^arch, 1918, that
the thread which entered into the weaving
of the gauze actually furnished, if tied into
one string, would have reached from the
earth to the sun. Surgical and dental in-
struments were the most difficult of all the
equipment to obtain. In pre-war times,
only about 10% of the domestic require-
ments for surgical instruments were pro-
duced in the United States; the rest being
imported, largely from Germany. At the
signing of the armistice there was a suf-
ficient quantity of these supplies in France
to have taken care of an army of 2,000,000
men for more than six months.
At the signing of the armistice, the Med-
ical Department had in sight sufficient sup-
plies and equipment for 700,000 hospital
beds, with 300,000 cots in reserve for cri-
sis expansion.
The designs of ambulances were per-
fected and approximately 2,700 of the Ford
type and 3,600 of the large G. M. C. type
have actually been delivered. As showing
what such a number of ambulances might
accomplish it may be said that one Evacu-
ation Ambulance Company alone, with 12
machines, reported the evacuation of 55,-
000 patients, and credits each machine with
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a mileage of 25,000 miles, during the pe-
riod from July 17, 1918, until it ceased to
function after the armistice.
The laboratory equipment of our Medi-
cal Department has been the most complete
and elaborate supplied to any of the Allied
Ariiiies. Biologic products have been fur-
nished in enormous quantities. Not only
has enough anti-typhoid vaccine been fur-
nish to vaccinate an army twice the size
of the total number of troops called to the
colors, but thousands of litres of anti-men-
ingitis serum, anti-pneumococcic serum, an-
ti-dysenteric serum, anti-tetanus serum and
diphtheria antitoxin have been furnished
at home and abroad.
The Air Service Division was maintained
during the height of aeronautic activity to
particularly supervise the Medical Depart-
ment activities pertaining to the Air Serv-
ice. It administered the medical service at
aviation fields and with mobile aviation
units, and established a central laboratory
for investigating all problems regarding the
health and well being of the aviator.
The Gas Defense Service was, during its
inception and organization, attached to the
office of the Surgeon General, and had to
do with all defense measures against poi-
sonous gases. Its primary function was the
development and manufacture of gas masks
for both men and animals. Other defen-
sive measures included fans, for removing
gas from trenches, sprays for the neutral-
ization of gases, instruments to detect the
presence of gas, substances for application
to the goggles of masks to prevent them
from fogging, etc. Ultimately the func-
tions of this section were taken over by the
Chemical Warfare Service at the War De-
partment, which handled all matters con-
nected w^ith gas warfare both offensive and
defensive.
The Food Division gave technical advice
on food products, rations, diets and food
conservation, made numerous food surveys
at camps and compiled statistical reports
on same. It also directed special laboratory
investigations relating to food preservation,
food conservation and food values.
It early became apparent to the Surgeon-
General's Office that schools for the train-
ing of civilian physicians in their duties as
medical officers were essential if the best
results were to be obtained. Consequently,
on June 1, 1917, training camps for medi-
cal officers and enlisted men of the Med-
ical Department were opened at Camp
Greenleaf, Chicamauga Park, Georgia, Ft.
Riley, Kansas, Ft. Benjamin Harrison, In-
diana, and Ft. Des Moines, Iowa. In De-
cember, 1917, the camps at Ft. Benjamin
Harrison and Ft. Des Moines were closed,
the personnel and equipment being trans-
ferred to Camp Greenleaf and Ft. Riley,
which were continued to the end of the war.
The purpose of these camps was to give
an intensive course of training in military
matters and in the application of the prac-
tice of medicine and surgery to the military
life. The course was primarily for medical
officers who had received commissions in
the army, and for instruction of a similar
character to the enlisted personnel of the
Medical Department. Subsequently courses
were given officers of the Dental, Veterinary
and Sanitary Corps.
During the continuance of these camps
approximately 15,000 medical officers and
140,000 enlisted men received instruction.
At Camp Greenleaf, in addition to in-
struction of a purely military nature, there
were given professional courses pertaining
to the various specialties.
(Continued on page 426)
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329
ORIGINAL
TICL^S
==^*
INSECT-BORNE DISEASE IN AR-
MIES.
BY
L. I. LLOYD,
Lieutenant R. A. M. C. (T.)
Hempstead Military Hospital, Hempstead, Bng.
Author of "Lice and Their Menace to Men."
Introductory. — The phenomenon of the
use of intermediate hosts by parasites,
especially worms, has long been known
to zoologists. The knowledge that in-
sects act as the intermediate hosts of the
parasites of many of the diseases of man
and animals is mainly the result of re-
search during the last three decades. The
suggestion that insects might be concerned
in disease causation had been made pre-
viously. Notably mosquitoes were sus-
pected of being responsible for malaria
and yellow fever. It needed, however,
modem methods of investigation to prove
these associations. The first definite proof
was forthcoming when Manson showed
that the worm which causes elephantiasis
was conveyed from man to man by the bite
of a mosquito. Bruce proved that the con-
veyance of the trypanosome which produces
the fatal nagana in domestic animals in
Africa was by means of the tsetse fly. Reed,
Carroll and their co-workers demonstrated
that the unknown virus of yellow fever was
carried by the common mosquito, Steg-
omyia fasciata, and about the same time
Ross incriminated the Anopheline mosqui-
toes in the transmission of malaria — per-
haps the most important discovery of all.
This was just twenty years ago, and since
then much knowledge has been gained; in-
sect after insect, ticks and mites have been
convicted, and disease after disease has
been added to the growing list of those
which are insect-borne. Especially during
the last ten years have we learned that these
phenomena are by no means peculiar to the
tropics but that the sanitarian of temperate
and cold countries also must take a vast
interest in the external as well as the in-
ternal parasites of man.
Some of these parasites, such as the itch
mites, which invade the tissues of the body,
are themselves the cause of disease. The
vast bulk, however, are harmless creatures
originally and only become dangerous when
they have infected themselves on the excre-
tions of diseased man, or have imbibed the
virus of disease while sucking blood from
man or animal. In a few instances the in-
fection may pass thru more than one gen-
eration of the insect or tick without the in-
termediary of a warm-blooded animal, but
usually this is not the case and each indi-
vidual commences with a clean sheet.
Rarely does the vector itself seem to suffer
any ill eflfects from the harborage of the
virus, tho this may be as truly parasitic
in it as in the higher animal. The fleas
carrying plague form an exception to this.
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The Bacillus pestis multiplies in the gut
of the flea until it becomes choked and in
its struggle to feed in the choked condition
it ejects a mass of the bacilli into the wound
it has made.
The Casual Association of Certain Dis-
eases vrith Insect Vectors. — For prac-
tical purposes we may divide the disease-
carrying insects and ticks into two broad
Fig. 1. ■ Sanitary Demonstration Center, Basra,
showing in foreground types of Fly-Proof
Latrines with petrol tins suspended from
sliding runners. The seat-cover on the
right is badly arranged. It falls back too
far to be self-closing.
classes. The first class includes those
which carry the germs in a mechanical man-
ner. In these the virus does not necessarily
multiply and the carrier is infective from the
moment when it first picks up the infection.
These belong to the Diptera, or two-winged
flies, and mostly fall into the families
Muscidae, Sarcophagidse and Anthomyidae.
The species incriminated are those which
haunt the dwellings of man and are at-
tracted to his food and to filth. The most
important ones are Musca domes tica (the
"house fly" or, as Howard calls it the
"typhoid fly")» Calliphora sps. and the allied
forms (the "blow flies"), Sarcophaga sps.
(the "flesh flies"), and Fannia sps. (the
"lesser house fly" and "latrine fly")- These
are all very prolific flies and their footless
larvse, or maggots, live in fermenting vege-
table matter, in dung, or in decaying flesh.
In hot weather the larvae grow at a surpris-
ing rate and have a very short pupation
period whicTi they spend buried in the
ground near their food. As an instance of
their fecundity, Musca domestica lays about
700 eggs and these may become adult flies
in a week. As generation succeeds genera-
tion while suitable conditions last, it needs
little imagination to realize the vast swarms
which may be bred in insanitary camps in
hot countries. At Gallipoli it was imprac-
ticable to land sanitary supplies, and sani-
tation was compulsorily primitive. It is re-
lated that there when a shell burst in "no
man's land" a vast black cloud of flies
arose, to slowly settle again. In some parts
the flies were so troublesome that when a
man received his ration he would thrust it
into his pocket and thence convey it in frag-
ments to his mouth, waving his hand over
it to ward oflf the swarming pest. Men re-
turned to England from the East unable to
eat jam owing to the nausea aroused by the
recollection of the swarms of flies they had
seen on this comestible.
Not all these flies breed regularly in
human excrement but all have a liking for
it. They divide their attention between
this and similar substances and the food
and drink of man. Naturally they fre-
quently carry particles of feces on their
hairy bodies and leave them on food. They
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331
take food themselves only in a fluid form,
all larger particles being filtered out by their
proboscides. It is therefore necessary for
them to dissolve or emulsify solids, such as
sugar and bread, before they can partake
of them. This they do by ejecting salivary
fluid on to the substance, allowing it to rest
there for a moment and then drawing it up
again into their crops. Often they regur-
gitate the entire contents of their crops in
the same manner. In this way a fly may
convey a considerable drop of urine or
liquid feces almost, straight from the la-
trine to the mouth of man. Further they
frequently defecate on to food and it has
been proved that the organisms of many
diseases are still virulent after several days'
sojourn in the bodies of the insects. After
these statements there is no need to mar-
shal any of the indisputable proofs that
these insects convey cholera, bacillary
dysentery, amebiasis and the enterics.
In the absence of flies, however, none
of these diseases would cease to exist thru
the world, since they are all also water-
borne, and 'insects form only one means of
conveyance. Their importance varies enor-
mously in different epidemics and may oc-
casionally be insignificant. In modern
towns, where the water supply is good, they
may be entirely responsible for an out-
break. The special conditions of warfare
also make them of great importance. The
modern army sanitarian has generally
means at hand for making water safe, but
he is often not provided with any means
for keeping down the fly population and
may be unable to improvise any. In Galli-
poli where, in spite of the very heavy flght-
ing, the number of sick evacuated (mainly
dysentery cases) almost equaled the total
of all other casualties, the trouble was prob-
ably due entirely to flies, since the water
supply of the troops was brought from over-
seas and was above suspicion. Fortunate
indeed is it that the mixed typhoid vaccine
proved so excellent in practice. Without
this means of prophylaxis, fly-borne enterics
might have reduced the armies in the East,
and possibly also in the West, to a state of
pitiful impotence.
In addition to these diseases, all pri-
marily of the alimentary tract, flies are also
to some extent responsible for conveying
maladies which are primarily of the exposed
surfaces of the body. Such are ophthalmia
and pyogenic infections. The virus is car-
ried in a mechanical manner from the sick
to the healthy, and no one who has watched
the flies clustering on the eyes of children
in the tropics, can doubt the important part
they play in disseminating ophthalmia. Lice
are known to be capable of spreading this
complaint, and also favus and tropical im-
petigo, all in a mechanical manner, but it is
doubtful whether they are of importance as
carriers of these diseases.
The D^>enclence of Certain Diseases
on Insect Vectors. — The second class
of disease carriers consists of those insects
and ticks which convey diseases in a man-
ner which is not mechanical. The vectors
are all blood suckers and the maladies they
carry are all primarily those of the blood
stream. In the absence of their vectors
these diseases would cease to exist thru
the world for they are transmitted in no
other natural manner. A characteristic of
all these is that the virus multiplies in the
bodies of the carriers and until the multi-
plicative phase is complete they are not
normally infective. In a few cases if their
bodies are crushed and inoculated while
they still contain fresh infected blood they
can produce infection. This is not the
natural manner and is of no practical im-
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portance. The list of vectors of this type
is now a long one, and as it is not practicable
to detail them separately here they are
shown in a table, only proven cases being
included. Of these diseases the ones which
have caused most sickness among the troops
are the three louse-borne diseases, malaria
and sandfly fever.
of the lice, however, were not understood
and. all early attempts to rid the men of
them failed, owing to a lack of thoroness.
Men were provided with clean shirts but
these quickly became infested from the
other garments which were not changed.
Blankets also were neglected and it was
only in the last year of the war that it was
Bloodsucking Insects and Ticks and Diseases of Man which are entirely conveyed by them.
Vectors
Disease
Causative Organism
Mode of
Inoculation
Mosquitoes
Anopheline and Culicine
Filariasis
Microfilaria Bancroft
Bite
Anopheline
Malarias
Plasmodium spp.
Bite
StegoMyia fasciata
Yellow Fever
Unknown
Bite
Culex fatigans
Dengue
Unknown
Bite
Sand flies
PhJehotomus
Dengue
Unknown
Bite
P. papatacii
Sandfly Fever
Unknown
Bite
P, verrucarum
Verruga
Bartonia hacilliformis
Bite
Tsetse flies
Qlossina palpalis
Sleeping Sickness
Trypanosoma gamhiense
Bite
O. morsitans
Sleeping Sickness
T. rhodesiepse vel hrucei
Bite
Horse flies
Chrysops
Bugs
Triatoma megistus
Calabar Swellings
Filaria loa
Bite
Chagas* Disease
Trypanosoma cruzi
Bite
Fleas
Rat fleas especially Xenopsylla
cheopis
Plague
Bacillus pestis
Bite
Uce
Body-louse and Head-louse,
Pedi-
cuius
Typhus
Rickettsia sp. f
0
Relapsing Fever
Spirochaeta recurrentis
t
Trench Fever
Rickettsia sp. t
• t
Ticks
Ornithodorus moutata
Relapsing Fever
(Cen-
tral Africa)
Spirochaeta duttoni
o
Dermacentor venustus
Rocky Mountain
Spot-
ted Fever
Rickettsia sp. f
Bite
•Bite, or inoculation by scratching of louse excreta,
t Inoculation by scratching of crushed lice.
JFouling of bites or scratches with louse excreta.
^Fouling of bites with tick excreta and gland juice.
Lice have always been the scourge of
armies and probably never more so than in
the Great War. In the early hectic months
it was frankly impossible to pay attention
to this pest. During this time on the West-
ern Front the lice, which were present on a
few of the more careless men, spread rap-
idly thru the whole body of troops until the
large majority of the men became infested.
Their cleansing became a Herculean task
calling for skilled organization. The habits
realized how important it was to pay atten-
tion to the hair on the men's bodies, on
which the lice frequently lay their eggs.
Further the treatment was not carried out
thoroly among the units and some men al-
ways escaped it and reinfested those who
had been cleansed. The disinfestation sta-
tions were often far from the front and it
was necessary to keep units in the fighting
zone for very long periods and during this
time no treatment was available.
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The armies, therefore, formed an ideal
ground for epidemics of typhus and re-
lapsing fever, but fortunately these diseases
never appeared on the Western Front. Had
they done so the toll of sick would probably
have been frightful. Another disease, how-
ever, at first unrecognized as a clinical en-
tity, did make its appearance and immobil-
ized temporarily large numbers of men.
This was trench fever, and tho it is not
usually a serious disease and never appears
to have had a fatal ending, repeated attacks,
especially in older men, led to chronic con-
ditions of ill health which necessitated many
organized campaign against the louse with
very beneficial results. It may seem sur-
prising that these investigations were not
carried out earlier, but it should be remem-
bered that trench fever research cannot be
done with experimental animals, as they are
not susceptible, so that it was essential to
work with volunteers. Had experimental
animals proved susceptible, as they are to
most insect-borne diseases, these results
would have been obtained very early in the
war. '
Altho typhus and relapsing fever did not
appear on the Western Front they played
Photograph hy Captain P. F. Gow, D. 8. O., /. M. 8.
Fio. 2. Open cone incinerator being used for the burning of manure.
of them being invalided or relegated to the
rear. In 1917, the War Office Trench Fever
Committee, of which Major-General Sir
David Bruce was chairman, with Major W.
Byam, R. A. M. C, in charge of the work-
ing party, and the American Red Cross
Committee, with Colonel R. P. Strojig in
charge, tackled the problem of its mode of
spread. Simultaneously they proved that
the louse was entirely responsible for the
transmission, tho on a minor detail they dis-
agreed. This was followed by a better
terrible havoc in the near East. Distress
and hunger are the great forerunners of
louse-borne diseases. When food is scarce
people are no longer able to afford to buy
soap and clothing. They cannot, therefore,
indulge in those regular changes of gar-
ments which prove so deleterious to body-
lice. They become dejected and indifferent.
If it is winter they crowd together for
warmth, undressing neither by night nor by
day. These conditions suit the lice as they
can pass freely from person to person, and
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can multiply without check. When the
diseases get a footing they spread so rapidly
that the hospital staffs are overworked and
can spare no time to cleanse the sick. The
infected lice migrate in large numbers from
the skin of the fever cases as they dislike
the increased warmth. They also migrate
at the death of their hosts. Hospitals thus
become the centers of infection and most of
the staffs contract the maladies. Such have
Fig. 3. Primitive method of removing Lice.
Front line trench, Anzac.
been the experiences in Roumania and Ser-
bia where typhus and relapsing fever gained
so firm a hold that the results of campaigns
were swayed by them.
Dr. H. Gideon Wells and Dr. R. G. Per-
kins of the American Red Cross Commis-
sion to Roumania have given an account of
the terrible devastation these diseases
wrought there. They tell us that in Mol-
davia, where two and a half million people
normally dwell, the population was doubled
by the advent of many refugees and Rus-
sian troops. Food was scarce; transport
broke down ; the people were badly housed
and clad in rags; fuel was almost absent
and the enemy was battering at their gates.
Add to this that it was a bitterly cold win-
ter, and a more suitable ground for a typhus
epidemic could not be conceived. The dis-
ease spread thru the country in a month
and nearly a million people became infected.
How many died from it is not known, but
in Jassy as many as 500 succumbed in a day.
Two hundred of the twelve hundred med-
ical officers of the country lost their lives
before warmer weather allowed the epi-
demic to be checked. The tale of Serbia
is equally harrowing.
The multiplication of lice in armies can
be prevented by careful attention to the per-
sonal hygiene of the men, and the swarms of
flies can be controlled by a well organized
sanitary scheme. Apart from the flies
which breed in corpses in "no man's land"
the armies are to a large extent responsible
for what they suffer from these pests, in
that they breed their own. This is not,
however, the case with mosquitoes and
sandflies. Like the flies they are natural
denizens of the occupied zones but the oc-
cupation does not necessarily increase their
numbers. The Army Sanitarian is, there-
fore, faced less with the formation of new
breeding grounds than with the eradication
of the old ones. This a far more difficult
problem.
Sandflies breed in cool damp places such
as the crannies of rough stone walls and in
damp latrines, and no method of destroying
them wholesale has yet been devised. The
adults are so small that they can pass thru
the meshes of all ordinary mosquito nets,
and practically the only thing to do is to
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adopt the palliative method of smearing the
exposed surfaces of the body with a grease,
such as lanoline, combined with some es-
sential oil such as citronella, cassia or
camphor.
Mosquitoes, as is well known, have
aquatic larvae, and the various species
affect different types of locality, from
running streams to small collections of
rain water in tins, or holes in trees.
Their most important breeding grounds
are swamps and pools. General Gorgas
showed in the Panama Canal Zone that
it is possible to reduce mosquitoes to
a harmless minimum by the draining of
swamps, the eradication of artificial breed-
ing placesr and the oiling of collections of
water which cannot be drained. For per-
manent occupation these large schemes are
not only justified but imperative. Time,
labor and money are all available and the
expenditure of these is quickly made good
by the resulting benefits. To the Army
Commander the problem is different. When
he takes his troops into a malarious country
he has no idea how long he will occupy any
particular zone. The stagnant positions of
the armies in the late war have been quite
unprecedented. If he expects, as he should
usually do, to move forward, it is easy to
understand that he would resent having to
provide working parties to draii* or oil the
swamps as they were reached. ' Often too,
the low country where the swamps lie would
be under the fire of the enemy guns and the
work of sanitation would be dangerous.
The most that can be expected of him,
therefore, is that he will make provision for
the protection of his base and the lines of
communication, and that he will avoid the
most insanitary places when strategy per-
mits him to do so. To some extent the
mosquitoes may be kept from biting by
means of substances repugnant to them,
and by the use of mosquito nets at night.
Even this is far less possible than in civilian
life for so many men are of necessity ex-
posed during the nights. The sick should
be carefully protected from the insects by
mosquito-proofed hospitals. When all the
facts are considered it is seen that malaria
is not a preventable disease in armies to the
Fig. 4. Latest type of cage fly-trap, in use at
Basra.
same extent that typhus, cholera and dysen-
tery are.
Salonika and the neighboring countries
proved a hotbed of malaria and sandfly
fever during the war. Lieutenant-Colonel
Castellani states that the latter disease was
pandemic at times in the Serbian Army,
while the British and French suffered ter-
ribly from malaria. So much has this been
the case that Salonika seems likely to usurp
the evil reputations of West Africa and the
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Panama, and to become in its turn the
"White Man's Grave."
The Localization of Insect-borne Dis-
eases.— Travel and commerce and war
have in times past played a great part in
the spread of diseases. The more rapidly
that transit is effected and the greater the
number of travelers, by so much more will
Fig. 6. The trough in which the sacking dips
contains the poisoned solution.
the opportunities of spread be increased.
Large numbers of men have become in-
fected during the war with diseases which
are not endemic in the countries from
which they come. Many return to their
homes suffering from these diseases in a
chronic form. It is, therefore, as well to in-
quire as to what are the chances of insect-
borne diseases being established in countries
in which they were not previously endemic.
In the absence of suitable insect vectors no
harm will of course accrue to the general
population from this. Many of the more
important vectors are, however, widely dis-
tributed thru the world. Few countries
could boast that they are devoid of mosqui-
toes and of lice. Are we, therefore, to
anticipate a wider distribution of malaria
and filariasis, of typhus, relapsing fever and
trench fever, than we have known in the
past?
As stated above there is a multiplicative
phase of the virus in the body of the vector
and this may be completed in a few days or
may occupy weeks in the diffeFent cases.
The multiplication may be by division
merely as in the plague bacillus in the flea,
or it may be part of a complicated life cycle,
in which there is a rejuvenating sexual
phase, as in the parasite of malaria in the
mosquito. In either case the insect which
has imbibed the infecting blood may be
likened to a tube of culture medium which
has been inoculated with an organism. Only
if the environment is suitable does the
organism develop. Now the temperature
of man is a constant factor and his body
forms anywhere a suitable breeding ground
for any disease virus, apart from questions
of immunity. This is not the case with an
insect whose temperature is influenced en-
tirely by that of its environment. A climate
with a relatively low temperature may,
therefore, prevent the development of the
organism. To quote a case in point, the
sleeping sickness of South Central Africa
is practically confined to the low hot coun-
try, tho the tsetse fly which conveys it
ranges equally over the adjacent high cooler
ground of the Tanganyika Plateau. It has
been proved that while the trypanosome
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337
which causes the disease can complete its
development thruout the year in the low
country, it can only do so during the hottest
months in the cooler climate. Even in the
coldest month, however, the flies become
infective if they are placed in incubators at
the correct temperature after they have fed
on infecting blood.
A second consideration is that for an in-
sect-borne disease to become established on
new ground a considerable abundance of
the vector must be present. The transmis-
sion of a parasite from animal to animal by
the intervention of a third is largely a mat-
ter of chance, and unless the chances are
enormously multiplied establishment is im-
probable. The chances in this case are as
follows: First the insect must bite the
diseased man at a time when the infecting
organism is present and numerous in the
peripheral blood. Second it must be an
individual which is capable of becoming in-
fective, since, for some reason that is not
understood, only a certain percentage, and
in some cases a very small percentage, of
the vectors is capable of developing infec-
fection even under the most suitable cir-
cumstances. Third it must survive the period
during which the infection is developing.
Fourth it must then come into contact with
a susceptible person after this development
is complete. These chances are of course
increased by the unusually large numbers
of cases of certain maladies, such as mala-
ria, which have been brought to some locali-
ties from the war zone. This disease has
become temporarily established in England, .
as yet very locally. Before the war it was
very rare and almost unrecognized as an
English disease.
Perhaps the best instance to illustrate the
necessity for an abundance of the vector is
the case of typhus. The body-louse is pres-
ent and the head-louse is tolerably plentiful
thruout the world but typhus only prevails
in the cooler parts of the tropics and in
temperate and cold regions, and in the latter
in ordinary times only where the people are
careless in their manner of living. Yet the
disease is not infrequently introduced into
other parts, where it may set up a little focus
Fig. 6. Egg of body louse attached to fibres of
clbth.
of infection and then die out. This has
happened occasionally in Canada owing to
the presence of the infection among Irish
immigrants. It is only when the louse popu-
lation becomes excessive that this disease
can establish itself and cause an epidemic.
If in America or Western Europe we be-
came careless in our manner of living,
ceased to bathe and change our under-
clothing regularly, the lice would increase
rapidly and we should, with certainty, suffer
from widespread epidemics of typhus, as
they do almost annually in Russia.
Lice do not thrive in the tropics partly
because the light simple garments there
worn are not well suited to them, and partly
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because there the temperature between
man's skin and clothing is higher than that
to which they are adapted. The converse is
the case with all the other insects associated
with man. Temperature has a great effect
on the rapidity with which an insect com-
pletes its life history, and consequently on
its numbers. An insect that can pass from
egg to egg stage in a week in the tropics may
take several times as long in a more tem-
perate climate, and may suspend animation
for half the year in a cold one. Also, in
the cooler countries the free-living insects
meet with a severe check every winter and
this reduces their numbers enormously.
There is no such general severe check in the
tropics, except where there is a prolonged
dry season which may reduce the numbers
From these considerations we see that the
insect-borne diseases of hot countries can-
not establish themselves with any readiness
in cooler climates in spite of the presence of
suitable vectors. Establishment is only
probable when the introduction of large
numbers of infected men gives increased
opportunities for the infection of the vec-
tors, compensating to some extent for the
paucity of the latter, and then only if the
climatic conditions are suitable to the de-
velopment of the parasite in the insect host.
If establishment is effected it is likely to be
only temporary.
The Control of Disease-convejrin^ In-
sects in Temporary Camps. — For the
prevention of insect-borne diseases in arm-
ies or among large bodies of men engaged
Fig. 7. Fragments of sewing cotton fouled by lice excreta.
of certain species. For this reason free-liv-
ing insects swarm more abundantly in a hot
country, and the period of their abundance
is more prolonged than in temperate parts.
To venture on generalizations, one may say
that in every case the range of an insect-
borne disease is less than that of its vector,
and that this phenomenon is intimately
bound up with the question of abundance.
Lastly the people in the most civilized
countries come less closely into contact with
the disease carriers owing to the habit of
living in large and sanitary towns. The
sick, from whom infection might arise, are
generally segregated in hospitals and their
excretions are not left exposed to the at-
tentions of flies.
in public works, the following summary of
methods may be given. The recommenda-
tions are taken from various sources with
which students of the subject will be famil-
iar. It is often difficult in Army Sanita-
tion to give credit where credit is due.
A. Prevention of Diseases Carried by
FKes.
1. Screen the sick from the flies. Dis-
infect or bum at once infective feces and
urine.
2. Trap or poison the flies. Poisons
that have been found useful are :
Sodium arsenite 2^, sugar 5%, water.
On roller towel.
Sodium fluoride 1/2 to 1%, sugar 5%,
water. In bottle provided with a wick.
Formalin 5 to 6%, sugar 5%, clear lime-
water 50%, water. In bottle provided
with a wick.
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3. Latrines and urinals should be fly-
proof and feces should be incinerated
when practicable. If open trench latrines
are used they should be dug deep and dark ;
the contents should be oiled daily, or treated
with cresol. Not more than a week after
they have first been used they should be
filled in, the last foot of filling should con-
sist of oiled earth which should be stamped
firm both around and over the trenches.
4. Animal dung should be conveyed
some miles from the camp, or it should be
tightly packed and covered with a firm
layer of earth and tar oil. In dry tropical
countries it may be spread in a thin layer
to dry. In Palestine it was used for road
making. It may even be advisable to in-
cinerate it.
5. Food must be screened from the in-
sects.
B. Prevention of Louae-bome Diseases.
1. The thoro and early disinfestation of
any cases of these, and their segregation
till this has been done.
2. Those handling the sick before disin-
festation should wear overalls impregnated
with creosote.
3. All men should have a weekly hot
bath and complete change of underclothing.
4. The hair of the head and the body
should be cropped short and it may be ad-
visable to eradicate the latter.
5. Disinfestation when necessary must
be thoro both for the individual and the
unit; neither man nor garment should es-
cape.
6. Disinfestation should be by heat
which may be either wet or dry. Chambers
should be tested to ensure that they are
efficient.
7. Disinfestation plant of a mobile char-
acter should be provided with every unit,
adequate to deal with sporadic cases.
C Prevention of Mosquito-borne Dis-
eases*
1. Screen the sick from mosquitoes.
2. Screen the healthy from mosquitoes
as far as possible by nets at night.
3. Use repellants for men necessarily
exposed at night.
4. The destruction of breeding spots
near places permanently occupied. What-
ever policy is recommended for places tem-
porarily occupied, that of laissez faire is
sure to be adopted.
D. Prevention of Sandfly-boitie Dis-
eases.
Use repellants.
£• Prevention of Bubonic Plague.
1. Avoid camping in native towns.
2. Destroy rats; stop up their holes;
prevent their access to waste food and so
avoid encouraging their breeding.
3. Those associated with outbreaks
should smear their legs and arms, outside
the clothing, with a paste made from grease
and naphthalene.
Conclusion^ — It cannot be said that the
war has taught us many new facts about the
conveyance of insect-borne diseases, but it
Pig. 8. Pediculus.
has marked the known facts with many bit-
ter underlinings. Before the war we were
moving in the right direction but we were
not moving fast enough. We had not paid
that attention to the secrets of insect life
which it is necessary for us to learn if we
are to combat them successfully. The in-
sect is a machine and its movements are all
responses to chemical and physical stimuli.
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If we study these we shall find weak points
in the chain and be able to devise scientific
formula for the eradication of the pests.
This can only be done, however, by careful
research carried out when the guns are not
throbbing in our ears. Wide rules of
thumb are not what are wanted. The weak
point of one mosquito may be the strong
point of another. Had detailed researches
been carried out as soon as the danger of
these disease carriers had been proved, vast
suffering could have been prevented during
the last few years and many lives would
have been fiaved. The writer would urge
a plan for a detailed study of every insect
which attacks man or haunts his food. The
list of insect vectors of disease is not yet
completed and it may still be proved that
the louse, the human flea, and the bed-bug
are responsible for some of our commonest
ailments.
At recent meetings of the Society of Trop-
ical Medicine and Hygiene, in London, Pro-
fessor W. J. R. Simpson and Lieutenant-
Colonel A. Balfour voiced the feeling that
has been felt by many, that sanitation should
receive more adequate attention in armies
than it has done in the past. The Army
Sanitarian should be no more compelled to
improvise his requisites than the Hospital
Staffs should be to improvise their beds and
dressings. With the earliest arrivals of ex-
peditionary forces should be representatives
of the Sanitary Staffs who should determine
by a rapid survey of the natives what dis-
eases the troops are likely to meet and req-
uisition their supplies accordingly. Until
this is done the endemic diseases of an oc-
cupied zone will always obtain a strong
foothold in the armies, and what might
have been the simple problem of prevention
becomes the much more difficult problem of
cure, and the Commander, with his troops
heavily depleted by sickness, is unable to
provide working parties for the necessary
schemes of sanitation.
[Note. — The photographs used in illustrating
this article are reproduced by the kind permis-
sion of Lieutenant-Colonel Andrew Balfour,
C. M. G., M. D., Director-in-chief of the Well-
come Bureau of Scientific Research, and are
selected from the unique series which he made
in many fighting zones. They were originally
used by him to illustrate his paper ''Sanitary
and Insanitary Makeshifts in the ESastern War
Areas." read before the Society of Tropical Med-
icine and Hygiene in London, November, 1918.]
HYSTERIA AND THE SURGICAL
SPECIALTIES IN WAR AND
PEACE
BY
ARTHUR F. HURST, M. A., M. D., Oxon.,
F. R. C. P.
Newton Abbott, Devonshire, Eng.
Temporary Lieut.-Col. . R, A. M. C, Officer in
charge of Seale-Hayne Military Hospital;
Physician and Neurologist to Guys
Hospital.
Specialists have in the past been too
much inclined to work in water-tight com-
partments. The neurologist has confined
his attention too exclusively to organic
nervous diseases and those neuroses which
lie so obviously within his province that
the patient comes to him on his own initia-
tive. On the other hand patients suffering
from neuroses of the larynx, ear, eye and
bladder and from traumatic hysterical con-
tractures, which give rise to deformities,
naturally look for help from the laryngolo-
gist, otologic, ophthalmologic, genitourinary
and orthopedic specialist respectively, so
that these conditions tend to be studied too
much from one point of view.
For over two years I have worked
with a number of keen and skilled
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341
assistants/ in a hospital devoted en-
tirely to the war neuroses. Medical
officers in charge of general and special
departments of other hospitals have with
increasing frequency sent us cases which
appeared to be of functional origin, and we
have therefore had an almost unique oppor-
tunity of investigating and treating a great
variety of hysterical conditions, which are
comparatively rarely seen by neurologists
in civil life. In this paper I shall briefly
describe a few of the more common neu-
roses, which are of special interest to other
specialists, concluding with a note about
certain traumatic neuroses, which are still
unfortunately too often regarded as organic
and requiring orthopedic treatment.
Larjm^ology. — Hysterical aphonia has
been very common in soldiers. It was most
frequently a sequel of the laryngitis pro-
duced by gassing, but it also followed ca-
tarrhal laryngitis, the emotion of fear and
exhaustion. The pain caused by attempting to
speak when laryngitis is present makes the
patient whisper, but if this is prolonged for
more than three or four weeks the aphonia is
almost invariably hysterical. It can be diag-
nosed without a laryngologic examination,
and I have noticed that the slight changes
often found in the cords as a sequel of some
acute inflammatory condition by expert
laryngologists have led them to regard the
condition as organic, and therefore not
amenable to psychotherapy. We have seen
many cases in which prolonged intralaryn-
geal treatment had proved useless, but which
'were cured at a single sitting by explanation
and persuasion. Each of a hundred consecu-
tive cases of aphonia at Seale Hayne Hos-
* Major J. L. M. Symns, Major J. F. Venables,
Capt. W. R. Reynell. Capt. S. H. Wilkinson,
Capt. G. McGregor, Capt. A. W. QUI, Capt. C. H.
Rlpman, Capt. R. G. Gordon, Capt. A. Robin
and Capt. J. W. Moore.
pital was cured at a single sitting ; the 101st
case was recognized to be organic by the
timbre of the voice, a view which was con-
firmed when one cord was found to be
paralyzed and an aneurysm of the aorta was
discovered. We cured all our cases by ex-
planation and persuasion, and have not re-
quired to use electricity, general anesthe-
sia or hypnotism for nearly a year. Mutism
is of course always hysterical and easily
cured by psychotherapy.
We now believe that stammering in
civilians as well as soldiers is hysterical and
should be curable by psychotherapy with
far greater rapidity than we formerly be-
lieved to be possible. Most of our cases
during the last nine months have been cured
at a single sitting, and recently Major J. F.
Venables taught two soldiers, each of whom
had been almost inarticulate from stam-
mering since early childhood to talk fluently
in less than an hour.
Otology. — In order to hear, it is neces-
sary to Hsten, listening being as active a
process as moving. This must have an
anatomical basis; perhaps the dendrites of
the nerve cells are thrown out at each cell-
station in the auditory tract when an indi-
vidual listens and are withdrawn when he
is inattentive. If a man has become tem-
porarily deaf owing to a loud explosion or
continuous gun-fire, he may become so con-
vinced that he will never hear again that
he ceases to listen. This is the origin of
hysterical deafness. It is consequently a
true nerve deafness; the patient's voice al-
ters like that of a deaf man, he may spon-
taneously learn lip-reading and in severe
cases the auditory-motor reflex, in which
the pupils dilate and eyelids blink in response
to loud noises, may disappear owing to
the blocking produced at the lower as well
as the higher auditory centers by the with-
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drawal of the dentrites when inattention is
extreme. The only signs of any value are
those which indicate vestibular disorder, as
this never occurs in hysteria, and an organic
lesion which is sufficiently severe to cause
complete deafness would almost certainly
involve the vestibule as well as the cochlea
or the vestibular nerve as well as the
cochlear nerve. All cases of concussion
deafness, even if the drums are ruptured,
are, I believe, hysterical, and recovery oc-
curs as soon as the patient is taught to lis-
tent once more, the auditory-motor reflexes
reappearing at the same time.
I believe that the^ question of attention is
of very great importance and many patients
with partial deafness from otosclerosis or
other causes can be greatly benefited by
being taught to listen, and to use whatever
power of hearing they still possess to the
greatest advantage.
Ophthalmology. — Vision like hearing
is an active process, but it involves a motor
as well as a psychical act. Not only has the
individual to look but he has also to open
his eyes by his levator palpebrae muscles
and to converge by means of his extensic
muscles according to the distance of the
object he wishes to see.
Conjunctivitis caused by gassing or sand
thrown up by the wind or by an explosion
gives rise to photophobia. The patient
therefore does not use his levator palpebrae
superioris at all, or if ever he attempts to
open his eyes a reflex protective spasm of
his orbicularis palpebrarum occurs. The
voluntary inhibition of the levator may be
perpetuated as hysterical ptosis, and the re-
flex spasm of the orbicularis as hysterical
blepharospasm, if, when the inflammation
has disappeared, the patient continues to
keep his eyes closed. On now teaching the
patient to contract his levator and to relax
his orbicularis, it is often found that he sees
indistinctly when his eyes open and a conver-
gent squint may be present. The latter is eas-
ily overcome ; the indistinct vision is due to
hysterical paralysis or spasm of accommo-
dation, and disappears on teaching the pa-
tient to accommodate normally. In severer
cases the patient is completely blind, this
psychical blindness being due to ^ the fact
that the patient does not look, and is thus
strictly analogous to hysterical deafness.
With psychotherapy the patient can be
taught to look, and normal vision returns.
In a case of absolutely complete blindness
of four and a half years' duration follow-
ing the explosion of a shell, the light re-
flex had disappeared, but reappeared with
the recovery of vision immediately the pa-
tient was taught to look. This loss of the .
pupil reflex to light and the much more
frequent loss of the blink reflex, when an
object rapidly approaches the eye, are
doubtless due to the same kind of dendritic
retraction due to inattention, as I have
described as occurring when the auditory-
motor reflex is lost in hysterical deafness.
It has generally been taught that homo-
nymous hemianopia is always organic. But
we have found hemianopia and other
homonyonous defects of vision resulting
from wounds in the occipital region, which
were due to the hysterical perpetuation of
a condition which was originally organic.
The loss of function having been largely
due to concussion and other transient
changes, -vision might have returned spon-^
toneously, but the individual having become
temporarily blind in one or more quadrants
of his fields of vision had ceased to look in
the corresponding directions and re-educa-
tion was required to teach him to do so, the
rapid recovery which followed this method
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of treatment proving that the condition
was really hysterical.
Deficient vision may result from con-
tinuous hysterical spasm of accommodation.
In one case of this kind the spasm had per-
sisted for three years before it was recog-
nized, and the very deficient vision which
it caused could only be partially overcome
by suitable lenses. The onset was sudden,
the patient having seen normally until he
was blown up. Well marked myopic cres-
cents were present in both eyes, presum-
ably as a result of the mechanical longitu-
dinal strain caused by the concentrated pres-
sure due to ciliary spasm. The myopia dis-
appeared when the patient was taught to
relax his ciliary muscles.
Genitourinary Disorders. — It is inter-
esting to find that prolonged sexual ab-
stinence diminishes rather than increases
desire, and that many married soldiers
found that they were impotent on return-
ing home after being at the front for two
or three years. In some cases exhaustion
was partially responsible for this. Rest, en-
couragement and in severe cases suggestion
under hypnosis were invariably followed
by recovery.
Incontinence of urine was very common
in soldiers; it was almost always hysterical
and rapidly responded to psychotherapy. I
believe that the enuresis of children must be
hysterical, as many of these cases were
simply relapses under the strain of active
service of a condition which had been pres-
ent in childhood, and in a few cases the in-
continence had never ceased, but was none
the less cured by explanation, persuasion
and re-education, even if it was diurnal as
well as nocturnal.
The incontinence which follows spinal
wounds and spinal concussion has always
been regarded as organic, but we have had
several cases which were cured by psycho-
therapy after lasting many months or even
a year or two. These were generally asso-
ciated with paraplegia, which was similarly
due to the hysterical perpetuation of a con-
dition originally organic.
Orthi^iedics. — ^The paralyses and con-
tractures following minor wounds, con-
tusions and sprains of the arm and leg,
which Babinski and Froment regard as re-
flex in origin, owing to their failure to cure
them by psychotherapy and to their asso-
ciation with vasomotor and trophic changes
are, I am convinced, really hysterical. Many
thousands of soldiers and pensioners are
still receiving treatment by massage and
electricity in orthopedic hospitals, altho they
could all be rapidly cured by psychotherapy.
In a series of 100 consecutive cases treated
at Scale Hayne Hospital, the average dura-
tion of symptoms before admission was
11 months, but 94 were cured at a single
sitting of an average length of 55 minutes,
the remaining six requiring various periods
up to three weeks. Major J. F. Venables
recently cured a man with a completely use-
less hand, dating from a wound received
in October, 1914, in just under five minutes.
Disuse leads to deficient circulation, with
cold, blue and sometimes edematous ex-
tremities, and this in turn gives rise to such
trophic changes as atrophy of the subcu-
taneous tissues and muscles, decalcification
of bone and the production of thin and
brittle nails. Restoration of function imme-
ditely restores the circulation, and this leads
to the gradual disappearance of the trophic
disturbances.
We have often noticed that when a man
IS rapidly cured of a contracture by psycho-
therapy, he continues to keep his limb in
the same abnormal position as before, altho
he is capable of moving it without any dif-
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ficulty in every direction. I believe that this
is due to the development of a new "pos-
tural length." If AB in diagram I rep-
resents the normal length of a muscle when
at rest, it can shorten to AC on active con-
traction and lengthen to AD on active re-
laxation, relaxation being just as active a
process as contraction. All muscles adopt an
intermediate length of this kind, the exact
length depending upon the habitual posture
of the limb. Thus the fingers are slightly
flexed when at rest, both during conscious-
ness and during sleep and anesthesia. In
order to extend them the extensors shorten
the abnormal posture remains during sleep
under anesthesia as well as when the pa-
tient is awake. It is in no sense hysterical,
but is organic, altho the structural con-
dition upon which it depends ought never
to be permanent. As soon as complete mo-
bility is restored, the patient should be
taught to keep his limb in the normal pos-
ture by an effort of will throughout the day
and he should walk up and down in front
of a looking-glass to see that he maintains
it. In the course of two or three days this
training results in a return to the normal
postural length, and the patient then no
B D
Diagram I
c E
-I L.
Dia^rarti II
and the flexors lengthen and in order to
flex them the flexors shorten and the ex-
tensors lengthen. If as a result of the con-
tinued contraction of one group of muscles,
whether as a result of organic disease or
hysteria, a new posture is assumed for a
long period, the anatomical structure of the
muscle fibers becomes altered, so that the
postural length of the contracted muscles
is abnormally short (e. g. AE in diagram II)
and that of the opposing muscles is ab-
normally long. When recovery takes place,
even if this occurs almost instantaneously in
an hysterical case, the muscle AE can con-
tract to AC and relax to AD, but it always
returns to AE when at rest. Consequently
longer requires to pay any attention to his
posture.
Orthopedic surgeons have long known
the importance of using splints to maintain
a good posture in cases of nerve injury. It
has generally been thought that this has the
object of preventing the paralysed muscles
being overstretched, as their contractility
might otherwise become impaired. In all
probability, however, the splint really acts
by maintaining the normal postural length
of both the paralyzed and opposing muscles.
That this is the more likely explanation is
shown by the improved results obtained re-
cently in cases of dropped wrist due to
musculo-spiral paralysis, the extreme hyper-
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extension formerly used having been re-
placed by moderate extension, which keeps
the postural length of the muscles normal
instead of increasing that of the flexors and
reducing that of the extensors.
The abnormal postures and gaits, which
are often adopted after a painful wound
has completely healed, are probably also due
to the development of abnormal postural
lengths of muscles, whilst the position of
greatest comfort was maintained before the
wound had healed. The condition is often
described as hysterical, but it is not pro-
duced by suggestion and is really organic,
tho easily curable by re-education.
Surgery of the Nervous System. —
Nothing is more likely than organic disease
to suggest a functional disorder. Conse-
quently it is very common indeed to find
the hemiplegia and paraplegia caused by in-
jury of the brain and spinal cord and the
paralysis caused by wounds of peripheral
nerves perpetuated as hysterical symptoms
after the original organic lesion has either
completely disappeared or improved to such
an extent that it can be responsible only for
a small part of the incapacity. But just as
the physical signs of such organic diseases
as tabes and disseminated sclerosis may pre-
cede the development of symptoms, so may
the physical signs persist when the organic
lesion has cleared up to such an extent that
it no longer causes any incapacity. We may
thus have hysterical paralysis following or-
ganic paralysis, which it simulates in every
detail, associated with organic physical
signs. Diagnosis is then impossible except
by seeing how much improvement follows
psychotherapy. By this means we have suc-
ceeded in curing many cases of apparently
organic paralysis, but the persistence of or-
ganic physical signs has shown that there
was some slight residue of the original le-
sion still present.
Other symptoms resulting from injuries
of the nervous system may be perpetuated
in a similar manner. Thus anesthesia fol-
lowing any injury to a peripheral nerve,
localized to the exact area of the skin sup-
plied by the latter, and sometimes actually
leading to accidental burns, was found in
several cases to be hysterical by its disap-
pearance— often within a few minutes — un-
der psychotherapy. Persistent headache due
to concussion, whether caused by direct in-
jury or a shell explosion, is often if not
always, of the same nature, as it disappears
with psychotherapy when all other forms of
treatment have proved useless. Major J. F.
Venables has recently cured two cases of
constant vomiting following concussion by
a single psychotherapeutic conversation,
neither patient vomiting again, altho they
were given a full diet after having been un-
able to- keep down the whole of a single
meal even of peptonized milk, for over a
year.
Hysterical fits are, I believe, much more
common than is generally believed, and they
may very closely simulate epilepsy. Such
symptoms as passing urine and biting the
tongue may occur, especially in a man who
has at one time suffered from true epilepsy,
as nothing is more likely to suggest the
occurrence of fits in an emotional individual
during times of stress than the memory of
true fits in the past. The fits will resemble
the early ones in those features which the
patient remembers or with which he is
familiar from what his relatives have told
him. I have seen a small number of cases
of Jacksonian epilepsy following head in-
juries which were perpetuated as hysteri-
cal fits; they resembled the original attacks
in every detail, but persisted when the pre-
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vious cause was no longer operative, and,
being hysterical, they were cured by
psychotherapy.
In conclusion, I hope that these notes will
show the need of closer cooperation in the
future between the neurologist and other
specialists. I hope myself to share one of
the clinical assistants in my Neurologic
Clinic at Guy's Hospital with each of my
specialist colleagues. Above all this is
wanted in connection with orthopedics, as
many hundreds of unnecessary operations
are performed and many thousands of
hours are spent in undergoing treatment by
massage and electricity which would be ren-
dered unnecessary if all orthopedic cases
were first seen in consultation with a neu-
rologist, or if all orthopedic surgeons re-
garded a neurologic training and especial-
ly a training in psychotherapy as an essen-
tial part of their education.
THE WORK OF AN ORTHOPEDIC
CENTER IN MACEDONIA.
BY
A. LOUISE McILROY, M. D., D. Sc,
Salonica, Greece.
Surgeon-in-charge.
The work done by the units of the Scot-
tish Women's Hospitals in France and Ser-
bia is now known thruout the allied world
and its origin in far away Edinburgh needs
no description. The idea of the establishing
of such hospitals, staffed and officered en-
tirely by women doctors, nurses, cooks,
chauffeurs and orderlies, originated in the
brain of Dr. Elsie Inglis, who herself died
as the result of her devotion to the wounded
in Serbia and the Jugo-Slavs in Russia.
The organization has increased in size since
its inception and the headquarters in Edin-
burgh (2 St. Andrew's Square), with its
branch in London, are centers of unceasing
activity and enthusiasm.
These hospitals consist of units from
about 200 to 500 beds, and are gifted to the
armies of France and Serbia. They are
entirely supported by voluntary contribu-
tions.
One important unit has been working
at the Abbaye de Royaumont near Paris
since 1914 under Dr. Frances Ivens. An-
other is at Sallanches in France for the
treatment of Serbians suffering from tuber-
culosis. One is taking care of the Serbian
refugees in Corsica since their retreat from
Serbia. Three units were given to the
Royal Serbian Army and wwked thru the
raging epidemic of typhus. Their energies
were only brought to an end by the retreat
of the army. Some of the staff of these ac-
companied the Serbian army over the snow-
clad mountains of Albania to a haven in
the island of Corfu. Others were taken
prisoners and remained behind to be eventu-
ally repatriated thru Austria and Switzer-
land.
At the present moment there are three
hospital units working in Serbia and Mace-
donia, one at Velles near Uskub in Serbia,
where the hospital is being taxed to its ut-
most capacity in the admission of sick and
wounded. This unit had been at work at
Ostrovo since 1916, and owes its origin
mainly to the generosity of American con-
tributions. It is known as the "American
Unit" and works directly under the Royal
Serbian Army. Dr. Isobel Emslie is its
chief medical officer.
Another unit, after working with the
Jugo-Slav divisions of the Serbian army in
Russia and Roumania, has been working at
Dragomananci, but is now on its way to
Serajevo to extend its activities among the
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Pig. 1. Group of Matron. Sisters and Masseuses.
Fio. 2. Entrance Gate.
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m
t
1
^^^^H
s
h
3P» ^-^ ^
r
1
^^^1
Fig. 3. The operating room for aseptic work. Sister in charge.
Fig. 4. Dental Department Patient is seen wearing an orthopedic foot.
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349
Fig. 5. A corner of the Mechano-Therapy Hut.
Fig. 6. Orthopedic Ward.
The upright poles are for mosquito nets. The electric light is run by an engine in the camp
belonging to the S. W. H.
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Jugo-Slavs now collected there. To it is
attached a large motor ambulance transport
column driven entirely by women. This
hospital is known as the 'TJsie Inglis" unit
and is supplied by the London Committee
of the S. W. H. A smaller transport column
is also at work in Northern Serbia. It fol-
lowed the Serbian army in its glorious ad-
vance thru the country. In several towns
staffed and equipped for 200 beds, the orig-
inal expense of outlay being defrayed by
the colleges of Girton and Newnham, Cam-
bridge. It continued work in France until
the autumn, when an order was received
from the French War office to evacuate the
wounded and proceed with the hospital to
Salonica, to join the French Expeditionary
Force sent out to the aid of- Serbia, on ac-
FiG. 7. Staff Tents.
the Scottish women drivers were among the
first to be welcomed by the population.
The work of the unit stationed at Salon-
ica for three years is the subject of the
present paper. It began its existence in
France in the spring of 1915, working as a
military hospital under the French War
Office at Troyes in Champagne. The hos-
pital was entirely under canvas and was
count of hostilities having commenced with
Bulgaria.
The staff, altho regretting their departure
from France, where the work with the army
officials had been so harmonious, fully re-
alized the importance of the unique honor
of a foreign hospital being chosen to ac-
company an expeditionary force. The
tents were taken down, the equipment
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351
packed, and the hospital, which included on
its staff as administrator, Mrs. Harley, the
sister of Lord French, set out for Salonica,
which it reached after a somewhat pro-
tracted and eventful voyage. On arrival,
orders were given to proceed to Gievgueli in
Southern Serbia, where the French were
establishing their hospital base. The
wounded were pouring in in great numbers.
cially observed in the Senegalese and other
black troops who were unaccustomed to
the northern cold, coming from their own
sunny lands. The bravery of the French
was magnificent, their endurance of pain
was remarkable. Thru all their suffering
their one thought seemed to be "Vive la
France." Away, here among the Balkan
hills in a little comer was that group of
Fio. 8. Exercise Ground.
and soon the hospital was busily employed
in doing everything possible for their com-
fort. During this time an unusual blizzard
was spreading over the Balkans and Gal-
Hpoli Peninsula and the soldiers not only
had to endure the wounds of war but were
almost frozen in the trenches filled with
snow. Many cases were admitted of frozen
feet suffering great agony. This was spe-
hospitals with their wounded. Close by on
a hill was the cemetery, the dead daily in-
creasing in their numbers. Behind were
the ridges of Serbian and Bulgarian snow-
covered mountains, and thru all, the boom-
ing of the guns coming nearer day by day.
Soon it was realized that the Serbian army
was in retreat and that the Allied Expedi-
tionary Forces were to withdraw. Orders
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were given to send the wounded as quickly
as possible to Salonica, and the hospitals
to follow with their staff immediately after.
Serbia was completely invaded by her
enemies, her armies had been cut off.
Nothing seemed to be left to hope for.
Those brave Serbian soldiers were leaving
behind them their beloved country, their
the hospital was overcrowded, even tho it
had increased its capacity to 300 beds. In
autumn, on the return of the Serbian army
from Corfu, hostilities were again com-
menced at the front, and during the whole
winter the hospital was full of wounded.
French, Serbians, Russians, Albanians and
Senegalese were admitted as the French
Fic. 9. Part of panorama showing Scottish Women's Hospitals fiUing in foreground.
Behind on lower ground are French Hospitals and on rising ground are Greek Camps,
left are seen the old battlements of the Turkish quarter of the City.
To
homes, not knowing if ever they would be
able to return. The Scottish hospital set
up its tents in Salonica, and has been at
work there ever since, constantly employed
in work for the French army. During the
summer of 1916, when the great heat and
unexpected epidemic of malaria and dysen-
tery almost threw the troops out of action.
authorities at that time were responsible for
the care of these nationalities.
In summer of 1917, it was felt by the staff
of the hospital that a hospital for the treat-
ment of disabled soldiers was very much
required in Macedonia, and that given the
necessary equipment such a department
should be inaugurated. It was felt that the
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French soldier invalided home had ample
opportunities for orthopedic treatment in
his own country, but that the Serbian, who
desired to remain as near his country as
possible, should be given the opportunity
of such treatment to counteract the disable-
ment of war.
Accordingly, in consultation with the
Orthopedic Centre."
Wooden huts were erected and marquees
with smaller tents and the work was begun.
The services of highly trained masseuses
from orthopedic hospitals in Britain were
secured and appliances were set up.
The orthopedic center mainly consists of
a group of huts : one divided up into opera t-
FiG. 10. See Figure 9. Part of panorama showing Scottish Women's Hospitals.
French military authorities, the Edinburgh
Committee gave permission to establish an
orthopedic department in the hospital, the
French general being desirious that 200
beds should be added to the 300 already
existing. This was accordingly done and
the hospital was moved to a more extensive
and higher site. The equipment for the
new department was supplied by a gift from
India and it is known as "The Calcutta
ing and sterilizing rooms, X-rays and a
dental department. Another hut is given
up to the massage department with a very
fully equipped electrical outfit, consisting of
various colored radiant heat baths, hot air,
vibrators, for the treatment of various joint
and nerve affections. Galvanic and faradic
electrical machines for the re-education of
disused muscles are also in this department.
Numerous appliances for the exercise of
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limbs, such as rowing machines, wheels,
pulleys, bars and bicycles are also employed.
Medicated hot water baths are used as a
preliminary to such treatment. On its way
from Scotland is a large hydrotherapeutic
hut for the use of the hospital, having the
most up-to-date baths obtainable, such as
whirlpool and aerated baths, douches, sprays
and pools. Classes in gymnastic exercises
are also held.
When improved to a certain extent with
treatment, the patients are gradually put
into the workshops and there taught the
re-education of their limbs in coordination
with their mind. In these huts or tents are
carried out cigarette-rolling, book-binding,
embroidery, furniture repairing and making.
In the carpenters' workshops splints are
made and other surgical appliances. The
shoemakers are taught to make orthopedic
boots and supports to suit disablements of
the lower limbs. There are no expert
workmen for teaching purposes, the men
work entirely under the supervision and
control of the women members of the staff.
These workshops also teach the patients to
take an interest in life, and are a means of
showing them that many occupations are
open to them when they return to civil
life.
Altho mainly intended for the Serbian
soldiers, the orthopedic department since its
inception has been largely used by the
French wounded, and numerous patients
are sent for special treatment from the
various surrounding hospitals. Outdoor
officer patients are treated, and these have
included among their number a number of
British army officials who have always
shown such sympathy and unfailing kind-
ness towards the hospital and its staflf of
British women.
The hospital has done its work for over
three and a half years mainly under canvas,
and has had the simplest equipment pos-
sible with efficiency. The surgical and
medical work has been left entirely to the
staff of women doctors. The entire ad-
ministration and discipline are under con-
trol of the staff and no French official has
been in residence. The hospital is the only
orthopedic one of its kind in the Balkans
and it has demonstrated the need for others
to follow. There are large numbers of
Serbian men disabled by the war, and these
require remedial treatment. The need for
such work is proved by the fact that the
hospital, now at the end of the war, is de-
veloping its activities more than ever. One
has only to see the poor disabled men under-
going their treatment, and to see them on
leaving, restored to comparative health and
fitness, to realize the value of such work.
The Serbian nation with its gallant army
which fought with its back to the wall to de-
fend its country only acknowledged defeat
when overwhelmed by misfortunes, an army
which has suffered as no other army has in
its retreat across the mountains, its men
dying in their thousands from cold and
hunger and with the knowledge that those
they left behind would have to endure priva-
tions and torture almost unspeakable in
their intensity and cruelty. Men, who to
the world apparently remained inactive for
months on the Macedonian front, enduring
the mental misery of exiles, almost afraid
to go back to the homes which they feared
to find empty or dishonored, but when the
command came to advance, fought and
carried themselves with a bravery which
won the admiration of every member of
the allied armies cooperating with them.
Their country has been won back by their
blood and thru blinding tears. Those who
have cared for the wounded Serbian sol-
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355
diers realize their nobility of character,
their absolute discipline and their grati-
tude for all that is done for them. They
have to be made to realize that* there are no
unfit, but that an occupation can be found to
suit each individual disablement. The
Scottish Women's Hospital for orthopedic
work is only a beginning, others must fol-
low as the necessity for such is great.
Salonica.
THE INFLUENCE OF PENSION OR
COMPENSATION ADMINISTRA-
TION ON THE REHABILITATION
OF DISABLED SOLDIERS.
BT
DOUGLAS C. McMURTRIE.
New York City.
Director, Red Cross Institute for Crippled and
Disabled Men; President, Federation ot
Associations for Cripples; Editor, Ameri-
can Journal of Care for Cripples.
When the pioneer efforts were made in
Europe to rehabilitate disabled soldiers
and return them to capacity for self-sup-
port, the first difficulty encountered was the
fear on the part of the men that an increase
of earning power would entail reduction or
cancellation of their pensions.
The same fear on the part of injured in-
dustrial workers, that the scale of their
workmen's compensation will be adversely
affected by return to work, keeps idle many
men who could return to a job either with
or without special training or "re-educa-
tion." It has been found, for example, in
one re-educational school for civilian crip-
ples that most of the compensation cases
apply for training the day the compensation
expires — ^after a long and most undesirable
period of idleness.
In the case of military pensions the deci-
sion as to whether earning power should
affect pension has usually been negative —
and therefore sound. There has been no
such clear-cut decision on this point in the
administration of compensation for indus-
trial disability. Altho the present study
deals only with the military pensions prac-
tice, there are to be deducted from the data
presented many principles which should
find helpful application in the field of work-
men's compensation.
Because the fundamental object of na-
tional pensions has been to compensate a
man for a loss in effectiveness and capabil-
ity due to active service, it has been a nat-
ural deduction that the amount of the pen-
sion should be based on the actual reduc-
tion in earning power; and that where an
injured man has been able to return to em-
ployment in which he earns as much or
more than he did before the injury, no prej-
udice to effectiveness has ensued, and no
pension, therefore, should be paid.
On the argument that the country
should not be expected to pay compen-
sation for an economic handicap when
no economic handicap exists, the prac-
tice of making pension dependent on
earning power might be regarded as
sound, were it not for a vital social consid-
eration. A man returns from the war with
health or strength impaired, and is awarded
a f)ension based on the average expectation
of loss of earning power of a man in his
physical condition. Being a man of char-
acter and ambition, however, he is not con-
tent to remain idle, so he seeks assiduously
for a job which he can fill, finds it, and
starts to work. Upon making report of his
earnings — tho his state of health be no bet-
ter, and perhaps worse — his pension is sus-
pended. It is certain that an average man
who has once lost his compensation on ac-
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count of getting a job will never make the
same mistake again.
Yet it is infinitely to the advantage of the
community that the idle man shall be set
to work, that the inactive consumer be
made a producer. The loafer in the
making is a much greater liability to the
community than the obligation for the pen-
sion payments. This consideration has led,
in experience, to the almost universal deci-
sion that pension should not be influenced
adversely by a man's earnings ; that the in-
jured ex-service man should receive every
encouragement to return to employment.
There is another argument in favor of
this decision: The impaired physical condi-
tion always involves personal inconvenience,
and usually imposes limitations on range of
activity in both work and play. This is a
distinct loss to the individual, and it seems
fair that the government should pay com-
pensation on this basis alone. The man
who has developed active tuberculosis in the
military service can never again be quite
free from the bondage of a hundred precau-
tions. Life will not mean quite as much as
it did before. The soldier who has lost one
leg thru amputation will forever be subject
to the inconvenience of his stump chafing
in hot weather, and he will never again be
able to play a game of tennis, altho he may
be able to attain a weekly wage as great as
that earned prior to enlistment.
With respect to cases of specific perma-
nent disability, whether partial or total,
there has been practical unanimity of deci-
sion among the belligerent nations that com-
pensation award should be fixed and irre-
vocable, and not influenced by earnings or
earning power. The specific disabilities are
typified by amputations, blindness, etc. The
ruling of the United States has been clear
and satisfactory with respect to such disa-
bilities.
With respect to non-specific disabilities
the decision has not followed quite the same
rule, and compensation has been canceled
in some cases when it was shown the claim-
ant had returned to work. Among the non-
specific disabilities are scores of a medical
nature, typically represented by phthisis,
cardiac insufficiency, kidney difficulties, etc.
Should these disabilities also be compen-
sated on the basis of medical evidence alone,
without respect to the current earnings of
the claimant? It is possible that the ex-
perience of other nations may provide
evidence helpful to a wise determination on
this point.
As will be evident from the subjoined
memoranda on the pensions practice of our
Allies and Germany, there has been sub-
stantially complete unanimity of decision
that earning should have influence on the
award in cases of non-specific as well as in
cases of specific disabilities.
^lost of the countries learned early that
such a ruling must be made if there were to
be any degree of success with the programs
of re-education looking toward returning
the injured men as self-supporting members
of the community. Great Britain altered
her practice later than the others, but mean-
while developed a most convincing demon-
stration of the necessity of the change. And
once the important decision was made, there
was energetic educational eflFort, thru post-
ers, leaflets, press articles, and the like, to
bring the ruling to the knowledge of the
men in military and naval service.
The general consensus of experience has,
in eflfect, developed the principle that pen-
sions or compensation authorities have no
concern whatever in the earnings of the
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357
claimant, and that the amount of the indi-
vidual's earnings should not even be asked.
The corollary to this principle is, of course,
that the award should be based wholly on
medical or surgical record or examination.
The following memoranda on the practice
of several countries have been prepared in
the Research Department of the Red Cross
Institute for Crippled and Disabled Men.^
The source of the data is in all instances in-
dicated by footnotes.
France.
Up to the passage of the new French pen-
sion law in March of this year, a French
soldier, disabled as a result of service, re-
ceived either a pension or a gratuity. Pen-
sions were governed by the law of 1831
and were granted only for a disability which
was adjudged incurable and of a certain de-
gree of gravity.^ Indemnities for lesser
disabilities and for disabilities of any degree
which could not be definitely pronounced
incurable were governed by the decree of
March 24, 1915, and were called renewable
gratuities. By this decree renewable gratu-
ities were divided into eight classes, corres-
ponding to proportional decreasing reduc-
tions of the normal working capacity. Total
abolition of the working capacity, 80 per
cent, reduction, or 60 per cent, reduction,
not, however, incurable, entitled a man to a
gratuity of the first, second, or third class,
respectively. Reductions of from 50 to 10
per cent., incurable or not, entitled to gratu-
ities of the fourth to the eighth class.** The
disability had to occasion at least 10 per
cent, reduction of the working capacity to be
entitled to any gratuity ; if it occasioned 60
per cent, or over, and was incurable, it was
entitled to a pension.
The amounts of the different classes of
gratuities were fixed by the same decree,
modified by the decree of December 29,
1917. They ranged for a private soldier
from 100 francs a year for a 10 per cent,
disability to 1,200 francs for total disability.
For the same degree of disability they con-
formed to the scale of pensions.
In the new pension law the word gratuity
is replaced by temporary pension, and the
only distinction between the permanent pen-
sion and the temporary pension is in the
matter of incurability. A man is entitled to
a permanent pension "when the disability
caused by the wound or sickness is recog-
nized to be incurable" ; to a temporary pen-
sion when the disability is not recognized
to be incurable.* This new law also
abolishes the eight classes of gratuities and
the old pension scale, and grades permanent
and temporary pensions by a scale of disa-
bility increasing by fives from 10 to 100 per
cent.^ The amounts range, for a private,
from 240 to 2,400 francs a year.
The amount of the gratuity, now called
the temporary pension, has depended wholly
upon the man's physical condition, that is,
upon the gravity of his injury, as deter-
mined by the medical examiners of the Dis-
charge Commission. It has been the duty
of the examiners to pronounce on the origin,
gravity, and curability of the disability, and
on the basis of the facts to propose the man
for a certain pension or gratuity.* In de-
ciding what reduction of the working capac-
ity is occasioned by a given condition, or in
other words what should be the amount of
the indemnity, the medical examiners were
first instructed (Instruction du 20 avril
]Q15) to refer to the figures established by
the application of the Workmen's Compen-
sation law.^ It was soon seen, however, that
such instructions were insufficient to secure
uniformity in the estimation of disabilities;
men with the same injuries were differently
rated by different physicians. To avoid the
injustice and the inevitable demands for re-
vision resulting from this situation, the
Commission Consultatwe Medicale of the
War Department drew up a table (Guide-
Barbme des Invalidites) which listed in de-
tail the different injuries and indicated the
corresponding reduction of working capac-
ity. The object, as the introduction to the
tables states, was not to impose upon the
examining physicians a fixed evaluation of
each injury but to furnish, as the name im-
plied, a guide which would contribute to-
ward securing uniformity.
Diseases which may have been contracted
or aggravated by reason of service are in-
cluded in the table, but the French prac-
tice in the early days of the war was to
consider disability caused by disease non-
attributable and to discharge such cases
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without pension. The new law makes sick-
ness attributable unless the state can prove
the contrary.® A new Guide-Barbme has
been issued to go with the new pension law.
The renewable gratuity was granted for
two years, and at the end of that time the
recipient was required to app)ear before the
Discharge Commission and to undergo a
new medical examination. On the basis of
the findings of the doctors the gratuity was
then renewed for another two years — at the
same rate if there had been no change in the
condition, at a higher rate if the condition
were worse, at a lower rate if it had im-
proved. If the disability was recognized
to be incurable, the gratuity was converted
into a life pension ; in case of a cure, it was
discontinued entirely.®
The temporary pension of the new law is
similarly granted and reviewed, but after
four years at the most the condition of the
pensioner is to be considered permanent
and the temporary pension either con-
verted into a permanent one or discon-
tinued. The new law also provides that
"any recipient of a temporary pension who
experiences a new complication or an aggra-
vation of his disability can, without waiting^
for the expiration of the two-year period,
send in a demand for revision which must
be acted upon within two months."^**
It is apparent, therefore, that the amount
of the gratuity or temporary pension is not,
either when it is first granted or when it is
renewed, conditioned by what the man does
or will earn. On this point M. Alexandre
Lefas. deouty from Ille-et-Vilaine, in a re-
port on French pensions presented to the
Inter-Allied Conference in London in May
of 1918, is specific and clear. He says:
"Note that in virtue of the military laws the
pension or gratuity due a disabled man is
calculated solely on the basis of his disa-
bility and rank, without consideration of
what he may still earn by working.'*^^
Speaking before the Conference, M. Lefas
added, "We have a medical table which
fixes the rate of disability according to the
wound. As a matter of fact, what is con-
sidered is not the incapacity for work, for
the disability pension is independent of the
wages the man may earn by working and
should be the same for all men of the same
rank who have the same wound. "^^
The fear that the pension would be re-
duced if the earning capacity were increased
operated, however, during the early years
of the war, to deter many disabled soldiers
from taking re-educational training, and it
was necessary for the government to com-
bat this fear by repeated announcement of
the real facts. A notice prepared by the
Office National dcs MutiUs et Reformes dc
la Guerre with the object of inducing more
men to enter the re-educational schools, and
signed by the two presidents of the Office*
the Minister of Labor and the Under-Secre-
tary of State for the Health Service, states
that "whatever their trade or their earnings,
in no case will the pension of wounded sol-
diers be diminished [thru re-education],
even if they earn more than before being
wounded.*'" Another notice on conditions
of admission into vocational schools, issued
by the Departmental Committees and based
on circulars of the Ministers of War and
the Interior, says : "The amount of the pen-
sion depends solely on the medical declara-
tion of disability. In no case can it be mod-
ified by reason of the fact that the bene-
ficiary has been re-educated. The amount
of the gratuity may always be revised, in
accordance with the functional condition,
whether the soldier is re-educated or not."**
This principle was finally made law by be-
ing incorporated in the Re-educational Act
of January 2, 1918, article eight of which
reads: "In no case can the amount of the
pension be reduced because of vocational
re-education or readaptation to work."*'
Great Britain.
Previous to the issuance of the Royal
Warrant of 1917, British pensions were
based upon the decrease in earning capacity
caused by the disablement.*® Upon his dis-
charge a disabled soldier appeared before a
medical board which made a rough estimate
of his decreased earning capacity and
awarded a corresponding temporary pen-
sion. After a time, perhaps in six months,
he would be re-examined, and if his earning
power had been increased thru training or
he had been able to secure remunerative em-
plovment, his pension might be decreased.
The new Warrant discarded this principle
and based the amount of the pension en-
tirely upon the soldier's rank and the de-
gree of his physical impairment.*' In a
schedule attached to the Warrant certain
specific injuries are graded as from 20 to
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359
100 per cent, disabling, and the pensions
corresponding to these different degrees of
disablement are fixed. For other injuries
and for disease it is provided that the pen-
sion shall be "assessed at the degree in the
schedule which is held most closely to repre-
sent the disablement corresponding to the
injury or disease."^® The pension scale
ranges for a private soldier from 5s. 6d. to
27s. 6d. a week. Men whose disablement
is assessed at less than 20 per cent, receive a
gratuity, or temporary allowance, depend-
ing in amount on the extent of the disable-
ment but not to exceed £200.^®
The pensions granted under this Warrant
may be either permanent or temporary. A
permanent pension is granted when the dis-
ability is fixed and permanent — that is, when
no change for the better or worse may be
expected. A temporary pension is granted
at the rate appropriate to the temporary dis-
ablement when the disablement has not
reached its final condition.^®
These provisions remain unchanged bv
the Royal Warrant of 1918.
The amount and kind of disablement pen-
sion due a man are determined by a Medical
Board on the basis of a medical examination
and the case history. Men who receive
temporary pensions are thereafter re-ex-
amined periodically — usually at intervals of
from six months to a year — by Medical
Boards, and their pensions are reassessed to
correspond to any change that may have
occurred in the degree of disability. As
soon as the condition is judged permanent,
a permanent pension is granted.*^ If the
disability becomes worse before the time set
for re-examination, the Local War Pensions
Committee, on the advice of its medical
referee, can make advances to the man until
the next reassessment.
The Warrant of 1917 states expressly
that "when a permanent pension has been
granted it shall not be altered on account
of any change in the man^s earning capacity,
whether resulting from training or other
cause."^^ The men evidently feared, how-,
ever, that their temporary pensions might
be on reassessment decreased. To reassure
them on this point, a pamphlet issued by
Major Robert Mitchell, Director of Train-
ing for the Ministry of Pensions, on the ad-
vantages of trainmg contains this state-
ment : "Let it be distinctly understood that
no reduction whatever to your disablement
pension can be made on account of anything
you may earn. A disablement pension,
temporary or permanent, is based solely on
the degree of disability and will not in any
way be affected by the amount of a man's
wages."^^
A man's earnings come into the question
only if he applies for an alternative pension
in lieu of a disablement pension. An alter-
native pension may be granted on applica-
tion to a man who shows that his minimum
pension with children's allowances, added
to the earnings of which he remains capable
(if any), is less than his pre-war earnings.
He may then receive a sum which added to
his present average earnings will bring his
income up to his pre-war earnings to a maxi-
mum of 50s. plus half of any pre-war earn-
ings between 50s. and 100s. a week.**
During a discussion of pensions in Parlia-
ment in September, 1917, Mr. Barnes, then
Minister of Pensions, was asked by a mem-
ber: "Is it a fact that the only case in
which a Medical Board can ask a man his
actual earnings is where they are fixing an
alternative pension ?" Mr. Barnes' answer,
"That is the only case," is unequivocal.*^
An official statement by the Ministry of
Pensions published in the London Times of
February 20, 1919, takes up the question of
alleged reduction of pensions. As a clear
and explicit statement of pension procedure
it is worth quoting in full.
It has been repeatedly stated in various
quarters that disabled men going before
medical boards have their pensions cut
down, the implication being that a delib-
erate policy of reducing p)ensions has
been instituted. The allegation is entire-
ly unfounded. Disablement pensions are
provisionally awarded for a period — it
may be three months, six months, or a
year — at a rate corresponding to the de-
gree of disability ascertained by medical
examination. On re-examination at the
end of the period (or before the expiry
of the period in some cases, as, for in-
stance, when the man's condition has
been reported by the local medical referee
to have become worse) the disability
may be reassessed.
Disablement pensions being based up-
on the principle of compensation for in-
jury or disease arising out of war serv-
ice, a disappearance or abatement of the
injury or disease and the return, or par-
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ORIGINAL AHTICLBS
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tial return, to normal health necessarily
involve a corresponding reduction of the
pension. Where the pension has been
reduced as the result of medical examina-
tion it is because the medical board has
certified an improvement in health. If,
on the other hand, the man's state of
health is found to have become worse
owing to injur}^ or disease arising out of
his war service, a higher rate of pension
is awarded. If the deterioration in health
occurs before the date originally fixed for
re-examination, the local War Pensions
Committee, acting on the local medical
referee's report, may, until the re-ex-
amination, make advances representing
the difference between the pension the
man is receiving and the pension to which
his actual condition would entitle him.
These advances are recoverable only
when the medical referee's report is up-
held.
The re-examination actually takes
place some weeks before the expiration
of the period for which pension is grant-
ed, and improvement in health does not
mean an immediate reduction of pension,
but a reduction only from the date (some
weeks later) when the former pension
expires.
It is important to remember that the
pensions with which the Ministry of Pen-
sions deals are granted because of dis-
ablement, not because of service in the
war.
Belgium.
The Belgian pension law of April 5,
1917, was passed as a temporary measure to
be superseded when the country should be
delivered and restored. There is, there-
fore, no object in analyzing its provisions.
Italy.
The Italian pension law of May 20, 1917,
divides disabilities into ten classes accord-
ing as they diminish the man's capacity for
profitable work from 10 to 100 per cent. A
man with a disability which falls into one
of the first eight classes receives a life pen-
sion of from 378 to 1.260 lire a year, with
supplementary allowances if he is totally
disabled and needs an attendant. For dis-
abilities of the ninth and tenth classes a
temporary allowance equal to a pension of
the eighth class is granted for a period of
from six months to six years.^*
When the gravity of the disability or its
permanent character cannot be definitely
determined, the law authorizes the grant of
a temporary pension based on the regular
pension scale. This may be granted for a
period of not less than one year or more
than five ; at the end of the allotted period it
may be renewed, converted into a life pen-
sion, or discontinued. After eight years
have passed, the condition must be consid-
ered permanent and the pension either made
permanent or discontinued.^^
A large number of sp)ecific disabilities
are listed under the ten classes, but the law
recognizes that there will be cases not there-
in included and provides that these shall be
''ascribed to the class which contains disabil-
ties causing an equivalent diminution of the
capacity for profitable work."** Additional
directions on the assessment of non-speci-
fied disabilities are contained in a circular
issued by the Inspector of the Military
Health Department to the District Directors
of the Department. This directs the ex-
amining doctors whose duty it is to deter-
mine "by analogy" the class of non-specified
disabilities to base their decision upon a
consideration of the "diminished functional
ability resulting from loss of organs, limbs,
or parts of limbs or from functional disturb-
ances."*®
It is evident, therefore, that the amount
of the pension depends on the doctors' es-
tiniation of the physical disability. That it
may not be reduced on account of an)rthing
the man may earn is expressly stated in
article nineteen of the pension law, which
reads : *Tn accordance with the present law
there can be no change in the pension
granted to a disabled soldier whatever de-
gree of re-education he may have attained or
whatever employment he may have se-
cured."'** False reports on this matter have
created in the Italian soldier as in his com-
rades of the other warring countries a re-
-luctance to take training, and it has been
necessary for the government to <;ombat
these reports by numerous published state-
ments. For example, a propaganda book-
let issued by the "National Board" to in-
form disabled soldiers of government meas-
ures in their interest contains the following :
''Disabled soldiers should know that the
pensions granted them by the state can
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ORIGINAL. ARTICLES
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361
never be in any way diminished or discon-
tinued whatever the recipients may earn by
their labor or employment."®^
Canada.
Canadian
vxdiiauiaiA pensions are divided into
twenty classes and are awarded in direct
proportion to the degree of disability, which
is graded from 5 to 100 per cent. The
mined by the Board of Pension Commis-
sioners on the basis of a report of his. med-
ical examination before discharge and the
other details of his condition. The per-
centage that any disability bears to a total
disability has been carefully calculated by
experts.*' For example, in the case of pul-
monary tuberculosis the following table has
been drawn up to serve as a guide in esti-
mating the disability percentage:
TABLE FOR ESTIMATING INCAPACITY IN PULMONARY TUBERCULOSIS.
N. B. — When It is considered advisable, medical officers will make an estimate of disability
graded at any percentage other than that named in the table. The terminology used, and its
assigned interpretation, is that employed by the National Association for the Prevention of
Tuberculosis.
Class
Condition
Clinical Description
Employability
Percentage of
Disability
1
Not improved
100
2
Improved
Where there has been
improvement sufficient
to allow the use of the
term.
These cases wHl, in all
likelihood, relapse on
any but the lightest
kind of work. During
the first six months, at
least, disability should
be considered as total.
Practically an active
case under ordinary
conditions of life, and
should rest at least 75
per cent, of his time, in
order to carry on in fair
health — hence a mini-
mum of 80 per cent, for
the first six months.
100
3
Quiescent
No constitutional symp-
toms; tubercle bacilli
may be present or not;
stationary or better in
physical signs, all the
foregoing having been
present at least two
months.
80-100
4
Apparently
arrested
Signs of a healed lesion
without any symptoms
for three months.
Should rest half of hia
time.
50-80
5
Arrested
Signs of a healed lesion
without relapse at end
of six months under or-
dinary living conditions.
Signs of a healed lesion
without relapse at end
of two years under or-
dinary living conditions.
Should rest one-quarter
of his time.
25-50
6
Apparently
cured
Only limitation of em-
ployability is that he
should avoid certain oc-
cupations involving un-
due exposure to dust
and debilitating con-
ditions.
Note. — In estimating disability the fibrosis and destruction of lung tissue, debility, and
tendency to relapse must be taken into account.
amount of a pension of the first class, or a
100 per cent, disability pension, is $600 a
year ; of a class 20 pension, for 5 per cent,
disability, $30. A permanent disability of
less than 5 per cent, entitles to a gratuity of
not more than $100.'2
A man's percentage of disability is deter-
All pensions, except in those cases where
the disability is obviously permanent, are
subject to periodical review. If, in review-
ing a case, the medical advisors of the
Board of Pension Commissioners find that
the man's condition has improved or grown
worse, they reduce or raise the estimate
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ORIGINAX. ARTICLES
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of his disability percentage, and he receives
a corresponding decrease or increase of pen-
sion. "A p>ension lasts as long as the dis-
ability for which it was awarded exists.*'^*
Increased earnings cannot effect a reduc-
tion of the pension. On this point the Pen-
sion Regulations contain the following ex-
plicit statement: "No deduction shall be
made from the amount awarded to any
pensioner owing to his having undertaken
work or perfected himself in some form
of industry."^** In other words, to quote
Reconstruction, the official bulletin of the
Department of SoldiersV Civil Re-establish-
ment : "A pension is compensation for dis-
ability, not payment for incapacity in any
particular line or branch of work — so a pen-
sioner need not worry that his pension will
be reduced if and when he finds employ-
ment, or fits himself for a trade, or takes up
any other means of earning a livelihood."**
Germany.
The German war pensions, for privates
and non-commissioned officers are governed
by the pension law of 1906. Under this law
the pension is composed of several parts.
There is, in the first place, the military
annuity (Militdrrente) , which is a pension
varying according to the degree of disability
and to military rank. The law fixes for
each rank the amount of the annuity for
total disability, and the annuity is in each
case granted as a percentage of that amount
according to the degree of disability as de-
termined by the military medical pension
boards. No annuity is paid if the disability
is less than 10 per cent.
There are, in addition, several supple-
mentary allowances. The war allowance
(Kriegszulaqe) is paid to all those who are
entitled to the military annuity as a result
of disability incurred in and as a result of
war service; its amount (fifteen marks
monthly) is fixed irrespective of the degree
of disability and of military rank.
The disability allowance {Verstumme-
lungssulage) is paid also as a fixed monthly
amount (twenty-seven marks), irrespective
of military rank, to those who have suffered
certain serious injuries : the loss of a hand,
of a foot, the loss of speech, deafness in
both ears. Men blinded in both eyes re-
ceive a double allowance, as do also those
who have lost two limbs : in fact, the allow-
ance is cumulative, and a soldier who has
been totally blinded and, in addition, has
lost both arms and both legs, should receive
six times the normal amount.'^ The allow-
ance may also be granted whenever the use
of a limb has been impaired to such an ex-
tent as to make the impairment equivalent
to a loss of the limb ; or when one eye has
been lost and the other has a vision less
than one-half of normal; or when the man
has suffered any other serious impairment
of his health that necessitates permanent at-
tendance by another person; in cases of
mental disease requiring institutional treat-
ment or of serious illness the amount of the
allowance may be increased up to fifty-four
marks a month.
There are also allowances of a less gen-
eral importance, as, for instance, the old
age allowance (Alterszidage) which is
given to men of fifty-five years and over
whose annual income is less than 600
marks; the air service allowance (Luft-
dienstsulagc) ; the tropical service allow-
ance {Troppenzulage) , and so on.
Of the several component parts of the
pension, one, namely the war allowance,
cannot be reduced under any circumstances
and is paid as a fixed amount as long as
the military annuity is paid, that is, as long
as there is a disability of 10 per cent, or
more.
The disability allowance may be granted
either permanently, if the injury may by its
nature be expected to be permanent, or for
the duration of the injury. The former is
evidently the case for amputations. On the
contrary, the allowance may frequently be
but temporary when granted for serious dis-
ease; in this case, moreover, the granting
is optional with the authorities, and the man
has no legal claim to the allowance.
The military annuity is subject to revi-
sion and may, upon an application of the re-
cipient or by a ruling of the authorities, be
increased, reduced, or withdrawn, if there
has been a "substantial change" in the con-
dition that determined its being granted.
Applications for an increase of the annuity
may be made at any time. A downward re-
vision or a withdrawal may take place
only once a year.*® "Substantial change"
has been defined in instructions issued in
1909 as a change in the degree of disability
equal to at least 10 per cent, of total disa-
bility.^^
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363
The pension is thus partly fixed and
partly variable, and the relative importance
of the two portions varies according to in-
dividual cases. In amputation cases the
portion that remains fixed will, as a rule, be
considerable. Thus, for instance, a private,
who has lost a limb and whose disability has
been estimated at 50 per cent., is granted an
annuity of 270 marks, which will be liable
to revision with every change in his condi-
tion; against this the portion that will re-
main fixed is equal to the combined amount
of the war and disability allowances, namely
504 marks. On the contrary, in cases of
internal disease no disability allowance is
granted as a rule, and consequently the vari-
able portion of the pension bears a much
higher ratio to the fixed one.
The question as to whether the amount
of the annuity depends upon the man's
physical condition only, or whether and to
what extent it may be aflfected by the fact
of his employment and by an increase in his
earnings, cannot be definitely answered. To
denote the disability on which the annuity
is based, the pension law uses the term
Erzverbsunfdhigkeit — incapacity for gainful
work. This is frequently interpreted as
referring to physical incapacity only. Thus,
one of the foremost authorities on the prob-
lem of the disabled soldier states that "a
substantial change cannot be seen in the fact
alone that the disabled soldier is able to
work for wages or that he succeeds in the
course of time in attaining better wage con-
ditions. We only have such a change when
the physical condition of the man has per-
manently and substantially improved."*®
The same interpretation, tho in a less cate-
gorical form, is given in a pamphlet issued
by the Prussian War Ministry for the in-
formation of disabled soldiers : "The eval-
uation of the degree of incapacity is based
mainly upon the physical condition of the
injured as determined by the injury, and
not upon his general condition or upon his
trade activities or the earnings derived from
them. The supposition that the resumption
of trade activities may in itself have as a
result a decrease or a withdrawal of the
pension is altogether wrong.""
In determining the degree of incapacity
in amputation cases the effect of artificial
limbs is taken into consideration. A higher
temporary pension may be granted while
the man is waiting for an adequate artificial
limb to be supplied.*^
On the other hand, it was possible to no
less an authority than Professor Konrad
Biesalski to state that the annuity "is fixed
according to the impairment of the earning
capacity, just as in the case of industrial
accidents, and this annuity may under cir-
cumstances be withdrawn, namely when the
man works and thus proves that his earning
capacity is no longer limited."*'
As a matter of fact, tho it has been gen-
erally recognized in Germany that the "pen-
sion psychosis" is the greatest obstacle to
the rehabilitation of the disabled, arid tho
continuous eflForts have been made to over-
come it by dispelling the idea that rehabili-
tation means a decreased pension, there
never has been given a definite pledge, such
as those given in France or in Italy, that the
pension would under no circumstances be
aflfected by the earnings. The assurances
that have been given in Germany are much
more moderate and more cautious.
A Prussian ministerial circular of Septem-
ber, 1915, states that "a decrease or a with-
drawal of the annuity can only take place in
the case of a substantial increase of the
earning capacity [underscored in the text] ;
to what extent employment in a gainful oc-
cupation may be considered as proof of such
an increase cannot be stated in a general
way." The circular further points out that
the payment of the war allowance will con-
tinue as long as the earning capacity of the
man is impaired to any measurable extent ;
no change in the amount of the disability
allowance is as a rule possible. Therefore
in cases of amputation, for instance, the
man, "in addition to an annuity correspond-
ing to the degree of disability," will receive
the two supplementary allowances, "irre-
spective of the income he may derive from
gainful employment." "The authorities
concerned have been requested, in order to
facilitate an unimpeded return of the dis-
abled to civilian life and not to interfere
with their vocational training and readapta-
tion to work, which in some cases may re-
quire considerable time, not to fix too short
periods for the revision of the pension."**
In the official publication of the Prussian
War Ministry devoted to the problems of
disabled soldiers we find mention of several
provisions made to overcome the apprehen-
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Amkrican Mbdzcins
sion of the men that to take up remunerative
work may mean a reduction or a loss of the
pension. These provisions include assurance
given to the men who may take up work
before the pension procedure has been com-
pleted that their earnings during the inter-
vening period will not affect the amount of
the p)ension; the maintaining of the prin-
ciple that revisions shall not take place more
than once a yeaf and a recommendation to
extend this period, whenever this may be
necessary, to two or three years or even
more; the issuing of special certificates to
those men whose injury does not permit to
expect a restoration of their earning capac-
ity to over 90 per cent, of normal, to the
effect that no complete withdrawal of their
pension will ever take place.**^
Paul H. Perls, of the Siemens-Schuckert
plant, who has been active in readapting dis-
abled soldiers to factory work gives the fol-
lowing statement of the relation of the pen-
sion to earning capacity : "The idea is fre-
quently found among disabled soldiers that
they will lose their pension if they enter em-
ployment. This idea is wrong. The war
allowance continues as long as there re-
mains any reduction of earning capacity due
to war service; the disability allowance is
paid as long as there is disability, which, as a
general rule, means for life. As to the mili-
tary annuity, it can only be decreased or
withdrawn if there has taken place a sub-
stantial change in the condition that had de-
termined the granting of the pension. Sub-
stantial change there is when the physical
condition of the disabled man has sub-
stantially improved, or when he has become
so much accustomed to his sickness or in-
firmity that the impairment of his earning
capacity has become less, as, for instance,
thru habituation to artificial limbs, or when
his earning capacity has increased thru ad-
ditional training. A decrease of the pen-
sion is always conditioned upon the change
in the degree of disability being of at least
10 per cent. The military administration
has repeatedly assured that the prescriptions
regarding the change of the amount of the
pensions of the disabled would be enforced
with the greatest benevolence. No disabled
soldier should fear that his annuity might
be reduced by the amount of his wages."*®
There is one provision in the pension law
by which the amount of the pension is di-
rectly affected by the fact of employment.
If, namely, the disabled man enters civil
service the payment of the portion of his
pension which is equal to 20 per cent, or less
of that for total disability, and of that por-
tion which exceeds 60 per cent, of that for
total disability, is susp)ended for the dura-
tion of his employment. However, an order
of the Imperial Chancellor, issued during
the war, has exempted from this provision
all state and municipal employees.*^
In direct relation to earnings is the so-
called supplementary pension (Zusatsrente)
which may under certain conditions be paid
out of a special fund created during the war
to disabled soldiers to cover the difference
of their pre-war earnings and their present
total income.
References.
1. In the study of the material I wish to ac-
knowledge especially the assistance of Mrs.
G. G. Whiteside and Mr. Alexander Gour-
vich.
2. Lol 11 avHl 1831. art 12, 13. 14. In: Val-
entino, Ch. Militaires bless^ et infirmes.
R6formes, gratifications, et pensions. Paris,
1918, p. 47-48.
3. D6cret du 24 mars, 1915. In: Dalloz. Guerre
de 1914. Documents officiels. Paris, 1915,
iv, 60-51.
4. Obelliane, E. Les pensions des victimes de
la guerre. Nouvelle lol du 31 mars 1917 sur
les pensions militaires. Paris, 1919, p. 6.
5. Ibid., p. 8.
6. Valentino, Ch. Militaires blesses et in-
firmes. R^formes, gratifications, et pen-
sions. Paris, 1918, p. 106-107.
7. Prance. Miniature de la Ouerre. Gulde-
bar^me des Invalidlt^s. Paris, 1917, p. 3.
8. Obelliane, E. Les pensions des victimes
de la guerre. Nouvelle loi du 31 mars, 1917
sur les pensions militaires. Paris, 1919, p.
7.
9. Valentino. Ch. Militaires blesses et in-
firmes. Reform es. gratifications, et pen-
sions. Paris, 1918, p. 139-140.
10. Obelliane, E. Les pensions des victimes de
la guerre. Nouvelle loi du 31 mars 1917
sur les pensions militaires. Paris, 1919, p.
7.
11. Inter-Allied Conference (the) on the After-
Care of Disabled Men. Reports presented
to the conference. London, 1918, p. 27.
12. Inter-Allied Conference (the) on the After-
Care of Disabled Men. Supplement to
volume of reports. London, 1918, p. 24.
13. France. Office National des Mutili^s et R&
fomi<^s de la Overre. Bulletin No. 1. Ann^e
1916. Paris, 1917. p. 11.
14. Ibid., p. 167.
15. France. Office National des MutiUs et R^
formes de la Guerre. Bulletin No. 3. Premier
semestre 1918. Paris, 1918, p. 3.
16. Winiams. Basil. Pensions. Recalled to Life,
London, 1917, i, 97.
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18.
19.
20.
21.
22.
23.
24.
17. Great Britain. Ministry of Pensions, The
drafts of a royal warrant and of an order
In council for the pensions of soldiers and
sailors disabled and of the families and de-
pendants of soldiers and sailors deceased In
consequence of the present war. London,
1917 (cd. 8485), p. 11.
Ibid., art. 1.
Ibid., art. 7.
Ibid., art. 5 (1).
Lefevre, J. The handy guide to war. pen-
sions, gratuities and allowances. How
granted and how obtained. Maidstone. 1918.
p. 6.
Great Britain. Ministry of Pensions, The
drafts of a royal warrant and of an order
in council for pensions of soldiers and
sailors disabled and of the families and de-
pendants of soldiers and sailors deceased
In consequence of the present war. London.
1917. art. 5 (2).
Mitchell. Robert. To disabled sailors and
soldiers. A few notes on the advantages of
training for your future, career. London.
1918, p. 4.
Great Britain. Ministry of Pensions. The
drafts of a royal warrant and of an order
In council for the pensions of soldiers and
sailors disabled and of the families and de-
pendants of soldiers and sailors deceased
In consequence of the present war. London,
1917, art. 3.
25. War Pensions Gazette, London, 1917, 1. 57.
26. Per le pension! prlvileglate dl guerra.
Rassegna di Assicurazioni e Previdenza 8o-
ciale, Roma. 1917, Iv, 1268-1285.
27. Ibid., p. 1272.
28. Ibid., p. 1270.
29. Ibid., p. 1284.
30. Protezlone ed asslstenza degll invalldi della
guerra. Rassegna di Assicurazioni e Pre-
videnza Sociale, Roma, 1917, Iv, 970.
31. Opera Nazionale per la Protezlone e I'Assls-
tenza degll Invalldi della Guerra. Agll In-
validi della guerra. Roma, 1918. p. 13.
32. Canada. Parliament. Pension regulations
for those serving in the naval forces of
Canada and the Canadian expeditionary
force during the present war. Ottawa, 1917.
33. Reconstruction, December. 1918, p. 12.
34. Reconstrtiction, December, 1918, p. 13.
35. Canada. Parliament. Pension regulations
for those serving In the naval forces of
Canada and the Canadian expeditionary
force during the present war. Ottawa. 1917,
p. 4.
36. Reconstruction, December, 1918, p. 13.
37. Schweyer, Franz. Deutsche Krlegsfflrsorge.
Berlin. 1918, p. 76.
88. Germany. Preussisches Kriegsministerium,
Uebersicht tiber Versorgungs-und Ptirsorge-
Angelegenheiten der Mannschaften. Ber-
lin, 1918, p. 14.
39. Adam, M. Mannschaftsversorgung. Berlin,
1918, p. 68-69.
40. Schweyer, Franz. Deutsche Krlegsftirsorge.
Berlin, 1918, p. 78.
41. Germany. Preti^sisches Kriegsministerium,
-Uebersicht flber Versorgungs-und Ftirsorge-
Angelegenhelten der Mannschaften, Ber-
lin, 1918. p. 6.
42. Ibid., p. 15.
43. Blesalski, Konrad. Die ethlsche und wirt-
schaftllche Bedeutung der Krlegskriippel-
fiirsorge. Leipzig, 1915, p. 17-18.
44. Fechner. Die Hlnterbliebenen-und Krlegs-
besch^dlgten-Fdrsorge In Kriegs-und Frle-
denszeiten. Berlin, 1915, ill, 5-7.
45. Von Langerman and Erl encamp. Versor-
gungsfragen im Krlege. Amtliche MitteU
lungen fiir Kriegsbeschadigte Oder versor-
gungsberechtigte Militarpersonen und fiir
Hinterbliehene von Heeresangehorigen, Ber-
lin, 1917, 1, 45.
46. Perls, Paul H. Wlederertiichtigung schwer-
beschUdigter Krlegsteilnehmer in der Werk-
statt. Zeitschrift fiir Kriippelfursorge, Leip-
zig, 1917, X, 298-299.
47. Fursorge fiir Kriegsteilnehmer, Berlin,
1917. ill, 165.
48. Vom Krieg zur Friedensarheit, Berlin. 1917,
lil, 35; Schweyer, Franz. Deutsche Krlegs-
farsorge, Berlin, 1918, p. 99.
THE PLACE OF MECHANO-THER-
APY IN THE RE-EDUCATION OF
IMPAIRED MOVEMENTS.
R. TAiT Mckenzie, m. d.,
Philadelphia, Pa.
Late Major, R. A. M. C,
Professor of Physical Therapy, University of
Pennsylvania.
Much mental confusion has been caused
by thinking of massage and mechano-ther-
apy as being an akernate for, or in oppo-
sition to, occupation in the treatment of
wounded men. It is scarcely more reason-
able than to debate the relative merits of
salad and ice cream as a complete diet.
They are both courses in an orderly se-
quence of treatment.
The muscles, especially if hampered by
imperfect nerve supply or starved by con-
stricting scar tissue, must first of all be
flushed with blood, either by hot water, by
radiant heat, or by diathermy; they must
then be manipulated and, in certain cases,
stretched by the operator, but when heat,
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massage and passive movement have done
all they can, the patient has still a long
way to go to complete recovery, and here
is the point at which the greatest diver-
gence of views begins.
From McKenzie's ''Reclaiming the Maimed."
Courtesy of the Macmillan Co.
Pig. 1. Inclined ladder for exercising the
stump of amputated leg with parallel bars
to help balance. On either side of the bars
are seen the inversion and eversion treads
for foot training.
There are three ways by which lost or
impaired movements are brought back:
1. Specially designed apparatus like the
Mosso ergograph for exercising specific
groups.
2. Gymnastic movements and exercises
which are not so accurate, but which can
be designed to train definite movements and
co-ordinations.
3. Handicrafts, in which the muscles
are unconsciously used for the purpose of
accomplishing some useful work.
Each of these, instead of being antagonis-
tic, is a link in the chain of a complete
treatment.
The most widely known system of mech-
ano-therapy before the war was that of
Zander, but during the last five years it
has fallen into general neglect, partly on
account of the great cost of an installation
and the complicated construction of the ma-
chines, partly from the real danger in em-
ploying an apparatus for stretching adhe-
sions which is driven by power beyond the
control of the patient and, lastly, from the
intolerable boredom that results from the
mechanical repetition of a single movement
without producing any apparent result.
Single and comparatively inexpensive ap-
pliances have been devised as a substitute
to bring into more general use this valua-
ble agent in the treatment of these condi-
tions, but even to the appliances which are
now used with such success in the many
hospitals and convalescent camps in France,
England, India, Canada, and at the
Clinic for Functional Re-education in
New York, I find a prejudice which I
believe is capable of analysis. It is com-
posed of^a sort of mental laziness that
resents having to learn a new thing, which
makes it so much easier to dismiss the
whole subject in the casual way, rather
than learn what it actually does accomplish ;
in fact, the same mental attitude that ig-
nored the whole subject of physical therapy
before the war. Just as the neglect of med-
ical electricity is due largely to lack of
knowledge of its technic, so ignorance,
sometimes accompanied by an unwilling-
ness to investigate the subject, is responsi-
ble for the small place occupied by mech-
ano-therapy in many military hospitals.
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367
'The exact place of mechano-therapy must
always be kept in mind. That place is im-
mediately after the patient has been pre-
pared by heat in its various forms and
manipulation, and it comes before the more
complicated and less regulated movements
of a craft. It is mqre closely allied with
medical treatment than it is with occupa-
tion, and to be successful, it requires an
knee, and walk somewhat as if the extensors
were really in action. This is also true of
many movements of the shoulder, arm and
hand. It is necessary, then, to analyze with
great care any action that is absent or im-
paired and to prescribe exercises that will
bear directly upon it.
The appliances here described, tho far
from complete are designed:
From McKenzie'8 "Reclaiming the Maimed."
Courtesy of the Macmillan Co.
FiQ. 2. Apparatus for ad- and abduction of the wrist — flexion and extension of the wrist and
pronation and supination.
accurate knowledge of the anatomy of the
parts involved. It is a commonplace to ex-
perienced workers that apatient will always
favor a weak muscle group by. using other
and stronger groups, where possible, to dis-
guise this weakness, so that an apparent
action is often shown where the muscles
are really impotent. With a little practice,
a man whose quadriceps extensor is para-
lyzed can throw his leg forward, lock his
1. To isolate the muscle group to be
developed.
2. To give resistance to the movement
by a graduated load.
3. To give an easy method, which can
be seen by the patient of measuring the
range of movement, and the amount of
work done.
4. To interest the patient, who watches
the progress of his work, both in amount
and distance and who feels a sense of ac-
complishment when he succeeds in tripping
the weight raised to the required height.
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The psychology of this is not new. It is
the same as that used by the proprietor of a
machine familiar to every frequenter of
the country fair. A post is hit by a mallet
and a pointer runs up a graduated scale.
If it reaches the top, it rings a bell, and
you get your money back. No man of
ambition can resist it, and so in these appli-
ances, the patient can compete against his
own record as seen by his own eyes, or
against the records of others having sim-
ilar disabilities and his interest in the work
is stimulated from day to day.
Some of the appliances are made for the
purpose of passive stretching, but they dif-
fer from the Zander machines in that they
are always under control of the patient.
He may be safely trusted to desist from
stretching adhesions long before there is
danger of rupturing them. If they ought
to be broken down by force, this operation
should be done by the surgeon, after due
considers^tion. Most of the appliances
about to be described have protractors at-
tached, so that the range of movement can
be watched by the patient himself, during
the exercise, and this additional incentive
given him to use his best efforts. The
measurement of ability to repeat movement
will be in terms of weight raised and num-
ber of repetitions. The maximum strength
of the grip can be taken conveniently by
partly inflating the cuff of a sphyg-
momanometer, and noting the height to
which the mercury is raised when the cuff
is squeezed. This is better for a partially
disabled hand than the ordinary dynamo-
meter.
The appliances for improving the strength
can be loaded with increasing weights as
the power to lift them returns and the pa-
tient can be interested in watching the ex-
tent of each movement, as shown on the
scale, in watching the rising weight as it
is lifted, in calculating the total amount of
work done in foot pounds, or in listening
to and counting the clicks of the ratchet,
as the movement is made.
The operator should be seated opposite
the patient in all hand and arm exercises
and should regulate the machines and the
amount of work done.
Upper Extremity.
1. Finger board, (a) For stretching
contraction of the fingers, in flexion, and
(b) for stretching abduction at the meta-
carpophalangeal joints.
(a) Extension of single fingers: The
fingers are placed on the board in moderate
flexion, find the finger under treatment goes
up the stair, step by step. Note the last
step at which the finger under treatment
can be raised from the step without assist-
ance. Depress the hand to stretch still far-
ther.
(b) Place the index finger against the
peg at 1 and spread the second finger out,
noting the farthest point at which it can
touch the peg. Repeat with the second,
third and fourth.
Repeat each movement not more than
five times. The patient then moves to the
next five appliances, the operator sitting
opposite.
2. Finger pulleys — for flexion and ex-
tension of the fingers. Strap the wrist to
the arm rest, insert the fingers into the
glove stools and fix them by elastic bands.
Add weights until they can barely be lifted
by the voluntary power of each finger. The
weights are increased as improvement goes
on, and the movements are repeated up to
the point of exhaustion.
1st exercise: High attachment. Flex
metacarpophalangeal joints, keeping inter-
phalangeal rigidly extended.
2nd exercise: Horizontal attachment.
Flex interphalangeal joints, keeping meta-
carpophalangeal joints extended.
3rd exercise : Low attachment. Extend
metacarpophalangeal joints, keeping inter-
phalangeal extended.
4th exercise: Low attachment. Extend
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369
metacarpophalangeal and flex interphalan-
geal joints.
The operator seated opposite the patient
should count the repetitions and encourage
his efforts. Each exercise to be continued
till movement shows flagging, and then
stopped. The most convenient weights are
shot bags, loaded to two ounces each, and
ulnar side to the thumb; draw the thumb
out in abduction. Repeat to exhaustion.
4. Finger treadmill — for voluntary flex-
ion of fingers. Strap the wrist and turn the
wheel by flexing the fingers in turn till ex-
haustion of each finger. The amount of
work done by a single finger can be cal-
culated by using that finger only, and rio-
From McKenzie'8 '^Reclaiming the Maimed."
Courtesy of the Macmillan Co.
Fig. 3. Apparatus for exercising the fingers and thumbs, showing creeping board for stretch-
ing the shoulder at the end of the table.
attached by hooks. They can easily be made
and repaired by the masseuse.
3. Thumb ad-and abduction — hand in
pronation. Attach the thumb stool on the
radial side to the thumb for adduction.
1st exercise: Draw the thumb across
the hand. Repeat the movement to ex-
haustion.
2nd exercise: Attach the stool on the
ting the distance and weight raised.
5. Circumduction of wrist for voluntary
movement, and for stretching. Strap both
the wrist and forearm, grasp^the handle, and
turn the wheel about twenty revolutions
each way. Move out the attachment to the
farthest possible point compatible with the
movement. The operator may assist at the
most difficult part of the turn, by turning
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the crank and so stretch a limited action.
6. Ad-and abduction of wrist. Place
the fingers under the straps on the hand
board, strap down the wrist and forearm,
ad-and abduct the hand, noting the range
of movements on the protractor. These two
movements should be done separately.
7. Flexion and extension of wrist. (1)
Grasp the roller overhand and wind up the
weight, without releasing the grasp by re-
peatedly extending the wrist. The scale
will measure the range of the movement,
and the weight and distance multiplied
gives the total work done in foot pounds.
Precaution : See that the movement is done
From McKenzie*8 *' Reclaiming the Maimed."
Courtesy of the Macmillan Co.
Fig, 4. Apparatus for rotation with the Rule
in flexion.
at the wrist only, and not at the elbow or
shoulder. (2) Reverse the grasp and re-
peat for flexion. Where no grasping power
is present, the hand may be held between
two plates at right angles to apparatus 6
and flexion and extension obtained.
8. Pronation and supination. Patient
stands facing the machine and grasps the
handle with the left hand, his left elbow
joint flexed, his right forearm across his
back, and his hand grasping his left arm
above the elbow to prevent sideward move-
ment. Set the weight and ratchet for supina-
tion and turn, counting the clicks for each
movement and noting the weight and the
distance raised. The measurement of each
movement will appear on the protractor.
See that patient does not move his elbow
out or in, or twist his body. Reverse the
ratchet and repeat for pronation.
9. Flexion and extension at elbow. ( 1 )
The patient faces the triplicate machine,
grasping the floor handle, the arm and cord
in line. Flex and relax the forearm. (2)
Patient faces away from the machine,
grasping the shoulder handle, the arm full
flexed, the upper arm in line with the cord.
Extend and relax the forearm. In both
these exercises, the position of the upper
arm must remain unchanged. If this is
not done, the direction of the pull is
changed.
10. Shoulder rotation. Grasp the floor
handle, the elbow on a bracket, shoulder
high, the forearm flexed to a right angle.
Pull up with the hand, thruout the whole
range of the shoulder movement without
changing the height of the elbow or its
angle of flexion.
11. Flexion and extension of the should-
er joint. (1) The patient stands with his
back to the floor handle, the arm down and
straight. Arm forward raise, and lower.
(2) Face to the floor handle, draw the
arm back and lower to position.
12. Ad-and abduction of the shoulder.
The patient stands with the side to the trip-
licate machine, shoulder attachment, arm
and cord in line. (1) Bring the arm for-
ward across the chest. (2) Patient stands
as in exercise 1, but using the floor attach-
ment. Bring the straight arm upward and
lower to position. (3) Patient stands with
his side to the machine, overhead attach-
ment, arm in line with the cord. Bring
the arm downward and forward, then
downward and backward alternately. (4)
The patient stands with the side from the
machine, grasping the shoulder attachment.
Extend the forearm and arm, keeping them
at the shoulder level.
13. Passive abduction of shoulder. Pa-
tient standing with side to the creeping
board, and the forearm rigidly extended.
Climb up the board by the fingers with a
straight arm, and note: 1st, the highest
point at which the fingers can be lifted
from the board by the patient; 2nd, the
level to which he can bring up his arm with-
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ORIGINAL. ARTICLES
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371
out bending his elbow. Keep the body
rigid thruout, not bent or twisted.
General movements that are of value in
treating the muscles of the upper extremity
are rolling up a ball of paper, throwing and
catching balls of all sizes and weights,
quoits, bowling, pingpong, crokinole, bil-
liards, weaving, knitting, rope splicing,
knots, the use of tools, like scissors, boring,
hammering, modeling, painting, bookbind-
ing, saddlery and shoemaking.
Lower Extremity.
14. Circumduction of the ankle. The pa-
tient sits with his foot strapped in place.
The range of movemeflt is regulated by a
thumb screw on the crank. The handle
is turned by the patient or operator for
this stretching movement, which should
precede the voluntary active movements of
the ankle.
15. Inversion and eversion of the foot,
(a) The patient walks on the inversion
ridge, a definite distance, with hand rail
support, (b) Ditto for eversion. Both
(a) and (b) are stretching movements, and
should precede (c) which is active, (c)
The patient is seated with the foot and leg
strapped to the apparatus. Evert the foot
against the weight on the cord, and note
the range of the movement on the pro-
tractor, and the total weight raised. Re-
verse this ratchet and repeat for inversion.
16. Dorsiflexion of ankle. The patient
sits or stands with his foot strapped to the
footpiece. Flex the ankle, raising the
weight. The extent of the movement may
be estimated by the number of clicks, the
exact measurement noted on the protractor,
and the total amount of work done is easily
calculated.
17. Rotation of the knee, (a) The pa-
tient is seated with the foot strapped to
the footpiece, and the leg against the brace.
He ad-or abducts the foot, rotating the
knee, the extent of each movement being
marked on the protractor, (b) The pa-
tient stands with the knee locked in exten-
sion and ad-or abducts the foot. This
movement measures hip rotation, if care
be taken to keep the pelvis fixed. In either
position, the movement of the flexed ankle
is slight.
18. Knee flexion and extension. Trip-
licate machine. Exercise 1. Face the ma-
chine, strap the foot to the floor attachment.
Movement: Flex the knee against resist-
ance. Exercise 2. Face from the machine,
strap the foot to the floor attachment, the
flexed leg and the cord in the same line.
Movement: Extend the knee against re-
sistance.
19. Hip ad-and abduction. Triplicate
machine. Exercise 1. Side to the machine,
the foot strapped to the floor attachment.
Movement: Abduct the thigh, keeping the
knee straight. Exercise 2. Side from the
From McKenzie'8 ''Reclaiming the Maimed."
Courtesy of the Macmillan Co.
Fig. 5. Apparatus for inversion and eversion
of the foot.
machine, foot strapped to the floor attach-
ment. Movement : Abduct the thigh, keep-
ing the knee straight.
20. Hip flexion and extension. Exer-
cise 1. Face to the machine, foot strapped
to the floor attachment. Movement: Ex-
tend the thigh with the leg stretched. Ex-
ercise 2. Face from the machine, foot
strapped to the floor attachment. Move-
ment: Flex the thigh, keeping the knee
straight.
21. Thigh flexion, knee flexion, foot
dorsiflexion. Patient steps thru the rungs
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of the horizontal ladder with parallel bar
arm rests. The ladder is made adjustable
for height at one end, and raised, to in-
crease the movement required to raise the
foot over each rung. This is especially
useful for leg amputation cases.
22. Thigh extension, knee extension,
foot plantaflexion — the bicycle trainer with
an increased load of distance or friction.
General exercises: Walking, hill climb-
ing, dancing, kicking a football, or hockey
puck, balancing, skipping.
In the treatment of stumps, a sheath
should be attached and the various pulley
weight movements carried out as if the
limb were intact.
Amputations. The re-education of am-
putation cases begins with the preparation
of the stump, and fitting of the artificial
limb for comfort, and for the correct bear-
ing of the weight. The patient should first
learn to balance, which may be made safe
if he be suspended by a belt under the
arms, working from an overhead trolley
or by grasping a bar. This inspires confi-
dence, and prevents falls, especially in ani-
putation at the thigh, where the balance is
very difficult to get. The patient then pro-
gresses to the use of sticks and progression
on a smooth surface. He should discard
crutches from the first. This is very im-
portant. He then learns to walk on a
smooth, level surface with one stick only,
to clear obstacles, like the ladder rungs al-
ready described, and finally to walk thru
soft sand on uneven ground up and down
inclines, and over obstructions.
Treatment should not stop at this point.
It can be combined advantageously with
light gymnastics and various forms of occu-
pation.
Treatment by occupation necessarily dif-
fers from it in that it is less accurate and as
a remedy it will be given in increasing doses,
whereas treatment by mechano-therapy and
corrective gymnastics will be gradually
abandoned as the patient gains control and
strength. Whether or not a movement like
sawing is given as treatment with the ac-
complishment a secondary consideration, or
whether the patient saws wood because he
wants to make a box, important as this dif-
ference is, the work accomplished by the
muscles will be much the same.
I will not at this place go into the ques-
tion of the mental attitude of the patient,
altho I am far from ignoring its importance,
but I wish to emphasize the fact that in
any course of muscular re-education, one
must not depend on inaccurate or haphazard
movements and that a complete course of
treatment must include analysis of muscu-
lar action and the accurate cultivation of the
powers that are weakened, by appliances
capable of measuring and recording pro-
gressive improvement when present, and
that many a period of convalescence can
be greatly shortened if this is recognized
and applied.
Note — Illustrations of these appliances can
be found in "Reclaiming the Maimed/' pub-
lished by the Macmillan Company.
SALVAGE OF MEN.
BY
J. E. MEAD, M. D., Major, M. C,
Detroit Mich., U. S. A.
Salvaging, in the common acceptance of
the term, means the restoring to some use
of material that ordinarily would be lost,
wasted or destroyed. For a long time keen
and wideawake leaders of industry have
realized the great importance of using seem-
ingly waste products, even to the minutest
detail, and by so doing millions and millions
of dollars have been added to their profits.
Also many new products have been devel-
oped and the original cost of many others
has been lowered to a marked degree. For
example, we may refer particularly to what
salvage has done for the packing and coke
industries. The list of by-products from
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the slaughter houses and coke ovens is long
and varied and these are obtained from
material that was once thrown away, wasted
or discarded as of no value.
What about the waste of human mate-
rial? Has it been so salvaged and used
to the best advantage that waste is elim-
inated or reduced to the minimum? In the
past, I think not. Of all our resources, la-
bor has received the least consideration.
Granting exceptions in isolated cases, after
the cream of a man's efforts had been ex-
tracted he was thrown on the scrap heap
and in many cases his best assets were lost,
not only to himself but to the state. Not
only was the good left in him lost but his
mere existence became a burden and a nui-
sance— a clog, interfering with the progress
of industry in the same manner as the
great piles of refuse from mines, saw-mills
and other industries caused annoyance and
embarrassment until thought, experiment
and necessity revealed the hidden treasures
therein concealed.
A benefit not to be despised, resulting
from the late world war, is the interest
aroused thruout the world in reclaiming to
usefulness sick and wounded soldiers. There
has been scarcely a paper or magazine pub-
lished during the past year that has not
contained some mention of the subject
with which this article is concerned.
This interest, once aroused, should continue
and expand until it embraces all branches
of industry and society in general.
Within the next two years, practically
all our wounded and invalided soldiers will
have been cared for, but every single year,
industry will continue to furnish more sub-
jects for rehabilitation, than came from the
entire American forces during the war. Will
these receive the same consideration and
attention? Let us hope they will. The
present enthusiasm will naturally subside
to a certain extent, but the economic neces-
sity will remain and should be constantly
kept in mind by those who have this subject
at heart. The good work so well started
should be kept up until no one physically
incapacitated for his own line of work by
accident or disease can be forced, or even
allowed, to become an object of private or
organized charity until every means has
been exhausted to make him a self-support-
ing and useful member of society.
The Ford system of salvaging men did
not result from necessity, nor from a scien-
tific study of economics. The inception of
the idea came from that principle of Mr.
Ford, expressed by the slogan "Help the
Other Fellow," this precept implying that
those who needed the greatest help should
receive the greatest assistance.
So, on January 12, 1914, Henry Ford,
while setting the minimum wage for em-
ployees of the Ford Motor Company at
$5.00 per day, a day's work consisting of
eight hours, issued instructions that no one
applying for work in the future should be
rejected on account of his physical condi-
tion excepting those suffering with conta-
gious diseases endangering the health of
fellow employees ; and furthermore, that no
one should be discharged on account of his
physical condition. On January 1, 1919,
the minimum wage was again raised to
$6.00 per day with the same rule regard-
ing cripples in force, for during those past
five years efficiency and production had in-
creased and the company had not yet gone
into the hands of a receiver.
It may be inferred that during the past
five years, with the bars let down "to the
lame, the halt and the bind," the employees
of the Ford Motor Company would number
a great many that were not up to the aver-
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age physical standard. Such was a fact.
At the present time there are 123 men work-
ing with either amputated or hopelessly
crippled arms, forearms or hands ; one with
both hands off; 4 totally blind men; 207
blind in one eye ; 253 with light perception
only in one eye ; 37 deaf and dumb ; 60 suf-
fering with epilepsy; 4 with both legs or
feet missing; 234 with one foot or leg am-
putated or hopelessly crippled; 1,560 suf-
fering from hernia of various types; 900
tubercular employees and 6,180 more, suf-
fering from other ailments or diseases,
bringing the total up to 9,563.
A fact of minor importance but probably
of interest is that Ford employees are mijius
1,031 of their allotted number of fingeis
or thumbs.
Let us take two average days in the em-
ployment office to show the daily accumula-
tion of defectives. The record for October
10, 1918 shows that there were examined
and hired 163 men, only 37 of whom were
able to pass the physical examination as
O.K.; 13 were found to have varicocele;
36 poor eye sight; 58 flat feet; 2 organic
heart disease; 31 poor teeth; 14 varicose
veins; 15 hernia; 1 nephritis; 1 club foot;
1 tuberculosis ; 2 chronic bronchitis ; 1 with
only one eye ; 1 deformed leg ; 1 with hemor-
rhoids and 1 mentally defective. On Octo-
ber 11, 1918 a total of 185 men were hired,
of whom 11 had varicocele; 23 poor eye
sight ; 58 flat feet ; 35 poor teeth ; 14 vari-
cose veins; 14 hernia; 7 with crippled
hands; 4 with defective hearing; 1 crip-
pled foot and 2 with crippled legs. Only
8 were found to be physically perfect.
How are these employees placed so that
their maximum ability can be realized in
the manufacture of the Ford product? A
man applying for a job is first interviewed
and the preliminar}^ employment papers
written up in the employment office. He
is then immediately referred to the exam-
ining surgeon, who gives him a most thoro
examination. If found to be suffering with
a contagious disease, dangerous to the
health of fellow employees, he is refused
immediate employment and the case re-
ported to the local health authorities. If,
however, his debarring ailment is acute and
probably will respond readily to treatment,
he is assured that when he can present a
clean bill of health he will be accepted.
One of the important questions on the
examining blank is that one pertaining to
the class o^f work that the applicant is fitted
to perform. If he is in perfect physical
condition, strong and well built, he is listed
for any work ; if in perfect condition but of
slight build, he is cited for moderate work
of any kind, but if found physically sub-
standard or suffering from any ailment or
disease, a note is made of his condition with
special recommendations to the employment
office to place him on a job, the require-
ments of which will not handicap him in
the performance of his work.
Once hired, a man is assured of perma-
nent employment, for, as stated before, one
rule of this company which is hard and fast
and which to my knowledge has never been
broken, is that no person shall be discharged
or laid off because he is physically unable
to do his work. This, however, does not
prevent an employee, who is acutely ill or
in need of rest and medical attention, from
obtaining a sick leave, with the assurance
that his job will be awaiting him on his
recovery.
During the past year the average number
of employees of the Ford Motor Company
was 33,000. As recorded before, 9,563 of
these were dther actual cripples or men suf-
fering with some ailment or disease or
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otherwise physically below par, including
many aged men between 70 and 80 years
old.
How is an equitable adjustment of the
work to the man accomplished? An ac-
curate card index is on file showing the
number of different jobs or operations per-
formed in the course of manufacturing the
various parts and of assembling the Ford
product. These cards give the department
number ; operation number ; kind of machine
and a description of the work, whether
light, medium or heavy; dry or wet, if wet,
the kind of fluid used ; clean or dirty ; near
an oven or furnace; condition of air in the
department ; whether one or both hands are
used; whether the employee sits down or
stands at his work; whether it is noisy or
quiet; accurate or inaccurate; natural or
artificial light; number of shifts; the ap-
proximate number of pieces handled per
hour; the weight of the material or piece
handled and a description of any strain the
workman is under.
There is a total of 7,882 of these cards,
describing that number of different jobs in
the factory. Of these, 949 are classified as
heavy work, requiring strong able-bodied
and practically physically perfect men;
3,338 require men of ordinary physical de-
velopment and strength, while the re-
mainder, 3,595, call for practically no phys-
ical exertion and can be performed by men
of the slightest build or physical develop-
ment. In fact, the last class of work could
be performed by women or older children
without taxing their strength. As many of
the lightest operations require the use of all
a person's faculties and would not be suit-
able for many of the cripples, another can-
vass was made to ascertain the number of
jobs that could be performed by the various
classes of cripples.
This list showed that 670 could be per-
formed by legless men ; 2,637 by one-legged
men ; 2 by armless men ; 715 by one-armid
men and 10 by blind men. To become pro-
ficient in these various occupations, the
time required was estimated as follows :
1,743 jobs, or 43%, would require one day
or less ;
1,461 jobs, or 36%, one day to one week ;
251 jobs, or 6%, one to two weeks ;
534 jobs, or 14%, one month to one
year;
43 jobs, or 1%, one to six years.
The last mentioned are skilled trades,
such as tool-making and die-sinking.
From the study of this subject of salvage
two fundamental facts became prominent:
First, there were 9,563 substandard men
who required more or less consideration in
order to secure efficiency from their labor,
and second, thruout the plant there were
over 14,000 jobs perfectly suited to the
various types and conditions of these phys-
ically substandard men. The problem then
became clear and the solution simple. It
was the rational adjustment of the two
factors, the man and the job.
While the procedure is simple, system is
necessary to properly carry on this work in
a factory the size of the Ford Motor Com-
pany and conducted on its liberal principles.
Therefore, there resulted the establishment
of a transfer department and thru it, all
cases receive individual attention and proper
adjustment. If for any reason the suit-
ability of a man for his work is criticized,
whether the complaint comes from the em-
ployee himself, his foreman, superintendent.
Medical Department or Educational Depart-
ment, the man is given a printed form
labeled "Request for Medical Examination"
and is sent to the transfer office. Here
he receives a thoro physical examination,
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the descriptive card of his work consuked
and if he is found in any way unfit for his
work, he is transferred to a job suited to
his condition. The work of this department
is facilitated by supplying it with a daily
list of "Help Wanted/' giving the number
of men needed and the class of work avail-
able in the different departments in the
factory.
This system necessarily creates a constant
change of labor from one department to
another but this inconvenience is more than
overcome by the contentment of the em-
ployee, the prevention of lost time and the
increase of production resulting from satis-
fied workmen.
Allow me to digress for a moment and
relate an incident that occurred a short time
ago, illustrating the efficiency of a totally
blind man. When first hired it was in-
tended to place him on the same work as
that being done by other blind men but, on
investigation, it was found that stock for
these men was getting low and other work
must be provided. Three different jobs
were soon found that he could do and he
was finally assigned to the Stock Depart-
ment, counting bolts, nuts, etc., for ship-
ment to the Branches. Two other able-
bodied men were already employed at this
same work. Two days later a note from
the foreman was sent to the Transfer De-
partment, stating that he could release the
two older employees as the blind man was
doing the work formerly done by both of
them. This is but one of many instances
that could be cited, showing the results of
proper assignment of work.
Criticism of the monotony and lack of
opportunity resulting from the modern
method of manufacture is often heard and
is probably in the minds of many who read
this article. These objectionable features of
modem labor have been realized by the
Ford Motor Company and very recently a
method devised whereby these contingen-
cies may be met and their objections over-
come.
Four of the larger departments have been
chosen for experiment and if proven prac-
tical, the entire factory will be placed under
the same system. In these selected depart-
ments the work has been classified accord-
ing to its desirability and the skill required
in its performance. There are three dif-
ferent classes of work in each department,
A, B and C, each class comprising from 10
to 30 different operations. The men in
Class A are eligible for promotion to the
next higher department as vacancies occur.
When these promotions take place the
vacancies made, cause a general advance-
ment all along the line, leaving the jobs in
Class C open to new men from an inferior
department or from the employment office.
Of course, an employee must show his
fitness for advancement or he will be passed
by those below him. By this plan the chance
to advance to the highest class of employ-
ment, that of tool-maker, is open to all em-
ployees who care to take advantage of their
opportunities.
If a man by this plan of promotion finds
that his mental qualifications bar him from
further progress, the highest position which
he has attained becomes permanent, or, if
not satisfied, he is transferred to an entirely
different department that might prove more
suited to his qualifications.
Under this system, physical defects will
play an unimportant role, for when such are
found to be interfering with a man's op-
portunities, special endeavor will be made,
thru the cooperation of the Educational
and Medical Departments with the man and
his foreman, to overcome the difficulties.
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Rehabilitation, as I, understand the term,
means the adapting and training of a crip-
ple for an occupation that will eventually
prove best suited to his physical condition.
The course probably takes many months to
insure proficiency and the period of instruc-
tion entails an expense which no private
industrial organization can be expected to
assume on a large scale. The Ford plan
does not exactly coincide with the govern-
ment system but is closely related to it and
with results practically the same. Its plan
is to place a cripple on a job of such a
nature that his services immediately become
profitable to himself and to the company
and then, by all the help and encourage-
ment possible, to advance him to the limit
of his qualifications.
Occasionally opportunities for real phys-
ical reconstruction present themselves. For
illustration two cases may be cited. Both
were afflicted with deformities of the lower
extremities, necessitating the use of two
crutches, thus seriously handicapping their
usefulness. One was an old employee and
the other was hired with the intention of
reconstruction. Both were operated on by
the medical staff with the most gratifying
results. Their full faculties were regained
and the use of either crutches or canes be-
came unnecessary.
In looking over the program several sub-
jects were noted, in which our company
has shown interest.
In^ our experience, deaf and dumb em-
ployees need no particular consideration,
for the 37 working at our plant have all
proven 100% efficient.
For the past six years the Ford Motor
Company has paid particular attention to
the problem of the tubercular employee.
One physician has devoted his entire time
to this subject. His duties comprise the
examination of all suspects, the proper as-
signment of their work, instruction in per-
sonal hygiene and the proper mode of living
— and a periodical observation of their
condition. Institutional cases are sent to
the different sanatoria at the company's
expense while those who are able to work
are assigned to departments especially
adapted to their condition. A majority of
the 900 known tubercular employees work
in the Salvage Department, which includes
the carpenter shop, lumber yard and TB
shed. The latter is a specially constructed
building assigned exclusively to active
cases that are considered contagious and
a menace to the health of fellow workmen.
It might be stated that the net profits from
the Salvage Department, the employees of
which are practically all tubercular, average
$70,000.00 per month.
In connection with the subject of bed-
side and ward occupations, brief mention of
a plan instituted in the Ford factory over
a year ago may be of interest.
The great majority of Ford employees
compelled to lose time on account of ac-
cidents consists of those receiving injuries
to the feet or legs, such as fractures, severe
contusions, etc., necessitating their confine-
ment to bed. As a rule, these cases after
the first few days are free from pain and in
normal physical condition excepting for
their inability to walk about. It seemed a
' great economic loss, both to the employee
and to the company, to have men lying in
bed at home or in the hospital, sometimes
for two months or more, when, if work
could be furnished them that could be done
while in bed, the saving to all concerned
would be considerable.
At the time this experiment was stafced
we had three men in our Factory Hospital
with broken legs, one had both bones in
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both legs broken and the other two had
fractures of the tibia. These injuries were
of about two weeks' duration, the pain had
practically subsided and the patients were
able to sit up in bed with head rests. Black
oil cloth covers were provided to keep the
bed clothes clean and the men were set to
work screwing nuts on little %. by 2" bolts.
The job is one that had to be done by hand
and kept fifteen or twenty men busy in the
Magneto Department, showing that it was
work that had to be done by someone and
not a useless occupation created purposely
for these men.
From the first the patients took to it with
enthusiasm and showed their appreciation
of doing something by increasing production
on this particular work 20%. The material
was brought to the hospital morning and
noon and was handed to the men by the
ward orderly as occasion demanded. The
men were much more contented, slept better
at night, ate better and I think recovered
more rapidly. They received their regular
wages, the company got the product of their
services and was not obliged to pay com-
pensation or gratuities, which generally
amount to at least $20.00 per week in each
case.
The happy results of the system of sal-
vaging men inaugurated by the Ford Motor
Company over five years ago have been so
satisfactory, and indeed profitable, that it
has been adopted by all the Ford interests,'
including the River Rouge Ship Plant, Blast
Furnace, Tractor Plant at Dearborn and
the many Branches thruout the world. If
every large industrial concern would adopt
a similar plan, showing no discrimination
toward the disabled in the hiring of men and
using discretion in their assignment to work,
it would hardly be necessary for the Gov-
ernment to institute such an elaborate and
comprehensive plan of rehabilitation as is
now under way.
Those in charge of this great work can
rest assured that any of the 5,700 former
employees of the Ford Motor Company,
who return from service in need of recon-
struction or rehabilitation, will receive every
care and attention necessary to make them
happy and useful citizens, and if any return
totally and hopelessly disabled, they and
their dependents will not have to seek
charity beyond that of their employer who
released them for their country's need.
EXPERIENCES IN WAR SURGERY.
GREGORY STRAGNELL, M. D.,
Harmon on the Hudson, New York.
Late Surgeon at Hospital Auzilaire No. 36 and
Hospital Auxilalre No. 2, Paris, France.
Many medical men entered the American
Army during the war with the expectation
of gaining a surgical experience. They ex-
pected to learn the latest technic in the
handling of traumatic injuries, the treat-
ment of infected wounds, procedures em-
ployed in the care of fractures, the locali-
zation and removal of foreign bodies, the
plastic operations for the reconstruction of
disfiguring scars or faulty repair of tissues
and finally the reconstruction of the men
themselves by the employment of o'rtho-
pedic surgery. In a word, they expected
to become surgeons — ^military surgeons.
Some of them did. For others' it is not
yet too late.
In the majority of instances the desire
of these medical men was not fulfilled, for
the great influenza pandemic was encoun-
tered and the majority of the physicians in
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the army were doing medical work instead
of gaining the surgical experience to which
they had looked forward.
My own expectations and experiences
were in direct contrast with these. When
I entered into military medical work
in the early part of the war, it was with
the idea of doing medical work to the ex-
clusion of surgery. For a time, during the
typhus epidemic, I was occupied with what
Serbia at the moment when Mackenseii
was ready to attack. It was during this
retreat, attached to the second Serbian
Army, that I had my first enforced military
surgical experience.
I make mention of this to try and show
the difficulties which beset the physician
who is not trained to care for wounded
men. This may be called an extreme ex-
ample, for the organization of the medical
Fig. 1. Burial of an American physician during the typhus epidemic in Serbia.
is termed internal medicine and there was
plenty of work to be done. However, after
the epidemic had subsided and we had a
spell of inactivity occasioned by a lull in
operations on the Serbian front, the Ger-
mans launched their great drive. Mack-
ensen was in command and he headed a
heterogeneous army of over a million men,
composed of Germans, Austrians and the
Bulgarians, who had declared war upon
branch of the army had been shattered
during the retreat. It was impossible to
provide medical supplies, for the transport
facilities were limited to ox teams, draw-
ing springless wagons, and they were taxed
to the utmost in carrying the so-called pri-
mary essentials, food and ammunition.
k was in this retreat that I experienced
my first training in military surgery. In
this jumbled mass of mangled humanity
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there was no semblance of order. Each
surgeon with his • disorganized staff tried
to do his best in treating the few wounded
he could reach. During every one of the
seventy wild and sunless days of this fight-
ing it rained or snowed. Often from the
crest of the hill we could see the advance
guard of the Austrians or Germans as they
rode up to a newly evacuated village.
Shortly after, their light artillery would
lying on the floors dressed in uniforms and
depending upon the heat of their bodies
for warmth. Occasionally a surgeon would
be working with untrained assistants, op-
erating in the most urgent cases ; the
other medical men had retreated with their
companies. Small buildings contained
thousands of men and bedding was seldom
seen. The rooms were so crowded with
the ragged brown bundles that it was nec-
Ftg. 2. Cemetery in Serbia after typhus epidemic.
send their monotonous shells against our
new positions and our machine gun crews
would try to hold the oncoming foe at
bay, to enable the body of our army to lum-
ber away to Albania and to safety.
Retreating, we would come to hospitals —
they called them hospitals. The largest
buildings in the community would be used
for the wounded, school buildings, bar-
racks and churches. The wounded were
essary to step between the bodies in walk-
ing thru. The odors from the unwashed
men and their undressed wounds did not
rise to heaven, but remained in the sealed
rooms, for there were no stoves and very
few blankets. There was no attempt at
sanitation, the bodily refuse was not even
removed. There was no food; we did not
bury the dead for we could not proi^erly
care for the living. Then word would
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come that the Newetchke were coming.
They feared the Germans more than they
feared death or exposure, and when they
heard the news and were told that all who
were able should retreat with the army, then
the mass would untangle itself and, with
varying degrees of speed, melt into the re-
treating army. Few were left.
I have seen men who had been recently
operated upon crawl away on all fours in
the dead of night and topple over — dead-:-
a few yards away from the hospital. The
of the surviving wounded, mingled with
the hordes of civilian refugees, were await-
ing their inevitable capture.
These men were not cowards. They
fought as courageously as any of the
troops in Europe. They were not afraid
to stand up and fight the foe and often
when the bugle sounded the order for
retreat they would hold their positions
against orders and die fighting. They did
not fear death or wounds; they feared the
torture which they knew would come with
Fio. 3. Dressing the wounded in a Serbian hospital.
recollection of the first two invasions of
Serbia by Austria with the tales and evi-
dences of the atrocities which had been
committed had not been forgotten. The
invaders found an empty and devasted
country, until they reached the Albanian
and Montenegrin borders. Here the men
could go no farther for the few available
roads were choked by columns of marching
troops and lumbering artillery. Here in
this barren country hundreds of thousands
captivity. They had learned their lesson —
too well.
There is no question that, in judging
from past events, their actions were "within
the realm of reason. The atrocities com-
mitted by the invading Austrian armies
were far more brutal than any which had
been done in Belgium. It is not to revive
old hatreds that I mention these but merely
to seek a satisfactory explanation for these
atrocities and for atrocities in general. War
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is a difficult thing to analyze and some of
the acts committed when the restraint of our
so-called civilization is removed and the
lower, perhaps the true man, is revealed,
leave us with a blank response. Excuses
are made, and we always retain the more
likely of these in defending our own men,
or those more nearly allied to us.
The actions of our foes were not lim-
ited to atrocities and extreme acts of bar-
barity but would shift to the other extreme,
his way. I thought no more about it. Three
o^clock next morning he came to the hos-
pital and hunted me up in my room. He
had brought me a loaf of bread. He ex-
plained that the field ovens had arrived
and the hot loaf had just been baked. He
had crossed the line of fire and brought
me the loaf of bread. I do not praise this
man. I do not understand this act any
more than the brutal ones which I had seen.
Is it the violence of war that takes the
Fio. 4. Serbian "untrained" nurses assisting at an operation.
and acts of great kindness, as in my own
case when I was a prisoner, may be truth-
fully recorded-. The following instance will
serve to illustrate: A few hours after I
had been captured and we were still under
fire, this time from our own artillery, a
German medical officer called at the hos-
pital in my charge and asked me if I had
food. I told him we had received nothing
to eat for the past three days. He went
brakes of reason away from men and places
them beyond the sphere of sanity?
If the retreating Serbs had known that
they would not be harmed by the invading
Germans they would not have fled like
frightened rabbits. The Germans in try-
ing to teach the Belgians a lesson of vio-
lence and intimidation had learned a lesson
themselves. They had by this time come
to the realization that they could not ex-
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ploit a conquered country to the best ad-
vantage by a reign of terror. So when
they found the cowering refugees they did
their best to calm and reassure them and
transported them back to their homes so
they could live in a settled country in place
of a devastated one. They tried their best
to prevent a feeling of hatred from per-
meating the people of the country, for they
knew they could never conquer a rebellious
people like the Serbians by violent meas-
ures.
was working with them that I had my first
systematic surgical training. Professor
Franz took me in charge. He was an eagle-
eyed individual and after a grilling exam-
ination w^hich he finished with a grunt he
gave me a table alongside his own and di-
rected the work. Formerly he had been
a gynecologist in Berlin. He should have
been a detective or perhaps a burglar. He
was ruthless and looked and acted as tho
the reputation of the military bearing of
his nation depended upon him. He was a
FiQ. 5. French Medical Mission in Serbia for typhus epidemic.
It was under these conditions that smat-
terings of surgical experience came to me.
Whenever we were able, we worked
as best we could; at times we could do
nothing. There were no bandages, no an-
tiseptics. The moaning men would plead
for aid and the best we could do was to set
fractures from improvised splints made
from doors or window frames.
Finally, the Germans overtook us and it
good surgeon, but a better officer from the
old German point of view.
He operated upon heads and abdomens
only and made no discriminations between
his men and the enemy. Many of the others
did. They would not give any surgical at-
tention to enemy soldiers until they had
operated upon their own men. We were
now at a front line hospital and for several
days under fire from the Serbian artillery
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and we sent all patients to the rear who
could be transported. Supplies were com-
ing in with regularity. Most of the appar-
atus had been transported by trucks. Ster-
ilizers filled with gauze, X-ray appliances,
splints and instruments were not lacking.
One of the things advocated by Franz
w^s the use of dry sterile dressings on
flesh wounds. He did not sanction the use
of antiseptic solutions unless the wounds
were obviously infected. I never learned
the reason for this.
Some time later we were transferred to
a hospital further back. Here the work
was less hastily done and there were effi-
cient women nurses, the first I had seen
since the beginning of the war. Later, on
the western front, I saw the women of the
trained British and French nurses and they
were far superior. But from my point of
view, after seeing the nurses and surgeons
of practically all the warring countries, the
best work was done by the American sur-
geons and nurses, the difference in the
nurses being the most marked. This diflFer-
ence was simply due to training and I do
not doubt that with the same quantity and
quality of training, the foreign nurses would
compare favorably with our own. Any
diflferences in ability were not due to lack
of devotion to the work they were doing.
The keynote to the work done in the
German hospitals was characterized by ef-
ficiency, to the point of ruthlessness and
brutality. The patients were not regarded
as human beings but only as parts of the
governmental machine, the aritiy, and their
first thought was to get the men back into
shape in all possible haste so they could
be sent back to the front.
In my short stay in the various German
hospitals, I did not see any surgical pro-
cedures which were not improved upon by
the AlHes on the western front. In the
handling of fractures in the Balkan beds,
in the localization and removal of foreign
bodies, as perfected by the French, in ab-
dominal surgery, which the British handled
in a phenomenal way, in the treatment of
infected wounds, and in many other vital
branches of surgery the Allies revolution-
ized the older methods. The Germans were
content as a general rule to stick to the older
methods. They were thoro and in this way
they got the most out of their methods.
They were not slow to adopt the devices
and appliances of the Allies, but in no
instance to my knowledge did they lead
the way in new discoveries. One exception
may be noted and that is in their handling
of neurasthenic and shell shock cases.
Psychoanalysis was used in a great many
of their hospitals and their results were
extremely favorable.
The innumerable spas afid health resorts
scattered thruout Germany and Austria
made ideal hospitals for treatment of their
war wounded. Austria, in the beginning
of the war, was as little prepared for the
handling of their wounded as France and
some of the other Allied countries, and con-
ditions due to the faulty transportation
were comparable to the conditions in Rus-
sia.
It was not until I came to France in the
later part of 1915 that I was able to see
wounded soldiers cared for in a thoroly
efficient manner. I first learned how the
' Carrel-Dakin treatment was applied and
how infected wounds were successfully
combated. The method of treatment then
in vogue was to have a continuous drip,
constantly irrigating the wound in all of
its ramifications. The original idea was to
mechanically cleanse the wound and bring
an antiseptic solution in contact with the
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organism in the wound depths and not de-
stroy the new growing tissues. Later, pri-
mary sutures and the modified secondary
sutures in connection with the improved
two-hour flushing system as perfected in
the Carrel Hospital at Cowpeys were used.
I found that fractures were treated by
suspension with applied extension, in place
of immobilization by the cumbersome plas-
ter of Paris splints. This enabled the pa-
tients to move about in their beds and pre-
vented ankylosis of proximal and distant ar-
ticulations, as well as allowing for frequent
dressings without pain to the men. Pas-
sive movements and massages were applied
before bony union had taken place. This
prevented many of the deformities similar
to those already which had occurred during
the first part of the war.
Afterwards I was fortunate enough to
work with Doctor Kouindjy of the V'al de
Grace Hospital in Paris and saw how men
were trained to useful occupations, who
ordinarily would be doomed to become in-
valids.
I also studied the methods which had
been evolved for the localization and re-
moval of foreign bodies and the extraction
of missies directly on the X-ray table with
the aid of the fluoroscope. The older meth-
ods required forty-five minutes for the lo-
calization of a fragment and additional time
depending upon the skill of the surgeon,
for its removal. Experiments with various
vibratory appliances were also instructive
and in many instances this was the method
of choice employed for the accurate local-
ization of foreign bodies.
These were the three most vital branches
of military surgery and I established the
newest methods in the French Hospital Xo.
36 under my charge in Paris, where they
were applied with the aid of a very pro-
gressive French staflf and proved highly
satisfactory.
In closing I wish to emphasize one point :
The recovery of the average wounded man
depends more upon intelligent nursing than
upon any technical procedures of the sur-
geon in the operating room.
My military surgical career, beginning in
the muddy Serbian retreat, ended in a mod-
ernized French hospital, with Americanized
nursing methods and employing the latest
available methods of treatment.
EXPERIENCES OF AN OTO-LARYN-
GOLOGIST IN THE ADVANCED
SECTOR.
HENRY HALL FORBES, M. D.,
Capt. M. C. U. S. A.
New York City.
The specialist in the Medical Corps in the
U. S. Army is no longer an experiment, and
the present war has shown the necessity for
the dfvision of the work and the value of
the Medical Reserve Corps. Too much can-
not be said in praise of the men, high in
their special departments, who were able to
give their services to the organization of
these same specialties under army condi-
tions. It was pleasing to note the courtesy
which was shown to me at all times by the
members of the Regular Army Medical
Corps. The warm, friendships formed will
undoubtedly continue and a mutual feeling
of professional respect will always exist in
the future between the regular and the re-
serve medical officer.
It was my good fortune to be selected as
the surgeon in charge of the department of
oto-laryngology in Base Hospital 116, and
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to have the distinction of the change from
civil life into the actual field of war, in the
Toul Sector in the eastern part of France,
in what I believe to be a record time. Leav-
ing New York March 25, 1918, we arrived
in the French village of Bazoilles-sur-Meuse
in the Vosges Mountains April 9. Two
weeks found us not only in the war, but
a part of the military activities of the
American Expeditionary Forces, and each
responsible for his part of the medical and
surgical care of the sick and wounded. The
early days were occupied by one and all in
organizing the various departments to which
we were assigned. A clinic was soon formed
in oto-laryngology and this expanded rap-
idly. Clinic cases alone treated during
June were 277, July 695, August 962. The
latter month showed, ear cases 360, nose
and throat cases 455, ear, nose and throat
Z7, During the six months beginning June
1, and ending November 30, a total of 3,469
cases were treated by me in the clinic. This
did not include the cases treated in the
ward and tent given over to oto-laryn-
gology, or the numerous cases thruout
the hospital either seen in consultation or
treated, in ^yhom the special region played
only a minor part in the sum total of their
injuries.
The surgical equipment was most ex-
tensive and I was able to obtain such mod-
ern aids as a Baranychair, a complete Soren-
son electrical pump, giving us positive and
negative pressure with a Coffin attachment.
I was able, thru the courtesy of our Quar-
termaster, Captain W. E. Mannear, to ob-
tain transportation for a complete broncho-
scopy set, a number of mastoid, tonsil and
sub-mucous instruments, these being "per-
sonal property" and most useful. A Barany
noise apparatus taken by me was one of the
few in the American Expeditionary Forces.
The commanding officer gave to my de-
partment, as to all others, every opportunity
for thoro and scientific work. Shortly after
our arrival other units followed until a hos-
pital center was formed of seven Base Hos-
pitals capable of treating between fourteen
and fifteen thousand patients. Thru the
courtesy of Col. J. F. McKemon, M. C, the
position of consulting oto-laryngologist was
given to me for the center. The oto-laryngol-
ogists of this country owe much to the ener-
gy of this efficient officer who, by his person-
al contact, made the work of every oto-laryn-
gologist a pleasure, and who left an envia-
ble reputation as the chief of this service in
the American Expeditionary Forces.
One can easily see how the work, as out-
lined above, would be quite sufficient to oc-
cupy the time of one man, and yet, the
War Department has other than profes-
sional work for its medical officers, and for
some reason, best known to the department,
an oto-laryngologist was selected as fire
marshal for this district, covering many
square miles, on whom fell the responsibil-
ity of the prevention of fires, as well as
organizing and drilling the fire fighting
forces. This added vastly to my knowledge
of the military side of our life even if not
adding to my professional experience. The
above is mentioned to show those who are
unfamiliar with the work of the Medical
Corps, that all the time of the medical
officer is not devoted entirely to profes-
sional duties, as we understand them, in
fact for many, their entire time was of
necessity given over to the executive man-
agement of the large hospital.
To attempt to go into detail in describ-
ing my special work would be lengthy and
uninteresting. To those who ask "was it
worth while" ? I have but one answer, "yes."
The opportunity, to give medical and sur-
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gical service to those in need, and to study
the types of injuries which could only oc-
cur in a war such as we have experienced,
was unlimited. The time to compile data
was not given to me, but the opportunity
was there and the lessons taught were most
valuable. War surgery did not allow us to
adhere strictly to the line drawn in civil
hospitals in selecting our cases, especially
was this true during the big drives when
large convoys of wounded were received.
Consequently the oto-laryngolog^st found
himself in charge of most interesting bor-
der line cases, many belonging to the
domain of the brain surgeon ; the cases not
only involved extensive injuries to the soft
parts and bones of the face but "were further
complicated by injuries to dura and brain.
Cases complicated by- eye injuries were com-
mon and were taken care of in the ward or
operated upon in conjunction with the
ophthamologist. In our hospital this serv-
ice was in charge of Lieut. Harold B.
Chandler, M. C, of Boston. Facial injur-
ies with sinus involvement were frequent,
as were also injuries in which foreign
bodies were still present in the sinuses,
especially the antrum of Highmore. These
cases gave us most satisfactory results.
They necessitated frequent irrigations
and dressings, calling upon the time of
both nurse and medical officer. Cases
were seen where injuries to or destruction
of the external ear had occurred, the mas-
toid being destroyed in part, or involved in
actual opening of the skull. Gunshot
wounds of the neck involving injury to, and
destruction of the larynx in part were fre-
quent. In passing it is well to mention the
steel helmet as a contributing factor in the
protection ot the brain from a number of
injuries which would have otherwise oc-
curred, thus reducing the number of pene-
trating as compared to the non-penetrating
wounds, giving us an intact dura mater in
our brain cases, and a subsequent lessening
of infection and following meningitis.
The helmet, however, has not been a
complete protector of the head, and frightful
wounds of the soft parts and bony frame-
work have occurred, caused by shrapnel
and bullet. The early recognition of the
extent and severity of these head injuries,
practically all being compound fractures
with varying injuries of the pia mater and
brain, many complicated by the presence of
foreign bodies, gave the surgeon an oppor-
tunity for quick judgment as to their oper-
ative treatment. The teamwork obtainable
by the special staff of a Base Hospital with
a neurologist, a brain surgeon, an ophthal-
mologist, an oto-laryngologist as well as a
fully equipped X-ray laboratory, was of
great aid to the surgeons and of most de-
cided benefit to the patients. The extensive
injuries to face, involving fractures of the
superior and inferior maxillae, which at first
were treated by us in conjunction with the
dental surgeon, were later put iii a class by
themselves, and transferred to the depart-
ment of maxillo-facial surgery. I had
thought my work would give me an oppor-
tunity to study plastic surgery, but I soon
found that cases calling for this work were
of necessity transferred to the rear before
their wounds had reached the stage when
closure was advisable.
Not alone were the problems of actual
war surgery to be met, but we were con-
fronted by many of the questions so often
encountered in civil hospitals. The diph-
theria carriers, both nasal and tonsillar,
were found to exist even in our advanced
area, and a ward for carriers was set aside
in one of the Base Hospitals forming our
hospital center. Nor could we avoid the
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ever present tonsil. Tonsillectomies were
condemned by the authorities unless most
urgent. The question was so pertinent that
I wrote a short paper for a clinical meeting
entitled "The Tonsil in Relation to Army
Efficiency." Efficiency was our watchword,
and every trained soldier taken out of the
firing line was a loss, and each day counted,
making his early return become a problem
which in the case of tonsillitis had to be
faced by the oto-laryngologist. It is interest-
ing to note that in one hospital, of which
I had temporary charge, with a mixed serv-
ice representing eye, ear, nose and throat
cases, that from April 17th to May 26th
there were 1*58 patients; of these 56 were
cases of tonsillitis or % of the service. Days
spent in hospital were 281 or six days for
every case, and these added to the day oflf
duty before and after admission, increased
the loss in working days.
The disposition of our cases becomes an
important question. It was quite easy to
say, and very pleasing for the patient to
hear, the letter "D", which meant home, or
not fit for further duty in the American
Expeditionary Forces, but there were class
A, class B. 1 and B. 2, class C. 1 and
C. 2, as well as class D and we all
felt our responsibility and realized that
it was our duty to put every man into
the field of work for which he was fitted,
and where he was a factor in maintaining
the fighting forces in France. The univer-
sal feeling of the patient was "to get well
and get back for another crack at the
Boche,'' and if possible "to get" the indi-
vidual responsible for his injury.
A nearby convalescent camp was avail-
able for such cases as might be returned to
the front area in a short time. The work
accomplished in this camp was most excel-
lent.
In closing it may be well said that the
government and the individual owe much to
the specialist and his work both at home
and abroad.
MEDICAL CARE OF TROOPS IN
BILLETED AREAS IN BORDEAUX
AREA, FRANCE (BASE SECTION
No. 2).
BY
HAROLD M. HAYS,
Late Major M. C. U. S. A.
New York City.
In October, 1917, the United States had
less than 100,000 soldiers in France. In
October, 1918, we had approximately 2,000-
000 "over there". Considering the size of
the other Allied armies, one can well
imagine that the French government was
hard put to it to find accommodations for
everybody. Any sort of a shelter was be-
ing utilized as a billet from the stateliest
chateau to the dirtiest sheep-pen.
One of the largest ports of entry for
Americans into France was the harbor of
Bordeaux. The amount of tonnage dropped
there was enormous and well filled the large
reserve ware-houses at St. Sulpice where
over one hundred large buildings, measuring
fifty feet wide by two hundred and fifty feet
long were erected. The number of troops,
up to June, 1918, coming into this port was
comparatively small when one considers
Brest, and the majority of them at first were
taken care of in the more f)ermanent camps.
But then there began an overflow of troops
to the Artillery Camp at de Souge and soon
it became necessary to prepare billets for
one hundred and fifty thousand men.
The. selection of proper billets for the
men had become a very important matter
and the French government had prepared
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for just such a contingency long before the
war started — that is for its own troops.
The mayor of each town or commune had
been ordered to keep on hand a Hst of all
houses having spare rooms that could be
used by officers and a tabulation of all
barns, lofts, empty buildings, sheep-pens and
the like for use by the men. It was then
merely a matter of the army officer going
out to the town, inspecting the billets, esti-
mating the number of men the place could
accommodate, handing in his report and
waiting for the troops to come in.
The Bordeaux region was fertile ground
for the accommodation of troops as far as
the American army was concerned. None
of the towns had been occupied by the
French army in nearly four years and the
people — that is what was left of them —
had thought that they would be further un-
molested. But we had appealed to the
French government for the room we needed
and they replied by referring us to the
French Mission who supplied us with the
list of towns we could use and a French
Officer who could go around with us and
make the kindly peasants understand that
we were worth while having..
I had been attached to the Base Section
for the matter of a month, during which
time I had been detailed on various sanitary
jobs at which apparently I made good ; for
on the 12th of June of last year I was called
in to the Base Surgeon's office to take
charge of all troops in the billeted towns.
I had .no more idea what I was to do than
the man in the moon and I hardly think
anyone else did either. At first it was
merely a question of passing on the sanitary
condition of the billets in a few towns but
the work expanded so rapidly that within a
short time it was necessary to have a certain
nurriber of assistants.
Our chief difficulty in the beginning was
to make the French understand that what
was good enough for a French soldier was
not necessarily good enough for an Ameri-
can one. In the first place the space allotted
to a French soldier measures approximately
eighteen square feet — three by six feet —
and the estimates for payment for space
had to be made accordingly; but it would
have to be a very small American to crawl
into a space that size. However, according
to French law, we had to pay a sou a day
Fig. 1. The author at Biarritz. Sept., 1918.
(about one cent) for that much space and it
didn't make any difference whether the
space was in someone's attic or in his wine
cellar. The officers were usually quartered
in separate rooms in beautiful chateaux and
if a bed came with the room, the charge to
our Government was a franc a day.
As soon as I saw what my work was to
be. I made up my mind that it would be
necessary to lay down a systematic plan so
that we could keep track of the towns seen,
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the number of troops each one would take
care of, the general nature of the billets,
distance from rail head, the quality of the
drinking water, bathing facilities and the
distance from the nearest hospital. This
data was put in the form of a preliminary
survey and kept on file.
The next important matter was to draft
sanitary regulations which could be given
to the commanding medical officer on his.
arrival for I felt almost sure that his knowl-
edge of sanitation as practiced abroad was
practically nil. Conditions were far differ-
troops and therefore the following points
are brought to the attention of the Medical
Officer :
SANITATION.
1. Latrines, Pit latrines should be dug
six feet deep if possible. Latrine boxes of
four holes each will be found in each vil-
lage to be occupied by troops and the size
of pit should conform to the dimensions of
the boxes supplied. Latrines should be
placed near billets holding the largest num-
ber of men and at least two hundred yards
away from kitchens and wells. Burlap, tar
paper or wood will be supplied for latrine
housings. Crude oil, sprinklers and straw
will be supplied in large, enough quantities
Fig. 2. Camp Hospital 79. Chateau at St. Andre de Cubzac usei for the 86th Division.
ent than at home, supplies could not be
gotten so readily and a man would have to
depend on his own ingenuity to supply
things that had always been at hand. So
before the troops began to arrive I drafted
the following sanitary regulations which
were later known as our Memorandum No.
8- June 18, 1918.
FOR MEDICAL OFFICERS OCCUPYING NEW
BILLETING AREAS.
Inspection of new areas has shown that
they are clean and sanitary. More care
must be used when such areas are used bv
to burn out pits. daily. Oil should also be
sprayed around latrines. Covered racks
for toilet paper should be placed in each
latrine. Two public latrines will be built
near main highways with signs indicating
their locations.
2. Urine Cans. Two cans will be sup-
plied to each battery (or company). They
should be used in billets only at night, and
taken away early in the morning. They
'should be emptied into latrine pits or a
special sump and a small amount of crude
oil placed in them after washing. They
should then be placed in latrines for use
during the day.
3. Horse Lines and Manure Dumps,
Xo horses should be placed in men's billets.
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The' horse lines should be at some distance
from kitchens. They must be inspected
daily and particular care taken to see that
manure will be swept and piled neatly. A
great deal of this manure will be removed
once or twice a day by civilians but too
much reliance should not be placed on them.
Suitable dumps must be found at least 400
yards from kitchens and billets.
4. Refuse and Garbage, It is particu-
larly important to see that billets and
grounds are properly policed. All refuse
should be burned as soon as possible. Six
garbarge cans are supplied for each kitchen.
A neat wooden stand should be made for
cans. It should be 6 feet long by 2^ feet
should be found or built. Ice-boxes may
be supplied or built. It is of the utmost im-
portance that daily inspection of kitchens,
mess halls and grounds be made. All
meat should be thoroly inspected daily.
Fly traps or screening for same will be pro-
vided.
6. Drainage. Kitchen waste water must
not be distributed over grounds. Sumps
which will trap the. grease can easily be
made.
7. Incinerators. Small kitchen inciner-
ators should be built in connection with each
kitchen to take care of the excess solid gar-
bage and waste from kitchen and around
billets.
Fig. 3. From left to right— Lt.-Col. Phelan, Major Gradle, Lt.-Col. Coburn and Major Thompson.
wide and should stand at least 18 inches
from the ground. The solid garbage should
be separated from the liquid. This can
readily be done by making a sieve out of
half a coffee barrel in the bottom of which
are bored half-inch holes. Four wire
handles can be made to hold the sieve in the
top of the G. I. can. The solid garbage can
then be emptied into a special can. Tin
cans should be collected separately, flattened
out and burned. G. I. cans should be kept
scrupulously clean both inside and out.
Some of^ the garbage may be collected by
civilians under supervision. The rest
should be burned. Liquid garbage may have
to be taken care of in a special sump some
distance away.
5. Kitchens. Kitchens should be located
near pumps or wells. Prop)er storeroom
8. All Drinking Water Must Be Chlo-
rinated and Placed in Lyster Bags. Most
of the wells are in good condition at present
but with the incoming troops usmg pit
latrines extra care must be taken. Wells
marked "not suitable for drinking pur-
poses'' should never be used.
9. Milk. Experience has shown that
the fresh milk in this region is not suitable
for drinking.
MEDICAL INSTRUCTIONS.
'1. A suitable building to be used as a
Hospital or Dispensary will be found in
each town.*
2. All cases which cannot be treated at
Dispensary or in billets and needing hos-
pital attention will be sent to Base Hos-
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pital No. 6 at Talence. If transportation
is not available, ambulance will be sent to
Infirmary on request of Medical Officer by
telephone.
3. A prophylactic station must be es-
tablished at once in each town in which
there is a medical personnel. Notice of its
location should be placed on the bulletin
board of each battery.
4. In case of doubt as to Sanitary or
Medical Regulations, it is suggested that
you confer with the Base Surgeon's office.
Henry A. Shaw,
Colonel, Medical Corps,
Chief Surgeon.
Shortly after the inspection of the first
towns in the Gradignan-Cestas region, some
Artillery Regiments moved in and our
troubles commenced at once. Everyone
was green and unfortunately the Medical
Officers had lived in luxurious camps over
in the States and had little knowledge of
practical sanitation, particularly as it was
practiced in France. Fortunately the water
supply was fairly good and the regulations
were very strict about the use of Lyster
bags. Yet men would go to the wells to
drink no matter what the regulations were
and to make matters worse they began to
fill up on the rotten Z'in hlanc and vin
rouge which these villagers supply. It is
a beverage that is not fit for an American
stomach unless taken in small doses in the
beginning. Moreover the men were not
used to sleeping in quarters such as we sup-
plied them with. All we could give a man
was a certain floor space and the promise
that his tick would be filled with straw as
soon as we could get it to him.
I had arranged with the Quartermaster
in Bordeaux that all billeted areas should be
supplied with sanitary material such as
latrine seats, G. I. cans, urine cans, crude
oil, etc., before the troops came in. And
while the number of tow^ns to be used re-
mained small, this was easy enough to do.
But the time soon came when he felt that
too much material would be stored away
and so he waited until we heard that troops
were coming in before placing out the things
that were needed. Considering the scarcity
of everything abroad, this was a wise pro-
cedure from his point of view but often it
meant that troops were in towns one or two
days or longer before they got the things
that were actually needed.
On the arrival of an organization, I
would immediately go out to interview the
Medical Officer in charge and see that he
understood what was required of him.
Most of them I found to be very intelligent,
perfectly willing to learn and extremely
anxious to take good care of their men.
The ability to do this depended a great deal
on the cooperation a medical officer could
get from his line officers most of whom, I
am glad to say, knew the sanitary end of
the game very well. I cannot commend too
highly the excellent work of Major English
of the 60th C. A. C. who was able to get re-
sults mainly thru the encouragement he had
from his fellow officers. His kitchen was a
model for the field and met every require-
ment admirably.
However, there were some officers whom
I interviewed who seemed unable to under-
stand the essentials of sanitation. They
were given drawings and explanations
galore and promised to do everything, but
the next time I came around, things were as
bad as ever. Numerous excuses were al-
ways given but excuses do not go in the
army. At times it was hard to be diplo-
matic and keep my temper particularly
when I got hold of a man who thought he
knew more than I did and tried to teach me.
I recall one instance where I came up
against an officer who had placed his kitchen
against a French house within ten feet
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393
of a manure pile. The flies were there in
millions, first feeding on the manure and
then on the food of the men. Moreover
his own latrines were within smelling dis- '
tance. When I remonstrated he tried to
tell me that if I would get him some muslin
to cover the eatables, the flies would not be
able to get at them. It never occurred to
him that it might be possible to remove the
manure and place his latrines some distance
away. I insisted on his carrying out my
orders but it was only when I informed
him that I was going to take up the matter
with higher Authority that I got the results
I wanted.
The Base Surgeon's Office in Bordeaux,
under the able administration of Col. Henry
A. Shaw, was extremely anxious that the
incoming troops should have the advantage
of being taken care of in the best manner
possible. First came up the question of in-
specting the town to be used. Then arose
the problems of supplying the organizations
with proper sanitary supplies and medicines
and finally the careful supervision of the
territories to keep them constantly in a
healthy condition so that with the change
of organizations, there would be no danger
of spreading disease.
We have already spoken briefly of the
sanitary supplies needed. The chief things
to consider were the proper placing of la-
trines with the obtaining of fly-proof boxes,
and the disposal of garbage and waste. One
only has to be around a camp for a short
time to realize how necessary it is to super-
vise such matters carefully; for the health
of the troops, particularly in summer time,
is in direct proportion to the amount of
filth. This fact was demonstrated in the
American camps over and over again. It
is bad enough to come into a French village
where manure is prized so highly that the
inhabitants will go into the streets with a
pail in hand and pick it up out of the
road, but when one adds to that the excess
garbage from kitchens that feed thousands
of men, he can get an idea of the situation
that presents itself.
As the climatic conditions were prac-
tically the same all over this region, it is
reasonable 'to suppose that the number of
flies and the consequent spread of disuse
depended upon the local conditions. In a
town like St. Jean de Lac where a large
Artillery organization was stationed, the
flies were comparatively few and therefore
this Regiment had little diarrhea or dysen-
tery. The kitchens were placed out in the
open where they were kept scrupulously
clean. The latrines were more than the
required distance away and as the latrine
boxes supplied were not fly-proof, the men
set to work to make their own. The urine
cans that were placed in the latrine housings
were well covered with prude oil and a
soldier was placed on guard at each latrine
to see that the men put the seat covers down
and that they kept the place clean; Sumps
for the collection of liquid garbage and
grease water were properly built according
to the plan I gave therp, a drawing of which
appears as Fig. 4. No material is needed for
this sump and if proper care is taken, it will
last for months. Moreover most of the
men were placed out in "pup tents" so that
they did not have to use undesirable billets.
Now let us view the opposite case. An
organization of the same size was located
but a short distance away. The Medical
Officer was careless and could not get the
cooperation of his line officers. The kitchens
were located behind French houses some-
times within a few feet of an old French
privy which had not been cleaned out in
years. Alongside of one kitchen was a
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road which the cows used going to and
from the bams and on which they would
deposit their dung. No one would clean
this up. The latrines were located near
the kitchens and were far from fly-proof
and no one was around to see that they were
properly used. Either a seat cover would
be thrown back or would be off its rusty
hinges and toilet paper would be flying
aro^ind everywhere. There was hardly a day
that we would not get a report of from five
to twenty cases of diarrhea or dysentery.
I had to inspect this organization frequently
and never did I see it in the sanitary condi-
tion that it should have been. Two or three
solids and liquids. A coffee barrel was
sawed in two, holes bored in the bottom,
suitable wire handles attached and this
was placed inside the galvanized iron gar-
bage can. The garbage was thus strained
and only the solid taken way, the liquid be-
ing thrown into a sump. Sometimes I f oimd
that the civilians did not come regularly for
their garbage, so I suggested that instruc-
tions be given them that they could have it
only if they came at meal times in order to
keep it from collecting around the camps.
The billeted area spread rapidly so that
we had under our control ev^ry town and
hamlet within twenty-five miles of Bor-
Tin can drain
Burlap screen
J'
Fig. 4. Special sump for kitchen grease (cross-section).
times I had explained to the Medical Of-
ficer the way to build a grease trap but it
suited him better to dig a big hole in the
ground in which the kitchen police threw
everything from a shin bone of a cow to
empty, greasy tomato cans. Meanwhile, the
flies had increased to so great an extent
that we could no longer use the town for
other troops.
Most of the garbage was collected by
civilians who need it badly for their pigs.
At first the solid and liquid garbage was
given away but I soon learned that the
people who took it in their narrow ox-carts
were likely to slop it along the roads, so
I devised an arrangement for separating the
deaux. After the first experiment with the
Americans, the French people got to like
them so well that they were disappointed
when a town was emptied. During the day
the men were kept drilling and otherwise
occupied. They swept the towns clean and
showed the French the value of cleanliness.
They played with the children and helped
the women with their work. At sun-down
the band would get out in the village square
and play for an hour or so. Every peasant
for miles around would get there somehow
and with a smiling face would show the
pleasure he felt at having les soldats
Americans there. At night the men would
quietly go to their billets and the peace of
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the little hamlet would be undisturbed un-
til morning.
One can well imagine that the labors of
our office were increased considerably when
many of these villages began to be occupied.
The problem of evacuation of sick to the
nearest Base or Camp Hospital became a
serious one. In each town we had attempted
to find a suitable building that could be used
as a Regimental Infirmary but oftentimes
the places selected were far from ideal.
Moreover, most of the organizations had lost
their medical equipment or it had been
taken away from them at the Port of De-
barkation where they were told that they
need not worry as they would always be
where they could get supplies. As I knew
the necessity of conserving supplies and
that at the same time these billeted organi-
zations could not get along with the little
they had, I made up a unit box of supplies
to meet the emergency with which they
were able to get along very well. We
could not attempt to take care of the seri-
ously sick and major operative work was
out of the question. We had an ambulance
call each morning at each of the Infirmaries,
but if an emergency case came up at night
we were up against it for most of the or-
ganizations were without transportation of
any kind. They did not even have a motor
cycle and passenger automobiles were a
luxury not to be thought of. I recall one
night when two cases of appendicitis oc-
cured in one regiment about fifteen miles
from town. The Medical Officer could not
get a Base Hospital on the telephone or
telegraph because the offices closed down
at six o'clock. He had no transportation
of any kind. He sat on the side of the road
for hours, hoping that some kind of a ma-
chine would pass. Fortunately a French '
taxi came along and with the help of the
driver and twenty dollars he got his patients
into town. Needless to say he never got
his money back. On account of this lack
of transportation, it was extremely difficult
to carry out proper sanitary regulations
for the companies or batteries were sparsely
spread out and in one instance I know that
the Medical Officer had to walk twenty
miles a day to cover his ground.
However, our problems were compara-
tively simple until the "flu" epidemic
reached us about the middle of September.
I had been detailed to Biarritz to take
charge of the Officers' Convalescent Hos-
pital there. Peremptory orders came for
me to get back to the office in Bordeaux as
the 86th, 84th and 34th Divisions were re-
ported to be on the way to our Base Section
and were to occupy territories north, east
and south of Bordeaux. The 86th Divi-
sion had come into St. Andre de Cubzac be-
fore its advance party and when I struck
them they were running around like a lot
of lost sheep. They had been hard hit by
the influenza epidemic on the way so that
some of their men had died at sea and
others had been left at hospitals along the
way. To make matters worse they had ar-
rived during a spell of rainy weather and
so it had been impossible to issue dry straw
to the men, many of whom had been
drafted less than three months before. As
soon as they came into a town, they would
throw themselves down on the damp floors
with the result that before long a goodly
number were down with temperatures.
I visited one regiment where out of twelve
hundred men, twenty-five per cent, reported
at sick call one morning with temperatures
of over 101. Of course not all of them had
influenza but enough of them had it to
make us worry.
The 84th Division had been sent to a new
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billeting area between Montpont and Peri-
geux of which I had never heard. Ap-
parently this region had been surveyed by
G. H. Q. (at Tours) and no notice had
been sent to us that it was to be used.
The only way that I found out that men
were there was when I happened to pass
thru one of the towns on a tour of inspec-
tion. You can imagine my dismay to find
out that I, at least the Base Surgeon's
Office, was to take care of thousands of
troops for which we were not prepared.
This leads me to a criticism that I often had
occasion to make. Instead of General
Headquarters realizing that they had re-
sponsible men in their various sections
whom they could trust implicitly, they very
often sent officers down from Tours to work
independently on exactly the same problems
we were engaged upon. Sometimes this
duplicated the work and at other times it
lead to serious embarrassment, as for in-
stance when I was sent out to pass upon the
suitability of certain buildings to be taken
over as hospitals. I would report that a
certain schoolhouse was not suitable and
have the report telegraphed to Tours. Then
a yoimg officer would come down and, after
his inspection, make an opposite report.
Either I was to be relied upon or else I
wasn't fit for the job. In this instance,
as long as I had been placed in charge of
the billeting work in that Base Section,
Tours should have left their hands off. As
it hapf)ened, no one knew who was respons-
ible for that area being used, with the result
that a re-inspection had to be made by our
office after the troops were already quar-
tered in towns that were not half large
enough to accommodate them all. If the
Division had come in at any other time, all
might have been well ; but they also had
been hard hit by the epidemic and it was
many a day before we were able to get
things straightened out.
Major William L. Moss, the epidemiol-
ogist of our office, and I went out to visit
the various regiments and finally agreed
on certain points that are contained in an
exhaustive report of his submitted to the
Chief Surgeon, Base Section No. 2 on Octo-
ber 8, 1918. This was based on our obser-
vations in the 86th Division and was sup-
plemented by the report of Lieut. C. A. L.
Binger who was sent otit to study the situ-
ation in the 84th Division. Out of about
23,000 troops Lieut. Binger found approxi-
mately 1,100 cases of influenza in five of
the organizations out of thirty-four. His
advice is incorporated in ^ the following
memorandum of the Division Surgeon :
TO LIMIT THE SPREAD OF SPANISH INFLUENZA
AND BRONCHO-PNEUMONIA.
1. All soldiers complaining of chilly or
feverish sensations, headache, backache or
general bodily pains, especially if they
have a temperature of 99 degrees F. or over,
should be immediately segregated from
their fellows.
2. Men should be ordered to cough,
sneeze and spit in their handkerchiefs.
3. Overcrowding should be constantly
guarded against and whenever possible pup
tents should be used.
4. It is more important for Medical Of-
ficers to keep constant vigilance on the well
than to spend all their time on the sick.
THE REPORT ON PREVENTIVE MEASURES IS
INTERESTING.
For the purpose of recommending pre-
ventive measures a tour of inspection was
made. Most of the chief billeting centers
were visited.
In some cases billeting conditions ap-
peared satisfactory. For example, at St.
Astier some of the troops were quartered
in great concrete sheds open at both ends
with dry concrete floors and ample access
of both sun and air. Headquarters com-
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397
pany were in dry, open sunny barns with
40 square feet of floor space for each man.
It is to be noted that this regiment had the
lowest disease incidence.
The highest was among the 309th Engi-
neers at St. Germain, where 236 cases and
2 deaths have already occurred. Here the
billeting conditions were shamefully poor.
Damp, dungeon-like cellars with no sun-
shine and no possibility of ventilation and
floor space less than 12 feet per man were
used.
The 338th Infantry, where the infection
is increasing, were housed at Montpont
where were small, dark, damp stone quar-
ters with no access of sun and no possibility
of ventilation. Here the Regimental Sur-
geon had moved the sick out into individual
shelter tents. These men were questioned
during a rain storm and had no complaint
from cold or wet.
It was obvious that a high morbidity rate
and poor billeting conditions went hand in
hand. The Inspector General was in per-
fect agreement and independently recom-
mended to the Commanding General that
the troops be put out in shelter tents.
Recommendations were made to the
Division Surgeon that all billets that did
not afford 40 feet of floor space per man,
had no access or direct sunshine and did
not have at least two portals for ventilation
should be condemned and men moved into
other billets meeting these requirements or
into shelter tents.
At first men who were seriously ill were
transported to the nearest Camp or Base
Hospitals but we soon discovered that more
complications, like pneumonia, developed
among the patients who were moved than
among those who were taken care of locally.
Apparently what the men needed more than
anything else was plenty of fresh air,
warm blankets and nourishing food — ^all
of which could be supplied them locally.
So I arranged that each town be provided
with a hospital tent large enough to care for
twenty patients and immediately set about
to find a chateau in each locality that could
be converted into a Camp Hospital. A cha-
teau near Perigeux took care of the 84th
Division and at St. Andre de Cubzac, we
took over the Chateau de Bouilh for the
sick of the 86th Division.^ After that in
less than no time we had the epidemic under
control and I am sure the number of cases
of pneumonia that developed and the num-
ber of deaths compared very favorably with
the number in the States. It was a noted
fact that the complications invariably oc-
curred in men who were less than three
months in the army.
When one takes into consideration the
rapidity with which the work had to be
done in France under handicaps that it
seems almost impossible to surmount, he
cannot help but feel that our soldiers were
taken care of remarkably well. Almost
without exception extreme conscientious-
ness was shown by the Medical Officers who
deserve a great deal of credit for what they
accomplished. And here again, let me say
that if it had not been for the open-minded-
ness of the "Regulars" who were more than
willing to meet us half-way, we would have
fallen down badly. As it was, the most
cordial cooperation was apparent and many
a suggestion of a "Reserve" man was im-
mediately taken up.
2178 Broadway.
Special Wounds. — ^When a portion of
the flesh is completely torn away, dress
daily with wet dressings until granulation
is well started ; skingra*ft if necessary. When
tissues are so injured that they will slough,
keep on a wet -dressing and trim them away
as they are ready. You will thereby (a)
avoid sepsis; (b) get a minimum of bad
odor; (c) have little or no pain; (d) pro-
mote rapid healing. — International Jour, of
Surgery,
» Fortunately the 34th Division did not arrive
in the La Brede area until long after the Divi-
sion Surgeon, Lt-Col. CofHn, was able to suit-
ably provide for them.
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REGIMENTAL MEDICAL WORK.
BY
DONALD MINER, M. D.,
Late Major, M. C, U. S. A.,
Jersey City, N. J.
It seems scarcely possible that anyone
could be interested in regimental medical
work other than that in action. The daily
inspection of men, quarters, kitchens and
latrines, the training of hospital corps men
and the other details that fill in the time of
a regimental surgeon do not sound at all
interesting, yet they are tremendously im-
portant in the building and welding into a
unit of the 3,700 officers and men that make
up a regiment of infantry. I doubt if
there is anyone whom the Commanding
Officer is more pleased to see wideawake
and reliable, than the surgeon.
Sanitation was greatly emphasized in the
American army and many are those who
have been "canned" for delinquencies
therein, from platoon commanders to regi-
mental K. O.'s. If then the regimental
surgeon could keep battalion and company
comnlanders on the job and give results
without disturbing the Commanding Officer,
that surgeon was making good. By cajo-
lery, by threats and by merely suggesting
and advising it was done and only results
counted.
The system most commonly used in
camps in the States was the daily inspection
by the surgeon of as much of the whole
regimental area as he could cover and of
each battalion by the battalion surgeon.
Reports were made in writing to the sur-
geon by the battalion junior and copies to,
or a verbal talk with, battalion and company
commanders. The greatest responsibility,
however, rested with the surgeon and he
was distinctly not on the job if an unsatis-
factory condition remained uncorrected
more than a day or two unless he had made
recommendation thereon to the K. O. The
division sanitary inspector with his keen
eye and inquisitive mind would quickly find
some of the following if they existed : un-
clean kitchen knives, cooks not in uniform,
ice-box with an odor, improperly balanced
menu, food inadequately protected against
flies, cracks in table containing food debris,
latrines not oiled, area inadequately ditched,
etc., etc. It makes me smile now to look
back on those reports and how important
they were to life then. To have a clean
camp, a low morbidity rate and a low vene-
real rate was the pride of every regimental
medical officer. We spoke with great glee
at mess after the weekly "short arm" of the
low venereal rate and I fear that many men
were given "light duty" with the connivahce
of the company commanders, to keep down
the non-effective rate, particularly if an-
other regiment in the division were ap-
proaching our good mark.
To be really successful at his game the
regimental surgeon and his juniors had to
be more military than professional. He
should have the respect of all and it was
necessary to know the Blue Book and the
customs of the service to hold to it. I have
seen more than once, a sanitary detach-
ment present a better alignment at review
or in "march past" than the rifle companies.
The wise surgeon, with the consent of the
regimental commander, weeded out his
hospital corps men, choosing carefully from
the companies, on the plea, and correctly,
that in action they would often work alone
on the field and must be competently intelli-
gent, yet big enough to be capable litter
bearers.
In France, nearness to the enemy made
other matters more important than sanita-
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399
tion. There in the trench work in
Alsace the surgeons' principal worries
were quick first aid and evacuation of
wounded and such things as supplies of
A. T. S. splints, etc., care and proper main-
tenance of Lister bags, details for raids, etc.
It was fine preparation and schooling on a
small scale for the work later, the big work
in the Meuse-Argonne.
Surely the tables of organization will
be rewritten some day and I imagine that
every M. O. who has done regimental work
in severe action is mighty curious to see
what changes will be made. That there is
room for improvement few will dispute I
believe, and I do not doubt that within an-
other year we would have made many of the
changes that the British and French had
found wise and profitable.
We "jumped off' from the old French
first line trenches, attacking northward, par-
allel with the Meuse, over a terrain of for-
ests and steep ravines that made evacuation
at times a critical problem. I believe the most
important points were to keep everyone in-
formed of the axis of liaison, the ambulance
company in the rear and each battalion med-
ical officer and enlisted man; secondly, to
keep a battalion aid post centrally estab-
lished and to attempt nothing more there
than the first-aid packet if not already ap-
plied, splints as necessary, and the import-
ant hypodermic of morphine, doing tags
only as time was found, but the greatest im-
portance rested on speed in getting the
wounded back. In order to do this most
effectively when the line was temporarily
stationary, advanced company posts were
made, generally at the company P. C. When
pushing forward, the battalion detachment
was to follow with the support companies
spread out with the battalion, having been
informed of the terrain as far as that was
possible from maps. Most emphatically
was it impressed on everyone as to the loca-
tion, or anticipated location of the battalion
aid post. From there, ambulance company
litter bearers or in some instances ambu-
lances relieved the jam.
It was appreciated before the "jump off,"
that the litter bearers of the sanitary de-
tachment would be inadequate in numbers,
so an order was obtained detailing four men
from the rifle coihpanies for that work.
This plan did not go well, ^s the company
litter bearers practically all disappeared
either to the front or the rear, the company
commanders naturally not having picked
their best men to be given to the medical
department. It was impossible to keep
tabs on them since they were not known
well enough by the medical personnel and
excepting for the great aid in litter bearing
furnished by prisoners, the battalion evacu-
ation would have fallen down on more than
one occasion.
For the information of the uninitiated I
should state that there are seven medical
officers, three dentists and fifty-one enlisted
men in the sanitary detachment of a regi-
ment of infantry. If the regimental sur-
geon keeps two at regimental P. C, the
Sgt. 1st. CI. and an orderly, it will give each
battalion two medical officers, a dentist and
about sixteen men. If the battalion sur-
geon keeps two or three as assistants at bat-
talion aid post it leaves obviQusly too few
men to act as litter bearers for one thousand
attacking troops.
Too little has been written and said of the
litter bearers in the fighting. They made their
carries under the most difficult and trying
conditions, working in pairs or fours, going
slowly and carefully thru the most intense
barrages of artillery and machine gun fire,
constant marks for snipers, unable to "flop"
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when the big ones landed near and without
that great moral help of being in with the
rest. Litter bearers also are not keyed up
to the exhilaration and excitement of the
riflemen, naturally, being unarmed, yet
brave things were done repeatedly, and
relatively very few received the awards
that were their due when those things were
given out.
We all, in regiments, envied greatly the
men in hospital work arfd their opportunity
to keep their touch and even to do new
things, yet now that it is all over we would
not give our memory of our own work
there, where things were happening, for the
most wonderful posts and opportunities
back of the lines.
SOME MEDICAL PROBLEMS OF
AVIATION.
BY
LEWIS FISHER, M. D.,
Major, M. C, U. S. A., Philadelphia.
AND
H. W. LYMAN. M. D.,
Captain, M. C, U. S. A., St. Louis.
Aerial warfare developed many medical
problems for which there was no precedent
and the Air Medical Service was forced,
therefore, to cope with many new and un-
foreseen conditions. In the beginning of the
war it was not realized that the medical re-
quirements of the Air Service were different
from those of the Line. In fact, the Air
Service was often used as a haven of
refuge for battered and worn-out infantry-
men. This was done with the supposition
that the duties of an aviator were rather
easy, since he sat in a ship which took him
around. The feeling that the physical de-
mands on the flier were much less than
those on the infantryman or artilleryman
was soon changed by the unusually large
number of casualties which occurred in the
Air Service. It became apparent that the
terrific strain of military aviation made ex-
traordinary demands upon the physical
stamina of the flier, and steps were taken to
select, thereafter, only those who, from a
physical standpoint, appeared to be best
fitted. Originally the medical care of the
flier differed in no way from that of the or-
dinary soldier. He was simply regarded
as a member of the same general organiza-
tion. Experience soon demonstrated that
each aviator was a fighting unit in himself
and any defect, therefore, physical or other-
wise, affected not an individual but an en-
tire "combat unit" of the Army. This was
especially true in the early part of the war
when aerial warfare consisted of one
aviator fighting one other aviator. Profit-
ing by the experience of the Allies, the Air
Medical Service of the United States Army
adopted as its keynote the study and treat-
ment of the aviator as an individual. The
activities of the Air Medical Service
naturally subdivided themselves into three
groups: Selection, Classification and Main-
tenance.
Sdection. — In the selection of the
flier it was deemed advisable to accept only
those who possessed the very best physical
and mental equipment. It was easy to
maintain the highest standard because of
the large number of volunteers of the very
best type who were making great efforts to
enter the Air Service. A high standard
was set, not for the reason that only such
highly qualified men could learn to fly, but
rather to avoid the waste and delay which
the training of men of a lower standard
might entail thru their breaking down under
the terrific strain of military aviation. The
candidate was required to withstand the
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most searching physical examination in re- As a result of the system of Physical
spect to his nervous, cardio-vascular, respi- Examining Units, there was always avail-
ratory, genito-urinary and muscular sys- able for training an ample number of men
tems. In addition, his eyes were to be prac- physically qualified for any demands which
tically perfect, his ears, nose and throat military aviation might make. Possibly a
without any noticeable defect, and his ves- few men were rejected who might have
tibular apparatus normal. become good fliers but, if so, their number
This work of selection was done by was far too small to affect in any degree the
Physical Examining Units organized in efficiency of the Service, however great the
various universities and hospitals by espe- disappointment of the individuals concerned,
cially trained officers of the Air Medical While a more or less perfect physique was
Service. The volunteer physicians on these one of the absolute requirements in a can-
units were specialists in their various didate for the aviation service, that of itself
branches, selected solely on their qualifica- did not assure his admission. After the
tions for this work. Thirty-five of these Physical Examining Unit would certify an
units were organized thruout the country individual as acceptable from a medical
and later, thirty-two more in various mili- standpoint, he was referred for an exam-
tary camps. By careful standardization and ination by a board composed of educated
supervision the work of the various units practical men who considered his mental
was kept as uniform as it was humanly pos- and general fitness.
sible to do. Because of the high standard The Air Medical Service realized from
set and rigid examination, approximately the very beginning thjit no set of tests,
30% of those presenting themselves for physical or psychologic, could possibly fore-
this examination failed to comply with the cast with absolute certainty who would and
physical standard set by the Air Medical who would not make a perfect aviator. But
Service (Form 609 A. G. O.). Failure to because the training of one entailed such
meet the visual requirements was the chief a large expenditure of money and time, it
cause of rejection. The commonest eye was deemed advisable to begin at least with
defects were: as perfect a specimen as it was humanly
Lack of visual acuity 3.3% possible to choose. Re-examination of the
Defective color vision 1.0% fliers at intervals during their training dis-
Muscle imbalance 7% closed very few cases where men, who did
Defective stereoscopic vision.. .5% ^ i. , . , ,. .
All other eye defects 4% "^^ possess the physical qualities required,
had been accepted by some Examining Unit.
Disqualified because of visual Clarification.— As more powerful
defects 5.9% ^ , . ... r - .
/*' motors and improved designs of airplanes
"" aT/Kat 'dXs °! . "°" 2.0% Tl '"'r '.' "''^ ""•"^'" °^ ^^^""^
Equilibrium tests 2.0% height to which a plane could be driven, has
Cardio-vascular system 1.5% gradually been raised until now it is in the
Yn^'^.t''^' •/ •; .It^ ^'^^"'^y ^^ 30,000 feet. At heights exceed-
All other defects 1.9% • i r nnn r . • r , ,
Disqualified in two tests 7.0% '"^ ^^'^^ ^^^^ '^ ^^^ ^^""^ ^^^^ "^^"X
Disqualified in three or more ^'^rs apparently in good condition fainted
^^^^s 8.6% or became incapable of performing the co-
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ordinated movements necessary to maintain
control of an aeroplane and as a result
crashed. Medical research proved that
this physical and mental disability was due
solely to the low percentage of oxygen en-
ing apparatus which was perfected at the
Medical Research Laboratory at Mineola,
L. I., and installed at the various flying
fields (Fig. 1 ) . By means of this apparatus,
the aviator re-breathes the air contained in
B^'l
^Smj^
1
w^Si^J
p
W M
1 . ^Si
'C , ^^H
^^^^^^■InFf In^i^^
s
lfc^
v^H
miz^ai..:^^
Courtesy of the Naval Consulting Board,
Fig. 1. Re-breather.
countered at high altitudes, and it became
necessary to examine and classify fliers as
to their ability to withstand the effects of
the oxygen want encountered in this type
of flying. This was done in the United
States Air Service bv the use of a re-breath-
a tank and gradually consumes the oxygen,
the carbon dioxide being absorbed by pass-
ing the exhaled air thru an alkali. This, in
the course of 25 or 30 minutes, reduces the
oxygen to about 7% or the equivalent of
an altitude of 28,000 feet. While undergo-
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403
ing the test his cardio-vascular and respi-
ratory systems are under continuous ob-
servation and the subject is constantly per-
forming three different tasks which require
close attention, discrimination and coordi-
nation. The test is ended at the point at
which he becomes inefficient. By this and
other data obtained during the "Unit Run,"
as the test is called, the aviator is classified
as to his ability 'to fly at high altitudes. It
was found that only 61% of carefully se-
lected fliers were able to exceed an altitude
of 20,000 feet with safety, 25% were un-
able to exceed 15,000 feet, while l4% be-
came unsafe at 8,000 feet. It was also
found that constant flying caused a gradual
deterioration of the flier in this respect and
that he gradually became "stale." A pe-
culiar feature of this susceptibility to oxy-
gen want, whether caused by excessive al-
titudes or long continued flying, is that it
is not recognized by the victim himself, who
fails to realize any deterioration in his ef-
ficiency. Consequently, it became necessary
to retest fliers at stated intervals in order
to certify to the Commanding Officer only
those who were "fit." As the different
types of planes, bombers, scouts, etc., de-
veloped and military aviation became more
complicated, it was also found advisable
to classify fliers according to their adapta-
bility for certain types of work, as far as
possible. Thus it would have been unwise
to select men for scout work who could
not attain an altitude over 8,000 feet with-
out danger of fainting or otherwise becom-
ing incapable of controlling their airplane,
as this type of flying involves combats at
the extreme heights to which a machine can
be driven and requires the maximum of
mental and physical alertness at all times.
Maintcnancc^Maintenance of the ef-
ficiency of the flier at its maximum con-
stitutes the third division of the work of
the Air Medical Service. Military aviation
involves such tremendous strain on the cir-
culatory and nervous systems, in addition
to the disabilities arising from low oxygen
want, that constant watchfulness must be
exercised to detect the first symptoms of
impairment which, if overlooked, are apt
to lead to complete inefficiency and disaster.
The importance of this work can be read-
ily understood when the records show that
less than 2% of the loss of aviators has
been due to the Hun and that defects in
the plane do not at the present time account
for more than 8^ . This leaves 90% of
the loss to be accounted for by troubles in
the aviator himself.
In the United States Air Service the med-
ical phases of this work are in charge of a
specially trained medical officer at each fly-
ing field known as the Flight Surgeon,
whose duties are to act as medical advisor
to the Commanding Officer and to main-
tain the mental and physical fitness of the
aviators on the field. In this work he is
assisted by a Physical Director who, like
the college trainer, sees that the fliers get
such physical training as will keep them
in good condition. There is also provided
a nutrition officer whose duty it is to see
that the "mess" is of proper quality, to
provide a modified training table suitable
for the work the aviator is compelled to
do, and to provide for such individual cases
as may require special dietetic treatment.
The facilities of the Medical Research Lab-
oratory are at the disposal of the Flight
Surgeon for any special examination he
may deem necessary in doubtful cases. This
ready availability of expert medical exam-
ination together with the close personal re-
lationship, which is fostered between Flight
Surgeon and the flier, enables him to dis-
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ORIGINAL. ARTICLES
Ambrxcan ^aDlcatm
cover early signs of staleness or beginning
inefficiency and take measures for their cor-
rection before they can result in disaster
to the pilot.
It is of course impossible in this paper
To counteract the effects of oxygen want
at high altitudes, an apparatus was devised
by Col. George S. Dreyer for the Royal
Air Force which automatically supplies the
aviator with the necessary amount of oxy-
^n
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Courtesy of the Naval Consulting Board.
Fig. 2. "Ruggles Orientator."
to describe all the activities of the Air Med-
ical Service, but one might mention a few
of the recommendations The Medical De-
partment made with a view of reducing
that "ninety per cent." of mishaps among
aviators.
gen at various altitudes. This apparatus,
with slight modifications, has been adopted
as standard in the United States Air Service
and has given complete satisfaction. To
show the efficiency of oxygen apparatus,
it is stated that one British squadron sup-
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ORIGINAL. ARTICLES
JUNX, 1919
405
y 1
mm^
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Pig. 3. "Ruggles Orientator.'
plied with the Dreyer apparatus has been
performing six times the work of any sim-
ilar organization working without such an
oxygen apparatus.
The large number of head injuries
brought out the suggestion that the cowl
be so cut out as to give eight inches more
room in front. A report from the Royal
Air Force, Canada, states that since this
change was made injuries of this type have
been practically eliminated. Another sug-
gestion was to fasten the safety belt with
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June, 1919
ORIGINAL. ARTIGX.BS
American Medicinb
rubber shock absorbers in order to reduce
the number of injuries to the abdomen and
chest. The intense cold of high altitudes
was overcome by designing electrically
heated clothing. The eyes were protected
by suitably tinted gc^gles, so constructed
that it was impossible for splinters of glass
to be driven into the eyes.
Another problem of peculiar importance
in aviation was that of dizziness. Since
fly'"g generally entails so much swaying
and whirling, it is not infrequent that the
aviator suffers from rotational vertigo. This
is especially true when any of the evolu-
tions known as "stunts" are attempted. In
actual combat the expert "stunt-flier" has
a decided advantage over one who was not
so expert in the various gyrations of his
plane. Since rotational vertigo is a per-
fectly normal phenomenon which manifests
itself whenever a normally-physically-
equipped individual is subjected to whirling,
this phase of aviation was carefully studied
by the Otologic Department of the Medi-
cal Research Laboratory. The well known
physiologic principles that rotation with the
head held in a certain position induces ver-
tigo less distressing than similar rotation
with the head in other positions enabled
the Otologic Department to formulate
rules which, if observed by the aviators
during their stunts, nullified the disturbing
effects of the vertigo. By far the most
important thing, however, was the employ-
ment of apparatus whereby individuals
could be rotated or whirled in different
planes — all designed to simulate conditions
during stunt-flying which trained the avia-
tor to interpret properly the various ver-
tigo impressions and thus lose all sensitive-
ness to rotational vertigo.
An otologic machine, lately adopted by
this Government, known as the Orientator
(Fig. 2) enables the flier to be trained in
all sorts of aerial maneuvers without ac-
tually leaving the ground. He thus be-
comes accustomed to the whirling incident
to stunt-flying and learns to manipulate
his controls with accuracy and delicacy in
all sorts of unusual positions, such as whirl-
ing while upside down. This will greatly
shorten the time of training and- save many
lives and ships.
MANAGEMENT OF VENEREAL
CASES IN CAMP: RENDERING
INFECTED SOLDIERS NON-CON-
TAGIOUS.
BT
S. WILLIAM SCHAPIRA, M. D.,
New York City
and
JOSEPH WITTENBERG, M. D.,
Brooklyn, N. Y.
To prevent transmission of venereal
disease to innocent persons requires care
under the best of circumstances. This prob-
lem assumes great importance in camp
where many of the conveniences of home
life are necessarily absent. The necessity
of rendering the diseased men non-con-
tagious becomes manifest when we say that
804 out of 1,954 newly drafted men from
the District of Columbia and Baltimore were
found to be infected with venereal disease,
on their examination in camp. Such a large
percentage of infected men may be unusual
but was found while one of us (S.) was in
charge of the genitourinary division of a
base hospital.
Both for the purpose of lessening the rav-
ages of disease in the individual as well as
to render the men fit for active service
without being an ever-present danger to
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ORIGINAL ARTICLES
June, 1919
407
their comrades, it was necessary to check
the disuse process and to render the men
innocuous to others as rapidly as possible.
The results obtained were so favorable as
to be worthy of report.
With chancroid, the requirement was
simple; the lesion had to be healed. With
gonorrhea, the test of fitness for active
service was the absence of the gonococci
from the urethra and its adnexa. With the
syphilitic cases the problem was more com-
plex because of the likelihood of recurrence
of superficial lesions. In this group the re-
quirements were that the patient must be
free from all clinical symptoms or signs of
syphilis, continuously for three months, be-
fore he was considered fit to be discharged
from the development battalion.
The results obtained in the treatment of
acute gonorrheal urethritis were better than
those we obtained among civilians. This
may have been due in part to a slight dif-
ference in the intraurethral treatment, a
description of which may be bf interest.
The routine treatment we used in civilian
clinic and hospital was that which is com-
monly used at present. The modified diet,
forbidding of alcoholic liquors, curtailing
the use of tobacco, advice as to hygiene,
sleeping on the side with light covering to
prevent erection, local dressing of the part
so as to permit of free drainage while pro-
tecting the clothing from being soiled, warn-
ing against carrying the infection to the eyes
of the patient or transmitting it to others
were those usually adopted.
The internal medication included the ad-
ministration of antiblennorrhagics, of
drugs to dilute the urine when that was too
concentrated and to keep the urine neither
too acid nor alkaline. The favorite anti-
blennorrhagics were sandalwood oil, in ten
minim doses three times a day after meals,
early in the disease till the acute purulent
stage was past, and the oleoresin of cubebs
or the balsam of copaiba in similar doses in
the subacute stage of the disease. Alkaline
diuretics like the acetate of potash were ad-
ministered when the urine was too concen-
trated or too strongly acid ; sodium benzoate,
boric acid or sodium salicylate in fifteen
grain doses when the urine was alkaline;
these were taken well diluated between
meals. Where painful erections at night
were not readily controlled by simple meas-
ures such as pouring cold water on the part,
etc., or were so frequent as to disturb the
patient's rest, bromides were administered
before retiring, and where that did not suf-
fice chloral was given.
The routine local treatment depended on
the stage of the disease. In those cases
which presented a hyperacute inflamma-
tion, where the glans or the meatus was
swollen, the local treatment consisted only
in soaking the penis in hot water for ten
or fifteen minutes several times a day, or
the application of lead and opium wash to
the organ. In twenty-four or forty-eight
hours the hyperacute symptoms subside and
the patient is ready for systematic treat-
ment of the urethra. This consists of the in-
jection into the urethra of organic silver
preparations which seem to have a selective
action on the urethral mucous membrane in
repressing inflammation due to the gonococ-
cus, while pus is being secreted; and iur
jecting astringents to tone up and heal the
mucous membrane after the purulent con-
dition has disappeared. During the period
when the pus has been largely diminished
in amount and the discharge is becoming
more and more mucoid^ the organic silver
preparation is being replaced gradually by
the astringent injection.
The organic silver preparations which are
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June, 1919
ORIGINAL. ARTICLES
American Medicine
most commonly used are protargol and
arg>rol. The first week of the disease we
prescribe a hand injection of a J4% solu-
tion of protargol to be injected three times
a day, after voiding urine to clear the ure-
thra of any pus that may be present, and
to be retained five minutes. By the end of
the first week, the urethra has become ac-
customed to the slight irritation of this so-
lution and its strength is increased to Yz of
1%. This is continued as long as the or-
ganic preparations of silver are indicated.
By the end of the second or during the
third week, the tissues of the urethra below
the surface (excfept the urethral follicles)
are cleared of the gonococci, the discharge
has become mucopurulent and the mucous
membrane is in a state of catarrhal inflam-
mation. The protargol injections are re-
placed gradually by a simple astringent so-
lution consisting of zinc sulphate and lead
acetate, one grain of each to the ounce,
which is retained one minute. At first one
of the protargol injections per day is sub-
stituted, then two, and by the time that the
gonococci have disappeared from the dis-
charge, which is now almost entirely mu-
coid, the astringent is the only injection
used. This injection is increased in strength
after the first week to two grains each of
the zinc sulphate and lead acetate to the
ounce of water. After about six weeks of
this treatment, between sixty-two and sixty-
five per cent, of the patients are free of all
signs of the disease.
In many instances the inflammation
spreads backward into the prostatic urethra
after ten or fourteen days. The classical
symptoms of acute posterior urethritis, fre-
quent and urgent urination with tenesmus
and perhaps with terminal hematuria are
often absent. In a large proportion of cases
the only sign found is a turbid second urine,
due to flowing backward into the bladder
of the pus which is formed in the posterior
urethra. Prompt discontinuance of all in-
traurethral treatment and putting the pa-
tient to bed will usually clear up this con-
dition in a few days. If the posterior ure-
thritis persists, instillation of a 5% solu-
tion of protargol or a 1-500 solution of sil-
ver nitrate gradually increased in strength
are needed, and if the condition becomes
chronic with persistence of infiltration in
the prostatic urethra, dilatation and irri-
gations or instillations are necessary.
In camp, the treatment of these cases
differed from the above in two respects.
Every case of acute gonorrheal urethritis
was kept in bed for from three to five days.
The patients were then allowed to be up
and about in the hospital, but were given
irrigations of the anterior urethra twice
per day with a J4-1% solution of protargol
in place of the three daily^ hand injections
given similar cases in civilian life. The
method of irrigation was as follows: The
patient would stand before the surgeon
with the irrigator about three feet above
the patient's pelvis. The nozzle was applied
to the meatus and enough of the solution
allowed to run in gently to fill the urethra
without overdistending it. The tip of the
nozzle would then be drawn away sufficient-
ly to permit the fluid to escape from the
urethra and then reapplied and the urethra
filled again. A half pint of the solution was
used at each sitting. The discharge would
become mucoid in from ten to fourteen days,
after which the patient was discharged
from the hospital. The ordinary treatment
as outlined above was then continued, ex-
cept that the patient would report once a
day at the hospital for a urethral irrigation
of protargol and would use an astringent
hand injection twice a day.
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ORIGINAL. ARTICLES
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409
The result obtained with this treatment
was a shortening of the period required to
eradicate the disease to five weeks, one week
less than was required at home in those
cases who made an uneventful recovery.
The percentage of cases which resisted
treatment was the same at home and in
camp. In fact this percentage was constant
with whatever form of treatment we used,
the only difference being in the duration
of the disease ; the obstinate cases all show-
ing some underlying cause for their refusal
to heal. Examination showed in these cases
the presence of some lesion left over from
some previous urethritis, stricture tissue,
new or old prostatitis, seminal vesiculitis,
unresolved edema or congestion of the ure-
thral walls due to persistence of underlying
infiltration, granular patches, erosions, ure-
thral follicles with rigid, infiltrated walls
and filled with infectious inflammatory
debris, periurethral abscess, papilloma of the
urethra, etc., or certain congenital conditions
which interfere with healing of inflamma-
tion within the urethra such as narrow
meatus; less often hypospadias and rarely,
epispadias.
These complications received appropriate
treatment. Dilatation of the urethra re-
moved the infiltration of its walls, and the
overlying areas of edema and catarrhal in-
flammation disappeared ; this treatment also ^
broke down the infiltration in the walls of
the gaping urethral follicles and expressed
their infectious contents; it destroyed the
granular patches and encouraged cicatriza-
tion of these and of erosions. Such of these
lesions as resisted the dilatation received
other treatment. Gaping follicles were slit
open thru an endoscopic tube, granular
patches were curetted and their bases
touched with a 50% solution of silver ni-
trate and erosions were touched with a
similar solution. Urethral polypi were
curetted away and their bases touched with
a 50% solution of silver nitrate; narrow
meati were enlarged by cutting; stricture
tissue, prostatitis, and seminal vesiculitis
received appropriate treatment. The large
majority of these cases and the infectious
cases of chronic urethritis were rendered
non-contagious in eight weeks.
The requirement in the luetic cases,
as explained above, was that all superficial
lesions — those of the skin and of the mu-
cous membrane — should have been absent
continuously for three months. The treat-
ment given these cases, both in the pri-
mary and in the secondary stages, aside
from the local treatment of the chancre
when that was present, was in courses. Each
course consisted of six weekly intravenous
injections of arsephenamine and con-
currently with these,, ten injections of
salicylate of mercury in one grain doses,
one injection every five days. In ter-
tiary cases, iodide of potash was given
also. A rest of one month from all treatment
followed, and if the lesions reappeared or
the Wassermann reaction became positive
again or had never become negative, the
course was repeated. In the vast majority
of cases the patients were ready for dis-
charge from the development battalion into
their regular organizations after one and a
half courses. The course and a half lasted
about fifteen weeks, the last three months of
which the patients had been free from su-
perficial lesions.
The results obtained can be clearly un-
derstood when we say that of two divisions
of troops only about seventy-five men re-
mained in the development battalion. Also,
of some 4,500 cases of gonorrheal urethri-
tis and 600 cases of syphilis, all with active
lesions, that were sent from surrounding
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410
June, 1919
ORIGINAIi ARTICLES
American Mboicinb
camps for treatment and were under ob-
servation only three months — too short a
period for any of the syphilitic cases to be
discharged under the requirements (three
months of complete freedom from any su-
perficial lesions), about 80% of the total
or 91% of the cases of gonorrheal ure-
thritis were discharged as fit for service.
Two other points of interest may be men-
tioned: the methods used in administering
the arsephenamine, and the microscopic and
serologic findings in the luetic cases.
At first the intravenous administration of
the arsephenamine was made in concen-
trated solution, 0.6 gram in 30 c.c. of sterile
distilled water with a Record syringe. A
thousand such injections were given at the
base hospital without any marked reaction
occurring. Orders were then received from
the surgeon-general's office that arsephe-
namine be given only in dilute form, 0.6
gram in 125 c.c. or more of water. Similar
results were obtained with this method.
Among several thousand intravenous injec-
tions of arsephenamine, only five or six
cases of phlebitis and periphlebitis de-
veloped, and these occurred when new men
were put in service to administer the drug.
In the regimental clinics this standard was
not reached, but even there the results were
good.
The initial lesions were examined for the
spirochete by dark field illumination. Forty
per cent, of the cases proved positive and
sixty per cent, negative after repeated ex-
amination.
The Wassermann reaction was taken in
every case of primary syphilis, none earlier
than three weeks after the appearance of
the sore. In 35% of the patients a positive
result was obtained and 65% were negative.
In patients with secondary lesions, the
Wassermanns, taken before treatment was
begun, showed 50% positives and 50%
negatives. In very few of the patients whose
sera gave a negative Wassermann did the re-
action change to positive after provocative
treatment. Of the 50% of the patients whose
sera were positive, 30 became negative and
20 remained positive. It must be remem-
bered that the period of treatment in the
base hospital was necessarily short and fur-
ther treatment no doubt gave better re-
sults.
1847 Madison Ave., New York^
591 Willoughby Ave., Brooklyn.
THE VOLUNTEER MEDICAL SERV-
ICE CORPS.
EDWARD P. DAVIS, COL. M. C, U. S. A..
President of the Cbrps.
Philadelphia. Pa.
After the first and most pressing needs
of the Army and Navy Medical Services had
been met, attention was turned to the ques-
tion of classifying the entire medical profes-
sion of the country, to meet possible needs
in the future. It was recognized that, while
many physicians were not eligible for ac-
tive service, the care of troops in this coun-
try and the needs of the population would
make unusual demands upon the profession.
It was, therefore, determined to classify the
entire profession by securing accurate data
concerning the education, experience, effici-
ency and general standing of members of
the profession.
The inception and authorization of this
work came with the approval of the presi-
dent, from the Council of National Defense.
The office force was that of the Medical
Section of the Council of Defense. The
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ORIGINAL ARTICLES
June, 1919
411
council already had, in each State, a com-
mittee; and, in addition to these, county
committees were appointed, the duty of the
committees being to pass upon applications
for admission, verify their data and thus
secure accurate and reliable information
concerning their eligibility. An insignia was
devised, approved and adopted, together
with a certificate, and these were furnished
to members at cost.
The affairs of the Volunteer Medical
Service Corps were in the hands of a Cen-
tral Governing Board, comprised of the
Surgeons-General of the Army, Navy and
Public "Health; representatives of their
offices as executive officers, and leading
members of the profession. Meetings of
this body were held at the building of the
Council of National Defense, in Washing-
ton, as needed.
As the work developed, it was evident
that the data obtained by this organization
was the most complete and accurate in-
formation in existence concerning the pro-
fession.- The work of enrolment proceeded
steadily and, in various portions of the
country, the services of the corps were util-
ized as occasion demanded. In Philadel-
phia, members of the corps formed a con-
sulting board for service with the Red
Cross, in caring for the families and the
dependents of soldiers and sailors. Mem-
bers of the corps also served in industrial
plants.
When the epidemic of influenza de-
veloped in October, 1918, the Public Health
Service called upon the corps for assistance.
Over 400 physicians volunteered to give up
their personal work to serve under this de-
partment. In acknowledging the valuable
aid thus rendered, Surgeon-General Blue, of
the Public Health Service, stated that the
service thus rendered by the corps had been
of the greatest value and amply justified its
formation and activity.
When the armistice was signed^ the
Council of Defense, after conference with
the Surgeon-General of each department,
decided that the data already obtained were
so valuable that an eflfort should be made
to complete the classification of the profes-
sion. At that time, in round numbers,
60,000 physicians had responded to the call
of the corps ; 669^ of the medical profession
was, in some way, at the disposal of the
government. It was, therefore, decided to
proceed with the classification of the profes-
sion, and to place the completed record in
the office of the Surgeon General, where it
will be available for the needs of any de-
partment of the government, in future emer-
gency.
In August, 1918, when the Central Gov-
erning Board was making every eflFort to
completely develop the corps, the president
expressed his warm appreciation of its work
and the Council of Defense again endorsed
its activity.
No formal action has been taken dissolv-
ing the corps and those members of the pro-
fesssion who joined its ranks constitute to-
day a body of medical men who may be of
the greatest service to the government in
future emergency.
The Greatest Asset. — In these days
when reconstruction is in the mind of every
one says Brewer (Boston Med. and Surg.
Jour., June 12, 1919), we hope that in the
plans that are evolved for the betterment of
the states, our law makers will not forget
that health is the greatest asset of the na-
tion and the states, and unless the vitality
of the nation is guarded in the new laws
that are to come out of this world's war»
we will have failed **to make the world
safe for democracy."
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JUNB, 1919
ORIGINAL. ARTICLES
American Hsdicinb
THE CARE OF SICK AND WOUNDED
FROM OVERSEAS, AT U. S. ARMY
DEBARKATION HOSPITAL No. 3
(GREENHUTS).
W. J. MONOGHAN.. M. D.,
Lleut.-Colonel Medical Corps, U. S. Army.
Offlcer-in-Charge U. S. Debarkation Hospital
No. 3, New York City.
The splendid achievements of the Med-
ical Corps of the United States Army for
the past two years will be reflected upon
the after-work of the war, not only on be-
half of the soldiers but upon civilians in
every walk of life of the generations yet
to come. The results will be much more
far-reaching than mere military service.
The general sanitary welfare of the nation
will gain tremendously in the general health
of the people and the cure and prevention
of disease, as- the result of the past few
years of study and practice in the medical
and surgical branch of the military service.
The training in discipline for American
doctors as the result of their army work
in systematic methods and executive man-
agement will be instrumental in developing
the better individual equipment of these
professional men when they go back to
civilian life, and will enable them to give to
their respective communities the benefit of
their studies in the greatest clinic the world
has ever known. The same efficient mas-
tery of unfamiliar and unexpected prob-
lems will be continued for the American
people, the citizens of this country, when
these same capable and self-sacrificing
American doctors return to continue their
labors in mufti. Few persons realize that
no class of men gave up more for the serv-
ice of their country than the physicians and
surgeons who joined the medical and sani-
tary corps of the army. Many of them
abandoned practice which had required
years to build up, and in the very nature of
the case other men took their places and'
will naturally retain them. It is not so
easy for a doctor, even a specialist to "come
back." Often he must begin all over again.
The self-sacrificing and cheerful elimina-
tion of personal interests that has char-
acterized the men and officers of the med-
ical and sanitary corps will never be fully
known.
To cite an example of the extent of work
accomplished, in the operation of which I
have been fortunate enough to participate,
is the part played by the Medical Depart-
ment in the United States Army Debarka-
tion Hospital No. 3, formerly the Green-
hut-Siegel & Cooper Department Store, at
18th Street and Sixth Avenue, New York
City. Almost without attracting atten-
tion, there sprang up within 84 working
days, in the center of the business section
of the city, the largest military hospital in
the country. In some respects it is the
best equipped hospital in the United States.
The conversion of this department store
into a hospital, the installation of more
than 4,000 beds, sick room and surgical
equipment, kitchen costing $48,700, mess
hall furnishing, the largest X-ray section in
the country, laboratory, operating rooms,
dental and other special treatment rooms,
facilities to accommodate 4,000 patients,
quarters for nurses, orderlies and other at-
tendants, including hospital escort unit,
medical and surgical personnel ready for
all emergencies and all kinds of cases, and
later the manner in which it was managed
by a staff of officers in the various special-
ties, is as tremendous an achievement as
anything accomplished during the war. Its
preparation meant a complete cleaning up
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ORIGINAL ARTICLES
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413
and redecoration, if its sanitary remodel-
ing and repainting can be called such.
It is probably the most cheerful hospital
in the world. The doughboys look a
trifle solemn when they arrive, but this
vanishes after a shower bath with an
abundance of hot water and the issuing of
freshly laundered hospital clothing; and
when they gather around the billiard and
pool tables or rest their tired racked bodies
the best theatrical talent furnishing the en-
tertainment for nothing, telephone and tele-
graph facilities, and a wonderfulUy equip-
ped library.
The first patient arrived November 23
last, and during the intervening seven
months since then there have been re-
ceived from the transports and passed on
after their first land treatment, either cured
and ready for civilian life and labor, or else
The Adjutant, Lieut. A. F. Anderson, M. C. in his office at United States ' Debarkation
' Hospital No. 3.
on beds equipped with springs and mat-
tresses which a millionaire sybarite might
find most comfortable, or visit the conserv-
atory with its many couches and chairs and
grove of potted plants, phonographs, a
piano that plays itself, what more can be
asked of a roof garden which wants to be
considered a conservatory ? There are bath
rooms, reception rooms for visitors, a
theatre with a seating capacity of 1,500,
escorted to military hospitals near their
homes for further treatment or, in special
cases, to hospitals especially equipped and
planned to care for particular types of
cases, nearly 37,000 men. The greatest
number of admissions in one day was 2,235,
and the largest number discharged in 24
hours was 1,538. The greatest number in
the hospital at one time was 3,900.
The weekly food consumption of the hos-
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June, 1919
ORIGINAL ARTICLES
American Medicine
pital running at full capacity is approxi-
mately :
10,000 lbs. of beef
3,000 lbs. of lamb
3,000 lbs. of veal
7,000 lbs. of chicken
2,500 lbs. of fish
2,000 lbs. of bacon
2,000 lbs. of ham '
2,500 dozens of eggs
2,000 lbs. fresh pork and sausage
30,000 clams
30,000 oysters
600 gallons of ice cream
6,000 quarts of fresh milk
2,300 lbs. of potatoes
2,500 lbs. of butter
2,200 lbs. of cereals
18,000 oranges
1,000 grapefruit
18,000 apples
3,000 lemons
10,000 bananas
15,000 lbs. miscellaneous vegetables
20,000 lbs. bread
Etc., etc., etc.
The cost of maintenance when running
at top speed is $6.00 per minute at this hos-
pital, $8,640.00 per day.
The great number of patients, the tre-
mendous expense of medical supplies, the
pay of medical personnel, nurses, orderlies,
cooks, military guards, escorts, etc., and
the policy of the army to give the men only
the very best of everything, whether med-
ical treatment, or the equally necessary
food, clothing, and quarters, is the justifica-
tion for this heavy expense.
It is, of course, necessary to maintain
discipline, and with such a "whale of a
proposition," this was no small task, for
it must be remembered that this organi-
zation comprises a personnel of 107 med-
ical officers, 306 nurses, and 961 enlisted
men, plus the great number of patients who
had to be assembled into one big, smooth
running machine; but with the aid of a
competent corps of assistants, chief of
whom is my Adjutant, Lieutenant Arthur
F. Anderson, this problem was worked out
most satisfactorily. It was accomplished
by the instillation and maintenance, by ever
watchful vigilance, of that mysterious
something called morale. Who can interpret
such an indefinite thing? Yet we know
that it is a most essential something upon
which depends the success of any organiza-
tion, whatever the status of that organiza-
tion may be. We know that it is the get-
ting the mind into a condition which will
instil into the whole being the desire for
efficient accomplishment, where the enter-
taining of a discouraging thought has no
place, and where an enthusiastic ambition to.
do duty's work for duty's sake is para-
mount. To maintain this state in an army
hospital, where the patients are on crutches
or with canes, or lack an arm or a hand, or
are less favored by the fortunes of war
and are blind, is a vital problem. Here the
state of mental depression, with distortion
of judgment, illogic reasoning and the
impatient magnification of trifles incident
to wounds or illness or delayed convales-
cence, and the subsequent subnormal con-
dition existing, brings about to a greater or
lesser degree a spirit of antagonism to dis-
cipline or anything that savors of restric-
tion, however necessary this may be for
the maintenance of order.
Immediately upon admission to the hos-
pital the opportunity to circumvent this
condition to a great extent presents itself,
for equally important with treatment, purely
medical or surgical, has been the psycholog-
ic work which we have done with the
men. In our hospital it has been no dif-
ferent from that in all the other great insti-
tutions in New York and other parts of
the country under army direction. When
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the sick and wounded arrive, one gets the
impression of great wondering eyes, thin
cheeks, soiled or creased clothing, and hob-
nailed boots. They all seem to think in
their quiet, uncomplaining, disciplined way :
"Well, here I am! what the comes
next?" To' answer that natural query
when the racked lads reach their native
land for which they have fought and have
longed and hoped for so yearningly, I make
it a practice to deliver a short talk to each
incoming contingent, extending a word of
welcome and letting them know that we are
proud of them ; explaining that we are ready
and happy to do everything possible for
them, and that the best in the world is
none too good; that if they have anything
to complain of, or if they only think they
have, I want to know it, because if I do not
know what their troubles are I will not
know how to correct them; that in this
hospital it never operates against a man to
make a complaint ; and that if he is too sick
to come to me, I will go to him. On the
other hand, we tell him if he is well treated,
to write home to his friends and tell them
so. This introduction is a big help.
In the after-treatment, we try to make
them realize that they have the country
back of them as well as ahead of them.
They know what they have done in the
field, and without coddling or spoiling
them we let them understand that we over
here know it too. They in turn send mes-
sages of reassurance to their friends and
relatives, and I am confident that when
these men reach home they will bear wdth
them for the rest of their lives an apprecia-
tion of what the army medicos did for
them. A greater service even than the sur-
gical and medical curative work is thus
performed, for if the men are dissatisfied
with army life when they arrive here suffer-
ing, depressed and devitalized, it gives a
new feeling, and this I believe is one of the
greatest cures for the social discontent and
the political unrest that are menacing the
entire civilized world.
The morale of the returning troops is in
the main satisfactory. These men, whether
in good physical condition or wounded, sick
or disabled, are happy to be home again.
The various warfare agencies and civilian
agencies functioning thru and within hos-
pitals, and the people at large by furnishing
entertainment and amusement, and an en-
vironment of comfort and hospitality have
given these men no time to become morose
or dissatisfied and are making every effort
to impress upon them that their work as
soldiers is appreciated.
On the other hand, the maintenance of
the morale of enlisted men of the Medical
Detachments assigned to duty in army hos-
pitals is different and difficult, for the rea-
son that the men know that the members of
the A. E. F. and other organizations of the
army are being demobilized and sent home
while they themselves are being held in-
definitely in the Service. The continuation
of these men on active duty is, of course,
most necessary for the reason that the hos-
pitals must be kept up and the returning
sick and wounded cared for until the last
man is sent home. Many of these men
feel that, thru no wish of theirs, they are on
domestic duty and that they are being dis-
criminated against because they are not
overseas men. It would seem that some
of the generosity in the matter of enter-
tainment to returning overseas men might
profitably be extended to the men whose
military service has been confined to the
drab routine of domestic duty without the
excitement and interest of overseas service.
As before stated, the Medical Detachment
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of our corps men, as they are called at
Debarkation Hospital No. 3, consists of
. 961 men who are ever ready for any and
every emergency twenty-four hours a day.
It is true that not all of the soldier patients
require constant attention. In fact, fortu-
nately, many of them can stroll around
with no one worrying about them or on ac-
count of them. However, actual medical
care plays a small part, from the point of
view of variety as compared with the other
duties to which the detachment has fallen
heir. Of course the hospital must be
guarded; also it must be cleaned and kept
clean. This is a daily task of no small pro-
portion, as the institution covers half of a
city block and is seven (7) stories high, has
600,000 square feet of floor space and
58,196 square feet of glass. All this the
corps men look after. It is no exaggera-
tion to state that there are at least a million
different pieces of medical and quarter-
master property in use here. Who but the
Detachment men check these up and hold
them in readiness for instant use?
When the soldier patients are received
fresh from the ships, the first step that be-
falls them is the taking away of their cloth-
ing and, on account of sanitary precautions
the sterilization of the same, followed by
the issuing of an entire new outfit. This
also the corps men attend to. Finally, the
linen and store rooms are presided over by
men of the Medical Detachment.
When it comes to administrative and
office work, here again it found the Detach-
ment man, and not infrequently it seems
that hospitals were created for no other
purpose than to provide an opportunity for
some red tape wizard to see how many
knots he could tie in the daily procedures.
Acting as assistants to the Adjutant, the
Registrar, the officer in Charge of sick and
wounded, reports, etc., the receiving officers
and the Detachment Commander, will be
found enlisted men of the medical depart-
ment. While their work is confining, tiresome
and exacting, they are at it ten and twelve
hours a day because they know it must be
done.
The mess and kitchen, with its 204 men —
cooks, kitchen police, and orderlies — also
have their important role to play, for the
feeding of 5,200 persons daily is surely a
man-sized job. During the month of
March this department served 416,113
meals. The immediate overseeing or over-
sight of this gigantic task is under the su-
pervision of Captain Carlton D. Haas, who
plans the menus for all meals a week in
advance. These cartes du jour are worked
out along the lines of the most modern
science and dietetics. Sixty-eight graduate
dietetians are in constant attendance in the
great kitchen supervising the preparation
and service of the food.
Most important is the Army Nurse Corps
of the United States Army, both of the reg-
ular service and of the Army Reserve Corps.
These are often incorrectly alluded to as
Red Cross Nurses. It has been my
privilege to watch with great admiration
the professionally efficient work, painstak-
ing and unselfish devotion of these uncom-
plaining, unselfish, self-sacrificing women,
whose patriotic zeal and desire to lend
their aid in humanity's cause has added one
more brilliant ray in the glorification of
American womanhood, and when the Great
Master remakes the heavens and resets the
firmament, may He place there one bright
star to be called the *'Army Nurse Corps
of the United States Army."
What is being done at Debarkation Hos-
pital No. 3 is simply an index of the work
of the War Department elsewhere, and that
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this effort and attention have not been in
vain is manifest in the success encountered
in recruiting the 50,000 men asked for to
replace the Army of Occupation. A few
days ago Mr. Baker expressed confidence
that the 5,000,000 men who are needed for
the permanent army would be readily se-
cured if the government continues the
policy of attracting men with educational
opportunities. The old time soldier was a
man whose ambition, if he had any, was not
stimulated. Officially Uncle Sam fed,
housed, clothed and paid him, etc., down to
medical treatment and entertainment. Again
quoting Mr. Baker: "The only way to
maintain an army in peace time is to make
it an educational opportunity." The above
words dovetail so well that they express
the purpose and attitude of the government
towards its army most admirably. "Stimu-
late ambition" and "make educational op-
portunity." These are the keynotes of an
almost perfect system. First, give a man
opportunity and then stimulate his ambi-
tion; and if he makes good, stimulate him
to further success and continued activity by
encouraging his ability and accomplish-
ments ; and this encouragement is given by
recognition, meaning promotion. Recogni-
tion of a man's service and ability is the
greatest stimulant to a man's ambition, not
the empty recognition which is required to
coax along or "salve" the path of those
who just drag thru each day doing
barely enough to justify their existence, but
the true recognition which every loyal,
zealous and ambitious man of this day
wants and deserves. Recognize his effort
and accomplishments and encourage him to
a continuance of the same, for to stimulate
a man's ambition is to make him ; curb his
ambition and the man is ruined; and any
one in the great machine who for any rea-
son, knowingly or unknowingly, curbs a
man's ambition and thereby kills his morale
and zeal by obstructing his progress in the
upward path, not only injures the individual
affected, but does so to the detriment of the
government which he is supposed to be con-
scientiously serving; for primarily the ma-
chine is being deprived of continued or even
better service which might, if not discour-
aged, be of added and material benefit.
Moreover, failure to recognize merit gives
opportunity to the opponents of the gov-
ernment, and exponents of the various
"isms," to criticize unjustifiably the system
of our government and of our army when
the fault lies not in the system, but with
those manipulating the system, the intent
and purpose of which are always to work
for the common good.
MEDICAL ACTIVITIES OF THE U. S.
NAVY UNDER ADMIRAL SIMS'
COMMAND.
HENRY REUTERDAHL,
Lleut.-Commander, U. S. N. R.
F.
Ten regular Naval hospitals were estab-
lished, four of them with more than 500
beds. In these hospitals more than 3,000
men could be cared for at one time, and
beds were so abundant that there was al-
ways room for persons not in the Navy,
such as the Army, Y. M. C. A., Knights of
Columbus, and the British Armv and Navv.
In addition, the facilities of the Naval
hospitals were extended to the personnel of
the State Department, various Government
Boards, official newspaper men, etc. One
500 bed hospital was exclusively devoted to
the care of the sick and wounded of the
American Army. These hospitals were
scattered from the extreme north of Scot-
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land, thru England and Ireland, along the
French coast and to Gibraltar.
All these hospitals had full outfits of sur-
geons, medical men and specialists, such as
orthopedic surgeons, X-ray operators, lab-
oratory men, etc. The hospitals had a large
personnel of Navy female nurses, and
the full Navy hospital ration was main-
•tained at all times. Every patient in all
these hospitals was made to forget for the
time being that he was away from his own
home.
In addition there were about 40 other
stations fully equipped with dispensaries
and beds, the latter ranging from 20 to 150.
In the main the numerous air stations
were on isolated coastal points, far removed
from any help, and the Medical Department
was necessarily made completely self-sus-
taining. In the most isolated places the
Medical Departments were fully equipped,
including complete surgical outfits, tiled
operating rooms, sterilizers, etc. The com-
pleteness of the equipment of these small
units was a constant source of admiration
and wonder to all who saw them.
On account of the hazardous nature of
aviation the Medical Departments of all
units were prepared to take care of 10%
of casualties of the entire force.
The activities of the Medical Department
were far-flung, extending from Archangel
to the Island of Corfu.
Before any locality was occupied by any
men of the Navy a thoro sanitary survey
was made, including elaborate chemical
analyses of the water, and if anything was
found wrong it was corrected, in order that
perfect health could be maintained. The
medical officers were constantly alert to
prevent the introduction of severe diseases
and plagues in the force, as there was a
constant menace of cholera, typhus fever.
Malta fever and malaria.
Large medical storehouses were estab-
lished in England and in France from
whence all the medical stores were issued to
all parts of the force. Thruout the entire
war the hospital and dispensary facilities
were at all times about double the demand.
The dead of the Navy were looked after
with a kindly spirit, and a large number
was embalmed on the spot and immediately
returned to their relatives at home. This
was done in practically all cases where local
laws or international agreement did not pro-
hibit immediate removal.
Immediately after the declaration of the
armistice, hospital ships and transports
started to return the Army sick and
wounded to the United States. This is
continuing in large numbers.
At the time of the armistice, units of
the Medical Department of Admiral Sims'
command were actively operating in ten
European countries.
RECREATION AS A MORAL FORCE
IN ARMY LIFE.
B. SHERWOOD DUNN, M. D.,
Paris, France.
History shows that one of the unvary-
ing concomitants of all great wars has been
a rapid and tremendous increase in secret
diseases to which the soldier on leave is
exposed by the congregation of lewd wom-
en in all of the great centers. By reason of
the call to arms of all the ablebodied men,
policemen as well as others, the regulation
and control of the social evil is relaxed and
soon assumes proportions that make it hard
to overcome. Our military leaders were
well aware of the existing conditions in
France and took extraordinary precautions
to protect our troops.
Nothing done by America in the great
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419
war has stupefied or puzzled the French
more than the huge expense of the numer-
ous leave areas created behind the Ameri-
can Army ; the numberless troups of actors,
singers, performers ; the cinemas, bands,
orchestras, baseball, football, games, clubs
and dancing halls; reading rooms, writing
rooms, to say nothing of the eating places,
canteens, supply depots stocked with can-
dies and many luxuries unknown to the
French soldier, as to the civilian, for two
years before the arrival in France of the
American Army. It seemed that this great
new army had come to France on a holi-
day, bent upon amusement rather than a
vital struggle of life with death and the
saving of a great cause for the safety and
benefit of future generations ; but gradually
there filtered thru the public mind an appre-
ciation, that behind all of this apparent care-
less and expensive frivolity lay a great pur-
pose for moral and physical good, directed
to the one end, of occupying the time and
attention of the soldier during his leisure
hours, and of creating- a stamina and moral
support of the fighting force.
All France is fully alive to the unprece-
dented increase in the social evil since the
outbreak of the present war, and as the
knowledge has spread that the American
Auxiliary Organizations were enlisting the
services of the leading Americans to come
to France and were expending hundreds
of millions in the effort and with the object
of furnishing constantly such variety of in-
teresting and attractive forms of occupation
and amusement as to keep our men away
from less desirable places and less danger-
ous companions, there sprang into life a
growing desire on the part of our French
friends to become a part of these forces
for good and help in every way to further
the far-reaching influences thrown out and
around the American soldier for his aid
and protection. This has resulted in a
movement thruout France, as revolutionary
as any social movement ever bom within
its borders, nothing less than the breaking
down of the barrier which from time im-
memorial has kept French family life as
safe from invasion, as any Turkish harem.
Inspired with the idea of facilitating the
acquaintance and intercourse between
Americans and the French, a group of
French people founded "French Homes" an
association to extend the hospitality of
French families to the American Expedi-
tionary Forces; the appeal of this society,
thru the press for rooms where Americans
might find comfortable quarters and fam-
ily life at reasonable rates met with instant
response thruout the whole country.
Americans who have lived in France and
know the French are aware that no homes
are more shut to the stranger or foreigner
than those of France. It is almost impos-
sible for an outsider to hope to enter their
sacred precincts, and this is one of the
prime factors that has prevented foreigners
from forming a just estimate of the real life
of the French home.
This barrier was broken down by a few
lines in the leading papers, an appeal to
French family circles for the homeless boys
whom America sent to fight for France, and
old aristocratic mansions opened their gates
wide to America's sons.
Letters flocked to the offices of French
Homes. Some of the noblest families bade
Americans welcome to their mansions,
where family Hfe would await them.
"It is little enough we can do to make
some return for all she has done for us,"
wrote a proud old duke, "but what little we
can do, let the Americans know we are
proud and happy to do."
"I have not been used to receiving perfect
strangers," writes a countess, "but all that
my home can offer will be gladly given to
help some American to feel he has a home
in France."
"I have two rooms," writes an old father.
"They were my two sons' rooms. Both
have been killed on the battlefield. I cannot
do better than offer what was theirs to two
American boys, brothers in arms of my two
heroes."
And in all ranks of society from the high-
est to the humblest the same touching trait
is to be found.
Here is a poor woman, who lives by sell-
ing vegetables, opens up her humble home
to an American boy; a writer offers to
share his "den" with an ally; an artist his
studio; here a clerk in a shop says "my
children may help to make up for a humble
lodging in making some lad feel at home
over here." ^
I but recently returned from my furlough
spent in Nice on the Mediterranean, which
has been made into one of the greatest
leave areas, and there I found an organi-
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zation of marvelous variety and efficiency.
Out in the ocean bordering the Promen-
ade des Anglais stands the Jettee Promen-
ade, a great palace built for the amusement
of the Nicois. This building has been taken
over for the American Army. Two bands
play daily in the two great halls forming
the two wings and separated by the width
of fhe main building, which contains a the-
atre, concert hall, dancing hall, where an
orchestra plays for dancing afternoon and
evening, and a great cafe filled with tables
where refreshments are served at. cost, with
a canteen supply store selling all sorts of
things including tobacco in all forms, can-
dies and sweets.
This building is exclusively for soldiers.
Officers are not received.
On the Place Massina there is a beautiful
theatre for officers with a great variety of
free nightly performances. Also the first
floor of a beautiful building consisting of a
dozen rooms fitted as a club with an enor-
mous hall for dancing that will accommodate
200 couples, where an orchestra plays from
3 to 6 and 8 to midnight. This club is con-
stantly crowded and here is exhibited a
working agreement between the army au-
thorities and local residents productive of
most excellent results.
Xo lady is admitted except by a personal
card, to secure which she must furnish her
name, address, and two city references;
this application is turned over to the local
Committee of French Homes who investi-
gate and pass upon the qualification of the
applicant. By this means all undesirable
"ladies" are excluded and as a result the
family of the Prefect, the mayor of the
city and all the leading families frequent
the club and join in helping to entertain
visiting officers. In the resultant acquaint-
ance many of these officers are invited to
the leading homes of Nice.
Now many Americans will learn to know
French women as they never knew them;
not the painted dolls they meet in places of
anmsements, but the proud and wonderful
women who helped to keep up the coura.ere
of absent husbands and sons, whose deli-
cate hands knew how to tend dreadful
wounds, whose fragile strength never grew
weary of long days beside the sick and dy-
ing in the hospitals. They will learn to
know girls as pure and sweet as those of
their own country, and, thanks to this so-
cial revolution, the time-worn prejudice
against ** frivolous French women," which
the American traveler has shown upon his
return from a trip abroad may be corrected.
146, A v. des Champs Ely sees.
CLEARING THE WOUNDED.
JOANNA WALTON HARTING,
New York City.
** Medical men never impressed me as
being such an heroic lot, but I am of a
different opinion since I worked with them
over there. They certainly showed the
stuff they are made of in the field."
It was merely as a casual remark that this
tribute to his brothers in the profession
came from Colonel Walter C. Montgomery,
the Twenty-seventh's Division Surgeon, in
the course of his warm-hearted praise for
the boys of that now famous body, which
will go down into history as the force which
smashed the "impregnable" Hindenburg
line and made the Kaiser say "enough."
It is not from the physicians and nurses
who have recently returned from duty over-
seas that one will learn of their share in
the fight for democracy. When they talk
of the war at all — ^and that is not often —
they glorify the fighting men in the field,
laud the officers who trained them to be sol-
diers, express admiration for the manliness
of the chaplains, acknowledge their debt to
the Red Cross; in short they give due
praise to every one concerned, but take little
credit to themselves. Their contribution
they seem to regard as a regulation per-
formance in the line of duty. It is only
thru the official records of heavy casualties
during days of continuous fighting, necessi-
tating day and night labor on the part of the
doctors, that one gets any idea of the service
rendered by the men in the medical profes-
sion and their colleagues, the nurses. If
their heroism be a revelation to one of their
own calling, their humility is no less a one
to the layman.
"On the day of the heaviest fighting in
the Hindenburg show we cleared four thou-
sand, and I heard but one man groan and
he was unconscious."
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This statement Colonel Montgomery puts
forth as signal proof of the American sol-
dier's grit — ^but what a magnificent record
for the doctors in attendance. Four thou-
sand men received medical attention in
one day, yet the Division Surgeon's praise
is all for the wounded men ; the feat of the
doctors is taken as a matter of course.
It was the duty of Lieut.-Colonel Lefferts
Hutton, Assistant Division Surgeon of the
Twenty-seventh, to insure the prompt evac-
uation of the wounded men from one med-
ical station to another. He worked at the
Advanced Dressing Station, which at Mt.
Kemmel was shelled out. But the doctors
were only intent on the task in hand of giv-
Miss MacDonald.
ing the best possible treatment to every
man passing thru, and of a upholding the
reputation of the Twenty-seventh Medical
Corps.
•"While we were in the thick of it we
never thought of anything but the work"
said Colonel Hutton. "The men felt worse
about being left behind and out of the scrap
than they did over their wounds. Even
the badly wounded ones would come in
cursing their luck for 'getting theirs' before
they had a chance to go further."
Colonel Edward H. Fiske, commanding
officer of Base Hospital No. 37 at Dartford,
England, to which the severely wounded
men were evacuated from France, usually
had between 2,300 to 2,400 patients with a
staff of only twenty-five doctors; yet he
never speaks of the heavy work entailed but
is all admiration for the boys and takes his
greatest satisfaction, in the success of the
operations which enabled so many of them
to return to the front or to duty behind the
lines.
At Dartford, which is on the Thames,
fifteen miles from London, the excitement
of the moment had died down, yet the men
displayed the same indomitable spirit as
they did on the field.
"When we let them know that we would
have to take off a leg or an arm" said Col.
Fiske, "they might just look at us a second
or two, rather wistfully, perhaps, and may-
be ask if we could not wait a little longer to
see if it could not be saved. That was all.
There was never an outward sigh or regret
for what they had given. Nobody can do
justice to the courage of our boys."
Miss N. Grace Bissell, who went over
with the Wellesley Unit, and was attached
to the Red Cross Mobile Hospital No. 114
spoke in a similar way.
"We would have to search for the seri-
ously wounded ; the boys would never tell.
One night I was putting a boy to bed and
found a tourniquet on each ankle. One
foot was gone, the other was hanging by
the Achilles tendon. He must have been in
fiendish agony.
"How did it happen, Buddy?" I asked.
"He could hardly speak, but he managed
to say 'I was going over the top when I fell
flat. I tried to get up and my feet were
gone, but it is alright.'
"That is just one instance" continued
Miss Bissell. "I could tell a score of simi-
lar ones."
This indiflference to wounds is cited again
by Colonel Montgomery.
"My orders to the staflf wefe *Dress the
wound a man tells you about, but then look
him all over.' It was an even chance that
another one or more would be found. Per-
haps they knew they had it but thought it
too inconsequential to mention. Perhaps
in the excitement they were not conscious
of it. Our boys fought like a pack of wild-
cats. They seemed to feel nothing until
they fell.
"Take for instance the case of vouns:
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Lieut. Schwab of the 107th Infantry, whose
whole lower jaw was blown off. He was only
a few feet from his captain, yet he motioned
with his rifle that he was going ahead.
Of course he dropped in a few seconds.
They bandaged him up on the field and he
was still conscious when they brought him
in. We clamped up the arteries, but he
died on the table. Can you imagine a man
wounded like that and still having the spirit
to go on?
**There was another boy who comes to
mind just now" went on Colonel Mont-
gomery. "He was shot thru the cheek.
Then another shot passed thru his larynx,
rendering him speechless. He went an-
other five hundred feet before a shot thru
the heart killed him.
"These men may receive citations but you
seldom get the real story of their bravery.
Only the men right at their side know it and
then they see so much of it that they take it
in a matter-of-fact way."
In a reminiscent mood Colonel Mont-
gomery turned to his old friends of the
Twelfth Regiment, N. Y. N. G.
*'You would come upon a big strapping
fellow lying there all covered with mud and
you could not realize that he was gone.
When you turned him over and saw his
face, you would know that he would never
move again."
Colonel Montgomery was silent for a
minute of two. Despite his training as a
surgeon and his experience in army camps
and on the field he has a heart as tender
as that of a child. It was evident that the
loss of his comrades had made a deep
wound. When he spoke again it was in a
verv low voice, "So many of them were my
old' pals."
Reverting to the more general aspect of
the American lad's behavior in the field he
continued, "The only thing a man ever
asked for when he was brought in was a
cigarette or a cup of coffee or chocolate.
The Red Cross was always on hand to
furnish that and whatever else was needed.
"In the Advanced Dressing Stations they
had their Primus stoves and two big urns
going night and day.
"Pain very bad. Buddy?" you would in-
quire of a horribly wounded boy.
" * Pretty bad', might be the reply.
"Want something to make you a little
easier r
" *If you have it'.
"You would never hear anything more
than that.
"It was the stoical way in which the
wounded men endured their sufferings that
enabled the doctors to accomplish what they
did. If we had to endure the groans and
lamentations which are often our lot in
civilian life it would have been mighty hard.
The courage of these men bore us up. There
was such magnificent cooperation on the
part of the men that the doctors would work
night and day, snatching a couple of hours
sleep whenever or wherever they could get
the chance.
"And right with us in the thick of the
fight and in every emergency was the Red
Cross. There was no red tape about it,
no explanations, no accounting. All we
had to do was to ask for a thing and we got
it in the shortest time it was humanly pos-
sible for transportation.
"Capt. Bobo, head of the Red Cross de-
tachment did not wait for a man to be sick
or wounded before helping him. He felt
his duty was to the man in the service
whether he was sick or well altho, of course,
the wounded men got the greater part of the
attention.
"It did not matter whether it was surgical
dressings, Greely packets, blankets or am-
bulances which were necessary, the Red
Cross was always on the spot when it was
needed.
"At Villers Fauchon we could not accom-
modate all the wounded in the M. D. S., and
hundreds were lying outside in a cold, driz-
zling rain. The Red Cross came forward
with two thousand blankets and did every-
thing to make the men outdoors as com-
fortable as possible.
"The Red Cross was a reserve on which
one could depend for anything at any time.
It was not a haphazard sort of aid. It was
a well defined, well thought out system cal-
culated to meet any emergency which might
possibly arise. Capt. Bobo was thoroly
conversant with all our plans and moves.
His detachment was composed of men who
had gone overseas to fight and for some
slight physical defect or reduced vitality
were found unfit for front line duty. They
had all the courage of the fighting men.
They were under fire almost as much as the
men at the front."
Colonel Hutton reviewed the three big
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423
engagements in which the twenty-seventh
participated with the British and Austral-
ians, and explained the procedure of the
Medical Corps in caring for the wounded.
"In the Belgium push, the Americans —
the Twenty-seventh from New York and
the Thirtieth from Tennessee — covered
nearly an eight thousand-yard line with the
British on either side. The Nissen hut
sheltering the Battalion Aid Post was about
one thousand yards back of the firing line.
It w^as to this point that the men were
evacuation hospital at Esquelbecq. Cases
that would require a long treatment were
then sent to England.
**At the Hindenburg show we could bring
the busses within fifteen hundred yards of
the firing line. The British thought our
Red Cross drivers were the most reckless of
men. The British were severely repri-
manded when they lost an ambulance, and
therefore they would not take the chances
the Red Cross men took. The Red Cross
thought more of getting the men back to
American Red Cross
Col. Fiske escorting King George.
carried from the field by the sanitary de-
tachment of the regiment. From there,
the wounded men were removed by 'hand
carry' or wheel stretcher to an Advanced
Dressing Station, one covering either flank
of the line, St. Dunstan being at the right,
Longbarn at the left. There we admin-
istered the anti-tetanus and morphine and
ligated arteries. After this, ambulances
carried the men to the Main Dressing Sta-
tion at Remy Siding, and from there they
were loaded on ambulance trains to the
the dressing stations than they did of a
shell.
"We established the A. D. S. at St.
Emilie in an old sugar factory which had
been dynamited by the Germans. The
M. D. S. was at Villers Fauch6n. This had
also been used by the Huns, but we salvaged
what we could and improvised an operating
room. On August 27 we took over two
British ambulance units, each consisting of
five Daimlers, two Fords and three horse
drawn ; but even at that, there was not suf-
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ficient a number, because the. casualties were
so heavy, and Capt. Bobo and Lieut.-Col.
Walter C. Bell made a whirlwind night trip
to Paris — a distance of 156 miles — ^and
brought back ten Red Cross ambulances.
"After finishing that job we were out of
line from October 2 until October 11. We
got a chance to get a real bath, a shave, a
regular sleep and other such luxuries.
**We went after the Huns again at St.
Souplet. In four days we moved the M.
D. S. to Busigny and established the A.
D. S. at Escaufort. The A. D. S. was at
Busigny and the M. D. S^ at Fremont,
while we evacuated to Roisel; The round
trip was nine hours, and as an ambulance
carries only four patients and at one time
there were 180 men waiting, you can im-
agine the congestion. We made the men
as comfortable as we could and there was
never a murmur. The trouble was caused
because the Huns were retreating at the
rate of ten miles a day and we had to travel
about fifteen miles a day to overtake them.
It is impossible to transport mobile hospitals
at that rate of speed. Travel was rendered
very difficult because the Boche blew up the
bridge over the LaSalle. In the Hinden-
burg show there were 2,511 wounded, sick
and gassed men and 1,266 walking wounded.
"At St. Souplet there were 255 stretcher
cases and 3,433 walking wounded. The lat-
ter were loaded on motor lorries and carried
to railhead from whence they were taken to
the evacuation hospital.
"At that time, also, the influenza epidemic
among the civilians was at its height, and
Capt. Bobo with Lieut. Theodore Reed of
Field Hospital 106 established an annex
across the road for those cases. Between
times everybody helped out.
"Yes, we kept on the job pretty steadily,
but you get used to that. Now, I think I
am just beginning to get tired. I think the
parade was too much for me,** laughed
Colonel Hutton.
Colonel Fiske, in speaking of his patients
at Dartford, said, "Naturally the men im-
proved more rapidly in England than they
could be expected to do in the evacuation
hospitals in France, where they were either
under fire or subjected to air raids. Their
nerves had a chance to grow steady again,
when they got across the channel.
"We usually received our convoys be-
tween 10 and 11 o'clock at night and nobody
ever went to bed until the new patients were
all in and settled. Everyone would turn
in and carry stretchers. The trouble we
had with the enlisted men doing hospital
work was that they all wanted to be trans-
ferred to a combat unit ; fortunately there is
an order forbidding that.
"They were just like a lot of youngsters.
As soon as they could get around they were
in mischief. They would steal away from
the grounds and cut up all sorts of pranks.
"But I think the American soldier is as
game a chap as ever walked the earth. No
matter how often we had to go at a man for
dressings or give an anesthetic for scra-
pings and that sort of thing, he never winced.
"The Red Cross kept them in wonder-
fully good humor. They conducted con-
certs, moving picture shows and all sorts
of entertainments. They supplied the boys
with all kinds of little comforts and did
not forget the doctors, either.
"I do not know what we would have done
without the Red Cross. It gave us vast
quantities of surgical dressings and other
supplies."
Touching on the more strictly profes-
sional phase of his experience abroad, Col.
Fiske said :
"We had some remarkably successful
cases of bone grafting and nerve suturing.
At one time there were forty-eight nerve
cases, all of which were operated upon.
When the men left the hospital, after two
or three months, thirty-eight of that number
were beginning to show signs of nerve re-
generation. We lost track of the other ten,
so we could not tell whether the operations
were successful or not. The nerve surgery
was under Major John Meagher of Brook-
lyn, but I did some of it myself. I could
not keep my hands out of it. All the opera-
tions were arm and leg cases where the
suturing was of large nerve trunks.
"When a large amount of bone tissue had
been destroyed we resorted to bone grafting
and had excellent results. Capt. Samuel L.
Fisher, also of Brooklyn, was in charge of
this work.*'
All the doctors were given a chance for
service in France. Col. Fiske spent six
weeks on the continent, and was there when
the armistice was signed. It was the Kinjsrs
County Hospital Unit which served at Base
37.
The American boys while at Dartford
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ORIGINAL ARTICL.es
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425
had their first chance to see royalty at
close range. King George and Queen
Mary, accompanied by Princess Mary
visited the hospital and escorted by Col.
Fiske, made a round of the wards and
chatted in the most friendly fashion with
the patients.
Miss Bissell, who went overseas last
April with the Wellesley Unit under the
auspices of the Red Cross, also had strenu-
ous experience in the line of duty. She was
at Red Cross Mobile Hospital No. 114 and
"There was not a thing we could do but
stay right there and trust to luck. Fortu-
nately no one was hurt" said Miss Bissell
in recalling the incident. The week her
unit was in Paris waiting for assignment
there were three aid raids in one night.
Ask Miss Peatrice M. MacDonald, . who
lost the sight of her right eye while on duty
with an American Red Cross team which
was loaned to the British for service at
Casualty Clearing Station No. 61 near
Bophling in Belgium, about sixty miles from
American Red Cross
The "Victory Parade" at the American Base Hospital, Dartford, near London, on Nov.
11, when the signing of the armistice was announced. The men on crutches were Invited
to parade in automobiles, but most of them preferred to walk, and they occupied honored
places in the line of march.
was present during the Chateau Thierry
drive when the hospital was subjected to a
German air raid on July 15, at which time
four persons were killed and several
wounded.
While her party was on its way to the
Toul sector in September, the train was
stopped many hours because a short dis-
tance ahead was a train filled with hand
grenades and star shells which had been
struck by a bomb from a Boche plane.
Dieppe, about her work and she replies, "I
want to forget it all except that we have
won the war. And to think that it only
took our boys six months to do it after they
really got on the job. Our boys are the best
on earth. I just went over to help them,
and I hope I did some good. They deserved
the best in the world."
Miss MacDonald served twenty-one
months overseas and has been awarded the
Distinguished Service Cross by Secretary
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ORIGTINAL. ARTICLES
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of War Baker and has also received the
British Military Medal for bravery in the
field and the medal of the British Red
Cross.
Miss Amy Patmore, chief nurse of Base
Hospital No. 8 at Sauvigny in France,
where there are 14,000 beds, sums up what
appears to be the feeling of all overseas
doctors, nurses and social workers.
**\Ve gave the very best of ourselves to
the work and considered it the greatest
privilege to be permitted to give. In my
belief that was the spirit of all the doctors,
the nurses and the Red Cross workers. And
it was the greatest privilege that could ever
be accorded to anybody on this earth to be
allowed to serve those magnificent boys of
ours. Nobody in this country, nobody who
has not worked with those men over there
can have any idea of their spirit, their
courage, their grit and endurance. Un-
flinchingly they faced the worst horrors this
world has ever known. They are the most
glorious on earth."
And from one who has been privileged to
go closer to those horrors than any woman
was permitted, and who knows the price
our boys paid for their patriotism, comes a
final tribute and perhaps the highest one.
*'Our boys did not need any reforming"
said Col. Montgomery. "They attended to
their religious duties each according to his
own respective faith. We had our regi-
mental chaplains, and fine chaps they were,
who were always ready to go over the top
with their boys. But apart from all that,
when a man can expect death any moment
and walks about unafraid, he is not a sub-
ject for reformation."
And one parted from Col. Montgomery
feeling that the sentiment he entertained for
our boys was much like that expressed by
Stephen Decatur for our country, "May she
always be in the right but — our country —
right or wrong."
An Unusual Reason for Exemption
from military service came out when a man
said to the members of a local exemption
board : "I don't feel that I can go into the
army, because I am a vegetarian." The
chairman looked at the man and answered :
"Well, good Lord, man, we want you to
fight the Germans ; it isn't necessary to eat
them."
ACTIVITIES OF THE MEDICAL DE-
PARTMENT OF THE UNITED
STATES ARMY DURING THE WAR.
(Continued from page 328)
These courses of instruction not only en-
abled the army to increase the supply of spe-
cialists for hospitals, but will also be of
great benefit to the civil communities when
these oflScers return to the practice of med-
icine at their homes.
In conclusion it may be said without fear
of contradiction that the Medical Depart-
ment of the U. S. Army during the present
war has furnished for the American soldier,
both at home and abroad, a greater degree
of sanitary protection against disease and
a higher grade of medical and surgical at-
tention than has ever been supplied to the
soldiers of any other country in this or any
previous war. Had it not been for the un-
preventable epidemic of influenza the suc-
cess in maintaining low sick rates would
have been truly marvelous. The benefits
of the activities of the Medical Department
are apparent not only today in the pres-
ervation of health and in the prompt cure
of the sick and wounded, but will be in-
creasingly evident in the future when the
seriously wounded again become happy and
self-supporting citizens as a result of the
high grade surgical and reconstruction serv-
ice provided for this class of cases. Credit
is due to the officers of the Medical Depart-
ment of the Regular Army who, in peace
days of slow promotion and seemingly little
opportunity, persevered in preparing them-
selves for this great emergency, and equal
credit is due to the physicians, the dentists,
the veterinarian and others from civil life,
who unhesitatingly abandoned their civ-
ilian pursuits, sacrificed their personal in-
terests and gave their best to the service
of their country in the Medical Department,
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427
cheerfully adapting themselves to the hard-
ships and unfamiliar conditions of military
life. Both groups of professional men of-
fered to the nation all they possessed, and
many made the supreme sacrifice in the
. performance of duty. In answer to the call
on the civil profession, equal response was
made* by the young and by the old, by the
specialist and by the general practitioner.
City and country responded with similar
enthusiasm. Special thanks are due to
those officers from civil life who, long after
the excitement of the actual war has passed,
must continue in the service attending the
needs of the wounded, while many of their
comrades, both in the Medical Corps and
in the line, are rapidly returning to their
homes and ordinary vocations. In view of
the enormous preponderance in the army
of physicians fresh from civil life it may
be said without reflection on the medical
officers of the regular army, that the great
achievement of the Medical Department in
medicine, in surgery and in sanitation is pri-
marily the work of the civil profession of
the United States and is due to the patriot-
ism, fidelity and ability of that great body of
practitioners. It is to be hoped that one of
the results of the great war will be the clos-
est sympathy between the Medical Corps of
the Army and the medical profession of the
country, resulting in the development of a
firm conviction in the minds of all civilian
practitioners that preparedness for war con-
ditions in the case of each and every physi-
cian of military age is a fundamental ne-
cessity for attainment to the highest type
of citizenship. In this brief review of the
Medical Department activities no reference
is made to the physicians who, as members
of Local and Advisory Boards, participated
in the operation of the Draft, but who could
not, imder the law, be commissioned in the
military service of the Army. Great in-
justice would be done, did I omit to call
attention to the difficult task which was so
well and faithfully performed by these
physicians connected with the Draft, and
which forms another of the important con-
tributions made by the American medical
profession toward the winning of the World
War.
Thyroid Extract in Myxedema and
Hypothyroidism.— In the treatment of
these cases Dock begins with a small dose
of thyroid extract, about 1 grain, t. i. d.,
increases it rapidly until physiologic effects
appear, and then reduces the dose until a
desired condition has been reached. He
advises that the dangers and precautions
in such treatment be kept in mind.
A Study of the Functions of the Thy-
roid Gland.— According to Stewart
(Southern Med. Jour., May, 1919) Wright
holds that the opsonins of the blood are
dependent upon the secretions of the thy-
roid gland. To prove this, StepanoflF and
Morbi by many experiments showed the
disappearance of the opsonins upon the
extirpation of this gland. Thus we see
at a" glance that the thyroid protects us
from infectious diseases, as we well know
that the opsonins of the blood are the an-
tagonists of all infectious organisms. For
further proof, Charrin showed how dogs
were easily infected by contagious dis-
eases after extirpation of the thyroid.
Greenfield, Murray and Lanz, after much
study of persons suffering from myxe-
dema, stated that they often died of tuber-
culosis or some other infectious disease.
The protective role of the thvroid gland
against infectious diseases is further evi-
denced, according to Roger, Garnier and
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Torre, by their observation of the fact
that during an epidemic of typhoid, with-
out exception persons with diseased thy-
roids succumbed to the fever.
That the thyroid gland governs oxida-
tion has been shown by Lorand and Moe-
bius. For instance, a hyperactivity of
the secretion, as in Graves' disease and
fevers in which we have increased oxida-
tion, is nearly always followed by an ex-
haustion of the thyroid function, a con-
sequent lowering of oxidation and the re-
sultant obesity usually observed following
low, continued fevers.
Not only does the thyroid protect us
from infectious disease, but it is also pro-
tects from certain drugs, especially alco-
hol and chloroform. De Quervain, Her-
toghe and Sajous all showed by many ex-
periments that animals with a healthy thy-
roid withstood alcohol without intoxication
in much greater quantities than those with
degenerate glands. This was also found
true with chloroform. In fact, dogs which
had their thyroids removed invariably died
from chloroform narcosis.
The thyroid also has peculiar control of
that function of the brain called the mind.
Myxedematous people, as we all know,
are apathetic, slow of thought and action,
defective memory, dull and stupid. The
wonderful effect of the thyroid upon the
intellect has been many times demon-
strated by the administration of the ex-
tract to cretinous children. They would
grow brighter, learn faster and become
more active in a very short time.
The thyroid also, as has been observed
by many investigators, controls the sexual
functions of the body. The sexual appe-
tite is lowered or lost in those with dis-
eased or degenerate thyroids. A full, well
developed thyroid, in man or women, is
indicative of a keen sexuality. A stringy
throat, a wrinkled neck is ofttimes posi-
tive evidence of sexual apathy.
The thyroid gland controls to a marked
degree, as untold experimental evidence
has shown, the digestive and metabolic
functions of the body. As is further evi-
denced by those who have a marked dis-
ease of the gland, they are always people
who seem poorly or improperly nourished.
To determine a case of thyroid deficiency, or
hypothyroidism, when it is not one of those
well-known and well-marked diseases fa-
miliar to us all, is often difficult; yet its
extreme importance should make us give
each symptom of thyroid trouble very
great weight, altho otiier conditions may
point to some different disease. A harsh,
dry skin, excess of. fat, waxy pallor,
wrinkled hands, flabby muscles, premature
grayness of the skin and hair, falling of
the hair, especially in patches as in alopecia,
poor appetite, dull mentality, melancholia,
constipation, watery menstruation, sexual
torpor, changes in the other ductless glands,
increased tendency to autointoxication —
these are some of the symptoms of a defi-
cient thyroid.
The PlttrigUndular Syndrome. — Leon-
ard Williams in his work "Minor Maladies"
says: "It is well for the reader to under-
stand that the interdependence of the en-
docrine glands renders it very difficult in
the present state of our knowledge to be
sure which particular gland is at fault. It
is exceedingly likely that some of what we
now take to be manifestations of thyroid
insufficiency of slight degree, are in reality
due to insufficiency of some other gland,
partly opponent and partly complemental,
such as the pituitary or the adrenal, which
may be stimjulated into increased activity
by the exhibition of thyroid extract. . .
In the case of adrenal insufficiency, some
of them, notably the infantilism, the low
temperature, the hairlessness and pigmenta-
tion are prominent symptoms. It is there-
fore evident that when one member of the
endocrine hierarchy is at fault, the mere dis-
turbance of the glandular balance is suffi-
cient to produce certain symptoms of which
one can only affirm that they point to a
disturbance somewhere in the endocrine
system — the pluriglandular syndrome, as it
is called."
The Hormones and the Vegetative
Nervous System. — Gallotti (Archivos
Brasileiros de Medicine, Jan., 1919)
argues that the harmonious action of the
involuntary organs is due in large part to
the hormones influencing the autonomous
and the sympathetic nervous system. He
reviews the action of the different endocrine
glands in turn, saying that the relations be-
tween the hormones and the vegetative sys-
tem must be studied before we can use
organotherapy intelligently.
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VALOR AND FIDELITY
June, 1319
429
"Heroes all
Who heard the clarion voice of Duty call.*'
Words are the mere chattels of the mind.
Emotion is a dumb thing. Besides, it is hard
to be eloquent in the face of the expected.
Groping for the language of tribute, tribute
to the achievement of the doctors who have
been honored in the service of their coun-
tr\% we find ourselves strangely at a loss
for an expression that will be as dignified
as the occasion that calls it forth. Again
and again there comes to us, repeatedly,
insistently, a single phrase: a triumphant
**I told you so !" For who expected less of
the doctors of the Nation than they
achieved? Of what our army would do,
we were for a long time in doubt. Not un-
til Chateau Thierry, and St. Mihiel, and'
the Argonne were we sure that our
soldier boys would fight so bravely and
magnificently, and the hearts of those at
home swelled with pride, and no little meas-
ure of relief, when they read the glowing
accounts of those battles. But of the men
in the Medical Corps there were at no
time any doubts. Self-sacrifice and ex-
posure to danger are a commonplace, every-
day incident to the doctor, and it was an
easy thing for him to expose himself to the
hazards of shell and gas in order to serve
the men who were serving in so splendid a
cause. Their response to the call of their
country was not a hesitant one. Presi-
dent Wilson's definition of the struggle as
one for the liberation of humanity appealed
strongly to men who, when they chose
their profession, dedicated the better ener-
gies of their lives to the service of human-
ity. For them, the war meant merely a
change of environment and not a change
of habit ; the comforts and conveniences of
the operating room at home were sur-
rendered for the discomforts of the field
dressing station or the damp dugout. In
other respects, their work remained the
same ; always subject to the need of the in-
jured, always at the call of the suffering
ones. And if this call subjected them to
privation, self-denial and constant danger,
they would be the last in the world to claim
any special honor for doing what it had
been their practice to do for so long, what
it was in their natures to do without hes-
itation. The doctors of the American Army
did what was expected of them, what the
tradition of their profession had taught us
to expect of them. In view of this splendid
tradition, we feel more could not be said.
And we are sure that those who were sin-
gled out for special honors will accept the
official tribute as one not only to themselves
but to the whole profession as well. In hon-
oring them, the government has honored
the entire medical profession of America.
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JUNB, 1919
VALOR AND FIDELITY
Amskigan Midzcinb
AMERICAN PHYSICIANS DECORATED BY THE UNITED STATES GOVERNMENT.*
Name
Rank
Corps
Citation
Andrew. A. Piatt Ueut Col.
Arrants. Wm. Ross Lieut.
Baker. Frank C Colonel
Barber. Thomas M Lieut.
Bass. Urbane F Lieut.
Beasley, Shad worth O. (deceased) Major
Beeukes, Henry Lieut. Col.
Billings. Frank Colonel
Bingham. Ernest G Colonel
Black. Frederic Wallace Major
Blake. Joseph A Colonel
Blood. Robert O Capt.
Bradley. Alfred B Colonel
Bunch. Henry Edgar Capt.
Burgher, Emil H Major
Clark. Albert P Lieut Col.
Comfort, Chas. W Capt.
Condon. Wm. J Capt.
Crile. George C Colonel
Crookston. William J Colonel
Crum, Leo J Lieut.
Darnall, Carl R Colonel
Davis. Howard H Capt.
Dickinson. Dwight. Jr Asst. Surg.
Diener. Louis Capt
Doudna. John F Capt.
Duffy, Mack M Lieut.
Edie, Guy L Colonel
Finney, J. M. T Brig. Gen.
Flint Joseph M Lieut Col.
Gage. Geo. H Capt.
Gee, Athel J Lieut.
Goldthwait. Joel E Colonel
Hall. James G Capt
Howard. Deane C Colonel
Howe, Geo. P. t deceased) Lieut.
Hutton. Paul C Colonel
Ireland, Merritte W. .'. Maj. Gen.
Jackson. Horatio N Major
Jones. Glenn I Lieut Col.
Jones, Percy L Colonel
Jones, Thomas E First Lieut.
Keenan, Wallis H Lieut
Keller, William L Colonel
Lee, Burton J Colonel
Lisa. James R Lieut.
Lyster, Theo. C Colonel
A. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
U. S. Navy
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
Distinguished Service Medal
Distinguished Service Cross
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
and Croix
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Service Medal
Service Cross
Service Cross
Service Cross
Service Medal
Service Medal
Service Medal
Service Cross
de Guerre
Service Medal
Service Cross
Service Medal
Service Cross
Service Medal
Service
Service
Service
Service
Service
Service
Medal
Cross
Cross
Medal
Medal
Cross
Service Medal
Service Cross
Service Cross
Service Cross
Service Cross
Service Cross
Distinguished Service Medal
Distinguished Service Medal
Distinguished Service Medal
Distinguished Service Cross
Distinguished Service Cross
Distinguished Service Medal
Distinguished Service Cross
Distinguished Service Medal
Distinguished Service Cross
Distinguished Service Medal
Distinguished Service Medal
Distinguished Service Cross
and Croix de Guerre
Distinguished Service Medal
Distinguished Service Medal
and Croix de Guerre
Distinguished Service Cross
Distinguished Service Cross
and Croix de Guerre
Distinguished Service Medal
Distinguished Service Medal
Distinguished Service Cross
Distinguished Service Medal
>Thl8 list Is not complete for new awards are being made daily, but this is doubtless the most com-
plete list thus far published.
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VALOR AND FIDELITY
June, 1919
431
Name
Rank
Corps
Citation
McCaw, Walter D Colonel M. C.
McGinnis, Geo. E Capt. M. C.
McKernon, James Colonel
McKibben, James M. (deceased) . . Capt. M. C.
McLelland, Wm. D Capt. M. C.
Manton, Walter W Capt M. C.
Martin, Claude A Capt M. C.
Maus» Louis M Colonel M. C.
Mayo. William Colonel M. C.
Miller. Reuben B Colonel
Miner. Donald Major
Morlson. James H. S Lieut.
Motley. Robert E Ist Lieut.
Mount, James R Colonel
Munson. Ed. L Brig. Gen.
Murdock, Robt. H. (deceased) Lieut
Murphy. Fred T Colonel
Myers. Chas. W Lieut.
Peck, Charles H Colonel
Petty, Orlando H Asst Surg.
Pincoffs, Maurice E Capt
Powless, Josiah A Lieut.
Pratt, Lester L Asst. Surg.
Ray, John (deceased) Capt
Rentfro. Chas. C Lieut.
Rhoads, Thomas L Colonel
Rosenwald. John P. (deceased) . . . Lieut.
Royster, Thomas R Lieut.
Ruffner. Ernest L Colonel
Russell. Frederick F Colonel
Salmon, Thomas W Colonel
Schochet, Sydney S Lieut.
Siler. Joseph P Colonel
Srygley, Blam F Lieut. M. C.
Stark, Alexander N Colonel M. C.
Thayer, William S Brig. Gen. M. C.
Tuttle, Arnold D. Colonel M. C.
Vaughan. Victor C Colonel M. C.
Wadhams, Sanford Colonel M. C.
Weaver, Ross B Lieut. M. C.
Weber, John F Lieut. M. C.
Wesselhoeft, Conrad Capt. M. C.
Wheat, Harry R Lieut. M. C.
Wheelock. Frank R Capt M. C.
Williams. Clarence M Capt M. C.
Williams. Prank Leo Lieut. M. C.
Wilmer, William H Colonel M. C.
Winter. Francis A Brig. Gen. M. C.
Wolfe, Edwin P Colonel M. C.
Young, Hugh H Colonel M. C.
M. C.
M. C.
M. C.
D. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
U. S. Navy
M. C.
M. C.
U. S. Navy
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
M. C.
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Difitinguished
Distinguished
Difitinguished
Service
Service
Service
Service
Service
Service
Service
Service
Service
Service
Service
Service
Service
Service
Service
Service
Service
Service
Medal
Cross
Medal
Cross
Cross
Cross
Cross
Cross
Medal
Medal
Cross
Cross
Medal
Medal
Medal
Cross
Medal
Cross
Distinguished Service Medal
Distinguished Service Cross
Distinguished Service Cross
and Croix de Guerre
Distinguished Service Cross
Distinguished Service Cross
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Service
Service
Service
Service
Service
Service
Service
Cross
Cross
Medal
Cross
Cross
Medal
Medal
Distinguished Service Medal
Awarded British Milit'y Cross
Distinguished Service Medal
Distinguished Service Cross
Distinguished Service Medal
Distinguished Service Medal
Distinguished Service Medal
Distinguished Service Medal
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Distinguished
Service
Service
Service
Service
Service
Service
Service
Service
Service
Service
Service
Medal
Cross
Cross
Cross
Cross
Cross
Cross
Cross
Medal
Medal
Medal
Distinguished Service Medal
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432
June, 1919
IN MEMORIAM
American Medicine
''If ye break faith with us who die,
We shall not sleet t tho poppies blow in Flanders fields. **
— McCrae
A communication received from Surgeon-
General Ireland early in May gives the fol-
lowing data in regard to the fatalities among
medical officers during the war:
Killed in action 45
Died of wounds 26
Died of accident 5
Lost at sea 4
Total deaths 80
A further statement from the Surgeon-
Generars office also gave a list of 290 med-
ical men who had died from disease while
in active service. Up to May, 1919, there-
fore, 370 doctors had made the ^'supreme
sacrifice" for their country. These figures
are only approximate, for the statistics of
the War Department have not been com-
pleted, and probably will not be for some
time.
In paying tribute to the medical men who
gave their lives while in active service one
thought persists, ''Greater love hath no
man than that he shall give his life for an-
other."
Bravely, fearlessly they went down into
the Valley of the Shadow, totally forgetful
of self and with only one purpose, one aim
before them, to relieve the wounded and
ease the last fleeting moments of the dying.
Probably to all of these doctors life was
never sweeter or more desirable. The
things we cherish are never dearer than
when we are confronted by the prospects of
losing them. Many had dear ones back home
whom they knew were praying for their safe
return. The future, aye, what plans they
had for the future! But when the call to
service came and the occasion arose to do
their duty, did they falter, did they give
one thought to the dangers that threatened ?
Not for a moment did they hesitate. Into
a hell of shot and shrapnel they went, know-
ing full well the chances they were taking.
But in this hell there were men in agony,
men whose life blood was flowing fast, men
whose eyes were growing dim, but whoise
lives might be saved by timely and skilful
ministration.
And so spurred by that spirit which has
always actuated the true physician in mo-
ments of great emergency, they went on to
where they were needed most. Many
seemed to bear a charmed life. Their faith-
ful service and indifference to danger
seemed to serve for many almost as a coat
of mail. But not for all and the list that
follows tells of many who went forth — and
did not come back.
There is little we can say aside from,
rest, brothers, rest. Nobly and well you
have played your part, and tho our hearts
are sad and heavy when we think of the
homes that w^ill know you no more, of the
loved ones denied forever the grasp of
your hands, the sound of your voices, the
joys of your companionship, we are proud of
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BY-WAYS AND HIGH- WAYS
JuxE, 1919.
433
your record and the way you have shown
the world that the American physician can
die as nobly and unselfishly as he knows
how to live.
Let no one say, therefore, great as is youf
loss to the Nation and those who prized
your love and friendship, that you have
died in vain. The nobility of your sacri-
fice has shown us anew the majesty of
that death which comes '*in line of duty" ;
in showing us how to die for an ideal you
have taught us how to live for a purpose.
PHYSICIANS KILLED IN ACTION.*
Baldwin, Joseph F., Ist Lt., M. C.
Barber, Timothy L., Capt., M. C.
Beasley, Shadworth O., Major, M. C.
Brown, Arthur S., Ist Lt, M. C.
Brown, Presley R., 1st Lt., M. C.
Clair, Frederick D., 1st Lt., M. C.
Craig, William F., 1st Lt, M. C.
Daniels, Hoddie W., Capt, M. C.
Dudenhoefer, Joseph E., Capt, M. C.
Fair, Wilford A., 1st Lt, M. C.
Finkelberg, Morris, 1st Lt, M. C.
Fitzsimmons, William T., 1st Lt, M. C.
Gochnaur, Orlando M., 1st Lt., M. C.
Hartwig, Gerhard F., 1st Lt., M. C.
Herrington, William G., 1st Lt, M. C.
Hudson, William B., Capt., M. C.
Jett, Richard L., Capt, M. C.
King, Emil, 1st Lt, M. C.
Leonard, Jerome M., Ist Lt., M. C.
Linch, Ballard C, 1st Lt, M. C.
McQuillan, James A.r Ist Lt, M. C.
Morgan, Harold S., 1st Lt., M. C.
Murdock, Robert H., 1st Lt., M. C.
Oglesby, Knowles G., 1st Lt, M. C.
Post, Dana C, 1st Lt, M. C.
Reed. Stephen J. H., Capt., M. C.
Renner, J. W., let Lt, M. C.
Sanders, Frank B., 1st Lt., M. C.
Saunders, Alonzo W., 1st Lt, M. C.
Sherwood, Robert A., 1st Lt, M. C.
Skilling, John G., Ist Lt, M. C.
Summers, Davis K., 1st Lt., M. C.
Vermilyea, Sidney C, 1st Lt., M. C.
Webster, Harrison B., Major, M. C.
PHYSICIANS WHO HAVE DIED OF
WOUNDS.
Bass, Urbane F., 1st Lt. M. C.
Beal, Howard W., Major, M. C.
Bull, William S., Ist Lt, M. C.
Burrell, G. 0., Ist Lt., M. C.
Davis, Reese, Ist Lt, M. C.
Ellis, J. G., Jr., Capt, M. C.
Faulds, Winfield S., 1st Lt, M. C.
Frazier, Francis V., 1st Lt, M. C.
Gibson, Burgess A., 1st Lt., M. C.
•This list is not complete owing: to difficulty of
getting exact names and other information.
Glascock, Alfred, Capt., M. C.
Goss, Paul Lewis, Ist Lt. M. C.
Hanson, Dave T., Capt, M. C.
Hilgard, Geo. E., Major, M. C.
Joyce, Whitney H., Ist Lt, M. C.
Klingen, Oscar M., Ist Lt., M. C.
Lieser. William A., 1st Lt., M. C.
McMichael, Charles P., 1st Lt, M. C.
McQuaid, Arthur F., 1st Lt., M. C.
MacFarland, James, 1st Lt, M. C.
Marowitz, Max, 1st Lt., M. C.
Mead, Theodore F., Capt, M. C.
Mooney, Edward L., 1st Lt., M. C.
Olsteln, Matthew F., Ist Lt., M. C.
Powers, Ralph E., 1st Lt, M. C.
Ranson, Glen D., 1st Lt., M. C.
Ray, John B., Capt., M. C.
Reed, Clinton V., 1st Lt, M. C.
Rosenwald, John P., Ist Lt., M. C.
Ryman, Herbert D., Capt, M. C.
Sage, Abner P. H., 1st Lt., M. C.
Shedd, Clyde Everett, 1st Lt., M. C.
Sunlight and Sense. — It is a common
form of insult to compare a human being
to an animal, but, to anyone who knows
animals well, the comparison would be re-
garded as a compliment. The animal is the
most temperate, the most gentle, the most
amiable creature in the world. Indeed, it
is one of the bitter facts of life that hu-
mans are not nearly as nice as animals nor
as sensible. One remembers the delight-
ful scene in Rostand's "Chanticleer," where
two cocks are fighting, clawing and mang-
ling each other viciously, when one of the
barnyard characters of the play (the hen
pheasant, is it?) enters. She is shocked be-
yond words at the sight of such depravity.
*'Gracious," she exclaims, "stop behaving
like human beings!" The French poet
Rostand knew animals and he knew men,
and men suffered by the comparison. In
one respect, certainly, the animal world has
always shown its superiority, and that is its
realization of the importance of sunlight.
We, who have scientifically come to the con-
clusion that sunshine is the greatest of
germicides and health promoters, who have
conceded its beneficial properties, have
shown ourselves inferior in intelligence to
the animals who, without science to aid
them, have always placed a just and abiding
estimate on the value of the sun's curative
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June, 1919
BY-WAYS AND HIGH- WAYS
Amkrican Medicini
rays. Animals rise with the rising of the
sun, and they retire with its setting. They
confine their activities entirely to the period
of the sun's daily rule, preferring it as a
timepiece rather than a bit of machinery
with a dial and two hands. One fre-
quently hears the expression, "As healthy
as an animal." Animals are healthy be-
cause they love the sun and avoid the dark
hours which are for rest. They spend
their energies only during the hours when
the life-rays of the sun are poured into
their bodies, with its stimulating effect on
their energies. And when dark comes, when
wasted energies cannot be replenished, they
rest.
Recently, man, the pale creature of the
night, determined to mend his ways and
imitate those of the animal world more
closely. He alone, of all creatures, had
fallen into the evil way of wasting the
precious hours of sunlight and coming to
life only when the healing rays of Sol had
sunk below the horizon, exposing himself
to the depressing influence of the night.
Penitent, he decided to advance his clocks
one hour and thus give himself one more
hour of sunshine. For two summers he en-
joyed the benefits of Daylight Saving,
basked one hour more in the clean light,
played an extra hour of tennis and golf,
and reaped the rewards of health and the
sound fatigue that brings peaceful rest at
night. Some day lovers of statistics will
compute the healthful results of this in-
telligent plan of living, and it will be found
that a heavy balance was entered on the
side of both health and happiness in the
ledger of human wellbeing. But a hand-
ful of legislators, ashamed of this descent
(descent they no doubt thought it!) to the
level of the animal state, decided to restore
man to his pathetic and lonely place as the
king of all creatures, and the Daylight Sav-
ing Law was repealed. "I am opposed,"
said one mighty champion of human and
Divine Law in Congress, "to usurping not
only the powers of the Executive and
States, but those of God Almighty, and
seeking to fix the time when the sun shall
rise and set." Brave, eloquent Senator,
does he not know that God Almighty made
the sun and that man made the clocks ; that
the booming of the sun in the east is Na-
ture's rising alarm, and that the clock by
which the Senator rises defeats the schedule
that Heaven has meant him to observe?
The lowly hen is more pious than the
Senator, and she can quote Divine Law
with less offense. More frank and less
offensive is the Congressman who asked
for a repeal of the law because it took the
farmers out into the fields while the dew
was there, "and everyone knows that when
dew gets on the body it makes sores."
Blushing with the sense of our deep and
criminal ignorance, we accept this verdict
of science as to the malevolent properties
of dew; and we are secure in the thought
that, with such mighty champions of Divine
and Natural Law at the helm of our State,
we cannot wander far on the path of error
and sin. But we fear that there are some
less gentle citizens of the republic, so cor-
rupt in their love of God-given sunlight,
so depraved in their yearning for blue skies
and dew-drenched swards, that they will not
accept supinely this pilfering of a gift that
comes straight from Heaven. They .will
resent deeply this railroading of Nature,
this amputation of an hour that has con-
tributed so much to happiness and health
and out-of-door contentment. For two
precious summers they have known the
joy of an added sixty minutes of sunshine,
of lolling in golden rays, of physical and
spiritual growth and expansion ; and a deep
growl of discontentment will issue from
the bosoms of countless thousands to whom
that hour has been a Godsend. If this
growl grows to a roar of anger, we will
not blame them, for the repeal of the Day-
light Saving Law is a masterpiece of pur-
blind legislation, unrivaled in its stupidity,
unmatched in its consummate, blank, stark
incompetence.
The Seedier as Educator. — The dis-
charged soldier, particularly the soldier who
has seen service abroad, occupies a very
special and very honored position in the
community to which he returns. However
modest his station before the war, he comes
back with an atmosphere of romance and
glory about him which gives him a new
and well deserved prestige. The younger
element look up to him admiringly, the
adults of the community are both admiring
and grateful, and his friends and relatives
feel a greater aflfection for him. In in-
numerable cases, army service has given the
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AlfVRlCAN MBDICINB
BY-WAYS AND HIGH- WAYS
June, 1919
435
soldier new manhood, added strength of
character, and he has come back to his old
home surroundings fitted for a leadership
among his associates which they are only
too ready to accord him. His place is a
high one, his authority is secure. Con-
templating this fact, there comes to mind
the thought that the returning soldier rep-
resents an opportunity for the government
that is rare and precious ; for, thru the re-
turning soldier, the government can convey
a message to the remotest corners of the
country and convey it in such a way as to
assure it being heeded . conscientiously.
The education of the soldier varies accord-
ing to the man and not all are fitted for the
same responsibility, but in one respect every
soldier can be successfully utilized as an
educator. Before being discharged from
the Army, every man receives careful in-
struction in personal and general hygiene
and he is encouraged to apply the lessons
in hygiene and sanitation learned in the
service to an improvement of conditions in
his home community. In many cases, es-
pecially in those of men coming from small,
isolated country centers, their experience in
the army is their first association with
group sanitation as well as individual clean-
liness, and the habits they form in the
Army will cling to them long after they have
left it, perhaps permanently. These habits
they will bring with them on their return.
Both as an unpretentious model to imitate
and as a conscious educator in matters of
hygiene, the homecoming soldier can serve
as a persuasive factor in improving sani-
tary conditions in every community. This
fact the government has realized, and one
must warmly commend the vision it has
shown in utilizing the educational value of
the discharged army man. This is propa-
ganda of the finest sort, and it is to be
hoped that the near future will see a vast
improvement in community sanitation and
health as a consequence of this course.
Some Medical and Surgical Develop-
ments of the War. — The medical and sur-
gical developments of the war have been
many and important. Up to the present
time the perspective is hardly clear, for
many events are yet too close to permit
us to estimate the developments therefrom
at their full worth. Certain of the sur-
gical developments will not be well adaptable
to civil practice for it must be borne in
mind that civil surgery diflfers in many re-
spects from army surgery. On the other
hand, other developments of the war from
the medical and surgical points of view can
be applied with success in ordinary prac-
tice. Of these developments, that which
appears likely to be of the greatest value
in civil practice is physical therapy. The
worth of no form of treatment has been
so emphasized by the experiences of the
war as physical therapy. Moreover, such
treatment is eminently applicable to the
conditions of civil life, especially in a coun-
try like America in which street, railroad
and industrial accidents are more prevalent
than in any other part of the world.
The time has now come to take
a survey of the developments, medical and
surgical, of the war and to endeavor to
form accurate conclusions as to their prac-
tical value. A special number of the
United States Naval Medical Bulletin has
just been published by the Bureau of Med-
icine and Surgery of the Navy Department,
which contains a remarkably comprehensive
report on medical and surgical develop-
ments of the war by William Seaman Bain-
bridge, Lieutenant-Commander, Medical
Corps, United States Naval Reserve Force.
Commander Bainbridge hais enjoyed ex-
ceptionally favorable opportunities for ob-
serving medical and surgical conditions in
England, France, Belgium and to some ex-
tent in Germany. The report comprises
the outcome of observations on the Western
Front and in England during December,
1917, and the first six months of 1918, made
pursuant to the instructions of the Surgeon-
General, United States Navy. There have
also been added certain data obtained while
in Germany during the autumn of 1915. In
making this survey, the following objects
were kept constantly in mind :
1. To record the surgical lessons of the
war based on the experience of our Allies.
2. To study anything likely to be of value
to the United States Naval Medical School,
Washington, D. C, or helpful in the prep-
aration of medical men and hospital corps-
men for active service.
A critical e^^amination of Commander
Bainbridge's report indicates that these ob-
jects have been attained with a very note-
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June, 1919
BY-WAYS AND HIGH- WAYS
AMBBICAN MaDIOINB
worthy degree of success. The salient
points in connection with the medical and
surgical developments of the war are con-
sidered carefully and the result is that the
ground is well covered. With regard to the
treatment of wounds, the author points out
that views have oscillated a good deal as
to the comparative merits of asepsis and an-
tisepsis during the progress of the war.
In September, 1915, Prof. Kocher of
Berne remarked to the author that **the
great lesson of the war so far is 'back to
antiseptic surgery.' Asepsis is not enough.''
Three years later in June, 1918, Major A.
L. Lockwood, D. S. O., said that "one of
the greatest lessons of this war is that
aseptic surgery and not antiseptic surgery
should be practiced, the former in all cases,
the latter associated with it in selected
cases."
From the purely therapeutic viewpoint
the surgery of wounds in the present war
may be grouped under fairly approximate
chronologic headings as follows :
1. The period of ordinary antiseptic
agents, second half of 1914 and first half
of 1915.
2. The period of wound drainage, com-
bined with antiseptics, 1915.
3. Introduction of hypochlorites, later
in 1915.
4. Evolution of the Carrel technic of in-
termittent wound instillation, early in 1916.
5. Ascendency of Bipp method, 1916.
6. Period of approximately equal use of
the Morison and Carrel methods, 1916-17.
7. Prominence of flavine and colored
wound pastes, such as brilliant green, 1917.
8. Progressive general adoption of
wound excision method, which had its be-
ginnings early in 1916, late in 1917.
9. Period of primary wound suture, im-
mediate or delayed, 1917-18.
10. Period of attempted selection, adapt-
ation and standardization, late 1918.
All these methods are described in detail
and the text is illuminated by a large num-
ber of excellent illustrations.
A particularly interesting feature of the
Bulletin, because of the general paucity of
information on the subject, is an account
of the treatment of war wounds by the
Germans. Late in 1915 when the author
was in Germany the ambulance and hos-
pital organization was extremely efficient.
The progress made in physical therapy was
very striking. Before the war, physical
therapeutic departments had been estab-
lished in connection with many hospitals
thruout Germany showing, of course, the
importance attributed to this line of treat-
ment in the rehabilitation of the wounded.
A chapter of the Bulletin which is es-
pecially valuable is that which refers to the
treatment of joint lesions by Dr. C. Wil-
lems. the noted surgeon in charge of the
Belgian Military Hospital at Hoogstade
and part of the Military Hospital at Bour-
bourg. Dr. Willems, at the hospitals of
which he had charge, revolutionized the
methods of treating joint lesions and his
success was so great that it appears likely
that existing views as to the treatment of
such injuries will undergo a great deal of
revision. For a long time previous to
the war the classical mode of treating joint
lesions was by immobilization. The
functional results, however, were so poor
that even before the war some tentative
efforts were made to devise a method
whereby the functions of the joint might
be preserved. Willems was the pioneer in
this direction and his methods of treatment
were directly opposed to those so long in*
vogue. His treatment is based on the prin-
ciple of immediate active mobilization of
the joint. The success of the method, for in
Willems' hands it has been most successful,
appears to be due to the complete drainage
which limits the infection to the synovial
membrane and prevents it from spreading
to the cartilage and bone.
Furthermore, Mr. J. W. Dowden, Sur-
geon to the Royal Infirmary, Edinburgh,
and who had first experience in a Terri-
torial General Hospital and for three years
in the Edinburgh War Hospital, Bangour,
is averse to immobilization of fractures by
splints, that is except when they are abso-
lutely necessary. In a notable paper con-
tributed to the International Journal of Sur-
(jery, April, 1919, he points out that in sep-
tic fractures, and practically all war wounds
were septic, mobilization and no splints
were followed by surprisingly good results.
Dowden goes so far as to state that the
greatest lesson learned from the war is to
avoid immobilization in treating fractures.
The chapter of the Bulletin dealing with
plastic surgery is of great interest. Atten-
tion is drawn to the fact that we are apt to
regard this line of work as a matter of re-
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AMUUCAN MSDXCINH
BY-WAYS AND HIGH-WAYS
June, 1919
437
cent development and to overlook the fact
that there is no other branch of surgery
in which such pronounced advance has been
made during the twenty-five years preced-
ing the war.
The care of the wounded from firing line
to convalescent camp is described by
Lieut.-Commander Bainbridge at length.
Thru the courtesy of Director-General
Goodwin of the British Army, he was en-
abled to follow every step in the handling
of wounded men from the moment of re-
ceiving first aid until they were either re-
stored to military duty or discharged as
unfit for further service. As a consequence
Hospital for officers at Highgate. Mr.
. Herbert J. Paterson, the honorary surgeon
in charge, and a gentleman who is well
known in this country, states very posi-
tively that he has come to the conclusion
that treatment in pure, fresh air amid quiet
surroundings means a shortening of the
stay in hospital by nearly one-third. The
convalescent camps in England are given
an extended notice and the physical reedu-
cation of the disabled is discussed ex- ,
haustively, but most interestingly.
The Bulletin is indeed a mine of valuable
information for the general practitioner,
the surgical developments of the war re-
Copyright by Underwood and Underwood.
A Delegation made up of the World's Most Famous Physicians and Surgeons who served with
Allied Forces photographed in front of City Hall, New York, before being taken around
city in automobiles. — These doctors are here in United States for history making confer-
ence which may result in radical changes of army medical practice.
the author is able to give a graphic account
of the various details with regard to the
transportation and care of the wounded,
which is an unusually complete and satis-
factory exposition of the subject.
Hospitals in France, Belgium and Eng-
land are described. Particular reference
is made to the small hospitals in England,
which many maintain are better adapted
for successful treatment than the large in-
stitutions, especially those in metropolitan
districts. A very successful hospital of
this smaller type is Queen Alexandra's
ceiving principal attention as might be ex-
pected, and the medical aspects thereof be-
ing dealt with only cursorily. Commander
Bainbridge very obviously enjoyed unusual
facilities for coming into close and intimate
contact with the conditions in the different
countries at war which he visited, and it
is equally obvious that he availed himself
of his opportunities to the utmost. The
Bulletin thruout is splendidly illustrated
with pictures which add much to the prac-
tical as well as historic value of the report.
The American medical profession is
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438
June, 1919
GENERAL TOPICS
American Medicine
greatly indebted to Commander Bainbridge
for the capable and tireless efforts that
have made this report possible. It is one
of the notable contributions to the medi-
cal and surgical achievements of the war.
Medical and Snrgleal Work as a Prisoner of
>Var« — Captain Alexander T. I. Macdonald
(British Med. Jour,, Mar. 29, 1919) describes
some of the ways in which the vaunted "effi-
ciency" of the Germans differed from the
British methods. Taken prisoner at a French
dressing station in March, 1918, Captain Mac-
donald and a colleague were held prisoners all
day treating British and German wounded
alike. There seemed to be no medical officer
with the German battalion, but only men be-
longing to the medical corps, or BanitiiU per-
sonnel. These men carried a small bag of dress-
ings containing, among other things, a hypo-
dermic syringe and solution of morphine, the
former fitted into a bottle containing absolute
alcohol to sterilize the needle. The injection
of antitetanic serum, tho regarded with sus-
picion at first, was for the most part submitted
to by the Germans. Stretcher-bearing as car-
ried out by the Germans was rather a crude
operation, and in the case of a patient with a
fracture must have led to extreme suffering.
A ground sheet, slung on a pole borne on the
shoulders of two bearers, contained the unfor-
tunate patient. Duckboards and other substi-
tutes were also used. The stretchers used by
the Germans further back were heavier than
the British ones and possessed the advantages
of a head support, hinges for folding and slid-
ing handles. The enemey medical officers re-
mained relatively far back at the Verhandplatz.
or dressing station. Here the author was struck
by the meager supply of surgical material.
Splints consisted of pliable wire— two thick
pieces Joined ladder fashion by thinner pieces,
which were much too pliable for the thigh and
leg, tho often employed for this purpose.
Volkmann's iron gutter was available for frac-
tures of the thigh, but did not secure extension
or immobility in transport as does Thomas*
splint. Marching further back from the dress-
ing station, the author passed a long line of
enemy transport ready to move; this consisted
of a wonderful conglomeration of vehicles, in-
cluding a brougham and pair, open landaus,
Russian droshkies, etc. The ambulance trans-
port consisted of small wagons capable of taking
two stretcher cases, drawn by Russian or Ru-
manian ponies and flying a small Red Cross
flag. The deficiency of motor ambulances was
made up to some extent by attaching to each
a string of two-wheeled trailers. Captain Mac-
donald and his colleague were then sent to one
of the Bavarian Kriegslazaretts overflowing
with British wounded who had received no fur-
ther dressing than the -first and were in urgent
need of attention. They lay on beds, on stretch-
ers, and on paillasses on all available floor space,
including that of the basement cellars. The
operating and dressing room was dirty and
sparsely furnished. A small coal stove served
for the supply of hot water and the sterilization
of instruments. A wash-hand basin was fitted
with a supply of cold water only and was with-
out waste pipe. Instruments were few in num-
ber and partly denuded of plating; this, how-
ever, was remedied later and a gas stove and
electric light provided. The most rigid econ-
omy was entailed in the use of surgical mate-
rials. Soap powder with sand, powdered wash-
ing soda, cakes of clayed earth and fine gritty
material admixed with soap were obtainable at
times; at other times there was no soap of any
kind and one had to trust to prolonged immer-
sion in sublimate solution to afford a degree of
surgical cleanliness. In doing dressings, there-
fore, extensive use was made of forceps and
the wounds were not touched with the fingers.
Rubber drainage tubes were scanty and were
not supposed to be cut, if not of suitable length.
Bandages were mostly of paper. For securing
splints, roller bandages made from lace curtains
or cotton dress materials were used sparingly
and were collected from time to time, washed,
and rolled again for use. A substitute for
cotton wool was provided in the shape of Belk-
St off, made from paper. A substitute for benzol
was used to prepare the skin, with tincture of
iodine for use as a final application. Open
wounds were cleansed by irrigation with diluted
hydrogen peroxide. Moist dressings of dilute
solution of aluminum acetate on lint covered
with Jaconet were used for cellulitis. There
was no shortage of anesthetics. In fractures
of the femur, extension from a clamp applied to
the skin over the lower end of the bone Just
above the condyles on either side was much
employed by the Germans; this resulted in the
skin over the points of pressure becoming
septic and sloughing, with great deformity and
shortening. The author points out that among
the medical cases a variety of nephritis and a
condition (the result of slow starvation) char-
acterized by weakness, shortness of breath,
emaciation, edema of feet and legs and anemia
was frequently met, as was infiuenza, often fol-
lowed by pneumonia. Diarrhea and dysentery
were rife; impetigo, furunculosis and scabies
were common. Pneumonia was rapidly fatal in
the poor starved men who often remained at
the camps for days without treatment before
admission to the hospital. Conditions were par-
ticularly bad among the newly captured men,
who were not only starved but also dirty and
ill-clad, having disposed of part of their cloth-
ing for food. These men received no Red Cross
parcels, and their condition was very different
from those in the next camp who received food,
soap and warm clothing from home. Drugs,
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GENERAL TOPICS
June, 1919
439
chiefly in tablet form, were of good quality. The
hospital dietary was divided under three main
heads: the ordinary diet consisting of half a
bowl of soup, replaced by boiled rice with a
spoonful of dried fruit on Fridays, black bread,
jam, so-called tea or coffee, with occasionally a
small piece of sausage for supper, or bread and
meal gruel. The black bread was sour and in-
digestible and contained sawdust, as the loaves
were rolled in sawdust. Form 2 was similar to
the ordinary diet, but three thin slices of white
war bread spread with margarine were given
instead of the black bread, and the soup was
rather more digestible. A small amount of
milk, an egg, which was usually bad, or a glass
of wine could be ordered as hospital extras.
Form 3 was supposed to be suitable for diarrhea
cases and consisted of thin gruel, pur6e of pota-
toes, etc. As the quantity of white bread given
was insufficient, patients as a rule ask to go
back to the ordinary diet. The beds in the
wards were of wood and were roughly con-
structed. Mattresses were made of paper sack-
cloth filled with wood shavings over which a
sheet was placed. In helpless patients bed
sores were inevitable. No rubber cushions or
water beds could be obtained and a shift was
made with rings of straw covered by bandage.
Clean bed linen was rare and there were no
means of disinfecting clothing. Baths were
given to walking cases and personnel at a large
factory in the town, which had been fitted with
bathing and disinfecting station. The con-
servancy system in the hospital was extremely
crude; the latrines were a source of nuisance
and in the summer flies were very troublesome.
At Conde, where the author spent several days
at a prison on the French frontier, a French
lady succeeded in smuggling to them bread,
lard, soup, and ragout from time to time. From
there Captain Macdonald was sent from place
to place, the last stage of his journey coincid-
ing with the outbreak of the revolution. On
Christmas day he left Germany with, as he
says, a higher opinion of British organization
than ever before.
than others to painful sensations; the chief of
these are the median and sciatic, more rarely
the ulnar and the crural. Occasionally nerve
pains following wounds persist and, instead of
improving, grow gradually worse until they
become unbearable; and soldiers have even
been driven to thoughts of suicide by this suf-
fering.
Thus history repeats itself! In our Civil
War, Weir Mitchell, W. W. Keen, and George R.
Morehouse called attention to the agony en-
dured by some wounded soldiers, whose suf-
ferings resisted every therapeutic aid. To this
condition they applied the term "causalgia."
Last year J. S. B. Stopford, of England, sug-
gested the additional term, "thermalgia."
In a i^ecent article Major Sicard. of the
French army, has described some of his ex-
periences with painful neuritis following
wounds. Major Sicard and his associates
literally tried everything: hot air, steam baths,
radiant light, constriction, electricity, injections
of gas and serum subcutaneously, and of air or
cocainized serum in the nerve sheath, even
dividing and reuniting the nerve. The whole
gamut of internal therapy was run from coal
tar products to morphine, with only temporary
results.
Finally Doctor Sicard had recourse to the in-
jection of alcohol intraneurally, which gave
good results in the twenty-one cases where it
was tried. This was done usually under a
general, but occasionally under a local anes-
thetic The nerve is freed from adjacent tissue
and from one to two c. c. of alcohol of from
sixty to eighty degrees is injected. The results
obtained were very encouraging. Nine ceased
to suffer immediately after injection, and in
forty-three cases treated by Sicard and his col-
leagues there was only one case of nonsuccess.
He concludes that in all refractory cases of
painful affections alcoholization of the nerve
trunk above the wound should be tried, after
the ordinary therapeutic methods have failed,
for we will undoubtedly have a number of these
cases before long.
War Kenritis and Shell Shock.— Much maga-
zine literature in the past three years has
made us fairly familiar, theoretically at least,
says an editorial writer in the New York Med.
Jour. (June 14, 1919) with the condition
variously known as shell shock, war neurosis,
war shock, etc., but we have not heard much
about war neuritis, altho the published observa-
tions of Tinel, Athanassio-Benlsty, Bablnski,
Well, Marie, and others, offer a wealth of neuro-
logic material. Of these writers Madame
Benisty and M. Marie have emphasized espe-
cially the extremely painful affections following
injuries to large nerve trunks. It is a bit diffi-
cult to explain why some wounds are very
painful, while others, apparently accompanied
by exactly the same amount of nerve injury,
are practically painless. About the nearest ap-
proach to a formula of any kind is the discovery
that certain nerve trunks react more readily
Endemic Malaria as a Military Problem. —
Haughwout (Philippine Journal of Science,
Nov., 1918) maintains that the recruiting of
men to form army units from areas where
malaria is endemic or epidemic is certain to
bring together many who, while apparently well,
are carriers of the malarial parasite. Such
carriers, in the presence of anopheline mosqui-
toes, are a source of peril both to any commu-
nity that is comparatively free from malaria
and to their own comrades. When undergoing
the fatigue and exposure of military training,
they are extremely likely to develop the dis-
ease in its active form. Especially is there
danger to neighboring troops if attendant condi-
tions are such as to render antimosquito
measures impracticable and quinine prophy-
laxis applicable only with difficulty. To ob-
viate this, carriers among recruits should be
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440
June, 1919
GENERAL. TOPICS
American Msdicinb
carefully sought out. No reliance should be
placed on the simple examination of blood
films, but use made of concentration or cultural
methods, supplemented in the negative cases
by provocative measures such as the adminis-
tration of adrenin, ergot, pituitary extract,
strychnine, quinine, or horse serum, or irradia-
tion of the spleen with the quartz lamp. These
provocative measures tend to awaken the latent
Infections and bring the parasites into the per-
ipheral circulation, where they can be destroyed
by the usual specific treatment. If quinine
fails to act and is not being sufficiently ab-
sorbed, adjuvants or some other form of treat-
ment should be used. If all measures prove
iruitless, the recruit should be honorably dis-
charged from the service. From the^ surgical
standpoint, the tendency of latent malaria to
become active under the influence of wounds,
operations and anesthesia should be borne in
mind.
Disease and IVoands in the War. — Science
made the World War deadlier than any previous
war, but medical skill restored the balance
(Modem Medicine, May, 1919). The instru-
ments of war were more destructive than ever,
but medical science was more reconstructive
than ever. More men were killed outright, but
fewer died from infections and neglected
wounds, and fewer from the ravages of disease
in proportion to numbers. Foresight and sani-
tation prevented contagion.
The compiled figures on pensions by the Eng-
lish Ministry of Pensions throw much light on
the relative distribution of disease and wounds
in the great war. While this war has been a
triumph for the physician in the conquest of
disease in the army, yet a majority of the pen-
sions granted down to September 1, 1918, were
granted on account of disease.
Out of a total of 421,877 pensions granted,
tuberculosis and chest complaints were respon-
sible for 47,078 or 11.2 per cent.; rheumatism
for 27.424, or 6.5 per cent; heart disease 41,699
or 9.9 per cent; nervous diseases 25,165 or 6
per cent; epilepsy 4,257 or 1 per cent.; miscel-
laneous diseases, including Bright's disease,
debility, ulcer of the stomach, varicocele, enteric
and malariac, spinal, appendiceal, amounted to
81,381 or 19.3 per cent
Altogether the number of persons pensioned
on account of wounds was 42 per cent of the
total as against 58 per cent on account of dis-
ease.
The data of American experience are still
meager, but reports from the Federal Board
for Vocational Education indicate that of the
7,710 cases dealt with up to Jan. 31, 1919, by
far the larger portion was due to disease.
Tuberculosis was responsible for 2,791 cases or
36.2 per cent; heart disease for 843 cases or
10.9 per cent; nervous diseases and shell shock
294 cases or 3.9 per cent; insanity 318 cases or
4 per cent. ; other diseases 2,291 or 29.7 per cent
The total number of cases on account of wounds
was 915 or 12 per cent
The short duration of American participation
in the actual fighting, and the large number of
men in camps make it probable that disease
will, by far, exceed wounds as causes of dis-
ability.
The contrast with previous wars is striking.
Our Civil War produced 309,790 casualties
from wounds and disease, of which 110,070 were
on account of wounds and 199,720 on account of
disease. Epidemics persisted and caused a
heavy drain upon the man-power of both armies.
Figures are not available to show the dis-
abilities other than death respectively by dis-
ease and battle wounds, but all the evidence
indicates that disease was the most powerful
factor in creating disabilities. This was de-
cidedly true of the Spanish-American War, in
which large numbers were permanently broken
in health. Diseases which wrecked the lives
of thousands in 1898 were entirely conquered
in the armies of the fighting nations in the
World War.
We trust that the achievements of medicine
in the war will be completely and popularly set
forth in the near future for the stimulus it will
give to preventive medicine.
America's Defective Manhood. — Following is
the record of the U. S. Surgeon-General on
rejections for the physical unfitness in the first
call of men for military service:
Venereal diseases 938,232
Heart disease 564,768
Diseases of the ear, including defects of
hearing 525,600
Diseases of the eye, including defects of
vision 421,704
Flat feet 346,392
Alcoholism 296,640
Disease of the organs of locomotion 277,128
Hernia 209,304
Disease of the skin 174,672
Under weight 173,160
Diseases of the respiratory system 156,600
Defective teeth 149,112
Weakness of mind 146,088
Defects of development 132,552
Diseases of the genito-urinary system,
non-venereal 124,992
Varicose veins 90,360
Diseases of the nervous system, except
as shown in detail 88,848
General diseases, except as shown in
detail 82,800
Tuberculosis 76,824
Varicocele 48,168
Insufficient- chest development 45,144
Diseases of the digestive system, except
as shown in detail 43,704
Physical debility 38,880
Curvature of the spine 36,144
Over weight and obesity 31,608
Hemorrhoids 22,608
Under height 21,096
Diseases of the circulatory system, ex-
cept as shown detail 7,560
Injuries 207,792
Rejected for causes not physical 1,721,304
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BUtorial OflioMt 18 IBmui 41 at St.. N«w York City. Publioatloa OHieesa 189 CoUei* Si.. Barliniton, Vt.
Oompl«lt 8«rl«t, YoL ZXY. No. 7
New Beriec, Yd. XIY. No. 7
JULY, 1919
f o on niBLT
qQNTENTS
BDITORIAIi OOMBmBrT 441
MEW AND THINGS 4S1
ORIGINAIf ARTICIiBS 487
liONDON liBTTBR 481
'PSrrSIOAIi THBRAPY 488
RATIONAL ORGANOTHE3RAFY 488
BY-WAYS AND HIGH-WAYS 4110
HYGIBNB AND DOSmnCS 402
TRELATMBNT 486
NBWS NOTES AND ANNOUNCBMSINTS 487
(Contlnuad on p«ff8 •)
CONTRIBUTORS
G^oive Blvner, M. "D^ New Haven, Conn.
Wnuam Blartin. M. IX, Atlantic City, N. J.
W. H. lUuid* M« D.* WashinfiTton, D. C.
Mmrrim H. Kahn, M. D., New York City.
HeniT O. Marey. A. M^ M. D.« LI*. D.« Boston,
Masa
J. G. Jlar, M. D., Cairo. Effypt.
latawd as Mcoad-olui maMar Jinnaiy tt, 1M6, al the foil Offiee al Bttrliogloii, Yt, ander Ad of Concreaa, Mareb 8, 1878.
Hot Weather Skin Irritations —
notably chafing^ prickly heat, sunburn and similar afFections
—are promptly relieved by
K' Y Lubricating Jelly
Applied liberally to irritated or inflamed areas, the pronounced cool-
ing and soothing action of this effective local remedy is at once
manifest. Smarting, burning and itching are quickly allayed and
local congestion is rapidly overcome. In fact, by its beneficial effects
upon the skin, as wdl as by reason of its water-solubihty, its abso-
lute freedom from staining skin or clothing, its non-greasiness and
the altogether unusual cleanliness of its character,
K^Y Luhricattng Jelly
is an ideal emollient
In €ollap8ibIe tubes at 25c
Obtainable at all Drug Stora8i
Sample on fsquest.
It relieves itching and burning when most ordinary relief
measures prove ineffective.
NEW BRUNSWIol N. J., U. & A.
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Adrenaliii CUoride Sohdioii
For ^pngrina Ik* note aiid pharpa, (mhn
«likitio& with four to fire tniiM tli TOtuae
of pkgFMologic mk solution).
Suppliod in ounee bottieg,ono in a ovrton.
Adrenalm hhahiit
For aprijing the note and pkuyvK (Ml
ttrengtk or diluted with three to lour
timee its volume of olire oil).
Supplied in ounce bottletbone in a carton.
0.
For aprajing the noee and phaijrns (after
dilution with four to five timee its volume
of phvMolofic eak eolution).
Suppned in ounce bottietbone in acarton.
Ghseptk NebaBzer
The most economical instrument for neb«^
ufiang the Adrenalin and Pituitrin piepa«
rations listed above. It atomiaes down to
the last drop.
fVice, complete widi duoat-pieee» %\J5.
Mixed UedioD PMacosa
For hypodermic or intravenous iigection.
Bio. 595. In lO^ul (ia<>:.) bulbs^ one
inapackage.
Bio. 597. In |.mil (IjCc) bulbs» five in
a package.
Ragweed PoUeD Extract
For prophylazis and traatment (Admin*
istered nypodermicalty.)
Bio. 660. Five tubesb with seari^jring
needle^ for diagnosis^
Bio. 661 Four 5.mil(5Xe.) vials (No. n
10 units; No. 2* 100 units, and Now %
1000 units per miT; No. 4, diluent).
Bio. 661. Number 3 vial 5 mils (5 Co.).
1000 units per miL
Parke, Davis & Co. ,
DBTKorr
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American Medicine
H. EDWIN LEWIS, M. D.» Afatunrimg Editor
PUBUBBB) MOimiLT BT THE AlOBIGlH MKDICAL PUBUSHIKG COMPAirr
Copnifflttod by tiie AowiImii Medieal PabUsbins Co., 1919
IBA S. WILE, Associate Ediiot
Complete Series, Vol. XXV, No. 7
New Series, Vol. XIV, No. 7
JULY, 1919
$2
AA YEARLY
•vU In Advance
The Priae Fight.— The big fight is over.
Midst the mingled plaudits and unvoiced
groans of thousands, the seconds for the
massive Willard cast their towels into the
ring and a new champion was hailed with
honor. It is not the spectacle recalling the
days of ancient Rome, when gladiators an-
nihilated one another to make an imperial
holiday, that merits description. There is
no need for inquiring into the causes lead-
ing to the rapid rise of the new conquerer,
or into the elements contributing to the de-
feat of the powerful but unpopular de-
throned Hercules. There is no reason to
attack or defend public exhibitions of fisti-
cuflFs, nor to question the moral values of
such exhibitions. It is useless to waste
words over the costliness of such a combat
at a time when thriftiness is urged upon
the masses. Nor is there anything to be
gained by pointing out the vast sums of
money which changed hands in the betting
ring. The amount of money involved as
prize for victor and vanquished, and the
short time involved in acquiring it, should
be, but is not, a matter of great concern. It
suffices to say that this prize fight had a
powerful hold upon the interest and imagi-
nation of the general public.
The real striking phenomenon, outside of
the fistic struggle, lies in the amount of
newspaper space devoted to the topic for
weeks in advance, and for several days fol-
lowing the event. The most capable cor-
respondents of the press, selected because
of their ability to grasp a news story, and
to embellish it in choice, attractive or
bizarre language, were sent to Toledo from
all sections of the country to herald the do-
ings of the combatants and their followers
for the daily delectation of innumerable
readers. More newspaper space was de-
voted to the heavyweight championship
contest than was given to many striking
events during the recent war. The epi-
demic of influenza failed to achieve popu-
larity in publicity equal to the comings and .
goings of the exponents of the manly art.
The annual meeting of the American Med-
ical Association received few inches of space
for each page devoted to the fight and its
various phases of development. Public
interest, however slightly existent at the
time the great fight was promoted, was in-
cited and stimulated daily until the event
appeared to assume the proportions of the
most noteworthy event of the day. Sports
held the center of the press stage, and items
of more permanent value were relegated to
subordinate positions.
The power of the press might equally
well be employed for the creation of a
vigorous public health opinion or for the
development of wider knowledge pertain-
ing to public health. Can one imagine
what the result would be if the united press
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442
July, 1919
EDITORIAL COMMENT
American Medicins
were to send a hundred chosen correspond-
ents to an annual meeting of the American
Medical Association, or of the American
Public Health Association, or of some
similar national health promoting agency,
with instructions to gather up columns of
news items affecting the nation? Can one
conjure up the benefits to be derived from
persistent reporting of interviews with
prominent leaders in health and sanitation
upon timely topics under discussion, or the
benefits that would be consequent upon
cumulative series of articles dealing with
personalities, researches and discoveries,
methods of .public health education, and
advances along medical and social lines, as
reflected in the activities of such an annual
event? It may be said that the public is
not interested*, but this is exceedingly doubt-
ful. Were one to grant a lack of marked
interest, it would be to deny the power of
the press to state that a campaign of special
correspondents' publicity would fail to
create an active interest. Despite the large
numbers of the population eagerly seeking
news concerning championship boxing con-
tests; there is an overwhelmingly larger
part of humanity that craves for wider
knowledge and information concerning the
art of healthful living.
A tremendous advantage would inure,
were editors to recognize the greater bene-
fits which they can confer thru the use of
special writers in connection with construc-
tive events in medico-social affairs. There
are countless opportunities for sob stories,
frank news items, didactic narrative, poetry,
political, social and economic notes, biog-
raphy, anecdote, humor, connected with a
large variety of public meetings which are
comparatively neglected or ignored save
for a brief Associated Press notice.
It would be a wholesome experiment for
the press of a single city or state to demon-
strate the truth or falsity of this opinion.
It is difficult to believe that any paper at-
tempting to offer this type of public service
would fail to achieve success. The public
health movement of today, for its greatest
effectiveness, includes public health educa-
tion. The part that the press is to play
in this direction has scarcely been consid-
ered or organized. The most valuable re-
sults will follow not the occasional or daily
medical notes of a column writer, but thru
the organization of featured means of cam-
paigning in behalf of a victory over disease,
as was done in connection with the deter-
mination of a victory, in the square ring.
Restricted Immigratioii. — In a discus-
sion of The Fourth Great Plague — Defec-
tives. (Modern Medicine, June, 1919),
M. D. Clark refers to the problem of in-
dustrial accidents, without, however, mak-
ing any direct relation between the sta-
tistics of industrial accidents and the num-
ber of defectives actually employed. The
burden of the argument thruout the dis-
cussion is that there has been an indiscrim-
inate admission of excludable aliens, who
may serve in part as progeiiitors of a line
of insane, feeble-minded, and criminal off-
spring. This was partly based upon the
fact that about one-third of the dependent
and defective classes cared for in New York
State, according to a report of 1912, were
aliens. It is true that since 1914 deporta-
tions have been suspended, and as a result,
nearly 4,000 excludable aliens have re-
mained in this country, of whom 1,723
were insane. This fact, however, does not
reveal any direct relation to the incidence
of industrial accidents.
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Ambrican Mbdioinb
BDITORIAIi COMMENT
JXJLY, 1919
443
In the factories of New York State ap-
proximately four-fifths of the workers are
foreign bom. The total number of acci-
dents each year, since 1915, when the Work-
men's Compensation Law became effective
has averaged over 274,000. At the present
time, reports of accidents are received at
the rate of 1,000 a day "representing a cost
of $13,000,000 a year as an initial expendi-
ture, to which must be added the cost of
medical benefits, administration of the Com-
pensation Law, wages, and cost of turnover,
all of which has increased the total direct
and indirect cost of accidents in the State
of New York $35,000,000 yearly, or a rate
of about $117,000 per day for each working
day in the year." If one grants that 70
per cent, of the applicants for compensation*
benefits require the services of an inter-
preter, there is still no evidence to indicate
that they are mental defectives.
While accident casualties undoubtedly
diminish the working potentials of the
country, they do not of themselves have a
dysgenic effect upon the next generation, in-
sofar as heredity is concerned. Patently,
the problem is more significant in relation
to immigration than to the general subject
of mental defectives.
Immigration is a matter of serious con-
cern today, not merely from the standpoint
of industrialism, but from the point of view
of public health. The tide of immigration
has apparently turned. Already a million
and a half of workers have left these hos-
pitable shores to return to their homelands
with their worldly goods, for the purpose of
participation in the rebuilding of devasted
areas and for caring for their families
which may be scattered or sorely in need of
increased protection and aid. It has been
estimated that fully five million aliens have
declared their intentions of returning.
These comprise the vigorous and active im-
migrants of a few years ago, whose partici-
pation in the labors of this country was
most necessary and productive. This loss
of manpower is not readily compensated
for by. native born workers, who are not
keenly anxious to participate in those pur-
suits denominated as "common labor."
The type of immigrants now coming to
this country has altered considerably. Dur-
ing 1915, 326,700 immigrants entered the
countr}', of which Italians supplied approx-
imately 15 per cent. ; English, 8^ per cent. ;
Germans, 6 per cent.; Greek, 5 per cent.;
Hebrew, 8 per cent.; Japanese, 2^^ per
cent.; Mexican, 3 per cent.; Scandinavian,
13 per cent. ; Slovak, 9 per cent. ; Irish, 14
per cent. ; French, 3^^ per cent. By way of
contrast, during the month gi March, 1919,
our immigration consisted of English, 18
per cent. ; French, 8 per cent. ; Irish, 5 per
cent.; Japanese, 7 per cent; Mexican, 28
per ' cent. ; Scandinavian, 5^ per cent. ;
Scotch, 7 per cent.; Italian, 2 per cent.
These changes are of considerable signifi-
cance, particularly in view of the fact that
our figures for immigration are still exceed-
ingly low.
While the first quarter of 1919 shows a
small increase over the similar period for
1918, it represents, for example, only about
one-sixth the immigration for the first three
months in 1913 or 1914. During the four
years of the war, beginning with January,
1915, the total number of immigrants ad-
mitted into the United States thru Decem-
ber, 1918, amoimted to 1,031,546, whereas
in 1913, the admissions amounted to over
1,380,000, and in 1914, because of the ef-
fect of the beginnings of the war, to
750,000. This, therefore, marks a tremend-
ous falling off in immigration which is now
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July, 1919
EDITORIAL COMMENT
Amkrican Mkdicini
to be accentuated by an unprecedented
emigration.
The demand for workers from abroad is
not great at the present time, as the surplus
of labor has not been absorbed by industry
after conversion from a war to a peace
basis. It will not be long, however, before
tlie question of replenishing the labor ranks
will be of serious moment, and then the
problem of determining upon the stock to
be .admitted will have an increased signifi-
cance. It is patent that future immigrants
must be physically and mentally sound.
They must be educable and adaptable.
Mental defectives and physical incapables
must be barred not merely for economic
reasons, but for the sake of promoting the
racial advancement of the peoples now con-
stituting the united nation. The health and
efficiency of the United States must be safe-
guarded thru the rejection of blood in any
way contaminated, devitalized, or dysgenic.
The serious consequences of war upon the
health of foreign lands increase the neces-
sity for rigid immigration laws, wherein
national sympathies shall not be permitted
to override sane judgments concerning
public health.
An immigrant may be an asset or a liabil-
ity. The one is a desirable ; the other is an
undesirable. The exclusion of undesirable
aliens is of greater consequence than mak-
ing provision for deportation under various
conditions. Deportability provisions must
necessarily exist, but the efficiency of the
system of admissions is tested by the infre-
quency of need for acting upon laws pro-
moting deportation. Exclusion of unde-
sirable aliens is more productive of public
health benefits than wide-open laws, with
compensatory provision for deportation.
The mental defectives, insane, criminal and
seriously diseased must not be admitted re-
gardless of their social or economic position
or the hazards of more or less immediate
dependency.
Infant Mortality^ — Despite all the care
it was possible to give during the war, and
made necessary by it, the deaths in the
United States during 1918 increased by at
least half a million over the number during
1917. During 1917, the number of births
exceeded by 60 per cent, the total number
of deaths,' whereas during 1918, the excess
of births had fallen to about 24 per cent,
over the deaths, based upon the reports of
162 out of 253 cities in the United States of
over 25,000 population.
According to the New York Milk Com-
mittee, the general infant mortality rate,
based on reports received from cities
comprising 26 per cent, of the population,
increased from 97.5 per thousand births to
104.1. The significance of these figures,
despite the fact that the Children's Year
had created many agencies for child wel-
fare, depends upon an appreciation of the
ravages of the influenza. The smaller
cities revealed the lowest infant mortality
rates, but the larger cities have a rate
lower than that found in cities with a popu-
lation of 50,000 to 100,000. The causes of
this variation are variable, but undoubtedly
involve the greater attention paid to public
health administration in large cities and
the higher degree of thought given to in-
dustrial hygiene.
That the rate of 104.1 is still very much
higher than warranted by our present state
of knowledge of infant hygiene is apparent
from the fact that Brookline, Mass., Madi-
son, Wis. and Pasadena, Cal. were able to
report infant death rates below 50. San
Francisco lowered its infant morality rate
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BDITORIAIj commbnt
JUI.T. 1919
445
from 73.6 in 1917 to 57.2 in 1918. These
represent standards and tendencies which
denote the possibilities of organization for
the care and protection of childhood. It is
interesting to note that while the • total
deaths at all ages in 1918 were more than
31 per cent, higher than in 1917, and the
living births were only 1.6 per cent, higher,
the infant mortality rate was only 6.7 per
cent, higher, while the percentage of deaths
under one year to the total deaths decreased
by 17.4 per cent. This, of course, is due
to the tremendously high mortality rate in-
cident to influenza among the active adults
between the ages of 25 and 45. Another
statistical evidence of the sad destructivity
of the recent jepidemic is found in the in-
crease in the percentage of still-births by
10.8 per cent, over 1917, while the still-
birth rate reflected an increase of 8.8 per
cent.
•
Infant Mortality and Birth Rate-
It is well known that a high rate of in-
fant mortality does not necessarily accom-
pany a high birth-rate. Ignorance, poverty,
industrial pressure, unsatisfactory food
supplies and inadequate housing play their
parts in determining infant mortality, irre-
spective of general figures as reflected in
birth rates. A single epidemic will vitiate
all figures interpreted in the light of eco-
nomic factors, when no relation is discern-
ible between the epidemic mortality and the
economic status of sections of the commun-
ity, or when the mortality arising from the
epidemic factor appears to have no regular
plan of distribution in the earlier age
periods as contrasted with later periods of
life.
While at first blush the increased mortal-
ity rate of 1918 might appear to be a reason
for discouragement and dissatisfaction with
modem methods of hygiene and sanitation,
when the complete figures are available and
an analysis of various facts shall have been
made in comparison with similar items in
1917, it will be evident that as a whole, the
infant mortality rate may be regarded as
remarkably low, considering all the elements
militating against infant welfare during a
period of war, food shortage, high cost of
living and pestilence. Undoubtedly, the
campaign of the Federal Government in be-
half of infancy has played a large part in
keeping down the infant death rate which,
had there been no epidemic, would have
fallen below any figures previously known
in this country.
The general interest in the welfare of in-
fancy and childhood, transmuted into active
and effective organization, is accomplish-
ing results that challenge one's admiration.
The perils of the second summer no longer
exist. The frightful fears of cholera in-
fantum, summer diarrhea, the dangers of
cutting teeth in the summer time and the
various other bugaboos of the previous two
decades have practically vanished. Prenatal
care, supervised midwifery, infant welfare
stations, district nursing and improved milk
standards represent a few of the most ef-
fective means of reducing infant mortality.
The development of medico-social efforts in
this direction has achieved rich rewards,
and their further growth will necessarily
cause still greater reductions in the mortal-
ity rate of infants. Preparation and organ-
ization based upon an understanding of
the fundamental problems involved can be
productive of naught but success.
Public health administrators are no longer
dealing with theories or experiments in this
direction. The facts are obvious. The
methods are almost standardized. Failure
to make use of the modem methods of
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July. 191»
BDITORIAIi CX>BiMENT
American Msdicins
lowering the infant mortality rate consti-
tutes an indictment of a community.
July and August — ^The months of July
and August stand forth prominently in med-
ical statistics as pointing out diseases re-
quiring particular attention. By way of
example, one need but note the tendency for
typhoid fever and malaria to increase mark-
edly, despite the fact that methods for their
control are thoroly imderstood.
The vacation tendency is responsible for
many deaths, particularly those of a violent
nature. During 1916, approximately 20 per
cent, of the deaths from violent causes oc-
curred during these two months. The in-
creased use of automobiles, the extension
of transportation, the growing speed along
the highways suffice to account for the fact
that the mortality from violent causes in
1916 was fully 3,000 more than during the
year 1911. The Safety First Movement
has much to accomplish in this direction,
altho the marked decrease due to the insti-
tution of a safe and sane Fourth of July
has had some effect upon the relative mor-
tality, even if it has not greatly affected the
total results.
A considerable improvement has been
noted in deaths from congenital debility, ex-
cluding premature births, which, as a rule,
begin to increase during the month of July,
A noteworthy decrease in deaths from this
cause to the extent of 1,200 lives was evi-
denced in 1916, over 1911.
It is striking to note that the gross mor-
tality from diarrhea and enteritis under two
years decreased very slightly during the five
year interval from 1911 to 1916, tho the
total figures referred to must be recognized
as representing results from a larger regis-
tration area during 1916 than during 1911.
Despite this fact, however, there was a total
decrease of approximately 2,000 recorded
deaths from the cause under discussion.
That this eflfect is real rather thafti apparent
is shown by a gross increase of 300 deaths
from diarrhea and enteritis, two years and
over in the same five year period.
Fortunately, the summer is not the time
for epidemics of contagious diseases, and
measles, scarlet fever, whooping cough,
diphtheria, influenza and even tuberculosis
show considerably lowered mortalities be-
ginning with July. Bronchitis, bronchial
pneumonia and pneumonia similarly are
relatively inactive during the hottest months
of the year.
The main factors apparently involved in
the mortality of July and August include
flies and mosquitoes, a lack of sanitation of
food and water supplies, the depressing ef-
' f ects of high heat and humidity, and a lack
of precaution against the hazards involved
in transportation of various kinds, plus the
dangers inherent in the games and sports of
the summer time.
Automobile Accidents^ — ^There is every
reason to believe that automobile regu-
lation calls for stringent action. In 1906,
automobile accidents were responsible
for a mortality rate of 0.4 per hundred
thousand population as compared with 7.3
in 1916. The most distressing feature lies
in the fact that 27.9 per cent, of the total
number of deaths from automobile acci-
dents were of children under 15 years of
age. In cities the death rate from auto-
mobile accidents and injuries is compara-
tively higher than that due to railroad acci-
dents and injuries. This indicates the special
need for the control of automobile traffic
under urban conditions.
Whether the habits of vacation by city
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AMERICAN MEDICn^a
BDITORIAIj CX>MM£NT
July, 1919
447
dwellers in rural communities are respon-
sible or not, there is a compelling interest
in the fact that typhoid fever and malaria
begin to flourish far more in the rural parts
of registration states than in the cities. The
necessity for the control of insect pests and
the importance of improving the sanitary
conditions in rural sections are thoroly un-
derstood, and only recently have received
a new impetus, so that figures of this char-
acter should begin to alter during the next
few years. The nearness of rural dwellers
to the source of food supplies and the de-
creased problem of refrigeration and sani-
tation are well exemplified in the tremend-
ously low mortality rate from diarrhea and
enteritis compared with that found in cities.
That this state is not due to a greater cli-
matic comfort in rural sections is suggested
by the fact that deaths from congenital de-
bility are higher in rural districts than in
urban sections. This is in part, of course,
due to the greater attention given to child
welfare in cities and the better facilities for
giving medical and nursing attention to
those stricken by disease.
The control of a comparatively few ele-
ments during the months of July and Au-
gust would result in a greatly decreased
morbidity and mortality rate. The dimi-
nution of contagious diseases cannot be at-
tributed to the eflfects of sanitation in toto,
but probably results from the failure of the
summer time to conduce to the optimum
conditions for the development and dissem-
ination of the causal agencies responsible
for epidemic diseases, which are not com-
pletely eliminated, but in their endemicity
appear to be greatly lowered in vitality and
weakened in virulence. Those diseases,
however, which do flourish at present dur-
ing the summer months, are strictly within
the category of preventable diseases, and, as
such, their continuance is not merely a
menace to public welfare, but a challenge
to the public health movement.
The conquest of preventable diseases is
possible with the expenditure of proper de-
grees of effort, with requisite organization
and reasonable appropriations of money.
Time, men and money should be able to
wipe out the needless mortality of summer,
beginning with July and August.
Indemnity or Preventi<nLr— The report
of the Wisconsin Social Insurance Com-
mittee presents the conclusion "that the ac-
ceptance of compulsory health insurance is
neither practical nor feasible at this time.'*
The reason for the rejection lay in the be-
lief that "there are no outstanding social or
economic conditions in Wisconsin at this
time which would make health insurance,,
as a compulsory measure administered by
governmental authority, either necessary or
expedient." Back of this statement is a
further belief that a health insurance act
cannot be enacted without an amendment
to the State constitution, if it were deemed
necessary to establish such mandatory leg-
islation. The alternative of a voluntary
system is rejected because of the serious-
and complicated administrative considera-
tions which would be involved.
The committee, after varying discussion,,
sums its problem up in this query: "Is it
more humanitarian to indemnify or to pre-
vent?" There is no question as to the im-
plied correct answer, if one must necessarily
make a choice, but on the other hand, the
two are not mutually exclusive. All eflforts^
at prevention will not eliminate disease and
accident, while indemnification will tend ta
increase general interest and efforts at pre-
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July, 1919
EDITORIAL. CX>MMENT
AUWBICAS MBDICINS
vention, in order to reduce costly compen-
sations.
Fully recognizing that sickness of the
wage earner, with consequent loss of wages,
is a serious problem, it is manifestly proper
that there should be a thoro investigation as
to the proper remedy to be applied. In
Wisconsin the committee reports that "it
is not satisfied that health insurance would
be a proper remedy." In order to be
constructive, while rejecting a specific
health insurance bill, the committee ad-
vises greater efforts be made to extend and
increase the efficiency of existent preventive
agencies. It recommends more liberal ap-
propriations by states and local communities
in order to increase the machinery of hy-
gienic agencies already in operation. Its
suggestions include the appointment of
county health officers, the development of
state health laboratories, with the hope
"that they may be made in the course of
time, centers of preventive medicine, and
become useful in the possible future de-
velopments of so-called group medicine."
It urges the general employment of physical
and medical examinations in public schools,
with considerable emphasis upon the funda-
mental necessity of providing adequate
methods of child and school hygiene.
It advocates the encouragement and es-
tablishment of district nursing centers for
the purpose of giving more proficient nurs-
ing care, especially during prolonged Jllness.
It points out the importance of seeking the
reduction of infant mortality as part of the
public health program, and advises the es-
tablishment of a bureau of child welfare in
connection with the state health organiza-
tion.
There is much merit in the suggestion
for greater financial aid from the legisla-
ture for the support of hospitals and sani-
taria, and its suggestion that every county
should have no less than one thoroly equip-
ped modern hospital for general purposes
must be accepted as a rational and far-see-
ing program. It is of the opinion that oc-
cupational diseases should be included in
the workmen's compensation act, that com-
prehensive housing plans should be adopted
to provide sanitary homes for the future
growing industrial population, a subject of
increasing importance to this country in the
face of present shortcomings.
Some Favor Health Insurance^ — ^
minority report was submitted advoca-
ting a compulsory health insurance law,
after disagreeing with the majority as to
the necessity for a constitutional amend-
ment as necessary for its adoption.
Waiving aside the constitutional ques-
tion, there is a marked difference of opinion
as to the advantages of indemnification, as
opposed to preventive measures. Herein
lies the most mooted topic discussed in con-
nection with health insurance. It requires
no long argument to prove that illness will
always exist. The greatest efforts of
public health work will never result in pro-
ducing earthly immortality. The best that
can be hoped for is the prolongation of life,
due to effective measures resulting in a cer-
tain indefinite postponability of disease,
with a reduction of some epidemics and,
possibly, the control or elimination of
others.
The general decrease in morbidity is a
marked advantage to the community, but
whenever wage losses occur, the burdens
must be borne by individuals, even tho
society as a whole may be responsible for
their development. It is merely an act of
justice that the burdens of wage loss should
be borne by the state instead of serving to
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Amkrican Mbdicinb
EDITORIAL COMMENT
July, 1919
449
weaken the powers and vitality of personal
units comparatively unable to stand the de-
privations following in the wake of many
accidents and diseases. The Wisconsin
Committee chooses to advocate increased
facilities for the prevention of disease and
to regard it as tantamount to securing the
complete reduction of preventable sickness
and consequent wage losses. With their
splendid premise, their conclusion is a non
sequitur, as the necessity for indemnifica-
tion cannot be removed, regardless of any
appropriations that might be made. The
extent to which wage losses will fall upon
society will undoubtedly be decreased, but
where existent, they will be none the less
devitalizing and opposed to the best inter-
ests of public welfare.
Wages and Cost of Living. — ^Wages
have increased, but so has the cost of living.
The United States Bureau of Labor Statis-
tics, in the early part of 1919, established
its opinion that $15.50 was the minimum
amount required to meet the necessary cost
of living to self-supporting women in the
District of Columbia. Among the items
comprised in this amount is an allotment of
50 cents a week for sickness, dentistry, and
oculist ; 20 cents for amusements ; 25 cents
for a vacation, and 35 cents for savings and
insurance — and it must be remembered that
this is a higher minimum than has been
fixed anywhere in the United States. It
is hard to understand how good citizenship
is encouraged by this minimum wage, which
certainly allows no opportunity for active
contribution to governmental loans or even
the purchase of thrift stamps. It is difficult
to appreciate how such a woman would be
able to give herself medical and nursing
care in the event of an illness depriving her
of her earnings, if any of the machinery of
prevention should fail to accomplish the
remarkable things hoped for by the Wis-
consin Social Insurance Committee. The
scant allowance made for savings in insur-
ance is obviously inadequate to enable her
to purchase health or accident insurance so
as to guarantee some financial return during
the period of enforced inactivity. Even
were she to apply the magnificient sum of
twenty cents provided for incidentals to this
use, she would still be unable to protect her-
self against the losses and hardships incident
to any serious affliction. As a matter of
fact, all her funds for insurance would
scarcely suffice to provide for a decent
funeral.
The possibility of accident or disease be-
ing existent, one may reasonably ask where-
in prevention plans will remedy in any way
the situations actually created by the inci-
dence of illness. The prevention of disease
and indemnification for disease, far from
being mutually exclusive, are essentially
complemental procedures, and the welfare
of society will be best promoted by the
adoption of both programs by public health
authorities.
Mental Defectives.— The interest in
mental defectives continues unabated. A
recent report entitled "Mental Defect in a
Rural County," by Treadway and Lund-
berg, is presented as a result of the collab-
oration of the United States Public Health
Service and the Children's Bureau.
The investigation demonstrates the ne-
cessity for combined medical and psycho-
logic examinations, supplemented by thoro
social investigations, in order to determine
the prevalence of mental defectives in com-
munities. The extensiveness and serious-
ness of the problem are marked in rural
communities and serve to emphasize the re-
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JXJLY, 1919
EDITORIAL. COMMENT
Amibican Medicine
sponsibility of society to provide adequate
care for the mentally defective.
The conclusions stress the importance of
a number of separate items which merit
the thought and appreciation of physicians,
psychologists, educators, philanthropists
and civic authorities. The medico-psycho-
logic examinations should always supple-
ment studies of social and moral reactions
in order to definitely determine the exist-
ence of mental defect. It is patent that re-
actions to environment may cause a men-
tal habitus simulating in a measure that
present among mental defectives. It is of
extreme importance to differentiate between
such attitudes or states of mind and those
dependent upon inherent cerebral defects
of congenital or acquired origin.
It is noteworthy that the percentage of
feeblemindedness among white males in
both the school and general populations,
from five to twenty years inclusive, was
found in Sussex County, Delaware, to be
greater than that among the white females.
This fact corroborates previous observa-
tions reported by the United States Public
Health Service in regard to school popula-
tions. Similarly, the percentage of mental
defect among colored school children was
greater than that observed among white
school children. This item probably will
require further investigation before it is
beyond the pale of reasonable criticism.
The problem of caring for mentally de-
fective persons is generally little understood
and for that reason is usually neglected in
rural counties, in states which make no
provision for tiie care of such persons. Ob-
viously almshouses are unsuitable for their
care. The practice of placing out depend-
ent children must be safeguarded lest men-
tal defectives from one state find asylum
in another state and thus add to the per-
centage requiring special attention.
Institutional care is essential for many
mentally defective persons who should be
segregated not merely because of benefits
accruing to themselves thru supervision and
training, but as a measure of protection of
the community against their lack of self-
control and their anti-social potentials. It
is necessary that mental defectives be
studied individually, and their home con-
ditions should be carefully weighed in order
to arrive at a sound conclusion as to the
type of care needed. Dependent feeble-
minded children should not be placed in
family homes, unless both children and fam-
ily can be properly protected by constant
and careful supervision.
Public protection calls for a recognition
of the relation between defective mentality
and pauperism, degeneracy, crime, alcohol-
ism, the dissemination of disease and other
social evils. All too long, mental defect-
ives have been regarded as problems merely
requiring psychologists and educators. They
have been recognized as aflfording problems
in connection with school organization. Only
recently, has there been sufficient attention
devoted to the relation between public
health and mental defectives. The subject
should commend itself to health depart-
ments as a legitimate field of inquiry and
control.
Surveys of the type under discussion
possess a distinct value in stimulating
thought and in focusing attention upon this
problem. The willing cooperation of the
United States Public Health Service indi-
cates a recognition by the Federal Gov-
ernment of the importance of the subject.
Its conclusions merit the flattery of imi-
tative investigations, and the establishment
of rational machinery to put into effect the
indicated types of relief requisite for the
protection of the public from the evils aris-
ing from neglected mental defectives.
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Amskican Meoicins
MEN AND THINGS
July, 1919
451
N AND THINGS
The Death of Dr. Jacobin — ^As we go
to press we learn with heartfelt sorrow of
the sudden death of that Grand Old Man
of American medicine,
Dr. Abraham Jacobi.
For a great many years
Dr. Jacobi has been one
of the country's fore-
most medical men. Re-
spected, loved, and hon-
ored by all who knew
him, probably no other
physician has ever held
a higher place in the af-
fectionate regard of his
colleagues than this Ger-
man-born but' true
American physician.
The extent to which his judgment and
opinion have been esteemed by all who
knew him, has been shown by the fact
that no public question of medical or soci-
ologic importance has been considered well
discussed or settled until Dr. Jacobi's view-
point and advice have been obtained. "What
does Dr. Jacobi think about it?" has been
a general inquiry if his opinion has not
been in immediate evidence. It has seemed
to be the common belief that his statement
on any given topic would be the sound,
common sense conclusion of a man who
knew what he was talking about, and whose
judgment, therefore, it would be safe to
follow. The enormous influence such a
man can wield for good has been abun-
dantly shown thruout the last twenty-five
years of Dr. Jacobi's life. During all these
years to the day of his death he has been
a sane, conservative adviser, a man who
has been able to see the right and help
others to see it, also. His poise, his kind
and sympathetic manner, and withal his
sterling honesty have made men trust him
as few men are trusted.
His loss is a very real one, and altho a
man in his ninetieth year must be expected
soon to pass on, the passing of Dr. Jacobi
has filled us with the deepest sorrow and
regret.'
These words are penned hastily and by
no means constitute the tribute we intend
to pay to this great American physician.
In our next issue, we shall have several
splendid memorial articles.
Well Done and FarewelL — It is cus-
tomary to record with words of welcome
the birth of a new medical journal. Too
frequently, their passing from a life of ac-
tivity goes unnoticed. The June issue of
War Surgery and Medicine was the final
one. Having had its origin in the necessity
of furnishing medical officers with literature
in abstract relating to war surgery and
medicine, its reason for existence no longer
persists. As an ephemeral, emergent con-
tribution to the literature of war, it de-
pended upon a number of collective ab-
stracts as a means of presenting a vast
amount of important material for the bene-
fit of medical officers at home and in the
field, who had little opportunity for search-
ing out the specific articles relating to their
special type of medical or surgical work.
The eighfeen issues which have appeared
have been of distinct service, and those who
have contributed in preparing the manu-
script and supervising the publication de-
serve the approbation and congratulation of
their colleagues whom they served. Those
who possess a complete file of the Review
of War Surgery and Medicine own a valu-
able compendium for future reference
which does not appear to be covered by an-
other single volume thus far available. The
only unfortunate fact is that the editors de-
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MBN AND THINGS
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cided to give no index, thus making it
somewhat difficult to locate various sub-
jects to which reference might be made in
the future. Inasmuch as the purpose of
the journal was to cover a period of emer-
gency with what may be regarded as sub-
ject matter of timely interest, tho possibly
without great permanent utility, this omis-
sion may be forgiven. The fact remains,
however, that the contents have all ap-
peared in other publications where they ap-
peared originally, with the exception, of
course, of the special orders and memo-
randa originating from the office of the
Chief Surgeon of the American Expedi-
tionary Forces.
The editors having deemed their services
ended, and the publication having ceased,
there is naught to be said or done save to
set up a monument attesting faithful serv-
ice and meritorious achievement. It ceases
to be published after its work is done, and
dies a self-sacrificing death, at the height
of its able career.
The Anti-Vivisection Fallacy. — Once
more the anti-vivisection issue comes to the
fore, this time by no less a personage than
one of our law-makers. Senator Meyers of
Montana. And once more one feels com-
pelled to call attention to a fact which, ob-
vious as it seems, has nevertheless escaped
the notice of so keen an intelligence as that
of the worthy Senator : that the chief weak-
ness of the anti-vivisectionists is that the
basis of their whole contention is their
humaneness, because it is the type of
humaneness which, oddly enough, has a
very decided quality of mischief and cruelty
in it. No doubt innumerable delicate souls
were touched to the point of tears by the
Senator's eloquent appeal to spare that
noble household pet, the dog^ from the
savage brutality of science ; but there must
have been a handful of thoughtful persons
who winced at the lack of insight, foresight
and hindsight which the appeal betrayed.
For, as in every case of such humane ap-
peals in the past by the anti-vivisectionists,
they have invariably lost sight of the fact
that their kindness toward the animals they
sought to protect involved a denial of kind-
ness to the whole human family; that, tho
they proved themselves humane in one re-
spect, they showed themselves cruel and
thoughtless in a much more important re-
spect. Despite the absurd insistence of the
anti-vivisectionists, the scientists who use
animals in their experiments do not do so
because they satisfy an unreasoning impulse
toward cruelty. They do so because they
are moved by a very commendable desire
to be of service to humanity. To deny
them the privilege of using animals in their
experiments would be to deny them the
privilege of serving humans. When we re-
call how much suffering humanity has been
saved as the result of experiments on ani-
mals, we cannot but feel that the cruelty of
the anti-vivisectionists is of a much more
positive type than that of the scientist, for it
condemns humanity to a slow process of
medical and surgical progress which in-
volves much needless suffering. Would
any anti-vivisectionist admit that he is more
concerned about the suffering of the animal
than that of the human? Hardly. Yet that
is inevitably the conclusion one must draw
from his contention.
In the case of Senator Meyers, his special
appeal is in the interest of the dog. As
usual, he fails to understand that there is
no suffering involved at all, that no dog is
submitted to the knife of the surgeon or
scientist without the administration of an
anesthetic which does away with all pain,
or nearly all pain. But even if the dog
did (endure hardship and agony, what then ?
The Senator bases his whole plea on the
strength of the dog's great service in the
war. He forgets that on the battlefield that
faithful animal was exposed to dangers in-
finitely more cruel and hazardous than those
to which the scientist exposes him. He was
used to carry messages thru barrages and
gas attacks ; he was employed to bring first
aid to the wounded under the heaviest of
shell fires; he was made to draw machine
guns into positions swept by rifle and artil-
lery. And, believing no less than the
Senator in the faithfulness and devotion of
that noble animal, we rather feel that he
was not at all loath to do all this for the
masters to whom he was so deeply attached.
Dogs have been known to sacrifice them-
selves in more than one instance out of love
for their masters. In view of his high
esteem of that animal, of his conviction that
he is man's most devoted friend, how can
Senator Meyers escape the obvious conclu-
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MEN AND THINGS
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453
sion that the loyal creature who exposed
himself to gas and shell and bullet in the
service of man would be just as ready to
expose himself to the knife and the experi-
ments of science in order to bring healing
and hope to mankind? If dogs were en-
dowed with speech, one cannot doubt that
they would approve more heartily of peace
service than of war service. Not only does
sacrifice in the interest of peaceful science
bring larger and more thankful rewards,
but it involves a great deal less danger and
suffering to the animal himself. Senator
Meyers* choice of the dog as the special ob-
ject of his charity, his choice of the dog's
war service as his best argument, are par-
ticularly unhappy ones. One is rather in-
clined to think that the dog is a much more
willing victim than the guinea-pig or the
rabbit, his nature is more self-sacrificing.
And, if the truth were known, it is as likely
as not that the dog would object very
strenuously to the Senator's effort to limit
his power to serve, or his privilege of suf-
fering to relieve the ills of mankind.
New York as a Medical Capital.— It
would be regrettable to think that the phy-
sicians of this country have waited until
Berlin and Vienna have been rendered im-
potent by the havoc of war to wrest the
medical leadership from them and to make
New York the Mecca of students of medi-
cine. The fact is, however, that, tho this
plan is only now being organized and
pushed forward vigorously, it was con-
ceived before the war and was unavoidably
held in abeyance because of uncertain con-
ditions. The project does not involve an
attempt, therefore, to reap any benefit from
the unhappy plight of the former medical
capitals ; it is merely the result of a pre-war
realization that the vast population and the
facilities of New York City have always
held out an opportunity which the authori-
ties have not shown themselves quick to
seize — an opportunity which was in reality
an obligation. Sensitive as we are, it is
amazing that we were not offended by the
annual spectacle of students and profes-
sionals wandering out of the country and
seeking the benefits that Berlin and Vienna
held out to them in the way of study and
specialization — benefits which New York
could not offer them, merely because its re-
sources, rich as they are, had not been em-
ployed. And yet all that goes into the
making of a medical capital New York has
possessed in a degree that even Berlin and
Vienna cannot boast. It has, in the opinion
of Health Commissioner Copeland, an
abundance of clinical and laboratory ma-
terial unrivaled by any city in the world.
The Health Department of New York City
has the greatest vaccine laboratory in the
country. There are 30,000 hospital beds
in the city, and there are more beds on
Blackwell's Island alone than there are in
all Vienna. This matter of the number of
hospital beds is an important one, in that it
promises unlimited opportunities to both
students and specialists as a fertile field for
their studies. And yet earnest students
have gone abroad in thousands annually to
cities where the opportunities are not nearly
as attractive. The fault, however, has not
been with the students ; it has been with the
authorities who have not possessed the vi-
sion to mobilize these resources and utilize
them for the benefit of medical progress.
Dr. Wendell C. Philips, general surgeon at
Bellevue, supported by a group of notable
physicians, has revived this commendable
plan, and an effort is being made to raise a'
fund of $50,000,000 to further it. There
should be little difficulty in carrying the
plan to success. In. addition to possessing
the physical resources, we are well supplied
in this country with the material for leader-
ship, with specialists who could give stu-
dents all the advantages of training which
they could obtain abroad, and with clinical
material which few European cities can
offer. With all these advantages, it is not
to be doubted that even before the war
New York City could have supplanted, cer-
tainly could have rivaled, Berlin or Vienna ;
and, if the money is forthcoming and both
public and profession are awake to the op-
portunity, it would be a comparatively easy
achievement in view of the present situation
of those cities. It is not at all unlikely that
European students, looking about for the
most comprehensive field for study, will
come to New York in future, aware of its
more extensive resources. Certain it is, in
any case, that the public in this country will
benefit very largely from the achievement
of such a plan ; for many students who can-
not afford the expensive luxury of study
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abroad will be able to make their more ad-
vanced studies in this country, thus putting
the opportunity of specialization within
reach of nearly all and raising the medical
standard thruout the country as a conse-
quence. In its own interest, if for no other
reason, the public should show itself most
friendly to the plan.
The Doctors' Dudemnuu— While East-
ern doctors are dawdHng their time away
with such trifling and inconsequent enter-
prises as making New York City the med-
ical capital of the Western Hemisphere and
trying to raise a fund of $50,000,000 for the
undertaking, two Minnesota physicians,
ready to lay down their lives with a gal-
lantry that must touch the hearts of every
romantic nature, are prepared to come to a
death-grip to prove whether germs cause
death or do not. Dr. H. A. Zettel, a St.
Paul electropath, does not believe that
germs cause death. Dr. H. W. Hill, ex-
ecutive officer of the Minnesota Public
Health Association, presumably does, tho
the telegraphic reports are not specific on
this head. It would appear that the dis-
pute between the gentlemen came to a stage
where the only honorable settlement pos-
sible was a duel to the death, and a challenge
was promptly forthcoming. It is encourag-
ing to think that the romantic and noble in-
stitution of the duel still survives among us,
despite the havoc that progress has wrought,
and it is to be hoped that the fastidious
formalities which graced that institution
were minutely observed. Dr. Zettel having
issued the challenge, it remained with Dr.
Hill to choose his weapons; and, tho he
was obliged to resort to an old practice to
satisfy his honor, he was modern and pro-
gressive enough to select a weapon more
in keeping with the times than swords or
pistols, implements discredited in a demo-
cratic age because of their association with
discredited militarism. He chose germs,
certainly an original and worthy choice,
and in the near future, unless craven spirits
intervene to stop it, the duel will take place.
Unfortunately, however, the choice of
germs as a duelling weapon, tho made in
good faith and with the most gallant in-
tentions, involves difficulties which the
gentleman perhaps did not foresee, or, fore-
seeing paid no heed to. Germs, regrettably
enough, are less tractable as weapons than
swords or pistols. In dealing with these
latter, one deals with inanimate objects
which have no volition of their own and
which lend themselves without trouble to
the purposes of man. But germs are not
inanimate, they are living things, and they
have a personality, and entity, that cannot
be overlooked. Germs have opinions of
their own, they have their likes and dislikes,
they have a well-established affinity for
some people and they have a very marked
antipathy for others. And, however fully
one may approve of the doctor's decision to
use germs, one cannot help wondering how
the germs will feel about it, whether they
may not resent this decision which was ar-
rived at without consulting their wishes in
advance. For it is well known how proud
and sensitive germs are, and, as likely as
not, they may rebel against what niay ap-
pear to them as an undignified and insult-
ing attitude on the part of humans. For a
long time now they have enjoyed the re-
spect, even the fear, of humanity, and who
can say that they will not consider the
Minnesota doctors' attitude a slur on their
national pride? If they do, and it is not
at all impossible that they may, the duel so
amicably arranged may suffer the direst
consequences. It has been arranged that
both gentlemen subject themselves to ex-
posure to germs of the most virulent type,
typhoid, smallpox, bubonic plague, and
other fascinating diseases; but what if tfie
germs should become sulky, should feel in-
sulted, and, at the critical moment, refuse
to enter into the dispute? What if they
should refuse **to bite" the fearless duellists?
It would be disheartening in the extreme.
It would be a disappointment from which
an anxious world would not recover so
easily. And it is a hazard which the duel-
lists cannot invite. In the interests of
science, in the interests even of the issue that
has arisen between the two gentlemen, one
feels impelled to suggest that they improve
their respite between now and the day of
the duel in trying to cajole the germs they
have selected into consenting to the use for
which they have been chosen, to persuade
them that it is in the interest of humanity
that they infect and infect with a good will
when the word is given.
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MEN AND THINGS
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455
The Case of Henry Ford. — Genius is,
in a sense, necessarily a form of limitation.
The human brain has a certain measured
capacity, and, if it attains its utmost de-
velopment in one regard, it must often do
so at the sacrifice of others. The price of
great knowledge about one thing, is often
the forced neglect of many other things.
Bearing this in mind, it becomes obvious
that a shrewd cynic could easily prove that
any genius is an ignorant man by ignoring
the one subject which the genius knows
thoroly and pressing hard for answers on
the subjects which he has had to sacrifice
in order to attain supremacy in his spe-
cialty. It is this method that has been
pursued by the lawyers who cross-examined
Henry Ford in the libel suit that has held
the interest of the country for so long and
which* has been given such wide publicity
by the newspapers. These lawyers so con-
ducted their examination as to leave the
public with the impression that Mr. Ford's
Ignorance is appalling. It is quite true
Mr. Ford showed that he was unfamiliar
with many things, but, by pursuing a similar
method, it would be a very simple task to
prove any highly specialized mind to be in-
competent. Jascha Heiffetz is the most
brilliant of the new violinists, a remarkable
musician, a genius in the fullest sense of the
word, but anyone bent on exposing his
ignorance could do so without any trouble
by ignoring the one subject he knows
thoroly and sounding him on every subject
but that. Thomas A. Edison is one of the
great geniuses of the world, but it is a
safe wager that he could not oflFhand hum
the andante of Schubert's C Major Sym-
phony or answer many questions in regard
to this nation's early history to save his life.
John Burroughs, the naturalist, like Edison
a warm friend of Henry Ford's, would
have an extremely uncomfortable time
trying to give the names of the three
leading batsmen of the National League,
a fact known to the shabbiest little street
urchin. The achievement of the lawyers
was a trifling one, and the public will
hardly as a consequence of it hold in less
esteem the man whose services in the last
decade or two have been so completely
the common property of the nation —
the man who defeated the Selden Patent
and thereby did such a great service to
the American people and American in- .
dustry ; the man who invented and brought
within the reach of the poor man an auto-
mobile which has no rival in point of econ-
omy and efficiency; the man who pointed
the way to employers thruout the land in
improving labor and factory conditions.
But there is much more than this to
counteract the impression the lawyers have
sought to establish. It is commonly recog-
nized that the skilled attorney, with years
of experience in the court-room, has a
great advantage over an inexperienced wit-
ness who is subject to the elements of nerv-
ousness, anger, personal antagonisms and
hastiness, and an unscrupulous cross-ex-
aminer can lead an unsuspecting witness to
make statements which are ridiculous or
erratic in the extreme. For example, it is
a comparatively simple thing to coax a
modest man like Mr. Ford to admit that he
is ignorant on many subjects. If for no
other reason, his modesty alone would pre-
vent him from admitting anything else. But
over and above everything else, there is an
element in the trial which has worked
enormously in the favor of Mr. Ford, as
far as the esteem and affection of the large
public is concerned. Anyone who has ever
served on a jury will know that the men in
the box invariably are distrustful of the
sharp witness and they are disposed to dis-
count the testimony of a clever individual.
On the other hand, they have a tendency to
lay great weight on the testimony of a retir-
ing, modest witness, believing that what he
says must be of value because he is not of a
type to invent subtle evasions. The effort
of a prosecuting attorney to trap such a
simple witness, an easy thing to do, counts
for very little and is often not even taken
into account in arriving at a verdict. What
must have impressed everyone who has fol-
lowed the Ford trial in the papers is the
amazing honesty, simplicity, and lack of
affectation in the man. He was as ready to
give testimony against himself as in favor
of himself in order to establish what he
considered the truth, and no one could fail
to admire his plucky willingness to assume
all responsibility himself. His is a remark-
ably simple, straightforward nature. And
his frank, humane, uncomplicated attitude
toward war is the attitude of the vast ma-
jority of men, whatever their intellectual
attainments may be. He hated war — ^most
of us do. He was afraid of preparedness
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— most of US are; and it is a pity that his
lawyers did not bring out the fact that :t
was German preparedness which made the
world war possible; it is a dangerous
weapon which the less conscientious ele-
ments are tempted to use in their interests.
He thought war was murder and he did
everything possible to keep this country out
of it in order to prevent murder ; and if he
bent all his energies toward helping his
country win the war once we were in it,
it was because of the humane realization
that it would be less costly in human life to
forward the war than to hinder it The
lawyers attempted to prove him inconsis-
tent, but he was consistent always. He was
the average human being who hates war
and who fights like the very devil when he
is made to do what he hates. The Ameri-
can Army was the powerful instrument it
was because it was an army of pacifists
forced to leave its peaceful pursuits and
determined to end war forever, to destroy
the nation that still believed in war as an in-
strument of progress and achievement. And
there is one detail which came out in the
trial which has the greatest significance in
revealing the quality of the man's earnest-
ness and honesty. Many sons of the rich,
swivel-chair patriots, rushed into cover
early in the war and got themselves soft
berths which kept them in safe places and
permitted them to wear khaki and talk
loudly of the great things they were doing
to help win the war. Mr. Ford's son, legiti-
mately exempted because he was important
in an essential industry, could have worn
khaki if he wanted to, but he never did
tho he could have done so with greater
justification than some of the noisy young
patriots. His father felt that he was merely
doing his duty, like the workers under him,
and that there was no reason for any special
ostentation on that account. It is things
like this, which have come up thruout the
trial, which have won a wide sympathy for
the simplicity and the genuineness of the
man. Whatever the extent of his general
knowledge, his heart has always been in the
right place. He may have been wrong in
some of his views, but it is one of the pre-
cious privileges of democracy that a man
may be sincerely wrong without incurring
any punishment. In pursuing what he felt
was the right, the humane path, Henry Ford
never violated the law, never employed any
methods but those which the constitution
permits every free citizen. His is a frank,
simple nature; but the great truths are as
accessible to the simple people as they are to
the sophisticated. And he tried to proclaim
the truth as he saw it. He spent a consid-
erable part of his fortune in trying to bring
this truth before the public. We cannot
help feeling that many millionaires have
spent their money in much worse ways than
that, and that many rich men, claiming to
be well educated have done a great many
things that Henry Ford's innate sense of
right would never let him do.
The Narcotic Question.— The narcotic
drug problem continues to serve as a sub-
ject of acrimonious discussion with its
solution apparently no nearer. T© the
regret of a good many thoughtful people,
Health Commissioner Copeland has insti-
tuted his promised system of registration.
It is too early to determine the success or
failure of this system and it is only right
to withhold criticism until it has been given
a fair trial. There can be no question but
that it has worked a great hardship on many
innocent sufferers and added greatly to
their cup of misery. But the ultimate ben-
efits may justify all this, and we hope noth-
ing will arise to cause Dr. Copeland to re-
sign before his ideas relative to the control
of drug addiction have been well and thoro-
ly tested. It is too bad that he was unable
to use the buildings placed at his disposal,
by the Rockefeller Foundation, for the plan
to use them to provide institutional care
for narcotic addicts was an admirable one.
Those who prevented its consummation
either thru prejudice or unwillingness to
furnish adequate funds have shown a most
deplorable lack of interest in this problem
qf drug addiction. Dr. Copeland's work,
however much some of us may honestly
disagree with him in regard to certain of
his methods of handling the drug addict,
surely deserved better cooperation from the
Mayor and the Board of Estimate. One
thing is certain, those who disagree with
the Health Commissioner in some respects,
cannot fail to approve his fight to have the
drug addict considered a suflFerer from a
definite disease requiring intelligent treat-
ment, rather than a vicious individual or
.criminal deserving correctional punishment.
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457
'ORIGINAL
TICLES*^^
RECONSTRUCTION AND THE MED-
ICAL PROFESSION.'
BY
GEORGE BLUMER, M. D.,
New Haven, Conn.
Reconstruction is the catchword of the
hour, and in discussing reconstruction and
the medical profession it is essential to
clearness to define the scope of the re-
marks, for there is little doubt that the
term "reconstruction" means many things
to many men. Furthermore the changes
which should be brought about in the or-
ganization of the medical profession may
be considered from many points of view,
so many in fact, that it is necessary to con-
sider only a few of them. With regard to
the significance of the word *'reconstruc-
tion" I would state that medicine has al-
ways progressed by evolution rather than
by revolution, and that while the word "re-
construction" may be used as a peg on which
to hang certain ideas, what we are really
endeavoring to do is to take advantage of
the present state of flux to accelerate cer-
tain changes which have been developing
for many years. With regard to the par-
ticular aspects of the reconstruction of the
medical profession which are to be consid-
ered, it has seemed to me that those which
are of the greatest interest to the general
' One of a series of lectures on the problems
of reorganization, delivered under the auspices
of Yale University on the Dodge Foundation.
public are the ones which concern the con-
tact between them and the profession, rather
than other more abstruse aspects, such as
medical education, or the purely scientific
aspects of medicine in which the general
public is not so widely interested.
An intelligent discussion of the changes
which should be brought about in the rela-
tionship of the medical profession to the
public demands a brief statement as to the
present organization and functions of the
medical profession, and the present atti-
tude of the public toward the profession
and its functions.
As at present organized the medical pro-
fession can be divided into two great groups :
First, the so-called practicing physicians who
come into contact with the public as indi-
viduals, and secondly, the much smaller
group of physicians who are engaged in
public health work, and come into contact
not with the individual but rather with the
community. It is hardly necessary to re-
mind an audience of this kind that recent
years have seen an increasing tendency to
specialize among both groups of physicians.
There have been those who have suggested
that the old type general practitioner or
family doctor was doomed to extinction,
a view which in .my opinion is entirely er-
roneous. It is, nevertheless, true that the
proportion of the practicing profession
which is engaged in special work has been
steadily increasing so that we now find
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many men who devote their entire time to
particular diseases: eye and ear, nose,
throat, diseases of the nervous system, etc.,
or who are confining their work to insti-
tutions. It is true that this process is seen
in its most intensive form only in the larger
cities, but it is also to be noted that modern
methods of transportation have made real-
ly remote country districts so scarce that
we are beginning to find groups of special-
ists developing in the smaller towns which
serve as centers for the surrounding coun-
try. In the public service group, too, spe-
cialization is beginning to appear as the old
broad field of public health is being divided
into smaller ones.
While the bulk of the medical profession
is still engaged in private practice the pro-
portion engaged in community work of
various kinds has been steadily increasing.
This increase has been due to a variety of
causes, but after all the most vital and
fundamental cause has been the general
growth of the feeling of social obligation
which in the case of the medical profession
has taken the form of an extension of vari-
ous forms of community work by physi-
cians. The school physician for example,
is the growth of the past generation.
Just as the organization of physicians can
be discussed under the two heads of the
public and the private physicians, so the
function of physicians can be considered
in the same way. The first function of the
great bulk of the medical profession is still
the treatment of disease in the individual
patient. On the other hand the work of
public physicians is almost entirely prevent-
ive, as in the case of the members of the
United States Public Health Service, health
officers, or school physicians.
It must be apparent from the preceding
remarks that the medical profession has in
the past been mainly concerned with the
cure of disease and to a lesser extent with
the prevention of disease. The chief hope
of the medical profession for nearly a hun-
dred years has been that it would in time
be possible to change the emphasis of* med-
ical practice from cure to prevention, and
the burning problem of the day concerns
the best methods by which this change can
be brought about.
We may assume to begin with that no
matter what steps may be taken to further
the prevention of disease, sickness, to an
extent that will require the services of large
numbers of physicians of the practicing
type, will continue for many generations,
if not indefinitely. He would be either a
very prophetic or a very reckless individual
who would undertake to predict the ex-
tent to which the applicaion of preventive
measures would in the future affect the oc-
currence of disease. We may of course
hazard some guesses as has been done by
Professor Fisher in his valuable report on
National Conservation, but it is well to rec-
ognize that while it is undoubtedly true that
tremendous improvement can be made, any
estimates as to the possible extent of that
improvement are nothing but guesses. Two
problems therefore confront us, one to de-
termine the best methods of improving the
treatment of disease and the other to ascer-
tain the best methods of preventing disease.
One of the most important factors in the
cure of disease is its early recognition and
its early treatment. Even the intelligent
public have not fully appreciated this. There
is often delay in calling the physician be-
cause many serious illnesses have in the be-
ginning the appearance of trivial indispo-
sitions. There are other delays which are
due to sentimental factors and still others
to financial factors. The most distressing
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July, 1919
459
example of delayed treatment due to factors
of sentiment is that presented by the insane.
There is a certain stigma in the minds of
the public which is attached to hospitals for
the insane, a stigma which results from tra-
dition rather than from reason. Further-
more the judicial procedures and the pub-
licity connected with the commitment of
an insane individual to an institution act
as*a deterrent. There is in many states a
lack of proper provision in the form of
psychopathic wards in connection with gen-
eral hospitals where voluntary commitments
without legal procedure are possible. These
unfortunate circumstances have the prac-
tical effect of causing the friends or rela-
tives of the insane to put off institutional
treatment to the last possible moment,
greatly to the detriment of the patient. An
example of what is meant by financial dif-
ficulties preventing the early treatment of
disease in the case of the worker who is
subsisting on a bare living wage which per-
mits of no waste of money. The patient
fails to consult the physician early because
he feels he cannot afford it. The investi-
gations which have been conducted in re-
cent years in connection with health in-
surance have indicated that notwithstand-
ing the fact that most large cities have their
free dispensaries, a not inconsiderable per-
centage of workers of the class named fail
to consult the physician when they are suf-
fering from illnesses which to them may
seem trivial, but which are in reality the be-
ginning of some chronic and incapacitating
disease. This is sometimes due to the lack
of evening clinics, the patient feeling that
time cannot be spared from working hours.
There are certain other aspects of medi-
cal diagnosis and treatment which present
definite problems of interest to the general
public and especially to the citizen of mod-
erate means. With the increasing complex-
ity of medicine has come an increasing ex-
pense to the public. In the old days the
armamentarium of the successful practi-
tioner consisted of a stethoscope, a reason-
able degree of intelligence, and a good bed-
side manner. There are still diseases so
obvious that nothing more than this is
needed for their recognition and treatment.
On the other hand, complications arise in
connection with the most obvious diseases
which require methods of investigation or
methods of treatment which were unknown
to our professional ancestors. There are
many diseases * which are exceedingly
obscure and their diagnosis involves
the use of various expensive procedures and
tests, such as X-ray examinations, bacte-
riologic and serologic examinations, blood
examinations, and extensive and costly
analyses of secretions and excretions.
Many of the laity know from painful ex-
perience that this is an expensive process,
and the statement not infrequently made
that it is the very rich and the very poor
who get the best medical treatment con-
tains more than a grain of truth. This in-
creasing complexity of medical practice has
resulted in a form of organization in the
profession itself which, while fairly com-
mon in the middle west and far west, has
not yet appeared very frequently in the east.
The form of organization to which I re-
fer is the so-called group practice. It is
perhaps best illustrated by an institution
like the Mayo Clinic where an association
of specialists of different kinds have built
up and organized an institution for the in-
tensive study of disease. In many of the
larger cities of the west, little Mayo Clinics,
so to speak, have sprung up. A group of
physicians consisting perhaps of a general
diagnostician, a surgeon, an X-ray special-
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ist, a laboratory specialist, and an oculist
and aurist have associated themselves so
that if a patient applies to any one of them
and is found to be suffering from some
obscure disease, each of the firm makes an
examination with his particular speciaUy
in mind, and the resulting conclusions drawn
from all of the examinations are much
more likely to solve the case than the con-
clusions of any one man of the combina-
tion. From the point of view of the pub-
lic, group practice is almost as expensive
as traveling around from specialist to spe-
cialist, altho the association of physicians
into a group very often results in a cutting
down of the overhead expenses for rent and
service, so that a regularly organized group
can give an opinion at a less expense than
a group of scattered specialists. Neverthe-
less the expense of this type of examina-
tion to the patient is so serious that unless
it is conducted in the charity wards of a
hospital only individuals with not inconsid-
erable incomes are able to afford it. An
attempt has been made at some places,
notably at the Massachusetts General Hos-
pital, to meet the situation by organizing
such groups of physicians in connection
with the outpatient department on a semi-
charitable basis. The patient unwilling to
be regarded as a charity patient whose ob-
scure condition is to be investigated pre-
sents himself or herself at the outpatient
department on stated days, receives the
group examination, and pays a modest fee.
The question of the prevention of dis-
ease is a complicated one in which three
main factors are concerned. These are the
nature of disease itself, the reaction of the
community to health problems, and the re-
action of the individual to health problems.
I have purposely avoided naming the phy-
sician as one of the factors, because he
serves merely as an instrument and his
functions will, in the last analysis, depend
upon what the public wants.
It goes without saying that in order to
prevent disease it is necessary to have a
clear conception of the nature of disease,
and here we meet with our first stumbling
block. Our knowledge of the nature of
disease, while it has grown enormously and
is constantly being extended, is still far from
complete. There are certain groups of dis-
eases, the infectious diseases particularly,
concerning which we possess sufficient
knowledge upon which to found a rational
system of prevention. On the other hand,
there are other groups of diseases such as
the so-called degenerative diseases like can-
cer, hardening of the arteries, Bright's dis-
ease, etc., our knowledge of which contains
very serious gaps. It is true of course that
tentative attempts at prevention can be
made even tho one's knowledge is not ab-
solutely complete, but it is clear that at any
rate for certain kinds of disease our efforts
at prevention will be for some time and to
a certain degree, a groping in the dark.
The present reaction of the community
to health problems can be pretty well esti-
mated from the experiences of the past
century, for the reason that it was during
that period that what may be called com-
munity preventive medicine, has been devel-
oped. The main function of public health as
developed up to the present time has been to
originate and organize methods of prevent-
ing the wholesale spread of disease and par-
ticularly of certain infectious diseases which
may be transmitted by methods controllable
in a large way. Such matters as the reg-
ulation of public water supply, the proper
disposal of sewage, the regulation of insan-
itary housing, the control of quarantine and
measures of this kind represent the type of
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public service that the medical profession
has been mainly giving during the past cen-
tury. The reaction of the public to such
measures has on the surface been satisfac-
tory, the measures being of course promul-
gated in the form of laws, the infraction
of which was punishable. It is not neces-
sary, however, to go very far below the
surface to find evidences of thr^e factors
which have obstructed progress in public
sanitation, these factors being indifference,
ignorance, and greed. The indifference of
the general public to the enforcement of
sanitary measures has usually been demon-
strated when as the result of that indiffer-
ence some widespread outbreak of prevent-
able disease has occurred. The indiffer-
ence is, no doubt, partly founded on igno-
rance, a factor which is more important in
connection with personal than with com-
munal hygiene. The element of greed is
an obstructing factor in various ways. It
is merely necessary to recall, as an exam-
ple, the fact that it has been necessary to
enact laws against unhygienic homes and
overcrowding because landlords of the com-
mercial class have been concerned with
their profits rather than with the health of
their tenants. Even at the present time one
does not have to go far to discover that
where there is a conflict between the laws
of heiilth and unscrupulous or unthinking
commercial interests, it is the laws of health
which usually suffer.
The question of the reaction of the
individual in matters of health is be-
coming an increasingly important one.
The nineteenth century was the century
of communal hygiene. The twentieth
century is to be the century of individual
hygiene. I do not mean by this to Con-
vey the idea that the work of communal
hygiene is at an. end. This is by no means
the case ; it must always continue. As time
has gone on, however, it has become increas-
ingly apparent that communal hygiene would
carry us so far and no farther, and that in
the last analysis the prevention of many dis-
eases is a question of individual hygiene.
It is difficult to estimate to what extent the
public has reacted to this view, which has
perhaps not become sufficiently diffused
among them to attract their attention. We
know that they have reacted to some extent.
Vaccination against smallpox is both a com-
munal and an individual matter. An in-
creasing number of individuals has volun-
tarily submitted themselves to vaccination
against other diseases like typhoid fever,
but as yet there has been no general reac-
tion on the part of the public as to the sig*
nificance and importance of individual hy-
giene.
It is clear then that in the prevention of
disease certain methods which are already
in use must be continued and must be ex-
tended. The community methods of dis-
ease prevention which have already been
mentioned, namely, the question of proper
water supply, proper disposal of sewage,
proper housing conditions, and adequate
health supervision by trained experts must
become universal. At the present time it
is fair to say that this aspect of preventive
medicine has not beefi carried to its log-
ical conclusion even in the most civilized
countries. Only the other day there was
a report in the Journal of the American
Medical Association of an outbreak of
water-borne typhoid fever in a fairly large
American city. The proper disposal of
sewage is notoriously lacking in a great
many American communities, particularly
in rural communities. The question of
overcrowding and improper housing has
been re-emphasized by the conditions of the
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war. A few months ago a prominent man-
ufacturer in a neighboring city told me that
many of his laborers who worked in eight-
hour shifts were living three and four in
a room, and that if a room had a bed in it,
the bed was generally continuously occu-
pied by relays of workers. While such con-
ditions as these are perhaps temporary, it
is nevertheless true that there are still
thousands of rooms in a city like New York
with no windows at all, or with windows
opening into a dark air shaft. In order
to completely carry out the known and
tried preventive measures of community
hygiene it will be necesary for the Ameri-
can public to accustom themselves to a much
higher rate of taxation than that which they
enjoy at present.
The problem of the education of the in-
dividual in proper methods of living and
of escaping disease is the most important
one before us at the present time. It in-
volves not merely the medical profession
but also the educators of the country, be-
cause it is clear that the problem is largely
an educational one. If every child were
taught in school the principles of right liv-
ing, including such matters as the princi-
ples of nutrition, and the proper choice and
preparation of food, fresh air, exercise,
bathing, recreation, and the known methods
of avoiding infectious diseases, a long step
would have been taken in the direction of
inaugurating individual hygiene. However,
the educational side of the matter is only
one side, and of itself would not suffice to
bring about satisfactory conditions. It must
be combined with compulsory physical train-
ing under professional supervision, for the
health training of the child, even tho ap-
preciated and understood by the pupil, will
often be counteracted by the ignorance, in-
difference and prejudice of the parent. The
professional supervision should begin be-
■fore the birth of the child. Work of this
kind has already been inaugurated in many
places under the general title of prenatal
nursing. While such work must of course
be under medical supervision, the actual
contact with the patient can be brought
about thru specially trained nurses, and the
great bulk of the work can and probably
must be done by them. Following the birth
of the child, particularly among those
classes who are .unable to afford the ex-
pensive help of a trained nurse, the work
of education should be conducted thru in-
fant welfare stations, as is already done in
many places. Some of you may have noted
that there is already a move to extend this
work and to carry it on beyond the period
of infancy into the period of childhood.
Dr. Emmet Holt of New York was, I be-
lieve, the first to suggest the necessity for
continuing infant welfare service as child
welfare service. His suggestion is without
question a most excellent one, the only crit-
icism of it being that it does not go far
enough. The principle under which pre-
natal service, infant welfare service, and
child welfare service have been originated
is the principle which must underlie the
individual preventive medicine of the fu-
ture. That principle is of course the peri-
odical medical examination of the individual
irrespective of sickness. It is, in a sense,
a return to the Chinese tradition of paying
the physician to keep one well, and paying
him nothing if sickness occurs. At the
present time we find only sporadic attempts
to put this principle into operation among
individuals past the age of childhood. Sev-
eral universities have health departments
before which students must appear at stated
intervals and submit to physical examina-
tion. Some of vou are doubtless familiar
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with the fact that certain life insurance
companies furnish free of charge an
annual examination to their policy holders,
and some of you are doubtless ac-
quainted with the work of the Life Ex-
tension Institute which for a small fee
furnishes an annual examination to its
members. All of these are moves in the
right direction, but like Dr. Holt's child
welfare clinic they do not go far enough.
What is necessary in order to carry in-
dividual preventive medicine to its logical
conclusion is the periodical examination of
every individual from the cradle to the
grave. It seems to me that by beginning
in infancy and childhood this can be brought
about and that this is the only way that it
can be universally brought about. One can
imagine a period in the future when it will
be just as natural for an individual to sub-
mit to a periodic health examination as it
is to clean the teeth or brush the hair. It
is this condition that we must aim for. One
of the great difficulties in the prevention
of many of the most serious chronic dis-
eases lies in the fact that we do not see
them until they have progressed beyond re-
pair. As a matter of fact we do not see
then) because we have not learned to rec-
ognize their early stages. A well-known
but somewhat iconoclastic Scotch physician
recently remarked of a learned volume on
hardening of the arteries that it was like
reading the third volume of a three volume
novel. In other words, it was a discussion
of end results and not a discussion of be-
ginnings, and the reason for this was not
lack of acquaintance with current medical
knowledge on the part of the writer, one of
the most learned of physicians, but was
merely an expression of the fact that no
one in the medical profession is at present
acquainted with the early manifestations of
arteriosclerosis. It is only by some system
of periodic examination that we shall ever
become acquainted with the early manifes-
tations of the chronic diseases and it is
hardly necessary to add that until we have
become acquainted with their early mani-
festations we shall never prevent them.
Any plan of individual preventive medi-
cine which involved merely the physical ex-
amination of the individual would be, to
say the least, one-sided. Along with proper
physical examination must go an adequate
mental examination. Not merely from the
point of view of health, but also from the
point of view of education and of success
or failure; in life this mental examination
is of the greatest importance. At the pres-
ent time the mentally fit children are pe-
nalized by their association with the mentally
unfit, altho in some cities a serious attempt
is being made to remedy this by the sort-
ing out of the mentally defective children
and placing them in special classes. From
the medical point of view the great neces-
sity is the recognition and segregation of
the feeble-minded. There is good reason
to believe that the number of feeble-minded
in the community is quite considerable. In
Connecticut Professor Gesell states that ap-
proximately one and one-quarter per cent,
of the children of school age are
definitely feeble-minded. It is frequently
not recognized by the general public that
the problem of the feeble-minded is quite
different from the problem of the insane.
An insane person once possessed a mind
and therefore there is a chance that he or
she may recover it. A feeble-minded per-
son is suffering from an inborn lack of
mind and this lack can never be supplied.
The most important medical aspect of the
problem of feeble-mindedness lies in the
fact that it is transmissible, and that if the
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feeble-minded are permitted to be at large
and to marry without restraint, the problem
will become with each generation a more,
rather than a less serious one. For this
reason routine mental examinations as well
as routine physical ones should be insisted
on. It may be added, tho this is not strictly
a medical subject, that there is little doubt
that methods will be perfected by the psy-
chologists whereby these routine mental ex-
aminations will result in an ability to apply
intelligent vocational guidance to young
adults at the outset of their life work and
to prevent many of the occupational misfits
which are now so common.
So far in discussing the reorganization
of the medical profession I have made no
reference to its possible future relation-
ships to other professions and particularly
to the nursing and engineering professions.
If it is true that the future of medicine lies
in the prevention of disease and that the
future of prevention lies not only in the
continuation of the present community hy-
giene, but in an extension of preventive
methods to the individual, it must be clear
that the medical profession as at present
constituted will be entirely insufficient to
carry on the work. This being so one of
two things must happen — either the medical
profession must increase tremendously in
numbers, or it must call in to aid it other
allied professions. The history of medical
education in the United States for the last
twenty years shows a progressive diminu-
tion in the output of physicians due partly
to the elimination of large numbers of com-
mercial medical schools and partly to the
increasing complexity of medicine with its
increasingly long and expensive period of
preparation. It seems probable that the in-
creased personnel, which will be demanded
by emphasizing individual hygiene, wjU not
be supplied from the ranks of physicians
but will result from the development of
trained helpers recruited from the nursing
profession and from social service workers.
It is not impossible that entirely new types
of public health workers will be developed.
One can. readily foresee that if the public
ever accepts to the full the principles dis-
cussed above, the number of communal
physicians and communal nurses will in-
crease enormously, partly, of course, at the
expense of the individual physicians and
nurses. There are already indications that
to some extent this process is taking place.
The increasing amount of work which is
annually done by visiting nursing associa-
tions, and the increasing number of nurses
who are going into public health work are
straws which show which way the wind is
blowing.
So far as help from the engineering pro-
fession is concerned, it is clear that this will
come not so much on the side of individual
hygiene as on the side of communal hy-
giene. Indeed it is already apparent after
two or three generations of communal hy-
giene that the engineering profession is per-
fectly able to occupy the higher positions
in connection with the administration of
sanitary problems, which were formerly oc-
cupied by medical men, and while I believe
it to be a mistake to eliminate the medical
point of view entirely from communal pub-
lic health, I do believe that much of the
work involved in this particular form of
preventive medicine can be carried on by
members of the engineering profession.
It does not seem particularly profitable
to present theoretical possibilities without
at the same time facing the practical prob-
lems connected with their adoption. So
far as I know no accurate figures are avail-
able at the present time giving the amount
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465
of money which is annually expended by
the American public for the cure of dis-
ease. The contemplation of the amount of
money that is annually expended for the
prevention of disease in the way of national,
state and municipal health departments is,
if contrasted with some other expenditures,
a subject likely to give rise to mixed emo-
tions. The United States Government is
willing to expend enormous sums in inves-
tigating the diseases of hogs, or the diseases
of wheat, but comparatively small sums in
investigating diseases of human beings.
There is a United States Department of
Agriculture, but there is no United States
Department of Health in the wide sense.
The amounts spent by States on their health
departments as contrasted with the amounts
spent on some other departments must be
a source of joy to the cynically minded, and
if those of you who are local tax-payers will
contrast the percentage of your taxes that
is devoted to public health with the percent-
age that is devoted to the protection of
inanimate property, you will, I think, find
food for thought. All of this leads up to
the question of whether an attack upon dis-
ease from the standpoint of prevention rath-
er than from the standpoint of cure will be
more or less expensive than the present
system. At the present time I think it is
safe to say that no one knows. It is quite
certain that in the beginning, that is before
the period when the new preventive meas-
ures have a chance to reduce materially the
prevalence of disease, the process would
probably be an exceedingly expensive one.
One of the forms of public education which
is most seriously needed from the stand-
point of health is the education of tlie tax-
payers in the point of view that they have
got to pay much larger sums than they have
been accustomed to pay for this particular
purpose.
Suminary. — If we attempt to summar-
ize what we have said in the form of con-
clusions, they would be about as follows:
(1) The medical profession is at pres-
ent mainly organized with a view to the
cure of disease rather than the prevention
of disease.
(2) It is highly desirable that the em-
phasis should be changed and that preven-
tion should be not only recognized as the
desirable ideal but that more active meas-
ures be taken to put it into effect.
(3) Aside from communal methods of
prevention, such as good water supplies,
good sewage, proper housing conditions,
etc., which must not only be persisted in
but must be made universal, the hope of
the future lies in individual hygiene.
(4) The basic principle underlying the
enforcement of individual hygiene is the
periodic health examination and this must
begin with the examination of the expect-
ant mother and must continue thruout the
life of the individual from infancy to old
age. Combined with it there must be ob-
ligatory instruction of all children during
the school age in the fundamental laws of
health, and to this must be added obliga-
tory physical training.
(5) In order to carry out this program
it will be necessary to greatly increase the
number of community physicians and at
the same time to greatly increase the num-
ber of their co-workers, the public health
nurses.
(6) It is doubtful whether a wholesale
change in the methods of medical practice
such as has been suggested can be brought
about in the first place without great ex-
pense. Whether this expense should be
met by an increase* in direct taxation or
whether it could better be met by the ex-
tension of the principles of health insur-
ance is a question which can perhaps be
more satisfactorily decided by the econo-
mists than by the physicians.
(7) The successful diagnosis and cure
of the more obscure diseases have become
so complicated and expensive that ways
must be found of permitting the average
citizen to avail himself of modem methods
at reasonable cost.
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SOME OBSERVATIONS ON CIRCU-
LATORY DISORDERS.'
WILLIAM MARTIN, M. D.,
Atlantic City, N. J.
There has been considerable progress
made in scientific medicine in late years,
and with this has grown a better knowledge
of circulatory disturbances, but concerning
some phases of these conditions there still
remain some points of dispute.
The mass of literature available upon
this subject should clarify the haziness of
the atmosphere, but unfortunately the de-
ductions are not uniform and different
writers have as many different views, which
tends to confuse. This applies to hyperten-
sion particularly. The word "essential" is
one that when applied to high blood pres-
sure opens up controversy. Some of the
prominent internists insist that high blood
pressure is essential to sustain the circula-
tion. Why should a blood pressure be es-
sential? In the Standard Dictionary one
of the meanings given to the word is, indis-
pensible, while another is, idiopathic or not
connected with any other disease.
In the case of a young physician under
the writer's care for some months running
a systolic pressure of over 200 mm. bg.
with a correspondingly high diastolic dur-
ing the early part of his treatment, the state-
ment was made by one of the prominent
internists that his pressure was essential.
This was subsequent to some weeks of ob-
servation and all known laboratory and
other tests having been made with negative
findings, the work being done in one of the
recognized high grade hospitals. He was
told to go home and forget it.
'Read before the Amer. Electro-Therapeutic
Asso.. at Boston, Mass, Sept., 1918.
He questioned the value of the advice
and sought treatment for what he believed
to be something pathologic in spite of the
above statement, recognizing that there was
at least an intestinal toxemia that needed
attention and which was largely responsi-
ble. In addition to this, there was a large
nervous element in the case which he recog-
nized. In his and the writer's judgment,
had his hypertension been essential to his
good health, he should not have had to
give up a large and lucrative practice on ac-
count of being too ill to attend to it, but
should have felt in prime condition. The
outcome of the case proved this contention.
The usual recognized methods of treatments
by auto-condensation, wave current, and
vibration, together with dietary and other
care, brought his pressure to normal, and
with this, a return to health and resumption
of his practice.
The word "compenss^tory" is another
that is over-worked by some. There are
cases that are satisfactorily recognized as
compensatory owing to organic changes,
but the statement that "nature does not
cause a pressure above what is necessary
for circulatory purposes" is not correct.
Those who make such a statement advise
against all methods of reduction other than
what can be dpne by rest and diet. The
falsity of this is being constantly demon-
strated by all who are treating such by
electrical methods.
In the cases of early hypertension, aside
from the intestinal toxemia, we will find the
nervous element to be the one factor that
stands out in a prominent way etiologically.
In normal conditions, the vaso-motor center
in the medulla is in a state of moderate
tonic excitation. It can be stimulated di-
rectly or reflexly. Fluctuations in the irri-
tation of the center accompany respiratory
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movements (Trauben-Hering Fluctuations)
as can be seen from the simultaneous in-
xrrease in blood pressure. The course of
the vaso-motor nerves is such that in part
meduUated and in part non-medullated
nerve fibres partly mixed with ganglion
cells, pass to the muscular coats of the
vessels. They make their exit thru the
anterior roots of the spinal nerves, then
pass thru the visceral branches into the
ganglia of the sympathetic cord where the
ganglion cells are intercalated in the course
of the individual fibres. In the sympathetic
cord they pass upward or downward and
finally hence either to the vascular plexuses
or thru other visceral branches again into
the trunks of the spinal or cerebral nerves
and from these to the respective vessels.^
This will explain the nervous element in
these cases of simple hypertension. The
sympathetics are most easily influenced by
the various outside influences, and while
there are no degenerate changes apparent,
the vessels in time assume a habit of con-
traction, which is the fore-runner of a per-
manent condition. Such cases were better
called hypertonia vasorum, where the nerv-
ous element seems to be the leading feature.
A form of circulatory disturbance now
easily recognized by the initiated but not
by the profession at large, is that known
by the term splanchnic neurasthenia. This
name is not altogether satisfactory, biit is
one that has been accepted as embodying a
certain definite series of symptoms, all of
which are fairly constant. The objection
is directed to the word neurasthenia. These
cases are frequently very neurasthenic, but
there is an early stage when these evidences
are not so apparent, yet show other signs
that are pathognomonic. Abrams coined
the term to meet the more advanced cases,
^Landois Physiology.
who usually have the '*blues," and who at
times show evidences of some mental in-
volvement. During the earlier stages when
the patient shows a moderate insomnia and
periods of nervous excitability, and perhaps
some anemia and a general lowered vitality,
and having periods of fair health, it would
not seem fair to place them in the category
of neurasthenics. These symptoms will
lead one to investigate the case carefully,
and when the usual findings are noted,
early treatment may save such from the
later stages. Owing to the usual ptoses,
hepatic engorgement, intestinal stasis, ir-
regular and reversed blood pressure and
pulse findings, these cases would be better
known as splanchnic relaxation or insuffici-
ency. They may be of a hypertension
type, but are more usually found with a
hypotension, but always with the reversed
pulse and blood pressure, sitting and lying
down, and unequal in the arms. Accord-
ing to Abrams "the factors which contribute
to the development of splanchnic neuras-
thenia are essentially nerve force lacking
in the muscles of the abdomen and in the
nervous mechanism which regulates the
supply of blood in the abdominal vessels."^
The splanchnic circulation is made up of
the portal vein and its branches and the
arterial branches of the celiac axis. Nor-
mally when one stands erect, the splanchnic
vaso-motor mechanism causes a constric-
tion of the vessels resulting in an elevation
of blood pressure. When this nerve
mechanism is defective thru loss of tone
or some other cause, the reverse is true,
the constrictive eflFect is lost and the vessels
become engorged' and the pressure falls.
This involves the liver in a series of en-
gorgements which condition soon becomes
pathologic. With this there is associated
' Spondylotherapy, p. 346.
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a venous stasis of the right ventricle. In
addition we have toxic symptoms as the
result of the hepatic and intestinal poisons
affecting the nervous system, largely be-
cause the circulatory stasis prevents their
removal and they are held in the liver with
the result of self poisoning.
This liver engorgement is one of the
more prominent features of splanchnic re-
laxation and usually can be found in all
stages of the disorder. This organ con-
taining normally about one-quarter of the
blood of the body, is necessarily easily en-
gorged, and in the early stages it may be
considered as compensatory. The ques-
tion arises as to when this ends and the
pathologic condition begins. . The solution
depends largely upon when one sees the
patient, early or late in the case.
In the treatment of this condition it is
well to beat in mind a few points. The
splanchnic is the most important of all the
vaso-motor nerves supplying the abdominal
viscera. Its fibres arise from the 5th to
the 12th dorsal inclusive, which corresponds
to the vertebral interspaces of the 2nd to
8th dorsal. Irritation of the communicating
branches between the 11th dorsal and 2nd
lumbar nerves causes a marked dilatation
after a primary contraction of the vessels.
This effect may also be produced by irrita-
tion of the vagus. Long continued irrita-
tion of the nerve finally causes exhaustion
and at the same time gives rise to symptoms
of paralysis of the vessel walls.^
It can be readily seen how vibration of
the vertebral interspaces corresponding to
the splanchnic vaso-motor nerves distribu-
tion will effect that area. Treatment ap-
plied for the relief of the splanchnic en-
gorgement and relaxation must necessarily
* Landois Physiology.
be of the type best suited to reduce this
and supply the necessary nerve stimulus.
It is well to check off fluoroscopically your
findings, ae well as to use the same measure
for "keeping tab" on the progress of the
case. In many advanced cases there will
be found a small or considerable bulging
of the aorta, almost aneurismal in type, as
well as the cardiac dilatation. This studied
by the flluoroscope, will be a great help as
well as adding interest in watching the
progress, for in the writer's cases, this had
disappeared with the lessening of the
splanchnic engorgement, and has disap-
peared before the hepatic enlargement has.
These cases do best, in the writer's judg-
ment, by the use of vibration of the spinal
area, diathermy of the liver, wave current
applied over the upper abdomen as well as
over the liver, together with exercises that
help to strengthen the abdominal walls. In
the sagging abdomens, with relaxed walls
and ptosis of the stomach with the intestinal
dropping, strapping with adhesive strips,
properly applied, will add much to the
comfort and have a distinct therapeutic
value. The Rose strapping method meets
the indications, using 2j4 in. Z. O. adhesive.
This must be removed at the end of a week
and renewed, and kept on for two weeks,
cleaning the skin well with alcohol before
renewing each time. The third strapping
may remain until it becomes annoying,
when another can be placed as before. This
strapping should be continued for three
months at least, when it may be left off en-
tirely, and if necessary, a supporting belt
may be worn. This will be unnecessary in
many cases, if the exercises have been kept
up. The effect of the strapping is more
than that of support. It keeps up a con-
tinuous slight skin stimulation and hyper-
emia which has its value in stimulating the
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peripheral nerves and vessels, all tending to
an added tonicity.
Some helps toward diagnosis in circula-
tory disturbances which are recognized are
the following : a high diastolic pressure de-
notes peripheral arid arterial resistance and
a low diastolic shows the lack of this. A
high pulse pressure with a low diastolic
shows low peripheral resistance with relax-
ation of the splanchnics- and an insuffici-
ency of the general circulation. When we
find a fairly high diastolic and a small pulse
pressure, we have insufficiency of the myo-
cardium and usually a condition of lowered
vitality.
It is pathognomonic of aortic insufficiency
to have a moderately high systolic and a
low diastolic with the high pulse pressure.
With a mitral stenosis one may have a
systolic of 140 mm. but it is not likely to
have as low a diastolic as 60 mm. with a
correspondingly high pulse pressure. In
compensated mitral stenosis we have a dis-
proportionately high diastolic (compensat-
ing vaso-constriction) and hence a low
pulse pressure.
Chronic interstitial nephritis usually
shows as a diagnostic sign the high systolic
and relatively low diastolic. We may find
hypertrophy of the left ventricle with a
persistent high systolic, particularly when
there is not good compensation. This con-
tinuing finally produces degenerative
changes in the vessels, and with this we
have a gradual lowering of the systolic and
circulatory failure.
Aside from the usually recognized
methods of treatment by electric currents
and other physical measures, we must bear
in mind that there are other things that
must be taken into consideration. Four
things are essential to the upkeep of normal
cell activity, rest and reaction, nutrition and
elimination. We must learn to see on all
sides of the case and meet all of the indica-
tions, and not allow prejudice to sway our
minds, but be ever broad and liberal minded.
Maryland and Pacific Avenues.
IS CANCER EVER OF OCCUPA-
TIONAL ORIGIN?
BY
W. H. RAND, M. D.,
Washington, D. Q.
*'Lamb," said Coleridge, "did you ever
hear me preach ?" The stammering wit re-
plied, "I nev-never heard you do anything
else." The homiletic habit becomes an
impertinence and a bore when projected
into general conversation; but here is a
little preachment on occupational cancer
which, it is hoped, the readers of American
Medicine may be disposed to r^ard with
tolerance, notwithstanding its "sidelong
moral squint" and hortative inplications.
Concerning the occurrence of cancerous
growths as a sequel of occupational injury,
external violence or irritation. Professors
Lubarsch and Theim, two of Germany's
foremost living pathologists, have come to
the same general conclusion by separate
and independent methods of research. They
hold that a malignant tumor never results
from a single injury, maintaining that no
scientific proof has hitherto been adduced
to show that the development of a carcino-
matous growth is ever traceable to an iso-
lated traumatism.
Lubarsch regards trauma as only an indi-
rect cause of neoplasms, remarking, "If one
wishes to determine the eflFect of a single
traumatism on the development of tumors,
he must include statistics to show how often
traumatisms occur in the same regions
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without leading to the formation of tum-
ors."^ Furthermore, the author's experi-
ments on animals tend to negative the theory
that the growth of tumors is accelerated by*
continual irritation practiced for many
months. In fact, Lubarsch proved that ir-
ritation often retards the growth, and some-
times even causes its subsidence.
Supplementing the work of Lubarsch and
Theim, and corroborating the conclusions
of French scientists, an article by Bullock
and Rohdenburg published in the Journal
of Cancer Research (No. 3, 1918) records
the results of experiments conducted with
a view to determining whether malignant
neoplasms ever originate from irritation.
The American investigators proved that
tumors which are indistinguishable morpho-
logically from human epitheliomata may be
caused in rabbits by the injection of irri-
tants; but they hold that the morbid prolif-
eration provoked by this means is not es-
sentially malignant.
This opinion coincides \yith that of the
French savants who claim to have demon-
strated microscopically that growths pro-
duced by irritation are benign tumors, re-
sulting from cellular hyperplasia, and are
not of a malignant nature.
The conclusions reached by the investi-
gators of both nationalities appear to be
identical; while the reserved and cautious
expressions of opinion by the American
authors and the open and unequivocal dec-
larations of the French illustrate the racial
and temperamental idiosyncrasies peculiar
to the respective peoples.
In reference to traumatism as an exciting
cause of cancer M. J. Petty, Asst. Surgeon
of Kawson Hospital, Buenos Ayres, main-
^ Verhandlungen des III. Intemationalen
Medizinischen Unfallkongressea zu Diisseldorf
torn 6 Ms 10. Aug., 1912.
tains that even thermal irritation occa-
sioned, e. g., by eating hot food, drinking
hot coffee, etc., may be a factor in the pro-
duction of gastric and lingual cancer.*
In this connection it is germane to the
matter tp point out that, in human subjects,
the parts most liable to trauma (the fingers,
the elbows and the shins) are by no means
most frequently the site of sarcoma or
carcinoma. While, theoretically, the influ-
ence of trauma may stimulate the growth of
a tumor, its effect is hard to prove in an in-
dividual case, because tumors do not in-
crease in size at a uniform rate, but inter-
mittently, with long periods of quiescence.
Dr; Lenoir of Paris affirms that trauma-
tism has little influence on cancer and occa-
sions it only in persons already predisposed
to degenerative processes.
Dr. Verstraete, formerly chief of the
surgical clinic at Lille, believes that re-
peated traumatisms or prolonged irritation
may cause the development of cancer, as,
for example, epithelioma of the lip in smok-
ers, and the so-called cancer of chimney-
sweeps.
Dr. J. B. Deaver of Philadelphia, describ-
ing a series of 534 operations for .cancer,
says that in only 13 per cent, of the cases
was there any history of traumatism. Wil-
liams reports that in 1,000 cases only once
did cancer follow an injury.
Writing of "Neoplasms of Occupational
Origin" Doctor Cesa-Bianchi remarks that,
* according to the present state of our knowl-
edge, there are but two kinds of occupa-
tional cancer, namely, those due to anilin,
and those caused by the Roentgen ray. The
misnamed "cancer of chimney-sweeps" and
the tumors of tar and paraffin workers are
mere proliferations of normal cellular ele-
* London Lancet, April 5, 1919.
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471
ments, and, in a strict sense, not new
growths at all.
It is proper to emphasize here the view
now universally accepted that a laboratory
diagnosis affords the only trustworthy proof
of the existence of cancer. Gross appear-
ances and clinical history often present
prima facie evidence of malignancy, but
this evidence is never deemed conclusive.
All recent research justifies a conserva-
tive and sceptical attitude as to traumatic
cancer. At its session of May 1, 1918, the
Societe de Chirurgie of France discussed a
report made by Dr. Vitrac of Liboume on
three cases of tumor presumably resulting
from injuries. There was a consensus of
opinion that new growths may develop un-
der the stimulus of traumatism ; but whether
tumors of this kind preexist as dormant
germs which are merely awakened to ac-
tivity by the injury, or constitute genuine
neoplasms, is conceded to be a question at
once difficult to determine and of great
medico-legal importance.
The conference recognized the usual dis-
tinction between malignant and benign
tumors; and while no one expressed a
doubt that traumatism might sometimes
cause an osteoma, the opinion prevailed
that sarcoma could not originate in any such
way. One member of the Societe, M. Arrou,
had seen a tumor, having all the outward
characteristics of sarcoma, in a little girl
several weeks after an injury. But when
this tumor had been removed, it was ex-
amined microscopically and found to be of
a purely inflammatory character.
In an address at a recent session of
L' Academic de Medecine the retiring Presi-
dent, M. Georges Hayem, in summarizing
the results of cancer research, said :
The study of these observations shows
that traumatism may accelerate the develop-
ment of a cancer previously existing ;' that
it may lead to the discovery of a tumor
hitherto latent ; but the evidences of a
purely traumatic origin of cancer are at
least doubtful, except in those cases, recog-
nized long ago, in which traumatism of the
bone sometimes results in the formation of
a neoplasm called sarcoma.^
The theory of the spread of cancer by
contagion ostensibly derives support from
the researches undertaken by Loir and
Legangneux at Havre, covering the period
from 1901 to 1916. It is to be noted, how-
ever, that their work related to the epidemic
ology of cancer, not to its etiology.
Are there cancer houses in Havre? To
this hypothetic question they answer:
**We find that from 1901 to 1916 there
were :
1894 houses in each of which occurred 1
death from cancer;
258 houses in each of which occurred 2
deaths from cancer ;
24 houses in each of which occurred 3
deaths from cancer ;
7 houses in each of which occurred 4
deaths from cancer.
1 house which occurred 5 deaths from
cancer.
Statistics show also that
211 times death from cancer occurred in 2
adjacent houses ;
39 times death from cancer occurred in 3
adjacent houses;
8 times death from cancer occurred in 4
adjacent houses; •
Once death from cancer occurred in 6
adjacent houses.
These results prove that there are groups
of dwellings which appear to be cancerous
foci."
Many of these cancer centers have a
common character. They are situated along
the margin of a water basin. The subsoil
is very damp, the ground water rising
within a few centimeters of the surface.
Besides, the cancer localities are all near
the markets, large stables or feed stores ;
that is, at points where rats abound.
^ Bui. de UAcade mie de Medecine, No. 1, p. 7.
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WHat role does the rat have in the eti-
ology of cancer? We do not know that it
has any. The authors say, "Not one of
the rats examined had cancer, and we found
the trypanosoma only in the blood of one
rat."
Still, it is a suggestive coincidence that
sewer rats abound in the infected localities.
These rats burrow in the subsoil, and their
fur is always swarming with fleas. It is
possible, at least, that the flea may transmit
the virus or germ of cancer with its bite.
In common with Virchow, a pathologist
primus inter pares of the 19th century,
Prof. Theim acknowledges, "We know
nothing of the real cause — the true genesis
— of cancer." But tho the essential pathol-
ogy and etiology of cancer are yet inde-
terminate, it is maintained by the respective
protagonists of current theories that hered-
ity, that infection^ that injury or that diet,
is the sole or main factor in the causation
of malignant tumors.
Bulkley says that cancer has become
more frequent as the people's diet has in-
creased in luxury, and especially since the
consumption of meat has become general.
His experiments shdw that mice fed on rice
cannot be infected with cancer, tho when
placed on a meat ration they quickly suc-
cumb, victims of cancer virus.
Knights of Sanitation in quest of the
origin of cancer appear to have become lost
in a bewildering maze, unable to orient
themselves. In pursuit of their object
some have toiled painfully along the high-
way of heredity without arriving at any
result. The mirage of infection has lured
many into a Sahara of arid speculation.
Pursuing the will-o'-the-wisp of traumatism
(including in this term gastric lesions
caused by ingested irritants) other pioneers
have found themselves mired in a bog of
uncertainties. Yet each of these exclusive
theories rests on a substratum of incontro-
vertible facts; and, as in the analogous in-
stance of tuberculosis, a correct interpre-
tation of all relevant phenomena must lead
to a just conclusion.
It is to be remembered that tuberculosis
was once held to be hereditary, and scien-
tific observation seemed to sustain the
hypothesis. But tho this opinion has been
discarded as untenable, all agree that a
tuberculous parent transmits to his off-
spring a debilitated constitution which pos-
sesses but slight power of resistance to
tubercle infection. To this extent, then,
there is a latent modicum of truth in the
theory of tubercular predisposition by
heredity.
Malaria is another disease of which the
etiology was long misapprehended. The
old and orthodox medical creed concerning
this infection accounted for intermittent
fever as a result of exposure to night-air
miasms. It is no disparagement of Austin
Flint to recall that, forty years ago, in his
Practice of Medicine he espoused and ex-
pounded this theory of malarial causation.
To that great clinician all the data appeared
to support the doctrine. The theory was a
legitimate and logical deducation from the
evidence then available ; for, beyond all con-
troversy, it was shown that malaria attacked
only such as had exposed themselves to
"evening dews and damps."
No one denies this fact today, but the
phenomenon is now differently inter-
preted, because new facts bearing on the
subject have since come to light. The dis-
covery that the anopheline mosquito is the
intermediate host of the malarial parasite,
that the infection is communicable to man
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solely by this insect's inoculation of its vic-
tim, and that the anopheles flies only by
night are links in the chain of evidence
which incriminate the mosquito as the
agent of infection.
Reverting to the cancer problem, it is
unlikely that the corps of trained observers
investigating this question are, like Ixion,
pursuing a cloud-like phantom. The elu-
sive shape which baffles detection is authen-
tic Juno; but to establish her identity it
would be absurd to fix attention exclusively
upon her gait, tho vera incessu patuit dea:
We have reached the same stage of scien-
tific knowledge in reference to cancer to
which our fathers had attained in the study
of malaria and tuberculosis fifty years ago.
To sum up, it may be that the human
embryo serves sometimes as an incubator
in which feebly-resistant seminal or germ-
inal cells become potentially malignant. But
will the abnormal cell degenerate unless
stimulated by trauma? Even then, is it
not possible that the new growth, if not in-
fected, may preserve a benign character?
In other words, may not each of the cur-
rent hypotheses as to causation of cancer
embody a partial truth ?
Cancer research has not yet reached the
goal of finality, but it is nearing its objec-
tives. Even failures in experimental work
teach valuable lessons. Sometimes they
indicate the necessity of more extensive and
more exact control tests, or perhaps the
futility of further exploration in that di-
rection.
But a rational theory of the cause. of
cancer must be a deduction which accounts
for all relevant facts; and Huxley's words
are well worth recalling in this connection :
"The man of science is justified, not by
faith, but by verification."
1440 Clifton St.
CARDIOVASCULAR DISEASES DUR-
ING THE WAR PERIOD.'
BY
MORRIS H. KAHN, M. D.,
New York City.
Chief of Clinic in Cardiovascular Diseases,
Mount Sinai Hospital Dispensary; Assistant,
Cardiographic Department, Mount Sinai
Hospital, New York City.
Introduction. — ^A classification of the
cases from one of the medical clinics of the
Mount Sinai Hospital Dispensary showed
that 3.8% had cardiovascular diseases. It
was found that for these cases general dis-
pensary care was inadequate. Cases of
heart disease as a rule require more time,
attention and social study than most other
medical conditions that present themselves
in a general clinic.
On this account a number of special
classes were organized for patients with
diseases of the cardiovascular system.
At the same time attention was directed
to the prevalence of heart disease in the
community. It was estimated by the Bureau
of Child Hygiene that approximately 15,000
of the 740,000 public school children in New
York suffer from diseases of the heart.
Mortality statistics revealed equally for-
midable figures. They showed that over
10,000 deaths are reported annually in New
York as due to cardiovascular causes. In
1912, 48,000 persons died from heart dis-
ease in the United States.
Recognition of the magnitude of the
heart disease problem and of its increasing
medical, social and economic aspects, and
recognition of the services of the several
cardiac clinics then existing, led to the
organization of the Association for the
Prevention and Relief of Heart Disease, in
the latter part of 1916.
* Report of a clinic conducted by the Mount
Sinai Hospital Dispensary.
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Later, in February, 1917, an organization
was formed of the Associated Cardiac
Qinics by affiliation of the physicians work-
ing in the various clinics specializing in dis-
eases of the heart.
In November, 1917, the executive work
and educational propaganda of these organ-
izations were temporarily discontinued on
account of the war.
The Mount Sinai Clinic^ — ^The purpose
of this survey is to siun up the experience
of two years in the clinic for cardiovascular
diseases. We shall confine ourselves to ob-
servations on the class for adult cases.
The Mount Sinai Clinics in Cardiovascu-
lar Diseases were opened in March, 1917,
and held two sessions a week, one in the
evening for adult cases and a day class for
children. Within six months the growth
of the clinics made it necessary to hold two
sessions weekly for each.
There are some details in clinic manage-
ment that apply particularly to cardiac
cases. In order to minimize the physical
strain and excitement of these cases, it was
deemed essential to avoid their waiting in
line for their tickets of admission or for
their medicine on leaving. The patients
enter the clinic waiting room directly and
obtain their tickets there. This arrange-
ment tends to avoid extraneous influences
that would affect the findings at the time of
the physical examination. The patients
rested and at ease are able more intelli-
gently to explain their condition and better
able to understand and remember the ad-
vice and instructions given.
It would be regrettable if the effect of
this measure, detailed tho it be, is not ap-
preciated, and if the rigidness of dispensary
attitude make it compulsory for cases
known to have heart disease to undergo the
physical strain of standing in line, so
blindly contradictory to the medical advice
given in the clinic.
The question of the dispensary fee is be-
yond the province of this report. We may
say, however, that many of the cases ex-
pressed it as a hardship for them and would
have to forego clinic care if the payment
were unavoidable. Patients with heart dis-
ease are frequently compelled to maintain
an economic struggle with healthy fellow-
men and any added drain is more or less of
an adverse factor.
The waiting room of the adult cardiac
class is arranged somewhat like a club room-
It is large, airy, pleasant and inviting with
a round table in the middle. Pamphlets,
magazines and newspapers for reading, and
checkers and domino games make the long
wait for examination less tiresome. Es-
pecially is this important for night classes,
to which patients come tired after their
work, and where they have to remain some-
times until ten or eleven o'clock at night.
Upon leaving the clinic, the medicine is
given directly to the patient from a mod-
erate supply kept at hand in the examining
room.
The whole attitude of the clinic must be
personal, interested and beneficent. That
this is appreciated by the patients is demon-
strated by their earnest cooperation and
regular and faithful attendance. This made
it possible for one nurse, single-handed to
do both clinic and social work.
Upon admission the social record is
taken. The complete medical history and
physical examination are then recorded.
Up to the present time a card system has
been used, the cards enclosed in an envelope
6x3 inches, convenient for preserving ad-
ditional data. Subsequent notes are writ-
ten on blank ruled cards.
Polygraphic tracings and electro-cardio-
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graphic records were made in many of the
cases and functional studies were made
when they were deemed of assistance in
determining the diagnosis and treatment.
Nmn^cal Data.— To May 1, 1919, dur-
ing the 26 months of its existence, 324 pa-
tients registered in the adult cardiac clinic.
Of these, 100 were discharged as non-
cardiacs and 30 died from cardiac and
other causes. The ages of the patients at-
tending the clinic, classified January 1st,
were as follows :
From 16 to 20 years.
From 21 to 30 years.
From 31 to 40 years.
From 41 to 50 years.
From 51 to 60 years.
Over 60 years
Male Female
19 25
28 38
28 22
19 18
13 8
8 9
115 120
In all, 1,436 examinations were made
since the establishment of the clinic to Jan-
uary, 1919. The number in each class
varied between 10 and 16 at a period.
There were classes with as high as 30 pa-
tients, but it was felt that adequate atten-
tion could not be given to all and the num-
ber was consequently reduced.
An important phase of the work was
remedying physical defects other than
cardiac, and correcting economic difficul-
ties. Eflforts were made to learn the family
conditions in each case, as cardiac cases
cannot be successfully treated if the family
conditions are ignored. Up to December
1, 1918, the nurse in charge of the cardiac
class had 2,574 office consultations and
2,220 home visits to patients.
Item Number
Cases registered In 1917 138
Cases registered in 1918 101
Patients who attended clinic during 1918.235
Visits made by patients to clinic in 1918.786
Patients in each class during 1918 average 11
Total number of cases registered up to
May 1. 1919 324
Discharged as non-cardiacs 100
Died from various causes 30
Cases remaining active May 1, 1919 194
C^ses admitted to various hospitals during
1918 38
Of these, to Mount 31nai Hospital 17
Cases admitted to Convalescent Institu-
tions during 1918 29
Of these, to Loeb Home 13
to Burke Foundation 7
to Monteflore Home 6
Cases given private convalescent care
during 1918 6
Cases given home convalescent care dur-
ing 1918 36
The following numerical data reveal the
family conditions ; the figures were recorded
January 1, 1919:
Item Number
Total number of members in the families. 558
Members in the famUles who are wage-
earning 152
Children under 16 years of age 293
Number of patients conducting their own
business 11
Families partially supported by charity
organizations 20
Social Case Reports. — ^What the social
work availed toward improving home con-
ditions can be illustrated by a few cases.
The following notes, laconically recorded,
will serve as illustrations.
Case I. — Cardiac patient, husband and six
children. January, 1917, three small rooms,
two of which were dark, one closed for the
winter to conserve heat. All slept in one
room, three beds, old and unclean bed-
clothes, and articles of clothing used as
covers. Oldest boy, 15 years, who had grad-
uated from elementary school before l4,
serving an 18 months term in the House of
Refuge. Girl 13, epileptic had spent three
years in Craig Colony. All the other chil-
dren had decayed teeth ; one had to have 10
drawn.
For 7 years the family had been under
the constant care of a large charity organi-
zation. Having before them the general
problem of relief, this institution, like many
others, overlooked the individual needs of
this family.
The family conditions were discovered
thru home visits. The woman was sent to
a convalescent home. The children, after
their teeth were treated, were sent to a
home. The rooms were cleaned, bedding
supplied, coal furnished. To the candy
stand which the charity organization had
initiated, fruit and newspapers were added,
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476 July, 1919 ORIGINAL. ARTICLES Amwbicjm MsDiciNa
increasing the income. Now the family 1. Compensated valvular lesions re-
lives in five rooms with bath and hot water, turned to the clinic monthly.
The cardiac patient, under the care of the 2. Patients under digitalis medication
cardiac clinic, is able to assist in manage- returned weekly or even biweekly when
ment of the stand. The family is self-sup- necessary.
porting, has refunded all money advanced 3. Patients with auricular fibrillation
to them by the cardiac class and the charity returned at first weekly ; as they became
organization. educated to control their medication, less
Case IL — Cardiac patient, wife and three often,
children ; former earning 25 dollars weekly 4. Cases of myocarditis returned weekly
as cloak-operator. Eight months of illness and later less often.
consumed all savings and exhausted the as- 5. Cases of aortitis, atheroma, hyper-
sistance of friends and relatives. After tension and thyrotoxic cases returned
improving, could not return to same occupa- monthly.
tion nor find other suitable work; became 6. Special cases under special observa-
despondertt. Thru home visits the condi- tion returned as often as required,
tion was discovered. Patient sent to a We endeavored to impress upon the pa-
country place by the cardiac class, and on ^. ^ ^- . _, - ^. ,
his return temporary relief was given. ^^^"^^ ^^^ importance of comparative rest
With the assistance of his verein, a bakery as the essential factor in the treatment. We
shop was bought for the patient. Family reiterated detailed instructions as to the ex-
is now self-supporting and has repaid all ^^^ ^^^e of living, and helped them to di-
money advanced. ,,,.... „r ^ . .
mitm*iAi* T-i-rii xi.1 T^ct and plan their activities. We advised
Medical Analysis. — ^The following table ^
, ^, • 1 J . them of the only relative value of med-
presents at a glance the numerical data ar- . . ^, -^ , r , . ,...
, J- ^ J- • Tx J ^ icines. The proper conduct of their life,
ranged according to diagnosis. It need not , , . ^ *^ ^
, _ , • J ^u 4. 4.1. J- 1 r xi, the relative amount of rest necessary, the
be emphasized that the medical care of the . , .
J. .. ^ . ... suitable adjustment to economic and in-
cardiac patients was given intensive , . , \, . , , , . , ,
, , dustrial conditions demanded special edu-
cation and guidance. The patients could not
rki««^^-4„ Active Dis- acquire this from a few minutes of advice
Diagnosis cases charged . ^
Mitral regurgitation 37 12 in the clinic, no matter how definite and
Mitral stenosis 39 4 i. .t* ..i. . y, \.
Double mitral lesion 14 4 emphatic that may have been.
Auricular fibrillation 19 6 For the most advanced cardiac cases,
Aortic lesions 11 4
Combined aortic and mitral . . 17 2 permanent care in a "home" proved to be
^""^"tZ^ortT^,.^''^^^^ 7 0 ^^^ ^^'^ s^l^^*^"- S"t ^s t^ds are not
Cardionephritic 11 2 usually available, it is difficult to find means
Myocarditis 13 2 - /
Heart-block 3 0 ^t adequate care.
^r/r^auricuiar " flbrtila: ' ' .^°' '^' '^'^y ^"^ -"^cr cases of heart
tion 2 0 disease, we endeavored to develop the edu-
Paroxysmal tachycardia 1 0 ^-ij • ^i_ji-
Auricular flutter 1 i cational and supervisory methods of care
Thyrotoxic heart ','.'.'.'.'//.'. 7 2 in the clinic. All patients with heart dis-
Congenital heart lesions 1 0 ^
ease should receive an education in the sub-
'^^^^ ^^^ ^^ ject of their malady. This can be achieved
The intervals between visits varied from in the clinic in a few sessions. During this
one to four weeks. The following rules time an estimate is made of the patient's
were generally regarded : capacity for work, and he may be shown
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AUCKRICAN MBDICINB
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July, 1919
477
how to adapt his life to his capabilities.
This may also be done during a sojourn in
the hospital for a period of two to four
weeks. We have seen patients who paid
no attention to their malady, which they
knew to exist, after a period of class study
or after a stay in the hospital lead a life
altogether different from before. They
recognized the importance of prolonged
rest, were able to estimate their capacity
for work, and learned the details in the
management of their disease. We have
found this form of education to be an ex-
cellent means for bettering and prolonging
the lives of these patients. The supervi-
sion of patients with heart disease at their
homes by a physician and nurse associated
with the special clinic has proven of great
value.
The Problem of a Livelihood for the
Cardiac. — ^Under concurrent favorable,
circumstances, cardiac cases may remain in
statu quo for years, and enjoy life in com-
parative comfort and independence. In
our endeavors to benefit them, however, we
often met with antagonistic home condi-
tions. Most of the patients were at work
at occupations unsuited to their state of
health, with little prospect of convenient
change. Women with large families could
not, with ease, take complete rest in bed for
several hours each day; nor could they
manage the other details of their day's ac-
tivities with an intelligent view to the state
of their heart disease.
The transfer of employees from one occu-
pation to another more fitting their state of
health results in an adaptation of the indi-
vidual to his work. Occupations which re-
quire much training are not generally suit-
able, because of the low wages during the
period of training. For cardiac patients
there could be made available certain non-
strenuous occupations, such as cashiers,
ticket-sellers, "ticket-choppers," etc.
It may be a correct idea to attempt to
segregate cardiac cases into an industrial
sphere of their own. Occupation for
cardiacs thus becomes the main problem in
social relief. For school children, voca-
tional guidance is imperative, with the early
selection of suitable occupations, thru co-
operation of school nurses and others with
the special cardiac clinics. For adults, a
few limited alternatives exist. First,
adopting a phase of his special occupation
to the physical capacity of the patient.
Second, changing the occupation. Third,
teaching a new occupation. The success
of the latter depends upon the proper selec-
tion of the cases, freedom from anxiety,
hygienic surroundings, • rest when needed,
and the chance of a work in which manual
and mental dexterity are substituted for
physical exertion. Fourth, establishing of
the handicapped in a small self-supporting
business.
PERSONAL REMINISCENCES OF
THE FOUNDER OF THE AMERI-
CAN MEDICAL ASSOCIATION.'
BY
HENRY O. MARCY, A. M., M. D., LL. D.,
Boston, Mass.
The preacher is supposed to commence
his sermon by the reading of a text. The
following is most fitting in emphasizing the
life work of Dr. N. S. Davis of Chicago.
''And his works do follow him."
—{Rev, 14-13),
Few here present knew him personally.
A long and intimate association was my
* Address at the SOtli Anniversary Banquet of
the Association of American Medical Editors,
June 10, 1919.
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478
JULT, 1919
ORiaiNAIi ARTICLES
AlIBRICAK MBDICINB
good fortune, all the more because he was
generally considered a reserved character;
often dictatorial and dogmatic. By the
medical profession of America he is chiefly
remembered as founder of the American
Medical Association. I won his friendship
by my early and continued loyalty to the
Association. Its history is instructive. For
years succeeding its beginning, attendance
was small, with seemingly little of common
interest and less enthusiasm. The profes-
sion as a whole lacked a bond of union.
The various medical schools and a very few
medical journals were centers of coopera-
tion; even the state societies were slightly
concerned beyond their own boun3s. I
first saw Dr. Davis at the Boston meeting
of the American Medical Association in
1863. The War of the Rebellion was at
its height and the number in attendance
small. Military surgery was naturally the
prominent topic.
In 1860, the country was lulled into con-
tentment by a widespread belief that a real
war, threatening the dismemberment of
States could never be seriously contem-
plated; that the heated discussions in
Washington were du^^to violent political
disagreement. The rec^^nt day parallel is
found in the slogan — ^"He kept us out of
war" which re-elected Mr. Wilson. A
great national conflict was held to be im-
possible. Dr. Davis was a relative of Jef-
ferson Davis. The firing upon F^rt Sum-
ter roused the masses of the North as from
a horrid nightmare dream. Dr. Davis was
an active Democrat, but an advocate of
peace; a warrant for his arrest as disloyal
had been issued. Excitement ran high in
Chicago. A mass meeting for recruitment
was called ; the immense hall was crowded
to overflowing.
The following anecdote is illustrative of
Dr. Davis. Feeling had arisen to fever
heat. Dr. Davis was seen elbowing his
way thru the crowd to the front of the
platform where he demanded a hearing: —
"Fellow Citizens — I am a Jeflfersonian
Democrat and I glory in the name. But
the time for peace has now passed. He
who dares to fire on that flag (pointing to
our National banner) is my enemy. In
further evidence of my loyalty," and here
a hush like a spell fell upon the assembly,
"since I cannot myself enter the army im-
mediately, I will gladly care for the families
of enlisted men without cost. I am com-
paratively poor in this world's goods, but
I own unencumbered this comer lot (locat-
ing the same) and will give a title deed to
the man who first signs the enlistment roll
tonight."
A scene of wild disorder ensued — the
•rush to the recruiting stand was beyond
description and the doctor was cheered to
the echo.
He was then the foremost citizen of
Chicago, a professor of medicine in the
medical school, and with Surgeon-General
Hammond, U. S. A. and Dr. Henry I. Bow-
ditch of Boston, was a leader in the new
study of sanitary science. He inaugurated
the movement for tunneling four miles
under Lake Michigan to give an unlimited
supply of pure water to the thirsty city.
The project for an enlarged cooperative
association for medical teaching received
his prompt attention. He established a
graded school of medicine for the purpose
of elevating standards of attainment. Upon
my return from the University of Berlin
in 1870 I was tendered a professorship.
The state of medical journalism of
America as well as the inefficiency of many
medical schools, called forth Dr. Davis'
severe criticism. His unsparing public
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AMBRIGAN HaDZOiNB
ORiaiNAIi ARTICLES
July, 1919
479
denunciation of their narrow local and
personal policies made him unpopular with
many editors and teachers. Out of this
confusion grew the idea of a weekly jour-
nal, to be established by the American Med-
ical Association. The plan was often dis-
cussed between us — how to secure the uni-
fied assistance of medical editors in general.
The final outcome was a meeting of Ameri-
can Medical Editors in Chicago. The loss
to this body of its early records is a serious
one and my statement is from memory.
We had thirteen editors in attendance
holding our sessions in the hotel parlor.
Dr. Davis was elected president. I was
honored with the secretaryship, being at the
time Associate Editor of the Annals of
Surgery,
A brief constitution and by-laws were
adopted. From that date annual meetings
have taken place in connection with those
of the American Medical Association. In
the course of time I became president. The
good work has progressed steadily in a
spirit of mutual helpfulness. The more
recent exponents of its activities are present
with us tonight, chief among whom is our
able Secretary, Dr. McDonald, who during
his long period of service has faithfully ad-
hered to the finest traditions of our nota-
ble beginning and without whom the es-
pecial interest of these meetings would be
wanting.
The Journal of the American Medical
Association was the logical result of these
efforts. Dr. Davis acted as Editor-in-
Chief without compensation.
Already in failing health, I earnestly pro-
tested against his acceptance of the task,
still a teacher with a daily clinic perhaps the
largest in Chicago, he was not to be moved
from his fixed purpose. "The Journal must
succeed. I shall give it unwearied service
as my last and best contribution to our pro-
fession."
The journal of the British Medical
Association — the British Medical Journal —
with a large subscription list in America,
totaling a circulation in both countries,
of about fifteen thousand copies, was the
only great national publication. Our am-
bition was a circulation of ten thousand
copies, which meant a safe financial basis.
Today the weekly issue is about seventy
thousand, and this is owing in large part
to the cooperative labors of this Association
of Medical Editors.
Success is inscribed in bold letters upon
'our standards for the uplift of the profes-
sion. Our past history is phenomenal. It
has held a welding power of nationwide
goodfellowship. It has greatly advanced
to the world championship the medical at-
tainment of the present.
To willing and competent hands, the
cherished memory of half a century of
united effort is committed. Cemented by
enduring friendships, the field still offers
new vistas not less inviting to an army of
co-workers for the common good. It has
been my privilege to attend every meeting
of this Association, except one, since its
organization. This is true also of my as-
sociate interest and attendance upon the
meetings of the American Medical Asso-
ciation. I believe I hold the record. The
service has been a labor of love.
Surgery has been practically re-written.
Medicine has likewise won noble victories.
If the medical teachings of the present day
were universally adopted, sickness would
be lessened by one-half, the productive
capacity of the race doubled, and life
lengthened by at least one-third. A heri-
tage of a century now belongs to the well
bom.
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480
July, 1919
ORiaiNALi ARTICUSS
AlIBRICAN MSDICINa
Our profession owes the world the solemn
duty of showing how this heritage may be
economically utilized. Upon, my brethren
of the Association of American Medical
Editors, this responsibility is laid in a
special sense. The trust is in safe hands.
Magnify it into a glorious success.
180 Commonwealth Avenue..
TROPICAL ULCERS.
BY
J. G. JISR, M. D..
Cairo, Egypt.
I think that this is the most appropriate
term by which to designate a class of ulcers
very frequently met with in the Sudan and
altogether different in their etiology, course,
etc., from the Oriental sore, Leishmaniasis.
The following is a resume of statistics
taken during five years of work on this
subject in different localities in the Anglo-
Egyptian Sudan.
Etiology. — In nearly 99% of the cases
reporting for treatment the patients stated
that the ulcers were initiated with an in-
jury such as an abrasion or wound caused
by a stone, kick, etc., hence the site of
greatest predilection has been the lower ex-
tremities. They are very much more com-
mon in male than in female patients, and
almost always occur between the ages of
four and twenty years. They usually ap-
pear in more or less epidemic form during
the cultivation and crop seasons.
Foreigners are equally subject to attacks
of the same, but on a very much smaller
scale, effecting by preference those staying
for long periods without changing the
African climate. The ulcers in this class,
tho equally refractory to treatment, riarely
if ever reach the enormous size they usually
do in natives.
The present article being compiled from
personal experience and in places where ac-
curate bacteriologic and microscopic work
was altogether difficult, one can hardly
dwell upon this side of their etiology;
nevertheless I would like to state in pass-
ing, that the microscopic examination of a
specimen film of the discharge revealed the
presence of pus cells, staphylococci and
streptococci.
Cowse. — The ulcers, as stated, nearly
always owe their origin to an injury. As
hardly any attention is usually paid towards
the cleanliness of the ensuing wound, or
otherwise, having become inoculated with a
specific germ hitherto unknown, the wound
instead of healing, begins to enlarge slowly
but steadily so that within the first 8 to 10
days a small ulcer is already in existence
with its membrane of unhealthy granulat-
ing tissue and an unusually profuse dis-
charge. The ulcer once established con-
tinues going on for years, if left untreated,
reaching large dimensions, there being no
tendency towards spontaneous recovery.
Characteristics. — ^The ulcers are usu-
ally round or oval but may very rarely be,
irregularly shaped. The margin is sharply
defined and the unhealthy granulating mem-
brane covering the base, fairly thick,
strongly adherent and often presenting
small nodular elevations.
The color, when the discharge is well
wiped off, is pinkish red. The discharge is
purulent in character, yellowish green in
color, seldom sanguinous and very profuse.
The ulcers spread superficially, never ex-
tending beyond the subcutaneous tissue,
nor exposing any of the deeper structures.
Treatment. — ^A daily hot bath was
regularly given as a routine, to all patients,
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AMERICAN MSDICINa
LONDON LETTER
JULT, 1919
481
medicated, with either tinct. of lod. or liq.
carb. deterg.
The following were the lines of treatment
that were most commonly used.
1. Boric Acid. The ulcers were well
packed with pulv. boric acid, and covered
with a dry dressing. This was, however, .
soon abandoned as it did not prove to be
very successful.
2. Carbolic Acid. Touching with the
pure acid on alternate days neutralizing the
surplus with rectified spirit, was attended
with better success than the former.
3. Touching with silver nitrate and
copper sulphate sticks on alternate days
proved to be successful in not a few cases.
4. Tinct. of Benzoin Comp. A piece of
lint exactly the size of the ulcer was soaked
in the tinct., applied to the ulcer and covered
with oiled silk and a dry dressing. Care
should be taken in applying this, as the tinct.
should not be allowed to come in contact
with the healthy skin.
5. Lotio Rubra. Applied in the same
way and under the same precautions as the
above ; only that the zinc sulphate solution
used should be 5%, in lieu of the 1% in
vogue in the B. P. This proved to be the
best line of treatment where the patients
refused to submit to more radical measures
and where the ulcers were of small dimen-
sions. In the larger ones, however, this
should be continued until the appearance of
the healthy granulating tissue; skin graft-
ing should then be performed to hasten the
cure.
6. Pacquelins* Thermo-cautery. The ul-
cers were cauterized, under local anesthesia
until the appearance of the healthy granula-
tions and then followed by skin grafting
when necessary.
7. Curettage. This was my method,
par excellence, being attended with better
results in a very much shorter time than in
any of the others.
It was performed under local anesthesia
and with an ordinary sinus curette. Care
should be taken to remove all the unhealthy
granulations, which often strip off in one
piece.
The small ulcers should be immediately
cauterized with pure carbolic or liq. lodi
B. P. 1898. In the larger ones, grafting
should be performed 24-48 hours later.
Complete cure was obtained in the worst
cases, under this line of treatment, in 4-6
weeks.
8. I would like to mention lastly a
method that was rarely performed but
which in selected cases proved to be very
satisfactory (small ulcers surrounded with
loose healthy tissue). The unhealthy
membrane was excised under local anesthe-
sia with a scalpel and the margins coated
with strong silken sutures. A cure was
obtained in 8 days where the patients were
given complete rest, thus allowing the
wound to heal by primary intention.
(From our Regular Correspondent.)
THE POLLUTION OF THE ATMOSPHEBE.
If there is one thing in preventive medicine,
and one thing in connection with widespread
disease, which is talked about more generally
than another and understood less, it is pollu^
tion of the atmosphere. Some people, who are
academically entitled to their opinions, spe^k
as tho the presence in the atmosphere of any-
thing in addition to its normal oxygen, nitrogen
and gaseous traces rendered its respiration in-
jurious, the origin of disease easy to compre-
hend, and the chances of recovery very poor.
Others say that so long as air is kept stirring
it can hardly be made too foul by the presence
of human emanations, and upon this view many
have founded their discounting of all atmos-
pheric pollution as a serious source of physical
disabilities.
As is often the case when direct differences
of opinion arise on medical questions, neither
side is right and neither side is wrong; for
while too much attention has certainly been
paid to the mere amount of carbonic acid pres-
ent in the air of crowded buildings, not enough
has been paid to the damage caused by solid mat-
ter present in the atmospheres of our large
cities. I do not know what steps you may take
in American cities to ascertain the amount of
impurity of this sort present in your great in-
dustrial towns, as a prelude to removing the
evil; but I venture to call your attention to the
very interesting report which has Just been
issued by the British Meteorological Office.
An advisory committee on Atmospheric Pol-
lution was set up some three years ago by
the Meteorological OfDce, and altho its activities
have been seriously interfered with by the war,
it has made three valuable reports, and the
fourth dealing with the year 1917-1918 has now
appeared. It is to some extent a summary of
monthly reports which have been published in
scientific Journals, but it contains some valua-
ble comments upon the evidence they have
amassed, and also a detailed account of some
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482
July, 1919
LONDON LETTER
AUCBRICAN MKDICINB
work done by Dr. Owens, F. R. S., the guiding
spirit of the committee, directed towards the
best method of measuring continuously the sus-
pended impurities of air, instead of depending
for information upon the amount of deposit oc-
curring on certain surfaces at certain intervals.
The report is based upon observations taken
at 24 stations selected as being in widely dif-
ferent environments. • Of these stations seven
worth .the unsheltered gauge is in the vicinity
of one of the main southern railway routes be-
tween the capital and the coast, and is there-
fore liable to smoke and soot contaminatldn
from the engines, when the wind is in the
favoring direction.
The following table* shows the total solids
deposited monthly at all the stations in metric
tons per square millimeter.
Station. 1917. 1918.
I Apr. May. June. July. Aug. Sept Oct. Nov. Dec. | Jan. Feb. Mar.|
43 >*
Bin
a CD
ia
^■0
Leicester
London: —
Meteorological Office
^Embankment Gardens
•Finsbury Park
♦Ravenscourt Park
♦Southwark Park
Wandsworth Common
Golden Lane
Malvern
Manchester: —
Queen's Park
School of Technology
Newcastle-on-Tyne
Rochdale
St Helen's
Coatbridge
Glasgow: —
Alexandra Park
Bellahouston Park
Blythswood Square
Botanic Gardens
Richmond Park
Ruchill Park
South Side Park
Tollcross Park
Victoria Park
17.21
12.96
16.58
15.70
23.37
11.76
7.23
9.09
2.60
10.44
12.72
44.28
24.50
10.64
7.69
11.86
13.76
11.56
7.55
13.43
4.89
5.69
16.70
8.09
37.70
6.61
15.03
36.33
4.84
14.64
5.15
13.30
15.60
19.64
34.60
17.53
19.06
20.18
19.22
23.26
21.20
23.82
16.53
13.20
16.58
17.95
16.61
9.38
11.72
29.82
16.64
11.55
2.47
11.85
2.55
15.70
11.40
20.07
34.60
14.02
16.55
13.54
19.98
31.30
16.25
14.21
18.11
15.20
27.82
15.40
9.16
11.51
28.26
15.11
17.36
13.56
10.00
18.13
2.96
6.20
14.50
19.81
34.63
16.84
15.78
9.72
10.63
10.90
11.46
10.98
8.44
10.50
10.79
9.04
19.76
16.20
20.59
21.75
16.87
16.86
3.73
15.87
3.94
14.30
21.80
28.50
34.63
32.13
18.61
12.40
10.04
15.64
11.97
15.39
17.60
9.96
9.00
10.82
6.18
10.45
14.10
12.11
3.96
9.46
1.34
11.50
18.20
21.93
34.63
13.94
14.29
10.60
7.55
11.34
10.58
12.43
9.76
10.26
7.74
8.77
13.66
12.53
34.66
14.05
12.49
35.78
2.81
17.62
1.52
14.40
21.00
17.70
35.69
20.04
19.52
14.43
18.30
17.65
16.61
12.13
25.49
7.78
6.97
24.25
10v81
7.53
20.28
9.59
1.75
10.90
13.20
15.10
35.69
22.60
13.03
11.79
15.67
16.41
16.83
11.44
7.53
18.28
14.35
8.23
ILIO
16.79
4.75
12.62
3.34
4.20
5.20
20.80
35.69
15.16
14.52
11.82
13.14
14.41
13.57
14.11
10.55
14.91
15.96
17.67
19.73
14.16
11.79
10.22
2.61
16.27
2.90
4.90
11.40
14^52
22.68
18.39
17.84
14.91
29.33
19.76
17.78
25,74
9.61
26.49
17.68
8.85
15.12
2.16
9.59
1.67
5.70
10.60
11.19
33.95
25.11
17.74
11.56
IZM
14.82
15.17
13.28
12.12
12.97
13.85
17.11
5.24
10.56
21.89
5.01
1.72
6.77
14.08
10.60
1.54
5.01
12.50
16.11
33.95
19.31
13.69
9.94
11.24
13.34
12.15
21.04
15.53
10.17
11.88
13.91
11.07
24.19
14.83
12.55
17.33
5.40
12.95
2.61
9.72
14.01
20.81
34.81
20.40
16.35
13.56
13.00
16.17
14.34
15.60
14.52
11.88
16.14
13.13
*The above table is supplied us thru the courtesy of the London Lancet.
are in London, and include a typically open and
thinly inhabited residential area like Wands-
worth Common, and a crowded factory district
like Southwark; nine are in Glasgow, and are
chosen to represent the best and worst of the
most busy and crowded industrial center of the
Kingdom; two are in Manchester; and the
others are at such foci of industry as Newcastle,
Rochdale, St Helen's and Coatbridge; at Leices-
ter a good example of a large country town in
open fields, but providing work for a big factory
population; and Malvern a lovely rural locality
on the ridge of one of the highest chains of
hills in the middle-west of England. At these
stations, during the year in question, the total
solids deposited monthly were calculated in met-
ric tons per square millimeter, and the pecu-
liarities of the exact position of collection are
noted below the figures. For example, in South-
wark the gauge is situated in the one open
spot available, a public park, and is not exposed
to any dirt arising from traffic, while at Wands-
The stations at which an asterisk is affixed
are those where the results may have been
affected by difficulties of collection elsewhere
attended to. The low, mean monthly deposit
at Malvern is representative of uncontamiiuited
country air.
The mean monthly deposits for each station
are set out in separate tables for summer —
namely the months of April to September in-
clusive, and winter — namely the three remaining
months of 1917 and the first three months of
1918 and these results are compared with the
results obtained from the gauges during the
preceding 12 months analogously subdivided.
The reasons are also set out why the deposits
have Increased after the interval of the year
at some stations and decreased at others, and
the net conclusion drawn is that there is some
indication of improvement of the atmosphere
during the winter months but that the degree
of pollution during the summer months is on
the increase. We are definitely warned, how-
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ever, that the returns for 1917-1918 must be
regarded as somewhat inconclusive, as the
shortage of bottles, due to war conditions, made
it necessary to use less satisfactory methods of
collection, such as open carboys placed under
outlets from the gauge vessels, a method of col-
lection calling far increased attention at a time
when intelligent inspection was not always easy
to obtain. Yet the broad accuracy of the results
is seen by the fact that at the Wandsworth sta-
tion the deposits decreased during the summer
months of the year, corresponding with the fact
that in the summer of 1917 railway traffic was
greatly curtailed, private traveling being enor-
mously restricted.
Comparing the winter months for the two
years, an increase was found in 1917-1918 in
total solids, tar, insoluble ash, and sulphates,
while there is a reduction in the deposit of car-
bonaceous matter other than tar, chlorine, and
in ammonia. The lesser consumption of do-
mestic fuel during the year explains certain of
these phenomena, and again brings a highly
technical piece of laboratory work into connec-
tion with the afTairs of every-day life.
Dr. Owens' method for measuring continu-
ously the suspended impurity of the air greatly
advances this branch of the work. By elab-
orate experimentation with special filters he
arrived at a filter which will operate automat-
ically, giving records at short intervals over a
period of 12 or 24 hours, on a paper clock. The
result indicates what may be regarded as hap-
pening to respiratory tissue from polluted air,
and at once the enormous possibilities for pre-
ventive and clinical medicine, latent in research
of this character, become apparent All urban
communities should clamor for coal smoke
abatement.
Under the Editorial Direction of Albert C.
Geyser, M. D., New York.
GENERAL CONSIBEBATIONS OF THE THEB-
APEUTIC EFFECT OF HTFEBEMIA.
Unconsciously the average physician as-
sociates two qualities, inflammation and
pain with hyperemia. Because hyperemia
is under normal circumstances one of the
principal factors of an inflammation and as
an inflammatory condition usually has pain
as an associate, it was thought that the
hyperemia or the inflammation was the
cause of the pain.
This opinion is so firmly rooted in the
minds of medical men, that to speak of ^n
inflammatory process suggests the presence
of pain and this suggestion is borne out by
actual facts.
When we really analyze the process of an
inflammation, we are led to inquire, what
useful function can we find that pain per-
forms ? We can and do account for all the
various component parts of an inflamma-
tory process. We know just what particu-
lar function each one is by nature expected
to perform, but if we stop to inquire what
possible good could come from a painful
condition in an inflammatory process, we
would be obliged to admit its utter inability
to serve any purpose at all.
Pain, therefore, is not the result of or in
any way connected with inflammation per
se.
It is, nevertheless, true that this pain may
and frequently is intensified by the hyper-
emia. Qoser observation, however, will
show that this increase of pain is only of
short duration after the inflammation or
hyperemia has adequately manifested itself.
In fact we are all agreed that inflamma-
tion is nature's reparative process. That
being so, the pain which was present as one
of the causative factors of the inflamma-
tion, must of necessity sooner or later yield
to this reparative influence and become miti-
gated and finally lost.
We are all familiar with the terrific pain
of dental caries, which during the acute
stage lasts from one to two hours to as
many days. As soon as the hyperemia and
its consequent swelling have taken place,
practically all of the pain vanishes. The
patient suffers from the immensely swollen
jaw, which is very tender to the touch, but
otherwise is free from pain.
A patient sustains a fracture of one of the
long bones. There is at once more or less
pain, yet as soon as the reparative process
or reaction has set in and swelling has taken
place there is a complete absence of all pre-
vious pain, assuming all parts to be in ap-
position.
From all this it seems that pain is not the
result of hyperemia. Still this question of
pain cannot be so easily disposed of.
Whenever we have a limb suflFering from
a toxemia, the result of a local infection,
every surgeon knows from actual practical
experience that when such a limb is raised
so as to favor the return circulation, that
the pain at once ceases.
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When this same limb is allowed to hang
suspended, the pain returns with all its
vigor.
To the casual observer this accumulation
of the venous blood, the consequent en-
gorgement and congestion are the direct
causes of the pain.
All this is an error pure and simple. If
that same limb is gradually lowered and has
become used to the amount of congestion,
now if active hyperemia is gradually added
to it, not only will the pain cease, but the
whole reparative process be hastened.
The pain in all these cases is due to an
interference with the circulation at the
point of the original injury. As soon as
the circulation has been reestablished there,
pain will cease. This reestablisment of the
circulation in the injured part can only oc-
cur as the result of increased local circula-
tion or as the result of hyperemia.
The hyperemia is not the cause of the
pain, but the result of pain.
In this connection it would be well to re-
member that stasis must never be mistaken
for hyperemia.
Strange as it may seem, while this old
theory of pain being due to hyperemia still
lurks in the mind of the physician, yet
that same physician knows only too well the
pain-relieving power of hyperemia.
A severe otitis media, neuralgia, myalgia
or even ostalgia are always benefited by
some agent capable of setting up some
counter-irritation which must result in a
hyperemia.
The hot water bag, the dry heated air,
hot compresses all have been used by the
physician and patient alike and seldom or
never with disappointment.
When a joint, suffering from chronic
rheumatism, is placed in a superheated air
apparatus, in less than one hour all pain
is gone.
We have caused here an increase in the
arterial circulation. In spite of the fact
that this same joint was red, tender and
swollen, after one hour of active hyperemia,
with perhaps an increase in the swelling
and certainly an increase in the local tem-
perature of the part, the pain is entirely
eliminated. At the same time while the
superheated dry air almost at once relieves
all the pain, it does not cure the disease.
This, like many other toxic manifesta-
tions, requires constitutional elimination for
its removal. While the superheated dry air
gives the patient relief, other measures must
be instituted. While the effect of hyperemia
is very marked in chronic arthritis, still
more effective results are obtained by the
passive hyperemia in gonorrheal rheu-
matism. If a joint suffers pain as the re-
sult of gonococcic invasion, the application
of the rubber bandage above the joint will
result in almost complete relief of pain in
one or two hours after its application.
In the use of the passive hyperemia care
must be exercised in its application. It
must never be uncomfortable and above all,
it must be applied for a great many hours
at a time. The more acute the lesion, the
longer must the passive hyperemia be main-
tained.
The more chronic the lesion the shorter
the time of application. All chronic lesions
are associated with more or less stasis, care
must therefore be taken not to increase this
but rather to mitigate the same.
In gonorrheal joints twenty to twenty-
two hours out of each twenty-four are
none too much. A superficial neuralgia is
quickly relieved of its pain by the applica-
tion of the vacuum cups. These cups simply
divert the bloodstream into the path of
lesser resistance and so cause a local hjrper-
emia with a consequent lessening of the
pkin.
In the application of a hot fomentation to
an impending abscess not only is the pain
almost at once relieved, but frequently it
happens that the whole process retrogrades
or at least hastens the suppurative stage and
causes elimination from the body of the
toxic material.
Concliisi<m8. — From such observed facts
we must come to the only logical conclusion
that pain is not caused by, but on the con-
trary, it is positively relieved by active as
well as by passive hyperemia.
We have seen how we accounted for the
statement that hyperemia could not be the
pain-producing factor, now we must equally
well prove that hyperemia is a pain-reliev-
ing agent.
Schleich has shown, that when any tissue
is properly infiltrated with certain sub-
stances, the pain is thereby diminished. He
was able to produce an equally perfect local
anesthesia with only one-half of one per
cent, solution of cocaine, while others with
a less perfect tissue infiltration were
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obliged to use the usual four per cent, solu-
tion.
This same method of tissue infiltration
with a very small amount of cocaine is
made use of by Bodine in nearly all of his
major operations without a general anes-
thetic.
It is the method of infiltration and not
the drug, for many surgeons have tried to
imitate Dr. Bodine, even with much larger
percentages of the drug, but few have ever
enjoyed his success.
It is well to note here that whenever we
have edema we seldom have acute pain.
With a hyperemia we certainly cause by
the outpouring of the serum a complete
cell or tissue infiltration, stimulating a
temporary edema, which may be an im-
portant factor in the pain-relieving qualities
of a hyperemia, especially of the passive
variety.
As previously stated the pain is the result
of the original injury. .
Assuming the original injury to be the
result pf a toxemia, which may be either
bacterial or chemical, have we not every
reason to expect that the sooner such poi-
sons are removed from the body, the sooner
will the pain disappear ? This quickened re-
moval can best be brought about by an active
hyperemia which causes an increased local
circulation in the affected parts.
Again, by the passive hyperemia and a
retarding of the return circulation with a
consequent dilution of the toxic material,
should we not find an easy explanation of
the pain-relieving qualities of such a hyper-
emia.
It has been observed by some that the re-
lief from pain in joint diseases was due to
an accumulation of fluids within the joint
cavity and so the articular surfaces were
forced apart, thereby relieving the intra-
articular pain.
I am of the opinion that this is a fallacy,
since we have abundant proof of the pain-
relieving power of an active or passive
hyperemia in locations where there are no
joint surfaces to separate, as in myalgia,
neuralgia and abscess formations.
If we desire a really scientific explana-
tion of the pain-relieving power of a hyper-
emia, let us follow Coley who in 1905 made
some observations by diluting pus with
edema fluid, taken from a diseased arm and
the same pus diluted with artificially caused
edema of the sound arm.
When rabbits were infected with edema
and pus of the sound arm they invariably
died as the result of toxemia, but when in-
jected with pus diluted with the fluid from
the diseased arm, while they sickened, yet
none died.
If the acconlpanying pain then is due to
toxi^ies from the germs, we have here a
clear demonstration of the antibody forming
power of the serum, when in contact with
diseased tissue.
The Therapeutic Effects of Hsrper^nia.
— Bier in his works has shown that a
certain infection gave a clear culture of
staphylococci, yet after a few hours of
passive hyperemia, the germs entirely dis-
appeared from the lesion.
Infections of all kinds respond almost at
once to hyperemia.
This is a well known fact to the natives
of the tropics where snake and poisonous
insect bites are more common.
As soon as a person is thus bitten, a
rather firm bandage is applied to prevent
the poison from entering the circulation,* as
they think, but in reality we see the results
of a passive hyperemia practically applied.
We know that the poison cannot be pre-
vented from entering the general circula-
tion, for the circulation within the limb
must be and is maintained even after a rea-
sonable constriction.
We have here a practical demonstration
of either the effect upon the germs them-
selves as shown by Bier or the poison dilut-
ing and neutralizing power as shown by
Coley.
Suppose for a moment that a snake bite,
an insect bite or the introduction of a simi-
lar poison has taken place, nothing is done
and adequate reaction takes place, we have
at first a swelling with edema, followed by
stasis.
Either the patient lives or dies ; if he lives,
either the part slowly returns to normal or
as is more frequent, a sharp line of demar-
cation sets in, gangrene supervenes and a
natural amputation is the result. Nature
prefers to sacrifice the limb and thus save
the life.
Is it not highly probable that the natives
of warmer climates, when they make use of
passive hyperemia in poisoned wounds,
after all show some method in their idea of
preventing the poison from entering the
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|[eneral circulation too rapidly and by forc-
ing the toxines to remain a longer time in
direct contact with the germs or poisons
destroy or neutralize the poison, thereby
acting in a similar manner to Koch's tuber-
culin.
Everything brings with itself the means
for its own destruction.
Again, the slowed blood stream may irri-
tate the surrounding tissue to new tissue
formation and so lead to the encapsulation
of the germs much as nature does in en-
capsulating T. B. germs within the lung
tissue.
One of the results of a passive hyperemia
is the increase of the percentage of C02 in
this delayed circulation ; an increase of C02
is inimical to all germ life.
Not only is the germicidal power of the
blood thereby increased, but in the presence
of an increase of C02 the red corpuscles
swell up and enlarge by absorbing the
watery element of the plasma making it
more concentrated and more powerful in
all its manifestations.
The antibacterial power of the blood de-
pends to a large extent upon its alkalinity.
The greater the C02 percentage, the
greater the alkaline products of the blood.
Behring has shown that tuberculosis is
very rare among lime workers. This he
thinks is due to the great percentage of
alkalinity within the blood as the result of
the inhalation of the lime-laden atmosphere.
We know that the edema fluid from a
given patient possesses greater bacterial
power than the simple blood serum from
the same patient.
Usually the serum is stronger in these
qualities than the lymph.
The bacteria are mostly located within
the lymph spaces, or just exactly where the
greatest amount of edema takes place.
In this way the good effect of a passive
hyperemia may be explained.
The theory has been advanced that per-
haps the serum, which flows from the
wounds after the application of passive
hyperemia, might be accountable for the
rapid healing effect; when we take into
consideration the fact that we have most of
our good effects where we have no open
wounds, it must become apparent that such
a bathing of the wound with serum is
merely an incident and really not at all
necessary to bring about the healing effects.
All the theories brought forward so far
may be true, but they all have a rather nar-
row view of the healing by inflammation.
Inflammation^ — ^As has been pointed
out over and over again, the process of in-
flammation is a complicated one and no one
element plays a greater part than another.
On the contrary the reaction by the cells
both fixed and wandering, the increased
blood supply, the fluid as well as the cor-
puscular element of the blood, the chemo-
taxis, the formation of antibodies and
alexin^s, the absorptive power of the
blood, all these contribute to the good effect
of a hyperemia.
It is unfortunate that the idea that in-
flammation is a pathologic state is so firmly
rooted in the minds of so many medical
men.
Inflammation and each one of its com-
ponent parts is a natural process of reac-
tion on the part of the uninjured cells.
We might well say, as long as there is
inflammation there is hope.
Hyperemia, no matter how caused, is one
of the elements of an inflammatory process.
Active hyperemia or an active increase
in arterial blood in any local area, is indi-
cated in all chronic conditions where ab-
sorption is the principal effect desired in
such conditions as persist after a partial re-
covery from some acute injury, such as
swellings, stiffness, edema, loss of func-
tion and pain.
Generally speaking active hyperemia
should be made use of in chronic, non-
bacterial but toxic conditions.
Passive hyperemia, or the increase of
blood by interference with the venous or
return circulation, is indicated in such con-
ditions where it is desirable that the blood
stream should remain in contact for a
greater length of time than normal.
It is therefore indicated in all acute con-
ditions, especially in the results of trauma
or bacterial invasion.
The longer the blood stream remains in
contact under such circumstances with the
diseased or injured tissue, the greater is
the counteracting influence.
Let me remmd you of the dangers in con-
founding a therapeutically slowed blood
stream with stasis.
After all, when we assist nature, or try
to do that which nature would have done,
do we see the real benefit of the slowing
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and the remaining in longer contact of the
blood stream with the injured tissue.
Absorptioii«p— Absorption is one of the
most prominent effects of a hyperemia.
When rapid absorption is desired the
active hyperemia is made use of while
slower or retarded absorption follows the
passive hyperemia.
Nearly 90 per cent, of all absorption
takes place 'thru the lymphatic system.
It was formerly thought and many text
books still teach that all or nearly all ab-
sorption takes place by the way of the
lymphatics.
A few tests will throw some light upon
this question.
There is no tissue in the body where
lymphatics are more abundant than in the
peritoneum.
Haidenhain and Orlow injected into the
peritoneal cavity soluble salts. These solu-
tions rapidly disappeared from the cavity
and were demonstrated in the urine, but no
trace of the salts was found in the thoracic
duct. It must have been absorbed by the
capillaries and not by the lymphatics.
Starling made similar tests, always find-
ing the salts in the urine long before they
could be demonstrated in the lymph. His
conclusions were, that they were primarily
absorbed by the capillaries, later thru the
general circulation, and appeared in the
lymphatic system by their presence in the
blood.
Hamburger ligated the thoracic duct, then
injected the soluble salts; the absorption
took place with the usual rapidity, but no
distention of the lymphatic system mani-
fested itself, showing that absorption had
taken place thru the capillaries.
J. Munk ligated the main lymphatic ves-
sels in the neck of animals, then severed
these vessels distally to the ligation, so that
all the flow of lymph was outward and no
entrance into the system could take place.
Injections of strychnine were made into
the scalp. The ligated as well as the non-
ligated animals died about the same time
and in a similar manner.
Upon testing^ the flowing lymph no
strychnine could be demonstrated, showing
that absorption did not take place by the
lymphatics, but by the way of the capilla-
ries.
Klapp injected a solution of sugar of
milk into the peritoneal cavity.
Milk sugar was used because of all sub-
stances milk sugar is the easiest to trace.
In this experiment, both the thoracic and
the lymphatic were ligated. The sugar
very promptly appeared in the urine, but
not a trace of sugar was found in the lymph
duct.
These tests leave no room for doubt ; they
establish for a fact that all watery or solu-
ble substances are absorbed by the capilla-
ries and not by the lymphatics.
These tests do not, however, negative the
probability that cancer cells and other small
solid particles are taken up and removed
by the lymphatics.
These same tests again point out to us
the physiologic basis for the therapeutic
use of hyperemia.
Where rapid absorption' is desired, the
capillary system must be filled to its utmost
and the circulation of the blood stream in-
creased.
This we accomplish by the means of the
active arterial blood increase brought about
by the application of dry heat and other
similar agents.
If we desire the rapid absorption of drugs
into the general system, the area of injec-
tion should first be heated, that is the local
circulation should be increased by the appli-
cation of heat, massage or similar measures.
The fluid itself should be at least of
normal body temperature.
The use of morphine or strychnine or
the normal salt solution are made more ef-
fective if measures have been instituted for
their rapid absorption.
On the other hand a slowed circulation,
such as results from a passive hyperemia
or the application of cold hinders the rapid
absorption by its capillary contraction.
Cocaine solutions for local anesthesia
should be cold.
The area to be injected should have a
slowed circulation, either by the previous
application of cold or by a constricted
bandage causing a passive hyperemia or by
the addition to the solution of adrenalin,
causing capillary contraction with the con-
sequent slowing of the blood stream in the
local area.
Because the passive hyperemia slows the
circulation, it should always be followed by
a certain amount of massage to re-establish
the normal.
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ORGANOTHERAPY
.^^
The Paraglandular Organs. — De Castro
{Anales de la Facultad de Medicina, July-
August, 1918) applies this term to the
formations which accompany the endocrin-
ous glands in the human body. They are
of the same embryonic origin, and attain a
certain degree of differentiation in their de-
velopment, but they are generally regarded
and classed as supernumerary accessory
glands or aberrant glandular nodules. He
is convinced that they represent a regular
system, and are not merely anatomic curi-
osities, morphologic accidents, anomalies or
rudimentary organs, as they have hitherto
been described. They form what he calls
the paraglandular system, an annex to the
system of the glands of internal secretion.
They represent an organic system in full
evolution. This allows the interpretation
of a number of contradictory facts which
have hitherto baffled observers, and explains
many phenomena in the human economy.
Each of the endocrinous glands is liable to
have its paragland, as also possibly the
epiphyses. There are also abdominal para-
ganglia, such as the organs of Zuckerkandl
ahd the cardiac paraganglia described in
1906 by Wiesel and Wiesner. The carotid
gland is not exceptional but occurs bilateral
in nearly every one. Other paraganglia
with chromaffin tissue are found along the
sympathetic. Luschka's coccygeal gland
is not chromaffin and hence does not be-
long to the paraglandular system. He re-
views each member of the system in turn,
with evidence from comparative anatomy
and physiology to sustain his views.
Di£Ferentiation of Elarly Tuberculosis
from Hyperthyroidism. — For sometime
Goetsch, of the Surgical Oinic of the Johns
Hopkins Hospital, has been practicing the
subcutaneous injection of 7.5 minims of a
1-1000 solution of adrenalin chloride in pa-
tients who present masked symptoms of
hyperthyroidism but in whom no positive
diagnosis can be made by ordinary methods
of examination {Med. Standard, July,
1919). H the patient, following the ad-
renalin injection, reacts with manifest
symptoms of hyperthyroidism, Goetsch be-
lieves that a positive diagnosis of the condi-
tion is justified. At the Trudeau Sanator-
ium, Nicholson and Goetsch tested 40 pa-
tients by this method. Of 18 patients,
whose diagnosis was "clinical tuberculosis,
questionable," 10 reacted positively and 8
negatively ; of 16 with a diagnosis of "clin-
ical tuberculosis, inactive," 9 reacted posi-
tively and 7 negatively ; and of 6 with active
clinical tuberculosis, none reacted positively.
The authors conclude that the test is a
valuable aid in determining whether the dis-
ease from which the patients are suffering
is purely a tuberculosis, a tuberculosis com-
plicated by hyperthyroidism, or a pure thy-
roidism. Hyperthyroidism, whether or not
associated with tuberculosis, will give a
positive reaction to adrenalin. Tuberculo-
sis, uncomplicated by hyperthyroidism, does
not react positively to adrenalin. They feel
that in a considerable number of border-
line cases presenting symptoms more or less
characteristic of both conditions, they can
now pick out those suffering with hyper-
thyroidism.
Corpus Luteum in Nervous Diseases.^ —
Climenko {Endocrinology,. January- March,
1919) reports some highly interesting stud-
ies of the effect of corpus luteum in male
neurasthenic cases. It was also adminis-
tered to patients suffering from organic
nervous diseases, such as multiple sclerosis,
and also in the early stages of dementia
praecox. In all of these the drug was inert,
corpus luteum had no effect on the blood
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489
pressure of arteriosclerosis, neither in the
male nor in the female. The best results were
obtained in young females, poorer results in
natural menopause and no results in surgi-
cal menopause. The hypodermic prepara-
tions did not give as good results as the drug
given by mouth. Contrary to the Sajous
statement, Qimenko found that corpus
luteum whenever efficient gives prompt re-
sults and large doses need not be employed.
He found that 2 grains is as large a dose as
one needs to use. Corpus luteum extract
acts best when there is every reason to be-
lieve that the native corpus luteum is still
present. The administration of the extract
cannot replace the function of the native
corpus luteum in pregnancy and probably
also not in menstruation. When menstrua-
tion is discontinued by virtue of disturb-
ance in the secretion of another gland, such
as the pituitary, corpus luteum will not pro-
duce menstruation. Inasmuch as corpus
luteum extract when effective produces al-
most always the same chain of phenomena,
Climenko feels that it is reasonable to con-
clude that (a) corpus luteum has a specific
action ; (b) the administered extracts prob-
ably do not act as the native hormone ; and
(c) that the extract, in all probability,
stimulates the native corpus luteum to
function. The two contraindications to the
use of corpus luteum are an abnormally low
blood pressure and profuse and frequent
menstruation.
Hormone Control of Renal Function. —
A writer in Endocrinology, October-De-
cember, 1918, points out that the possibility
of adrenalin control of the kidney has not
been investigated so extensively as in the
case of pituitary extract. It has been de-
monstrated that adrenalin produces diure-
sis, and recently Addis, Barnett and Shevky
have shown that this is accompanied by an
increase in the urea excreted. These authors
think that adrenalin stimulates (secretory)
sympathetic termination. Cow on the other
hand has not only demonstrated a direct
vascular connection between the medulla
of the suprarenal and the kidney, but has
shown that under certain conditions ad-
renalin is poured by this path into the kid-
ney, producing a diminution in the flow
of the urine. Gunning has also found that
intravenous injections of adrenalin cause
an inhibition in urine flow in both anes-
thetized and unanesthetized dogs. The in-
hibition, however, is very brief, as he says
that it persists until shortly after the blood-
pressure reaction is complete. Altho he did
not observe diuresis following, it would be
well to base conclusions upon urine flow
over longer periods of time, as Addis and
his collaborators did. Moreover, the deter-
mination of some constituent in the urine,
such as urea, per unit of time, is highly im-
portant. It may well be that very small
amounts of adrenalin such as those ab-
sorbed from subcutaneous injection cause
diuresis which can be detected over periods
several hours in length, while larger doses
which are effective immediately produce
the opposite result. However, the hypothe-
sis that the adrenal produces some sub-
stance which is necessary for the mainte-
nance of normal kidney function needs
further confirmation. The work of Marshall
and Davis is very suggestive. They found
decreased excretory power in the kidneys
of adrenalectomized cats. Of course this
might be explained by the lowered activity
of the tissues in general.
It is possible that other hormones may
influence kidney activity. Cow extracted a
diuretic substance from the mucous mem-
brane of the alimentary canal, especially the
duodenum. He suggests that this substance
is carried by water on its way into the
blood stream from the gastrointestinal
tract. Piticarin has shown that secretin is
also diuretic in action.
The question of hormone control of the
kidney is extremely important, and altho
it appears that we are well along toward its
solution, there are many points still un-
settled. It is only thru carefully controlled
experiments of long duration by both labo-
ratory and clinical workers that it can
finally be answered.
The Thyroid and Fetal Growth. — Ac-
cording to Williams (International Journal
of Orthodontia, January, 1918) that the
thyroid secretion is essential to the develop-
ment of the fetus is shown by several facts.
* * * It is normal for women during preg-
nancy to develop an enlargement of the
thyroid glands, which subsides rapidly
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after the child is born. By no means the
least important function of the thyroid
gland is that of fixing the calcium salts in
the body. In order to permit of bone
formation in the fetus, the mother is obliged
to provide more secretion than under nor-
mal circumstances she requires, and the
gland consequently hypertrophies. After
the birth of the child, the increment being
no longer necessary, the gland resumes its
usual proportions. In some women this
prolonged call of pregnancy has the effect
of unduly exhausting the gland, and they
are unable in consequence to suckle the
child, for lactation is dependent upon a due
supply of thyroid secretion. Such women
generally become obese and lethargic, and
remain so for varying periods until the thy-
roid has had time to recover itself. Judi-
cious thyroid medication will frequently not
only enable a mother to suckle her infant,
but will materially shorten the period of
her postpartum difficulties.
The Relation of the Ovaries to Metab-
oliam. — Recently studies have been made
by many observers on the influence of the
internal secretion of the ovary on metab-
olism. The tendency to increase in fat after
ovariotomy or the menopause, has been at-
tributed to cessation of the action of the in-
ternal secretion of the ovary. Lowy and
Richter believe this to be due to diminished
oxidation, while Magus and Herz incline to
the view that it is due to lessened bodily ex-
ercise after castration, the result of influ-
ence on the psychic sphere of the individual.
— Rothrock Journal Lancet,
An American Physician the First to
Fly Across the English Channel.— There
are few lines of huihan endeavor that med-
ical men have not contributed to or helped
to promote in one way or another. The
field of aviation oflFers no exception to the
rule and altho it is not generally known, to
a physician belongs the honor and credit of
having been the first to make a cross-chan-
nel flight. This was a Dr. JeflFries, an
American physician, in regard to whose
life and career, very little, unfortunately, is
known.
Accordingly to Dr. John Poynton writ-
ing in the London Lancet (July 5, 1919)
he was the hero, however, with a companion
named Blanchard, of the first crossing of
the Channel, tho he had previously as-
cended with the same aeronaut from the
Rhedarium, near Grosvenor-square. "The
account of this Channel flight written by
himself" states Dr. Poynton, "is a record of
serene bravery, for an undertaking of this
kind was a big thing in those days. Strong
adverse winds had delayed the departure
from Dover, and it was not until January
7, 1785, that the ascent was made on a still,
bright, winter day. The aeronauts made
very slow progress in their balloon, for in
50 minutes they were only one-third of the
way across the Channel. Trouble soon
commenced and took a simple shape, the
balloon insisting on descending into the sea.
Ballast was heaved over, and then followed
numerous pamphlets, which one would have
thought from modern experience of such
things would have lightened almost any-
thing. For awhile, indeed, there was an
improvement but not for long ; the precious
instruments had to go, the balloon trap-
pings, an empty bottle, their great coats,
their lesser coats, their breeches, and so on.
But what a man ! He climbs up the netting
and is enraptured at the lovely view he ob-
tains as the balloon slowly revolves! Un-
derneath a January sea is waiting for him,
above is a winter sky, and around his im-
mediate person a deficit of clothing ! Fortu-
nately for us all, just as they neared the
French shore the balloon swept upward,
cleared the cliflFs, and carried them over
the forest of Guines. Trouble was not
over yet, but it was of a slightly diflFerent
kind now, and the doctor's feelings must
have been akin to those of the boy who eyes
the volume and character of the birch that
awaits him. It will be apparent that as the
balloon was again rapidly falling, some im-
portance was to be attached to the nature
of the tops of the trees upon which they
were landing. Jeflfries thought they looked
both high and hard, and he does incidently
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admit that he and his colleague were cold.
Now comes the acme of resource and as
great a proof of bravery, as ever the world
can claim, he remembers that their bladders
are full — for the weather was cold and the
bottle they threw over was empty and the
reflexes in those hardy old days were ap-
parently impervious to fear. He estimated
that thus they lightened the balloon by
some 4 to 5 pounds and, glorious to tell,
they landed softly on those trees and were
soon warm and safe in the kindly hands of
French hosts/*
The Blood Lust. — Bernard Shaw once
said, with his usual trick of hitting the nail
on the head, that the average man is far be-
low the average; and, with fresh instances
of violence and brutality crowding the front
page of the newspapers every day, one can-
not escape the conviction that humanity is
much less humane than we like to pretend
it is. One looks to Russia and is appalled
at the massacres perpetrated by the Bolshe-
viks and even by some of the reactionary
elements. One looks to Korea and is
shocked at the maltreatment of a race
struggling for freedom. One looks to
Poland and gasps at the reports of anti-
Jewish pogroms. One looks to the Adriatic
and is amazed to find Italians and French,
so recently allies, murdering each other. In
the hope of relief, one looks to our own
country and blushes at the record of lynch- ,
ings, race-riots and violence under this head
recalling the brutality of officers toward
military offenders. What is the meaning
of all this? In 1914, before the war, tho
the world was not altogether free of sav-
agery, it was a rather peaceful place com-
pared with what it seems today. What has
brought about this change? It is not an
easy thing to say, but, in asking one's self
this question, baffled tho one may be, one
cannot help suspecting strongly that the
war has had a great deal to do with it, that
it is closely linked with the brutality which
is so much in evidence thruout the world.
But, whether war is responsible for man's
brutality or man's brutality is responsible
for war it is difficult to decide. It is a
patent fact that perhaps only one person
in a hundred can honestly admit that he ap-
proves of war, that he likes it and that he
would welcome an opportunity to resort to
. armed conflict. The other ninety-nine
frankly admit that they hate war, they are
pacifists in the best sense of the word, and
they entirely ag^ee with Henry Ford's
opinion that war is murder, however justi-
fiable it may be in the rare instances when
it is murder in self-defense. Of course,
war is murder, it is a hideous and wrong
thing — ^and that is why the whole allied
propaganda put all its effort into the slogan
that this last war was one to end all war.
And yet is it not a strange thing that war is
possible when only one man in a hundred
approves of it and ninety-nine despise it?
Even if we accept the radical viewpoint
that, of the ninety-nine there is one man, a
capitalist, a banker, a munitions maker, a
food profiteer who is the real maker of
wars, is it not still strange that one man
who wants war because he likes it and one
man who wants war because it is profitable
can win over to their purposes the ninety-
eight who do not want war and abominate
it? There can be but one explanation of
this unique instance in which a negligible
minority can prevail over an overwhelming
majority : there must be some element in the
composition of the ninety-nine which they
have in common with the one man who likes
war and which they possess in a greater
measure than they are aware. That ele-
ment is what is popularly known as the
blood lust, the aboriginal cruelty of primi-
tive man; what the psychoanalyst would
call the sadistic component.
It is an acknowledged fact that in every
man the sadistic and masochistic com-
ponents, in varying degrees, exist side by
side. In the normal man they are a neg-
ligible factor. In the primitive man, the
sadistic element was predominant. Sur-
rounded by hostile forces and elements
which he could combat only by force, he
was able to live only by killing. The habit
of killing goes back eons in man's develop-
ment. But the recent development of the
brain and the more recent development of
the moral sense brought about the repres-
sion of the sadistic impulse — repression,
one must bear in mind, not destruction.
One of the marked qualities of the grow-
ing child is its cruelty, and the child goes
thru the same stages of development as the
race. This cruelty goes thru a process of
repression during adolescence and seems
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to disappear at maturity. Actually, it does
not disappear — it merely is not permitted to
show itself. Yet, existing as it does, there
must be an outlet for it or the individual
will pay the penalty. Many neurotics are
merely the victims of an unsatisfied sadistic
component, repressed because it would be
wrong to satisfy it. But war is the logical
vehicle for the satisfaction of this impulse.
Brutal tho it is, morality and the considera-
tion of conscience do not stand in the way.
It is the one human activity in which bru-
tality becomes almost a virtue. Military
text-books are the best evidence of this.
War is man's exhaust valve, thru which he
can release all his pent-up savagery and do
so with the approval of his fellowmen, with
the approval even of his own conscience.
The strain of civilization, under which he
frets but which he is obliged to endure, is
cast off and he can do the things his re-
pressed self wants to do and caa do without
the danger of rebuke or reprehension. But
the particularly unhappy aspect of the last
war is that its long duration and its extreme
violence have made it very difficult for men
to revert to their old way of living, to their
old repressions, to the conversion of their
sadism to legitimate channels. A soldier
on leave was dining in a London restaurant.
In the course of an altercation with a com-
panion he drew his revolver and shot him
dead. In the ordinary course of things,
the same man might have been satisfied with
using his fists, but the habit of murder and
violence had taken root in old soil. It
seemed a trifling matter to him, and the
court before which he appeared was amazed
at the man's callous indifference when he
gave an account of the episode. In Siberia,
in Korea, in Poland, in Fiume, in sections
of our own country, men have reverted to
the primitive type, they have for five years
lived under conditions in which it seemed
right to kill, the discipline of civilization
has worked off, the channels of violence are
free and unobstructed. Is this the explana-
tion of the increase of crime and murder
thruout the world since the conclusion of
the war? If it is, then the makers of peace
have a greater problem before them than
the disposition of territory, the rearrange-
ment of boundaries, and the realization of
political ideals.
9 HYGIENE
i AND
\ DIETETICS
Nats and Frnits in Feeding of Children*—
I>r. George Dow Scott has recently pointed out
that among the laity there was a firm convic-
tion that nuts give rise to Indigestion and
fruits caused hyperacidity. To some the knowl-
edge that nuts were highly nutritious was new.
Nuts, however, contain water, protein, fat, sugar,
storch, crude fiber, and ash In large propor-
tions. Each kind of nut has Its particular
caloric value. Dry nuts are very high In nutri-
tive value and contain more fat than any vege-
table substance known. In nutritive value nut
butters are far above ordinary cream butter.
The writer has given nuts to children as a
substitute for meat because of the nutritive
value, in Intestinal fermentation. The propor-
tion of the diflTerent food elements varies in
the diflTerent varieties of nuts. The discomfort
of eating nuts Is due to faulty mastication and
to the erroneous habit of giving them to chil-
dren after a hearty meal, between meals or
late at night, whereas they should form an in-
tegral part of a meal.
Dr. Scott spoke of the parts that nuts played
in the dietaries of other peoples and said that
mothers in this country should understand the
food value of nuts better, giving a variety of
nuts to suit the individual child, but it must
be understood that they are given as an addition
to the diet. Cautiously, after weaning, the cliild
should be given nut butter. Such butters must
be more carefully prepared than those for older
children. The nut kernels are pounded in a
nut mill until of a creamy consistency,
strained thru two layers of clean boiled muslin
or a fine wire sieve. Fruit juice of finely cut
or mashed fruit should be added. The stools
should then be watched for undigested particles
or any chemical disarrangement as diarrhea,
duodenitis or enterocolitis. If the butter agrees
the quantity can be gradually increased, care
being taken to avoid overstocking the child's
stomach or digestive capacity. In the consti-
pation of infants nuts form a valuable aid as
a lubricant on account of their oils, but they
act as irritants because of the large amount of
refuse which they leave.
Fruits should be given to Infants because they
are palatable, refreshing, nutritive and because
of their salts, their diuretic, laxative, tonic and
antiscorbutic action. A fruit regime is devoid
of toxins and supplies an unfavorable culture
media for bacteria. In scurvy, stomatitis and
other digestive conditions, the fruit juices will
be found almost a panacea on account of their
antiscorbutic qualities. In conclusion, the nu-
tritive qualities of fruits and nuts are not to
be depreciated; these foods are not to be given
to the child as a pleasurable and luscious appe-
tizer only, but as a food addition to the general
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493
diet, stimulating, nourishing and exhilarating
it to a stronger mental and physical existence.
The Carrier of Malaria* — The malaria mos-
quito, says a writer in the Scientific American
(June 14, 1919), tho no new problem, consti-
tutes an ever-recurring one. Every summer
we have this pest with us, and every summer
we are obliged to wage all over again the war
upon it. This year the subject deserves, and is
in fact receiving, more than the usual atten-
tion. While we have so many of our soldiers
in the camps we are confronted with a series
of artificial and highly concentrated seats of
possible infection, in which the conditions of
living, while subject to the closest control, are
very far from those of ordinary civilized exist-
bat this unseen foe, because they were ignorant
of its nature. As the name indicates, they
imagined that the attack came from the air —
preferably from the night air, which their fancy
endowed with all sorts of evil qualities. It was
not until 1897, thru the discoveries of Ross and
others, that the life history of the malaria par-
asite became known; and of course even now
the old ideas prevail in many uninformed quar-
ters. With our present fund of knowledge, in-
telligent defense against malaria is feasible;
and this year of all years, when so much is de-
pendent upon the health and working efficiency
of the nation, the subject is being given partic-
ular attention.
Malaria is transmitted by certain members
of the mosquito family. Since this discovery
was made, mosquitoes In general have received
a good deal more attention ihan before, and
By eoartesy of the Sci^MtiHv AimericaM
Fk;. 1. Head structure of the female mosquito, which does all the damage in connection with
malaria propagation.
ence, and therefore likely to lead to all sorts of
sanitary troubles, despite that control. At the
same time we are putting forward a project to
grant unoccupied lands to our returned soldiers
which involves considerable danger. Such land
as is available for this purpose is of necessity
land which has not heretofore paid the cost of
reclamation. This necessarily means that it is
land on or about which there is an undue pre-
ponderance of water. The resident of Florida
or the Mississippi Valley may be sufficiently
acclimated to survive the conditions which sur-
round him; the man from New England or the
Northwest, suddenly and without preparation
set down in these conditions, must inevitably
succumb.
The scourge of malaria is as old as history
Itself. As early as the fourth century B. C.
there are indications which are now accepted
as authentic of malaria epidemics; the disease
is conceded to have been a potent cause, if not
the dominating cause, in the decline of the
Greek civilization. The ancients could not com-
new species are constantly being found. Altho
the insect in question is a tropical one, it is
by no means confined to the tropics, some 40
diflferent species having been identified in the
United States alone. They range as far north
as the Arctic Circle; and In Alaska, Greenland
and on the tundras of Siberia, where other in-
sect life is scarce, they constitute a terrible
scourge. Explorers tell tales of the mosqui-
toes on the snows of the Far North which make
the misdeeds of the Jersey variety seem tame
in comparison.
Mosquitoes in general are good travelers, tho
possessing little power of self-locomotion or
even of self -direction. Like the old-style bal-
loons, they go when and where the wind llsteth;
and, with a mild and favorable breeze, they
will migrate to 35 or 40 miles distance from
their breeding places. They vary In size from
one-sixteenth inch to the huge Jersey **Gallinip-
pers" of half an inch.
While any old kind of mosquito is a nuisance
to have about the place, it is fortunate that
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they are not all pathogenic. In fact, of the 40
American varieties, the only one which has
been convicted of evil practice in the matter
of carrying disease germs is Anopheles Maculir
pennis, or the spotted-wing mosquito. The pres-
ent discussion will therefore be confined to this
species.
Mr. Mosquito does not bite; his bill is so
blunt that he could not be a blood-sucker if
he wished. It is Mrs. Mosquito who does all
the deadly work of fever propagation. She is
most active around dawn and after sunset. She
avoids strong light and prefers dark colors. She
is essentially a domestic creature, staying
around houses by preference. In the autumn
the males die, and the females seek winter
quarters. They hibernate in dark comers of
cellar and garret, and on the first warm day
and the uncovered cistern.
In this stage the larva must have air, which
it breathes through a siphon tube located near
its tail. The normal position of the little ani-
mal is just below the surface, with tail pointing
upward. It is at this time that the presence of
an oil film over the water of habitation is
fatal to the young mosquito; the oil clogs the
siphon and the larva suffocates. This is by
all odds the simplest and most effective way of
destroying mosquitoes. It is simple because
the problem of locating the pests is an elemen-
tary one ; it is eflfecti ve for the same reason that
prolonged immersion in water is an effective
way of destroying a man.
During the larval stage, which lasts from
seven to 14 days, the malarial variety can be
distinguished from all others, by the curiously
By courtesy of the Scieptti/ic Amsriran
Fig. 2. Museum model showing head detail of male mosquito, which does not bite or suck
blood.
of spring are out laying their eggs. Save when
extended by the arrival of this hibernating pe-
riod, the life of the female is one or two months;
the male, on the other hand, lives but a few
days. The food of the mosquito is the juice and
nectar of plants, and of course blood — tho not
necessarily that of man; animals, reptiles, and
even caterpillars are bitten with the same free-
dom.
The female mosquito lays from 50 to 100 eggs
at a time, on any quiet bit of water. In about
three days they hatch, and tho at first the larva
is very small, it grows rapidly and attains full
development in a few days. We have then the
familiar wrigglers of the old-time rain-barrel
inclined, by virtue of the fact that it lies with
its body parallel to the surface of the water,
while the other species hang with their heads
downward. When the larva is ready to grad-
uate, a T-shaped crack appears in the skin of
the back, from which the pupa emerges. The
pupa remains in the water, but does not eat.
It represents the period of growth during which
the internal changes begun in the larva are
carried to completion, resulting in the adult
mosquito. The most critical moment in the
life of the mosquito is when it emerges from
the pupa shell. As is the case with so many
other insects at this stage, the wings are not
hard or dry enough to fly at once, and the
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495
creature is easily upset and drowned. In this
way the flow of tidewater into marshes where
moequltoes have bred kills great numbers of
them.
In the adult mosquito there are to be recog-
nized three major parts: The head, the thorax
to which are attached the wings and legs, and
the abdomen. The head has two large com-
pound eyes composed of several thousand sim-
ple eyes or facets. This enables the mosquito
to see in all directions. In front of the jaws
are two branch-like growths with 15 or 16 joints,
and at each joint a whorl of fine hairs. These
are the antennae, or organs of hearing. Beneath
is the proboscis, or tool-box. First comes the
labrum, Ihe mosquito's drill, a long implement
with a groove on the under side thru which the
blood of its prey is sucked. Next comes the
hypopharynx, a thin blade which can be closely
appMed to the under side of the labrum to form
a closed channel for the passage of the sucked
blood. The hypopharynx has a fine tubular
channel of its own inside, and it is thru this
that the malaria spores enter the body of the
host. At the two sides and below the labrum
are two pairs of slender lance-like instruments
with spear-head points. These also enter the
wound and help to brace the mosquito's head
while its owner is enjoying his meal. It is
probable that they fill the additional purpose
of making the blood flow more freely. Below
all this is the flexible sheath which is longer
than the rest of the outflt and serves to cover
the various organs and protect them while not
in use. On either side of the proboscis are the
maxillary palps or organs of touch.
The body is composed of three rings, the mid-
dle one bearing the wings. The latter are so very
thin and delicate that they practically refuse
to make any impression on the photographic
plate, save where they are reinforced by ribs
covered wtth fine scales. The arrangement of
these ribs varies with the species; in the ma-
larial variety there are four black spots on each
wing which give rise to the name maculipennis
already mentioned.
The legs are hollow tubes with the muscles
inside. They are connected with the body by
the coxal or hipjoint. This joint allows great
flexibility of movement, and is altogether a very
creditable bit of engineering design. The mos-
quito has three pairs of legs, of seven joints
each. The hindermost pair is not employed in
walking, as may be readily observed, but acts
to balance the insect in flight and as an organ
of touch. The mosquito has two pumps with
which he extracts your blood; and when they
both get under way you are relieved of a large
drop of blood and inoculated with a goodly col-
ony of malarial spores in less than a minute.
In view of the great timeliness of all discus-
sion regarding the malarial mosquito and ways
of meeting its ravages, the American Museum
of Natural History has installed an exhibit
consisting of large models of male and female
maculipennis, together with the various stages
in the development to the adult insect. It is
from these models that the photographs shown
herewith are taken.
The Cockroach: Its Destructlonur— Holt in the
London Lancet reports a long series of experi-
ments on the subject.
Summarizing the results of the experiments
as a whole, they seem to indicate that many of
the substances which have been supposed to kill
the cockroach have really acted by driving it
away and so leading to its disappearance. Such
gregarious migrations have been observed, but
have hitherto been otherwise explained. For
quick destruction stoving with bromine or sul-
phur dioxide is apparently best. For domestic
application the daily use of creosote, wood
naphtha, or the oil of rosemary, eucalyptus, or
cltronella placed near the haunts of the cock-
roaches for two or three weeks, should effect-
ually disperse them. Where these are Inad-
missible on account of their smell, odorless
dusting powders may be used. Of these sodium
fluoride was found to be the most effective. It
is also cheap and keeps Indeflnltely.
These experiments may have some value as
applied to Insect pests. The cockroach being
abundant and of large size, it has been possible
to use it as an "indicator" and to observe the
results more accurately than would be possible
with small insects. Other things being equal,
the same results should follow in the case of
many other insect pests.
Chocolate in the War«— What chocolate did
in winning the war will never be fully realized.
In all the lexicon of the Red Cross and other
war relief activities probably no word spells so
much of comfort, and nourishment, and cheer
to wounded men and well men In the trenches.
In solid and liquid form, on the fleld, in the
trenches and back of the lines, chocolate was
the flrst demand. Its popularity over coffee as
a drink was largely due to the superior food
value in the chocolate, to the greater ease with
which it was prepared, and to Its more lasting
nourishment A Red Cross fleld worker writes
In his diary, "For one week I made from 250
to 300 gallons of chocolate daily, besides help-
ing to serve the boys with socks, cigarettes and
treat their various ailments with the drugs we
had on hand." Again a chaplain writes, "I
talked, read and prayed with them, wrote let-
ters for them, and left them chocolate."
American Aid Checks Tvphns In Bonmania.—
Fifty carloads of surgical dressings were sent
from Red Cross Headquarters in Paris to Rou-
mania where the Red Cross commission found
the hospitals almost devoid of supplies, accord-
ing to Lleut.-Col. H. Gideon Wells of Chicago,
American Red Cross Commissioner to Rouma-
nian Col. Wells, who Is professor of pathology
at the University of Chicago, and has been di-
recting Red Cross relief operations in Roumania
for the last four months, returned to America
the last week in June. Ten Red Cross ships
have landed millions of pounds of supplies in
Roumania, all of which have been distributed
under his direction.
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**From the members of the royal household
down to the humblest classes, everyone you
meet admits that America's practical help came
just in time and saved Roumania from starva-
tion and the spread of typhus," said Col. Wells.
**None of the war-stricken countries we have
assisted could be more grateful. The effort to
get food, medicines and the needed supplies in
some measure to all parts of the country has
been successful and work on restoration of the
transportation facilities was progressing finely
when I left a few weeks ago. The Red Cross
is now distributing supplies from ten different
points in the country. Typhus is still prevalent,
in parts of Roumania, but American doctors and
nurses appear to have the situation well in
hand."
REATMENT
Neosalvarsan in the Treatment of Anthrax.^
The Medical Record (Feb. 1, 1919) calls atten-
tion to the idea which obtains today that the
non-septic forms of anthrax are amenable to
various kinds of treatment, some of which may
be quite simple, while septic anthrax, like all
sepsis, is very refractory to any plan of treat-
ment. The alleged remarkable cures which find
their way into literature are usually of local-
ized forms, which, while they may present a
marked constitutional reaction, are seldom sep-
tic in the true sense of the term. Much con-
fusion is associated with the management of
the disease on this account. Whether serum
treatment has ever actually prevailed over true
bacteremia is still open to doubt. In the Cor-
respondenz-Blatt fiir Schweizer Aerzte (Nov. 9,
1918) Gsell refers to the use of salvarsan in
this affection. In the original case of Becker
the 'general condition was bad, but the blood
remained sterile, and this was true of the other
related cases. Salvarsan was successful in cases
of this type, but made an inglorious failure in
others in whfch bacteremia was present. Only
in the laboratory did this remedy cure septic
cases, the bacilli dying in the blood within a
short time, as shown by failure to develop blood
cultures after treatment. The case referred to
was not of especial severity, and was not septic
at any time, but yielded so promptly to in-
travenous injections of neosalvarsan that the
result deserved to be called favorable.
Acute Diarrhea In Infancy. — An editorial
writer in the Medical Council (July, 1918)
points out that castor oil, or milk of magnesia,
may be indicated early in the case; and, in the
breast-fed, the mother may have too rich milk
and need to reduce her diet and take more exer-
cise. Many cases of indigestion resulting in
diarrhea are due to too much fat in the babe's
food, and it must be reduced. These cases are
apt to develop an acidosis due to the fat taking
up the alkali, and the stools become very acid
and high fever develops. After a cathartic,
sodium bicarbonate is demanded; and a glu-
cose or maltose sugar should be added to the
diet.
There is rarely too much sugar in breast-
milk; but bottle-fed babes often suffer from
sugar and other carbohydrate indigestion, with
resultant diarrhea. Sugar indigestion makes
green stools, as a rule; but there are no ma-
croscopic characteristics of the stool absolutely
diagnostic of the form of indigestion. ^
Diarrhea from excess of milk or cane sugar
is more severe than when from starch or mal-
tose-dextrin preparations. Treatment here de-
mands an initial purge, a 12- to 24-hour fast
and the dropping of sugar from the diet for a
while. Protein is the food best borne and fat
must be cut In quantity. Skimmed milk, with
cereal diluents, serves well; but do not make
the mistake of keeping the patient off of a min-
imum sugar diet any longer than is necessary.
Babes do not thrive well without some sugar.
Starch has been unduly blamed for causing
diarrhea. A well-baked sUrchy food is toler-
ated in small quantities by very young infants.
It is remarkable how some laboratory-fed babes
pick up when the mother begins to experiment
with a little baked wheat addition to the diet.
Indeed, we have personally seen mashed potato
stop a persistent diarrhea in very young chil-
dren.
When the mother's milk causes diarrhea, it
is more apt to be from too much protein than
from an excess of sugar. A menstruating nurs-
ing mother is apt to have an excess of protein
in the milk, and nervousness and fatigue may
act the same way. Take the babe, partly off
the breast milk and give a substitute weak in
protein. Excess of protein causes watery alka-
line stools.
Removal of Tonsils and Adenoids.— Bloom in
the New Orleans Med. and Surg. Jour, for April,
1918, gives an account of his observation on the
mental and physical state of children follow-
ing the removal of tonsils and adenoids. He
draws the following conclusions:
1. Children exhibiting some alterations in
the normal histology of tonsils and adenoids
give marked evidences of mental retardment.
2. Rheumatism, syphilis and tuberculosis
from hereditary and environmental points of
view have but little significance as causative
agents of diseased tonsils and adenoids.
3. This series of fifty-seven cases did not ex-
hibit the pathologic entities attributable to
tonsils and adenoids, namely, endocarditis,
myocarditis, rheumatic fever, chorea, etc.
4. In all there were twenty-nine causes for
the removal of these glands— the marked im-
provement was evidenced only in cases where
(1) persistent sore throat and tonsillitis with
temperature; (2) frequent attacks of suppura-
tive otitis media; (3) mouth breather and sup-
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AMBRICAN MBDtCII«B
NOTES AND ANNOUNCEMENTS
July, 1919
497
purative lymph nodes were the factors of their
removal.
5. Adenoidectomles should always be prac-
ticed where the child is a mouth breather
before the tonsils are enucleated. .
6. The largest tonsils (by weight) were
those removed from patients who previously
had measles and scarlet fever; the smallest from
children who had mumps and whooping cough
prior to operation.
7. Only one child gave a history of pneu-
monia before the tonsils and adenoids were re-
moved.
8. No relation between abnormal and dis-
eased teeth on the one hand and glands on the
other.
9. Weight Status— The weight curve showed
appreciable improvement after ten years of
age; gains were noted between 7 and 10 years,
inappreciable before this time. Children with
diseased tonsils are practically all underweight,
namely 3 to 26 per cent.
10. Gratifying results were obtained in
ninety (90) per cent, of forty cases where re-
ports and statements were secured and especially
marked in cases where frequent colds, tonsillitis
(with temperature), and mouth breathing were
the factors for their removal.
11. Frequent temperature traced to the ton-
sils and adenoids should be the indication for
immediate removal after the acute symptoms
have subsided, despite the fact that the child
might be between the age of 12 to 24 months,
respectively; on the other hand, if there is no
temperature but the patient suffers from symp-
toms attributable to tonsils and adenoids do
not remove these organs until the child reaches
the age of 6 years. Finally, it is my hope that
these modest findings will not be misunder-
stood, remembering this is the viewpoint of a
pediatrician.
Pyretotherapy a New Thought in the Modern
Treatment of Disease. — Pyretotherapy is a word
Invented by Mr. Konteschweller Titus (Paris
Thesis 1918) to describe treatment by drugs
that raise the temperature and create fever. In
a chapter on the history of this treatment,
which for that matter is wholly contempora-
neous the author sets forth to prove that vac-
cinotherapy is not always specific and that
heterovaccinotherapy (the treatment of several
very different diseases by anti-typhoid vaccine,
of typhoid fever by pyocyanic vaccine, of lupus
by the streptococcus, etc.) can only yield its
' good effects by the rise of temperature thus de-
termined. Pari passu the colloids also act by
virtue of the febrile reaction to which they
give rise. Investigation of certain diseases
moreover shows a rise of temperature as a
process of cure, natural fever possessing the
same curative action as artificially induced
fever. It is especially the sharp ephemeral rise
of temperature that seems to do good.
Many patients have been found amenable to
this mode of treatment. Typhoid fever, measles,
scarlatina, erysipelas and pneumonia have been
treated by means of the colloids, injections of
milk, nucleinate of soda and vaccinotherapy
and the author attributes the good results to
the fever thus induced. Acute rheumatism is
especially amenable to this treatment, more
particularly gonorrheal rheumatism. Instances
of the same kind are met with in surgery (in-
fected wounds, septicemia), in dermatology
(psoriasis), in ophthalmology (conjunctivitis
trachoma), and in syphilography.
Mr. Titus has tried a large number of these
pyretogenous agents and he describes them
seriatim. He remarked particularly the good
results of certain of them in gonorrheal rheu-
matism. His most original researches, how-
ever, bore on the treatment of urethritis and
salpingitis by intravenous injections of kefir.
He describes the procedure which he followed
and gives the detailed notes of eleven cases in
which he obtained very encouraging results.
Doubtless It would not be difficult to discover
matter for criticism in this observer's views and
the conclusions he draws from researches an-
terior to his own as well as from the latter.
Nevertheless, the idea is original enough and
sufficiently logical for it to be of interest*. His
work may conceivably embody a commencement
of explanation of phenomena that have re-
mained more or less mysterious, the which are
dally becoming more numerous.
Treatment of Gunshot Wounds.— After a com-
plete surgical cleansing and drying with abso-
lute alcohol the whole wound-cavity, Livingston,
Tubby and Mackie (Lancet, Feb. 15, 1919) rec-
ommend the application of paste of acrifiavine.
The paste contains one-half of one per cent, of
acrifiavine in a mixture of one part bismuth
subcarbonate with three parts of paraffin. In
cases of infected fractures, etc., the establish-
ment of free drainage and removal of all
necrosed tissues are followed by irrigation with
eusol for from two to five days. The remaining
necrosed tissues are then excised, the wound is
thoroly washed out with alcohol, and it is filled
with the acrifiavine paste. This dressing does
not require changing more often than about
once weekly. The wound rapidly becomes sterile
under it and fine, healthy granulations develop
rapidly.
NEWS NOTES""
ANNOUNCEMENTS
$1^00,000 Asked to Fight Influenza.— The
American Medical Association at its closing ses-
sion at Atlantic City passed a resolution calling
upon Congress to provide a fund of at least
$1,500,000 to finance measures for the preven-
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498
July, 1919
NOTES AND ANNOUNCEMENTS
American Mbdicinb
tlon of influenza epidemics. The resolution
stoted that there was grave danger of more
destructive outbreaks of the disease. If pro-
vided the fund will be used in research work
by the Public Health Service, officials of which
told the delegates that the causes of the disease
were still a matter of speculation.
Medical Editors' Electloiu— The American
Medical Editors' Association, at its golden anni-
versary meeting held on June 9th and 10th, in
Atlantic City, under the presidency of Dr.
George W. Kosmak, of New York, elected the
following officers for the ensuing year: Presi-
dent. Dr. Seale Harris, of Birmingham, Ala.;
first vice-president. Dr. B^anklin Martin, of
Chicago; second vice-president, Dr. H. S. Ba-
ketel, of New York; secretary. Dr. Joseph Mac-
Etonald, Jr.. of New York, (reelected); execu-
tive committee. Dr. George W. Kosmak, of New
York; Dr. Edwin Lewis, of New York, and Dr.
D. S. Fairchild, of Clinton. la.
Col. R. P. Stronar's Appolntmentn-Ueut.-
Gen. Sir David Henderson, director-general of
the League of Red Cross Societies, has appointed
Col. Richard P. Strong of Cambridge, Mass., a
member of the United States Medical Corps, as
acting director of the Bureau of Hygiene and
Public Health of the League. During 1915 Col.
Strong served in Serbia as director of the
American Red Cross and International Sanitary
Commission that fought the typhus epidemic
in that country. He was subsequently a mem-
ber of the A. B. F., being associated with the
department of infectious diseases of the chief
surgeon's office. He is a member of the Inter-
Allied Sanitary Commission and has directed
the American Commission's research investi-
gation in trench fever.
alcohol by drug stores have been provided. All
prescriptions must be preserved, and each month
the names of patients and the total quantities
dispensed to each during the month must be
transmitted to- the collector of Internal revenue.
Pharmacists have been advised to refuse to fill
prescriptions if they have reasons to believe
that physicians are dispensing for other than
strictly legitimate medicinal uses, or if patients
are obtaining thru several physicians quantities
in excess of normal amounts.
A Franeo- American Medical Ententes—An As-
sociated Press report from Paris says that an
organization has been formed there with the
object of establishing permanent relations be-
tween American and French physicians and
surgeons. Several commissions have been ap-
pointed by the organization. One of these will
have in charge the establishment of a course
of teaching for American physicians visiting
France and another the founding of a bureau
of information. A third commission will ex-
amine into means of organizing an exchange of
articles on medical and surgical subjects be-
tween the journals of the United States and
France.
New Physiologic JonrnaL— The first number
of the Journal of Qeneral Physiology will make
its appearance on September 20. This journal
will appear bi-monthly and is intended to serve as
an organ for publication of papers devoted to
the investigation of life processes from the
physiochemical point of view. The editors are
Dr. Jacques Loeb, of the Rockefeller Institute for
Medical Research, and Prof. W. J. V. Osterhout,
of Harvard University. The subscription price
is $5 a volume and subscriptions should be sent
to the Journal of General Physiology, Publica-
tion Department, the Rockefeller Institute for
Medical Research, Sixty-sixth Street and Avenue
A, New York City.
Government Regolates Dispensing of Alco-
holic Drinks by Physicians and Droggists.— The
Internal Revenue Bureau of the Treasury De-
partment has issued ney regulations governing
the dispensing of alcoholic drinks by drug
stores and physicians for medicinal purposes.
Physicians may prescribe wines and liquors
for internal use, or alcohol for external use,
but In every such case each prescription shall be
in duplicate, and both copies must be signed in
the physician's handwriting. The quantity
prescribed for a single patient at one time shall
not exceed one quart, and in no case shall a
physician prescribe alcoholic liquors unless the
patient is under his constant personal super-
vision. All prescriptions must indicate clearly
the name and address of the patient, including
the street and apartment number, if any, the
date when written, the condition for which it is
prescribed, and the name of the pharmacist to
whom the prescription is to be sent to be filled.
Similar detailed restrictions on the sale of
The Effeminate Warrior. — A new story of the
Red Cross bag comes from Harvey D. Gibson,
former Red Cross Commissioner for Ehirope
who has recently returned to this country. He
got the story from one of the workers in a Hos-
pital Hut in Dijon. Everybody who has ever
seen a wounded soldier knows the bag of gaudy
cretonne with the little Red Cross in the corner
in which each boy keeps the bit of shrapnel
the doctor dug out of his knee, the last letter
from home, the picture of his girl, his tooth
brush and all his most cherished possessions.
One of the boys in the Dijon Hospital had just
been presented with his bag, a pink and white
one. He accepted it gratefully; then he began
to laugh. "Say," he declared, "if someone had
told me two years ago that I'd be goin* to war
with a wrist watch on one wrist and a bracelet**
— he held out his Identification disk — "on the
other and a cretonne bag in my hand! Say, I'd
'a pasted him one!"
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BmemnHedicine
PUBLISHED MONTHLT
Baitorial OIHo»gt 18 Ummt 41 at i^t.. lf»w York City. Pvblieatiea Offio«si 189 College St., B«rliA«tom, Vt.
Conpl0te SeriM, YoL XXY. No. 8
K«w B«ri«s, Yol. inr. No. 8
AUGUST, 1919
C2 nn TSABLT
CONTENTS
BU>ITORIAI< COMMBNT 4119
MKW AND THINGS . . i 511
ORIGINAIi ARTICI^BS 515
PHYSICAIi THBRAFY 546
RATIONAIi ORGANOTHBRAPY 650
BTIOLOGY AND DIAGNOSIS 552
TKDATBiSSNT 562
GBlNBRAIi TOPICS 555
.NE2W8 NOTBS AND ANNOUNCBMBNTS . . . 550
(OontIlia«d OB PMT* i)
CONTRIBUTORS
S. ADOLPHUS KNOPF, M. D., New York City.
ROGBR G. PBRKINS, M. U^ Prlzren, Serbia.
BI. FORD MORRIS, JR., BI. D., Atlanta, Ga.
JOS. B. FUU>, BI. D., New York aty.
GBORGB M. GOULDk BI. D., Atlantic City, N. J.
CASPBR Im RBDFIBI^D, CbJcagro, 111.
Entorod mm MooBd-elMt malker Jannaiy 28, 1006, aft ftbe Post Office aft Bnrlington, Yk, vnder Aek of CoDgreis. March 8, 1870.
Hot Weather Skin Irritations —
notably chafing, prickly heat, sunburn and similar affections
—are promptly relieved by
K' Y Lubricating Jelly
Applied liberally to irritated or inflamed areas, the pronounced cool-
ing and soothing action of this effective local remedy is at once
manifest. Smarting, burning and itching are quickly allayed and
local congestion is rapidly overcome. In fact, by its beneficial effects
upon the skin, as well as by reason of its water-solubility, its abso-
lute freedom from staining skin or clothing, its non-greasiness and
the altogether unusual cleanUness of its character,
K'Y Lubricating Jelly
is an ideal emollient
It relieves itching and burning when most ordinary relief
measures prove ineffective.
In ooUapnUe tubes at 25e.
Obtainable at all Drug Storas.
Sample on request.
NEW BRUNSWICK, N. J., U.S. A.
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Adrenalin Chbrile Sohilkm
For tpngring the noae and phanyta. (alter
diludon wim lour to five timea ila Tolume
of plkjnologic aak aolutum).
SuppBed in ounce botdea,oii« in acartoii*
For tpiasring tke noae and pliarynz ( fufl
•irangth or dilated widi three to toitf
timea ito ▼olume of oHve oil).
Supplied in ounce bottlea^one in a cartom.
0.
For aprajing tlie noae and l
dilution with four to five timee ito ^
of phjrnologic aak aohition).
Suppoed in ounce botdeibooein acarton.
Ghseptic NebaEzer
The moat economical inatrumeni for neb*
uliiing the Adrenalin and Pituitiin piepa-
lations Hated above. It atomircta down to
die laat drop.
Price, complete with tLioat>piece, $1.25*
Kxed Infection Pliyiacogen
For hypodermic or intraveooua injection.
Bio. 595. hi lOLmil (lOuCc) bulbil one
inapackafe.
Bio. 597. hi l-mil (UCc) bulbe, five fat
npackafe.
Ragweed PoDen Exinct
For prophylazb and
)
(Admin-
Bio. 680. Five tubei» with acari^jring
needle, for diagnodt.
Bio. 682. Four5.nul(5Xc)viala(No.l.
10 unite; No. ^ 100 unite, and No. 3i
1000 unite per mOs No. 4, diluent).
Bio.681. Number3viaL5mila(5 Cc).
1000 unite permiL
Parke^ Davis & Co. «
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American Medicine
H. EDWIM LEWIS, M. D.. Mammging Editor
Fdbli8hu> Mohthlt bt no AmmoAH Mbokul Pubushikq Gompant
Covrrlfflited by Uie Amniean Medical PabUshinc Co.. 1910
IRA S. WILE, Associate Editot
Complete Series, Vol. XXV, No. 8
New^ee, Vol. XIV, No. 8
AUGUST, 1919
$2.00 ^^^^^
In Advance
Obedience to Law^ — ^The Section on
Preventive Medicine and Public Health of
the American Medical Association at its re-
cent meeting adopted the following resolu-
tion:
"Resolved, That the Section on Prevent-
ive Medicine and Public Health of the
American Medical Association recommend
to the House of Delegates that it ask the
constituent associations to consider the ad-
visability of such amendments to their by-
laws and to those of this* association as will
eliminate from membership any physician
who willfully fails or refuses to comply with
local or State laws for the prevention of
disease, including especially the provisions
in such laws requiring the reporting of cases
of communicable diseases."
If it were possible to secure the coopera-
tion of all physicians in the enforcement of
our health laws, the work of health admin-
istrators would be greatly facilitated. The
benefits that would i-esult would be of in-
estimable value. It is not too much to ex-
pect members of the American Medical As-
sociation to live up to their responsibilities
to the general public. The right to practice
IS given by the State, and should carry with
it the obligation of fulfilling all the duties
to the State.
While the above resolution related to ac-
tion on the part of special associations of
physicians, a recent enactment of the Public
Heahh Council of the State of West Vir-
ginia carries with it a demand for action
with reference to the reporting of infec-
tious diseases that is far more rigorous than
previous laws because it provides for the
revoking of a license. As printed in the
Bulletin of the West Virgina State Depart-
ment or Health, July 19, 1919:
"Any physician who has been convicted
of failure to report cases of infectious or
contagious diseases to the local health
officer shall be deemed guilty of dishonor-
able conduct, and may at the discretion of
the Public Health Council, have his license
revoked."
Furthermore, the health officer is held
accountable for his prompt investigation of
cases of infectious or communicable dis-
eases within 24 hours after the receipt of
a report of the existence of such infectious
or communicable disease. The health
officer may be removed from office for
failure to send in a weekly report of infec-
tious diseases as required by law, and he
may be found guilty of neglect of duty and
removed from office at the discretion of the
Council for failure to prosecute any phy-
sician who fails to report infectious or com-
municable diseases as required by law.
By many, regulations of this character
may be considered altogether too rigorous
to be just. On the other hand, unless there
be a law of this character, with jaws that
bite and claws that scratch, there is a tend-
ency towards laxity in the performance of a
duty of paramount importance to the public
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500
AuauBT, 1919
EDITORIAL COMMENT
Ambrican Mkdicinb
welfare. If the medical profession is
brought to realize the enormity of the of-
fense against public welfare in failure to
report infectious and communicable dis-
eases, there is every reason to believe that
a more prompt and conscientious system of
reporting will be instituted.
Drastic legislation within the bounds
of reason is by no means a hardship, and if
such rules as have been established in the
State of West Virginia prove themselves
to be of service in securing more eflfective
cooperation on the part of the medical pro-
fession, there is every reason to believe that
such enactments will be incorporated in the
laws of other states. There appears to be
no intermediate punishment for a first of-
fense, but inasmuch as all action is within
the discretion of the Council, it is probable
that warnings will be given before the
severe penalty of license revocation will be
employed. It is obviously proper that the
State possess some means of securing the
enforcement of its health laws, and the
question of maintaining a position in the
community is one which should appeal most
forcibly to physicians. To have one's
license revoked for failure to live up to
state regulations is a reflection upon the
integrity of an individual, but this is by no
means as serious as the fact that a revoked
license deprives the individual of all rights
to continue in the practice of medicine, for
which years of preparation have been re-
quired.
If the resolution of the Section on Pre-
ventive Medicine and Public Health is ac-
cepted by State and County Societies thru-
out the land, there would undoubtedly be
less reason for a state regulation as in-
augurated in West Virginia, tho there still
would be some members of the medical pro-
fession insufficiently interested in public
welfare, who, outside of all association mem-
berships, would have to be stimulated to the
performance of their public duties. These
two resolutions aflford much food for seri-
ous reflection, as indicative of the necessity
of securing more forceful measures to pro-
tect the public against violation of the
public health laws referring to the reporting
of infectious and communicable diseases.
The Mortality of Negroes^— The health
problems of the negroes are numerous. The
necessity for initiating provisions for car-
ing for the colored population becomes more
imperative as efforts to lower the mortality
rates of the whites approach maximum
standards. Unfortunately, statistical ma-
terial available fails to be based upon the
experiences in sections of the country where
the colored population is most dominant.
The great mass of the negro population re-
sides in the non-registration area. In 1915,
only 30.4 per cent, of the negro population
were living within the registration area. In
consequence, all statistical statements relat-
ing to negroes must be regarded as incom-
plete, and, in many instances, inadequate for
the drawing of absolute conclusions. There
must, naturally, attach some degree of un-
certainty to the calculation of birth rates
and death rates for the country as a whok,
and when such a large proportion of a single
class of the population fails to come within
the registration area. It is possible, how-
ever, to tentatively note the more persistent
characteristics of mortality figures which
present specific death rates within the area
of registration where differentiations are
made according to age, sex, and cause of
death. Even here, there is room for ques-
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AMBRICAN ICEDIGXNa
EDITORIAL COBIMBNT
August, 1919
501
tion as to the relative accuracy of reporting
facts relating to the negroes, as compared
with similar items referring to the whites.
In the recent volume on "Negro Popula-
tion" issued by the Bureau of the Census
appears a vast amount of statistical material
conservatively, but fairly interpreted. In
the discussion of mortality,, one notes that
the expectation of life for negp"oes is con-
sistently lower than that estimated for
whites, male or female. This is partially
due to the high infant mortality for negroes
and the lower degree of survival thru in-
fancy and adolescence. The duration of
maturity and old age indicates that the
average number of years lived in the ages
20 to 60 years is 18.0 per negro child born
to 27.1 per white child born of the males,
and the figures are respectively 19.9 and
28.6 for female children. It is only fair to
remark that these figures are based upon
the ten original registration states and the
District of Columbia, thus evidencing a cal-
culation of negro expectation of life upon
experience in communities where the negro
population is relatively small.
Leaving out of discussion the exceed-
ingly high infant mortality rate among
negroes, which, however, has shown a con-
stant marked improvement, one notes
among the specified causes of death a con-
sistently higher mortality rate for negroes
compared with whites, with the exception
of such causes of death as cancer, cirrhosis
of the liver, diphtheria and croup, measles,
diabetes and scarlet fever. The great
decimator among negroes is tuberculosis,
with a rate of 463 per hundred thousand
population in 1910, compared with 148 for
whites. In this year, tuberculosis was re-
sponsible for 182 out of every thousand
deaths reported for negroes. Pneumonia
and organic diseases of the heart and
nephritis caused 692 deaths per hundred
thousand population for the negroes as
compared with 377 per hundred thousand
population of the whites. The pneumonia
rate was twice that among the whites.
The serious problem presented by these
figures challenges our state systems of health
administration, and provides much food for
thought as to the safety of the colored pop-
ulation in a democracy. Undoubtedly, a
considerable proportion of the mortality
from tuberculosis and pneumonia is bound
up in environal conditions that are pro-
nouncedly unfavorable. The entire answer
cannot be found by stating that the figures
for the negroes are highly colored in view
of the fact that the rural population, to
which such a large proportion of the ne-
groes belong, is not adequately represented
in our mortality .statistics. Where com-
parisons are made between rural and urban
death rates for negroes and whites, the
balance of strength and vitality is shown to
be on the side of the whites. Urbanization
may condition a higher mortality of whites
and negroes than living in rural sections,
but there is insufficient evidence to show
conclusively that negroes suffer more from
this cause than do the whites.
In view of the higher incidence of vene-
real diseases among negroes, it is astonish-
ing to find so little attention paid to this
subject. The only tabular mention made is
in connection with infant mortality, where-
in it is shown to be a cause of infant mof-
tality to the extent of 30 per thousand
deaths. Even at this rate, it follows in
seriousness diarrhea and enteritis, prema-
ture births, congenital debility, bronchial
pneumonia, and pneumonia, acute bronchitis
and convulsions. It is more serious than
any of the communicable diseases.
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AUGUBT, 1919
EDITORIAIi COMMENT
Ammwcaw Mkdicinb
It is noteworthy that in fecundity che
negro woman apparently is more fertile
than the native white woman, but offers
fewer children than are found among
foreign bom white women. The number
of children under five, per thousand women
15 to 44 years of age, varies in different
sections of the country, and this holds true
for the negro as well as for the white. Nor
is it strange to observe a decreased pro-
ductivity on the part of negro women by no
means dissimilar in relative proportions to
that noted among white women. For ex-
ample, the number of children under five,
per thousand married females 15 and over,
in 1900 was 842 for negro and 643 for
white, while in 1910 these figures had fallen
to respectively 711 and 588. The contrasts
for various sections of the country are well
illustrated in the figures of the South and
the West for 1910. The South gave a
figure of 757 for negro women and 749 for
white; the West 315 for negro and 518 for
the white. If the birth rate among the ne-
groes is actually decreasing regardless of
the cause, it is fair to assume that the infant
mortality rate will show marked decreases
within very few years. With a continuity
of more or less unfavorable economic con-
ditions, the fewer children bom, the lower
is the mortality rate. The decreased fertil-
ity, therefore, of negro women may serve
as a check to the infant mortality rate, pro-
vided, of course, that syphilis does not play
too prominent a part in the cause of con-
genital debility and malformation.
The negro population of the United
States today furnishes a very serious
question that must be faced in the
spirit of the present time, rather than in
the spirit of bias or prejudice that still
may linger in some quarters as a result of
the mental attitude engendered by the days
of slavery. The problems of industry, with
all the difficulties of hygiene and sanita-
tion, call for no greater thought and effort
than do the needs of the negro population.
The high mortality figures still existent for
this single group, comprising fully ten per
cent, of the population of the United States,
are a sad reflection upon municipal, state and
governmental care given to these people
whose economic, social and health salvation
must be worked out in this country. This
state of affairs may be regarded by many as
belonging only to the South. Public health,
however, recognizes no state boundaries or
limitations. The fact that the negro is
growing to be more migratory emphasizes
the importance of a larger measure of effort
to overcome the physical disabilities con-
stantly undermining their vitality. Tuber-
culosis or pnevunonia among negroes is as
serious a public health problem as similar
conditions existent among whites. The
uniformly higher mortality among negp"oes
in northern communities is sufficient rea-
son to believe that public health efforts
might well be directed toward them in the
aim to improve general conditions of living,
freer from the likelihood of death at every
age period. The mortality and morbidity
figures thus far available for the negro pop-
ulation constitute a serious indictment of
our vaunted civilization, and our attitude
towards the health and development of the
negroes of this country.
Home Nurses. — ^At various times stress
has been placed. upon the necessity of in-
creasing the number of persons capable of
nursing. The experience of the past year
taxed our resources beyond our ability to
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EDITORIAL COMMENT
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503
give any form of care approaching adequa-
cy. Thousands of persons undoubtedly died
because of a lack of nursing service. There
are many duties that the average person
•can be trained to perform, which would be
of the utmost benefit in the home during
times of health, but which would be of par-
ticular value in event of sickness. Public
school systems have not devoted sufficient
attention to the practical phase of home
nursing, so as to incorporate courses in the
curriculum. Secondary schools and wom-
en's colleges have been even more sadly
neglectful of this duty of fitting girls and
young women for assuming their responsi-
bilities for nursing care. There is a lack of
educational facilities which must be supple-
mented by some other machinery, and none
can be more productive of effective results
than the institution of practical courses in
nursing under the auspices and direction of
municipal government.
The City of Chicago has recently estab-
lished what is to be known as the Chicago
Training School for Home and Public
Health Nursing. A capable faculty is to
be selected and doctors and nurses of the
health department are to cooperate in the
training oi women desirous of acquiring
this direct information. The course of in-
struction is to be furnished without cost. It
is to cover eight weeks, with three lessons a
week. The arrangement of attendance has
been fixed so that the course will be given in
the afternoon and in the evening, with two
sections running on alternate days of the
week, thus making it possible for a large
group of persons interested to take advan-
tage of the facilities afforded.
The lectures and demonstrations, as out-
lined in the Bulletin of the Chicago Depart-
ment of Health, July 19, 1919, are to cover :
(1) Bedmaking — medical, surgical, mater-
nity and fracture bed. (2) Cleansing baths
— ^baths for reduction of temperature, hot
and cold packs. (3) Maternity nursing
(care of mother and infant). (4) First
aid — ^medical and surgical; poultices and
stupes. (5) Care of contagious disease pa-
tients.
This experiment in municipal edbcation
under the auspices of the Health Depart-
ment commends itself and merits emula-
tion. It should have the whole-hearted
support of the medical profession, because
it will make for more careful nursing, and
a more intelligent conception of the part
that medicine plays in maintaining public
health. All advances in bedside nursing
constitute an aid to the physician, and pro-
mote the successful issue of sickness,
whether acute or chronic.
The example set by Chicago can be
adopted in communities, large or small.
There is no reason why state institutes can-
not be held in rural communities, with an
itinerant corps of lecturers and demon-
strators capable of giving the desired in-
struction. Intensive work, supplemented
by courses of reading, with possibly a
traveling exhibit, would go far towards
raising the standards of nursing experience
and preparation for home nursing thruout
the country.
In the face of the bitter suflFering in
the past, while meeting epidemic conditions,
there is every reason to fortify ourselves
against a repetition of our state of unpre-
paredness. The time is ripe to devote time
and money for the purpose of securing im-
proved education within the home. Thus
will develop an ability to meet the contin-
gencies which naturally grow out of the
invasion of disease. There is every reason
to believe that suffering will be mitigated,
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EDITORIAL COMMENT
Annie AW Mbdicinb
some degree of contagion averted, with a
marked lessening of mortality at all ages.
Every woman, particularly those who are
mothers, should be able to take tempera-
tures, record the pulse and respiration, keep
a bedside record, and intelligently carry out
orders left by physicians. This knowledge
is not in itself highly technical, nor is it too
difficult to be absorbed by persons of aver-
age mentality. The end product of instruc-
tion of this character is not to be regarded
as a trained nurse, but merely as a person
with a practical working knowledge of how
to solve some of the ordinary problems aris-
ing out of every-day living, with all its vari-
ous hazards from disease and accident.
Bronchitis^ — ^A number of medical con-
ditions have been rather contemptuously
designated "minor maladies." The term
is unfortunate in that it fails to present the
true picture of the pathologic conditions
in relation to social welfare, economic loss,
or the spread of contagion. In a workman,
obliged to lift heavy weights, hernia is by
no means a minor affection. Chilblains are
hardly trifling for those who must work in
communities where the climate is cold for
a considerable portion of the year. The
ordinary cold and bronchitis scarcely merit
the inferior position employed in the term
"minor malady."
Soper, Boston Medical and Surgical
Journal, July 24, 1919, has written upon
"Bronchitis, The Most Significant Disease
of the War." The singling out of bron-
chitis in this way may come as a distinct
revelation to those who have been accus-
tomed to regard it as of trifling importance.
Soper points out that the significance of
bronchitis exists : first, on its own account ;
second, because of its connection with other
respiratory diseases such as pleurisy, pneu-
monia and empyema; third, because it
provides means for the spread of infections,
"which, altho not strictly respiratory, are
believed to be transmitted in a respiratory
manner."
Bronchitis was the most prevalent disease
during the war, not merely in its associa-
tion with other communicable diseases, but
as an independent infection, which was al-
most universal in the Army and Navy
camps during 1917 and 1918, particularly,
during November, December and January.
In all probability, a considerable propor-
tion of the alleged bronchitis was of a pneu-
monic type, altho many so-called bronchitis
visitations were passed over under the
terminology of "colds." Unfortunately,
one attack of bronchitis confers no im-
munity, but to the contrary, appears to
make individuals more susceptible to future
attacks. With a large proportion of men
suffering from bronchial disturbances, the
number entering into the hospital for this
disease was comparatively small. Statistics,
naturally, give no information regarding
the part bronchitis played in laying a
foundation for the more terrifying and dev-
astating conditions such as pneumonia,
pleurisy and empyema. But few soldiers,
however, escaped bronchitis and, with it, a
variable degree of impairment of physical
effectiveness.
Bronchitis undoubtedly led to numerous
fatalities as an intercurrent disease with
measles, scarlet fever, and other infectious
diseases, altho Soper suggests that the bron-
chial pneumonia following measles, for in-
stance, might have been due to a bronchitis
antedating the attack of measles. Bron-
chitis probably is not per se a cause of a
serious mortality even tho it may be the
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AMKUGAN MBDIOXm
EDrrORIAL COMMENT
August^ 1919
505
most prominent symptom present at any one
time. The terminating condition is more
likely to be a pneumonia.
The prevalence of bronchitis has not
given rise to any definite information as to
its specific causation. Numerous micro-
organisms have been isolated, and various
contributory causes have been alleged.
Problems of clothing, exposure to dust,
draughts and fumes are known to have
some relation to the development of bron-
chitis, if only to the extent of serving as
predisposing causes. The control of alleged
conditions increasing susceptibility to bron-
chial attacks would tend to decrease the
frequency of its occurrence, and would
serve to lower the likelihood of a secondary
visitation of more fatal respiratory diseases.
It is patent that an epidemic of bron-
chitis is practically beyond control, insofar
as modem methods are concerned. Even
the mask, to which the recent epidemic
called attention, has been proven to be in-
adequate and for continuous use, is dis-
tinctly impracticable. The control of cough-
ing, spitting and sneezing depends for effect-
iveness upon an appreciation by the public
of its dependence on self-applied re-
straints for self-protection and for the pur-
pose of protecting those with whom they
come in contact. The dangers of dissemi-
nating contagious diseases during a period
of bronchial cold are greatly increased and
the paroxysmal expulsion of germs is a con-
stant threat to those gathered together in
close spaces.
A Crowd Disease. — ^According to Soper
bronchitis is essentially a crowd disease in
the sense that it occurs when people are
crowded together and shows a preference
for persons who are not accustomed to
crowds. In all probability, there are other
factors entering into epidemics of bron-
chitis besides mere conditions of crowding,
as they may occur in isolated communities
where crowding, such as is found in
churches, places of amusement and con-
gested schools is lacking.
A question might be raised by the state-
ment that the relative immunity which city
people enjoy toward respiratory infections
may be explained upon the theory of ac-
quired immunity thru repeated exposure to
small doses of the virus.
Under war conditions, overcrowding
might have been prevented to some extent,
but crowding is an essential factor in the
massing of military forces. It is of signifi-
cance, however, that there was much less
sickness in the camps composed of tents
than in those provided with wooden bar-
racks. The lesson for civilians from army
experience includes a recognition of the
part that bronchitis plays in the causation
and dissemination of disease. Further, it is
important for civilians to understand the
relation between overcrowded homes, cars,
schools, churches, dance halls, moving pic-
ture theatres and other places where men,
women and children congregate for various
purposes to the development of coughs,
colds and bronchitis. Most essential of all,
however, is the recognition of the fact that
bronchitis is by no means to be disregarded
and scorned as a "minor malady", but one
that is of serious consequence under condi-
tions of congestion and crowding, particu-
larly when opportunities for adequate heat-
ing and ventilation do not exist.
Industrial Specialists^ — ^The growth of
industrial medicine promises to yield large
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AuauBT, 1919
BDITORIAIi COMMENT
AmucAK UmBtaam
benefits to industry and at the same time
to provide a new field for medical special-
ism. According to Selby in his Studies of
the Medical and Surgical Care of Indus-
trial Workers, Public Health Bulletin,
Number 99, "Industrial medicine may be
defined as the theory and practice of med-
icine, applied to the purpose of preventing
and alleviating sickness and injury among
industrial workers in order that they may
enjoy the benefits of continuous productive
employment." It is patent that this defini-
tion involves many phases of medical ac-
tivities including sanitation and preventive
medicine, general diagnostics and internal
medicine, emergency and orthopedic sur-
gery, roentgenology, orthodontia, dental
prophylaxis, as well as other specialties,
such as those pertaining to the eye, ear, nose
and throat. With this interpretation, it is
obvious that preparation for industrial med-
icine requires a broad general training and
an intensive experience in connection with
industry, together with a decided interest
in the development of an industrial prac-
tice, not as a side issue, but as the main
line for life work.
The value of industrial medicine as a
means of promoting quantitative produc-
tion or of reducing the cost of production
without lowering the quality has been
sufficiently demonstrated to secure the sup-
port of employers. Employees have begun
to realize the personal advantages procur-
able from the adoption of rational systems
of medical service in industry.
In order to appreciate the scope of work
involved in the promotion of satisfactory
relations between employers and employees,
thru the medium of industrial medicine, one
need but note some of the types of service
required :
"1. Treatment of injuries in dispensary.
home, or hospital, by physician, attendant,
or consultant, including orthopedic and re-
constructive surgery when necessary. 2.
Opinions as to disabilities from injury
and recommendations as to compensation
awards. 3. Rehabilitation of impaired
workers. 4. Regular factory inspection
designed to uncover conditions that are
inimical to health, and written recommenda-
tions to proper officials for their correction.
5. Studies of the effects of methods, proc-
esses, and machinery operations upon
health and body functions, relating to
posture, eye strain, monotony, speed,
poisons, etc. Written recommendations to
proper officials when effects are found to
be harmful and advice to employees which
will enable them to minimize the harmful
results of processes from which hazards
cannot wholly be removed. 6. Physical
examinations of applicants for employment,
and written recommendations to employing
officers relative to applicants' fitness for
work. 7. Examination of employees when
their shop efficiency falls off, unless the
reasons are evidently not physical; advice
and treatment, or aid in obtaining treat-
ment to such as need it ; and written recom-
mendations to foremen when deemed wise.
8. Examination of employees who do not
feel well or do not appear well to their
foremen or fellows; advice to employees
when it is indicated; and written recom-
mendations to foremen if altered working
conditions are essential. 9. Monthly ex-
aminations of all process workers, those
who may be engaged in any work that may
in any way have ill effects, and of food
handlers. 10. Health instruction by per-
sonal talks in the homes or factory, by lec-
tures, posters, or pamphlets. 11. Records
of data that will assist in the prevention of
accidents and sickness. 12. Cooperation
with other establishments and local, State,
and national health authorities."
These are merely suggestive of numerous
opportunities for correlating industrial phy-
sicians to plant organizations. Wherever
possible, whole-time service is indicated, but
when half-time or part-time service suffices
such facts should be determined by the
actual needs of the industrial plant rather
than from considerations of the amount of
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Ambucan Mbdicinb
EDITORIAIi COMMENT
AUGUBTj 1919
507
time at the disposal of any particular phy-
sician. Ordinary physicians in general
practice, with a wide knowledge of the
theory and practice of medicine are not
necessarily fitted for industrial service.
Special training is required to enable them
to adapt their knowledge to the require-
ments of industrial work and to secure such
supplemental information regarding sociol-
ogy and economics and industrial processes
as to fit them to make due and proper inter-
pretations of the various problems that may
arise in connection with their work. The
growth of industrial medicine is rapid, and
Its wants can be satisfied only by the provi-
sion of specialists in this field, who have
had the requisite preparation. In this con-
nection, it may be said that post-graduate
courses in industrial medicine are greatly
needed and medical colleges have a field for
future service that cannot be overlooked if
they are to keep pace with the demands of
civilization thru medicine. It is essential
that medical colleges do not merely provide
courses in instruction in industrial sanita-
tion and medicine, but that some form of
affiliation shall be worked out whereby
practical experience may be secured by
students in well organized industrial medi-
cal departments engaged in the practical
application of industrial theories in daily
life.
This work must be further supplemented
by a wider knowledge of the nature,
methods, advantages and technic of indus-
trial medicine, so that its intent and pur-
pose will be thoroly appreciated by employ-
ers and employees, as well as by the medical
profession.
Industrial Medicine and Its Remunera-
tion.^— From the remunerative side, in-
dustrial medicine is more attractive than
many other phases of public health work.
To quote from Selby, for illustration, in an
establishment of 500 to 1,000 employees, a
physician spending one-half hour daily re-
ceives $900 a year, and another putting in
as much time as is necessary receives $1,200
a year. One company pays its chief phy-
sician serving part of the time $2,000 a year.
In an establishment of 1,000 to 2,000 em-
ployees, one doctor is paid $3,300 for three
hours daily. The salaries of full-time doc-
tors vary from $1,200 to $3,000 per year,
etc. The indications are made plain: "(a)
That the remuneration of industrial physi-
cians is very evidently a matter of individual
bargaining; (b) that physicians who render
service only on request are better paid pro-
portionately than part-time doctors; and
(c) that part-time doctors are better paid
in proportion to the time they give than
whole-time doctors." It is natural in
the beginning of a new form of specialty
having commercial value, that there should
be considerable diversity in the remunera-
tion, but with the growth of a better under-
standing of the financial value of industrial
medicine, there will be an increased demand
for industrial physicians, and here, as in all
other lines of commerce, there will be a
* natural evolution in the scale of wages, de-
pendent upon the law of supply and de-
mand, and the relative ability of individuals
who perform the services for which they
are employed.
There is little doubt that within the next
few years the industrial values of physicians
will have achieved a higher plane, and that
the regularity of hours of employment, the
organization of duties and the perfection
of. technic in various directions will make
the practice of industrial medicine highly
desirable from every standpoint involving
the physical and mental comfort and satis-
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August^ 1919
BDITORIAL COMMENT
AaCSRICAN Mbdicins
faction of the medical attendant specializ-
ing in industrial medicine.
The Prevention of TNT Poisoning.—
While the use of trinitrotoluol has al-
ready decreased and will undoubtedly play
a smaller part in the aifairs of the world,
knowledge concerning its toxicology and the
prevention of poisoning thru handling it
possesses considerable value. A recent re-
port by Voegtlin, Hooper and Johnson
(Public Health Reports, June 13, 1919),
presents the results of experimental study
of TNT poisoning. While the original
work was bas^d upon the study of poison-
ing in dogs, a further investigation was
later carried on in a large shell-filling plant.
The symptoms of TNT poisoning include
cyanosis, constipation followed by diarrhea,
saliyation, incoordination, icterus and
anemia. Diagnostic tests for the recogni-
tion of early poisoning depend upon the
recognition of anemia and the presence of
bile pigments in the urine. The blood of
workers should be tested every eight to
fourteen days and those revealing a de-
crease of IS to 20 per cent, in the hema-
globin below the initial figure should not be
permitted to continue the handling of TNT.
Similarly, the presence of bile pigments in
the urine, indicating a disturbance in liver
function, may be the precursor of a rapjdly
developing toxic jaundice, and thus is an
indication for the cessation of the danger-
ous employment.
A high protein diet has proven to be use-
ful in increasing the individual resistance
to TNT poisoning to some extent, and
workers with this substance should eat at
least 150 to 200 grams of meat daily be-
sides other nourishing foods. It, of course.
is not possible to create an immunity to the
chronic poisoning dietetically, but this is of
particular importance in view of the fact
that there appears to be a variation in sus-
ceptibility on the part of different workers
due to differences in permeability of the
skin.
The experiments in this country and in
England have definitely shown that skin ab-
sorption is the principal factor involved in
the contraction of TNT poisoning in man,
tho this does not serve as a reason for
neglecting proper ventilation of all rooms
in which it is utilized. As a protection
against absorption thru the skin, a shellac-
castor oil varnish is recommended which
may be applied directly to the skin, or for
the preparation of impermeable cotton
gloves. As a supplemental precaution,
workers should be obliged to wash their
arms and forearms with a ten per cent,
solution of sodium sulphite before leaving
the factory each night.
While lowered hemaglobin is an indica-
tion for the removal of a worker from his
special process, it is equally important to
exclude all workers possessing a low grade
of anemia or any other symptom suggestive
of a lowered power of resistance. Such in-
dividuals should not be permitted to handle
TNT, regardless of any protective meas-
ures that might be provided.
Considering how little was known of the
subject at the beginning of the war, and the
rapidity with which munitions work was
developed in this country, it is most credit-
able that our investigations of the hazards
in munition factories have been so general
and successful. The knowledge of indus-
trial diseases has advanced tremendously,
and, with it has come a better understand-
ing of symptomatology, and, most import-
ant of all, prophylaxis. It is impossible, of
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ikMBBICAN MSDICINB
EDITORIAL. COMMENT
August, 1919
509
course, to remove every hazard connected
with the manipulation of poisonous ma-
terials, but the application of principles al-
ready developed gives promise of a de-
creased relative morbidity from such sub-
stances as TNT.
A Home Missioiu — ^No small measure
of the accomplishments of missionaries in
foreign fields has been due to their solici-
tude for the health of unchristianized
peoples. The history of the eflforts of med-
ical missionaries thruout the world is a
tribute to the spirit, courage, and dominant
will as well as the enthusiasm and deep sym-
pathy that mark the spiritual physician
and medical religious enthusiast. The chain
of hospitals, dispensaries, traveling clinics
and centers of hygiene which spans many
parts of the globe bears witness to their
monumental efforts to combine the precepts
of religious teachers with the practices of
the noblest physicians.
Many of the problems of home missions
have been attacked thru the establishment
of missions and settlements in the midst of
communities that have deteriorated phys-
ically, and, for biologic or economic rea-
sons, have fallen behind in the struggle for
existence. The institutional church has
sought to create a closer harmony between
theology and home living, with the ultimate
end of securing conversion or of bringing
the "wicked" nearer to salvation.
In the vast rural sections of this country,
the church stands forth resplendent as a
leader in moral thought. In our large cities,
ministers, priests and rabbis are found listed
among the good citizens having at heart
the welfare of their communities. Their
services to the public have been various and
marked with a broad understanding of the
social problems involved in communal re-
habilitation of the ideas and ideals for which
the church militant has been wont to
struggle. Too frequently, there has been a
marked contrast between the public activi-
ties of our theological guides in their public
capacity and in their private position. The
church, as the center of moral interest, has
not always directed its energies towards at-
taining a similar power in the field of edu-
cation. Outside of visitations to the sick,
and the performance of the usual conven-
tional formalities near, at, and after death,
there has been inadequate attention paid to
the physical welfare of congregations.
During the war, without exception, all
denominational churches succeeded in unit-,
ing in cooperative effort various groups of
their congregation for the accomplishment
of a definite purpose, tending to bring about
the early and successful termination of
strife. With the signing of the armistice,
many of these activities, their purpose seem-
ingly accomplished, ceased. The vital in-
terests engendered by participation in a
dominant service were permitted to lag and
disappear. The call to service did not con-
tinue, and when the great patriotic cry for
help was no longer heard, ears did not seek
for other fainter appeals for succor.
A splendid opportunity presents itself to
church leaders thruout the country. There
is no reason why the church should not be-
come the living hygienic center of a parish,
a community, a village, or a township.
What a tremendous gain there would be in
health and vitality if each denomination,
thru its organized governing bodies, were
to establish a lecture circuit combining there-
. with exhibits, pageantry, posters, music and
the various other devices known to pub-
licity agents and propagandists with the
view to raising the health standards of their
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August, 1919
EDITORIAIi COMMENT
AMTOICAN MBDIGIia
congregations. The cooperative study of
infant and child welfare, the methods of
prevention of disease, scientific home mak-
ing, budget making, first-aid to the injured,
the prevention of tuberculosis, respiratory
diseases, venereal diseases, the plagues of
flies and insects, the sanitation of farms
and dwellings, the protection against the
hazards in various industries, and countless
other topics would afford a basic training
that would make for better citizenship and
more church going. It would be a simple
matter to stimulate an interest in local prob-
lems relating to child labor, recreation, phys-
ical training, the reduction of illiteracy, if
the church, in a unified eflfort, would pre-
sent the facts to its communicants in terms
of personal effect and local benefit.
The need for a health program of this
character is emphasized in rural communi-
ties, where the status of the church as an
effective factor in communal activity is
higher than that existent in urban sections.
The possibilities of leadership along health
lines would inure to the benefit of portions
of the population for whom the health
message is particularly urgent.
The real home medical mission might
easily be established if missionary zeal were
directed to the presentation of a health
program among rural churches. Souls may
be won thru the saving of bodies. The
/ church institute, the medical elevation of
communal standards and the education of
men, women and children in the science and
art of right living may become as effective
in attacking the problems of the American
people as they have proven themselves to
be in attacking the ignorant traditions of
foreign peoples, to whom medical mission-
aries have gone in large numbers. Let the
church rise to its present opportunities, co-
ordinate its efforts, crystallize the ideas of
its workers, and then push forth upon a
campaign for raising health standards thru-
out the Nation. Let it strive in cooperation
with all organizations, public and private to
evidence a dfeeper interest in keeping alive
and well a larger number of communicants
for whose souls the church is ever anxious
and willing to struggle.
State May Provide Doctor's Office.—
The state may provide the doctor's office in
the future and it may guarantee all or part
of his income as an outcome of the growth
and wider application of medical science,
according to the forecast of a well known
New York physician.
The government will establish a depart-
ment of health eventually, he believes. He
discusses what its scope should be, and how
far it should confine its work to the preven-
tion of disease. There might come about a
centralized, coordinated administration of
health activities. An effort should be
made to provide adequate nursing service
and constructive medical practice in com-
munities at a distance from the large
centers, where these needs are poorly met
today.
The physician may some day be freed
from the struggle and worry that he en-
dures now by reason of the competitive and
commercialized aspect of his profession.
But the state must recognize that medi-
cine is a profession and not a trade, leaving
the physician wholly free to think and
act, to study and to serve.
S. S. Gbldwater, M. D., former Commis-
sioner of Health of the City of New York,
in Modern Medicine (May, 1919) thus
sees the medical science of the future as
one of the foremost social sciences. He
cites the fact that vital statistics available
in the United States are too incomplete to
be of as much value as if they could be
gathered for 100 per cent, of the population.
The present statistics, he says, represent
only 70 per cent, of the population.
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^
N AND THINtjS
Hogs, Bees and Babies. — Why is it that
statistics are regarded by almost everyone
as a dry subject ? Nothing could be farther
from the truth. On the contrary, the life
of the statistician is, one is tempted to think,
one interrupted emotional debauch; for, in
the supposedly dry-as-dust figures in which
he deals, he finds more of the human come-
dy and human tragedy of life than is to be
found on the stage, in books, or even in
life itself observed at first hand. What, for
example, could convey more emphatically
the immeasurable folly of human kind than
the statistical item which appeared in the
press recently: "The last legislature of
Kansas made the following appropriation:
For the health of hogs, $25,000. For the
health of bees, $8,000. For the health of
babies, $7,000." What a shriek of delight
the Chronic Cynic must have emitted when
he read that item! What material for
satire, what grounds for pessimism repose
in these innocent figures! And how dis-
heartening it must be to those who have the
wellbeing of humanity at heart to know the
attendant facts: that for four years Dr.
Lydia De Vilbiss, as chief of the Kansas
Department of Child Hygiene, has worked
successfully toward the reduction of child
mortality; that she asked for four field
physicians and an enlarged office force to
increase her work and was refused; and
that she has resigned her office rather than
continue her activities without adequate
support. So that Kansas will continue to
look after the welfare of its hogs, it will con-
tinue to make life endurable for its bees,
but its babies will have to do the best they
can with the help of Nature.
The story of Kansas would not be so
pathetically hopeless if it were only a de-
tached instance ; but it is the same story in
almost every community of the country. Is
is not singular that, tho all education has
been toward the respect for human life, all
political activity has confined itself to re-
spect only for animal life ? Propaganda for
the better care of our horses and cows and
cats and dogs has always been successful;
there has been no limit on the funds that
could be raised toward that end. But prop-
aganda favoring the better care of humans,
of babies, the aged, the defective, the dis-
abled, has always had to beg in vain for
years before it could get a favorable hear-
ing; it has had to beg many years more to
get favorable action. And when finally the
legislators yield, they magnanimously vote a .
paltry $7,000 for work on which the future
of the country depends more than on any
other single thing: the care of the young
who are to be the citizens of the next gen-
eration. Who is at fault for this incred-
ible myopia, this amazing incompetence to
deal with one of the most vital problems
confronting the nation? It would be idle
to seek out any special individuals for
blame. Rather, one is inclined to lay the
blame at the door of our faulty education.
In a large sense, it is due to the lack of
imagination and the presence of a stubborn
materialism which sees hogs and bees as a
profitable investment and cannot see babies
in the same light. But in a still larger sense,
one may find the origin of this folly in the
inadequacy of one of the commandments
with which, from our earliest days, we are
made familiar: Thou shalt not kill. From
this commandment we acquire our ponder-
ous and immutable respect for human life,
but, once having fulfilled that behest, we are
content. We feel that we have acquitted
ouijselves of our obligations in sparing
human life, for nowhere in the Ten Com-
mandments are we enjoined to do more
than that : we are not asked to educate, to
improve, to preserve. But, fortunately for
the beasts of the world, there are no com-
mandments governing our conduct toward
them. We are permitted to kill them, and
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we do. We are allowed to hunt and shoot
them, and we do. Yet, feeling our obliga-
tion toward them, we discharge it by giving
them consideration and care which we think
superfluous in the case of humans. And so
legislation in favor of beast and fowl goes
on apace, and legislation in favor of unfor-
tunate humans lags woefully behind. They
may consider themselves lucky that they are
permitted to live! One is reminded of
what a cynic once said when an old lady of
his acquaintance beat her dog cruelly : "She
treats him," he commented, "as badly as
tho he were a human being."
Speeding Up Evolution. — Professor
Franklin H. Giddings, of Columbia Uni-
versity, one of the leading sociologists of
the country, is of the opinion, often ex-
pressed before his classes, that the Civil
War freed the negroes from slavery at a
cost much greater than their emancipation
' was worth, that the violent process by which
it was brought about left the negroes in a
condition of unacknowledged equality which
has often resulted in suffering and injus-
tices which they did not endure as slaves.
What Prof. Giddings emphasizes is the fact
that, left to the slow but sure process of
evolution, the negro would have come into
his freedom, by the inevitable course of
progress, in a few years anyway and that
his freedom, if the result of evolution, would
have been a real and not an artificial thing.
There would be no race riots such as have
made Europe wonder at our barbarism, no
violent hatred of a man because his skin is
black, no tendency to make a whole race
the scapegoat of a few individuals* offenses.
These outrages are merely a symptom of
the fact that the white population of the
country were compelled to accept the equal-
ity of the negro but they were not convinced
of his equality — a conviction which could
have come only as a consequence of slow
education. In other ^yords, speeding up the
tranquil and somewhat sluggish process of
evolution is a rather imperfect business.
Evolution doesn't like to be hurried, and
one anticipates its ultimate results only with
dire consequences. The emancipation of
the negro by violent means is a case in
point : The negro, particularly in the South,
is at least as much the victim of injustice
as he was before 1860, and it would appear
that the hurried and untimely enforcement
of national prohibition may prove another
case of the serious consequences of forcing
evolution to a premature issue. American
Medicine has always felt a friendly sym-
pathy for the temperance movements of the
past, even for the prohibition movement so
long as it was conducted along the lines of
moderation and rational education. These
movements were meeting with a wide and
encouraging response, popular feeling was
swinging in their favor, and in due course
of time they would have come into their
own as a consequence of a growing con-
viction and the demonstrated value of their
philosophy. Even among the drinking pub-
lic the doctrine of temperance was sub-
scribed to, the wisdom of moderation was
conceded, and the propaganda was making
friends everywhere, friends whose accept-
ance of the principles of temperance and
rational prohibition was sure in the genera-
tion to come. The process of evolution
was moving on at its normal pace. But, with
a suddenness that came as a shock to mod-
erate men, the prohibition forces were able
to summon their numbers and influence leg-
islation to such a degree that, almost over-
night, the country found itself flung vio-
lently forward along a course which it had
been following so easily and comfortably.
The public, climbing at leisure, suddenly
found itself kicked upstairs. Evolution had
proved too slow for a handful of zealous
agitators, and it had been given a dose of
ether and alcohol to thrust it over the top.
Prohibition had become the law of the land
before the public could express its opinion
at the polls, and so to many it seemed that
the heavy cost of the Civil War was to be
paid once more for a reform that was bound
to come, at no cost at all, in due time ; that
all the imperfections and injustices and
dangers that attend a speeding up of evolu-
tion were to be repeated. The public was
once more forced to accept a condition be-
fore it was convinced of its wisdom or de-
sirability.
Prohibition and the Alarming Drug
Figures* — The uneasiness which prevails
among the more moderate element of the
nation's leaders as a consequence of this
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513
abrupt and dangerous plunge into the haz-
ards of complete prohibition is hardly al-
layed, in view of the close connection be-
tween prohibition and drug addiction, by
the figures issued by the committee ap-
pointed by the Treasury Department to in-
vestigate the traffic in narcotic drugs. One
cannot help feeling that prohibitionists have
acted like a doctor whose patient was suf-
fering from a headache and from a violent
blood disease at the same time, but who
treated the headache and neglected the
dangerous disease. This committee confined
its investigation to traffic in opium and co-
coa leaves, their preparations and habit-
forming alkaloids. It issued these amazing
figures on per capita consumption of opium
in this country, Italy, Germany, Portugal,
France, Austria and Holland:
**Annual consumption in the United
States, 470,000 pounds, or 36 grains per
capita; Germany, 17,000 pounds, or 2
grains per capita; France, 17,000 pounds,
or 3 grains per capita; Italy, 1,000 pounds,
or 1 grain per capita; Portugal, 2,000
pounds, or 2j^ grains per capita ; Holland,
3,000 pounds, or 3 J4 grains per capita ; Aus-
tria, about 3,000 pounds, or J4 grain per
capita. As the average dose of opium,"
continues the report, . "is one grain, the
amount consumed in the United States per
annum is sufficient to furnish 36 doses for
every man, woman and child." Further-
more, an investigation of the number of
addicts in this country shows that there are
at least 1,000,000 users of drugs — the esti-
mate is as high as 4,000,000 by some author-
ities. Concerning the possible effect of pro-
hibition the committee says: "The consen-
sus of opinion seems to be that the number
of addicts will increase when the prohibi-
tion laws are carried out. These opinions
are based, for the most part, on the theory
that drinkers will seek a substitute for alco-
hol and that opiates and cocaine will be
found most satisfactory for this purpose.
This opinion receives some support from in-
vestigations in southern states where prohi-
bition has been in effect. In these states the
sales of narcotic drugs and cocaine have
greatly increased."
That prohibition encourages an inevitable
increase in the use of drugs has been shown
so often that the committee's report may
be considered unduly timid in its conclu-
sions. Some months ago, when prohibition
was still in the balance, there appeared in
these columns a summary of the conse-
quences of prohibition in Vermont in so far
as it affected the consumption of drugs in
that State. The figures were quoted as a warn-
ing to the rash prohibitionists. The figures
issued by the Treasury Committee are here
reproduced not as a warning — it is too late
for that — ^but as a chastening indication of
the results to be expected from the temerity
the propagandists have shown. It has been
pointed out again and again in these col-
umns that the danger of forcing drinkers
to accept vicious substitutes is greater and
more injurious to the community than the
danger involved even in the intemperate
use of alcohol. Even before prohibition
came into effect, the United States con-
sumed twelve times as much opium and co-
caine as its nearest rival. Now the drug
problem is bound to become more perplex-
ing and troublesome than ever, and this at
a time when the authorities are bending all
their energies, tho greatly handicapped, in
coping with this serious menace. The task
of the health authorities, who are trying to
check the use of drugs, has been immeasur-
ably increased, their difficulties have been
unnecessarily multiplied. One can only
hope that their undertaking will not be
rendered entirely hopeless.
Health Courses in Public Schools^ —
One of the very first curiosities which an
infant shows is about its own body. It is
curious first about its toes, its hands, its
limbs, and soon shows a marked interest in
its entire mysterious body. Nine adults in
every ten can recall this infantile but per-
fectly normal curiosity in themselves, but
they recall at the same time it was invari-
ably discouraged as something indecent and
forbidden by their parents, so that with
adolescence came the natural conviction that
the body was something which should be
given as little thought as possible. Their
attention was drawn to mechanical toys, to
building blocks, to books of fairy lore and
magic ; but the marvelous mechanism of the
human body, the magic manner in which it
works, were not considered matters for
children's curiosity, and so parents have
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generally failed to capitalize and utilize a
natural tendency in the child which, if prop-
erly encouraged, would prove most valuable
in later life — interest in the body and the
instinct to take proper care of it.
With the opening of the schools in Sep-
tember a new principle in the education of
children is to be carried out, a principle
which will tiy to correct the error referred
to above, which will certainly succeed if the
program announced early in the summer
is faithfully followed. At the Conference
of SanitaiT Officers and Public Health
Nurses, held in June at Saratoga Springs.
Dr. William A. Howe, of the State Health
Department, announced that a syllabus in
health courses covering every grade in the
public schools had been prepared for the
purpose of giving the pupils instruction in
the care of their bodies, and that graduates
of state normal schools hereafter must be
qualified to teach public heahh. Thus the
state once more invades the domain of the
family, taking upon itself a function which
has hitherto been regarcled as strictly the
mother's concern, and in doing this the au-
thorities are revealing a true understanding
of the tendency of the day. The modern
family, while not disintegrating, is distinctly
too preoccupied with its own problems to
give children the care they should have;
there is the increased difficulty of making
ends meet financially, there is the obligation
the woman feels of pursuing a career or
of helping the man in pursuing his, there
is the desire to realize a real companionship
on an equal footing between the man and
the woman, or there may be a very definite
wish on the part of the woman to fulfil her
individuality rather than sacrifice herself
for racial purposes. All these things mili-
tate against the proper care of the young,
the children get less and less attention, and
it becomes the duty of the state, in self-
protection, to take over these neglected re-
sponsibilities. As time goes by it will be-
come increasingly evident that the state is
the real guardian of the young, and One
may look forward to this guardianship with-
out misgiving. The tradition that the moth-
er is the best caretaker of her child has
proved merely a tradition. Of those moth-
ers who are willing to educate their children
in the necessary things, only a small propor-
tion is really capable of doing it satisfac-
torily. The trained educator of children is
by far the more satisfactory, and the tend-
ency, even on the part of devoted mothers,
is to entrust the bringing up of their chil-
dren to skilled educators. Th^ function of
the mother is being reduced to influence over
the child's emotional and moral life, and
that is a big enough task. In the hands of
specially trained teachers engaged by the
state, the child can learn such things as the
care of its body by means of reading and
practices which could be made as engaging
as reading about kings and princes. It
has the advantage of being the product, not
of one woman's instinct or impulse, but the
collective experience of sources of students
who have put their whole heart in their
work. As Dr. L. Emmet Holt, of Columbia
University, said at the conference: "The
time has passed when health can be placed
entirely in the hands of the mother, who, in
most cases, received all her knowledge from
her own mother before her." It is difficult
for the modem mother to compete with
the professional educator. The circum-
stance should be an encouraging rather than
a discouraging one, for it thus leaves the
woman freer to fulfil her duty to herself —
a duty which becomes more and more ur-
gent as woman's part in the life of the state
increases.
JUST WHISTLE A BIT.
Just whistle a bit if the day be dark.
And the sky be overcast;
If mute be the voice of the piping lark.
Why, pipe your own small blast;
And it's wonderful how o'er the gray sky track
The truant warbler comes stealing back.
But why need he come? For your soul's at rest
And the song in the heart. Ah! that is best!
Just whistle a bit if the night be drear,
And the stars refuse to shine,
And a gleam that mocks the starlight clear
Within you grows benign;
'Till the dearth of light in the glooming skies
Is lost to the sight of your soul-lit eyes.
What matters the absence of moon or star?
The light within is the best by far!
Just whistle a bit if your heart be sore,
'Tls a wonderful balm for pain.
Just pipe some old melody o'er and o'er
Till it soothes like summer rain.
And perhaps 'twould be best, in a later day.
When Death comes stalking adown the way.
To knock at your bosom and see if you're fit.
Then, as you wait calmly, Just whistle a bit.
— Paul Lawrence Dunbar.
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American Msdicinb
ORIGINAL ARTICLES
August, 1919
515
^ORIGINAL
TICLES
ABRAHAM JACOBI, M. D^ LL. D.
IN MEMORIAM.
BY
DR. S. ADOLPHUS KNOPF,
New York.
Five and sixty years ago he came to these
fair shores
Where, years before, the Pilgrim Fathers
landed,
Like them to find the home of freedom he
had come;
A place where men could think and act
like men, not serfs.
Because he had rebelled against their rule,
Against their autocratic ways and imjust
laws,
The rulers of those serfs imprisoned him
for two long years.
They thought to break his spirit in this
way.
But made instead a greater champion of the
rights of man.
When free at last, he said farewell to all
that was most dear
And sacred in the land where he had fought
and suffered.
Where he had struggled hard that others
might be free.
There long ago a Schiller spoke for free-.
dom
And there the dying Goethe cried "More
light, more light !"
How greatly then was such light needed
To make of German soil a worthy free-
man's home!
He wisely chose to come to free Columbia's
shores,
Her doors are open wide for men like him ;
She gladly welcomed him, a rising ^Escu-
lapius,
Eager to serve her well with heart and
mind.
A life of service then began, so great, so
useful and so long,
That I feel loath to try to trace it here,
For fear I shall not give him half his due.
Long years before I saw the light of this
good world
He was a master, teacher of my teachers;
His fame as healer spread o'er all the
world ;
His students numbered thousands, and still
more
Are those who read his books on healing
arts.
Thus everywhere are his disciples found,
He had become the Nestor of us all.
He founded clinics where the poor could
bring
Their children and receive quite free that
care
For which the rich so gladly paid in gold.
The rich or poor were all alike to him.
Those little sufferers that he loved so well.
Often I heard him called ''The little chil-
dren's savior."
A grateful mother, first with tearful eyes
And choking voice told me she loved to call
him thus ;
No greater honor, holier name could ever
come to man.
And yet, with all the honors heaped upon
him
He had not changed in kindly simple ways.
The poor were always welcome to his home,
The struggling student found a listening
ear.
And when the powers that drove him o'er
the sea.
Became aware of his gr^at fame and skill,
Wished his return, and honor to their seat
of learning,
To make him Herr Geheimrat, Excellens,
He simply answered them, "I thank, you,
no."
He had not lost his love for freedom'? holy
cause ;
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He loved America with love more true
Than some who were unto her blessings
bom.
In this last, greatest war for freedom of the
world
His heart beat faster, regretful that no
longer
Was he young enough to join the army of
crusaders
Who crossed the seas to help our brother
nations
To free themselves and us from tyranny
and shame.
The God of battles still was with us, for
we fought
For right, and so our sacrifices shall not be
in vain.
And he was blessed at last to see the dawn.
Autocracy already in the dust, now free-
dom's holy might
Shall reign supreme in lands which suffered
long
From tyranny, and now arises hope
That even his old homeland shall be free.
Columbia's and Britannia's boys, Italians
and fair France's sons
Are brothers all and freedom's champions,
Prepared to help all honest efforts for an
honest peace.
This shall bring freedom to their one-time
enemy,
If he will learn to rule himself,
Will learn to love instead of hate
And realize the wrong his monarch did the
world.
Peace on this earth, good-will to men, shall
sound anew,
Glad tidings of this greatest gift to man.
A little over six months ago the above
tribute was addressed to Abraham Jacobi.
It was a unique occasion. American friends,
who during the war had tried to help the
small number of true democrats still exist-
ing in Germany to bring about an over-
throw of the autocratic government and
thus hasten peace, had united at a dinner to
honor the venerable physician, philanthro-
pist and patriot because he exemplified in
his own person the former ardent fighters
for German Democracy and had become the
typical American who unselfishly wished
freedom not only for himself but freedom
for all mankind. Dr. Walter Damrosch
presided, and Dr. Jacobi, in the best of
physical health and spirits, responded with
vigor and brilliancy to the various tributes
paid to him by the toastmaster, by Mr.
Franz Sigel, Frederick L. Hoffman, Jacob
Schiff, and the author. It was my good
fortune to discover in an artist's studio the
picture of Abraham Jacobi which he him-
self had designated as his favorite. When
I wrote him that I had at last succeeded in
getting that much desired photograph and
sent him a reprint of it, he wrote in his
inimitable and often humorous way: "The
picture is fine. Your friendliness makes
our people believe that I am as good look-
ing a person as your photograph makes me
appear. By the way, I am getting vain,
and a few of my pictures would be wel-
come to me sometime or other."* When
my little tribute was published it was illus-
trated with this portrait and sent to many
of his friends and admirers. The responses
received in acknowledgment would indeed
in themselves form a unique tribute to the
great man and would make a good sized
volume.
Dr. Abraham Jacobi was bom May 6,
1830, in Hortum, Germany; he received his
preliminary education at the g3rmnasium in
Minden, from which he was graduated in
1847. He entered the University of Greifs-
wald as a student of medicine the same
year, studied in Goettingen in 1848, and re-
ceived his degree of M. D. at Bonn in 1851.
He had joined the German revolutionary
party with Carl Schurz in 1848, was im-
prisoned in various places for his political
activity and for lese majeste from the
summer of 1851 to 1853, in which year he
.fled to England and from there came to the
United States. Dr. Jacobi married in 1873
' The picture here reproduced Is the one re-
ferred to as Dr. Jacobl's favorite picture.
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Dr. Mary Putnam, a sister of Major George
Haven Putnam of New York. Dr. Mary
Putnam Jacobi was one of the first women
physicians of this country and the first
woman who graduated from the celebrated
University of Paris. She died in 1906.
Dr. Jacobi was the first to occupy a chair
for diseases of children in an American
college. He held this position in the New
York Medical College from 1860 to 1864,
in the University of New York from 1865
to 1870, and from 1870 to 1902 in the Col-
lege of Physicians and Surgeons. He re-
mained Professor Emeritus of diseases of
children in that institution (Columbia Uni-
versity) up to his death. In 1903 he re-
ceived a call to the chair of Pediatrics
from the University of Berlin, which he
refused.
There is hardly a position of honor which
the American medical profession did not
bestow upon Abraham Jacobi. He was
president of the New York Pathological
Society, the New York Obstetrical Society,
the New York State Medical Society, the
New York Academy of Medicine, the
American Pediatric Society, the Associa-
tion of American Physicians, ^the American
Climatological Society and the American
Medical Association. He was an honorary
member of many of the medical societies
of the United States and abroad and an offi-
cial delegate to fiearly all the international
medical congresses held during the last half
century. Dr. Jacobi was a visiting and
consulting physician to many of the leading
hospitals of New York. Roosevelt Hos-
pital, where he had held many a clinic as
professor of diseases of children, honored
him by calling the baby ward after him.
His literary contributions are too numer-
ous to be summed up here. The eight
volumes of "Collectanea Jacobi" give a fair
idea of the literary activity of this great
man. His text-books on diseases of chil-
dren have become classic and been trans-
lated into a number of foreign languages.
He has been honored with the degree of
LL. D. by the Universities of Michigan,
Columbia, Yale, Harvard and Jefferson.
Abraham Jacobi was not ungrateful for the
honors bestowed upon him by past or
present generations, nor had he forgotten
the hospitality accorded by the United
States. On the first page of his "Collectanea
Jacobi" we read : "In memory of great and
good men long departed, citizens of a hos-
pitable country in gratitude for countless
favors and honors received at the hands
of colleagues, pupils, societies and univer-
sities during half a century."
Now after this brief sketch of the life
of the great physician I should like to re-
produce a few of the messages which I re-
ceived from his colleagues, friends, pupils,
admirers and patients in acknowledgment
of the receipt of the tribute above referred
to as well as some of the striking eulogies
paid to Dr. Jacobi after his passing away.
Dr. Wm. C. Braisted, Surgeon-General
of the Navy and president-elect of the
American Medical Association, wrote as
follows: "I was most pleased to receive a
copy of your splendid and appropriate
tribute to Dr. Jacobi who has for so many
years 'deserved well of the republic' and
adorned our profession."
Rear Admiral George H. Barber of the
Medical Corps of the U. S. Navy: "I ap-
preciate very much your courtesy in send-
ing me your tribute to Dr. Jacobi. I have
always held him in great reverence since
my student days at the College of Physi-
cians and Surgeons in New York."
Surgeon-General Rupert Blue of the
U. S. Public Health Service : "The copy of
your brochure, written as a tribute to Dr.
Jacobi, has reached me, and I am indeed
glad to have it in my library. It is a highly
fitting tribute to the life and work of so
eminent a member of the profession, and I
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am proud to say that it expresses exactly
my feelings of the Doctor's long and useful
career."
Surgeon-General William C. Gorgas: "I
have known Dr. Jacobi all my professional
life, now over forty years. He was a pro-
fessor in the medical class when I^was a
student, and a "Visiting" in the Hospital,
when I was house surgeon; and in all
these years since that time we have kept
up our intercourse thru the Medical Asso-
ciation and otherwise. He was not only a
great professional man, but was also one
of the kindest and best men I ever knew."
Dr. Walter B. James, ex-president of the
New York Academy of Medicine: "I have
read your poem on Jacobi and find it most
graceful. Dr. Jacobi deserves all of the
goods things his friends say about him."
Professor W. W. Keen of Philadelphia:
"Thanks for the Jacobi reprint. I join
heartily in every word of your tribute to
the veteran Jacobi. Everybody loves him.
It's nice to tell him so."
Mr. Adolph Lewisohn, philanthropist:
"I received your letter enclosing reprint of
the tribute which you paid to my friend.
Dr. Jacobi, and I congratulate you upon
the beautiful expressions contained therein.
Dr. Jacobi has been a friend of mine since
fifty years and, as you know, I am one of
his ardent admirers."
Dr. David R. Lyman, president of the
National Tuberculosis Association: "Your
tribute to Dr. Jacobi puts our profession
under a debt of gratitude to you for say-
ing so beautifully to him what we all feel
toward him. My sincere thanks."
Dr. Charles Mclntire, secretary of the
American Academy of Medicine: "I was
interested in reading your tribute to Dr.
Jacobi. He is a grand old man and worthy
of all praise."
Drs. William J. and Chas. H. Mayo of
Rochester, Minn., both ex-presidents of the
American Medical Association : "Thank you
very much for your kind thoughtfulness in
sending us a copy of your eulogy to Abra-
ham Jacobi. It is a beautiful tribute to his
life and character. We are glad to have it
for it is most interesting. His photograph
is an excellent likeness and we shall have
it framed for our gallery of famous physi-
cians."
Sir William Osier, Regius Professor, Ox-
ford, England: "Delighted to receive your
Jacobi tribute. What a fine picture of the
dear old man! Poem and picture will go
in my bibliotheca literaris. What a hard
trial it must have been for him all through
the War 1" Sir William wrote me again on
July 26th, saying: "And the dear Jacobi
has gone. Well, nothing to regret. Such
an innings!"
Dr. Charles A. L. Reed of Cincinnati,
ex-president of the American Medical Asso-
ciation: "I am more delighted than I can^
easily express over the receipt of the splen-
did picture of my dear friend, Dr. Jacobi,
and of your interesting lines in eulogy of
him and his great achievements. He has
practiced medicine in this country nearly as
long as I have lived. From the days of
my youth his writings have been an inspira-
tion. In my fuller years my acquaintance
with him became a bulwark of strength.
He impresses me as possessing in eminent
degree what have come to be recognized as
the three cardinal virtues of the new civil-
ization. They are lawfulness, service, and
courage. The cardinal virtue of lawful-
ness is observance of the natural law that
makes for human happiness and human
welfare. The cardinal virtue of service
consists not in words or even in mere
thoughts but in the doing of things that
will help others so to harmonize themselves
with the natural law that they may achieve
welfare and happiness. The cardinal vir-
tue of courage is the willingness to strive,
fight, and sacrifice for a recognition and ob-
servance of that natural law which impells
us to our bejter destiny. Dr. Jacobi has
thought these things, done these things, and
lived these things in such eminent degree
that he has become not only their expositor
but their exemplar. His example must
forever stand as an inspiration for all who
strive for the right."
Professor Beverly Robinson, M. D., New
York City: "The subject of your tribute is
fine — ^none finer. Your tribute of Jacobi is
worthy of him, our grand old man for
whom I have a deep affection and highest
esteem."
The Rev. Maxwell Savage, Unitarian
minister, Worcester, Mass. : "Thank you for
your tribute to Abraham Jacobi. He must
be indeed a rare personality. What men
they were who sought and sacrificed for
liberty ! Your lines set forth the free spirit
and the hope of free men."
Mr. Nathan Straus, philanthropist and
founder of free sterilized milk depots: "I
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deeply and sincerely share your opinion of
Dr. Abraham Jacobi. It is gratifying to
see this opinion so beautifully expressed in
your tribute. Dr. Jacobi has been of im-
mense assistance in my work. Much of its
success and universal adoption is due to his
influence, for which I am deeply grateful."
Professor A. Van der Veer, ex-president
of the American Medical Association: "I
have read your tribute to the grand Nestor
of our profession. Dr. Jacobi, with delight.
It is complete, and I congratulate you upon
being able to put into words that which we
have learned from our association with Dr.
Jacobi, for so many years, i, e,, the bright
and noble side of life."
Rev. Stephen S. Wise, an ardent admirer
of Dr. Jacobi, recalls in his letter to me the
celebrations of the great physician's 70th
and 80th birthdays and expresses the hope
and prayer that God might spare the pre-
cious life of Jacobi so that we might have a
fitting celebration of his 90th birthday which
he believed should be made a better and
finer thing than all the others.
A letter received from Prof. John A.
Wyeth, ex-president of the New York
Academy of Medicine and the American
Medical Association, is too personal to per-
mit its reproduction even in abstract form,
but he calls Dr. Jacobi affectionately his
"lifelong friend and beloved mentor."
Many other touching responses were sent
to me in acknowledgment of receipt of my
eulogy of Jacobi. They came from all
over the United States and Canada. Lack
of space does not permit me to mention
more than a few of the men who had come
under the influence of Jacobi, and nearly
all of them spoke of him as their beloved
master and friend. Among the men who
embraced this opportunity to pay tribute to
Abraham Jacobi while he was still among
us were Drs. Thomas M. Balliet, Frederick
Bierhoff, Vincent Y. Bowditch, Percy L.
Boynton, Samuel A. Brown, Joseph Byrne,
Julius Cone, Charles L. Dana, J. H. Elliott,
Arpad G. Gerster, Irving H. Hance, Charles
J. Hastings, Graham Lusk, Carlos F. Mac-
Donald, Joseph M. Mathews, Wm. J.
Schieflfelin, Henry Sewall, Henry L. Shive-
Iv, Chr. Sihler, Frederic E. Sondern, George
David Stewart, Wm. L. Stowell, and Ber-
tram H. Waters.
There is one more letter from which I
desire to copy at least a few lines. It came
from a grateful mother and speaks for it-
self: "Allow me to express my apprecia-
tion for the copy of your tribute to Dr.
Jacobi, which so aptly expresses the senti-
ment of untold thousands to the great
doctor. I, too, happen to be one of those
grateful mothers you speak of. — Mrs.
Harry Crayder."
No one has been able to tell the world the
personal qualities of Abraham Jacobi in
mot-e beautiful language than his lifelong
friend, the late Carl Schurz, who, on May
6, 1900, at the seventieth birthday celebra-
tion, spoke the following impressive words :
"For fifty years I have loved him and been
proud of him as a man of science of whom
I know how learned, how conscientious,
how indefatigable, how helpful and how
justly renowned he is ; as a citizen of whom
I know how patriotic, how courageous, how
unselfish, and how public spirited he is;
and as a friend, whose nobility of heart
only those can cherish and esteem as it de-
serves who know him best."
I feel sure that all who had the rare privi-
lege of knowing Jacobi intimately have al-
ways had the same thoughts of him in their
hearts.
And now, the master, the sage, the friend,
the mentor, the lover of little children, the
ardent patriot, the great physician, is no
more. He passed away peacefully on
Thursday, July 10th, at Lake George, with
the members of his family, Drs. Francis
Huber and Willy Meyer at his bedside.
The daily newspapers and weekly medical
journals which appeared soon after Jacobi's
death are full of praise of the man's
achievements and qualities as a physician,
teacher and citizen. The New York Tribune
spoke of him as famous in many lands and
as one of the most eminent medical practi-
tioners of his day. The New York Times
said : "Dr. Abraham Jacobi practiced medi-
cine in this city about 65 years and had
become not only the foremost authority in
pediatrics but the dean of the American
medical profession as well." The New
York Herald gave an abstract of an appeal
addressed to his colleagues during a liberty
loan campaign, in which he said: "As one
of the revolutionists of 1848, one of those
who hope to bring about the destruction of
autocracy and the establishment of democ-
racy in Germany seventy years ago, this
great war makes an especially powerful ap-
peal to me. When I recall all those bril-
liant, unselfish, patriotic youths who gave
up their lives for their country in the futile
effort to overthrow Prussian militarism at
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that time, I wish that Carl Schurz and
hundreds of others might have lived, as I
hoped to live, to see Prussian militarism
and hypocracy stamped out once for all.
Long live my country and yours! Long
live America !"
Stedman of the Medical Record, under
the caption "A Great American and a Great
Physician," begins in his editorial on
Jacobi's decease with the following impres-
sive words: "In the death of Dr. Jacobi,
America as well as the profession of medi-
cine, has lost one of its great men. Al-
tho not in politics. Dr. Jacobi was largely
in public life and was, in a quiet way, a
power for good in the country. Bom a
German, there was never a Mayflower de-
scendant whose Americanism was more
genuine in feeling and more positive in ex-
pression than his. He had learned by
actual experience the evil of Prussianism,
and when, five years ago, the Hohenzol-
lem and their robber barons began their
predatory invasion of their neighbor's lands,
Jacobi was among the first to recognize it
for the despicable thing it was, and he let
no counsel of neutrality, no inward call of
the blood, no outgivings of German State-
paid professors dissuade him from warning
his fellow countrymen of the true meaning
of that rush to loot."
The Journal of the American Medical
Association, after tracing his brilliant med-
ical career, concluded its tribute by saying:
"Dr. Jacobi was perhaps equally well known
as a great citizen. He was a formidable op-
ponent of prohibition and an ardent advo-
cate of birth control, and in every other
matter of public interest he was a con-
spicuous character."
How deeply he was interested in the
tuberculosis problem, I have had multiple
occasions to observe. As a member of our
local Tuberculosis Committee, he was more
prompt in attendance than many of the
younger men. To me personally he proved
a wise counselor, guide and friend in my
anti-tuberciilosis work and ' a constant in-
spiration. He expressed kindly approval
when he thought well of my work, criticized
my shortcoming's frankly and, encouraged
me in hours of disappointments, trials and
sorrows. On the fly leaf of one of his books
which he presented to me, he wrote : "May
you never lose your pleasure in public spir- -
ited work." He wished the younger genera-
tion to be imbued with the same spirit of
service to the public good which was char-
acteristic of him thruout his long life.
Dr. H. Edwin Lewis, in the July number
of American Medicine, pays him the fol-
lowing touching tribute: "We learn with
heartfelt sorrow of the death of that grand
Old Man of American medicine, Dr. Abra-
ham Jacobi. For a great many years Dr.
Jacobi has been one of the country's fore-
most medical men. Respected, loved and
honored by all who knew him, probably no
other physician has ever held a higher place
in the affectionate regard of his colleagues
than this German-born but true American
physician.
"The extent to which his judgment and
opinion have been esteemed by all who
knew him, has been shown by the fact that
no public question of medical or sociologic
importance has been considered well dis-
cussed or settled until Dr. Jacobi's viewpoint
and advice have been obtained. *What does
Dr. Jacobi think about it ?' has been a gen-
eral inquiry if his opinion has not been in
immediate evidence. It has seemed to be
the common belief that his statement on
any given topic would be the sound, common
sense conclusion of a man who knew what
he was talking about, and whose judgment,
therefore, it would be safe to follow. The
enormous influence such a man can wield
for good has been abundantly shown thru-
out the last twenty-five years of Dr. Jacobi's
life. During all these years to the day of
his death he has been a sane, conservative
adviser, a man who has been able to see the
right and help others to see it, also. His
poise, his kind and sympathetic manner,
and withal his sterling honesty have made
men trust him as few men are trusted."
Lillian D. Wald, the founder and head •
of the first Nurses' Settlement in America,
in paying her tribute to Jacobi in The
Survey, speaks of him as the great lover of
children. She relates the following incident
which, as she says, took place at the hearing
of the Board of Estimate and Apportion-
ment on a very hot day with regard to the
opening of a small park. "Dr. Jacobi was
there before me, and I besought him to go
home, he looked so ill. 'I got out of a sick
bed to come,' he said. Tor over twenty
years I have wanted a little fresh air in
that crowded part of New York, and surely
neither the weather nor a sick bed can keep
me from trying to make a speech for the
children.' "
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Dr. William J. Robinson, the editor of
"Collectanea Jacobi," dedicated the 200th is-
sue of Critic and Guide "To the memory
of Dr. A. Jacobi, a good physician, a good
man and staunch friend."
Mr. Oswald Garrison Villard, the editor
of The Nation, paid a glowing tribute to the
"Last of the Forty-eighters." In the issue
of The Nation of July 19th he said:
"Jacobi was always to be had for any move-
ment for betterment. If they formed a
committee of seventy or one hundred his
name was always on it. Yet, he having the
modesty of the truly great, few people re-
alized how steady was his contribution to
reform causes. The City Qub, the Citizens,
Union, Civil Service reform, better hous-
ing, the medical care of the poor and every
movement for combating human disease
came to this wise man for his support. And
wise man he was. That magnificent head,
the shaggy brow, those all-comprehending
eyes formed a countenance to awe and im-
press until one knew the kindliness and
warmth underneath and that he was always
as generous to worth as he was tender to
the little children who were his chief con-
cern. Yet he could castigate with a vigor
that spared no one when his feelings were
deeply aroused, as when he heard of some
friends who sought to apologize for the
dastardly sinking of the Lusitania and to
argue that the Germans had a legal excuse
for that atrocity. That he never forgave.
He saw in the Germans going to war and
their method of conducting it merely the
flowering of the Prussian system of gov-
ernment against which' he as a boy had re-
volted, the inevitable result of universal mil-
itary service and the drugging of the con-
science of the people by the various forms of
state benefactions." "Dr. Jacobi was of
the old type of physician who was also
counselor and friend. He was always more
interested in aiding the children of the poor
than those of any other class. The uncol-
lected and uncharged fees of Abraham
Jacobi for services rendered would have
made a half dozen physicians well-to-do.
Is it not a perfect ending to this life of un-
ending service that tho eighty-nine, he
practiced to the last? Four days before his
death his last prescription restored to health
a little babe. How touchingly, how ex-
quisitely fitting! Who can behold his life
and not feel that sometimes cheer, goodness
and profound merit do find their reward on
earth ? To have known him was to receive
a quickening of faith in all humanity be-
cause that rock of character of his was so
immovable from its base."
A simple but impressive funeral service
was held over the remains of the great
physician at the Academy of Medicine on
the afternoon of Monday, July 14th. The
auditorium of the Academy was crowded
to the doors by the men and women who
had gathered there to pay the last honors
to their departed friend. Major George
Haven Putnam spoke of the sterling quali-
ties of Abraham Jacobi as a physician, as a
man, as a patriot, emphasizing the sturdy
Americanism of his battles against over-
whelming odds. He praised Dr. Jacobi as
an ideal citizen who had rendered invaluable
service to this community by his activities
in building up the Civil Service Reform As-
sociation, whose counsel had been sought
not only in sanitary and medical but in
civil aifairs as well. Dr. Reginald Sayre
spoke of the medical career of Dr. Jacobi,
calling attention to the invaluable work
which he had done for the Academy of
Medicine. This may justly be called his best
monument, for it was due to Dr. Jacobi's
wisdom, foresight and sagacity that this
great medical institution has attained the
high standing which it now enjoys in our
community. Dr. Jacobi may however be
remembered longest thru his ministry to
the little ones, for as Dr. Sayre well said,
"Abraham Jacobi is dead but his influence
still lives, and it will be felt as long as
children are born and require medical care."
A life such as Dr. Jacobi's should and
must be an inspiration to the present as to
future generations. Scientific medicine,
pure Americanism, civic obligations and
our duties toward our neighbor and man-
kind at large, have been taught to us by him.
His great intellect and learning, with the
finest qualities of heart and mind he de-
voted to the service of his fellowmen.
Abraham Jacobi entered public life in the
storm and striess of the German revolution ;
he left it peacefully in the quiet of his
beautiful country home in his much loved
America, having lived to see the dawn of
the new day his dreams had visioned long
before.
What a wonderful life of nearly ninety
years I Doing good until the last and then
to fall asleep, beloved and honored, with all
who knew him saying, "Well done, thou
good and faithful servant."
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AUGUST, 1919
ORIGINAL. ARTICLES
American Medicine
BRINGING HEALTH TO SERBIA.
BY
DR. ROGER G. PERKINS,
Prizren, Serbia.
(Director Public Health and Sanitation Divi-
sion, American Red Cross Commission to
the Balkans.)
From the medical standpoint, Serbia has
suffered more than any other of the Allies.
With three hundred and fifty doctors in
1914 for a population of some five millions,
the losses in medical men since then have
but for the aid of the Allies and of the
United States.
The problem was perhaps most difficult
in southern Serbia, which at the outbreak
of the war had been freed from the Turk-
ish rule for only a few years, for dominion
under the Turkish empire had left the
natives less receptive to progressive meas-
ures than the inhabitants of the more en-
lightened north, or what is known as Old
Serbia. The population is more hetero-
geneous than in the north, with large num-
Fio. 1. Major R. G. Perkins, A. R. C. Major Frothingham, A.
Major Mintie, British Representative of Allied Food Commission.
Dr. Elitch, Food Director for Southern Serbia.
R. C.
been so great that less than one hundred
are now available. Deaths were frequent
enough by the ordinary accidents of war,
but when the typhus swept over the land
in 1915 and 1916 so many of the doctors
died of the very disease they were striving
to check that soon there were scarcely
enough to carry on. Medical conditions
in the country would have been impossible
bers of Turks in most of the communities,
and the most conspicuous structures are
the slender minarets of the mosques, form-
erly eloquent with the Mohammedan call
to prayer, now silent for the most part and
often turned to other uses.
The occupation of southern Serbia by
the Bulgars in 1915 was a terrible burden.
The great plantations of mulberry trees
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523
for the properous silk trade, which brought
in large revenues to the districts bordering
on Greece, were systematically cut to the
ground over large districts, the vineyards
were destroyed, the tobacco plantations laid
waste, and all the factories and warehouses
belonging to these trades are gone. In
many villages the only houses that are left
more or less intact are those formerly oc-
cupied by Turks or Bulgars, while the rest
have been systematically gutted of every-
thing, doors, windows, even to the floor and
which the grass and weeds soon spring up
and hide the very site.
The bridges and tunnels on the railroads
were almost entirely destroyed and still are
only partly repaired and the fearful roads
thru this country of rocky mountain passes
and mud plains have played havoc with
motor transport. Every defile is marked
by the remnants of trucks which have slid
off the road and rolled to the bottom where
they lie with their wheels sticking helplessly
up intc? the air. Thru lack of sufficient
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pnl
1 ^1 iRnH MS^^Z^^^M
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^3
Pig. 2. Turkish house at Prizren, Serbia, converted into American Red Cross Hospital.
roof beams, so that returning villagers find
but a cheerless welcome. In many places
the entire population had been deported in-
to Bulgaria, as far as the very shores of the
Black Sea, and is now finding its way back,
little by little, in rags, without money, to
the villages it called home. In the villages
since time immemorial the houses have
been built of mud and bricks, strengthened
with straw, like our adobe, and when the
tile roof is gone, the rain soon melts a twor
story house into a pile of mud and straw on
shipping and thru the needs of the Allies
on the other fronts, it has been impossible
to make up the losses, and now there are
but few cars available and fewer shops and
supply depots. Most of the draft and rid-
ing animals are gone — ^taken away by the
enemy, or marking the lines of retreat by
the whites with their bones, so that a few
oxen and horses in poor condition, and a
good many microscopic donkeys make up
the main methods of communication thru-
out the countryside.
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With these practical difficulties and with
many areas having only one doctor for
seventy-five thousand people, not much
imagination is needed for appreciation of
the medical situation. The American Red
Cross obtained the release of twenty-five
physicians from the United States Army,
and added a staff of about forty trained
nurses to work with them. Groups of doc-
torjs and nurses were distributed to such
points as were moderately accessible, given
such medical supplies as could be dbtained,
in the clefts of the fertile valleys round
about, with no main railroad nearer than
thirty miles. On good days the patients
are received in the courtyard of the hos-
pital, formerly a Turkish residence turned
over to us by the local authorities. The
gates are thrown open and the motley wait-
ing crowd pours in and lines up against a
rope barrier near the dispensary table.
Clad in the quaint Turkish, Macedonian
and Albanian costumes, each person's vil-
lage marked by the pattern and arrange-
FiG. 3. American Red Cross nurse dressing
Serbia.
and told to establish themselves as best they
could. Each center handles its medical re-
lief work in connection with the distribu-
tion of food and clothing.
The basis of the work is the free dis-
pensary, and a view of the day's work of
any one of these is a touching picture.
"Take one afternoon in a little town in the
mountains bordering on Albania; with its
picturesque red-roofed houses and crooked
streets, it is the center for thirty villages
tuberculous foot at dispensary at Gostovar,
ment of his clothes, they make a gay pic-
ture in the sunlight — till one looks closer,
when one sees that there are the lame, the
halt and the blind, brought in to the healer
by their friends and relations. Every ill
to which human flesh is heir is here, save
only the results of gluttony — a sin not pos-
sible now. But the saddest part is that
many, many of them are so far advanced in
(disease that they are beyond treatment.
Tuberculosis is ever before one's eyes —
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tuberculosis of the lungs, the bones, the
joints, the skin, and in all stages and at ku
ages. All the skin diseases, boils and ab-
scesses that go with unsanitary living con-
ditions, venereal diseases and their results,
deformities of all sorts — everything in fact,
from epilepsy to ingrowing toe-nails comes
to our dispensaries."
And they come on foot, on donkeys, in
ox-carts, from the village itself, from ten
miles away, from twenty to thirty miles
away. Many have walked for five or six
Cases that need surgical attention or med-
ical care that can only be given in the hos-
pital are taken in as far as possible, but at
the best the space is limited, and many must
be refused, tho we know that little can be
done for them at home. Day after day
they return and are treated at the dis-
pensary and at least they carry away with
them hope, and this often helps them to re-
cover. As many cases as possible are
visited at their homes, and when necessary
they are given food, clothing and simple
Fig. 4. Turkish boy with bronchitis brought many miles on father's back to be treated at
American Red Cross Dispensary at Gostovar, Serbia.
hours to get to the doctor, and must sleep
somewhere by the roadside no matter what
the weather, before they reach home again.
One child with bronchitis was brought ten
miles on his father's back ; another boy with
a tuberculous foot, so far gone that ampu-
tation was the only remedy, was carried
over from another village on a litter by his
father and mother; an old man with ad-
vanced dysentery came fifteen miles in an
ox-cart, only to die in the hospital before
morning in spite of all possible care.
remedies, but for each that is treated there
are many who never get to the doctor, who
never come to the attention of the visiting
nurse. In Mohammedan countries the nurse
is especially valuable for no man is per-
mitted to enter the Turkish houses, and un-
less the patient can be brought to the clinic
heavily veiled, she is inaccessible except to
the nurse or woman doctor.
And the people are so grateful for the
attention. When making the rounds, men
and women rush up to the Red Cross car
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and tell how they were at the "kolnitza" or
hospital and how they have been improved.
"I can walk behind my plow" says one. "I
can see now to do my sewing** adds an-
other. "My baby is fine," or "Can you
come and see my father while you are
here?" Farther off where there has been
no Red Cross dispensary, less than a day's
journey away, they came to me when I
stopped for a meal or the night and asked
me to see cases. When surgical help was
needed in each direction, with a simple faith
that the American doctor would make
to teach the ordinary rules of health, how
can the poor people know that it is their
insanitary way of living that causes their
worst diseases?
That insects may carry disease is hard
for them to understand, and such a thing as
screening or any other protection against
mosquitoes is unknown; consequently
everyone in the swampy valleys has malaria,
and at the dispensaries one sees patients
with such terrible shaking chills that they
cannot make connections between their cig-
arettes and their mouths.
Fig. 5. A Serbian boy who walked eight miles every other day to the American Red Cross
Dispensary to have an infected eye treated.
everything come out all right, it was hard
to have to tell some that it was hopeless and
that we could not help them.
Nor is this all the Red Cross stations
have been doing. In their wake, wherever
they have been, follows a dawning of sani-
tary knowledge. Movies, lectures and
traveling exhibits help greatly to convey
these lessons to the people. In New Ser-
bia, few can read, and with no organization
Loss of teeth in assorted lots before the
age of twenty is so common as to cause no
surprise. However, at the dispensaries
when the fearful state of the mouth, of one
person is called to the attention of another
who is still in better shape, there is a sud-
den demand for tooth brushes and what is
more, there is increasing evidence of their
use. The dentists attached to the medical
service go from town to town and have no
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lack of clients.
Those who eat food that has not been
cooked since it was handled run the risk
of any of the very widespread intestinal
diseases. In the villages of the plains,
there are only cesspools in more or less di-
rect communication with the shallow wells,
and in the hill towns where the swift
streams come down from the snow-capped
mountains, it is the pretty and picturesque
and highly insanitary custom to have a
little stream of water diverted from the
main channel and running thru the ground
floor of the house. Into this stream fall
all the waste products of the house, and in
the main stream, where join all the collec-
tions from the village, the community clothes
are washed and the children play. The
people argue that these things have always
been done, why stop them now ? We know
by long and painful experience at home
that the hereditary affection for the moss-
covered and infected well is hard to over-
come, but it will be a long time before much
can be done in Serbia, but a beginning is
being made. Orders are given the mothers
who come with their pathetic sick babies to
the dispensary to boil the milk from their
tuberculous cows and also to boil the water
they mix with it or give the children to
drink, and each child that improves helps
to spread the gospel.
In each town where there were municipal
baths of any sort we stimulated their use,
which had often been discontinued from
lack of charcoal, and where there were
none we started them. One of our methods
of propaganda as to the proper uses of
water was to refuse all material assistance
until their cards had been checked at the
bathhouse to show that a proper bath had
been taken.
In time the Red Cross must leave Serbia.
The good work that has been begun must
not be allowed to end. The Serbs are very
responsive and anxious to advance their
country, and as far as possible we are train-
ing them to take over the work that the Red
Cross has begun. In respect to orphanages,
schools, sewing rooms and similar activi-
ties, this is comparatively easy, but the
real lack of doctors and nurses cannot be
met so readily. America's reputation is
very high in Serbia. They believe us to be
dfsinterested, and they trust us more than
any other nation. If means can be found
to continue some of the Red Cross work for
a period of several years it will be a real
step forward in cementing the friendship
that is the basis of a real solid League of
Nations.
THE DIAGNOSIS OF EARLY
PULMONARY TUBERCULOSIS.
BY
M. FORD MORRIS, JR., M. D.,
Atlanta, Ga.
"Find out the cause of this effect.
Or rather say the cause of this defect;
For this effect defective comes by cause."
Shakespeare's "Hamlet."
When we wonder why it is that one-
seventh of the earth's human inhabitants
pass to the great beyond as a result of the
ravages of tuberculosis^ we come to the con-
clusion that this high death rate is the re-
sult chiefly of two causes : the failure of the
people to seek medical advice until the dis-
ease has passed the curable stage; and the
failure of physicians to discover the pres-
ence of tuberculous infection when the
symptoms and physical signs are slight.
Obviously, then, the remedies for such a
state of affairs are two in number. First,
the public should be educated more in mat-
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ters medical; they should be taught that
this disease like
"Pale Death with equal foot strikes wide
the door
Of royal halls and hovels of the poor."
— Horace.
And they should be impressed with the
wisdom of consulting competent physicians
for the relief of minor symptoms, for such
are the beginnings of tuberculosis. The
other remedy is the exercising of diligence
and thoroness, by every physician to whom
the public comes for advice. It is a good
plan to suspect and search for pulmonary
tuberculosis in every patient. A popular
Chinese proverb says that "Nature is better
than a middling doctor." Whether this is
true or not, of course, we will not argue;
but certain it is that no practicing physician
should be a "middling doctor," when the
diagnosis of early tuberculosis is the crite-
rion. It is certain that if one will study
each case, possibly in the manner herein-
after outlined, he will rarely miss the diag-
nosis.
A complete history is extremely valuable.
The cause of the death of the patient's
grand-parents, parents, brothers and sisters,
and husband or wife is very important. In
this connection, it is well to remember that
the "chronic bronchitis," with which so
many ancestors suffered, was usually pul-
monary tuberculosis. A history of tuber-
culosis or of chronic respiratory trouble in
the patient's family is the first link in the
diagnostic chain.
The past history of a patient is of even
more value than is the history of his family.
A record of incomplete recovery from an
attack of measles or whooping cough or in-
fluenza is very suspicious. Fistula-in-ano
is a tell-tale symptom. Pleurisy, ischiorectal
abscess, and glandular involvement in early
life usually mean tuberculosis. Many his-
tories reveal the fact that the onset of
tuberculous symptoms was just subsequent
to an attack of "grippe" or a "severe cold."
Frequent and protracted "colds" are often
forerunners of pulmonary tuberculosis. The
exudative diathesis, chorea, spasmophilia,
angioneurotic edema, sciatica, herpes
zoster, psoriasis and erythema nodosum
have been noticed frequently to precede the
onset of pulmonary tuberculosis. In a
series of autopsies on asthmatics, done by
Minnig, tuberculosis of the lungs co-ex-
isted with the asthmatic condition in an even
100 per cent, of the cases. A history of
hemoptysis, however slight, in the absence
of an evident lesion in the mouth or of a
lesion in the heart or kidneys, is practically
pathognomonic. It is well to remember
also that in this country, the negro, the
Scandinavian, the American Indian, and the
Irish are particularly susceptible to tuber-
culous infection of the lungs, and that
workers in steam laundries, glass-grinders,
steel-grinders and furriers are prone to con-
tract this disease. It is said that all miners
will contract consumption if they follow
their occupation for a few years. Occu-
pations involving exposure to extremes in
temperature, to dust and to dampness are
favorable for the development of phthisis.
Personal habits and unhygienic living con-
ditions are frequently preparers of the soil
wherein the germs of consumption later
work such havoc. The role of tobacco in
the causation of this disease has not been
definitely settled, but certain it is that many
an unfortunate victim has been deluded by
the terms "cigarette cough" and "chronic
bronchitis" until even the Angel of Death
was outside his door. Some one has said
that "alcohol makes the bed of the con-
sumptive." The same is also true of other
forms of debauchery. ("Let the wicked
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forsake his way," sayeth the wise Isaiah.)
A history of tuberculous association is ex-
tremely important and ominous. '
A complete history of the present illness
is most important. It is well known that a
patient having incipient pulmonary tuber-
culosis may relate several of a large num-
ber of symptoms, some of which are not
the least suggestive (to the patient) of lung
trouble. Among the most common sus-
picious symptoms, we may enumerate the
following:
(1) A persistent cough, which may be so
slight that its presence is admitted by the
patient only after a careful questioning.
The patient may, and usually does, say that
he has a "cold." The cough is nearly al-
ways more noticeable in the morning; this
coughing usually produces some sputum.
It has been said that "when there is a long
persistent and otherwise unexplained cough,
accompanied by either a subnormal tem-
perature, or one that rises slightly in the
afternoon, a probable diagnosis of tuber-
culosis should be made."
(2) A loss, or a capriciousness, of ap-
petite, often accompanied by some digestive
disturbances, is a frequent complaint.
(3) Malaise is very frequent. This may
amount to only a loss of that feeling known
as "pep"; or it may be a quite noticeable
increase in weariness at the end of a usual
day's work. As the disease progresses, a
more pronounced loss of strength occurs.
(4) There is practically always a slight
and persistent rise in the temperature. This
increase occurs in the late afternoon or
early evening. In some cases, however, it
occurs in the morning. In order to dis-
cover this fever, one should take the tem-
perature every two hours, and should let
the thermometer remain in the patient's
mouth for five minutes each time. Ac-
cording to Abrahams, in 80 per cent, of
cases, at some time during the twenty-four
hours the axillary temperature on the af-
fected side is from 1*" to 1.5° C. higher than
that of the unaffected side. Exercise will
usually cause a prolonged increase of tem-
perature. If there is no elevation of tem-
perature, especially after exertion, active
tuberculosis is very probably not present.
(5) An increase in the pulse rate is
nearly always present in early cases. This
acceleration may be present at any and all
times, even with the patient at absolute rest.
A pulse rate, in early pulmonary involve-
ment, of less than 70 is extremely rare,
and a rate of 75 is quite uncommon. The
undue and prolonged increase in the rate is
usually especially noticeable after exertion
by the patient. When exercise fails to in-
fluence the pulse abnormally, active tuber-
culosis is probably not present.
(6) A loss of weight, often so slight
that the patient is unaware of it imtil he
weighs, is usually present.
(7) Slight dyspnea, after exertion, is a
common symptom.
(8) Hemoptysis, in the absence of a lesion
in the mouth, heart, or kidneys, in a man,
but not a woman, means pulmonary tuber-
culosis.
(9) Hoarseness, whether intermittent or
continuous, is very suspicious.
(10) Often times the blood pressure is
subnormal.
Other suggestive symptoms are slight
nervousness, sweating after slight exertion,
recurring colds, chilliness after slight ex-
posure to cold or dampness or to a current
of air. Fistula-in-ano is practically always
due to the tubercle bacillus.
Of these symptoms, the five most impor-
tant are evening increase in temperature, in-
crease in pulse rate, cough, loss of weight
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and loss of strength. According to Norris,
"the protracted existence of any two of
these symptoms requires a good cause to be
shown why the diagnosis of puknonary
tuberculosis should not be made."
Physical examination:
In some cases, the chest is poorly de-
veloped and the chest measurements are
subnormal. According to Garvin and his
co-workers, in aine cases of incipient pul-
monary tuberculosis, the total lung volume
was found to be within normal limits, as
well as the middle capacity, but the vital
capacity was diminished. The expansion
in the right apex is normally more than that
in the left.
Litten's diaphragm shadow is useful in
determining any difference in the amoimt
of excursion on each side. In normal
chests, the excursion is about two and one-
half inches ; with forced breathing, the ex-
cursion may amount to three and one-half
inches. Excepting in people who are very
fat or who cannot or will not breathe
deeply, this sign is always present in normal
chests. But in cases of pneumonia of the
lower lobe, pleuritic effusion, extensive
pleuritic adhesions and in advanced cases
of emphysema, this shadow is absent. In
early cases of pulmonary tuberculosis, there
is, on the affected side, a slight diminution
in the diaphragmatic excursion, as revealed
by the diaphragmatic shadow.
In early cases, there is practically never
an increase of tactile fremitus. It is neces-
sary to keep in mind the facts that, in the
majority of cases, the maximum of fremi-
tus is felt over the anterior aspect of the
apex of the right lung, that fremitus nor-
mally also is more pronounced over the
upper parts of the lungs than over the lower
parts, and, that this tactile sensation nor-
mally is somewhat greater over the right
lung than it is over corresponding parts of
the left lung. However, in some appar-
ently normal chests, the spoken voice-
sounds are louder over the base of the left
lung than they are over the apex of the
right lung.
Practically all clinicians are firm in the
belief that the earliest physical signs of
tuberculosis involvement are discovered
over the upper portion of the lungs, most
frequently at the right apex. But Lopez,
in an extensive experience in Argentina,
says that he has found an isolated apical
involvement in only a very few cases, and
that the tubercle bacilli locate first in the
glands around the hilus and attack the
lower lobes more often than the regions
above.
Normally, percussion elicits a dull note
over the right apex, the second right inter-
costal space, the in trascapular spaces, be-
tween the seventh cervical and fourth or
fifth dorsal vertebrae. Shattuck, in a
careful study of the normal variations of
pulmonary resonance, found that dullness
at the right apex in front frequently ex-
tends below the clavicle to the second rib,
and that slight relative dullness of the left
apex, behind and of the left base posteri-
orly is common. Percussion produces a
dull note normally also over the deep area
of the heart and, according to some, also
over the superficial area of the heart. Flat-
ness is normal over the scapulae, and ac-
cording to some writers, over the super-
ficial area of the heart. In these early
cases, no physical signs are pronounced, as
a rule. When infiltration of the right apex
occurs, the normal dull note becomes duller
but not fiat. This particular note may be
described as "subdull" or "dull-fiat." In
case infiltration of the left apex becomes
the seat of early changes, the normal re-
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sonant note becomes dull. It is important
to remember that, if the percussion note
over the left apex is as dull as the normal
note over the right apex, the left apex is
the location of infiltration. It is easier to
detect the change in the left apex by de-
pending more on percussion on the anterior
than on the posterior aspect of the left apex.
Fishberg makes the statement that changes
in resonance and breath-sounds, elicited
over a limited area of the chest, if foimd
anywhere below the third rib anteriorly or
the fifth dorsal spine posteriorly are not of
tuberculous origin, provided there are neg-
ative findings in the apices. Some writers
consider, instead of dullness, a hyper-res-
onant note as the earliest change* possible
to elicit by percussion.
In practicing auscultation, the examiner
must always remember that, normally,
bronchovesicular breathing is heard over
the right apex, over the second intercostal
spaces close to the sternum, and over the
interscapular spaces. Bronchial breathing
is normal only over the trachea or larynx.
Vesicular breathing is normally heard over
the portions of the lungs not included in
the above-named areas. When early tuber-
culous processes are present in the lung, the
normal vesicular murmur changes to
bronchovesicular if the involvement is in
the pulmonary areas over which vesicular
breathing is normal. If the infiltration oc-
curs in those parts of the lungs in which
bronchovesicular breathing is normal, the
respiratory note changes from an inspira-
tion and expiration of equal duration so
that the expiration becomes of longer dura-
tion than inspiration. Thus we see that
bronchovesicular breathing over the left
apex denotes infiltration, whereas that same
breathing over the right apex is normal. A
prolonged expiratory sound over the right
apex signifies early tuberculous involve-
ment usually. Both the whispered voice
and the spoken voice are more or less in-
distinct over normal left apices, whereas
they are normally fairly distinct over the
right apex. Mentioned is the fact that the
spoken voice soimds over the left base are
louder jn some normal chests than over the
right apex. The increased whispered voice
sound is considered pathognomonic of in-
filtration, when it occurs on the left side.
A decreased respiratory murmur, and a
jerky inspiration or cog-wheel breathing are
suspicious* findings; but more important is
the presence of rales.
Persistent and localised rales — whether
they be moist, dry, crackling, crepitant or
other variety — they are considered as very
valuable evidence in the diagnosis of early
phthisis. The crepitant rale heard at the
end of inspiration over either apex is a
classical sign — provided the rale does, or
the rales do, persist after continued breath-
ing. Potassium iodide in 5 grain doses given
three times daily will often vitalize rales.
Having the patient cough and breathe while
the examiner listens over the apices, and,
listening carefully over the acromial end of
the clavicle will both often detect the pres-
ence of rales when no other method will.
In the great majority of cases of early pul-
monary tuberculosis, the only rales of im-
portance are those heard over and near the
apices. Rales are always pathologic. A
single rale or many rales, if localized and
persistent, may be considered as the earliest
evidence of tuberculous involvement ob-
tainable by physical examination.
Careful and frequent examinations of
the sputum should be made in all suspected
cases. The finding of tubercle bacilli there-
in is considered as absolute proof of an
active tuberculous process in the lungs. In
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Slater's estimation, the sputum of patients
in the incipient stage, when examined in
sanatoria where most careful work is done,
is positive for tubercle bacilli, at any time,
in not more than 33 per cent, of cases. The
older method of staining the untreated
sputum is rarely successful.
The antiformin method is much more
productive of positive results. A technic
frequently used is as follows : a mixture of
one part of antiformin and of five parts of
sputum is allowed to stand for several
hours, the mixture is then diluted with
water or alcohol and centrifugalized ; the
sediment is collected several times, the final
sediment being stained and examined.
In order to demonstrate the presence of
the tubercle bacillus in the sputum, differ-
ent workers have devised several excellent
variations of the above-mentioned anti-
formin method. One of these variations is
the following technic used by Ymaz: To
a mixture of equal parts of sputum and 50
per cent, antiformin solution, which mix-
ture has been boiled, is added an equal
amount of syrup (jarabe) with a specific
gravity of 1,260. To this mixture is added
a small amount of ether, which is then well
mixed, to form an emulsion. After centri-
fugation at high speed for some time, the
tubercle bacilli will be found in the whitish
zone that forms at the plane separating the
two fluids.
The Ellerman and Erlander method of
sputum examination is a most excellent pro-
cedure and is often productive of positive
results when other methods have failed.
The technic is as follows: The entire
expectoration of three days is collected in
a clean, wide-mouthed bottle. To this is
added an equal volume of 0.6 per cent,
sodium carbonate solution. After shaking,
the mixture is placed in an incubator and
allowed to digest at a temperature of 37® C.
for twenty-four hours. The time of diges-
tion should be increased with thick, puru-
lent specimens. The mixture is removed
from the incubator and should consist of
two layers ; the upper, cloudy fluid ; and the
lower, a varying amount of homogeneous
sediment. The entire fluid portion is
poured off (into 5 per cent, lysol or similar
solution) ; and to the remaining sediment
is added four or five volumes of 0.25 per
cent, sodium hydrate solution. The mix-
ture is next transferred to a suitable vessel
and boiled for one or two minutes. Large
test tubes (eight by one, inch) or small
beakers are found convenient. After cool-
ing, the mixture is transferred to 50 c. c.
centrifuge tubes and centrifugated at high
speed for ten or fifteen minutes. The result-
ing sediment is smeared upon two or three
slides, making rather thick smears, and then
stained in the usual manner.
To stain the tubercle bacilli, the Ziehl-
Neelson method is the one most generally
used. The fixed smear is first stained with
carbol-fuchsin, then decolorized with 3 per
cent, hydrochloric acid in 95 per cent,
alcohol, and then counterstained with
methylene blue. According to the method
used by Lewis and Krauss, a mixture con-
taining 20 c. cm. of a saturated alcoholic
solution of pararosanilin and 80 c. cm. of 5
per cent, phenol solution is substituted for
the older carbolfuchsin, with equally as
good results and with a saving of some time.
If no tubercule bacilli are found, the sput-
um should be examined for l)rmphocytes.
A lymphocytosis of from 30 to 50 per cent,
is highly suggestive of tuberculosis, and
above 50 is diagnostic.
Even when some other attempts to
demonstrate the presence of tubercle bacilli
in the sputum have failed, the cultivaiion of
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Koch's bacillus from the sputum is some-
times successful. The best of such methods
is probably that of Petroff, which is as fol-
lows: about 5 c. cm. of fresh sputum are
mixed with sterile 3 per cent, sodium hy-
droxide solution, in a sterile bottle; with
frequent shakings of the bottle, the mixture
is incubated at 37** C. for thirty or forty
minutes, a piece of sterile litmus paper is
placed in the mixture and the mixture is
neutralized with sterile normal hydrochloric
acid ; the mixture is then centrifugalized at
high speed for ten minutes ; the sediment is
then planted on Petroff's gentian-violet-
egg- veal meditun ; and this implanted med-
ium is incubated at a temperature between
38° C. and 39° C.
Probably more in use as a diagnostic
agent than PetrofF's method is the lowly
guinea-pig which receives into each groin,
as well as intraperitoneally, an injection of
a uniform amount of sediment resulting
from the centrifugalization of washed and
digested sputum. The usual procedure is
to autopsy the guinea-pig at the end of six
weeks. In the event that the sediment in-
jected into this little laboratory animal con-
tains tubercle bacilli, the autopsy will re-
veal characteristic signs of tuberculous in-
fection. The X-ray of the injected guinea-
pig for five minutes every other day for at
least six days usually hastens the tubercul-
ous process to such an extent that a positive
diagnosis may frequently be made from a
nodule removed under local anesthesia, at
the end of two weeks.
There was a time when much faith was
placed in the results of the various tubercu-
lin tests. At the present time, however,
excepting in children under four years of
age, the different tuberculin tests are not
considered as very valuable, by the majority
of workers. Some, however, consider a
marked local and constitutional reaction,
following the introduction of the diagnostic
dose of tuberculin, as proof of an active
tuberculosis. The opinion of a great many
diagnosticians is summarized by Brown in
the following words :
"No modification of the tuberculin tests,
as yet devised, differentiates clearly clinical
tuberculosis that demands vigorous treat-
ment from non-clinical tuberculosis that re-
quires only a God-fearing life."
The complement fixation test, however,
is extremely valuable in the diagnosis of
early tuberculosis. The test is positive in
about 85 per cent, of the early cases, is
sometimes present before a diagnosis by
physical or X-ray examination can be
made; this test is negative in non-tubercu-
lous individuals and in syphilitics who are
clinically free of tuberculosis. The inten-
sity of the reaction decreases or the test
becomes negative simultaneously with the
arresting of the tuberculous process — just
as the Wassermann test does in cases of
syphilis. It is evident, therefore, that a
positive complement fixation test means an
active tuberculous condition, and, that a
negative reaction means nothing. The best
results have been obtained by the use of
Miller's antigen and the partial antigens of
Deyke and Much.
Altbo the examination of tj^e blood is not
of as much value in the diagnosis as is the
complement fixation test, it may help con-
siderably in arriving at a diagnosis, es-
pecially when the complement fixation test
has not been done. The lymphocytosis
present in tuberculosis is more apt to be
relative than absolute, in contradistinction
to the absolute lymphocytosis (usually ac-
companied by an eosinophilia) which is
usually present in cases of syphilitic in-
fection. According to Bachman and Lucke,
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the lymphocytic picture has an inverse ratio
to the percentage of polymorphonuclear
neutrophilic leucocytes ; in other words, the
more advanced is the disease, the higher is
the percentage of the polymorphonuclear
neutrophilic leucocytes and the lower is the
percentage of the lymphocytes. Bachman
and Lucke found that, in the first stage of
pulmonary tuberculosis, the polymorpho-
nuclear neutrophilic leucocytes averaged 56
per cent, and the lymphocytes 24% o P^r
cent, and that the Arneth index increased
approximately 6 per cent.
The X-ray is a most valuable agent in the
diagnostician's armamentarium. The X-ray
is capable of revealing changes in the lungs
which cannot be demonstrated by any other
method. In many cases, the X-ray plates
reveal structural changes before the appear-
ance of any physical signs, and, in prac-
tically all cases, these photographs show
changes much greater in extent than the
physical signs indicate. About the only
early change shown by the fluoroscopic
method is a slight diminution in the amount
of expansion on the affected side. Plates
made by the stereoscopic method or by
sending the rays obliquely downward in
line with the chin so as to project the
clavicle downward and clear the apices of
the Jungs, show the earliest changes. There
is some diversity of opinion as to where the
first changes occur. However, according
to Lapham, "the first abnormal condi-
tions are seen in the enlargements of the
bronchial glands, the second set of changes
consists in thready infiltrations running
from the root up towards the apex of the
lung." To quote Hubeny: "The first
points of election appear to be in the first
and second interspaces near the median
triangle and toward the periphery of the
lung near the angle of the scapula." In the
words of Pf abler "one finds this evidence
most frequently at the apices and particu-
larly at the inner portion of the apices of
the lungs, extending down along the para-
vertebral border ; this evidence may occupy
also the apices of the lower lobes or the
outer portion of the middle lobe in adults,
while the disease, in children, seems to ex-
tend most frequently outward from the
roots of the lungs." In 60 of 62 patients
in the incipient stage (37 of whom had no
physical signs of consumption but all of
whom had or had had positive sputum), ex-
amined by Bushnell, the X-ray examina-
tion showed paravertebral tuberculosis
above the hiluses. The fan-shaped area of
thickened linear markings representing the
course of the lymph channels draining the
infected area is considered of much value
by many radiologists, especially by Dun-
ham, Holmes, Aaron and others. "In early
and slight lesions where a low grade inflam-
mation was spread by continuity of mu-
cosa, the fan appeared wide open and dis-
tinct." Altho these pulmonary pictures
show us the site and extent of the involve-
ment, they, like the tuberculin tests, do not
tell us whether the tuberculous condition is
active, quiescent or healed.
One should not rely too much upon any
single method of arriving at a conclusion
as to the tuberculous or non-tuberculous
nature of any case. One should use all of
the methods outlined above, if necessary, in
order to make a correct diagnosis. "Art is
long, and Time is fleeting." — But he who
works will win.
In the detection of incipient phthisis, the
opportunity for the display of medical
learning and for the rendering of real hu-
manitarian service to our fellowmen is ex-
ceedingly great. It seems possible and
probable that, if every case were diagnosed
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in its incipiency and were given proper
treatment, this scourge of the ages — ^this
same consumption with which Moses cursed
the disobedient of his people — would be-
come, within a hundred years, only a bitter
memory.
References.
Aabon: The Roentgen Rays in the Diagnosis
of Diseases of the Thoracic Cavity. Trans.
Amer. Cong, Int. Med., reported in Med,
Rec, January 12, 1918.
Abrahams: Early Pulmonary Tuberculosis;
The Signs and Symptoms. (N, Y, Med,
Jour., 1916. Vol. CIV, pp. 204-208).
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Bachman and Lucke: The Differential Blood
Count The Arneth Formula and Doehle's
Inclusion Bodies in Pulmonary Tuberculo-
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the Lungs as Shown by the Roentgen Ray.
(Southwest Med., May, 1917).
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Chadwick and Morgan: The Diagnosis of
Tuberculosis in Children. (Boston Med.
and Surg. Jour,, Aug. 2, 1917).
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Tests in Tuberculosis. (Jour. Amer, Med.
Asso., June 2, 1917).
EcKFORo: The Use of X-rayed Guinea Pigs in
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Rec., September 8, 1917).
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Heis and Sampson: Comparison of Physical
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Holmes: X-ray in Phthisis. (Boston Med.
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(Nederlandsch Tijdschrift voor Oenees-
kundle, September 15, 1917).
Keilty: Isolation of the Tubercle Bacillus
from Sputum. (Jour, Exper. Med., July,
1916).
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Toung Men. (Military Surgeon, January,
1918.
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by Necropsy Findings. (Am^r. Jour. Dis.
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(Semana Med., May, 1917).
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SURGICAL TREATMENT OF
HALLUX VALGUS AND ITS
COMPLICATIONS.
BY
JOS. E. FULD. M. D.,
New York City.
Attending Surgeon, Park Hosp., Instructor in
Operative Surgery, College of Physicians
and Surgeons, Columbia University;
Assistant Visiting, City and Gou-
vemeur Hospitals.
Hallux valgus is a deformity in which
the great toe is abnormally abducted, or
turned out. In modem life where comfort
so often gives place to the requirements of
fashion, pointed shoes make hallux valgus
exceedingly common. It may vary from
the simple hyperadduction which gives
comparatively little discomfort to the de-
formity in which the great toe is outwardly
displaced and subluxated, the bursa over
the metatarsophalangeal joint is inflamed,
forming a bunion, and the head of the first
metatarsal bone is markedly hypertrophied.
The condition, which is rarely seen in the
newborn, may be caused by rheumatoid
arthritis, and in fact a dry, inflammatory
arthritis is found in nearly all cases which
apply for treatment. Injury and systemic
disease play very little part as etiologic
factors. The great majority of cases, how-
ever, may be traced to ill-fitting shoes, either
pointed or too short, or too narrow, and
for this reason the deformity is more fre-
quently found in women than men, prob-
ably because they more often choose style
rather than comfort and their muscles are
less able to withstand the deformity effected
by pressure over the joint. In China,
where the native shoe is pointed and right
and left are alike and interchangeable, hal-
lux valgus is practically universal, only the
barefoot population being exempt.
The evils of an improperly shaped shoe
are not appreciated generally by the laity
and too infrequently by the profession. The
narrow pointed shoe or one too short for
the foot may produce pain causing the
wearer to walk on one side of the foot, the
foot becomes abducted and a flat or weak
foot is the result; the toes are crowded
toward the median line of the foot, the
great toe is adducted and in turn forces the
second toe into dorsiflexion forming hallux
valgus and hammer toe. High heels also
crowd the foot forward, the mechanism
then acting as in the too-short shoe, the
great toe is dorsiflexed and adducted, the
interphalangeal joints and the great toe de-
viate outward, thus forcing the first meta-
tarsal bone into inward displacement, its
head protrudes and hypertrophies forming
the so-called "enlarged joint." The in-
ternal lateral ligament of the joint is
stretched and the external lateral ligament
is shortened and thickened. The tendons
on the inner side are lengthened and those
on the outer side are shortened. The soft
parts over the inner aspect of the joint are
thickened and enlarged and include a bursa
with a superimposed corn or callus. This
bursa becomes inflamed and may suppurate.
I have seen cases of cellulitis of the foot
arising from neglected bursitis. The great
toe being thus turned out, its function as an
inward brace to the foot is destroyed and
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the elasticity and spring of the step are de-
creased. Pain is caused by the pressure of
the shoe on the acute bursitis, by pressure
on the anterior tibial nerve between the
shoe and the underlying part of the bone
and also on the nerve fibres between the
bony outgrowth on the base of the first
phalanx of the great toe and the side of the
first phalanx of the second. If, as is usually
the case, there is associated with the hallux
valgus the condition of dorsiflexion or ham-
mer toe of the second phalanx, the rubbing
Fig. 1. Bony projection. A-B, line of excision.
of the shoe or its pressure causes a painful
callus or corn over the phalangeal joint of
the second phalanx.
Treatment. — Relief can sometimes be
obtained in slight cases by wearing proper
shoes and right and left socks or stockings
with a separate compartment for the great
toe. The toe should be massaged and cor-
rected manually several times a day and a
soft plug should be worn at night between
the first and second toes.
Several operations have been devised for
the cure of this condition. Rowlands and
Turner removed the prominent inner half
of the head of the first metatarsal bone and
sometimes the prominent inner basal angle
of the first phalanx, divided the extensor
brevis hallucis, and sometimes lengthened
the extensor longus hallucis. Tubby chiseled
oflF the prominent head of the first meta-
tarsal bone, divided the ligaments and the
extensor proprius poUicis tendon, and re-
placed the phalanges in position. In cases
where the head was greatly hypertrophied
and there were marked symptoms of arthri-
tis, he excised completely the head of the
metatarsal bone, taking care to remove the
Fig. 2. C, capsule; T, tendon of abductor hal-
lucis to be transplanted.
projecting spur on the outer side of the
first phalanx. The sesamoid bones were
also removed, as pressure on them subse-
quently caused pain. After the operation
he advised that a wedge of gauze be worn
between the first and second toes. Inas-
much as the intact metatarsal bone is a
necessary part of the arch of the foot, he
found that these patients must use a valgus
plate for walking. William L. Keller found
that all the old operations for the relief of
hallux valgus were unsatisfactory. Resec-
tion of the head of the first metatarsal toe,
successful in the flat-footed individual, in-
jured a normal arch. He devised an opera-
tion which sacrificed no part of the plantar
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ORiaiNAJL ARTICLBS
American Medicins
articular surface. C. H. Mayo recom-
mended that the bursa be interposed be-
tween the joint surfaces after excision of
the metatarsal head. In other words, the
Fig. 3. B, Bony projection; T, tendon of ab-
ductor hallucls; C, capsule.
bursa was transplanted to the space formed
by the resection of the articular head of the
first metatarsal, the joint surface of the
first phalanx being left intact. Von Berg-
mann resected the base of the phalanx and
the head of the first metatarsal. Gold-
thwaite, Painter and Osgood believe that
the Hunter operation of removal of the
metatarsal bone is almost uniformly satis-
factory when the proper operative technic
and after-treatment have been observed.
Henry Ling Taylor advised the use of an
elongated, or Thomas heel, or shoes straight
on the inner side. If operation is necessary
he believes that oblique incision of the head
of the first metatarsal is as good as any.
Royal Whitman considers that the primary
object should be to remove the projecting
bone. He also stretched and divided tis-
sues that resisted a corrected position.
The cure of hallux valgus calls for a
surgical procedure that takes into consid-
eration not only the correction of the de-
formity but the preservation of the weight-
bearing function of the foot.
There are in fact three requirements for
a successful operative procedure for the
cure of hallux valgus.
1. The correction of the deformity.
2. The prevention of recurrence.
3. The preservation of the longitudinal
arch.
In correcting the deformity it is rarely
necessary to resect a head of the metatarsal
bone and I have confined myself to chisel-
ing off the bony exostosis with the perios-
teum that covers it. This preserves the
longtitudinal arch and also corrects the de-
formity.
Author's Operation. — ^To prevent the
recurrence, I have devised and found feas-
ible a transplantation of the tendon of the
abductor hallucis from its usual insertion
in the plantar surface of the base of the
first phalanx to the periosteum covering the
middle of the inner surface of the same
bone.
After a Ihoro trial of the various op-
erative methods, this operation has given me
Fig. 4. T, tendon transplanted and sutured;
C, capsule sutured.
the best results. The simplicity, ease and
safety with which it can be performed, in
my opinion, warrant its trial in these cases.
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539
It allows the patient to walk well and ab-
solutely without pain; the great toe re-
mains in perfect position and is naturally
mobile; and it does not affect the weight-
bearing function of the foot.
Technique*
The steps of the operation are as follows :
1. Under general anesthesia, forcibly
move the great toe in all directions, stretch-
ing the contracted tissues.
2. Paint the foot and toes with iodine.
3. Make a slightly curved incision,
about two inches long, beginning one-half
inch in front of the bony prominence on the
inner side of the great toe. A semi-circular
flap of skin and subcutaneous tissue is dis-
sected free from the bursa and turned down
over the joint, so that the subsequent scar
will not be at a point of pressure (Fig. 1).
4. The soft parts are retracted. The
tendon of the abductor hallucis is now seen
under the head of the metatarsal bone and
is dissected free from its attachment to the
base of the first phalanx (Fig. 2).
5. A flap is now made, including the
bursa, capsular ligament, and periosteum,
and turned down, exposing the bony de-
formity to view (Fig. 3).
6. Apply the chisel to the bone at the
junction of the condyle and globular head
of the metatarsal, and excise the hyp>er-
trophied bony projection longitudinally
backward (Fig. 3).
7. Irrigate the wound with hot saline
solutions.
8. Replace the capsule to cover the raw
surface of the bone and fix it with catgut
sutures.
9. Subcutaneous division of the con-
tracted internal lateral ligament and fascia.
10. The tendon of the abductor hallucis
is now transplanted to the middle of the
inner surface of the first phalanx, and
sutured with fine silk, or Pagenstecher
thread, to the periosteum (Fig. 4).
11. Qose skin in usual manner.
12. A plaster-of-Paris bandage is ap-
plied to the foot and toe, holding the toe in
a slightly overcorrected position, and al-
lowed to remain for a week or ten days.
After-Treatment.
If the patient carefully observes instruc-
tions as to the wearing of properly shaped
shoes, no further post-operative treatment
will be necessary.
OVERLOOKED CAUSES OF FAIL-
URE TO CURE SYSTEMIC DIS-
EASES BY SPECTACLES.
GEORGE M. GOULD, M. D.,
Atlantic City, N. J.
Guesses and estimates have been made by
many to fix the proportional nimiber of
cures of systemic diseases by scientific cor-
rection of ametropia. They have proved
wide of the mark because of the reserved
opinion that the ametropic correction was,
or was not, accurately diagriosed; or that
the systemic disease was not caused by
eyestrain. The strange and striking mis-
take was the assumption that if the work
of the best, or favorite, oculist did not stop
the headaches, general nervous diseases,
denutritions, hysterias, nervous break-
downs, neurites — the hundred masquer-
adings of migraine — then the cause was,
decidedly, not eyestrain. This logic may
have seemed sound and beyond controversy,
but it was in fact valueless and without
significance, because many modifying
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AUQUST, 1919
ORIOINAL ARTIdJBS
Ambrican Mbdicinb
and contradicting facts had been over-
looked, facts which thru the eyes concern
the patient's health, the progress of med-
icine, and the success of therapeutics.
However impolitic and impolite it may
seem, there is one qualification that the
statisticians of therapeutic successes and
failures need to be reminded of — "the best"
and most trusted of ophthalmic surgeons do
make occasional errors in prescribing
glasses; and this is because they have not
learned that traumatism excepted, the vast
majority of surgical operations on the eyes
could and should have been avoided by the
correction of ametropia.
Second only to uncorrected or incorrectly
corrected ametropia, dirty lenses are the
greatest cause of eyestrain. Combine these
two factors and we get the acme of evil.
Few patients keep the two bits of glass
constantly clean and perfectly polished, as
they must be to meet the demands of the
eyes and brain, during every minute of the
fifteen waking hours of each day. Those
may be the worst sinners who have been
most seriously warned and shown how to
avoid or remedy the evil. And yet it can-
not be doubted that oculists not only pay
too little attention to the danger; there is
usually only a hurried word of command
or caution which, instead, should be etched
deeper in the mind by repetition, illustra-
tion, explanation and warning of the dan-
ger of neglect; and this despite the risk
of making the patient think the oculist is a
crank and exaggerator. Some will forget
the advice, and some will fear breakage of
lenses. Opticians should be repeatedly ad-
vised to second the efforts of the oculist in
the matter. It is a good plan to give the
patient a label or tag to paste on his mirror
with the injunction. Clean my spectacle
lenses, now, and six times every day! In
many occupations it is more necessary than
in others, biecause of steam, dust^ fog,
sweat, etc. Many lenses are set too close
to the eye-ball and lashes by optician and
patient. Sometimes the lashes should be
slightly trimmed in order not to set the
lenses too far from the cornea. Opticians
themselves may be guilty in setting the
lenses so they will strike the lashes.
When a patient writes complainingly, I
may tel^raph "Trouble probably lies in not
keeping glasses clean." A visit to the ocu-
list may be necessary. There is a double
duty in recognizing the fact that the pa-
tient may not be cured of his systemic dis-
ease, and that the general physician will
not learn the truth about eyestrain and the
influence of scientific spectacles in helping
him to cure the diseases he is working up-
on. There is no relief of eyestrain reflexes
to the general system with dirty lenses ; and
if this is true the statistics of the puzzled
general physician will be wrong and his
labor will be in vain.
Next to dirty and no lenses as a cause of
eyestrain and its systemic results is failure
to wear the spectacles constantly. Patients,
for one reason or another, will leave the
glasses off, altho it results in a return of
the old morbid reflexes. Every patient
should be repeatedly warned, begged, com-
manded, to wear the spectacles every minute
of the waking life. And often they can-
not, or will not explain why they have not
done so. The third blunder (or crime) is
the use of eye-glasses instead of spectacles.
Eye-glasses are of little or no use; and,
usually increase, rather than lessen, the
eyestrain. In trying to make them cling to
the base of the nose they will often, or
generally, be so placed or displaced that the
axes of astigmatism (in scientific refrac-
tions) are changed from those determined
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ORIGINAJL ARTICL.B8
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541
by the trial frame and lenses. The oculist
who habitually permits eye-glasses will, at
least should, suffer in medical reputation
because he will miss therapeutic results.
Vanity is often a great encourager of eye-
strain diseases. The wide-awake general
practitioner should not generally permit his
patients to have eye-glasses.
If the systemic reflexes present are those
often due to eyestrain, and if the patient is
over 40 years of age, the cure is conditional
upon wearing bifocal spectacles all the wak-
ing hours of all days. Sick patients must
wear them as well abed as afoot, if awake,
altho "not looking at anything in particu-
lar." Striped wall-papers are more harm-
ful than the unfigured. No reading should
be carried on by the sick or well while
abed.
There are some occupations which re-
quire a presbyopic correction differing from
that of the usual reading and writing dis-
tance correction, and nearer than the clear-
est distance-work. I have successfully
ordered trifocal lenses in a few cases.
Instances sometimes occur of astigma-
tism not at 90° or 180° and the patient (or
poor optician) had replaced the dropped out
lens *'up-side down", thus instantly produc-
ing intolerable eyestrain. One of these pa-
tients came several hundred miles to have
me, in a few seconds, insert the lens cor-
rectly, at the proper axis of astigmatism,
and instantly ending the patient's torment-
ing eyestrain.
Another patient living 300 miles away
wrote of severe eye-trouble suddenly ap-
pearing and continuing for the last week
or ten days. Correspondence failed to
bring any explanation, and the patient was
compelled to make the long journey to my
office. I at once found an almost invisible
fleck on the outer surface, at the center of
one of the lenses, and precisely opposite the
pupil in reading, etc. "Out in a lively
wind-storm and sand blew in your face?"
I asked. "Yes." A new lens gave relief.
For stone-masons I order several pairs of
piano lenses, one after the other to be used
as "fronts" until flecked by the flying bits
frequently striking the face.
Quack opticians nowadays are making
the bequacked world wear big round "sun-
glasses" with colored lenses — "any color
you wish," "to protect the eyes." The
glass itself is usually a nightmare of imper-
fection : they press against the eyebrows and
cheeks ; they are dirty ; and they create eye-
strain and morbid reflexes. Next week a
new evil will be concocted.
Yet another unrecognized source of eye-
strain is the universal ignoring of the fact
of the normal right-eyedness in the right-
handed, and of left-eyedness in the left-
handed. From this results handicap in all
work and function by glasses that reverse
or interfere with the normal ocular and
cerebral rightness and leftness governing
cerebral rightness or leftness intermediat-
ing physical and psychical function and ac-
tion. It should be made a crime by law
to attempt making good left-handed chil-
dren into bad right-handed ones. And the
modern school desks are great makers of
lifelong diseases and functions.
There are yet many other unrecognized
methods whereby there is great increase in
the frequency and hurt of neglected eye-
strain in producing systemic diseases. A
more general recognition of the power of
ametropia to engender these systemic ef-
fects would make physicians, general and
special, more successful in the treatment of
systemic diseases, more hopeful in prog-
noses, and more correct in their statistics of
cures.
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ORIGINAL. ARTICLB8
AinnUOAN MBDIdNS
ANIMAL POWERS IN HEALTH AND
DISEASE.'
CASPER L. REDPIBLD.
Chicago.
Originally, lawyers were employed to get
their clients out of the troubles into which
they had fallen. At the present time law-
yers are hired to keep their employers out
of jail. Experience has taught the public
that preventive legal medicine is better than
a cure.
The old time physician was called on to
cure his patient after that patient had be-
come more or less battered by contact with
some of nature's operations. Since the
days of Jenner, however, we have begun to
appreciate the fact that it is just as well to
use a little preventive dope when we can..
It is fairly probable that boards of health
will become more and more prominent in
the future, and that the curing of disease
will be a continually diminishing part of the
physician's business. '
I am not here concerned with the em-
ployment of some specific vaccine or anti-
toxin for some specific ailment, but with
fundamental principles involved in ward-
ing off sickness of all kinds. When those
fundamental principles are fully under-
stood it will probably be found that most
specific preventives and remedies are really
nothing but special applications of general
principles to special cases. I say "most"
because draining swamps to exterminate
mosquitoes and using an alkali to neutralize
an acid represent a class of things which do
*For previous articles on animal powers by
Mr. Redfleld, see Amebican Medicine for Febru-
ary and October, 1917, and August, 1918. For a
condensation of the facts relating to the inherit-
ance of development acquired by exercise in
man and other animals, see Redfield's Dynamic
Evolution, published by G. P. Putnam's Sons,
New York.
not come under the present consideration.
A large proportion of human ailments
is due to the actions of microscopic para-
sites or to the presence of poisons in the
system. Disease-producing bacteria are
generally present in healthy persons, but
those persons remain healthy because their
powers of resistance are greater than the
powers of attack possessed by the germs.
But let a person's vitality fall below some
certain point, and disease catches him. Or
a person who has become weakened by a
long battle with one disease quite easily
falls victim to another.
The question of health is a question of
power to resist disease. If a person has
sufficient power he remains healthy. If he
does not, he becomes sick. One of the ob-
jects of boards of health is to remove
causes of disease so that even the weak
will not succumb, but one of the main ob-
jects of the individual physician should be
to develop the powers of resistance in in-
dividuals so that they .will not fall victims
of those germs which get by the boards of
health. The object here is to point out
how animal powers are developed, and from
a general consideration of. that process to
indicate how powers of resistance to dis-
ease are developed.
The military authorities take our young
men and put them thru intensive physical
training. That training takes off fat and
puts on muscle. According to a statement
sent out by the U. S. Government during
October, 1918, the men in the training
camps had gained an average of twelve
pounds per man. As this gain was accom-
panied by a loss of fat on a considerable
proportion of the men, it is evident that the
actual gain in muscle is much more than
an average of twelve pounds per man.
But the gain in physical strength and
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543
power is much more than the gain in
weight. Thus, a man who would gain
about ten per cent, in weight of muscle
would gain about one hundred per cent, in
physical power, and the real object of this
training is to give the men that power which
will enable them to stand up in a fight
against similarly trained men. According
to the military authorities it requires a year
or more of this intensive training to make
men physically fit to go to the front.
When a person is worn out by illness the
usual physician's advice is to "rest and re-
cuperate." That is good as far as it goes,
but "recuperate" means only to regain what
was lost, and that is not enough. Disease
caught him at the place where he was. He
should be carried along to a point at which
he has more powers of resistance than he
had before, and powers are not developed
by "rest." They are developed only by ex-
ercise, and to make the matter clearer we
will look at it from different angles.
Trotting horses are trained to trot, and
are entered in trotting races. It requires
the expenditure of a great amount of power
to trot a mile at high speed, and the greater
the speed the greater the power required.
If a horse is continually exercised at the
trot (trained) year after year to an extent
approaching the limits of his capability of
effort, he will continue to gain in trotting
power year by year. Part of this is repre-
sented by gain in speed and part is repre-
sented by gain in endurance. The records
show that the part of this gain which is
represented by increased speed may con-
tinue up to at least seventeen years of age.
Milk-producing organs belong to a class
of organs or glands which are somewhat
different from muscles. Holstein-Friesian
cows are noted for milk production, and
when these cows are regularly bred and
regularly milked they continue to increase
in milk-producing power up to at least
twelve years of age. The records which I
had available for investigation did not go
beyond this point for the same cows of-
ficially tested in successive years.
Not every cow tested shows an increase
in milk produced every year. Occasionally
a cow falls back and produces less milk
than she produced the year previously.
The available records do not show the
cause of this falling oflf, but there are prob-
ably various causes. One of these may be
due to relative idleness during the preced-
ing year which would consist in the cow not
being urged in milk production except dur-
ing the short period when she was under
official test.
This would correspond to muscular idle-
ness. It is well known that a sedentary
man will lose the muscular strength he had
previously. With horses, trotting power
will continue to increase as long as intense
trotting exercise is continued, but if a horse
stands idle more than a few days his trot-
ting power begins to fall off, and continues
to fall oflf as long as he is idle.
The brain is a still different organ, and
its work is represented by intelligence, un-
derstanding and memory. The Binet
system recognizes the development of men-
tal power year by year in children, and in
ordinary aflfairs we recognize the same
thing in later life. The older man has bet-
ter understanding and judgment than the
younger man, and understanding and judg-
ment are products of mental power. It re-
quires more mental power to remember
many things than to remember a few, and
it is not possible for a young man to carry
as many things in his memory as an older
man can.
This matter of developing power by ex-
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ercise and losing it by idleness may be
traced in the vegetable kingdom as well as
in the animal. Plants which at first are
difficult to reproduce by cuttings because
they have only a feeble power of producing
roots, gradually gain that power by many
repetitions and later become very easy to
reproduce in that way. And plants which
are continually reproduced by cuttings and
not by seed gradually lose the power of
producing seeds.
Our domesticated plants have developed
tremendously their powers of producing
fruits, grains, leaves, roots or flowers ac-
cording to the lines along which their efforts
have been directed. But while man has
been developing the powers of plants along
certain lines, he has been coddling them by
protecting them from competition with wild
plants. Because our domesticated plants
have not been compelled to fight for room in
which to exist, they have gradually lost
the power to fight, and are no longer able to
maintain themselves when deserted by man.
Power is developed by exercise and is lost
by idleness.
Plants produce seeds. To casual obser-
vation, a seed looks like a dead object, but
it has the power of sprouting and growing
into a new plant like that which produced
the seed. That is, the seed has that power
provided it is fresh. But let the seed lie
idle for one, two, three or more years and
that power gradually declines and finally
ceases to exist. And a plant which comes
from a seed which germinated with diffi-
culty because it is old, is itself weak as com-
pared to a plant coming from a fresh seed.
Organisms, animals and plants, have in
them powers of performing certain acts.
Those powers are developed by causing
the organism to exercise more than some
certain minimum amount per unit of time,
which minimum amount of exercise has a
definite relationship to the amount of power
existing in the organism at the time. Thus,
the amount of exercise necessary to keep
an athlete in condition to enter an athletic
contest is more than that necessary to keep
an ordinary person in ordinary condition.
Just as we use the term "cold** to represent
some degree of heat which is less than some 0
assumed normal, we use the term "idle-
ness" to represent an amount of exercise
less than that necessary to prevent a decline
or degeneration of the powers of an organ-
ism. The rate at which such powers de-
velop or decline is determined by the ex-
tent to which the exercise is more or less
than that minimum amount, and the total
gain or loss is represented by the product
of the excess or deficiency and the length
of time the gain or loss is continued.
If a man swings Indian clubs and dumb
bells he develops strength in the muscles
of his arms. If he practices running, then
the development is in the muscles of his
legs and not in his arms. If a horse is
trained at the trot he develops his trotting
muscles and not his running muscles. When
a cow works hard at milk production it is
her lacteal organs which are developed and
not her legs. If a man begins by taking a
small amount of arsenic and gradually in-
creases the dose, he develops a resistance
which soon enables him to take, with im-
punity, an amount large enough to kill many
men. The resistance which he thus de-
velops is to that particular drug, and not to
some other drug.
If a man is attacked by a disease for
which he has not previously developed a
specific resistance he is quickly laid low.
His system immediately starts to fight that
disease and in doing this draws upon the
reserve energy stored in other organs as a
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result of exercising them. Because the par-
ticular kind of resistance wanted has not
been previously developed, the disease at
first makes headway and the man grows
worse. But as the fight goes on, the power
of resistance to that disease increases, and
as soon as it becomes greater than the
power of attack, the man begins to improve.
By the time he has completely mastered the
disease he has developed great powers of
resistance to that specific disease, but as he
has drawn that power from his other re-
sefrves, he is otherwise weak. He must then
'Vest and recover," which means that he
must get back into his other organs the
equivalent of the power which has been
drained away in fighting the disease.
Now it is evident that a man cannot be
prepared in advance with the specific resist-
ance required to meet every possible dis-
ease which may attack him. The best that
can be done is to have the man develop re-
sistance for a few of those diseases to which
he is most liable to be exposed, and then to
develop a general store of reserve energy
which may be called on at short notice to
combat any disease which may make its ap-
pearance.
When a man exercises his legs he develops
power in his legs, and when he exercises his
arms he develops power in his arms; but
in exercising either of these the develop-
ment of power is not confined to the legs or
arms. When he runs his heart must pump
more blood per minute, and that extra work
which the heart does develops its power so
that it is easier for it to pump the required
amount.
To aerate this extra amount of blood the
lungs must handle an extra amount of air,
and this exercises a whole series of muscles
about the thorax. To provide the energy
which is to be stored in these various mus-
cles as a result of this exercise, the man
must eat more and this in turn puts more
work on all of the organs involved in the
processes of digestion and assimilation. In
fact, physical exercise of the kind employed
in intensive military training develops the
power of every organ in the body.
When a man is attacked by a disease for
AVhich he has not previously developed a
specific resistance, the system calls upon the
general supply of energy to furnish that
needed to fight that disease. If, by physical
training, the man has developed a large
store of energy in his organs, there is a
good supply to be drawn upon and his
chances of recovery are good. If, by rea-
son of a strictly sedentary life, the man has
only a small store of energy in his body,
then his chances of recovery are not good.
Hence, regular physical exercise by which
a man develops the strength of his organs
is a way of putting a man in condition to
resist any disease which may come. When
we remember that fighting disease of any
kind involves the use of animal energy to
do the fighting, it will be evident that the
general development of physical strength
by physical exercise is the only way of pre-
paring in advance to meet diseases of an
unanticipated kind.
Let us turn to a consideration of special
diseases, and for the purposes of illustration
we will take the spirochaete. Our present
way of fighting "His Corkscrew Majesty"
is to poison the animal as we would poison
rats. But is there not a way of developing
resistance to this invader?
It is well known that the blood of differ-
ent species of animals has different reac-
tions, and that parasites like the spiro-
chaete cannot live in blood of all kinds.
For example, the cow cannot contract
syphilis.
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Let us take some other animal, as the
rabbit or guinea pig, in which the spiro-
chaete can live, but where he will meet a
blood reaction quite different from that of
man. Let us inoculate this animal and
thereby start a special strain of spirochaetes,
and from time to time pass this strain along
in series to other animals of the same kind.
Living in a new environment and meeting
a new blood reaction, this strain of spiro-
chaetes will gradually develop its powers
of meeting this particular reaction. Being
away from the reactions peculiar to human
blood and not exerting itself to meet such
reactions, the powers of the spirochaete to
meet the human reaction gradually decline
as the result of lack of exercise in that line.
After a period of time which we cannot
now estimate, a human being is inoculated
with this strain of spirochaetes. As the
parasities of this strain have lost much of
their power to meet the human blood reac-
tions they are able to make only a feeble at-
tack upon the man; but the system of the
man fights this attack the same as it would
fight any other attack. In this fight the
man develops power to resist attacks of this
kind, and if the disparity between the
powers of the man and the powers of the
parasite are sufficient, the spirochaetes are
destroyed and the man becomes immune to
a genuine attack of syphilis.
While this example of developing resist-
ance is imaginary it is not wholly visionary.
Thus, if a cow be inoculated with the virus
of smallpox, and the strain be passed along
in series thru ten or more cows, then, if a
human being is inoculated with this strain
the result is cowpox and not smallpox. In
other words, if the protozoon responsible
for smallpox lives for a time in a blood re-
action different from that of man it loses
its power of making a serious attack upon
human beings.
A consideration of the history of vaccina-
tion gives us some additional information
on the development of powers by exercise
and the loss of such powers by idleness.
When a person is vaccinated he develops
the power of resistance to smallpox, and
that power is greatest immediately after
the completion of the incubation period.
But as time goes on the acquired resistance
gradually declines until it becomes, prac-
tically zero in ten years or less. Upon re-
vaccination, the power of resistance is again
developed, but as time goes on again this
newly acquired power again declines.
1
tinder the Editorial Direction of Albert C.
(Peyser, M. D., New York.
CLINICAL DUGNOSIS AKD PHTSIOLOGIC
DIETETICS.
There are two reasons why there is such
a dearth of literature on this subject. Un-
til very recently the average patient could
not force himself to the belief that his phy-
sician was entitled to a fee for merely ad-
vising him regarding his daily diet. In fact,
when the physician realized that perhaps
all of the symptoms of which the patient
complained were directly traceable to errors
in his diet, it seemed necessary to prescribe
a placebo.
A sugar pill, with definite directions as
to how many teaspoonfuls of water should
be used as a solvent, and how many minutes
before a certain meal this was to be taken,
would accomplish two things: First, the
patient was pleased with the placebo; sec-
ondly, his mind was diverted from the real
thing to be accomplished — the correction of
the diet.
Medical advice as to proper dieting is a
commodity much as anything else, the mar-
ket value depending upon the supply and the
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PHYSICAL. THERAPY
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547
demand. The state of mind of the average
patient did not create any appreciable de-
mand, therefore the supply fell into disuse.
That is the first reason why there was so
little written or said about man's diet.
The second reason depends directly upon
the first. In order to prescribe a physio-
logic diet (and any other is worse than use-
less) it is necessary to make a thoro physi-
cal examination of the patient, the blood,
the urine and the feces. The human being
is the sum total of the intake of food, the
oxidation and the output of the waste. It
will, therefore, be appreciated that in order
to prescribe a physiologic diet, more time,
more real scientific knowledge is required,
more genuine work has to be performed,
than with any other system of therapeutics.
Of course this had to be paid for and as
long as the patient was not willing to ap-
preciate this, the physician neglected this
branch of his work. This is a perfectly
natural consequence and no blame attaches
to the physician.
During the last few years, however, f*\
this has changed. The public has awakened
to the fact that there is a wide difference
in food values and qualities. Pure food
law bills have been passed, the Board of
Health has caused to be thrown into the
streets thousands upon thousands of quarts
of milk that did not measure up to the stand-
ard, it has condemned large quantities of
fruit unfit for the open market, adulterations
of all kinds have been prosecuted and the
eyes of the public have been opened. Now
the educated patient recognizes the value of
pure food during health and even to a great-
er extent during sickness, for it is realized
that since man is the result of the intake
and the output of foods, his power of recu-
peration will largely depend upon his food
intake.
The patient has learned the value of sci-
entific diete ; there is created a demand and
the physician is ready to supply that de-
mand.
We are now prepared to examine a little
more closely the term "Clinical Diagnosis."
For the past few years there has been a
tendency to neglect this branch of medicine
and the average doctor has gotten into the
habit of depending upon the laboratory for
the diagnosis. Far be it from me to detract
j one iota from the laboratory. Some of the
most valuable knowledge that we now pos-
sess in medicine could never have come to
light had it not been for the microscopist,
the pathologist and the chemist. These in-
stitutions are valuable aids. They assist us
to practice but they do not practice medi-
cine. All of these individuals only see a
very small, minute portion of the patient
and their report is based upon that small
part of the whole. The physicjan deals with
the patient as a whole. According to the
laboratory report a patient has a certain dis-
ease, yet clinically he shows not the slightest
interference with his physiologic functions ;
the question is, has this patient the disease
that the laboratory report says he has ? Dis-
ease means some disorder, some interference
with the bodily functions, a cei-tain state
of unrest or some inharmonious action of
some one or more of the organs of the body.
Thousands of Wassermann examinations
are made upon patients who give a positive
reaction, yet these same patients never had
an initial lesion, neither do they now show
any of the signs or symptoms of syphilis.
The question is, have they or have they not
b'yphilis, when all clinical manifestations are
wanting? Other patients are examined by
the Widal reaction for typhoid and declared
positive, yet they never felt better than at
that particular time. Another has his throat
examined for Klebs-Loeffler bacilli ; they are
found to be present, yet- not the slightest
inconvenience is manifested by this person.
Has this person or has this person not diph-
theria? Another patient who is really suf-
fering from chronic Bright's disease, who
is emaciated to a degree, so short of breath
that he can barely walk ; after a few weeks
his urine shows hardly a trace of albumin,
practically no casts, so according to the lab-
oratory report the urine is getting better,
but the patient is dying. A patient is suf-
fering from diabetes mellitus ; he is passing
large quantities of urine daily, loaded with
a high percentage of sugar ; his thirst is al-
most ravenous. The attending physician cuts
off all of the protein material and adminis-
ters opium. When after a few weeks this pa-
tient's urine is examined in the laboratory,
it will be found less in quantity, nearly free
from sugar, while the patient is suffering
from diabetic gangrene and slowly but surely
passing on. Another patient suffering from
the same disease follows his vocation day
after day and for the past twenty years
has, according to the laboratory, passed
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large quantities of sugar and should have
been dead long ago, but he seems to enjoy
his life just to upset the calculations of lab-
oratory reports.
A patient's sickness, therefore, should be
judged clinically first, aided perhaps by the
laboratory, and again clinically last. Does
the history of the patient have much bearing
upon the diagnosis of his disease? From
a clinical point of view it does not. If the
patient's history does not fit the clinical man-
ifestations it is so much the worse for the
history. The taking of a careful personal
history should never be omitted.
If it serves no other purpose, it assists
the doctor in becoming acquainted with his
patient. The first step in the diagnosis is
to know your patient's parents, then the
brothers and sisters, then the patient and
lastly his offspring, if there are any. It
would also be well if some competent office
assistant could do all this clerical work and
not until after the doctor has made a proper
physical examination will the previous his-
tory of the case become really appreciated.
Invariably this should start by noting the
electrical. reactions along the spine. While
these electrical reactions cannot tell us the
nature of the lesions, they can and do tell us
the anatomical location of whatever the na-
ture of the lesion might be.
The intestinal tract is twenty-four and
more feet in length. A lesion in one part
would interfere with the physiology of that
particular part first and the constitutional
manifestations or symptoms would be sec-
ondarily in accordance with that. As each
and every patient is a law unto himself it
follows that each patient will show his per-
sonal equation in the symptoms of which
he may complain. If the physician makes
his deductions from these symptoms as they
are interpreted by the patient we can see
how easy it would be to arrive at a wrong
diagnosis. When, however, we discover
that a lesion exists in any certain portion
of these twenty- lour feet of the gastroin-
testinal tract, then we are able to reason
from cause to effect and not from imaginary
effect to a non-existing cause, as is only too
frequently the case.
Let us suppose now that our patient clin-
ically shows some derangement with the
gastrointestinal tract. The electrical ex-
amination shows a reaction from the third
to the seventh dorsal vertebra. The branch-
es of the sympathetic fibres from this r^on
are mainly distributed to the stomach. We
know from this that whatever the nature
of the lesion is, it is located in the stcwnach,
or in other words, there is something ab-
normal, something interfering with the phys-
iology of that region. You may say that
you knew that before making the spinal ex-
amination.
Suppose your patient to be a woman com-
plaining of feeling distressed after eating
in the region of the stomach, that she fre-
quently raises gas, has eructations of a very
acrid nature that seem to bum the back of
the mouth, the tongue is coated, the breath
foul, and vomiting is a frequent occurrence,
has no appetite, in fact has an abhorrence
for even the smell of food, is dizzy and suf-
ers from headaches. Naturally such an ar-
ray of symptoms might lead anyone to sus-
pect some fault with stomach digestion.
Make a spinal examination of such a patient
and to your surprise find absolutely no re-
action from the third to the seventh dorsal,
but find a marked one between the first and
second lumbar, and you would have a dem-
onstration of reasoning from effect to cause.
This patient has something going on in the
uterus which may be anything from a pr^-
nancy to an old laceration or even carcinoma.
In a case of this kind then, after making the
spinal examination and reasoning from
cause to effect, we would at once know what
reflex gastric symptoms this patient is en-
titled to. We would then appreciate whether
the symptoms were exaggerated or mod-
ified according to the personal equation of
the patient. Let us take the case now where
we had a reaction in the gastric region. Can
we tell from this what the nature of the
lesion is ? No ; all that we know is the ana-
tomical location. Knowing the anatomical
location we are prepared to investigate the
physiology of that region. The stomach has
certain physiologic functions to perform.
The clinical manifestations when cleared of
all personal equation will tell us the kind
and the amount of interference.
The principal function of the stomach de-
pends upon the presence or absence of the
gastric juice, especially the hydrochloric
acid.
He may have an increase or a deficiency
of HCl. Besides acting upon the fibrous
portion of the animal matter and chemically
dissociating the component parts of meats
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and certain vegetable substances the HCl
after imparting to the prepared, foodstuflfs
an intensely acid reaction tends to call forth
the pyloric reflex. Not until the acid food-
stuff has been passed onward in the duode-
num or neutralized is the pyloric reflex re-
moved so that more food can again escape
out of the stomach. Too much acid will
keep the pylorus closed too long; the food
remains in the stomach, hence a sense of
weight and fulness after eating, spasm or
cramps, which are caused by the contrac-
tion of the organ, cause the expulsion of
gas and intensely sour foodstuffs into the
esophagus. The patient describes this as
sour and burning. Certain foods have a
tendency to increase the flow of HCl, while
others only in a very minor way call forth
the acid.
Foods causing diminished gastric flow.
Fluids: Ordinary water, tea, cocoa and
cream.
Spices : Table salt, 0.9% solution.
Solids: Raw tgg albumen, especially if
dissolved in water, the pure carbohydrates,
as sugar and starch, wheat bread, fats, well-
cooked meats, sauces without spices, fresh
fish, poultry, veal and pork. Cooked sweet
fruits, vegetables, as potatoes, rice, sago,
asparagus, spinach, cauliflower, and red
beets. Soups without extracts. Vegetable
soup, oatmeal and puree.
Use plenty of fresh butter and cream.
Foods causing increased gastric flow. Flu-
ids: All alcoholic and those containing
C02. as wine, beer, table waters, caffein
free coffee, skim milk.
Spices: All salt concentrations over
0.9%, mustard, pepper, cinnamon, paprika
and flavoring substances for soups.
Solids : All roast meats, hard boiled eggs,
raw, broiled or slightly cooked meats, the
dark meats, salted and smoked meats and
fish, meat extracts and meat soups, dark
coarse bread, toast. All vegetables unless
given in the form of puree.
Use little or no fat in preparing these
dishes.
We see here that we have certain foods
physiologically indicated, or, as the case
may be, contra-indicated in lesions of, or as
agents interfering with the physiology of
the stomach;
Ulcer of the stomach will thru its own
irritating qualities cause an increase in the
flow of gastric juice analogous to rare or
raw meats.
The motility of the stomach is augmented
by the presence of acid, causing the well-
described pain by the patient as gnawing,
which is satisfied by eating small quantities
of food and made worse when large quan-
tities are taken, especially if they are of
the contra-indicated kind.
In case of insufficient hydrochloric acid,
all such substances that require large
amounts or are digested in the stomach are
contra-indicated. Since it is the function
of the stomach to dissociate it seems rea-
sonable that all coarse vegetables are con-
tra-indicated, while all the finely prepared
substances are physiologically beneficial.
AN UNUSUAL CASE OF VENEREAL INFEC-
TION IN THE FEMALE.
Mrs. R. admitted exposure to infection,
presented herself with a well marked swell-
ing just inside the labia ma j oris on the left
side. There was no discharge from urethra,
vagina, nor ardor urini. The gland of
Bartolini was tender, but no fluctuation
could be elicited. A vaginal tampon was
inserted above the gland to prevent lateral
pressure, thereby adding much to the com-
fort of the patient. The tampon was re-
moved daily, followed by a hot douche.
After the eighth day there was percep-
tible softening with localized fluctuation.
The abscess was opened at its lowest point.
In the course of one week recovery had
taken place. About this time the patient
complained of sudden "gushes" of vaginal
discharges. Upon the insertion of a bivalve
speculiun the os uteri was seen to be exud-
ing a profuse, tenacious, yellow, muco-puru-
lent discharge. With a cotton swab a
smear was made and submitted to the labo-
ratory. The report was "a diplococcus, in-
tracellular. Gram negative, morphologically
typical of gonorrhea."
At no time was the urethra involved,
neither was there a vaginitis nor any phys-
ical discomfort beyond these "gushes".
Treatment. A uterine electrode was in-
serted into the body of the uterus ; twelve
hundred milliamperes were allowed to run
for thirty minutes from a diathermia appa-
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ratus. The patient was instructed to use
a hot vaginal douche mornings and eve-
nings. After the sixth treatment, the dis-
charge had almost ceased, and the electric
treatments were discontinued. The patient
continued the hot douches for another week
when she was entirely free from discharge,
and has remained so for the past four
weeks. A smear taken from the vaginal
walls proved negative as far as gonococci
were concerned.
Conclusions. This was a case of gonococ-
cal infection, with suppuration of Bartho-
lini's gland. There were no clinical signs
of urethritis nor vaginitis at any time, altho
we had a uterine canal infection with a copi-
ous discharge. Since the gonococcus dies
in a temperature of 104° F., diathermia was
employed in the acute stage of the disease
with a quick and perfect recovery. Neither
internal nor external medication was used
except the heat mentioned.
The Pituitary Gland in Epilefisyd — In a
recent issue of Archives of Neurology and
Psychiatry (Aug. 1, 1919), Tucker, of Rich-
mond, Va., in a paper on the Role of the
Pituitary Gland in Epilepsy, expresses the
opinion that he believed that convulsions,
whether pathologic and called epilepsy or
otherwise, were symptoms of underlying
diseased conditions, and therefore were or-
ganic and not functional. Among these un-
derlying conditions was a secretion of the
pituitary gland. He agreed with Gushing
that the pituitary secretion gave a substance
which had to do with cortical cell stability,
and that when the secretion was diminished
or absent convulsions might ensue. Hypo-
pituitarism was divided into two types:
First, the congenital or chronic type, in
which the patient gave evidence in the past
of the usual syndrome of the hypopituitar-
ism, and might have convulsions as he ap-
proached adolescence. The second, or trans-
itional type, might present clinical evidence
of normal or even hyperpituitary secretion
in the past, but as adolescence approached
diminished secretion was shown by lack of
perspiration, increase in fat, increased sugar
tolerance, slowed pulse, lowered blood pres-
sure, and at times convulsions. The radio-
graphic findings in the cases reported con-
firmed the clinical observations. The first
type showed a small fossa with enlarged
processes and roughened sella, and the sec-
ond type enlarged fossa with large processes
and roughened sella. These bony out-
growths encroached on the fossae. A num-
ber of cases was reported and the satisfac-
tory result of pituitary feeding was shown.
Blood Regeneration and Bone Marrow
Activity. — ^Altho the length of life of the
red cells of the blood is still unknown, there
is no doubt, claims an editorial writer in
the Jour, A. M. A. (Aug. 16, 1919), that
they undergo disintegration sooner or later.
Sometimes their destruction is hastened by
disease ; sometimes the erythrocytes are lost
to the body thru hemorrhage. It becomes
important at times, therefore, to learn to
what extent reparative processes are taking
place and whether red cells are being re-
turned to the circulation. Microscopic ex-
amination of the blood during rapid regen-
eration of the erythrocytes reveals the pres-
ence of nucleated forms. Nucleated red
cells have therefore been taken as "an in-
evitable feature of rapid blood regenera-
tion." As Macleod has pointed out, how-
ever, changes in the mode of red blood cell
formation may be responsible for the nucle-
ated forms.
Some time ago Warburg showed that
whereas normal human blood consumes
very little oxygen, blood such as that of
birds, which contains nucleated erythrocytes,
may evince a high oxygen absorption. Mora-
witz has observed, however, that even in
mammals blood obtained during the regen-
eration following an anemia may show an
absorption of oxygen that cannot be ac-
counted for by nucleated cells or by sub-
stances possibly dissolved in the plasma.
The explanation seems now to have been
furnished by Harrop of the Medical Glinic
at the Johns Hopkins Hospital, Baltimore.
Starting with the assumption that the red
cells in the blood which appear reticulated
after certain methods of histologic staining
are "youthful erythrocytes," Harrop has
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found that blood which contains abnormal
numbers of them has an oxygen absorption
proportional to the percentage of reticulated
cells present. These two factors are interde-
pendent ; according to Harrop, both are due
to the presence of abnormal numbers of
youthful cells and both are probably rather
accurate indicators of ftmctional regenera-
tion in the bone marrow and of the amount
of blood regeneration. According to this
latest American research, normal mature
human erythrocytes have no oxygen con-
sumption measurable by present methods.
Furthermore, when it is measurably in-
creased in the blood of individuals with
anemia, the oxygen consumption has no di-
rect relation to the severity of this symptom,
and no constant relation to histologic ab-
normalities in the erythrocytes other than
increases in the number of reticulated cells.
A large proportion of all the non-nucleated
red blood cells in the bone marrow is re-
ticulated. Accordingly, the increase in the
number of these forms, along with increase
in the hemoglobin of the blood and a greater
oxygen consumption thereby, is indicative
of increased activity of the bone marrow.
Irritable Heart. — Satterthwaite writ-
ing in Therapeutic Gazette, (May, 1918)
says that according to Bram (N. Y. Med,
Jour,) patients with thyroid disease are
amenable to non-surgical treatment in 75
per cent, of all cases. He uses quinine hy-
drobromide, iron, arsenic, phosphorus, and
the suprarenal gland.
On the other hand, in such instances
some recommend the X-ray or radium. The
consensus of opinion appears to be, how-
ever, that while their action will at times
be beneficial, they may aggravate the symp-
toms. The X-ray has caused death. All
agree that rest and hygienic treatment
should precede any form of treatment that
may be dangerous to life.
As to operative measures, it should be
remembered that other ductless glands are
apt to be involved, so that the removal of
the thyroid or any part of it may fail to
reach the source of the disease. In case
there is an associated thymus disease, as
shown by the peculiar nodular growths in
the mucous membrane of the upper air
passages, or in the skin of the nose, with
or without symptoms of obstruction, there
is call for the removal of the thymus or a
part of it.
It is manifestly important, therefore, in
cases of irritable heart, to examine for the
symptoms of disease of the ductless glands,
so as to institute the proper remedial meas-
ures.
Pituitary Treatment in Female Dis-
eases.— Dalche (Revue Mens, de Gyne-
cologie et d'Obstetrique, May, 1919) dis-
cusses the use of pituitary by the mouth,
preferring the dry extract of the whole
gland in doses of two to four cachets a
day of 0.10 gm. each. This treatment can be
applied in every case of metrorrhagia, and
it often will give good results. But success
depends on its being kept up perseveringly
for weeks and months with bleeding fibro-
mata, diffuse fibromatosis and sclerosis of
the uterus, retrodisplacement with conges-
tion, virginal metrorrhagia, intermenstrual
dysmenorrhea — whenever, in short, the aim
is to modify a condition of long standing.
For example, a young girl with too frequent
and too profuse menstruation should take
the pituitary extract every day for a month,
then for two weeks each month, beginning
the week before the anticipated menses and
continuing till the close. The other two
weeks he orders 10 drops of tincture of
hamamelis in a little water before the two
principal meals. In case of a fibroma he
alternates the two pituitary weeks with other
organotherapy, and may conclude with
roentgen treatment. Congestions and exces-
sive functioning of the ovaries or thyroid
may likewise benefit by pituitary treatment,
as also certain types of headache, even those
suggesting false brain tumors, with exacer-
bations at the menstrual periods. It seems
in these cases as if the endocrine upset had
induced congestion in the pituitary body and
that this congestion was what causes the
headache. The action of pituitary treat-
ment is not restricted to the genital organs ;
it may attenuate and suppress the hot flushes
and sudden sweats of the menopause and
other symptoms of ovarian insufficiency. It
seems to promote sleep, appetite and diure-
sis, and combat asthenia.
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ETIOLOGY AND DIAGNOSIS
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ETIOLOGY
j|piAfiNn.<;f
The Diagnosis of Acidosisr— Much has been
written on acidosis, says a writer in Modem
Medicine (May, 1919), but apparently the need
for more and continued instruction still exists.
Macleod gives a fairly complete readable dis-
cussion of the present status of this illusive
phenomenon. In particular he calls Attention
to Sellards' simple test, viz.^ under normal con-
ditions only five grams of sodium bicarbonate
can be taken a day without making the urine
alkaline. When the alkaline reserve, however,
is seriously depleted, that is, when acidosis
exists, large quantities of bicarbonate, even as
much as 100 grams a day can be taken without
making the urine alkaline. This test has been
found of particular value in the diagnosis of
acidosis accompanying certain forms of renal
disease. He concludes that Sellards' method is
no doubt the best test of acidosis at present
available in routine clinical work.
Tabercolln in Diagnosis. — Bergmann
(Deutsche medizinische Wochenschrift, Jan. 16,
1919) argues that it is possible with the tuber-
culin test to distinguish between inactive tuber-
culosis which is on the point of flaring up and
tuberculosis which is slumbering. For exam-
ple, a man with indecisive lung findings has
slight fever. If the titrate^ skin tuberculin
reaction is positive, then he had better be kept
under close observation. If it is negative, then
the fever must be due to other causes.
Carcinoma of the Gall-Bladder^— Gallstones
are an important item in the etiology of car-
cinoma of the gall-bladder. Deaver (Med. Rec-
ord, July 12, 1919) says that in line with modem
preventive measures it becomes a vital neces-
sity to prevent if possible the formation of gall-
stones, or failing this, to avoid the possible
consequences which the irritation of their pres-
ence may cause and remove not only the gall-
stones but the primary source of infection that
has given rise to their formation.
Bronchial Asthma«— Bronchial asthma is sup-
posed to be in part the result of the sensitiza-
tion of the patient to the proteids of bacteria,
foods, and miscellaneous substances, according
to Thro in N. Y. Med. Jour. (Mar. 22. 1919).
For example, Walker states that in his series
of patients studied fifty-five per cent, were sen-
sitive to some protein and the non-sensitive were
probably due to chronic bronchitis, cardiorenal
complications, or emphysema. By some investi-
gators it is thought to be a straight infection
with bacteria. Hay fever, which is, as is well
known, closely related to asthma, is supposed to
be due to sensitization to the pollen protein of
certain members of the vegetable kingdom. This
has been proved experimentally by Koessler.
Urticaria, eczema and angioneurotic edema are
likewise supposed to be due in part to sensitizap
tion to various proteids.
Recent investigations have thrown some light
on that obscure condition called bronchial asth-
ma, with the profitable result that such investi-
gations have led to the alleviation of the symp-
toms of this distressing disease in a number of
patients. While speaking of therapy it is hardly
necessary for me to add that before the patient
is treated for bronchial asthma it must be as-
certained that the symptoms are not due to
cardiac, renal, pulmonary or pituitary disease.
Due. consideration must also be given to the
idea advanced by Pottenger, as to the rela-
tion of the vagus to the disease. Recent inves-
tigations have added confirmatory evidence to
the statement made by Meltzer and Wolft-
Eisner that asthma is to a great extent a man-
ifestation of anaphylaxis or allergy. It was
found, that in the lungs of animals that had
died of anaphylactic shock, there was a con-
traction of the bronchioles and it is sup-
posed that a similar condition exists in the
asthmatic spasm. The nerve center controlling
the muscles in the bronchioles in asthmatics
is in a state of unstable equilibrium. These
ideas are more acceptable than the idea that
asthma is due to a congestion of the mucous
membrane in the lungs.
REATMENT
The Prevention of Inflnenial Pneumoniae —
The following exceedingly interesting and sen-
tentious communication by Dr. J. M. W. Kitchen
appears in the Medical Record (April 19, 1919).
"Notwithstanding the natural medical antipa-
thy to advocating anything: new in the way of
treatment that is not backed by accepted theory,
I venture to offer a suggestion in view of the
widespread acknowledged helplessness in pre-
venting pneumonia complicating infiuenza.
I studied medicine because of an inherited
tendency to many repetitions of attacks of
bronchitis. I probably have had at least two
attacks a year ever since I can remember, many
of which have been of infiuenzal origin, and in-
numerable threatening congestions. When I
was a very young man, the late Professor
Loomis wrote me a prescription containing
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TREATMENT
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553
opium and . Hoffman's anodyne. In the course
of years I have modified the excipient with an
apparent energizing influence in the sum-total
effects secured. I have never had my pharma-
cist make up the prescription given below, pre-
ferring to produce the effect of my own com-
pounding. I have all the constituents made for
me separately, and I do the compounding. It
requires a period of holding and blending to
secure the best result. There is no question
tbat my life has been prolonged by this medi-
cine.
The most attractive theory I have read as to
tbe causation of pneumonia complicating in-
fluenza is that the intensity of action in the
larger air passages and the character and
amount of the mucoid product act, thru gravita-
tion downward, to clog the air cells, and hence
incite the pneumonic process. If this is so,
why not do as I personally have done hundreds
of times to myself, and secure sufficient sedation
of the respiratory tract to moderate at least the
Intensity of the morbid action, and frequently
entirely stop it? It seems probable that the
same influence which relieves pain and dis-
comfort also depresses vital activity in the in-
vading bacteria, as well as in the cells of the
mucosa. Hoffman's anodyne of the best makes
is soothing, and is nearly all exhaled thru the
respiratory structures. In some cases it is the
only agent that will go directly to and favorably
affect the smaller air passages. In my bad at-
tacks I also use active counterlrritatlon. Cam-
phorated oil on the nose externally is the best
'cold in the head' remedy that can be used.
Mustard pushed to even a blistering effect, ap-
plied at various areas of the chest, is vastly
helpful. Breathing cool air, but not so cold as
to be irritating, is also helpful Usually if
enough of the sedative is given, circulatory ac-
tivity is sufficiently repressed, without requiring
rest in bed. The late Dr. Alonzo Clark used to
commend to the consideration of his classes the
maxim that 'Ck)d shall be feared and the in-
testinal tract be kept patent.' He also used
opium for peritonitis with beneflcial results.
I submit the suggestion for what it may be
worth. Light attacks may not kill when severe
ones would. It may be worth trying somewhat
extensively. The prescription follows:
^ Grams
Tinct. opii 4
Spts. aetheris comp 17
Glycerinl 32
Syr. pruni virg 32
Syr. toluUni 21
Syr. picis 10
Syr. glycyrizce 10
M. Sig.: Teaspoonful every three or
four hours.
This formula costs too much to permit its
being used as an advertised nostrum; but if
some manufacturing pharmacist could hit the
knack of compounding it so as to secure the
right effect, it could be dispensed under medical
direction. After all, the profession will ulti-
mately be called on to direct the consumption
of all narcotics and stimulants."
Management of Constipation Among School
Girls*— Brydon (Virginia Medical Monthly,
June, 1918) calls attention to the frequency of
constipation among otherwise normally healthy
school girls, and ascribes it to flve causes, viz.,
dietary indiscretions, insufficient exercise, in-
sufficient ingestion of fluids, lack of regularity
in defecation, and cathartic drugs. The flrst
of these consists in the ingestion of enormous
amounts of sweets, pickles, crackers, and other
prepared foods looked upon as a necessary ad-
junct to the monotonous school fare. Most of
this material is readily assimilated and lacking
in residue. In the treatment, a list of foods
rich in cellulose is given, viz., cabbage, toma-
toes, onions, spinach, corn, string beans, lettuce,
cucumbers, asparagus, wheat and rye bread,
and the coarser cereals, oatmeal, corn meal,
and hominy. Bran is a valuable help and
should be used as an addition to cereals, breads,
etc. Some fruit should be taken at each meal,
if possible, and before retiring. To be avoided,
in a general way, are excess of eggs or milk,
sweets, pastries, nuts, cheese, crackers, new
white bread, hot bread, toast, macaroni, rich
stews and gravies, most chafing dish products,
condiments and soda fountain drinks. The
reasons for these dietetic recommendations are
carefully explained. As regards lack of exer-
cise, most girls, in spite of having gymnasium
work twice a week, lead almost sedentary lives.
A half hour walk, covering a certain distance,
must be added by the girl patient in her daily-
schedule. Invariably these patients do not
drink enough water. The necessary corrective-
suggestion is best effected in the form of ques-
tions, bringing out the fact that the body loses
twelve glassfuls of water a day, while the fluid
in solid foods only makes up about four. Ir-
.regularity of defecation is overcome only by
impressihg the proper mental attitude on this
point on the patient. As regards drugs, their
dangers should be explained as impressively as
possible, and the girl required always to report
if she needs a laxative, as well as at regular in-
tervals. In those already inured to the laxative-
habit cascara is given, three minims three times
a day, increased one drop daily until a good .
daily movement results, then reduced one drop
daily to complete cessation. Suppositories,,
enemas, abdominal massage and calomel are to
be avoided.
The Value of Teast In Oastro-enterltls. —
Yeast has been used in the treatment of gastro-
enteritis of adults and infants by Drs. Thier-
celin and Chevrey (Rev. de therap. med.-che.
1899, pp. 797-803) with marked beneficial re-
sults. They gave a suspension of yeast to
children by rectum, 2 or 3 times a day after the
rectum had been washed out. The children
were held by the nurse in such a position that
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TREATMENT
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they could not expel the suspension. Food was
withheld until the fever fell.
Cures of chronic gastro-enteritis were treated
the same way. In one case of dysenteric diar-
rhea (in an adult) that had resisted other treat-
ment for more than a month, the remedy was
used with success within 48 hours after first ad-
ministration. The adult cases were given yeast ■
by mouth as well as by rectum. (One case in an
adult was a case of muco-membranous enteritis,
which improved very much under yeast treat-
ment.)
It stands to reason that yeast will exert a
greater influence on the gastrointestinal tract
when it is given by mouth than when it is given
by rectum alone. Yeast also has a beneficial
effect on infants with gastro-enteritis when it is
given by mouth. This is shown to advantage
in the results obtained by Sittler in the
treatment of infants with gastro-enteritis with
yeast by mouth (Munch, med. Wochenschrift,
1906. No. 63. pp. 1761-1762). Sittler's plan was
to cut out milk from the diet, to substitute
weak tea or albumin water and gradually to
work up to heavier preparations. The yeast
was given in sweetened water. When necessary
the bowels and the stomach were irrigated and
other medicines were employed. Under yeast
treatment the odor of the stools became less
objectionable, and the number of stools was
diminished. Vomiting soon ceased. In some
cases a cure was obtained when yeast alone was
used. In other cases yeast had a beneficial
effect when calomel, bismuth, or irrigation had
not produced satisfactory results. The weakly
acid reaction of the stools favors the action of
the yeast. In one case only did the diarrhea
become worse under yeast treatment. The treat-
ment can be satisfactorily combined with the
administration of bismuth or tannalbin.
In a more recent publication Sittler investi-
gating the stools of infants has determined that
yeast with lactic acid and lactic acid bacilli
favors the growth of the bacillus bifldus (a
favorable organism) in the stools. He states
that treatment with yeast, lactic acid, and lactic
acid bacilli may be combined to advantage with
treatment with the astringents.
The Rapid Care of Scarlatina.— Mangitta
(Oiomale di Medicina Militare, Jan. 31, 1918)
describes his treatment of scarlet fever with
a combination of chlorophenol, quinine and
camphor. Two injections are sufficient in a
case of moderate severity, twelve to twenty-four
hours apart, given preferably intramuscularly
in the gluteal region. Every feature of the
disease is ameliorated and the course aborted.
Mangitta considers that this method changes
the treatment of scarlet fever from a passive to
a markedly active one, and reports in detail
seven cases to support his assertions. A marked
feature of this method is the almost immediate
subjective feeling of well-being, with a rapid
drop in temperature.
Some Cllnieal Aspects of the Recent Influ-
enia Epidemic*— The epidemic thru which we
have% recently passed says Eshner (New York
Med, Jour., Feb. 1, 1919) was noteworthy for
the relative rapidity of its invasion, the wide
extent of its distribution and the comparative
suddenness of its decline. It seemed compara-
ble to a conflagration that burned flercely until
it had consumed the inflammable material with-
in its sphere of action. About eight per cent,
of the population was attacked by the disease
according to the author, with a mortality of be-
tween eight and ten per cent. Many mild cases
were given scant or no attention. As with in-
fectious diseases in general the prevalence was
greatest where congestion was densest and hu-
man intercourse most intimate. It seemed as tho
adults between twenty and forty suffered most,
altho children by no means escaped, while old
persons were attacked in smaller number.
Negroes appeared to exhibit little susceptibility
to the disease. The number of pregnant wom-
en attacked was striking, altho the proportion
may not have been excessive. The association
was not a happy one. The exact nature of the
disease will have to be established by the bac-
teriologists.
Clinically the disorder took the form of an
acute infective process of which the respiratory
apparatus bore the brunt in the vast majority
of cases. The onset was in general insidious
rather than abrupt, with chilliness, commonly
repeated in the course of the attack. Backache,
headache and general pains of varying degree
of severity were early symptoms. The tempera-
ture course may fairly be described as erratic,
and did not always bear a direct relation to the
severity of the other symptoms. Sometimes it
was high (105") in an apparently mild case,
while it might be moderate in the presence of
conditions that seemed grave. Again it would
fluctuate widely in the course of even a few
hours. As a rule it subsided within a few d^ys.
to rise again after an afebrile interval. Not
rarely it ascended again from several to many
days after the attack had apparently come to an
end, eventually declining by lysis, sometimes
over a protracted period.
In some cases there was coryza. Nosebleed
was not uncommon and at times profuse and re-
peated. In almost all cases there was cough,
altho not always at the beginning. Often this
was most obstinate and distressing, interfering
with sleep, at times from its violence productive
of severe pain in thoracic and abdominal mus-
cles, and in some instances inducing vomiting.
In many cases there was persistent complaint
of a sense of rawness of the throat and behind
the sternum. Expectoration was often difficult,
yielding a small amount of tough mucus. Quite
generally the sputum was blood-tinged, often
resembling watermelon juice, at other times ^e-
ing rusty, and in some instances consisting al-
most wholly of pure blood. Not rarely there
was sharp pain in the chest, aggravated by
breathing or other movement. Frequently
there was dyspnea, at times of great intensity
and occasionally attaining to the degree of a
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555
veritable air hunger. Cyanosis was common
and in some instances quite pronounced. The
appetite usually was impaired, at times wholly
lost. Nausea was common and vomiting fre-
quent. Usually me bowels were constipated.
As a rule sleep was disturbed, often to a marked
degree.
In most cases urinary excretion appeared to
be normal, but in a number of instances the
amount voided was markedly diminished and in
some instances there was total anuria for as
long as twenty-four hours and more. There
was little Opportunity to examine the urine dur-
ing the course of the attacK, but examinations
made at later periods failed to disclose evi-
dences of nephritis. In one case there was
hematuria.
Sweating was a noteworthy and almost dis-
tinctive feature, and it could not always be at-
tributed to the medication. In some cases it
appeared early and was repeated thruout and
even beyond the duration of the attack. Not
rarely it was quite profuse and patients fre-
quently were literally drenched in the transuda-
tion. Delirium occurred frequently and some-
times was quite active. Some patients in this
state got out of bed despite attempts at re-
straint and walked into the street in their bed-
clothes and thus t>recipitated a fatal issue. One
case presented symptoms of meningitis and
after apparently responding to treatment the
patient died finally after many weeks. In some
cases depressive psychoses followed in the train
of the disease. Naturally there was, as a rule,
considerable loss of weight, and the ensuing
debility lasted for a considerable period of time.
In mild cases the disease came to an end in
from three to five days. Sometimes this period
was followed by a remission or intermission,
upon which a second febrile period developed.
In this interval many patients were tempted to
get up from bed, with resulting intensification
of the previous symptoms and aggravation of
the general condition. Also this period not
rarely marked the onset of symptoms of pneu-
monia.
The physical signs with reference to the lungs
were extremely variable. In some even when
the sputum was blood-tinged the physical evi-
dences of pneumonia were not conclusive be-
yond peradventure of doubt; nor did the sub-
sequent course of the disease bear out the sus-
picion of pneumonia. In many cases there were
slight or more extensive areas of impaired
resonance in one or both lungs, with roughened
or bronchial breathing, while in a smaller num-
ber there were the percussion dulness, the
bronchial breathing, and the bronchophony of
lobar pneumonia, often associated with the fric-
tion-rub of pleurisy and at times with the
egophony of an effusion. In some cases the two
forms of pneumonia appeared to be associated.
Tinnitus aurlum and impairment of hearing
were observed in a number of cases, in some ap-
parently unrelated to medicamentous ori^n.
The absence of articular and cardiac complica-
tions, endocardial and pericardial, was note-
worthy. The foregoing statements are based
on observations made in some 400 cases, all seen
In private practice.
The Influence of the War on Medicine.— The
Great War has shown the value of team work,
specialization, antiseptics, new methods of treat-
ing wounds, fractures and shock; better methods
of killing parasites, particularly the terrible
louse; and added emphasis has been given to
the importance of sanitary measures looking
to the prevention of typhoid and other filth
diseases {Canadian Jour, of Med. and 8urg,,
May, 1919).
Fine progress has been made in the treatment
of wounds of the heart and lungs. The lesson
of early investigation, by operation, of wounds
penetrating the abdominal walls has been
learned. The treatment of the various war
neuroses underwent considerable change during
the progress of the war — for the better.
In how far Dakin's solution, Wright's salt
solution, Morrison's Blpp, and Di-chloramlne T
will supersede bi-chlorlde, carbolic acid, and
iodine in the treatment of infected wounds, re-
mains to be seen.
Marked advance has been made In orthopedic
work and in plastic surgery, particularly of the
face in all its parts.
Much good work has been done in lesions of
the central and peripheral nervous system, and
added light has been thrown on many mental
conditions.
We hope that many of our fighting brethren
found time to make notes of their more inter-
esting cases, and that they will elaborate these
notes, and that from time to time they will be
published in the medical press for the benefit
of the profession at large.
Some Things to Bemember About Robber
Gloves. — First. They are perishable articles
and costly.
Second. The life of the glove can easily be
shortened by Just a little every-day carelessness.
Third. Before a nurse is given any respon-
sibility about the care of rubber gloves, she
should be Instructed as to the cost, the proper
way of putting on and taking off gloves, proper
methods of sterilization, etc.
Fourth. Teaching what not to do in hand-
ling rubber gloves is important.
Fifth. Experience has shown that the life of
the glove is prolonged by sterilizing by boiling
in water as compared to sterilization by steam
under pressure.
Sixth. Grease and oils cause softening of the
rubber.
Seventh. The general care which a nurse
gives to gloves when not In use — before and
after operation — has almost as much effect in
determining the length of life of the glove as
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NOTES AND ANNOUNCEMENTS
AlCBRIGAN MBDICINS
i
the wear and tear given by the surgeon. If
gloves are wet before removing from the hands
they are less likely to tear.
Eighth, The best way of ptittlng a patch on
rubber gloves should be known by every nurse.
Ninth. Uses for worn-out rubber gloves should
be demonstrated to nurses early in their course.
An ingenious operating room nurse found a
dozen ways of utilizing the rubber in the glove,
after its days of usefulness in the operating
room were over.
Tenth. Every nurse should be able to write
a concise complete answer to the following
questions: What are rubber gloves used for?
How should they be prepared for use? What
special points about rubber gloves should a
nurse observe before, during and after opera-
tion?
A pad for protecting the eyes during anes-
thesia was made of cotton, covered with rubber
cut from the back of a glove, the cotton and
rubber being sewed together.
A cover for a saline flask.
Rubber bands of varying widths cut from
fingers of rubber gloves have found many uses
in the hospital.
Protectors for wide-mouth bottles containing
surgical dusting powder, also for test tubes.
Finger-cots of varying sizes may be secured by
cutting oft the fingers of rubber gloves which
are no longer useful in actual surgery.
Strip can be cut for subcutaneous drainage
to be used instead of gutta percha or rubber
dam.
Patches for mending gloves and bath caps,
also hot water bottles.
A protector for a gall-bladder drain. Lastly
the pieces left are collected and sold as "old
rubber." — The Trained Nurse, May, 1919.
Incompatibility of Quinine and Aspirin*— Dr.
Saenz de Santa Maria Y. Marron, writing in
El Siglo Medico, and quoted by the Medical
Record, relates that during a year's experience
in the use of aspirin he has learned that the
combination with quinine is an undesirable
one. In giving remedies in combination we ex-
pect synergism in action, a result superior to
that obtained by uncombined use. Failure to
obtain a heightened effect is itself sufficient to
do away with the combination. But in such
combinations we may get failure of a higher
tjTJe — either refusal of one remedy to act or
else actual untoward result. of some kind. The
writer states that his expectation was often de-
frauded, and cites examples. There was one
patient who was getting 25 cgms. of each drug
three times daily, and who showed on the fol-
lowing day a severe tachycardia, restlessness
and adynamia. The case was one of Influenza,
In which in the author's experience, the heart
frequency is by no means unduly great, by
reason of some action by the grip toxin on the
vagus. The possibility of an Idiosyncrasy was
dashed by noting analogous behavior in a series
of other cases. The problem was taken to the
pharmaceutical laboratory, and the evidence
appears to show that under the catalytic action
of aspirin in the stomach or blood the quinine
was changed to a toxic derivative which was
termed quinotoxin. This latter, an insomer of
quinine, appears to be known to chemists, and
it has the reputation of being able to cause
death. The brevity and vagueness of the
article prevent a complete visualization of the
author's notions on the subject, but he is op-
posed to polypharmacy on the principle that
while one remedy may potentize another in
some cases, there is also a danger that one
remedy can denature another into a toxic sub-
stance. The lessons are plain, for every al-
leged synergistic combination must have this
possibility excluded before use on man. and new
substances must not be carelessly mixed with
old ones.
HEWS NOTES "»
ANNOONCEMENTJ
A School of Occopatloiial Therapy.— The
first number of the Bulletin of the St. Iiouis
School of Occupational Therapy is being dis-
tributed among those who are likely to spread
the knowledge that instruction in occupational
therapy is being systematically conducted in
St. Louis. The course will prepare students to
teach occupational therapy to physically and
mentally handicapped, and convalescents in
public and private institutions, and to meet
the demand of the government for reconstruc-
tion aides in military hospitals so long as that
need exists. The next class opens September
16, and includes sixteen weeks of craft work
and twelve weeks of hospital practice. The
cooperation of the Barnes Hospital, the City
Hospital, and the City Sanitarium offers ample
opportunity for practical instruction. This is
a splendid opportunity for young men and
women with a high school education and the
instinct of helpfulness to enter a field that will
prove congenial and profitable.
Medical School in China Opens. — The Peking
Union Medical College, Peking, China, which
has been built under the direction of the Rocke-
feller Foundation, will open for the instruction
of students in October, 1919. The college will
give a four years' course in medicine and an ad-
ditional year of special work in hospitals or in
laboratories. The school will be coeducational.
There is also a premedical school offering a
three years' course preparatory to admission to
the medical school. This premedical school was
opened in September, 1917.
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BNERI(MI£D1CINC
PUBLISHED MONTHLT
BdMorUl OtHommt 18 Bast 4l0< St.. If*w Tork City. PnbUeatioA OIIImsi 189 C*U«i«'S(.. BnrllaitoA, ▼<•
Oomptoto SarlM, YdL XXY. No. 0
Vtm Series, Yol. XIT. No. 0
SEPTEMBER, 1919
$2.00
TllBLT
In Utuoo
CONTENTS
Bdltortal
BfoB aad rnUiiffs
Oridnal ArttdM
Fftysleiil l&aFBpy
Ratkmal Orsanoikempy
Br*^K'i^a7B ABd Hlgkway
AjnooiT tke Books
OovreopondoBoe
Qtmerwd Topies .
Nows Noteo and
«71
B75
614
614
616
617
(OoBtlniMd OB PftffO i)
CONTRIBUTORS
B. 8. TALBOOY, M. Ji^ New York City.
GBOBGB DOW SCOTT, A. B« Bw 8.» H. D., Now
York City.
DATID M. VlAJPULN, M. D., Now York City.
PHUjIP OGINZ, BL D^ Brooklyn^ N. Y.
BICHABD HOONBB; VL D., Boston, MaBB.
'W. H. BAND, M. D., Waahinffton, D. C.
H. B. ANDE2B80N, M. D., Toronto, Canada.
BntoMd it ttooad-elAM nutter Janaaiy SB, 1906, •! ttio Foil Oftco al Barlington, Yk, onder Ael of Gonffrrat, lUioh S, 1879.
Hot Weather Skin Irritations —
notably chafing, prickly heat, sunburn and similar affections
—are promptly relieved by
K' Y Lubricating Jelly
Applied liberally to irritated or inflamed areas, the pronounced cool-
ing and soothing action of this ^ective local remedy is at once
manifest. ^ Smarting, burning and itching are quickly allayed and
local congestion is rapidly overcome. In ract, by its beneficial efFects
upon the skin, as well as by reason of its water-solubility, its abso-
lute freedom from staining skin or clothing, its non-greasiness and
the altogether unusual cleanliness of its character,
K^Y Lubrtcattng Jelly
is an ideal emollient
In oollapribla tubes at 25e.
Obtainable at all Drug Stoves.
Sample on rsqueat.
It relieves itchiog and burning when most ordinary rdiel
measures prove inefiFective.
NEW DRUNSWICK, N. J^ U.& A.
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V^ fteie ke anodier
qrilendc (rfinfloenza?
A RE we to hmre a recunrenee ol Am plague which diettroyed half a
JTwk milium Eves in this country a year ago> In all probabilily. yes.
A review of the records of previous epidemics warrants the
assumption that the scourge will reappear this fall and next winter.
In the event that this theoiy proves correct; how can fine medkal
profesnon cope vrith the disease?
Prophylactic vaccination is the rational imxedure. hi support of this
contention we cite two illustrations:
In one locality* during the recent epidemic, 3437 persons were
immunised vrith Influenza-Pneumonia Vaccine (Prophylactic). Of diis
number only six died, and Aese had but one injectioiL Among those
who received two or three injections there were no deaths.
In another locality 800 persons were immunized: 461 received one
inoculation, 224 received two, 95 received three. Only twenty cases oi
influrtn?gi developed among those who had one or more inoailatioiis.
But two deadis occurred, and these were of persons who had only one
inoculatioiL
As a prophylactic Ae vaccine is a^lministiwaJ in diree giadnated
doses at intervals of three oi four dasrs. The first dose is two mad on^
half billions (1/2 mil); the second, five billions (I mil); the third,i
and one-half billions (I 1/2 mils).
InfhienzA-Piieuinoiiia Vaccine
(Prophylactic)
Bio. 612. HiTM bulM 0/2 mfll I mfll I tflnukh
ooa prophylactic teeatmenL
Bio. 633. Throe ^yiinstt ( 1/2 mil, I milp I l/lnilt).
Bio. 634. One 5-mil TiaL
Bio. 635. One 20-mil viaL
We oommend diis vaociBe to die conaderation of physicians.
Parke, Davis & 0>mpany
DETROIT
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American Medicine
H. EDWIH LEWIS, M. D.. yfanrngiHg Editor
PUBUBHU) MOinHLT BT THB AMBRICAX MBDICAL PUBUBHUCQ COMPANY
CopfTlffhfted bj the Amtrican Medieal PobUsUnc Co., 1919
IRA 8. WILE, Associate Edtio*
Complete Series, Vol. XXV, No. 9
New Series, ^ '
, Vol. XIV. No. 0
SEPTEMBER, 1919
to no YEARLY
#^.UU In Advance
National Medical Licensure. — The fed-
eralization of service for war purposes of
more than 30,000 physicians revealed many
weaknesses in our methods of medical edu-
cation. The experience of the Army and
Xavy is suggestive of various inequalities
in licensure as practiced during the past
decades in the various states in the Union.
We have repeatedly called attention to the
necessity of a standardized examination for
medical practitioners thruout the United
States.
The National Board of Medical Examin-
ers seeks to conduct examinations, with the
assistance of state examining boards, for
graduates in medicine who are candidates
for licenses to practice medicine. Accord-
ing to Walter L. Bierring, Modern Medi-
cine, July, 1919, the certificate of the Board
is accepted for admission into the Army,
Navy, and Public Health Medical Service
without further mental examination. Prac-
tically two- thirds of the State Boards of
Medical Examiners "have already signified
their acceptance and endorsement of the
Board's certificate." This degree of pro-
gress Sfi most encouraging, and prob-
ably within the next few years, some of the
barriers will be broken down and a single
examination, held in various centers of the
country, will suffice to provide an adequate
test of the capability of those applying for
licensure.
The requirements for admission to ex-
amination by the National Board of Ex-
aminers, include a certificate from an ac-
credited four-year high school, two years
of pre-medical college work, including at
least one year each of chemistry, physics,
and biology, and a reading knowledge of a
foreign language, graduation from a so-
called Class A medical school, and one year
of interne service in an approved hospital.
The examinations thus far conducted pro-
vide for a short written examination in
various subjects, combined with a practical
test, the examinations covering a period of
six days with a Sunday intervening to pro-
vide for rest.
Endorsement of the Plan* — The plan
has been favorably reported by R. W.
Powell, Registrar of the Dominion Coun-
cil of Canada and Colonel Charles Dercle,
who represented the French Medical
Service in the Surgeon General's office, dur-
ing the period of war activities.
While thus far the National Board of
Medical Examiners has not been successful
in its aim to unify and standardize medical
examinations thruoUt the United States, it
has recognized the necessity of an interna-
tional standard of medical practice. It is
therefore seeking the endorsement of the
examining bodies of France, England and
Italy with a view to receiving their co-
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560
Sbptember^ 1919
EDITORIAL. COMMENT
American Mbdxcink
operation, and eventually arriving at an
international recognition of medical stand-
ards of American medical practice as rep-
resented by their plan of examination.
Certificates have been granted to those
who have given adequate evidence of their
capability in the theory of practice of medi-
cine thru the successful completion of com-
prehensive and essentially practical tests
covering medicine, surgery, obstetrics,
chemistry, physiology, clinical microscopy,
bacteriology, hygiene, applied anatomy and
the surgical specialties.
Considering that the National Board of
Examiners dates its origin to 1915, it is
patent that its accomplishments thus far are
fully commensurate with the importance
of this subject, considering the interference
with its development incidental to military
activities. While the original intention was
to hold examinations in Washington, cir-
cumstances have demonstrated the imprac-
ticability of this procedure, and efforts have
been made to hold examinations in the
larger medical centers, such as New York,
Chicago and Philadelphia, while during
1918 examinations were held at the Med-
ical Officers' Training Camps at Fort Riley,
Kansas, and Fort Oglethorpe, Georgia. It
would appear to be desirable to distribute
the centers of examination more widely, so
that there might be at least one center in
each state and territory of the Union. In
order to popularize the movement, it should
be made as practicable as possible, and be
well suited to the convenience of the young
men whom the National Board of Examin-
ers hopes to interest because of the advan-
tages to be derived by holding a single
license to practice, recognized thruout the
United States and probably Europe.
Some questions may arise as to the diffi-
culties involved in this plan, but the com-
plete success of the movement will be de-
termined by the facilities afforded those
desirous of taking advantage of the univer-
sal test. State reciprocity will gradually
follow the introduction of a type of exam-
ination which proves itself acceptable to
the various State Boards of Medical Exam-
iners. An incidental benefit will accrue
thru raising the standard of medical edu-
cation in those states willing to grant and
receive reciprocity because of the provision
for the graduation of applicants for na-
tional licensure from a Class A medical
school. Similarly, the development of a
fifth year devoted to interne service in an
accredited hospital will gain adherents, if
it be made an included item, imperative in
medical education previous to licensure.
Possible Objections. — No doubt consid-
erable objections will be raised because of
these two factors which should appeal to
these interested in the improvement of med-
ical education in the United States. The
ai)ol()gists for lower grade medical schools
and the appeals of those solicitous for the
welfare of the poor but honest graduate, for
whom a period of intemeship might prove
a hardship, are likely to interfere with the
rapid growth of a powerful sentiment in
favor of a single type of examination as
proposed by the National Board of Exam-
iners. Similarly, many will claim that
faikire will deprive an individual of the due
and proper rewards of time, money and
energy expended in securing medical train-
ing, regardless of the fact that the general
public deserves to be protected against those
who have gone to medical school for a full
period of time, and, because of low stand-
ards, have succeeded in passing examina-
tions, but who are, to all intents and pur-
poses, incapable of the efficient practice of
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AMERICAN Medici NB
EDITORIAL. COMMENT
Skptember, 1919
561
medicine. Naturally, there will be opposi-
tion by medical institutions, other than those
belonging to Qass A, unless they possess
the inclination and the funds to better their
plants, equipment, personnel, curriculum
and their requirements for admission so as
to be eligible to Class A.
Under the present plan, State Boards are
not necessarily omitted, and state authority
is still recognized for providing its own
standards for medical licensure. The cer-
tification of the National Board of Medical
Examiners, however, represents a form of
test and examination which is, in a sense,
supplemental to that generally given by the
various states, but is of such excellence and
value as to be accepted by the various State
Boards as satisfactory evidence of fitness to
practice within the State.
Certainly, while international recognition
is being sought, it should be possible for
the National Board of Medical Examiners
to secure the acceptance of their certifi-
cate thruout the United States and its pos-
sessions. To ask for foreign recognition
before it receives universal state sanction,
places the National Board of Medical Ex-
aminers in an illogical position. If Ameri-
can State Boards of Medical Examiners fail
to accept and honor the certificates issued
by the National Board of Medical Exam-
iners, it can scarcely be said in full truth
that there is any American standard for
medical practice.
Herein is an opportunity for State Med-
ical Societies to perform a constructive
piece of work thru agitating for the accept-
ance by their respective states of the plans
of the National Board of Medical Exam-
mers.
Arachidic Bronchitis. — Arachidic bron-
chitis is a formidable term which has been
introduced by Jackson and Spencer in dis-
cussing a special form of bronchitis due to
the aspiration of peanut kernels into the
lower air passages. (Journal of the Ameri-
can Medical Association, August 30, 1919.)
The accident giving rise to the condition
described is not so frequent, but the serious-
ness of the symptoms and their resemblance
to those of laryngotracheal diphtheria war-
rants fuller information regarding this dis-
ease state, most common during childhood.
The symptoms include dyspnea, restless-
ness, cyanosis, a distressing cough, often
paroxysmal in older children and associated
with the expectoration of a pinkish gray,
thick, tenacious, purulent sputum. Heart
rate and respiratory rate are usually higher
in proportion to the temperature, which
has an irregular septic type of course. An
asthmatoid wheeze is present in a large
majority of the patients. Aphonia rarely
occurs. Chest inspection usually reveals a
lessened expansion on the side of the
foreign body; there is impairment of reso-
nance to percussion ; and auscultation re-
veals a dimunition of the intensity or an
absence of the transmission of the breath
sounds. Loud, bubbling, sonorous and
sibilant sounds are heard thruout the chest,
often with the greatest intensity, however,
over the site of the foreign body. At times
marked dulness in the lower portion of one
side of the chest, together with the absence
of breath and voice sounds may be inter-
preted as evidence of a pleural effusion. A
roentgenogram is of great service in con-
firming the nature of the patholic condition,
even tlio the foreign body, the peanut, rarely
causes a demonstrable shadow.
The syndrome appears to be quite dis-
tinct. Some inherent factor in the peanut
makes it more irritating than other forms
of foreign body in the bronchi. The path-
ologic condition is so severe that, if not
properly treated, fatality may ensue or an
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Sbptbmber. 1919
EDITORIAL COMMENT
American Medicine
abscess of the lung develop. The progno-
sis is grave, unless the foreign body is re-
moved. If the peanut is extracted with an
early bronchoscopy, convalescence is usually
rapid. If dyspnea is very pronounced,
tracheotomy may be required to facilitate
the removal of the purulent secretions ; and
a bronchoscopic removal of the peanut thru
the mouth may be effected as soon as the
wound has sufficiently granulated.
The definiteness of the symptoms, to-
gether with their serious nature, forms suf-
ficient reason for giving particular atten-
tion to this type of bronchitis. It does not
constitute a new disease, but evidently rep-
resents a more or less particularized respi-
ratory affection due to some peculiarity in-
herent in the peanut, which serves to in-
crease the danger from its inhalation into
a bronchus.
The refinements of medical diagnosis de-
pend upon the investigation of details.
Large groups of affections are today clas-
sified under the generic terms which are
constantly being attacked with a view to
disintegrating them into their various com-
ponents. Bronchitis obliterans, for exam-
ple, undoubtedly contains a number of in-
dependent conditions insofar as etiology is
concerned, as do acute or chronic bron-
chitis. The report of investigations upon
special groups of cases reveals most valuable
information, as has been evidenced, for ex-
ample, in the special studies of industrial
poisons, such as lead, phosphorus and
TNT. ]Medical nomenclature may be
greatly enlarged thru the production of new
terms, but at least there will be clarity in
the terminolgy, together with greater ac-
curacy and definiteness. Arachidic bron-
chitis conveys a far more definite verbal
picture, insofar as cause and effect are con-
cerned, than does a term based merely upon
the patholog}' of the condition.
Lipovacdnet. — Prophylaxis, thru im-
munization, has demonstrated its efficacy.
There are numerous difficulties tending to
limit the practice of inoculation with bac-
terial vaccines. In order to obviate some
of the obstacles which have arisen, lipovac-
cines have been developed. E. R. Whit-
more, American Journal of Public Health,
July, 1919, points out that the fact of re-
peated dosage has served as a serious draw-
back to the use of bacterial vaccines, so
much so, that it is only where compulsory
vaccination is mandatory that one may
secure a hundred per cent, inoculation
where repeated dosages are required. This
difficulty is overcome by the use of a lipo-
vaccine, which is a suspension of bacteria in
oil that offers at one injection the entire
amount of bacterial material required. The
slow absorption of the oily suspension per-
mits the development and continuance of
the immunity reactions with results that are
eminently satisfactory, and with less reac-
tion than when multiple doses of smaller
amounts of bacterial material are injected.
Experiments tend to prove that the bacteria
in oily emulsions do not deteriorate during
long periods of time, and that a larger num-
ber of organisms may be injected at one
dose and that a more lasting immunity may
be secured because of this fact.
As a practical measure, it is patent that
inoculation with lipovaccines decreases the
inconvenience and delay from the vaccina-
tion, simplifies the keeping of records, and
facilitates vaccination against various dis-
eases without increasing the number of in-
jections over what has been the custom to
give, for example, in the triple typhoid vac-
cination alone.
Because of the slow absorption, the re-
action is not marked, and the likelihood of
severe reactions is immeasurably decreased,
a matter of considerable importance in con-
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American Mkdicink
EDITORIAL CX>MM£NT
Skptembkr, 1919
563
nection with the protection of an army or
of an industrial community, where absence
from work may result in loss of wages, de-
creased production, or both. The Army has
now adopted the triple typhoid lipovaccine
as its official vaccine, and experiments are
being continued on lipovaccines of the pneu-
mococcus, meningococcus and dysentery
groups.
It must not be forgotten that while lipo-
vaccines possess considerable advantage for
use in prophylactic inoculation, they are un-
suited for therapeutic uses wherein rapid
absorption is essential in order to promote
the desired curative reactions.
From the standpoint of economy in time,
money, effort and storage, as well as be-
cause of effectiveness, the lipovaccine prom-
ises to supplant the older and more widely
known bacterial vaccines suspended in
saline solution, for prophylactic purposes.
The greater ease with which prophylactic
inoculation can be secured, the wider its
sphere of usefulness and the greater likeli-
hood of its more general adoption. Lipo-
vaccines strengthen the hands of health offi-
cers who can provide for immunization thru
a single inoculation more effectively than
when multiple injections were required.
The summation of advantages is contingent
upon a larger experience with a wider
variety of organisms than has thus far been
employed for lipovaccines. At least, there
is great promise in this preventive agency.
Vital Statistics. — ^Vital statistics, long
regarded as the dryest form of human ex-
pression, gradually are being recognized as
possessing practical value. The investiga-
tions into *the cost of living are bringing
forth statistical material without end. The
fluctuations of gold, the frequency of ac-
cidents, the records of births and deaths, the
seasonal variations in rainfall, the chances
of tossing coins so that heads will appear
are expressed thru the use of charts, graphs,
curves and plottings to make prominent
the facts concerning them. Heights, weights
girth of chest, the circumference of the
head, the possession of Darwin's tubercle,
life expectancy, marriages, divorces, the
likelihood of twins are discussed with due
and proper recourse to statistical calcula-
tions. The presentation of technical papers
upon various phases of medicine and sur-
gery with statistics, true or unintentionally
false, are of frequent assistance in elucida-
ting the text and in driving home facts and
arguments.
Despite the value of utilizing statistics,
the average person fears, abhors or fails to
understand their significance or use. The
general feeling of many is expressed in the
^ ancient saying, "Figures do not lie, but liars
often figure." Even if liars were to figure,
their results would not constitute a statistic
in the truest sense of the word. Others are
wont to say that anything can be proven by
statistics— ^an equally false assumption.
Statistics is the name applied to facts ex-
pressed by figures. The method of utiliz-
ing these fact symbols permits classification,
comparison, correlation, generalization and
interpretation by the inductive or the de-
ductive method. It is imperative that the
forces of logic be brought to bear upon
statistics, but it is more important that the
recorded statistic itself be recognized first
and foremost as a fact. The falsifications
thru figures, which has cast doubt upon
many tabulations, have been due to failure
to deal with the hard facts as Gradgrind
would have demanded. With the posses-
sion of fundamental verities, the correct-
ness or incorrectness of interpretation must
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September, 1919
EJDITORIAL COMMENT
American Mbdicinb
necessarily depend upon the accuracy of
logical analysis or synthesis. Figures, them-
selves, do not tell a story. They are mere
fact symbols, whose meaning may be re-
vealed only by the application of intel-
ligence.
A knowledge of statistical method is
necessary in order to make classifications,
groupings or combinations of facts, them-
selves true, so that an end result will be
equally precise and accurate. The average
medical writer, utilizing figures, depends
for the most part upon the determining of
averages, the arithmetical mean. It is pa-
tent that generalization from small numbers
of facts is likely to possess numerous weak-
nesses. The reporting of a series of four
patients of whom two died, would give a
mortality of 50 per cent. To regard this
figure, however, as more than the index of
the experience of the particular reporter
would be manifestly unwise. Nevertheless,
medical literature abounds in statements of
mortality probabilities on the basis of such
an inadequate representation or group. It
is patent that had the series included six
and the mortality been two, the mortality
for the series would have fallen to 33%
per cent., or, if out of the four only one had
died, the figure 25 per cent, would have been
established for the mortality of that series.
It is only when large numbers are involved
that statistical figures aflford a reasonable
probability of accuracy in generalization.
It becomes more and more necessary for
medical men to acquaint themselves with
topics to which little attention is given in
medical colleges. It is practically necessary
for every worker in public health, the
municipal administrator or the worker in
industrial hygiene, to possess some famil-
iarity with vital statistics with a view to un-
derstanding their derivation, organization
and interpretation. It is impossible to
over-appreciate the increasing significance
of vital statistics as a basis of constructive
planning in public health work. The rapid
strides so recently made are merely indica-
tive of the tremendous growth that this
branch of social science will undergo under
the urge of the public for definite informa-
tion regarding the problems for which ap-
propriations are sought.
Unfortunately, a considerable proportion
of the profession still finds itself lost in the
maze of statistical charts, graphs, cartoons
and posters which have been devised for
illustrating and illumining the subject-
matter of campaigns for the protection of
public welfare. There is even a larger
proportion which finds itself incapable of
preparing material in such a manner as to
make it understandable to others. In a
sense, the employment of statistics is for the
purpose of aiding in the visualization of
facts. Some persons are incapable of
visualizing anything, and for them, vital
statistics possess unusual difficulties.
The end and aim of the statistical
method is to facilitate the understanding
of human life. It is a tool in the hands of
scientists interested in the generation, devel-
opment and death of human kind. Its ap-
plicability is general from the registration
of a single birth -to the complete enumera-
tion of the world's population in a universal
census.
Medical text-books abound in various
types of charts from those giving the facts
of temperature, pulse and respiration to the
more intricate diagrams illustrating the re-
lation between polynuclear leucocytosis and
septic infection, or to charts illustrating the
relative frequency of morbid conditions in
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AMBBIGAN MSDIOINS
BDITORIAL COMMCNT
SlCPTBMBBR. 1919
565
various sections of a commiinity. A work-
ing familiarity with practical clinical charts
has not sufficed to inculcate the full appre-
ciation of statistical procedure, and many
capable clinicians are embarrassed by the
numerical presentation of facts, only
slightly more complex than those with
which they are familiar. There is incom-
plete understanding of the doctrines of
chance and probability in connection with
medical problems. The mind that grasps
the statistical phases of medicine is more
able to grapple with problems of prognosis,
of recurrences of epidemics, of possibilities
of malignancy and of the chances of out-
come of various clinical practices.
Vital statistics form practically the
foundation of preventive medicine, and, as
such, merit careful consideration. It is un-
wise to call upon medical educational institu-
tions to adopt everything that is of service in
public health, because the curriculum, un-
fortunately, is not capable of infinite ex-
pansion. There is ample reason to believe,
however, that medical education is not to be
regarded as satisfactory, from the stand-
point of modern preventive medicine until
undergraduates receive at least three lec-
tures Upon the nature, criticism and inter-
pretation of vital statistics in their practical
application to public health progress.
Rural Health Organizatioiu — ^The prob-
lems of rural health education are of par-
amount importance. The wide distribution
of homes over large territories, the lack of
easy facilities for communication, a sparse-
ness of medical institutions create a prob-
lem entirely distinct from that existent in
urban communities or in closely grouped
village populations.
The recent study of Maternity and In-
fant Care in Two Rural Counties in Wis-
consin, Bureau of Publication, Number 46,
of the Children's Bureau indicates certain
lines of effort necessary to secure adequate
care during maternity and to lower the in-
fant mortality. It appears to be a strange
note to find that the safety of mothers and
babies demands primarily the building of
permanent and usable roads. The sugges-
tion is fraught with peculiar significance on
reading "none of the other needs can be
adequately met until such roads cover the
county so thoroly that no home, even a re-
mote hill farm or forest clearings shall be
a mile and a half — or even half a mile —
from a passable road." It is patent that
not merely transportation facilities are re-
quisite, but availability that permits home
visitation on the one hand, or recourse to
Centralized institutions as an alternative.
Those accustomed to living in sections of
the country where the good roads movement
has been highly developed fail to recognize
the serious problems that exist in various
parts of the United States due to a lack of
funds to provide proper road-beds, pass-
able and usable at all seasons of the year.
For the development of systems of visiting
nursing, home education and various types
of inspection, it is obvious that improved
roads are of paramount importance.
After roads are provided, altho the work
should not be delayed because of this short-
age, comes the provision of county public
health nurses, whose function it would be
to establish close relations with the homes
with a view to holding periodical meetings
for the purpose of exhibits and lectures on
topics connected with public health. When
possible, health centers should be organized
in villages or country schools where mothers
might find a central point for the intercom-
munication of ideas and for formulating
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EDITORIAL COMMENT
Amkbigan Mh>icins
plans of mutual help and interest, with the
improvement of health conditions as the
ultimate aim.
It should be possible, under state or
county auspices, to secure an examination
of all children, either in connection with
special celebrations in honor of infancy and
childhood, or as part of the routine work of
state exhibitions or fairs. As much atten-
tion should be given to the promotion and
betterment of the human stock as to the
development of commercially valuable
breeds of animals.
Within large territory, it is difficult to
have an adequate form of home nursing
unless several communities organize for the
support of a community nurse, who would
be available to help women and children at
time of sickness by affording them the
essential nursing. Such a plan would un-
doubtedly require the districting of a county
with a nurse assigned to each district. In
many foreign countries, it is part of the
responsibility of small districts to select
]>romising women and actually pay for their
education and training upon the condition
that they return to their own community for
their future work. This has found its
highest development, of course, in the pro-
vision for the training of midwives. Some
plan of this character might serve to pro-
mote the welfare of rural sections and in-
augurate a system of self-provision for
needs thus far unsatisfied.
The dearth of trained attendants or
practical nurses is peculiarly significant in
rural communities, tho it should be possible
to interest competent women with some
training and experience in the home care of
the sick to take up definite community work
under the direction of a central registry.
The practical phases of home nursing
should be under the direction of a district
trained nurse who would serve in a super-
visory capacity.
For emergency service, the cooperative
hospital, under the joint auspices of several
counties, is of the utmost importance; but
this agency could only function properly-
after the roads have been improved suffi-
ciently to permit the ready transportation
of the sick to the hospital, or the com-
munication of the hospital thru ambulance
or other conveyance with the home. Im-
petus in this direction has already given
rise to numerous improvements in rural
hospital service in the sparsely settled sec-
tions of Canada, where the Victorian Order
of Nurses is particularly interested in the
solution of this problem.
As a fundamental procedure, however,
the State Board of Health must take cog-
nizance of the situation and make the neces-
sary adjustments in its staff to provide for
a special division or officer charged with the
responsibility of promoting the health of
children thruout the state, with particular
stress upon the rural sections. A Bureau
of Child Hygiene, under state auspices,
offers a remarkable opportunity for effective
work in making provision for the health
care of women and children, particularly in
the rural sections, which are scarcely or
rarely reached by the infant and child wel-
fare activities increasingly developed by
municipalities.
The problem of the country doctor is of
growing importance. A realization of the
difficulties and obstacles of rural practice,
the necessity for medical omniscience, the
demand upon his time, energy and skill in
practical and theoretical matters fill his daily
life to such an extent that despite greater
sympathy with numerous rural problems,
there is scant opportunity to devise plans or
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American Mbdicinb
EDITORIAL. COMMBNT
Septbmbbr, 1919
567
to secure their fruition. Whatever redounds
to the benefit of the community advances
his welfare. The organization of state
schemes of heaUh education emphasizes the
importance of the family physician, and
leads to a greater respect for his ability, ac-
complishments and potentials. In rural
sections it cannot be denied that reducing
the impassability of roads, the introduction
of the public health nurse, the provision
of community nurses and the installation of
practical, supervised home agents would
enure to the advantage of the country
doctors. There would be greater security
for doctor and patient, an improvement in
the njedical service of the community and a
distinct advance in rural health conditions.
Pathology and Necropsies. — In a dis-
cussion on "The Relation of Pathology to
Practice," Journal of the American Medical
Association, August 23, 1919, Francis
Carter Wood calls attention to the tendency
of modem medicine to neglect pathology.
He concedes that the lack of interest in
pathology is largely due to faulty medical
instruction, due to the fact that the courses
in anatomy and histology are usually devel-
oped from the biologic aspects, rather than
as an aid to the understanding of pathologic
anatomy. He emphasizes the inadequacy
of teaching as the natural result of a lack
of necropsies. He points out the difficul-
ties that arise when the student, after com-
pleting the regular courses in pathology,
** falls into the hands of men instructing in
the clinical branches, who often know less
pathology than he does, impossible as the
fact may seem."
In a broad sense, pathology is a funda-
mental part of medicine, and should be
utilized in the theoretic and practical work
of including diagnosis, prognosis and treat-
ment.
MacCarty and Broders, Journal of Lab-
oratory and Clinical Medicine, August,
1919, suggest the value of pathologic sup-
ix>rt in ordinary diagnosis. The association
of pathologist and clinician strengthens the
work and judgment of each one of the
pathologico-clinical team. They suggest
various ways in which the clinical pathol-
ogist aids the clinician, and thus, directly
the patient. Obviously, gastric analyses,
bacteriologic and serologic examinations,
urine and blood examinations, and the study
of fresh tissues afford a weahh of informa-
tion, which may confirm a diagnosis, cor-
roborate a suspicion, cause reason for
doubting a diagnosis, or draw attention to
accessory pathologic conditions.
There is, however, a marked difference
in the possibilities of clinical pathology and
a basic pathologic study underlying the
practice of medicine. The ability, for ex-
ample, to understand the picture of a pul-
monary condition as revealed by inspection,
palpation, percussion and auscultation is of
far greater consequence than the knowledge
of the size, shape and color reactions of the
bacillus tuberculosis as recovered from the
sputum. The pathologic status of the kid-
neys, in an individual suffering from
nephritic edema, is of more importance than
a knowledge of the chemical reactions of al-
bumin and globulin in the urine. A visual-
ization of the alterations at the pylorus re-
sulting from carcinoma ventriculi is more
essential than the determination of an ab-
sence of hydrochloric acid or the presence
of Boas-Oppler bacilli. Even the deter-
mination of the Wassermann reaction does
not convey any picture of the pathology of
syphilis.
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SXPTEMBBR, 1919
EDITORIAL. COMMENT
Ambrican Mbdicinb
The tendency of the past few years has
been the overdevelopment of clinical path-
ology, with regrettably insufficient attention
to either gross pathology or pathologic
histology. As a result, the medical practi-
tioner is far more familiar with clinical
pathology and places a greater degree of re-
liance upon it in diagnosis than is desirable.
There is greater understanding of func-
tional disabilities of the kidneys as deter-
mined by dye excretion tests than there is of
the changes in the component parts of the
kidneys by reason of which the delay in ex-
cretion occurs.
The fault undoubtedly lies in the organ-
ization of the teaching of pathology in our
medical schools. There are only a small
group of medical institutions in the country
which aim to make pathology the hub of
medical teaching. The system of correlat-
ing pathologic and clinical medicine has not
been thoroly evolved, and, in consequence,
the real understanding of the alterations of
tissues is not closely associated with the
signs and symptoms revealed by medical
examination for purposes of diagnosis and
prognosis. The ordinary methods of teach-
ing clinical diagnosis fail to drive home the
importance of underlying pathology as the
reason for the alterations that are inter-
preted as clinical symptoms. The clinical
study of a typhoid patient might well be
supplemented by illustration of the various
pathologic lesions, gross and microscopic,
that are caused by the bacillus typhosus and
further attention given to these factors
when a necropsy of one who has died from
typhoid fever presents itself.
Essentially, an improvement in our
American system of securing autopsies is
required. A lack of interest, certain well-
known traditions and questions of sentiment
apparently are permitted to outweigh pro-
fessional interest. This leads to failure in
securing an opportunity to check up diag-
nostic skill and to understand the details of
the various lesions, some of which produced
symptoms, and were noted, and others,
which, while of profound importance, re-
mained undiscovered during life. The
proportion o'f necropsies which are obtained
in our large hospitals fail to be commen-
surate with the educational needs of the
staff and of medical students.
If pathology is to grow in this country
and post-graduate study is to be encouraged,
there is every reason to believe that the
first step to be taken involves greater inter-
est in the securing of autopsies, particularly
in those instances where scientific detail de-
mands them. The great body of medical
knowledge can be enriched thru a develop-
ment of post-mortem examinations. Cer-
tainly, this obtains most specifically in con-
nection with the medical education of un-
dergraduates and should present unusual
opportunities for post-graduate study, or
for the practical training and experience of
the general practitioners of medicine in all
parts of the country.
Mental Hygiene and School Progress*
— ^The schools are again open and the work
of education proceeds as of old, with pos-
sibly a little more stress to be placed upon
physical training, Americanization, voca-
tional education and the training of the
physically handicapped, thru special classes
for the crippled, the blind, the deaf and
those who are mentally defective.
The trend of modem educators reflects a
larger interest in the problems of psychol-
ogy and psychiatry. As has been true in
the case of the physical care of normal
children, great advances have come from a
recognition of the needs of those suffering
from physical defects. In a similar way, a
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EDITORIAL. COMMENT
September. 1919
569
recognition of the problems of the mentally
afflicted, or those with limited mental ca-
pability, has given rise to a large volume of
data applicable to the general educational
processes provided for normal children.
Physical training was virtually an out-
growth of the teaching of hygiene, partic-
ularly as related to the harmful effects of
alcohol and tobacco. While the teaching
probably had very little to do with the devel-
opment of prohibition, nevertheless, alcohol-
ism may be said to have been largely respon-
sible for the introduction of physical
hygiene into the curricula of public school
systems. Today, the development and ex-
pansion along this line have been marked by
the increased time, attention and thought
given to plays, games, recreation in general,
drills, athletics, gymnastic pursuits, together
with a small, and usually inadequately
taught, measure of hygiene in the class-
room. There has been a wide interest in
school hygiene, in the provision of sanitary
school houses, with adequate light, heat and
ventilation, with properly devised seats and
desks and blackboards. Some attention has
been given to text-books, with reference to
their proper printing and general typo-
graphical form along hygienic lines.
On the other hand, while physical hy-
giene has received marked cultivation, there
have been sad evidences of failure to grasp
the necessity of giving equal attention to the
general subject of mental hygiene. Pos-
sibly the schools are not to be blamed for
this, at least not nearly so much as should
be members of the medical profession, be-
cause the knowledge of the rules and prin-
ciples of mental hygiene have not been
widely known or appreciated. Insufficient
information concerning the subject has been
handed on to teachers in training, and, as a
result, they cannot be held sharply to ac-
count for failures in observing the rules of
mental hygiene. Some evidence, however,
of an awakening along this line is shown
thru the wise development of inquiring at-
tendance officers, visiting teachers and the
establishment of psychologic departments
in connection with public school systems.
Mast education is always difficult, and
the more crowded the classroom, the more
complicated becomes the problem for the
teacher and the less possible is it for the in-
dividual child to be recognized as any larger
unit of life than a part of a class. Hence,
it is not unusual for individual children to
develop faulty mental habits, or to manifest
symptoms of mental unrest, or even disor-
der, without attracting the notice that would
be given were he to limp or to be hard of
hearing.
Pollock, Boston Medical and Surgical
Journal, August 14, 1919, suggests that
"Mental indigestion is probably the most
prevalent cause of failure in school. The
remedy lies in preparing suitable food for
each child." Here, obviously, the presenta-
tion of the remedy depends upon a knowl-
edge of the digestive capacities of the indi-
vidual child. It is an appeal for individual-
ization in education. This is a subject con-
cerning which volumes have been, and may
still be, written without satisfactory results,
until some machinery is set in motion that
provides for the thoro physical and mental
examination of every school child. The
determination of the course of study for
most children is based upon the principle
that all children must be prepared for a col-
lege education and the subject-matter must
conform fairly regularly to the plan of
things which was long ago worked out by
colleges as essential for higher education.
These standards, however, were devised
when the bulk of college men were prepar-
ing for the ministry, and later, only slightly
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Skptembbr, 1919
EDITORIAL. CX)BiMENT
Ambrican MH>icuni
modified when a larger number of college
students elected to enter law and medicine.
Today, the standards are hopelessly false,
insofar as they may be said to bear no direct
relation to the vocational adaptation of the
bulk of our school population. This fact,
in itself, constitutes an indictment of our
interest in the mental progress of school
children.
One may speak of exercises, rest, en-
vironment and physical handicap as factors
in attaining proper mental hygiene, but
greater consideration must be given to the
innate mental possibilities of the child itself.
The determination of mental capacity is of
greater economic value than the search for
mental incapacity. That section of the
school population which represents the high-
est four or five per cent, is being notoriously
neglected, not merely in matters of educa-
tion, per sCf but in every form of mental
hygiene which would influence its mental
growth.
School tyttemsy as a whole, have failed
to act as tho they were cognizant of the
child with superior abilities. If the same
degree of thought and attention were
lavished upon the superior child that is now
given to the inferior child, the moron and
the high-grade imbecile, there would be a
remarkable growth and advancement in the
educational standards of our communities.
Mental hygiene demands that the mind have
an opportunity to function to its maximum
potential. The social gains that would ac-
crue from cultivating bright children, in-
stead of permitting them to mark time, can-
not be overestimated. The work for mental
defectives must go on, but its aim is largely
along the line of insurance to the public to
protect it against the various evils that
might arise from wholly uncontrolled habits,
ideas and activities. From this group, little
economic return is expected, save insofar
as self-support may be made possible.
From the bright children, however, are
to come the great minds of the future.
From among them is to develop leadership
in philosophy, science and art; and social
progress is to be hastened thru their higher
education. It is a sad truth that greater
educational advantages enure to those who
are likely to fail in the struggle for life
than to those whose contributions to human-
kind will repay every effort made in their
behalf.
From the standpoint of mental hygiene, it
would be most interesting to inquire into
the opportunities aflforded bright children
in our schools. It is not to be denied that
exceptional children are skipped from class
to class, particularly, if anxious and intel-
ligent parents request that such steps be
taken. The rate of progress thru element-
ary schools should not be conditioned by the
interest of the parents alone, but should pro-
ceed normally, as the result of the pedagog-
ic principle of advancing a child at a rate
of speed that is warranted by its mental
ability. If school courses are especially
prepared for the defective children in un-
graded classes; if more highly trained
teachers are demanded ; if classes are made
smaller; if school lunches are provided; if,
in fact, every facility is given and little ex-
pense is spared in trying to educate those
educable within fairly definite limits, how
much more freely should communities spend
public funds for the benefit of the higher
types of children, who are failing to receive
an education and training commensurate
with their capabilities. This, at least, is one
practical problem of mental hygiene which
school authorities might well consider at
this time of reopening the schools ; and, in-
cidentally, it is a subject not unworthy of a
place upon the program of intelligent and
thoughtful medical societies.
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September^ 1919
571
N AND THINtjS
The Conference of Women Doctors. —
The international conference of women
doctors, which took place recently in New
York attracted more serious attention on
the part of both public and laity than such a
conference ever could have done before the
war. Tho the woman doctor is no longer
a pioneer, except in far Eastern countries,
her ability and fitness were not definitely
and convincingly proved until the large-
scale demands of the war showed that, in
point of skill, endurance and courage, she
was able to hold her own with the best of
the men physicians. It is odd, as it is
meaningless, that the criterion by which the
woman physician is judged by the public is
the man physician, and she is considered
favorably or unfavorably according to the
measure in which she approximates that
criterion. Such an attitude on the part of
the public ignores the fact that the woman
physician may have a social function com-
plementary to, and apart from, that of
the man. In fact, most women physicians,
at the very outset of their careers, mark out
for themselves a course which will give
more ample attention to the social aspect of
medical practice which the men have neg-
lected— it is not their intention to replace
the men, but to supplement their work and
to apply themselves more closely to the
moral and ethical phases which they are
perhaps better qualified for an account of
their sex. In this respect, it is worth not-
ing that practically the entire program of
the conference confined itself to just these
social and moral aspects of the doctor's
function — motherhood, children, the home,
the sex problem. Consciously or uncon-
sciously, the woman doctor finds herself
drawn to these interests, and it should be
heartening and encouraging to the laity that
this is so and that the women are giving
close attention to problems which the men
have considered too little in recent times.
However, it is well that the war served to
demonstrate that the woman physician is
the equal of her brother, for it laid at rest
preconceived notions and prejudices which
placed her at a disadvantage; and, having
proved this, she can go on, unembarrassed
by such prejudice, to do the work for which
she is so greatly needed. And this work
she is better qualified to carry on than the
man physician. Certainly she has in all
cases shown a livelier interest in the moral
aspects of medical practice than the men.
The dominant subject of the conference
was, as announced early, the sex problem.
The purpose of the women was to clarify
the situation and attempt a solution. There
is nothing especially novel in this undertak-
ing. The sex problem has been on many
occasions before this the concern of the
doctors the world over, and it will continue
to be for a long time, no doubt. Whether
the women will be able to achieve more than
the men it is hard to say. That considera-
tion is not one of vital importance. But it
is a fact that the efforts of the men in this
direction have grown a little stale by re-
peated failure, and the women come to the
problem with a fresh energy, perhaps a
fresh point of view. Singularly enough, it
is the one problem in which the medical pro-
fession has been unable to make any real
progress. The sex question is today as
baffling and intricate and unsatisfactory as
it was a hundred years ago — if anything, it
is more complicated, in view of the new
position of the women. The attempt to
solve the problem from a distinctly mascu-
line point of view is no longer adequate.
The solution, if there is any, must be one in
which the women are recognized as the
equals of man ; and the fact that the women
physicians have taken up the problem gives
assurance that they will not be likely to as-
sign a subordinate role to their own sex.
The attempt to deal with the problem at all
should be welcomed heartily. However
often the attempt has been made before, a
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September. 1919
MEN AND THINGS
American Medicine
new attempt is a sign of progress, and it is
to be hoped that the women will be able to
succeed where the men could not.
But, in taking up the problems of the
home and of motherhood, the women at the
conference were distinctly treading familiar
ground and were treating a subject which
they are better qualified than the men to
cope with. There may be a disposition to
feel that, because of the divergent opinions
expressed at the conference, the efforts of
the women were futile. It is absurd to ex-
pect that this complicated problem can be
settled at a single meeting. But it is inter-
esting to observe that the doctors at the
meeting were at one with the conventional
mother in the belief that the mother alone
is the best guide and educator of her chil-
dren. The issue raised by Mrs. Charlotte
Perkins Oilman, that children should be
taken from their mothers and put in the
hands of competent, trained nurses, who
were especially fitted for such work, was
vigorously contested. The doctors, unlike
the educators at the conference, adhered to
the old, conservative faith in the importance
of the mother's role. However, an im-
partial observer could not help but feel that
the educators had the better of the dispute ;
and, in pointing out that the disposition to
bear children does not necessarily assume
the ability to bring them up, Mrs. Oilman
and her adherents were rather closer to the
fact than the doctors. Nevertheless, the
willingness the conferees have shown to
cooperate with specialists in the various
fields that touch upon their medical interests
and activities is an encouraging mark of
their progressive and enlightened attitude:'
and, if they persevere in their efforts, the
health of the family, as well as its moral
wellbeing, is sure to benefit as a conse-
quence of their labors. The wide publicity
which the conference was given in the
newspapers indicates the interest the public
feels in the activities of the women doctors.
Once this interest might have been hostile.
Now it is distinctly friendly. The women
are plowing in a fertile field, and whatever
success they have will reflect credit both on
their sex and on their profession.
Doctors' Unions. — ^The drift toward
organization which is the dominant note in
industry thruout the world is now making
itself evident in the medical profession. In
three separate sections of New York City
and in fifteen upstate counties the effort to
form doctors' unions has met with a suc-
cess for which the press representative of
the Bronx Physicians' Ouild vouches. Ex-
plaining the motives that prompt the lead-
ers of the movement, this representative,
himself a physician, maintains that the doc-
tor needs a union as much as the tailor, or
tinsmith, or conductor, or steel-worker ;
and, defending the charge that a union
would tend to commercialize the profession,
he explains that doctors live under com-
mercial conditions and so must consider the
commercial point of view. Not so long ago
an eflfort to unionize physicians, after the
manner of the workingman, would have
seemed grotesque and would have been sub-
ject to stern criticism as a move which
would injure the dignity of the profession.
Today, when there is such a wide sympathy
with workers the world over and with their
eflforts to make themselves masters of their
destinies, any attempt at organization as a
step toward preserving the rights and in-
tegrity of any calling commands interest
and respect ; so that what once would have
been regarded as a burlesque must now be
taken very seriously. It must be noted
that the movement thus far is confined, ac-
cording to report, to the average general
practitioner whose reward has never been
adequate at best, and who, in the last five
years, has had a very severe time trying to
stretch his income to meet the ever-increas-
ing cost of living. In fact, it is emphasized
that the present attempt to unionize the doc-
tors is confined to the "under-dog," and that
the **big fellows" — the men of large in-
comes— may well be left to take care of
themselves. In that respect, the movement
is a frank and earnest effort to improve the
position of a class of professional men who
feel that their interests have suffered be-
cause of the lack of organization and who
wish to fortify a position which has become
precarious.
In view of this, it certainly is incumbent
upon one to take the movement seriously;
and, in a large sense, it is clear that such
an effort has some very commendable as-
pects. Doctors are bound closer together
than workers, in that the worker's obliga-
tion is confined to himself, w^hile the doc-
tor's responsibility is toward the commu-
nity. Disorganization and contention among
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MEN AND THINGS
Skptember. 1919
573
physicians would be injurious, therefore,
not only to the practitioner but to the
public ; and any effort toward organization,
toward a better entente, toward a standard-
ization of fees, of course with necessary
modifications, would be welcome. But to
go farther than that is rather hazardous,
and the attempt to unionize the doctors
goes very much farther than that. The
medical profession suffers no indignity in
being placed on a level with the worker's
calling. We have arrived at a social stage
where the worker's place is considered an
all-important one, and rightly so. The
question is not whether the worker and
doctor can be considered in the same class,
but whether they can be confined by the
same rules and governed by the same re-
strictions. After all, reduced to its simplest
form, the problem of the worker is one only
of working conditions — hours, environment
and pay. The only link between the med-
ical profession and the laborer is that of
compensation, and, firm a link as it is, it is
scarcely enough on which to base a complete
parallel, for the question of hours or of
environment does not enter into considera-
tion in the case of the doctor. He cannot
hold out for an eight-hour day. Until dis-
ease recognizes an eight- hour day, the doc-
tor will have to hold himself in readiness
twenty-four hours a day. As for environ-
ment, the doctor creates his own. He does
not work in a shop or factor}- : his office is
liis own. There remains, then, only the
question of pay.
The Question of Fees. — But in the mat-
ter of pay, it is hard to say how one can
ever come to an agreement that will do
justice to the innumerable delicate consid-
erations that arise in the case of the doctor.
With the worker, that is a simple matter.
His skill and productivity govern his earn-
ings, and these are the only elements that
count. Here again the parallel between
the doctor and the worker is an imperfect
one. Skill is a factor in both cases, but
productivity does not figure in the phy-
sician's activity. On the other hand, there
are elements in his calling which are en-
tirely lacking in the worker's. It is too
elastic to be confined within narrow rules.
There is, for example, the doctor's person-
ality. It is a commonplace observation
that personality is one of the indispensable
endowments of the successful physician.
Of two doctors with equal ability, one will
effect a greater number of cures merely be-
cause of the confidence his person inspires
in his patients. This is a familiar psycho-
logic element. But how, in an effort to
standardize fees, will this element be meas-
ured? Furthermore, the worker is com-
{)ensated for every bit of work he does, but
the doctor is again and again called upon to
do scientific, charitable and other work
for which he gets no compensation; and
that adds a further complication to any
effort to regulate his earnings.
The fact is that the movement to union-
ize the doctors is less a necessary, pro-
tective measure than it is a symptom and a
protest. As such, it should be earnestly
considered. As a definite, final issue it is
hard to see how it can be satisfactorily
carried thru. One must regard it merely
as an indication of the unrest that is stir-
ring in all classes, the wilful aim of the
"under-dog" to reap the reward of the
sacrifices he was called upon to make in
such large measure in the war. And in this
effort he has clashed with an element of
the public which has shown itself stubborn
in relinquishing its accustomed privileges.
The consequence of this clash is the innum-
erable strikes thruout the country that are
paralyzing its productivity and promoting
bitterness and hardship that might have
proved avoidable if both sides showed a
more accommodating spirit. The tend-
ency in all but labor quarters is to blame the
worker for his impatience and his intracta-
bility, his refusal to be patient ; but such a
judgment does not take into account the
equally blameworthy stubbornness on the
part of the employers and capitalists who
have refused to retreat a single step from
an almost feudal insistence on their privi-
leges as a class. Sabotage has been con-
demned in the workers, but the deliberate
sabotage that was practiced by capitalists in
danger of losing their possessions during
the war has had little publicity. There are
altogether too many men of wealth and
power without any understanding of the
crisis they face, without any comprehen-
sion of the deep meaning of the unrest thru-
out the world, without any realization that
they must move with the tide of progress or
go down. There are a few enlightened, in-
telligent, far-seeing employers and capital-
ists who understand the spirit of the times
and who are trying to lead the contending
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classes to a better understanding; just as
there are among the workers a few leaders
who are striving for moderation and intelli-
gent cooperation. But these are in the
minority and their voices are scarcely heard
above the roar of accusations and recrim-
inations. It is high time that both sides
showed a more sensible willingness to sub-
mit to reason, that both sides realized that
in acccMnmodation lies the solution of their
troubles.
Health ForesU and Health Towns.—
In the last issue of American Medicine
there appeared what may have been con-
sidered by some a cynical summary of the
expenditures voted by one of the States for
the improvement of the condition of hogs,
bees and babies, the lowest appropriation
going to the babies; and attention was
drawn to the unintelligible circumstance
that this singular disrespect for human well-
being is characteristic of almost all of our
legislatures. Since that comment was writ-
ten. Gov. Smith, of New York, has awak-
ened to the realization that the Legislature
of his own State has shown a most magnani-
mous concern for forests and a most ap-
palling indifference to humans. "We think
little of the millions that we spend in con-
serving our forests," said the Governor,
"but at the same time we give little thought
to the State's greatest asset — the health and
welfare of the people." The Governor, being
a shrewd leader, with a keen understand-
ing of the motives that prompt legislators,
spoke of the health of the community, not
as an obligation, but as an "asset." A more
sentimental critic would have attempted (as
in fact we attempted in our editorial last
month) to appeal to our legislators on the
ground of humaneness. . We must pay a
tribute to the (lovernor's better understand-
ing and knowledge of the weird legislative
sj>ecies. It was absurd to believe that
Senators curry favor with bees and snap
their fingers at babies because they are
brutal and inhuman. It is not a question
of whether they love bees better than babies.
Iwer vigilant, as practical, worldly men
should be, of the revenue of the State and
of the prosperity of its citizens, the gentle-
men of the Legislature put their investment
into what they thought the more profitable
enterprise. Bees paid dividends and bab-
ies did not. And so bees were to be en-
-'ouraged and subsidized.
Governor Smith referred to the wellbeing
of babies and citizens as "assets." Legis-
lators, presumably, respond to the appeal
of "assets." The following memorandum
is therefore respectfully submitted to the
legislatures of the country:
The Metropolitan Insurance Company is,
as may be surmised, not a charity enter-
prise. It is a business organization, the
legitimate aim of which is maximum divi-
dends. Three years ago its directors,
shrewd business men, voted to give the Na-
tional Tuberculosis Society $100,000 to es-
tablish a "health town." When level-
headed insurance directors spend such a
large sum of their company's money, they
naturally expect it to bear interest, however
indirectly it may be. Framingham, ^lass.,
was chosen for the experiment. The lead-
ing spirits of the town, level-headed busi-
ness men, saw a good opportunity for in-
vesting the town's money, and raised the
per capita expenditures for public health
from thirty-nine cents to one dollar. The
purpose of this experiment was to show that
in many cases sickness and death, particu-
larly tuberculosis, can be eliminated by
medical treatment and careful nursing, per-
sonal hygiene and adequate health adminis-
tration. The experiment proved an un-
qualified success. In 1916, before the ex-
periment was begun, eighty-one babies per
thousand died ; during the first year of the
experiment this was promptly reduced to
sixty-one per thousand. Previous to the
inauguration of health conditions in this
town of 16,000 souls, 121 persons died in
one year from tuberculosis. In the first
year of the test this was reduced to ninety-
nine deaths, in the second year to seventy-
nine, in the third year to seventy-six — ^and
this reduction occurred while the town in-
creased in population. At the end of three
years the town leaders were well satisfied
that their investment of sixty-one cents ex-
cess tax for health was an exceedingly prof-
itable one. The directors of the insurance
company felt that their $100,000 experiment
was beginning to pay them better than if
it had been sunk in first mortgages. Health
towns, it was discovered, paid. The health
of babies and adults was actually an "as-
set," which could be measured in dollars and
cents. We beg the indulgence of legisla-
tors for our carelessness in overlooking
these facts and for sentimentally regarding
the health of babies and adults merely from
a humane point of view. , ,
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ORIGINAL. AKTICLJBS
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575
ORIGINAL
TICLES*^^
THE GENESIS OF SPEECH.
BY
B. S. TALMEY, M. D.,
New York City.
The biogenetic law of Ontogeny being a
recapitulation of Phylogeny has become al-
most an axiom in the science of biology.
The experience of the race thru all the by-
gone ages of organic evolution, from the
single-celled individual to man, is recapitu-
lated in the experience of every human
being. By the study of the behavioristic
traits in the development of the child,
from the moment of conception to adult-
hood, we are able to trace the different
steps the race has taken in the evolution
of every human faculty thru the ages.
Hence, the close analysis of the develop-
ment of articulate spech in the infant will
give us a hint of the course speech de-
velopment has taken in the human race.
The new-bom infant is devoid of almost
all animal instincts except metabolism
(B. S. Talmey, Love, p. 102). But soon
the infant begins to show some traces of
the faculties of the arboreal ape-man. The
infant, in the first month of its life, pos-
sesses the ability to hang on hands like the
ape. Such an infant will grasp its mother's
finger and hold on to it with a force out of
all proportion to its general strength. The
thighs of the infant are usually bent at
right angles to the body, pointing to ar-
boreal life. The legs of the infant are
comparatively short compared with the
trunk, as in the anthropoid apes. During
this entire so-called arboreal period the in-
fant is perfectly dumb. Only after it has
learned to sit up and stand up in an erect
position, after it has learned to lift its head
up heavenwards it begins to respond to ar-
ticulate speech.
From this behavior of the infant we may
judge the course speech has taken in its
evolution thru the ages. Before begin-
ning to retrace the development of articu-
late speech it will be of advantage to inquire
into the nature of language in general.
Language, consisting of gestures and
emotional vocal expressions, is met with in
almost all higher animals.^ In the animal
language is an instinct, i. c, it is based upon
the experience of the species, not upon that
of the individual. It is not subject to
gradual development with the growth of
understanding. When the mother-hen dis-
covers a worm and emits a certain sound
"clack" the young chicks of a day know the
meaning of the call and gather around the
mother. The meaning of this simple sound
is known to them by inheritance, they do
not need to learn it. The dog conveys his
feelings by different definite sounds. He
whines when in pain, he growles in anger,
* Different emotional sounds, of rage and en-
treaty, of pain and warning, may be easily dis-
tinguished in the dog and many other animals.
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and barks in entreaty. These different
primitive unarticulate sounds are not sub-
ject to individual development; they are
an inheritance from his species. He knows
these sounds even when brought up alone,
in solitary confinement, without ever hav-
ing heard the voice of another dog.
The primitive animal sounds generally
lack articulation, altho the mechanism for
articulate vocal expression is present in al-
most all higher animals. Compared with a
wind instrument the animal's lungs repre-
sent the bellows, the trachea represents the
windpipe, the larynx the voice box and the
vocal cord the metallic reeds. Pharynx,
mouth and nose represent the resonators.
All these organs are possessed by almost all
higher animals and are all set functionating
in the production of any sound. The cords
are thrown into vibration^ by the air of the
expiratory current, forced against them
from below, and these vibrations produce
simple tunes. The air waves started by
the cords are modified by the resonance
cavities, pharynx, mouth and nose which
* In quiet breathing the vocal chink or the
fissure of the glottis is of a triangular shape.
When a tone is produced the vocal cords close
the fissure more or less. Vibrations are char-
acterized by amplitude or extent and by fre-
quency. The amplitude is due to the volume of
air expelled by the abdominal and expiratory
muscles. The frequency of the vibrations is
determined by the length of the vocal cords and
by the elliptic fissure of the glottis. Upon the
amplitude or the extent of the vibrations de-
pends the intensity of the sound, and the fre-
quency of the vibration stands in relation to
the pitch or height of the tone. The more fre-
quent the vibrations the higher is the tone.
Tones are named and intervals Judged by the
musical pitch. The degree of acuteness in man
is about five octaves.
The attributes of tonal sensations are inten-
sity, pitch and timber. Intensity and pitch de-
pend upon the two qualities, the amplitude and
frequency of the vibrations. The timber de-
pends upon the number of the constituent over-
tones. The vocal cords, like any other musical
instrument, originate several over- and under-
tones. The blending of these tones constitutes
the timber of the voice, e. g.^ the feminine tim-
ber.
give character to the tone.
These resonators produce also the differ-
ent vowels which are brought forth by the
change of size and shape of the resonance
cavities.^ The vowels "e", '*a", "a", are
broad-lipped. The lips in the enunciation
of these three vowels are stretched. In "e"
the mouth is only a little open and not
rounded, in "a" the mouth is more open and
more rounded, in "a" the aperture is quite
wide open and still more rounded. The
vowels "a'*, "o", "u"^ are round-lipped. In
**a" the mouth is wide open, in "o" it is less
open, in "u" it is little open.
Every sound is composed of tone and
noise. The noise forms are consonants,
the tone forms are the vowels. The con-
sonants are produced by the gums, tongue,
teeth and lips. In the gutturals "g", "k",
"ch" and in the liquids "1", "n", "r" the
tongue is pressed against the palate ; in the
dentals "d", "t", "th" the tongue is pressed
against the teeth, and in the labials **b".
"p'\ "f" and "m" the lips are pressed
against each other.
The peripheral mechanism for articulate
speech is present in almost all higher ani-
mals. The nervous centers which preside
over the different organs of speech are also
present in some animals, e. g., the parrot.
What these animals are lacking is the cor-
tical speech center. Expiration, phonation
and articulation are in perfect order in the
parrot ; but the parrot's articulate speech
is effected by imitation. The animal does
not know the meaning of the words it utters.
It repeats tunes and words it hears without
ever evincing any understanding. When the
^The five cardinal vowels 'V (in far), "a"
(in name), "e" (in theme), "o" (In note) and
"u" (in cool) are met with In the cat's call
m-e-a-a-o-u.
*The sign "u" in this article denotes always
the sound "oo" as in cool.
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577
dog responds to the order of the master, it
is the gesture concomitant with the order
which conveys the understanding, not the
articulate voice. He does not grasp the
verbal value of the spoken sounds ; he waits
for the gesture.
As in the parrot, the same phenomenon
is met in the infant. In the beginning the
infant's prattle represents an echolalia, or
an automatic speech mechanism. Only
after a certain time has elapsed, and a num-
ber of words have been transmitted and de-
posited within the auditory area of the
brain^ the child begin? to grasp the mean-
ing of such words, and only then it is able
to think. Abstract thinking is done in
words. Abstract thought!, therefore, de-
pends upon language. The leading char-
acteristic of man is the power to think and
to express his thoughts in words. Only
after the development of external language,
internal language or abstract thought be-
came possible. Ideation requires the suc-
cessive grouping of memory images.* The
impulse for speech comes from the mind or
the inner world. Thence the impulse
travels by the motor nerves to the speech
organs at the periphery where the sounds
are produced. The combination of the
sounds forms words and an intelligent com-
bination of words forms human speech.
Speech is thus a product of the revival of
memory images and the complex motorial
^ Articulate sounds are imparted as auditory
stimuli to the third gyrus of the left frontal
lobe of the cortex of the brain and are de-
posited there as words of others. These articu-
late sounds constitute within the auditory area
for the receptions of these adequate sensations
acoustic images.
' The images represent the effects of past
stimuli enregistered on the cerebral cortex, es-
pecially the effects. of the auditory, visual and
tactile stimuli, the most important sources of
human perception. By the conjoint action of
kinesthetic, visual, tactile and olfactory sen-
sory groups, certain percepts may be called up
in mind.
or kinesthetic coordination in the cortex of
the frontal lobes. These centers are being
modified by ontogenetic variations in the
human species.
The first names the infant gives to things
are onomatopoetic, or sound imitations, as
"wow-wow" for the dog in imitation of his
bark. Sometimes names indicate qualities,
as "hot" for stove. Because the labial
sounds "ma-ma" or "pa-pa" are the easiest
for the toothless infant to pronounce — he
needs only to press the lips against each
other — these names are given to father and
mother. But in the beginning every man
is papa. Only with the growth of mental-
ity the name papa is associated with the
father only. By this time every definite
composite percept of an object is followed
by its name. The child has learned to think,
and thinking is done in words.
When we revert to the phylum and try
to trace the remote beginnings of human
speech we must first inquire into the nature
of animal language. Animal gestures and
sounds are all emotionally toned. The
emotions furnish the motives for the effort
to come to an understanding.* Among soli-
tary living animals, all other primary emo-
tions do not require any particular means
of imparting the same to others; but the
emotion of sex demands some form of un-
derstanding between the two mates. Among
such solitary animals sex emotion is hence
the main and paramount motive for the
quest of some means of informing the mate.
Sounds peculiar to the male serve as a call
to the female, an indication of his presence.
The females are attracted by the sounds of
their future partners. Such sounds as the
* The primary emotions are fear, rage, hunger
and sex. The first emotion noticed in the low-
est type of aquatic animals is fear, founded
upon the conservation law. Sex arrives the
latest in the life of the individual.
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drumming of the snipe's tail, the tapping of
the woodpecker's beak, the harsh, trumpet-
Hke cry of certain water- fowl, the cooing of
the turtle-dove, the song of the nightingale
make it easier for the sexes to find each
other. In the thick foliage of the tropical
jungle melody of voice offered to the man-
ape the best means of attracting and charm-
ing the female. Many insects have the
power of producing stridulous sounds. In
some families of Homoptera and Orthoptera
the male possesses organs of sound which
he uses incessantly during the pairing sea-
son. Some male fishes make noise during
the spawning time. Male frogs and toads
emit various sounds at the pairing time.
The male tortoise utters a hoarse, bellowing
noise during the rutting season. The giraff
and porcupine are said to be completely
mute except during the period of estrum.
•The powerful sex stimuli are required to
spur the will of these animals to strain their
muscles and to surmount all obstacles.
When the sex organs swell the bird sings,
the cock crows, the cat meaaous and the
boy at puberty experiences a change in the
register of his voice.
The voice is thus sex-linked. It is used
primarily not for warning and giving
alarms, as some investigators maintain, but
for alluring and winning the mate, or as a
stimulant to mating. In animal allurement
the rhythm of the sound is the essential
part. The cat in the rutting season, when
calling for her mate, emits her "meaaous"
in regular intervals. The song of the male
bird is marked by the regularity of its
rhythm. Rhythm is a basic universal trait.
The swing of the cosmic rhythm is present
in all life, and propagation of life is rhythm-
linked.
During the pre-human stage of the race
rhythmical calls for his mate have been
emitted by the arboreal man-ape in his
primeval tropical forest.^ Such calls are a
phenomenon of courting among all animals
and the man-ape in his native wilds
could not have made an exception. Such
erotic calls became enregistered within the
auditory area of the cerebral cortex. The
feeling-ton^ of these calls imparted to the
listening mate certain emotions experienced
at the consummation of mutual rapture. By
apperception, the perception of such a
sound of the mate called up certain associa-
tions of emotions experienced in the previ-
ous sex-ardor. The idea in the pre-human
animal, just as in the other higher animals,
was quite vague, midway between percep-
tion and conception.
But while all other animals remained
static, the man-ape steadily progressed,
especially with his assuming the erect posi-
tion his progress in speech became rapid.
The man-ape had first to give up his quad-
rupedal posture and assume the biped erect
position before he could learn to express his
emotions by articulate speech. He had to
learn to stand and walk erect and lift his
face from the earth heavenwards, better to
perceive visual and auditory sensations.*
The keener perception of these auditory
and visual sensations produced clearer
memory images which were necessary for
the creation of human imagination. This
in turn led to human conception which is
no longer sensory. The percept is sensory ;
the idea is not, altho it is an offspring of the
former.
*The value of the mimic language within
the dark tropical forest In the wilds of the man-
ape was almost nil. He had to make use of
vocal sounds to impart his presence to his mate.
*A sensation possesses three attributes, qual-
ity, intensity and affective tone. In music,
quality or "Tonfarbe" Is represented by volume
and pitch, volume expressing the massiveness
of the tone and pitch denoting its height. Low
tones are large and massive, high tones are
thrill, thin and sharp.
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With the change to the erect posture, the
man-ape changed into an ape-man and be-
came a terrestrial dweller. Even then it
was the erotic gesture, the alluring tone,,
the rhythmical noise of allurement which
created the first thoughts. The feeling-
tone of the rhythmic sounds emitted by the
ape-man evoked in the mate, especially at
the estrual period, vague inarticulate long-
ings, and the undifferentiated aspirations
found their adequate expressions in rhyth-
mic responses, music being the clearest lan-
guage to express emotions, or rather their
variations. For while sensations vary
little, the variations in emotions are innum-
erable and great. Poetry precedes prose.
The first stimulus to vocal articulation
was thus sex-linked. A powerful stimulus
was necessary for the awakening of the
heroic will to drag the face away from the
beaten track and drive it forward along
a new path. Progress is an evolutionary
process, but evolution often becomes tired,
slackens its pace, stops or falls asleep in the
road. To arouse it vigorous shaking is
necessary. Such a powerful stimulus
emanated from the sex-ardor.
Once vocal understanding . was accom-
plished in the interest of sex articulate
sounds became in use for warnings and
alarms. With the change to the erect
posture the ape-man became a hunter of
small animals. As a terrestrial dweller he
was surrounded by a greater number of
enemies than when he lived in his trees, and
he found more protection in numbers. He
assumed the life of the pack like the wolf .^
Within the pack it was necessary for him
to learn how to impart to his fellows the
three other primary emotions, fear, anger
*The present domestic dog probably became
at this period his steady companion and best
friend which he remained to the present day.
and hunger. These four primary emotions,
sex, fear, anger and hunger thus formed
the motive power for articulate speech.
The first roots of human vocal language
were onomatopoetic, in the imitation of
natural sounds and noises. Before the child
learns the animal's name he calls the dog
"wow-wow." Later by imitation of the
adult's speech he learns the real names of
things. The first vocal articulations of
primitive man's speech were the imitations
of natural sounds. Verbs and adjectives
formed the main part of his speech. These
articulate sounds were registered on the
cerebral cortex* and constituted acoustic
verbal images. Kinesthetic impulses from
the muscles of externalized speech were al-
so sent to the speech area in the third frontal
convolution, where the sensory stimuli were
enregistered and memory images stored up.
The number of significant sounds increased
with the number of ideas and things. The
state of a people's civilization determines
the richness of language. With the growth
of man's intellect he learned to articulate
^ The center of speech is situated at the end
of the acoustic tracts in the auditory area for
the reception of acoustic phenomena. The audi-
tory, visual and motor centers are bound to-
gether thru association tracts. The auditory,
visual and kinesthetic sensations produce in
these centers perceptual and ideational proc-
esses. The sensory stimuli pass then to the
motor part of the reflex arc, and the verbal
images of articulate sounds are then reproduced
at the periphery by the particular speech
organs.
All intelligent animals possess association
memories and they express their feelings and
thoughts by gestures, mimicry, pantomime and
articulate cries. The wave of the limb, con-
traction of the face, expanding of the eyes, the
cry of pain, the start or fright are all means
for mental expressions. What animals lack is
the intellect for articulate speech. Animals,
like the parrot, are provided with the mechanism
for the production and modification of sounls.
They are endowed with an acoustic apparatus
for the transmission of the impressions of sound
to the brain, and the brain perceives the sounds :
but the animal lacks ideation. Hence a limited
number of simple sounds to express its cardinal
emotions suffices for its simple needs.
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more and more sounds. The farther man
advanced in civilization a vaster number of
visual, auditory and kinesthetic memories
were lodged in the zone of language.
But before memory images can be stored
up or enregistered they must first be pro-
duced, and before they are produced a
pathway must be created. The creation
of the pathway has taken its initial steps
at the courting season of the man-ape be-
fore he lived in hunting packs. It is
during puberty, the first courting season of
the individual, when especially in the boy
the vocal organs undergo marked changes.
The angle of the two plates of the shield
becomes more acute, and the vocal cords in-
crease in length in proportion of 5.10, while
in the girl the angle remains the same, and
the cords increase only in proportion of 5.7.
Her voice remains soprano or contralto, al-
most the same as in early childhood, while
the high voice of the boy is changed into the
tenor or bass.
This change is an inheritance from our
remotest ancestry' of the man-ape stage. It
was while sitting on some bough in the
primeval tropical forest,^ when at puberty,
or at the first estrual period, the man-ape
boy uttered his first alluring sounds for his
young mate. The combined effect of proper
tone quality, of inflection and emphasis,
made for an intelligent and sympathetic re-
lationship between himself and his listener.^
It was the love stress that taught man the
first sound of articulate speech, just as the
erotic urge taught the bird its first songs.
Melody is primary and universal, and music
* At that remote period the silent force of
propinquity did not suffice for the attraction of
the young mates. The wooing male had to emit
special sounds, well understood by the young
female.
*The sympathetic relationship once estab-
lished, they henceforth lived in strict monogamy
as most of the anthropoids do to the present
day.
is the clearest language to express emotions,
especially the emotion of love. Thru rhyth-
mically emitted sounds the man-ape, just
as the bird, sent his first messages to his
healthy female. Rhythm being an organic
part of life, the tonal feeling left an indeli-
ble imprint in her and awakened root-ideas
already at a time man's progenitor was still
a quadrimanous arboreal animal. The
psychic over-tones* of the erotic allurement-
call formed the root ideas of articulate
speech and the mnemic elements served to
the formation of a pathway for the audi-
tory and kinesthetic sensations.
Once the pathway for the reception of
auditory and kinesthetic sensations was
formed, the evolvement of an articulate
vocal language was comparatively easy.
This evolvement was effected during the
long period of hundreds of thousands of
years when the ape-man was living in
packs like the wolves. As a biped, ter-
restrial hunter the ape-man often found
the necessity of warning his fellows of the
approach of danger, or of calling for help
when attacked, or . of inviting his fellows
when a source of food was discovered.
Hence sounds of warning, of entreaty, of
fear, of rage, had to be singled out to make
himself understood by the fellows of his
group in the dark as well as in the light.
All such sounds led to the evolvement of
articulate speech.
Language is a function of relations. The
same subject must possess an apparatus for
the production and reception of the signs
of language. Not only man but all higher
animals possess certain organs for the
mimic expression of language-signs and
^ Sex with emotional over-tones and sympathy
resonance constitute human love. The idlur-
ing overtones of the ape-man created human
speech. These emotional tones brought the
mental processes to a focus and provoked the
faculty of human awareness.
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581
at the same time organs or receptors for
the comprehension of the meaning of such
signs. The function of language is to
transmit .to the outside world the impres-
sions, longings and determinations of the
animal. The power to manifest these im-
pressions would only be of any value if the
individual possessed at the same time the
ability of comprehending the language of
the other.
But while the animal possesses only the
apparatus for the production and reception
of gesture signs, man is endowed with the
faculty of producing and comprehending
ajrticulate speech which is effected by respi-
ration, phonation and articulation. This
mode of language is the best means for the
expression of sentiments, ideas and the
will of man. It has enobled man's char-
acter, elevated his culture and extended his
mastery over the material elements of life.
171 W. 126th St.
THE TRANSITIONAL PERIODS IN
THE NUTRITION OF THE AB-
NORMAL INFANT.
GEORGE DOW SCOTT, A. B., B. S., M. D.,
New York City.
The term "transition" signifies a passage
from one place to another, from a condi-
tion or action to another, a bridging over as
it were, and that word brings out ideally
that which I wish to convey. There are
certain periods in the first year of the in-
fant worrying and harassing alike to the
mother and to the physician. When the
infant is artificially fed from birth there ex-
ists a longer or shorter period before the
new modified food "takes a hold" or it may
be wrongly modified, of improper tempera-
ture, unclean, etc., and successive diarrhea
or constipation, gas flatus and eructations,
bloody stools, a rapid or slow elevation of
temperature, colicky pains, decrease in
weight and with loss of subcutaneous fat,
may follow.
Then again there is the time when the
normal breast fed baby cannot, on account
of the poor quality of the mother's milk
and irregular feedings perhaps, gain that
adequate nourishment needed before this
milk assumes its natural condition. After
the contagious diseases there is noticed a
serious physical, physiologic and nervous
depressional stage where appetite is poor,
the temperature is often subnormal, the
skin discolored and wasted and the infant
whiny and pitiable. In the summer diar-
rheas of infancy following the severe food
intoxications with vomiting and foul-
smelling, bloody and curdy diarrheas, there
is likewise a period of severe physical and
mental inertia and exhaustion. And many
such conditions can be enumerated where
physical disorders are followed by a physio-
logic depression.
The general picture is a familiar one, the
body is wasted, the central nervous system
is exhausted, the internal secretions are al-
tered, weakened and depleted undoubtedly
of some of their essential ingredients, and
the digestive mechanism is much below par,
sunken eyes peering out of deep sockets,
the skin clinging to the primitive skeleton,
eczemas, a sunken abdomen, thirst, lips dry
and subnormal temperature, hunger with-
out satisfaction, weakness or prostration
all mark a nutritional abyss. Such cases
suffer from a fat, protein and carbohydrate
starvation but primarily from a fat starva-
tion for the body being in need of the latter
calls upon its reserve supply of carbohy-
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drates and proteins. We know also that
stored fat is a reserve of potential energy
and should be brought into use in such
wasting disease as I have described attend-
ant upon failure of nutrition. There is a
certain amount of fat present in almost all
our foodstuffs. Some of this stored fat is
derived from sugar and from proteid sub-
stances besides being obtained from fatty
foods. Now clinically fats have served their
purpose well where not only has there been
loss in weight and a wasting of the tissues,
but where the stomach has been affected
and is sensitive to protein foods. This is
not hard to understand. The fats are not
completely digested until they reach the
small intestine where they undergo action
by a pancreatic enzyme called steapsin and
another lipase of the bile into glycerin and
the fatty acids. Some of the free acid
unites with the sodium of the alkaline bile
and intestinal juices to form a soap. The
latter emulsifies the rest of the fat, hasten-
ing the action of the steapsin and promoting
its absorption.
The food of man is of course divided
into two great classes, nitrogenous or flesh-
forming, the carbonaceous, or energy-pro-
ducing. Nitrogen and carbon constitute
the chief ingredients of the former; oils,
fats and carbohydrates form the principal
essentials of the latter.
The primary function of oils and fats, if
you will, is to produce heat. The combus-
tion of 1 gram of carbon to carbon dioxide
produces 8080 calories, while the presence
of oxygen actually reduces the calorific
value of the substance. Hence the higher
proportion of carbon and the lower amount
of oxygen the greater will be the heat-pro-
ducing power of foods. The fats are much
richer in carbon than in starch, or sugar,
containing 2>4 times as much. Physiologists
believe that in our economy 1 part of fat is
necessary to 10 parts of carbohydrate. The
fats are more easily assimilated than the
carbohydrates ; they are, besides, more pal-
atable and assist in the digestion of other
articles of food.
In truth most of the fat of our foods is
oxidized to CO^ and H*0 in the tissue cells
as fast as it comes to them affording molec-
ular and chemical energy and maintaining
the normal temperature, reducing or elevat-
ing it in fever or in exhaustion conditions,
thereby liberating a large amount of heat.
How much fat is needed for a certain in-
fant cannot be computed in the terms of
calories but must depend upon the metabolic
processes functioning in that individual in-
fant as a certain amount needed to stimu-
late the metabolism of the proteins and car-
bohydrates. And just here an interesting
experiment by Dr. Hindhede, a Scandina-
vian specialist might be mentioned. This
physician has apparently tried to prove that
an individual can keep well and work on
a fatless diet if sufficient carbohydrates,
namely starches and sugars, are provided.
Such a diet to my way of thinking might
be given to an individual of adult age and
in the best of health and vigor and who in
many years has accumulated a sufficient
amount of body fat from which to draw or
to which might be duly added an even
greater amount from the ingestion of fresh
sugars and starches. I fear that the good
doctor would come a cropper did he try the
same experiments upon infants.
In a previous article I tried to point out
the value of fats in the form of butters —
oleomargarines and the like in the diet of
children, and it may be said right here that
the American public has a mistaken idea of
the manufacture of oils and margarines ap-
pearing to believe that they are manufac-
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583
tured from refuse found in garbage and ref-
use cans. But in this article dealing with
infancy where the butters as such are not
so easily administered as are the oils, I am
again trying to point out the indication of
fat in the diet. Now altho "pigs is pigs"
fats are not necessarily fats, or carbohy-
drates carbohydrates or proteins proteins.
To make the point clear, animal proteins
are harder to digest than either those of
fruit or vegetable. Milk and cane sugar
cause more digestive upheavals than does
fruit sugar or fructose. Why then should
not vegetable fats such as the oils be more
easily digested or at least just as easily as-
similated as the animal ? And observations
seem to warrant this conclusion. The
public has a grossly misinformed idea as to
the assimilation of fats and many a mother
is at the present time stuffing her infants
with cod liver and other oils with cream
mixtures, irrespective of stomach and in-
testinal disorders with the view of increas-
ing the bpdy weight. Moreover, it is a fact
that in some infants cream mixtures — ^a
high per cent, of animal fat — can be pushed
to a marked degree. Yet in others we find
with the same amount of fat a pasty look-
ing infant with pale looking mucous
membranes and much intestinal gas with
meteorism and tenesmus, at times having
diarrheal fatty and curdy stools; yet in
the same infant if we reduce the ani-
mal fat and in addition give a certain
amount of the vegetable — the oils I mean —
we get a fat storage, other things being
equal a normal stool and a healthy infant.
It must be remembered that in the normal
healthy mother the normally adequate breast
milk is derived from many sources and
under that number come both animal and
vegetable fats.
The question of what oil to use depends
to a great extent upon our nose, our eyes,
our tongues and upon our pocket-book
whether it be olive, cotton seed, cocoanut,
peanut or corn oil. They all have practi-
cally the same chemical composition and
digestibility, but on the whole the olive oil
is to me preferable, as it undergoes much
less of a chemical change in its manufac-
ture, this oil being used more in its natural
state.
Our little ones are apt to digest an oil
they like better than one they do not like.
Each country seems to have its favorite oil.
In our country cotton seed, cocoanut and
peanut oils as well as corn oil are rapidly
coming to the front on account of their di-
gestibility and cheapness. In Russia the
oil from the sunflower, in Europe generally
the soy bean and sesame oils are extensively
used. These edible oils form a highly con-
centrated and a usually easily assimilated
food. Pure oils and fats are practically
free from water and contain no indigestible
substances such as the crude fibre of vege-
tables and the cartilage and tendon of meat.
Cotton seed oil for instance is a very cheap
and a very common substitute for olive oil
and as compared to beef at 20 cents a quart
will yield more than 5 times the amount of
body energy, but of course will not have the
same tissue-building properties.
Who of us has not hidden himself away
in a nook of his own library or in a spot
in the public library and read some delight-
ful little book such as Prof. Tucker^s
"Ancient Athens" — or perhaps another on
Modern Greece and Italy? And possibly
with surprise we learn that olive oil formed
an important food and even luxury in an-
cient days and that the famous athletes of
those times were given gaily ornamented
jars of olive oil for prizes. Today down
in our crowded tenement districts the Italian
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ORIQINAL. ARTICLES)
American Msdicins
woman gives the baby, if ill, warm olive oil
as she has been taught to in far away Mes-
sina. In truth there is no one thing, to my
mind, which links the past so much with
the present as olive oil; justly famous in
those days it is not thoroly appreciated in
our country in these modern times. You
remember that I said an oil must suit the
individual tasfe — it must be digestible and
be of certain caloric value altho valuable
time is wasted in estimating the specific
caloric percentage which our little patient
requires. The taste of oil is important.
The Russian accustomed to his sunflower
oil would think the bland, highly refined
American cotton seed oil, for instance; taste-
less and the likes and dislikes of infants
and children while impractical and some-
what imaginative are, safe to say, persist-
ent. The Italian and American olive oils
are par excellence, the ideal vegetable fat
food for infants and it really matters little
that the domestic product is not so rich in
fat as that of Italy, 20-30% compared to
40-60%. Olive oil, chemically consisting
mostly of oleins, undergoes as was said, but
very little chemical change in its manufac-
ture and its finest grades are those ex-
pressed from the fruits with the least possi-
ble subsequent treatment.
Now the flavor of olive oil depends upon
the variety of tree, the stage of growth at
which the olives are gathered and upon the
method of separating the oil from the pulp,
for fruit picked before ripe is bitter. The
finest grade oil is made from selected olives
pressed by hand between cloths, the result-
ing oil washed in water to remove impurities
subsequently decanted from the aqueous
layer and sold under the name of virgin
oil. The commercial oil. on the other hand,
is crushed between millstones, then ex-
pressed at low pressure. The virgin oil is
of a pale yellowish-green color. The low
grade oils possess a bitter flavor. The purest
olive oil at low temperature will yield stearin
in abundance. Olive oil consists chiefly of
palmitin, stearin and olein and contains
much more olein but much less stearin
than the ordinary solid fats. In cotton seed
oil, sesame oil and in other seed oils used
as food the quantities of palmitin and
stearin are still smaller and together with
large quantities of olein contain consider-
able quantities of linolein. Cotton seed oil,
often the fraudulent substitute of olive oil
but in truth a much demanded oil, under-
goes a very extensive process of manufac-
ture. It may in fact be divided into two
general classes, the Bald or black. The
first variety derived from the smooth lint-
free seeds of the South Sea Island cotton
and the second variety originates from the
white or woolly seeds of the Uplands and
similar cottons which come from the guns
with a fluffy white coat of lint upon them.
Both these varieties contain about 20% of
oil. Crude unrefined cotton seed oil is not
suitable for human food for altho it has a
pleasing nutty flavor it contains coloring
matter and other foreign substances such as
albuminous bodies and free fatty acids. It
must therefore be refined, often bleached
and deodorized; the acids must be neutral-
ized and removed and the major portion of
the coloring matter refined away. The
margarines are largely made from these oils.
Cotton seed oil in common with most of the
other vegetable food oils contains such a
large proportion of so-called stearins mean-
ing glycerides of palmitic and similar fatty
solids that in cold weather the stearins
separate out, giving the oil a milky appear-
ance and rendering it. less desirable as a
food in cold climates. To remedy this the
so-called summer yellow grade is "win-
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ORIGINAL. ARTICL.E8
September, 1919
585
tered"— that is held for a time in chilled
rooms or in tanks surrounded by cold brine
until it becomes semi-solid. This semi-solid
mass is then pressed or run thru a centri-
fuge to separate the solid stearin from the
lower melting oleins. The oleins by the
way are present in all animal fats but in
greater quantities in vegetable fats. They
are solvents for stearin and palmitin and
are at ordinary temperatures nearly color-
less with a specific gravity of 0.914, with-
out odor or marked taste but become rancid
if exposed to the air. Now the boll-weevil
has within a comparatively short time been
creating havoc in the raising of cotton.
Suppose then in the case of failure of this
fat food in the high cost of olive oil there
is a marked demand for an edible oil, we
then turn to other similar American prod-
ucts to help us out, peanut oil for one. The
production of this oil is in the United States
still in its infancy and there is as yet but
little demand for a high grade peanut oil.
Another oil rapidly coming to the front
under several names and aliases is corn
oil — just as valuable and just as necessary
a food as the other oils enumerated, and as
we turn to store windows and sign boards
we see a product of corn oil advertised
under an attractive name. Corn oil exists
in the small germ-portion of our common
Indian com and altho the germ itself is
more than half oil there is only from
36.5% of oil present in the entire kernel.
This oil has as yet not become a common
household product but is used as a table
and as a cooking oil. Now the difference
between an oil and a butter is one we may
say of degree and dependent upon the tem-
peratures. Fats and butter become oils
when melted and reversely oils, become but-
ters when solidified — all the fats and oils
as already pointed out and used for edible
purposes belong to the same general type..
It must be remembered that the ingestion
of fat alone over an extended time will not
keep life within the infant because there is
a constant loss of tissue protein from the
body which finally weakens the vital
organs. This fat will, however, act as a
bridge to the time when our normal diet
takes a firm grip. Bartman . noticed that
fat given to the extent of 150% of the
energy requirement was readily absorbed
and spared the protein to a maximum of
7%. Sometimes he noticed that when
much fat was given there was an increased
elimination of nitrogen in the stools. If a
large amount of fat is taken in it is burned
up producing heat, and does not draw upon
the body fat while the amount of protein
consumed remains the same.
I cannot but feel, therefore, that in these
subnormal transitional conditions seen in
infancy that in the oils given in drops and
up to 1, 2, 3 drahms at a time and warm,
heat-producing, easily digestible and assimi-
lated as they are, we have a bridge which
stretching across an abyss of uncertainty
links together the abnormal with the
normal.
40 East 41st Street.
Hydroneidirosis. — In connection with
the correction of the obstructing cause of
hydronephrosis, it is well to reduce the size
of the Tpelvic sac by excising a portion of
its wall. — Urologic & Cutaneous Review.
Inguinal Hernia. — In inguinal hernia
put patient under influence of chloroform
or ether, and lift the person clear off the
bed by the feet for several minutes; di-
rectly the bowel will return into its place. —
Med. Summary.
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586 September. 1919
ENDOCRINE TROPISMS.
(Pituitary Tropisms)
BY
DAVID M. KAPLAN, M. D.,»
New York City.
It is not only a privilege, but a duty to
place before you some of the views that
prevail among men who have given special
consideration to the study of the endocrines.
I want to emphasize the fact that it is high
time for all those who minister to the sick,
to cease worshipping the false Gods of
pathology and by removing the smoked
glasses of credulity from their eyes, view
the subject of "disease" in a cold blooded
manner, analogous to that of the expert ac-
countant, who reviews the books and ac-
counts of a bankrupt.
The ability to improve the heklth of a
sufferer from a study of the phenomena
that a dead-house supplies, is non-existent,
as daily occurrences teach us only too well.
He who still persists in the use of such sup-
port for the rationale of his therapy, is suf-
fering from a mental myopia which sooner
or later will be detected by the sufferer to
the detriment of the medical profession.
The mushroom like appearance of healing
cults is not so much the result of greed, as
it is the direct outcome of our own failure
to "deliver the goods." I do not wish to
enter upon a long discussion of hypothet-
ical speculations, but will speak to you di-
rectly from the shoulder, by at once dis-
missing "the thing you want," i. e., post
mortem lore and the structure built there-
upon, and replacing it by "the thing you
need," i. c, therapeutics.
Thanks to those who opened my eyes, I
am able to tell you that life, health and dis-
ease are in the vast majority of instances
* Paper read before the East New York Med-
ical Society. April 15, 1919.
ORiaiNAL ARTICL.B8
Ambuoan MHMCuni
the resultants of function and not of struc-
ture. Long before the most skilled patholo-
gist can detect any structural change, ab-
normal function sends its message of dis-
tress to the patient's sensorium. And
when the condition is such that a structural
diagnosis can be made with precision, is it
not too late for drugs? Is it not a much
saner policy to study the ways and means
whereby perverted function can be made
so that it does not interfere with the pa-
tient's conscious self?
It is necessary at the very beginning to
recognize the fact that the great majority
of structural changes do not become normal
with 'the remedies in vogue for their re-
moval. This being the case, then why
bother about them? The reconciliation
between dysfunction and the patient's com-
fort is the chief concern of the endocrine
student, who nine times out of ten deals
with complaints that as yet have no definite
pathology, and hence for the want of some-
thing in its place I have used the term
"tropism." The term is to be used in the
same spirit that the word "prodrome" is
used in the infectious fevers and in ordinary
parlance has the same significance as the
word "clue." It is the department of en-
docrinology that very often furnishes the
"clue" to the dysfunction of one or more
glands that may be responsible for the en-
tire tangle of complaints that the patient
displays. As one advances in the study of
this most interesting as well as mysterious
branch of medicine, the conclusion that
gradually dawns upon the observer is the
fact that there are no one-glandular dis-
eases, and that the designations of the past
were the result of a too limited acquaintance
with the workings of the endocrines. This
opens a new field not only for diagnosis,
but preeminently for therapy.
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As an introduction to what is going to
follow, I must enjoin you to discard all
antagonistic feeling towards him who prac-
tices medicine in a fashion that you disap-
prove. Intolerance is the root of all our
therapeutic shortcomings, and the real in-
centive for all kinds of cults to peddle their
wares. We must divest ourselves of this
great pest, and instead of prematurely rel-
egating a form of treatment to the rubbish
pile, we must first ascertain whether it does
not possess some redeeming features. Let
us be charitable in our conclusions and not
too hasty with our indictments.
In dealing with this most fascinating sub-
ject of the endocrines, which sounds more
like romance than medicine, you will kindly
remember that the body activities are sub-
ject to three epochal changes of endocrine
supervision. As the domination of one
nears its end, the successor begins to mani-
fest its ascension to power by subjective
and objective phenomena of a definite char-
acter. The first period dates from birth
and lasts until so-called puberty, or as en-
docrinologists are beginning to term it, the
"gonado-advent." This rather short but
very important period is dominated by the
thymus, and usually disappears as its suc-
cessor enters to assume control. At this
time certain forces begin to manifest them-
selves which even to the casual observer
prove that something unusual is going on in
the young person. This is the critical
period in which a new function is about to
be born, foreign to the thymic period of
life. The *'gonado-advent" is at hand, and
its introduction is always accompanied by
manifestations which I believe are appropri-
ately designated as an "endocrine crisis."
This crisis is again experienced during the
"gonado-pause" (so-called menopause). It
will be repeated at different times during
this presentation that at no time of their
activities do the endocrines work inde-
pendently of their associates, and that the
word **tropism" is used to signify a certain
train of subjective and objective symptoms
which give a "clue" as to the gland that
is not functioning as it should.
The second period of life's activities is
dominated by the gonads and lasts thruout
sexual life. By this time the thymus has
entirely disappeared. Quantitatively, and
qualitatively, the gonads are assisted by the
other endocrines. And now the human
being has solved the purpose of his being
and is ready to prepare for the last lap
of life's race, thru the "gonado-pause."
While this administration of the endocrine
government is taking place a second "endo-
crine crisis" perturbs the equilibrium of
the body and the soul and various incon-
veniences are experienced before the ad-
renals, which now assume control, are
fully established as the final guides thru the
remnant of human life ; and the adrenals
continue to labor until the final and per-
emptory summons. All these factors must
be remembered for they will help to under-
stand the why and wherefore of this or that
phenomenon, which to the mind, unaided by
endocrine experiences, will appear mysteri-
ous and unsolvable, and the perplexed doc-
tor will have to depend upon the meaning-
less diagnosis of neurasthenia in order to be
able to extricate himself out of his dilemma.
To resume our subject, it may interest
you to know that all babies in good health
owe their pink cheeks to arsenic; but this
arsenic is not the crude chemical found in
Fowler's solution, but the subtle organic
molecule found in the thymus gland. Here
is a distinct therapeutic hint, and I advise
you to try thymus extract in the next pale-
cheeked baby you come across and note the
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ORIGINAL. ARTICLES
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result. Endocrinology can only be appre-
ciated when it is earnestly practiced, and
no amount of talk will convince one as
much as a failure or a success in its actual
application. An attempt to account for a
failure is frequently more instructive than
the rapid cure that often rewards the endo-
crinologist.
To return to the use of thymus in pale
babies: It is not the lack of arsenic that
makes the baby sick, but rather the absence
of endocrine harmony that is the cause of
this, and many other phenomena that the
child presents, besides its palor. The error
having occurred during the temporal regime
of the thymus, it is wise to begin treatment
with it, and observe whether the missing
note has been properly supplied and the
endocrine discord thus eliminated. I use
the term "properly" with a purpose, for
here we can see the propriety of comparing
endocrine therapy with music ; it is not suf-
ficient merely to strike the proper note; it
must be given at a proper time and in suit-
able dosage. By giving too much, one pro-
duces not only discord, but also complicates
matters to such an extent that the subse-
quent handling of the sufferer is made ever
so much more difficult. Such experiences
also make the doctor skeptical as to the
value of endocrine therapy. The harm done
by giving too little is infinitesimally less
than when too large a dose has been ad-
ministered. Patients who have been mis-
managed by overdosing are the bugbear of
the endocrinologist, and by far the most
difficult cases he is called upon to help.
To the child's economy the gonads are of
least use, but as the "gonado-advent" ap-
proaches their domination makes itself ap-
parent in devious ways in different people.
No matter how mild the transition from
childhood to that of adult life, certain per-
turbations occur, objective and subjective,
justifying the name "endocrine crisis'' for
the phenomenon. This period of life is
full of concern for parent and doctor. The
discerning physician must keep his eyes
open and be on the qui vive, as the most
critical period of human life, both for
man and woman is at hand. From an en-
docrine point of view, untold misery is the
result of a poorly guided youth; many a
case of the fatal form of Basedow's dis-
ease could have been prevented if the doc-
tor had known what frequent hives means,
what a rapid heart and an overintelligent,
bright eye signify in a developing young
woman. To know what this means is to
understand endocrinology. That young
woman could have been saved by sparing
her in every way, particularly from mental
shocks, and by having her mind fortified
by the sound advice of a mother, broad-
minded enough to explain to her daughter
the meaning of her newly developed func-
tions. If carried out diplomatically such
management will prevent the terrible an-
archy of the cardio-vascular and sym-
pathetic systems encountered in a Base-
dowic.
So much for the mother's part in prophy-
laxis of exophthalmic goitre. The doctor,
when he notices the first signs of gonadal
unrest, in a too profuse menstrual flow, in
an ovarian cramp, or in an irregularly ap-
pearing flow, must prescribe small doses of
ovarian extract extremely cautiously. Give
one dose and observe the effect, and do not
repeat the dose unless some improvement
has taken place in the symptomatology of
the patient. When the menstrual phe-
nomenon has been restored to absolute
normal function, the doctor will have ac-
complished a service for which he is en-
titled to the everlasting gratitude of his
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589
patient. It will be learned from this in-
troduction to the prophylaxis of exophthal-
mic goitre, that the gonads have a great
deal to say in the development of this dis-
ease, and even when the trouble has already
made itself apparent in a mild form, it is
possible to change its course for the better
by instituting careful gonadal therapy,
medicinal, hygienic and psychic. Another
point that was not emphasized sufficiently,
besides the bright eye and general nervous
make-up of these young women, is the com-
plexion, which is very rarely dark or bru-
nette, their skin being clear and their teeth
almost perfect. They wear low cut waists
summer and winter, they prefer cold
weather to warm and relish a cold bath.
The chances for a boy to develop exoph-
thalmic goitre as a result of a constitutional
defect in his gonadal apparatus are practi-
cally nil. Nevertheless, he needs as much
care as his sister. If there is a maladjust-
ment of his endocrines during his "gonado-
advent" particularly if he is of dark com-
plexion, with overhanging eyebrows, is ex-
ceptionally bright at school and displays a
virtuoso tendency, the physician must be
able to see into the future, and forestall an
impending dementia praecox. Such a boy is
best managed with very small doses of su-
prarenal extract or with thyroid, but each
step must be watched and recorded, and if
the desired change in the symptomatology
does not take place, other drugs must be
given. Such boys may complain of sleepless
nights, hot flushes, loss of appetite, constipa-
tion and masturbation. They may even at
this early date show a religious tendency, or
any other peculiar trait that makes the par-
ent anxious for the child's health. The doc-
tor must be warned against the ever-increas-
ing tendency to consign such patients to a
sanitarium. The evil is thereby immeas-
urably enhanced, and the attitude towards
the suflferer of "out of sight, out of mind'*
is to be deprecated, as the occasional hypnot-
ic and a little exercise on the lawn of
these "repair shops for human derelicts"
is not only devoid of therapeutic value, but
do actual harm, and the downward course
of the incipient malady is, so to say, given
a kick, from which few ever recover. There
is no denying the fact that there are many
unfortunates for whom such institutions
are the only place, but they are the cases
that have gone so long without rational
therapy, that the harm is irreparable and
tissue changes have taken place that supply
the pathologists with material for publica-
tions, describing the pathologic changes in
dementia praecox.
It is the duty of the physician to be able
to detect the material out of which a de-
mentia praecox candidate is made and thus
prevent the full development of the disease
at a stage when therapy is still capable of
influencing the endocrinopathy. For as long
as the doctor is able to keep his patient out
of a sanitarium and still prevent him from
becoming an extra-social being, he is doing
his duty. At this juncture the doctor's toler-
ance is put to the test, for endocrine
therapy is not the only means of accomplish-
ing this; one must make use of the drugs
and methods that go against the grain of his
convictions.
Here comes in your reformation. Do not
remain the slaves of allopathic orthodoxy.
Remember that the homeopath, osteopath,
and even the Christian Scientist have oc-
casionally given proof of their usefulness.
I have patients who tell me that after years
of apparently authoritative treatment^ the
only lasting improvement which they no-
ticed was at the hands of one of the men
who practiced one of the above methods of
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healing the sick. Regardless of my allo-
pathic or regular training I was glad that
the patient felt better, but felt sorry that
my brethren in medicine could not detect
the symptoms upon which a certain osteo-
path expended his energy and gave the re-
lief which the sufferer was expecting from
us. It is absolutely imperative that we
learn the methods of the other fellow, and
thereby become proficient all-round thera-
peutists, no matter to what school the spe-
cial way of treatment may belong. There is
no patent on how to treat patients, and no
one need be ashamed of any method, pro-
plaints. I have in mind the unfortunate
Oscar Wilde, who as a result of medical
ignorance was put in prison instead of in a
hospital, and as the subsequent course of
his malady became histo-pathologic,. a
brain tumor was diagnosed in Paris, most
likely of the pituitary gland, as he suffered
in his last days from most severe supraor-
bital headaches, for which a noted surgeon
promised relief by operation. What could
have been done when he was still a boy
and indulged in pranks that deserved the
attention of the endocrinologist, is only a
matter of conjecture. The association of
Fio. 1.
vided it helps to cure. If needs be, recom-
mend an osteopath, but do not permit your
patient to wander away from you in dis-
gust, and accidently consult the osteopath,
and get his relief contrary to your approval.
It is wise to remember, that once the full-
fledged disease has overtaken the sufferer,
it is much better policy to leave allopathy
and endocrinology alone, and try some of
the other methods, a few of. which were
enumerated above, and in this connection
I would earnestly recommend homeopathy.
It is not amiss to remind you that many
individuals go thru life with very few com-
Fio. 2.
the pituitary gland with the gonads is a well
known fact. It is only necessary to re-
mind one of the Froehlich type of adiposo-
genital dystrophy. But the dysfunction is
not only pictured by the structural or histo-
pathologic change, but shows a definite al-
teration in the psychic machinery of the in-
dividual. This is the main reason for in-
troducing the picture of Oscar Wilde, whose
dystrophy was chiefly a psychic one, as his
actions amply proved.
In photograph No. 1 we have a 10 year
old boy who is normal physically, but oc-
casionally displays unusual fatigability. He
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ORIGINAL ARTICLES
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591
is a fairly good scholar, tho poor in mathe-
matics. In photograph 2 the resemblance
to No. 1 on general lines is apparent; the
boy, who is 11 years old, suffers from a tic
of his eyelids and angles of mouth, and
displays a choreiform movement of the left
hand. He complains of occasional frontal
headaches, and besides his rotund bodily
contour also shows a slight hypogenitalism.
Compare with photograph No. 3.
In the fourth photograph we see a 16
year old boy who, besides his acromegaloid
giantism, suffers from very bad headaches,
the pain being over both eyes and periodic
Fio. 3.
attacks of great weakness, which necessi-
tated his removal from school. His trouble
began before the "gonado-advent" ; in fact
so proximal to the gonadal assumption of
power was the abnormal work of the pitui-
tary that he barely escaped acromegaly in
its full-fledged form. It seems to me that
if the gonads in their psycho-somatic entity
retain their powers sufficiently to curb the
dysfunction of the pituitary gland, that such
an individual will escape the more serious
and automatically debilitating forms of this
endocrinopathy, and that there will be es-
tablished an equilibrium, which will require
no help from the doctor. The patient ap-
peared before me in 1918 for the second
time regarding his draft in the army. He
had much trouble in obtaining preferred
classification, as he was able to pass most of
the tests applied by the examining surgeon.
It is not at all a rare sight to meet an ac-
romegalic on the pohce force, or in the mili-
tary service.
Adiposo-genital dystrophy never out-
grows its psycho-somatic stamp. Opera-
tions on the pituitary gland serve only to
save the eyes of the patient. Occasionally
the tumor shows such rapid growth, that
Fig. 4.
life is endangered and immediate opera-
tion becomes imperative. The fifth photo-
graph shows a boy who was to be oper-
ated upon the same week as the photograph
was taken. His hypogenitalism is very
marked, and his female contour is very
striking. Severe headaches and increasing
vision defect together with other signs of
increased intracranial pressure, aside from
the limitation in his visual fields, required
operative interference. Photographs 5 and
6 represent two different ways in which ab-
normal endocrine function may display its
activities. In 5 we see the somatic error
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ORIGINAL. ARTICLES
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in its classical form, in 6 we have the tro-
pism only, i. e., merely a clue of what the
individual might be, but psychically he dis-
plays sufficient evidence to place him among
endocrinopaths.
Regardless of the pituito-tropic tendency
in adiposo-genital and acromegaly patients,
the former never becomes the latter, and
vice versa. As before mentioned, many
pituito-tropic individuals rarely complain
of anything; nevertheless, if one studies
their make-up critically and compares that
make-up with an endocrinopath, a certain
error in common may be discovered by the
Fig. 5.
discerning eye. The headaches, if any are
supraorbital, the digestive disturbances if
any, are accompanied with much gas forma-
tion, and peculiarly enough, a pituito-trop
will manufacture gas out of nothing and re-
gardless of the most careful non-ferment-
able diet. A pituito-trop human being need
not show the perverted vita sexualis of an
Oscar Wilde, but that there will be some
sort of a tantrum in his sexual life is quite
a certainty. All pituito-tropic people are
very methodical and rhythmic in their
work and avocations. They are extremely
fond of music, and are actually pained by
discord. They make the best musicians
(Ysaye, Fradkin, McCormick) as rhyth-
micity is one of the chief qualities of pitui-
tary function. Menstruation is a monthly
phenomenon because of the proper work of
the pituitary gland, and when a girl is the
subject of an adiposo-genital syndrome, her
menstrual rhythmicity is conspicuously
changed. A mature woman menstruates 13
times in a year, but the slightest disturb-
ance in the pituitary changes this number
of monthly fluxes.
The boy presented in photograph No. 5
barely escaped hermaphroditism, whereas
Fig. 6.
in photograph No. 2 for some unknown
reason the tropism assumed a form of
motor unrest of the choreic type. In con-
nection with this latter manifestation, per-
mit me to refer to a young girl of 17 who
was treated for four years by authoritative
neurologists for a most persistent chorea.
When I first saw her she could hardly
walk, and when she did so she mimicked to
perfection the grotesque gait of a well-
known screen actor. At first it did not
dawn upon me that it could be a case of
endocrine interest, but when her psyche
was analyzed together with her soma, I
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ORIGINAL. ARTICLES
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593
came to the conclusion that there was a
primary pituitary defect at the bottom of
the entire trouble, secondarily giving rise
to catamenic distress. She always had
severe menstrual pains and in her mentality
displayed the tastes of a child of twelve.
She was treated with ovarian extracts but
they proved of no benefit. Not until small
doses of pituitary extract were employed
did she show a tendency to improve. She
was totally cured in less than four months.
It is incumbent upon us as physicians to
be able to distinguish between "tropisms"
and "endocrinopathies" and not to treat end
products of disease with drugs, cases like
the one pictured in No. 5. The harm has
been done, and no amount of drugs will in-
fluence the condition to any appreciable ex-
tent. In patient No. 5 it was a question
of saving his sight and his life, which the
surgeon undertook to accomplish and did,
but the dystrophy was not influenced in the
least. We must learn when to treat and
when to admit our limited capabilities.
In considering the second alarming period
of human life, or the second endocrine
crisis, we must not forget that the "gonado-
pause" takes place in men as well as in
women, and that it is a far more difficult
task to be able to treat the former than the
later. The riddle is further complicated
when one is called upon to treat a man who
had some sort of a tantrum during his
sexual life. To disentangle his complaints
and to furnish a tangible meaning to the
story hidden therein is much more of a task
than the untying of the proverbial go rdian
knot. Unfortunately, today as in the past,
the method of Alexander the Great is re-
sorted to without considering the mutila-
tion which often follows.
A patient of this kind presented himself
to me with a history nineteen pages long,
including the methods of treatment and
diqignoses made in his case. Not one phy-
sician looked further than his gastro-in-
testinal tract for the endless story of his
troubles. To rn^e he reiterated his com-
plaints, describing with great skill his sub-
jective discomfort, but he was taken aback
when I touched upon the question of his
znta sexualis. Here was noted the fact
that in two years he had only one sexual
contact, regardless of the opportunities
which offered themselves on numerous oc-
casions. His mannerisms were those of a
young woman, combining forced grace and
an attempt to appear neat and sweet. Altho
but a few years in this country, he never-
theless uses very choice and studious
phrases. The desire to make an attractive
impression is evident in every move or
word. When he stands he assumes the
posture of Venus of Milo, and occasionally
gives his pelvis a gentle twist such as girls
do when they try to turn on their heel
while wearing a tight skirt. His hair is
long and wavy, apparently ordering his
barber not to trim it short. His face was
hairless. His pelvis was distinctly feminine
and his hips large, dimpled and pink, like
those of a baby. He was given ovarian
extract and a week later came with the re-
port that he indulged sexually twice during
that time. His gastro-intestinal discom-
forts were only slightly influenced. In pre-
scribing pituitary extract for a female pa-
tient one must be guided by the eflfect this
drug has on her periodic functions. Even
a woman's dysfunctions, when they assume
a periodic expression, should be treated with
pituitary extract, carefully noting any
change in the symptomatology.
We will assume that the human being
has entered by this time upon the last lap
of life's race and said a final goodby to the
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Ambbican MB>icii<rs
gonads, and that the endocrine administra-
tion of the body is being transferred to the
adrenals. He enters this accompanied
by manifestations which I designate as
"endocrine crisis." They need not be
severe enough to require the help of a doc-
tor; nevertheless, and regardless of free-
dom from discomfort, some physician may
tell him that his blood pressure is high. Of
course his blood pressure is high, and it
should be so, because his adrenals are now
the governors of his functions. In addition
to the high blood pressure they also have
hot flushes, occasional attacks of asthenia,
and a score of other manifestations may
present themselves. Now, in older life,
the blood pressure and other inconveni-
ences of a subjective nature, may be bene-
ficially influenced by allopathic doses of
thyroid or homeopathic doses of suprarenal
extract. It is my intention. to devote this
paper to the elucidation of "pituito-tro-
pisms", and hence I shall not go into the
tropisms of the other endocrines, which will
be the subject of another communication.
But before going any further, do not mis-
construe the purpose of this communica-
tion ; I do not want you to be carried away
by my enthusiasm beyond the limits of prac-
ticability, nor do I expect you to abandon
allopathy or regular medicine; it is also
not implied in this article that one should
go about scrutinizing people and endeavor
to detect in this or that person a candidate
for exophthalmic goitre or dementia prae-
cox. It is the doctor's duty to be able to
designate them properly when they come to
his office. When they display a "tropism"
towards any of the particular glands of life,
and when their complaints justify your en-
docrine interpretation, then and only then,
prescribe endocrine therapy.
If vou bear in mind that small doses are
better and safer than large ones, you will -at
least not harm your patient, nor will you
aggravate his complaints to an extent that
will forever banish from your mind the
desire to use endocrine products again.
One not infrequently reads in medical
journals the statement of prominent doc-
tors who employed this or that endocrine
product in this or that endocrinopathy, un-
successfully. Upon a close study of their
reports the reason for their failures is very
apparent. One tries to cure acromegaly
with pituitary extract; another, dementia
praecox with gonadal extracts; every one
of them uses piledriver tactics, and then
publishes articles about his failures. It is
quite evident that the end products of en-
docrinopathy cannot be cured at all, and
when one tries to do so with huge "allo-
pathic" doses, given in the proverbial
t. i. d. fashion, all one can expect is actual
harm.
Above all, remember to be tolerant and
charitable; this is very important for the
student of endocrinology who earnestly
tries to improve his patient's health. It may
interest as well as surprise you that one
may influence the thyroid function not only
with thyroid extracts, but with ovarian ex-
tracts, pituitary extract, cod liver oil,
spongia and ferrum, given homeopathically,
as well as with the use of mechano-therapy
and osteopathy. If one takes his time to
determine why these various methods have
at times "delivered the goods" it resolves
itself into the fact that in the case of ova-
rian extract, one has a powerful endocrine
drug having an inhibitory thyroidal influ-
ence. When the ovaries are at rest, as is
the case in pregnancy, the thyroid increases
in size as a result of this temporary
lethargy. By giving ovarian extract one
accomplishes just the reverse. However,
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ORIGINAL ARTICLES
September, 1919
595
every Basedowic does not respond to this
therapy, and other means must be used to
influence the malady. Very advanced cases
do not respond to anything. Pituitary ex-
tract works indirectly by influencing the
gonads. Cod liver oil, aside from the fact
that it supplies an excellent fuel for the in-
creased metabolic needs of the patient, also
contains organic iodin in a very suitable
form. Spongia furnishes organic iodin in
a potentized form as prescribed by the
homeopath. Metallic iron is prescribed on
account of its homeopathic relationship to
the complaints of a Basedowic, such as sup-
pression of menses, protruding eyes, or en-
larged thyroid, cardiac palpitation, exces-
sive nervousness, marked muscular debil-
ity, etc., etc. Mechano-therapy and osteop-
athy, by manipulating the cervical sym-
pathetic, often produce a quieting effect up-
on the overworked thyroid. The method
best suited for a given case depends entirely
upon the therapeutic training of the doctor,
who, alas, heretofore cared more for a cor-
rect designation of a disease than for its
removal.
It is quite clear that every case must be
treated on its merits, and that hard and
fast rules will never produce the true thera-
peutic artist, for therapy is as much an art
as painting or music. If one will begin
now he will still be one of the pioneers in
this work, and I am certain will contribute
materially to the elucidation of endocrin-
ology and endocrinopathy. For only as
long as you are able to distinguish between •
"tropism,'* and "endocrinopathy," i. e,, be-
tween therapeutable cases and those which
are only of value to the pathologist and the
sanitarium, will you find satisfaction in
treating endocrine disorders. Endocrin-
ology should be studied in its incipient
forms, for then only can we change the in-
dividual so that he will not become an en-
docrinopath. In a future address I hope
to bring before you the "tropisms" on ad-
renal, thyroid and gonad cases, as well as
such therapeutic suggestions as have come
to my notice.
8 West 86th Street.
OVARIAN SECRETION— ITS RELA-
TIONS TO THE HUMAN FEMALE
ECONOMY AND THE PRACTICAL
OVARIAN ORGANOTHERAPEUSIS.
PHILIP OGINZ, M. D.,
Assistant Gynecologist, Kings County Hospital;
Attending Gynecologist and Assistant to
the Department for the Study of Blood
Symptoms of the Female in the
£3{tst New York Dispensary.
Brooklyn, N. Y.
It is my endeavor in this paper to show
the relationship of the ovarian internal se-
cretion to the female economy; also, to
mention the indications for the administra-
tion of ovarian extract to gynecologic pa-
tients who may be suffering from ovarian
dysfunction. The cloud of uncertainty re-
garding ovarian organotherapy has been re-
moved by such men as Dr. Thomas Osborne
of Yale, so that today the prescribing of
ovarian extracts in office routine should be
as definite as the prescription of pituitrin
or ergot. A thoro understanding of the
action of corpus luteum places in your hand
a weapon of singular merit in specific cases.
A consideration of any one of the duct-
less glands demands a knowledge of the
whole endocrine system. It is difficult to
dissociate ovarian hormone activities from
other ductless glands hormones. It has
been experimentally proven that the vari-
ous glands furnishing internal secretions
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are inter-related and inter-dependent upon
each other. In order to maintain the phys-
iologic functions of the entire human body
it is absolutely essential that all ductless
glands, i. e,, pituitary, thyroid, adrenals,
thymus and gonads work in harmony, some
by inhibiting the actions of others, like
thymus and ovary; others by working in
harmony, synergistically, as for example,
the thyroid and ovary.
It is conceded by the majority of investi-
gators that a pathologic condition of any
one of the glands of internal secretion
throws the entire chain out of equilibrium,
as regards their maintenance of the normal
physiologic activities of the body. Thus
we know that thyroid and pituitary insuffi-
ciency may cause the genital organs to re-
main infantile. Diseases of the above struc-
tures may cause retrogression of the genital
even after normal function had been estab-
lished, thus suppressing menstruation and
causing sterility. We find that similar dis-
orders occur after the removal of the
ovaries before puberty, showing that all
ductless glands have a certain amount of
influence in the proper development of the
female genitalia.
In order to comprehend more fully the
functions of the ovary and its secretions in
the human female, a brief consideration of
anatomic relations, histologic structure and
physiologic functions of the ovary may be
of benefit.
The ovaries are situated on either side of
the uterus, near the pelvic brim and close
to the outer end of the Fallopian tube. Each
ovary projects from the posterior wall of
the broad ligament; it is thru this attach-
ment that the ovary receives its blood
supply. Like all endocrine glands it has
a very rich blood supply, being supplied by
the ovarian artery, a branch of the ab-
dominal aorta, and the tubo-ovarian artery
a branch of the uterine artery.
The ovary is made up of ova, held in
ovisacs of Graafian follicles, together with
connective tissue stroma and connective
tissue cells, which are so densely formed
that the nuclei appear almost together. The
connective tissue becomes thicker toward
the periphery with fewer individual cells,
and forms the tunica albuginea, or capsule,
on top of which is a layer of epithelial cells.
These epithelial celk are the remnants of
the germinal epithelial layer from which
the ova and Graafian follicles are derived.
That portion of the ovary in which the
blood vessels, lymphatics and nerves enter
is known as the hilum. Immediately about
the hilum and extending inwards is the
medullary portion which contains the blood
vessels, lymphatics, nerves and connective
tissue holding them together. The medul-
lary portion of the ovary does not contain
any Graafian follicles.
It is an established fact that the ovary
has a double function, its principal one be-
ing the formation of the ova; here nature
is very lavish in endowing the woman at 18
with about 3,600 ova and maturing about
200 of them during her life time. The
other function is that of furnishing an in-
ternal secretion which is taken up by its
rich vascular supply and whose influence is
felt almost by every organ. It is conceded
by the profession at large that the ovary
furnishes certain hormones which induce
menstruation, maintain pregnancy during
the early months, exercise a potent influ-
ence in the development of the individual
determining the secondary sexual char-
acteristics, such as the development of the
breasts, external genitals, uterus, etc. and
maintains with the other secretory glands
important trophic influences on bones, the
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597
fatty tissue and general metibolism.
The fact that the ovary furnishes an in-
ternal secretion was proven by the trans-
plantation and implantation of ovarian tis-
sue in castrated women. As a result of
these experiments we are able to rule out
ovarian influence thru direct nerve con-
nection and adopt the theory that the ovary
secretes a substance which acts on distant
organs thru the agency of the blood stream.
It is also a common clinical experience that
the symptoms which follow cessation of
the ovarian function, all derangements
which constitute the menopause are influ-
enced by the administration of ovarian ex-
tract. Further proof that the ovary does
furnish an internal secretion is shown by
the very substantial evidence gained from
the removal of the ovaries in animals.
Granting then the ovary does furnish an
internal secretion, the question now arises
as to what part of the ovary presides over
that function. This question has been in
dispute for many years among investigators
and clinicians. The fact is universally ac-
cepted however that the follicular appa-
ratus as well as the interstitial glandular
substance have distinct endocrine functions
determining the fofm of the body. The in-
terstitial glandular substance performs its
most important functions during the pre-
puberty stage, while the Graafian follicle,
with its corpus luteum exercises all of its
influences after puberty. The corpus
luteum forms within the Graafian follicle
after the discharge of the ovum and is
derived from the epithelial cells lining the
follicle. In its full development, the corpus
luteum presents the characteristic picture
of an internal secretory gland with large
pale cells lying in close proximity to thin
. walled blood vessels, much like the adrenals.
Since the interstitial glandular substance
has the same histologic structure as the
corpus luteum, it is fair to admit that it
also furnishes hormones that are of bene-
ficial use to the female economy, tho the
knowledge of their specific action is in-
complete.
The most important factor of ovarian in-
ternal secretion is the corpus luteum. It
presides over the implantation and develop-
ment of the fertilized ovum in the uterus,
the increase in size of the uterus at the time
of puberty, as well as the cyclic changes in-
cident to menstruation. It prepares the
uterus for the implantation and develop-
ment of the fertilized ovum, menstruation
taking place in case of failure of impregna-
tion. The corpus luteum inhibits ovulation.
It has been shown experimentally that
ovulation can be accelerated by the removal
of the corpus luteum. The absence of
ovulation during pregnancy is thus assumed
to be due to the continued existence of the
corpus luteum.
Removal of the influences exercised by
the ovarian tissue or the cessation of their
function by castration, produces changes in
other ductless glands. Among these may
be mentioned the pituitary gland, the hyper-
trophy of which is the cause of skeletal
deviatfons, and accumulations of fat, but
not to the extent that it was formerly as-
sumed to be. While it is true that con-
spicuous obesity in women both after cas-
tration and the menopause and even in those
suflFering from functional amenorrhea does
exist, nevertheless, the fact remains that
many women who are destined to become
fat usually begin to increase in weight long
before the menopause and often reach their
maximum weight before menstruation
ceases; this diminishes the importance of
that observation. Often the increase after
menopause is only apparent, for at that
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time the external tissues lose their firm
contour and fat settles into irregular and
baggy folds, giving the impression of in-
crease in size tho there may not be any
increase in actual weight. In like manner,
the increase of fat in women after a double
oophorectomy has been overestimated.
This operation does not add more to their
weight than after any other operation. An-
other ix>pular misconception regarding the
results of double oophorectomy is that cer-
tain features of the male type may be ac-
quired, such as deepening of the voice,
increase in facial trichosis, coarsening of
the skin and assumption of a general mas-
culine character. Clinical tests do not seem
to verify this.
All the other symptoms, such as hot
flushes, perspiration, dizziness, insomnia
and various nervous manifestations which
castrated women or those who have reached
the end of their ovarian functional activities
show, are well known to all and are sup-
ported by broad clinical observations.
In the discussion of the therapeutic value
of the ovarian extracts, I wish to emphasize
the fact that the combinations of ovarian
substances together with chemical thera-
peutic measures in common use prove of in-
valuable aid in combating the various symp-
toms which arise thru ovarian dysfunction.
Before we can prescribe intelligently for
patients, it is absolutely essential that we
eliminate all pelvic inflammatory diseases
in their active state, new growths and the
various uterine displacements. We may
gain valuable information by taking a com-
plete history, particularly as to age, occu-
pation, social standing, marital relationship,
a premenstrual history to determine the ex-
istence of any congenital malformations or
displacements of the organs, also a post-
marital menstrual history as to whether the
patient is suffering from any form of mens-
trual derangements, paying particular at-
tention to pain in reference to the menstrual
cycle. The post-partum and post-abortive
states, whether the patient had some form
of sepsis, or any remaining after-effects,
must also be taken into consideration.
Having ascertained the above data it be-
comes necessary to make a pelvic examina-
tion, in order to exclude pathologic condi-
tions, as the ovarian extract treatment will
positively fail in their presence. We must
remember that it is our object to replace
only normal ovarian hormone activities, the
lack of which is producing functional symp-
toms, and only after the correction of such
pathologic conditions as uterine displace-
ments, new growths and inflammatory con-
ditions, if symptom's still persist, should
organotherapy be tried.
In cases where the ovaries are destroyed
by disease, removed by operation, or inac-
tive from congenital maldevelopment or
physiologically reduced by menopause,
ovarian extract, two grains twice daily, to-
gether with a suitable tonic, nerve sedative,
or proper stimulant will give encouraging
results. In conditions of infantilism it
favors the further development of the re-
productive organs and 'the establishment
of their activities.
In dysmenorrhea and in disturbances
preceding menstruation such as nausea,
vomiting, headaches, dizziness, etc., corpus
luteum in doses of two grains twice daily
in conjunction with a stomach sedative dur-
ing the week prior to the onset of the flow
will relieve these symptoms. In cases of
amenorrhea or delayed menstruation of
girls and women, corpus luteum together
with a suitable tonic and improved hygienic
surroundings will tend to establish a normal
flow. The value of ovarian extract in small
doses in menopause has been sufficiently
demonstrated in everyone's experience, but
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I wish to impress the importance of com-
bining the ovarian extract with a nerve
sedative (in such cases). Hyperemesis of
pregnancy has been successfully combated
with the intramuscular injections of one
mil of corpus luteum daily, for not more
than 12 days, some cases responding to
four doses. Some clinicians report a few-
favorable results in the treatment of steril-
ity by the use of corpus luteum. Changes
of the skin of the face particularly about
the chin, most evident before menstruation,
have been treated with two grains of ovarian
extract twice daily, one week before onset
of the period. In women past the meno-
pause for several years, who suffer from
pruritis (not due to diabetes), senile vagi-
nitis, vulvitis with remote changes, instabil-
ity, flushes, etc., the ovarian substance in
conjunction with local treatment and suit-
able nerve sedatives has been of benefit.
Contraindications for the use of the ex-
tracts are mainly acute inflammatory pelvic
conditions, pregnancy and hypersexual ex-
citability.
Conduftion. — ^The value of ovarian
therapy is seen in the treatment of patients
suffering from functional deficiency or ab-
sence of ovarian internal secretion ; follow-
ing in importance is its value in menopause
cases, and in young women with functional
amenorrhea. Other types of cases in
which ovarian therapy is surprisingly
efficacious are represented by patients suf-
fering from deficient circulation of blood to
the external genitals, such as pruritis,
kraurosis, furunculosis and other affections
of the vulva in elderly women.
Thus the beneficial effect of ovarian
organotherapy, it is safe to say, has passed
the stage of theory and speculation and it
is now an established fact.
490 Stone Avenue.
UPSIDE-DOWN POSITION IN
TREATMENT OF VAGINITIS.
RICHARD HOGNER, M. D.,
Boston, Mass.
For more than 15 years I have used the
upside-down position in the treatment of
vaginitis of small girls. A strong person
takes hold of the baby's or child's both feet,
turns it upside-down, holding it swinging
free in the air; at the same time another
takes hold of its both arms, for controlling
the position and keeping them away. The
vagina I fill to overflow with some anti-
septic, such as argyrol solution or oftener
with tannin glycerine or some other gly-
cerine combination. The heavy solution
goes down to the bottom; the whole "cul
de sac'* will be reached by the application,
which if glycerinated will long adhere
and maintain its action. The procedure is
repeated daily till restitutio ad integrum,
which as a rule comes fairly fast. Never
do I permit such a home-treatment, as the
position looks too cruel and the parents
often do not dare to take it up, fearing the
objections and criticisms of "friends" who
think they know more than the "harsh"
doctor. The child can stay very long in
the upside-down position without any dis-
comfort ; however, till used to it, it always
cries and fights against it.
Recently I have applied the position in
treatment of vaginitis (gonorrheal) in full-
grown women and with real "quick cures."
After a little practice the upside-down posi-
tion is easily taken from a low table or
high bedstead, the legs thereupon, the body
— with head down — in the air and the el-
bows and forearms on the floor. The
vagina almost opens itself; is filled to
overflowing with the antiseptic chosen
(often potassium permanganate) and the
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ORIOINAIi ARTICLJDS
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patient stays as long as she can, long enough
to disinfect thoroly. The advantages of
this treatment are: painlessness (the usual
swabbing of the vagina is always painful),
and thoroness, as the "medicine" reaches
everything, also between the folds, which
it helps to flatten out.
HYGIENE OF THE DOOR-KNOB.
BY
W. H. RAND, M. D.,
VSTashlngton, D. C.
Stationing himself in the anteroom of a
toilet in a governmenjtal department build-
ing prior to the noon-time luncheon, a
Washington physician recently took note
of the behavior of the twenty-nine male
clerks who visited either closet or urinal
just before leaving the premises for a
neighboring cafe.
Of the entire number only three (ap-
proximately ten per cent.) availed them-
selves of the lavatory facilities,* before go-
ing to eat ; twenty-six left the building with-
out approaching a wash-bowl.
Now, since every man on leaving the
room was obliged to pull open a heavy door,
his hand of necessity grasped the door-
knob. Waiving the question whether there
were any venereal or typhoid carriers in
the group, each of the twenty-six may have
deposited vigorous intestinal flora, or a
drop of urine, on the aforesaid door-knob.
In that case, the immaculate three who
cleaned up were not much better oflf than
the rest, for they had to handle the con-
taminated door-knob, befouled by their un-
washed associates.
The incident illustrates the fact that train-
ing in elementary personal hygiene is
^ These were ample, with plenty of soap and
hot and cold water.
shamefully neglected. Over and over again
it has been demonstrated in the laboratory
that the majority of human hands are
loaded with fecal bacteria. These are dis-
tributed in a most altruistic fashion by di-
rect contact, as in band-shaking, or indi-
rectly, as by door-knob pollution. Now
tho all this potential mischief may be done
inadvertently and without malice, it is safe
to give new emphasis to the old admonition
that
**Evil is wrought by want of thought
As well as want of heart."
Secretions from the nose and throat con-
stitute an accessory and inexhaustible source
of infective door-knob defilement, and here,
too, the vectors are the hands. But for the
present it is unnecessary to make an ex-
haustive enumeration of the modes of man-
ual or digital infection. The sole purpose
of this screed is to insist that the observ-
ance of sanitary laws is a moral obligation
and a reciprocal duty. Voltaire says that
hygiene is a virtue, rather than a science.
So much the better. Virtues are to be
practiced, not labeled, indexed, pigeon-
holed and forgotten.
It is a matter for gratulation, therefore,
that Red Cross officials are planning to
conduct a campaign of public health educa-
tion by means of exhibits, lectures and
demonstrations before the Chautauqua as-
semblies in their chief circuits thruout the
country during the current season. A proj-
ect so sane in conception and so salutary
in its aims is just what might have been
anticipated from that elastic and adaptable
organization.
It is hoped that the apostles of this
itinerant mission may not only impart an .
adequate knowledge of hygienic principles,
but that they may be able to adapt their in-
struction in sanitation to practical ends and
to the needs of common life.
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ORIGINAL ARnCIiBS
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601
General progress in sanitary reform is
exceedingly slow, like the movement of a
glacier. Before any advance can be made
in public hygiene, the mass of community
sentiment must, be acted upon and set in
motion by the genial warmth of an en-
Kghtened social conscience.
So long as the public mind remains inert
and indifferent in reference to the subject,
it will be impossible to institute improve-
ments by means of esoteric theories or lab-
oratory analyses, tho the scientific demon-
strations and research work deserve to
rank as crucial experiments.
This is not to depreciate theoretical in-
struction or disparage the service of the
laboratory. Their aid is indispensable ; but
until utilized, reduced to practice and ap-
plied to living conditions, science never gets
anywhere. Academic hygiene merely marks
time, without advancing a single step.
With iteration and emphasis it should be
urged that the requirements of physical
well-being must be enforced. But this en-
forcement is feasible only thru coopera-
tion, that is, thru the intelligent, voluntary,
universal observance of hygienic laws. A
League to enforce sanitation must be
formed.
Doubtless the delicately manicured young
men in the departmental civil service here
referred to hold themselves to be daintily
neat and tidy in their personal habits. But
they and the rest of mankind need to be in-
structed by precept, by example, by rational
and detailed explanation, but, above all, by
patient drill and practice, how to be clean.
It is apparent to any observer that habits
of personal hygiene need to be cultivated.
To be convinced of this necessity notice how
people generally perform their ablutions.
They commonly draw or pour a little water
into a wash bowl, and then dip and wring
their hands in it with the distressed and
reluctant air of an eight-year old boy that
is required to take a bath. Then they
swazzle their faces over with the same dirty
fluid in which they have rinsed their hands,
and the task is done. Watch out and note
how prevalent this form of hydrophobia is.
It ought not to be necessary to point out
that, after scrubbing the hands, the water
used for the purpose should be thrown out
or drained away, and a fresh supply taken
for the face. Of course, the ideal clean-
up is secured by opening the faucet and
washing the face and hands with hot run-
ning water and soap.
Interdigital scouring should be thoro,
and the nail-brush should be vigorously
plied to clean out the favorite ghettos of
bacterial nidification — their "bed and pro-
creant cradle."
Instruction in the proper use of the tooth-
brush should also be given, and the method
should be demonstrated over and over
again, until the habit of brushing the teeth
on both their buccal and lingual surfaces
has become an automatic and routine prac-
tice.
These are only a few obvious examples
of hygienic procedure which should be
standardized. But all training along the
lines of health conservation must be per-
sonal and specific. It should begin with
intensive drill in the home, and be followed
up and coordinated, without any discon-
tinuity, thruout the entire period of educa-
tion, from the days of the bookless kinder-
garten to the end of post-graduate tuition.
A revised old classic I append
'To point a moral" and make an end: —
This is the house that Jack built.
This is the W. C. door
That hung in the house that Jack built.
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ORIOINAIi ARTICLB8
Ambrican Mbdicinb
This is the door-knob
That oped the door,
The heavy W. C. door,
That hung in the house that Jack built.
This is the man with the fecal hand
That turned the door-knob
That oped the door,
The heavy W. C. door,
That hung in the house that Jack built.
This is the small and cleanly band
That followed the man with the fecal hand
That turned the door-knob
That oped the door,
The heavy W. C. door.
That hung in the house that Jack built.
This is the doctor
That took his stand
To watch the small and cleanly band.
That followed the man with the fecal hand
That turned the door-knob
That oped the door.
The heavy W. C. door.
That, as we have said before,
Hung In the house that Jack built.
TONSILLITIS AND PHARYNGITIS
AS A RESULT OF ORAL SEPSIS.
H. B. ANDERSON, M. D.,
Toronto, Canada.
The linking up of the chain of evidence,
anatomic and pathologic as well as clin-
ical, to explain certain well recognized in-
terrelationships of disease has progressed
rapidly during the past few years. In 1903
Schottmiiller described methods for differ-
entiating various types of streptococci on
blood agar cultures, and later Rosenow pub-
lished his researches on transmutations with-
in the streptococcus-pneumococcus group
and attributed a selective affinity on the part
of these organisms, under favorable cultural
conditions within the body, for certain
organs and tissues. The demonstration of
varying degrees of virulency in different
strains of streptococci and the predilection
of some to attack certain tissues, an affinity
which Rosenow believes is variable at diff-
erent times depending on the source and
conditions under which the organisms de-
velop, has shed much light on the causation
of many common diseases due to focal in-
fection. The work of Billings and many
other investigators has contributed largely
to further progress along these lines, of the
greatest clinical importance. Thus we have
now a satisfactory explanation of the fre-
quent clinical association of appendicitis,
gastric and duodenal ulcer and gallstone
disease, secondary to oral and tonsillar in-
fection.
The relationship of tonsillitis to rheuma-
tism and of the latter to the erythema group
of skin diseases has been recognized for
years. Next it was shown that appendi-
citis might be due to hematogenous infec-
tion from the tonsils and that infection in
the latter might also initiate acute or
chronic disease of the kidneys. Thus, there
has been a gradual tracing back of many
systemic diseases to important original foci
of departure for the infection producing
them.
The fact that tonsillitis is often secondary
to oral sepsis and that marked cases of the
latter are almost invariably associated with
tonsillar infection, has not received from
either throat specialists or general practi-
tioners the recognition which its practical
importance warrants. It is not even men-
tioned by many authors of recent standard
works in diseases of the throat.
W. D. Miller in 1889, in his epoch-mak-
ing work on the "Microorganisms of the
Human Mouth," refers to this association
and it is especially emphasized by Wm.
Hunter in 1900 in his work "Oral Sepsis,"
in which he states that tonsillitis and
pharyngitis, like stomatitis and septic gas-
tritis, are directly due to the diseased con-
dition of the teeth, tho he comments on the
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American Medicine ORIQINAIj ABTICLBS September, 1919 603
notable failure of authors to recognize a frequently lead to the discovery of a focus of
condition so obvious on careful examination infection responsible for an obscure sys-
of these cases. teniic disease, or account for the persistence
Few clinicians can have failed to note of symptoms or incomplete cure after a se-
that attacks of sore throat not infrequently vere oral infection has been removed by den-
follow dental treatment. tal treatment.
For some time I have made it a point to During the past winter I have made
examine closely the throats of all office pa- swabs from the interior of the crypts, the
tients suffering from dental infections. peritonsillar tissue or from the escaping pus
A general catarrhal condition with red- in 330 routine office cases, usually one swab
ness and hypersecretion of the throat is from each side. Cultures on blood agar
commonly evident, and a tendency to were made by R. W. Mann with the follow-
hawking, recurrent attacks of cold or dry- ing results:
ness of the throat is frequently complained Cases Alone %
of. Often there is little local discomfort, streptococcus, unclassified 16 2 4.7
and the tonsils oftea are atrophic, con- g^^^rsteptT. . ! ! ! : ! 'Is ^4 lil
cealed and may present little superficial evi- Strept Viridans 81 24 24.5
1 r . ui A .• . r . staph. Albus 220 56 66.6
dence of trouble. A history of recurrent staph. Aureus 46 9 13.9
•attacks of tonsillitis or the escape of case- ^*^"" Mucosa 12 0 3.9
Otis material from the crypts, however. The non-hemolytic streptococcus was
may often be obtained. found most frequently in contrast with the
Pressure by a spatula backward and out- streptococcus viridans, which is most fre-
ward on the anterior pillar of the fauces, quently found in suppurative lesions about
so as to extrude the tonsil, and bring it into the teeth. This may be due to a transmu-
view and then pressure with another blunt- tation in streptococcal types in the passage
ended spatula compressing the tonsil itself, of infection from teeth to tonsils.
will often cause the escape of pus, either While the type of streptococcus varied
from the crypts or from the peritonsillar considerably in different months the pres-
tissue. I recently saw a patient with recur- ence of pathogenic bacteria in the tonsil
rent renal hemorrhages of some years' dura- does not necessarily mean that the pa-
tion in whom ordinary view of the throat tient is suffering from active disease, yet
showed no evidence of diseased tonsils. The if pus and other evidences of the inflamnia-
latter were quite small, but firm pressure tion are present, it suggests an active infec-
caused a stream of thin, yellow pus to es- tion capable of producing systemic disease,
cape from the right supratonsillar fossa, and improvement of the latter following
Tonsils which have been clipped, or tags enucleation of the tonsils is additional evi-
which remain after incomplete enucleation, dence of the virulence of the organisms iso-
are especially liable to be infected, the scar lated. Moreover, in recent epidemics in
tissue sealing in the pus, so that evidence military camps, it has been shown that
of infection is slight on inspection ; also the carriers of streptococci are most liable to
''^S^Rcd spongy tonsil with fissures and gap- develop pneumonia, secondary to measles
ing follicles, is often the seat of disease. A or influenza, and that of the most virulent
thoro examination as before described will type.
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PHTSICiLL THERAPY
Ambhxcan MbdiciKe
The usual mode of tonsillar infection
from the teeth is probably by swallowing,
tho no doubt it may also be thru either the
blood or lymph streams, as there is lym-
phatic connection between the posterior
teeth and the throat.
The presence of dental infection in cases
of tonsillectomy or enucleation has many
clinical bearings of importance. This applies
especially to clipping operations or where
tags of tonsilla tissue have been left. (1)
The persistence of focal infection in the
mouth is likely to keep up the systemic symp-
toms for which the tonsils were removed, or
at least to permit only a partial cure. This ac-
counts for many unsatisfactory results from
the removal of infected tonsils. (2) Oral
infection tends to aggravate the inflamma-
tory reaction in the throat following opera-
tion and at times keeps up a persistent
sore throat from which one may often
obtain cultures of streptococci long after.
(3) It is possible that removal of the tonsils
in severe cases of oral sepsis may even'
increase the tendency to systemic infection
by taking away one of the barriers to its
entrance into the circulation.
The question therefore arises, "What is
the surgeon^s proper course of action in
cases of oral sepsis with associated tonsillar
infection?" Obviously if tonsillitis is fre-
quently secondary to the oral trouble, the re-
moval of the latter should precede operation
on the tonsils. It is possible that this course
would make more successful our efforts to
deal with tonsillar infection by local treat-
ment rather than by operation, tho Billings
says the infected tonsil cannot be successful-
ly sterilized by any known method of treat-
ment, and entire removal is the only safe
procedure.
REFERENCES
Miller, W. D.: Die Microorganismen der
Mundhohle, Leipzig, 1889.
ScHorTMUELU&B, H.i Der Artuntersuchenden
der fur men schem Pathologem Streptokok-
ken durch Blutagar, Munch. Klin. Woch.
1903, 849.
RosENow: Transmutation Within the Strepto-
coccuB-pneumococcus Group. Jour, Inf. Dis.,
1914, XIV, 1.
Billings, Frank: Focal Infections, Appleton
ft Co., 1917.
HuNTEB, Wm.: Oral Sepsis, Cassel ft CJo., 1900.
Anderson, H. B.: Appendicitis as a Sequela of
Tonsillitis. American Jour. Med. 8c., CL,
4, 151, 1915.
Under the Editorial Direction of Albert C.
Geyser, M. D., New York.
T»E 50N-SURGICAL TREATMENT OF GAS-
TRIC TLCER,
A therapeutic procedure must be based
upon the causative factor of the disease.
What is the cause of gastric ulcer?
According to the universally accepted
dictum, gastric ulcers are divided into the
acute and chronic forms. Such a division
sheds little light upon the question. It is
reasonable to suppose that every chronic
ulcer, at some time or other had an acute
beginning. It is also possible that this
acute beginning of the ulcer was preceded
by a still more simple lesion such as an
erosion. The causes for a simple erosion
are so manifold that we must come to the
conclusion that every gastric erosion is not
followed by an acute ulcer. In fact the
great majority of simple erosions undergo
spontaneous recovery after removal of the
cause. It must be admitted that it is prac-
tically impossible to diagnose simple ero-
sions of the mucosa of the stomach, but
that such lesions do occur, there can be no
doubt.
We may be equally certain that some of
these simple erosions do not undergo spon-
taneous recovery and that they may be the
starting point of an acute ulcer of the stom-
ach.
As one cause of an acute ulcer we must
consider anything, therefore, that may be a
causative factor of a simple erosion of the
gastric mucosa.
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605
We will not attempt to enumerate all the
possible causes of simple erosions.
The stomach is subject to trauma over
any part of its inner surface, especially at
the fundus, yet we seldom find acute ulcer
in this region.
Ulcers of the stomach occur at different
locations in following proportions :
On the lesser curvature 35%
Posterior wall 28%
Pylorus 14%
Anterior wall 9%
Cardia 6%
Fundus 3%
Greater Curvature 3%
Anterior wall 67%
Thus it becomes apparent that erosions
may occur anywhere upon the mucosa.
Nearly 75% of all gastric ulcers are lo-
cated in the upper mucosa of the stomach,
reaching from the esophagus to the pylorus.
Such a distribution is not a coincidence;
there is a definite c^use for its occurrence.
The blood supply of the stomach is de-
rived from numerous branches of the celiac
axis which forms a rich capillary net work
beneath the submucosa. There is nothing
unusual or noteworthy in the blood supply.
Yet some authors have laid great stress up-
on the fact that first an anemic area is pro-
duced, and that the erosion takes place as
a consequence of self digestion.
"The nerves to the stomach consist of
the terminal gastric branches of the vagus,
and the sympathetic fibres of the solar plex-
us. Both are almost invariably composed
of non-medulated fibres. Numerous small
ganglia (according to Remack) form plex-
uses with these nerve fibres, either between
the layers of the muscular coat or in the
submucosa. From these plexuses nerve
fibres run thru the muscular tissue, or the
glandular tissue of the mucous membrane."
(Luciani's Human Physiology,)
"Until recently the direct influence of the
nervous system on gastric secretion was
regarded as doubtful. The results of ex-
periments were either negative or less ob-
vious than for the salivary secretion. * * *
The gastric secretion does not depend ex-
clusively upon the secretory fibres of the
vagus, since the stomach is capable of suf-
ficiently digesting alimentary substances
introduced into it, even when vagi have
been divided. This suggests that other
secretory fibres, spinel or sympathetic in
origin influence the gastric glands; but
there are at present no experimental proofs
of this conjecture. * * * Heidenham as-
sumed that the digestive capacity of the
stomach persists even after division of the
centers of all cranial and spinal nerves to
the stomach. It is probable (altho it has
not been experimentally demonstrated) that
the gangliar plexuses in the walls of the
stomach represent a system capable of spe-
cial reflex activation of secretion." (Luci-
ani's Human Physiology,)
Since most of the ulcers of the stomach
were found upon the lesser curvature of
the stomach the surgeons developed a cer-
tain technic. A "V" shaped piece was re-
moved and the edges again coaptated. After
a time a large percentage of these operated
cases again came to operation and it .was
found that as a result of the *"*V" shaped
section hourglass contraction had taken
place. This technic was then abandoned
and others substituted. The results were,
however, that only too frequently a second-
ary operation was necessary ending in a
complete gastrectomy. When we recall the
fact that a gangliar plexus exists between
the layers of the stomach then take into
consideration the surgical fact that hour-
glass contraction resulted from localized
operations upon the lesser curvature, we
have a strong reason for suspecting that
such a ganglionic plexus may be located at
the lesser curvature. If such is the case,
then the resulting hourglass contraction
is easily explained.
There is still another factor which must
not be overlooked. The muscular coats of
the stomach are arranged in three layers.
There are two principal layers, the ex-
ternal longitudinal and the internal circu-
lar one. A third layer of oblique fibres ex-
tend over the great pouch only ; it extends
obliquely over the fundus from left to
right and ceases at a distinct line extend-
ing from the left margin of the esophagus
to about the junction of the middle with
the last third of the great curvature. This
anatomical fact is interesting, for it is about
the point where the oblique layer pf fibres
ceases that the stomach becomes constricted
during the movements which are incident
to digestion, dividing the organ into two
tolerably distinct compartments*
The ulcer is usually situated at the lesser
curvature; if then a "V" shaped piece is
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PHTSICAIi THBRAPT
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removed — assuming that a possible gang-
lionic network is located at this point — ^the
removal of it, in whole or in part, will ac-
count for the interference with physiologic
function. Since, however, the exact loca-
tion of these ganglionic centers is still a
mooted question, may not the arrangement
of the muscular fibres be responsible for the
hourglass contraction which as a rule fol-
lows the removal of the ulcerated area?
It is for this reason that the present day
operators have agreed to do a gastrectomy
and an end to end anastomosis of the re-
maining organ. Such a procedure, not only
involves a more serious operation, but the
patient is minus a larger part of an organ,
the loss of which may have a serious influ-
ence upon his future longevity.
The Ulcer Itself. — ^The lesion varies in
size from less than one inch to three or
four inches in diameter; it is essentially a
localized necrosis. Of importance is the
fact that these ulcers are surrounded by a
zone of stasis. There are no signs of active
inflammation, hence almost an entire ab-
sence of the process of healing. The gas-
tric ulcer, acute or chronic, presents a com-
plete demonstration of the fact that with-
out inflammation there can be no repair.
It also suggests the possibility, that if some
of the phases of an inflammatory process
could be inaugurated at* the site of the
lesion, healing or repair would take place.
Physiologic Anatomy. — ^The sympa-
thetic ganglia located between the third and
seventh dorsal interspaces supply the
stomach with the vaso-motor control. All
repair of injury in any part of the body is
under the immediate control of the sympa-
thetic system. The blood supply to any
part or organ is directly dependent upon
the condition of the sympathetic ganglia
with which it is connected. When the
ganglia are in a state of active hyperemia
the impulses emanating from them are tonic
in character, producing a capillary contrac-
tion at their distal extremity. When the
ganglia are in a state of anemia the im-
pluses, if any are sent out, are weak caus-
ing relaxation, engorgement and stasis at
their distal extremities. Either one of these
conditions long continued with the sympa-
thetic ganglia supplying the stomach would
lead to the very condition that is found in
acute or chronic ulcers.
Indicated Therapy. — Since neither long
continued hyperemia nor anemia of the
sympathetic nervous ganglia lead to repair
of tissue, it follows that any means that
will restore an equilibrium must bring with
itself the means for a cure. If we apply to
the spinal region between the 3-7 dorsal
region a flexible tin electrode 2-4 inches in
size, and another one of the same material
but larger is applied over the gastric area
in front of the body, we can, by the aid of
diathermia heat the entire region. After
one hour of such application, a spinal ice
bag should be applied to the same dorsal
region for thirty minutes. Since relaxa-
tion takes place quicker and easier than
tonicity, only one-half of the time is re-
quired for the cold application. These two
treatments should be applied twice daily
during the acute clinical manifestations,
later once daily, then on alternate days.
Personally I have. not been impressed with
the results from special dieting. On gen-
eral principles I have recommended a bland
diet. If acidosis is present it must be
overcome by the administration of alkalies.
The above outlined treatment will symp-
tomatically relieve practically every case of
clinically diagnosed acute ulcer of the stom-
ach.
Conclusions.
1. Every therapeutic measure must
have for its first object the removal of the
cause.
2. Chronic ulcer of the stomach may
result from anything capable of causing a
simple erosion.
3. Seventy-five per cent, of all stomach
ulcers are situated somewhere on the lesser
curvature of the stomach : too often to be a
mere coincidence.
4. Surgical removal of the ulcer locally
is followed in seventy-five per cent, of the
cases by hourglass contraction of the stom-
ach ; also too often to be a mere coincidence.
5. The ulcer is always preceded by a
localized anemia and stasis.
6. The blood supply to the stomach is
under the control of the sympathetic gang-
lia of the 3-7 dorsal interspaces.
7. Ninety per cent, of all clinically diag-
nosed cases of ulcer of the stomach have
been completely and permanently relieved
by applying heat and cold to the sympa-
thetic region.
8. In unrelieved cases that have come to
operation, the patient suflfered from the ad-
hesions and not from the ulcer.
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RATIONAL. ORGANOTHERAPY
September, 1919
607
DIATHERMIA IN THE POST PARALYTIC
STAGE OF POLIOMYELITIS.
^liss G. age 22 years suffered an attack
of poliomyelitis at the age of one and a half
years. The treatment of poliomyelitis, in
many respects, was about the same ninteen
years ago as it is today. In the main
it consisted of the application of exter-
nally applied heat, massage, and the caus-
ing of muscular contractions by either the
galvanic or the faradic current (now con-
demned as not only useless but as possibly^
harmful). The result of this treatment
was that the left leg from the hip down
remained in a state of flaccid paralysis.
From the non-use atrophy had set in to a
marked degree. The left shoe required a
cork sole four and one-half inches thick.
It was in this condition when Doctor I. L.
Nasher, her family physician, referred the
patient to me in October, 1916.
Upon examination we found complete re-
action of degeneration in all of the muscles
of the affected limb with the exception of
the quadriceps extensor, which showed a
partial reaction only. The leg and foot be-
low the knee was cold, blue and flaccid.
There was shortening of four and a quar-
ter inches ; the foot was two inches shorter
than its fellow and correspondingly smaller.
The patient was subjected to the diather-
mic method of treatment. One year later
the X-ray plates showed lengthening of
the leg bones amounting to three-quarters
of an inch. During the same time three-
quarters of an inch had to be removed from
the cork sole.
The greatest progress has been made since
October last; another one-half of an inch
has been removed from the cork sole.
This past summer the patient took up
swimming and has almost perfect use of the
entire limb. During the time of treatment
her shoemaker has been obliged to change
her last four times. This had not been
necessary for six years preceding. The
foot is now one-half inch shorter than its
fellow and, to the casual observer, of the
same size and general appearance as the
right foot.
In many of the cases previously shown
or reported the question always arose ; is it
not possible that these cases would have
recovered without treatment? Who shall
say that they might not have done so? In
this case nineteen years had elapsed since
the acute attack. During all of this time
nothing was left undone in the way of
treatment. The patient did not, however,
recover the use of her limb and there was
superinduced the usual amount of atrophy.
Within less than two years from the be-
ginning of the treatment with diathermia
from a Telatherm apparatus, the entire limb
has grown in length and circumference, the
foot is almost normal in size and the func-
tion of the limb has been restored to use-
fulness.
Dr. H. Wolf showed a case before the
orthopedic section of the Academy. In his
case both the upper and the lower extremi-
ties were involved. No treatment -showed
any results until diathermia was used on the
lower extremities only. When shown be-
fore the section, this patient could walk un-
aided ; the upper extremities, which were
purposely not treated were as flaccid as be-
fore.
Taking these and similar cases as testi-
mony, we are forced to the conclusion that
diathermia, so far, is the only agent that
has shown real results in the 4ong standing
ca.ses of paralysis following anterior polio-
myelitis.
Clinical Identification of the Th3rroid
Hormone. — In an excellent paper pre-
sented at a recent meeting of the Associa-
tion of American Physicians by Drs. E. C.
Kendall and H. S. Plummer, the authors
discuss the thyroid hormone. In 1915 the
isolation of the thyroid secretion in crystal-
loid form was accomplished. Since then
efforts had been directed to the accumula-
tion of the substance. Structural and em-
pirical formulae were determined and later
preparations were made to prove the fomiu-
iae. These synthetic formulae were stud-
ied and the substance was found closely
related to the amino-tryptophan group.
With the isolation of a single crystalline
substance, quantitative measurements were
possible. There were two points to be con-
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September, 1919
RATIONAL, ORGANOTHERAPY
American Medicine
sidered : ( 1 ) What the substance did in the
body; (2) how was this action brought
about. Thyroxin was really an amino-acid.
The word thyroxin was an abbreviation of
"thyro-oxy-indol." From a study of the
absence of this substance, one was justified
in saying that thyroxin was not essential to
life. Its action was superimposed upon that
of the amino acids of the body. With com-
plete absence of thyroxin, however, there
was a lack of flexibility in the energy out-
put, as seen in myxedematous individuals.
Probably there was one part of thyroxin in
ten million in the blood, two parts in ten
million in the tissues, and three parts in ten
million in the liver. The equilibrium exist-
ing in normal individuals lay within very
narrow limits. There had. to be close rela-
tions between the amount in circulation
and that in the tissues. There was less than
one-third of a grain functioning in the en-
tire body. The question as to its mode oi
action was examined, as to whether iodine
was necessary to its function. It was found
that the NH group was essential to the ac-
tion of the substance. Tests were made
upon tadpoles to see which part of the sub-
stance exercised influence in metamorpho-
sis, whether the organic nucleus or the
iodine. It was found that metamorphosis
was influenced by the acetyl derivatives and
that thyroxin, therefore, had a closer rela-
tion to the acetyl nucleus.
Fatigue at the Front. — Cheyron (Med-
ical Press, Aug. 28, 1918) reports that
he found that fatigue is the clue to many
clinical pictures, and he cures them by rest,
repeated laxatives and restriction to water,
with administration of quinine. Some men,
it appears, returning from the trenches at
Verdun, had reached such a stage of auto-
intoxication from prolonged constipation
that enteritis followed, and several weeks
elapsed before normal conditions were re-
stored. He advises the use not only of
drugs but of glandular extracts, including
that of the testicles, "concluding with a
course of tonics and means to recalcify the
orcranism."
Post-influenzal Hypothyroidism. — ^That
the endocrine glands are affected by an at-
tack of influenza was evident in the epi-k
demic of last fall. The, chief influence is
upon the adrenals, tho other glands are
commonly aflfected. In Progresos Clinica
(abstract Journal A. M. A., July 12, 1919,
p. 157) Dr. W. L. Albo details two cases in
each of which, following an attack of in-
fluenza, girls of 11 and 10 developed som-
nolency and headache and became forgetful.
These were the only cases of unmistakable
hypothyroidism he encountered, although he
had many cases of post-influenzal nervous
and mental disturbances, neuritis, menin-
gitis and meningeal reactions, chorea, mild
or paralytic, and psychoses. In one of these
hypothyroid cases, under thyroid treatment
the somnolency improved at once, the head-
ache disappeared by the third day and the
memory returned to normal the fourth or
fifth day. In the second case the headache
yielded to the thyroid treatment, but the
somnolency and the impairment of the
memory persisted for over three weeks ; the
ultimate outcome is unknown. In conclu-
sion Albo remarks that the toxemia of in-
fluenza may sometimes have the opposite
effect, increasing thyroid functioning and
entailing symptoms of exophthalmic goiter,
esj)ecially in persons with simple goiter or
otherwise predisposed.
Intrathoracic Goiter, Showing a Thy-
rotoxicosis*— Leiner cites a case (N. Y.
Med. Jour,, Aug. 2, 1919) in which Forch-
heimer's treatment of quinin hydrobromate
and ergotin resulted in improvement, but
when it was stopped a relapse occurred, both
subjectively and objectively. When the pa-
tient received ovarian extract some im-
provement was noticed in regard to her hot
flushes and tremor. Then she was given
5 grains of thymus extract three times a
day. No exacerbation of her thyrotoxic
symptoms was observed.
Pituitary Extract in Incontinence of
Urine. — ^After three or four subcutane-
ous injections of the pituitary extract, given
once a week in doses of 0.2 to 1.0 mil.
(Cc), depending upon the patient's age.
incontinence of urine has disappeared in
even the most inveterate cases, and there
has been no recurrence for three or four
months. — Urologic and Cutaneous Rczneiv.
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Ambbican Medicine
BY-WAYS AND HIGH- WAYS
September, 1919
609
TTie Prescription of AlcohoL — ^The re-
striction^ imposed on physicians of prescrib-
ing a limit of one pint of alcohol in ten
days to any individual is one of the most
myopic and unintelligent measures that has
ever found its way into the statutes. The
intention of the measure is obviously of the
best ; it is meant to curb the dishonest prac-
titioner and prevent him from evading the
prohibition regulations by prescribing
enough alcohol to favored "patients" to
render them immune from the threatened
and impending drought. But the mind that
conceived this measure, well informed as
it was of the merits of sobriety, was ex-
ceedingly ill informed regarding medical
needs. The result is a measure which is an
affront to the honest doctor and which is
hardly a safeguard against the dishonest
one. There are many loopholes thru which
any doctor so minded can easily escape
the restrictions imposed; and the sole up-
shot of the measure is to obstruct the well-
intended practitioner only, for his honesty
will forbid him tp tamper with any statute
however mischievous it may be. The result
will most certainly prove regrettable to the
doctor and very costly to the public. The
limit imposed, one pint in ten days, is mani-
festly dictated by the desire to confine the
amount of alcohol obtained illicitly with the
aid of a doctor to so small a measure that
it will hardly serve the cause of inebriety.
In point of fact, this limit merely serves to
endanger the lives of innumerable patients
suffering from ailments in which the
use of alcohol in ample quantities is ab-
solutely essential. The one-pint-in-ten-
days restriction can only create mischief
and can do no good at all. For, if alcohol
is required at all in medical cases, it is re-
quired in large doses. Manifestly the
father of this measure had a vague no-
tion that alcohol was indispensable in some
cases, but he must have "been very ill-ad-
vised as to the amount essential. In any
highly toxic condition, such as pneumonia,
certain types of influenza, and in elderly
people, at least several ounces a day are re-
quired. At this rate a pint would not last
very long. A reduction of the dose to
meet the 'limit the law imposes would merely
involve a complete defeat of the efforts of
the doctor. A reconsideration of the meas-
ure, with a closer scrutiny of the needs of
medical efficiency, is absolutely essential.
As it stands now, it is merely a monument
to the blindness and the bigotry of those
who wall insist on absolute and unqualified
prohibition at whatever cost. The difficul-
ties that complete prohibition will bring in
its train will prove sufficiently trying and
troublesome in their effects on the healthy
members of the community without inviting
a dangerous restraint upon the needs of ail-
ing ones.
Motor Accidents and Speed Laws. —
Despite the increase and complication from
year to year of laws regulating the motor
traflSc, accidents have been increasing con-
sistently. The authorities, facing this ex-
traordinary phenomenon, are at a loss to
explain this increase ; and yet the explana-
tion of the failure of traffic laws is really
very simple. Anyone who has ever been in
Paris must have been impressed by the
utter disregard with which chauffeurs drive
their cars thru the crowded boulevards.
They no doubt are familiar with the some-
what exaggerated legend that a man who is
hit by a taxi will escape as fast as his legs
will carry him lest he be arrested for imped-
ing the traffic. They will recall that there
is no speed limit in the city, that drivers
can go as fast as they like. And yet acci-
dents are much rarer in Paris than they are
in New York, where there is a speed limit.
From this, one may gather that the trouble
with bur motor regulations is that they
are designed entirely to reduce speed, des-
pite the fact that the average driver's in-
difference to speed limits is proverbial. In
Paris, the man at the wheel can be arrested
only for careless driving. The penalty is
based on the quality of his driving and not
on its tempo. In that respect they show
greater wisdom than our own authorities.
Rarely is it the fast car that gets into
trouble. Nine times out of ten accidents
are the result of reckless driving. Ambu-
lances have the right of way on city thoro-
fares and they drive as fast as the engine
will propel them. The in frequency of
ambulance accidents is ample evidence that
speed has very little connection with mis-
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BY-WAYS AND HIGH- WAYS
American Mbdicink
haps. Doctors' cars are at liberty to break
the speed laws, and yet doctors are rarely
guilty of accidents. The sooner the author-
ities take their attention away from the
speed element, which few drivers ever re-
spect, and turn their efforts to eliminating
careless or unintelligent or mischievous
driving, which they can really prevent, the
sooner will the number of accidents begin
to show a decrease. The penalty for care-
less driving should be severe and it should
be rigidly exacted. Fast driving should not
be penalized unless it occurs in circum-
stances which make it reckless. And one
of the first things the authorities should do
is to attack incompetence at the wheel.
Misdemeanors on the highway are of
frequent occurrence. There are two classes
of drivers who are perhaps the cause of
more accidents than any other. One is the
proud owner of a small car who bears a
grudge against every large car that travels
the same course as his. He hears the signal
behind him from a huge machine of pre-
tentious appearance which wants to pass
him, and at once he increases his speed. At
no price will be allow the aristocratic ma-
chine to show its heels to him and his faith-
ful little "flivver." When the heavy machine
swings wide and moves to pass him, he
swings wide and obstructs its path. He is
proud, stubborn, unreasonable ; and as often
as not he swings right into the. path of the
larger car and finds himself the victim of a
rear-end collision which is his own fault,
having cut off the other car without a
timely warning.
The other offender is the woman driver
who does not look where she drives but
**drives where she looks." It is a well-
known characteristic of the woman at the
wheel that her eyes will be not on the road,
where they should be, but on the occupants
of the passing car. The result is that she
will often crowd the other car to the edge
of the road or drive so close that the other
driver will have to swing away sharply to
avoid an accident — often without success.
It is such driving that is at the bottom of
most mishaps, and it is to such driving that
the traffic authorities should give closer at-
tention, if they would reduce the appalling
number of motor accidents.
Ignorance and a Low Death Rate. —
Physicians engaged in civilian relief work
in the Balkans have had a hard fight, not
only against disease, but against the ignor-
ance and superstitution of the natives. In
Montenegro, where these men took hold of
the situation recently, there were only four
native physicians, or one to every 100,000
inhabitants, and as a result of this and of
the years of ferocious and incessant war-
fare, in which the country has been engaged,
a fatalistic habit of mind with regard to
illness had been engendered which was ex-
tremely hard to combat.
One of the commonest superstitions —
which is quaint enough as long as one is not
continually opposed by it in daily practice —
is that disease is carried about by devils,
or jinni, who ride the winds at night. Of
course if one holds such a belief the only
sane thing to do is to keep all windows
hermetically sealed, and this every good
Montenegrin does, with the result that
tuberculosis has made terrific inroads.
Nothing so alarms these rough and physic-
ally courageous mountaineers as fresh air.
One old fellow with chronic laryngitis in-
sisted that his affliction was due to too short
a tongue and refused to take the remedies
prescribed. On being assured that the gar-
gle given him would infallibly enlarge that
organ, he followed directions with the re-
sult that his trouble presently disapi)eared.
In Albania, where epidemics followed in
the track of war, and where many died for
want of the simplest treatment, the greatest
difficulty was experienced in persuading the
sick to come to the Red Cross dispensary
for treatment. When, however, a few of
the bolder spirits had at last ventured down
from the mountains and had experienced
prompt relief, the rumor spread like wild-
fire thru the country that these foreign
doctors were miracle workers and there was
no further trouble.
We laugh at ignorance and naive super-
stition and are prone to forget that in
great tracts of our own supposedly en-
lightened country the same conditions pre-
vail. In the cities, health bureaus and med-
ical associations have largely succeeded in
doing away with this. But in rural districts,
out of touch with urban life and lacking its
advantages, there is often a complete ignor-
ance of the commonest principles of sanita-
tion and hygiene.
The puWic health campaign of the Ameri-
can Red Cross, announced as part of its
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AMBSXCAN MBDICINB
AMONG THE BOOKS
September. 1919
611
peacetime program in connection with the
annual roll call, to be held November 2n(l
to 11th, is aimed at just these conditions.
It hopes, thru the organization of com-
munity nursing service, thru the stimula-
tion of interest in public health and the
stamping out of preventable disease, thru
the offering of courses in first aid, home
nursing and hygiene and child care, to be
a factor in bettering such conditions. It
aims to cooperate with local medical as-
sociations and public health organizations
of whatever kind in the rural districts and
without trespassing on the territory of any,
to join with them in a campaign which shall
make the rural death rate, what it should be
and has never been, as low as that of the
cities.
AMONG
THE
BOOKS
It is expecting the impossible to seek for
mathematical formulae described with the im-
agery of a modern novel, but, nevertheless, this
book offers students of public health an oppor-
tunity to familiarize themselves with the essen-
tials of the science of demography, thru the
study of vital statistics in a practical, entertain-
ing, and serviceable manner.
DKS^
Tital Statistics*— To vitalize vital statistics
Is by no means a valueless performance. At
the present time, there is greater use made of
statistical methods In the presentation of com-
mon facts than has been the custom for many
years. Whether one figures the batting averages
in the big league, or computes the record of a
surgical service, or calculates the Index of the
price of commodities, wittingly or unwittingly
a definite statistical procedure must be em-
ployed.
The average book devoted to vital statistics
appears cumbersome, ponderous and uninviting.
I,n this particular, Vital Statistics, by George
Chandler Whipple (John Wiley and Sons, 1919).
is a noteworthy exception. Altho containing
over five hundred pages, a paper almost as thin
as India paper, with bright red flexible covers
and edges of gold, makes one think that there is
some excellent readable literary work within
the covers. And there is, but it is the type that
the format would lead one to suspect, and yet,
withal, there is a bit of the novel, a little po-
etry, some humor, and pages of didactic narra-
tive, illustrated by charts, maps, cartoons,
diagrams and designs in such a manner
as to make vital statistics really appeal,
and be attractive. Whipple, whether he Is dis-
cussing cumulative groupings, logarithms, the
classification of population, or the methods of
computing specific death rates, uses a simple
language that makes the beclouding of his mean-
ing almost Impossible.
Industrial Efficiency.— The war has ended,
but industrial effort continues. The various
experiences which were realized during the
mobilization of our industrial resources for pro-
moting war will be turned to advantage in the
great commercial war which Is fighting for the
world's markets.
In all the machinery of production, the most
delicate and sensitive is the human machine,
concerning which Frederick S. Lee has written
so humanly in The Human Machine and Indus-
trial Efficiency (Longmans, Green and Company,
price $1.10). While most of the facts presented
formed the substance of the Cutter Lectures
on Preventive Medicine and Hygiene under the
title of Industrial Efficiency and the War, the
facts and principles enunciated are equally ap-
plicable to the industries of peace.
Here is an effort to interpret the human
machine on a physiologic basis, with a view
to determining the various conditions requisite
for promoting not merely a maximum output,
but for the purpose of conserving the vital
machinery itself. The study of hours of labor
and rest with relation to output reveals a
physiologic curve of working power, not merely
for the day but for the week. It is recognized
that the character of the work, while of pri-
mary Importance, Is modified by various en-
vironmental conditions causing fatigue. The
place that rest occupies as a physiologic anti-
dote to fatigue is properly set forth, particularly
in connection with the length of the working
day, which, thus far, physiologically, may be
properly set at eight hours a day. The disad-
vantages of overtime work and night work are
explained upon physiologic grounds.
The old traditions regarding the comparative
industrial worth of men and women are par-
tially supported by apparently increased sus-
ceptibilities to industrial poisons on the part
of women, and the fact that the greatest de-
grees of efficiency can be secured for the two,
only under slightly different conditions; a fact
of the utmost importance considering that wom-
en have become an indispensable factor in the
industrial world.
The relation of industrial medicine and welfare
work in connection with promoting the physical
condition of wage earners, formerly recognized as
an incident to industrial development. Is now
appreciated as an essential for the advancement
of the health and contentment of the worker,
and the promotion of his good will, all of which
act "as lubricants to the human machine and
are Indispensable to its highest efficiency."
The strongest appeal of the book is the de-
mand for exact tests in determining the ex-
istence of fatigue, and in solving the various
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September, 1919
AMONG THE BOOKS
American Medicine
other questions as to human potentialities in
Industry. The methods of organization of work,
and the details of all the operations involved,
together with testing of the respiration and
pulse, and the muscular balance are necessary
to supply adequate physiologic data upon which
to base conclusions. The author rightly de-
mands the proper scientific basis for the or-
ganization of industrial work thru laboratory
and experiments, particularly in industrial
plants, so that our knowledge concerning the
human machine may be enriched. Science will
serve to yield incontrovertible evidence for the
scientific management of factories, the enaction
of adequate industrial legislation, or the insti-
tution of such environmental conditions as
would promote the health and longevity of the
human machine.
Mental Hygiene in Childhood.— The growing
appreciation of education involves revaluations
of curricula and methods of instruction. Sim-
ilarly, there is an increased importance of rec-
ognizing the medical and psychologic problems
involved in educational affairs. The stress be-
ing placed upon mental hygiene makes it nec-
essary that physicians secure a wider under-
standing of educational problems.
The Mental Hygiene of Childhood, by William
A. White (Little, Brown and Company) offers an
explanation of the hygiene of childhood as in-
terpreted from the point of view of a strict
Freudian psychologist. Whether one accepts
the view or not, he has written a book which
merits careful reading. There is a perfectly
logic presentation of this particular form of
philosophy as applied to child nurture, particu-
larly for the prevention of mental deformities.
In order to determine the educability of va-
rious types of children, it is important to dif-
ferentiate their abilities and disabilities, wheth-
er the mental standard be above or below nor-
mal. Constructive educational work requires
differential diagnosis as the basis of adequate
treatment. Just as certainly as does the ordinary
problem of determining maladies and their
causes exists before instituting therapeusis.
Much light is shed upon this phase of the edu-
cational problem in the splendid book of Au-
gusta F. Bronner, The Psychology of Special
Ahilitiea and Disahilities (Little, Brown and
Company). Herein are discussed such topics as
the special defects in problem work, language
ability, and in separate mental processes, along
with the variety of defects in mental control.
The basis of interpretation of defects is based
upon psychologic examinations, including the
Binet-SImon scale and the Healy-Femald tests.
The field covered affords abundant opportunity
for interesting physicians to achieve a better
understanding of many of the problems which
are bound to find their way into their offices.
(The Macmillan Company) presents the basis of
scientific testing of mental powers in funda-
mentals. It shows the importance of measure-
ments utilized in connection with psychologic
tests as a basis for determining mental powers
in lieu of the ordinary examination methods
so long tried and yielding increasing satisfac-
tion.
While it is true that all the tests described
are not of equal merit, they may be recognized
as being on trial for specific purposes and sub-
ject to alterations or revision or rejection as
the future may determine. The theory of meas-
uring ability upon a definite scale is far more-
sound than to place dependence upon old mark-
ing systems as a measure of either school work
or mental power. The real benefit of standard-
ized measurements is to express power in terms
of known units of a definable character. Fur-
thermore, it possesses the advantage of serving
as a check upon the methods and factors in
teaching and learning, all of which are now
lumped together in a single mark that ignores
many valuable factors. The value of educational
measurements is increasing and it is desirable
that more attention be given to this topic in
connection with the routine work carried on
in medical colleges.
Social Measurements^— The freedom with
which physicians make use of statistics ac-
counts for much of the weakness involved. The
technic of measurement is largely limited to
a knowledge of the law of averages. A knowl-
edge of medians, modes, skewness, average de-
viations, the formation and interpretation of
graphs and surface of frequency are not appre-
ciated. The effectiveness of group measurements
or the correlation of variables is almost com-
pletely unknown or neglected.
For this reason, 3uch a volume as E. L.
Thorndike's, An Introduction to the Theory of
Mental and Social Measurements, Teachers'
College, Columbia University, possesses a def-
inite value for those charged with the respon-
sibility of tabulating statistical material in con-
nection with hospital work or any other form
of applied medicine where accuracy is requisite
to give any value to the results.
Education^— The standardizations in medicine
and surgery find their analogues in education.
Educational Measurements, by Daniel Starch,
Dishonesty in Children.— Not infrequently a
physician is challenged by a problem of dis-
honesty that terrifies some parent. While gen-
eral common sense may be of assistance in
directing counsel and advice, a wider apprecia-
tion of the subject matter would make a coun-
selor more authoritative. Hence one finds
much of value in William Healy's, Honesty, a
study of the causes and treatment of dishonesty
among children (Bobbs Merrill Company). The
author discusses not only the mere question
of moral development, but analyzes the relation
of home conditions and parental behavior, com-
panionship, discipline, amusement and adven-
ture as related to honesty and dishonesty. He
dwells at length upon the mental, physical, and
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AMONG THE BOOKS
September, 1919
613
social habits of children, devotea much space to
the problems of abnormal mentality, and the
facts relating to impulsions and obsessions.
Underlying the entire work is the attitude
of the diagnostician, who seeks to determine
the underlying cause and does not attempt to
see a general principle for universal applica-
tion. Every cause of dishonesty is individu-
alized, and the causation must be thoroly in-
vestigated before a form of treatment is de-
fined. It is at once an exposition of the general
subject, and a gentle but firm guide and coun-
selor to those who would treat a character
defect with wisdom born of a long experience.
viously to give in the most concise and clearest
language possible one generally accepted method
of treatment which has proven its value. The
result is exceedingly satisfactory and the entire
subject is so well covered that both graduate
and undergraduate cannot fail to derive much
valuable and instructive information therefrom.
Medical Electrlelty.--Electricity now plays a
much more important rOle in the treatment of
various diseases and conditions of ill health
than is generally realized. In the rehabilita-
tion of disabled soldiers it has proved of par-
ticular service and it is patent that as a res\ilt
of the experience thus gained, it will be much
more largely employed in civil life. Many books
on the subject have been written but perhaps
the best work ever offered to the medical pro-
fession on electro-therapeutics was that by the
late H. Lewis Jones, M. A., M. D., F. R. C. P.
This book,* which has been revised and edited
by Lullum Wood Bathurst, M. D. (P. Blakiston's
Son ft Co., Philadelphia), has reached its sev-
enth edition. Dr. Bathurst is exceptionally well
qualified to edit the book as for many years
he worked in collaboration with Dr. Jones. It
is interesting to note, as pointed out in the
preface, that the lines of progress in electro-
therapeutics foreshadowed by Dr. Jones in the
last edition of his book, namely, the exercise
on the one hand of the ionic, and on the other
of the thermal effects of electricity, are being
fulfilled. In the present edition the newer and
more precise methods of the electrical testing
of muscles are described, and In all respects the
subject matter of the last edition Is brought up
to date. The book In its present form will con-
tinue to hold the first place among books deal-
ing with electro therapy, and the greatest credit
Is due to Dr. Bathurst for his excellent editing
and revising.
Gynecology* — There have been published In
recent years a goodly number of books on gyne-
cology, some of them of almost portentous size.
The volume before us Is of quite modest dimen-
sions, but remarkably complete and comprehen-
sive. A Manual of Oynecology, by John Cooke
Hirst, M. D. (W. B. Saunders Co., Philadelphia),
is a presentation In book form of the material
used by the author In teaching students of the
University of Pennsylvania during the past
twenty years. In some sections, notably those
devoted to Injuries of child olrth and their con-
sequences, diseases of the breast, and hemor-
rhage, he has deemed It best to consider the
question from the point of view of both the
obstetrician and the gynecologist Since the.
work of both so Intimately connected presenting
the subject In this- manner tends to thoroness
and clarity, the main aim of the book is oh-
Genitonilnary Diseases and SyphiU8.-;Geni-
tourlnary diseases in general, and syphilis m
particular, are occupying a good deal of the
attention of members of the medical profession
at the present day, while syphilis has become
a matter of general public interest It is now
well recognized that syphilis Is one of the most
serious problems of the day and that the war
has accentuated the gravity of the situation.
The book dealing with Genitourinary Diseases
and Byphilis by Henry H. Morton, M. D., F.
A. C. S. (C. V. Mosby Company, St. Louis), Is
the fourth edition of this popular exposition
of the subject It Is well known that remarkable
progress has been made In genitourinary sur-
gery during the past few years. In fact, the
treatment of venereal diseases has been placed
on a much more scientific basis, a statement
which applies of course with greater force to
the treatment of gonorrhea than to that of
syphilis. The entire subject of the treatment
of genitourinary diseases has been developed
to an almost Incredible extent, and operations
for the cure and relief of various genitourinary
conditions, which were not thought of ten years
or so ago, are now performed with uniform
success. Among the most recent means of
treating these states of 111 health may be men-
tioned the application of the high-frequency
current to the treatment of benign tumors of
the bladder and the employment of radium In
carcinoma of the bladder and prostate. With
regard to the value of radium combined with
subsequent fulguratlon, Morton is of the opinion
that this combination seems to offer more In
Inoperable bladder cancers than anything else
which has yet been found.
The portion of the work dealing with genito-
urinary diseases in general has been thoroly
revised and affords an excellent source of ref-
erence. However, under existing circumstances,
the part of the work in which the venereal dis-
eases are discussed Is bound to be of par-
ticular interest. The chapters on syphilis are
exhaustive, but little is said concerning preven-
tive or rather direct prophylactic treatment.
Also none of the other therapeutic measures
outside of salvarsan and mercury are referred
to. The chapter on gonorrhea In women by Dr.
Albert M. Judd Is especially worthy of notice
and, taken all In all, the book is a wonderfully
able work. It is beautifully and profusely il-
lustrated, there being no fewer than 330 illus-
trations and 36 full page colored plates. It Is
an authentic and trustworthy exposition of the
subject.
Pediatrics*— The study and treatment of the
diseases and abnormalities of children have
always been especially the concern of American
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September, 1919
CORRESPONDENCE
Amsrican Mbdicinb
physicians, and the development and progress
in this direction have been largely due to prac-
titioners on this side of the Atlantic. Among
the names of men who have won a recognized
place in this branch of medical research and
practice that of Kerley is one of those that
particularly stands out. The Practice of Pedia-
trics, by Charles Gilmore Kerley, M. D. (W. B.
Saunders Co., Philadelphia), tho yet in its sec-
ond edition, has already become a standard
work on pediatrics. It deals with the subject
of children's diseases from beginning to end,
and while, naturally there are some points on
which the author differs from the general view,
still the book provides one of the fullest and
clearest expositions of pediatrics extant. Dr.
Kerley very plainly holds some original opin-
ions and possesses the courage of his convic-
tions. The chapters on influenza and syphilis
are especially to be commended. With regard
to treatment of what Kerley terms tardy hered-
itary syphilis, he says that his experience with
salvarsan has been thoroly unsatisfactory. He
points out what many practitioners in these
days are somewhat inclined to overlook, that,
as in the treatment of tertiary syphilis in the
adult, the iodides often play an important part
in the late hereditary form in children. As
he states, much better results are not infre-
quently obtained with the so-called *'mixed
treatment." Since the previous edition was
published in 1914, the progress made in pedia-
trics has rendered necessary many changes and
a considerable amount of revision in the present
volume. Twenty-five new articles have been
added, sixteen chapters largely rewritten, and
lesser changes made in many others. A great
deal of the old material has been removed, and
in its place has been substituted matter which
is in accord with the noteworthy progress that
has been made during the past few years. The
result is a well-balanced, well-written book in
which the subject of pediatrics in all its phases
is clearly and comprehensively set forth. The
work should prove of great value to the prac-
titioner as well as the student of medicine.
CORRESPONDENCE
New York, Sept. 20, 1919.
To the Editor,
Amebicax Medicine:
The 150,000 physicians of the country should
protest against the clause of the Prohibition
Enforcement Law, now before Congress which
compels them to take out a "permit" to pre-
scribe alcoholic beverages in quantities not to
exceed an arbitrary limit laid down by a lay
body. Already physicians are compelled to take
out a Federal and State License to prescribe
opium and its derivatives. This is obligatory
under an act passed mainly to control the sale
and distribution of narcotic drugs after these
were used as a substitute for the alcoholic
beverages denied the negroes of the South under
the Prohibition Laws originating in that section
of the country.
If Congress can limit the use of alcoholic
beverages to sacramental and medicinal pur-
poses, it should be competent to punish all
offenses against such enactments wiUiout pass-
ing an oppressive license law affecting the
whole medical profession. Inasmuch as clergy-
men do not have to take out a permit it might
be presumed that physicians would receive the
same consideration. This perhaps would be the
case were it not for the fact that the Anti-Saloon
League esteems every physician a potential
boot-legger, a conclusion shared evidently by
Congress in compelling them to be licensed and
supervised by the Department of Internal
RjBvenue.
The Anti-Saloon League also claimed that the
"American home" would be converted into a
speak-easy unless forcible entry and search were
permitted without the formality of warrant.
Congress refused to enact any such measure of
prohibition enforcement. The imputation is
equally false that all the members of a profes-
sion elsewhere recognized by governments as
not only an honorable but an honored one, will
have to be licensed like the liquor dealer to
prevent them from carrying on the trade of
"boot-legging" in the United States.
John P. Davin, M. D.
117 W. 76th Street.
REATMENT
Gla8 Bacillus Infection In Wounds* — Gas ba-
cillus infection could of course occur in any
wound but did occur almost invariably in
severe wounds, particularly in those of the
lower extremity associated with fracture, vas-
cular injury and muscle damage. Van Beuren,
Jr. (K. Y. Med. Jour., June 14, 1919), says that
such a wound was always far more extensive
beneath than in the skin and its depths hid
rough missiles and bits of clothing or equip-
ment. Its crevices were filled with blood clots
and it was walled by muscle, fascia and apo-
neurosis, torn, contused and loaded with in-
driven fragments of comminuted bone and with
extravasated blood. The regional blood supply
was locally or massively interfered with. There
was also infection, usually with a varied flora,
including the gas-forming, saprophytic anae-
robes.
In the early part of the War surgeons began
by simple incisions and drainage, but they rap-
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AMBBICAN MBDIOIKB
TREATMENT
Srptbmber, 1919
615
idly arrived at a fairly standardized procedure.
Only general rules could be formulated, as much
depended upon the judgment of the operator.
1. Use nitrous oxide oxygen anesthesia, if
possible.
2. Prepare the part with minimum delay and
trauma.
3. Avoid tourniquets.
4. Make incisions longitudinally and one-
half again as long as you think they need be,
both in skin and fascise.
5. Leave as much skin as you dare, in de-
bridement
6. Go between rather than thru normal mus-
cles and do not cut across them unless you
have to. Better a long separation between two
than a short cut across one.
7. Open the wound as thoroly and freely
as you possibly can.
8. Excise all torn, crushed, discolored, non-
contractile muscle until you have left only that
which is firm, of normal color, actively con-
tractile, and which bleeds readily.
9. Make a careful and consciousness search
for and remove all loose bone, soiled and torn
fasciae, and foreign bodies, especially clothing
and blood clots.
10. Stop the bleeding. Leave the wound
wide open and. separate its walls with wet
gauze, laid in — ^not packed in.
11. Use Carrel tubes if you know that they
will be properly cared for, otherwise omit them.
12. Use plenty of dressings and make careful
splint fixation of the part.
13. Do it all as rapidly as you properly can.
Carrel-Dakin instillation was considered the
best postoperative local accessory treatment
when properly applied. Serotherapy remained
to be considered. Doctor Van Beuren said he
had no personal experience with this method
and that while serotherapy promised much for
the future, it had not had much opportunity
for performance in the past, or if it had reports
were not available. The results of the series
tried out by the British and the Americans were
not yet available, but the speaker had been in-
formed they were encouraging if not as bril-
liant as had been hoped for. The sera used by
the British, French and Americans were either
specific antiperfringens (anti-Welchii), anti-
oedematiens (antlbellonensis), antivibrion sep-
tique or a combination of the three, preferably
with antitetanic serum Included. Intravenous
administration was perhaps most effective but
was not always possible. For preventive use
is was usually given subcutaneously and intra-
muscularly and the combined sera used, the
dose being from ten c. c. to sixty c. c. repeated,
if symptoms developed. For curative injections
the appropriate specific serum or sera were used,
after the infecting organisms have been identi-
fied, in twenty c. c. to sixty c. c. doses, repeated
as indicated. Here the intravenous method was
generally combined with intramuscular injec-
tions. Dr. Van Beuren, Jr., in his conclusions
states that one may with fair confidence assert
that future improvement for gas bacillus infec-
tion of war wounds would rest upon: 1. Pre-
ventive serotherapy; 2. Earlier operation, due
to more rapid transportation. 3. Observance of
the correct operative procedure. 4. Curative se-
rotherapy.
Digestibility of Bacon«^Katherine Blunt and
Marguerite G. Mallon {Journal of Biological
Chemistry, May, 1919) report a series of ex-
periments undertaken to test the accuracy of
Rubner's statement that bacon fat showed a
low utilization, 17.4 per cent, of the fat eaten
being lost in the feces. Their work developed
results that showed Rubner*s views to be er-
roneous, as they found that bacon fat was about
as digestible as other soft fat, and that the
nitrogen is also as well digested as that of other
meat. The average percentage of digestion of
the fat of slightly cooked bacon was 96.3, and
of much cooked bacon ninety-seven, while the
average percentage of utilization was respec-
tively 92.8 and ninety-five.
Treatment of Extensive Septic Wounds.—
H. Gardiner (Lancet, December 7. 1918) holds
that the chief use of gauze dressings is to pro-
tect wounds from extraneous infection, and that
the objection8ni>le features of their use can be
avoided if some other means of preventing in-
fection be provided. The following' proves more
satisfactory: The wound is incised and all
pockets are opened up in such a way as to
obtain the maximum effects of gravity in carry-
ing away the discharges. Then an ordinary
gauze packing is applied and bandaged on for
the sole purpose of checking bleeding and ooz-
ing. This is removed after forty-eight hours
and the wound cleansed by syringing with some
mild antiseptic such as boric acid, or weak
eusol. solution. A guard of appropriate size
and shape is made of perforated zinc and bent
to form a cradle over the infected part. This
is place in position and covered by a sterile
towel and a bed cradle is put on to hold up the
bedclothes. The discharge which runs from
the wound is absorbed by a sterile wool or
sphagnum pad placed beneath the part Twice
daily, or oftener, the wound is uncovered, syr-
inged and swabbed out, the pad changed, and
the zinc cradle, towel, and bed cradle are re-
placed. This treatment is continued until all
pockets are closed by granulations, the whole
wound surface is granulating evenly, and the
discharge has practically ceased. Then the
wound is dressed in the usual way until com-
pletely healed. At times difiiculties are en-
countered, such as the inability to utilize
gravity fully, or the problem of keeping the
part in position during sleep. The first of these
is overcome by the insertion of a small gauze
wick which hangs down over the edge of the
wound; the second by the use of a suitable
splint The advantages of the plan are: Per-
fectly free drainage, absence of tendency to
form pockets; absolute painlessness of the treat-
ment; absence of all manipulation of the
wounded part, and great economy in dressing
materials.
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September, 1919
GENERAL TOPICS
Ambrican Mbdicinx
Wounds Affecting tbe Bladder. — Georges Luys
in his excellent, article in the Medical Record
(May 3, 1919) states that among the war
wounds of the genitourinary organs, those of
the bladder with those of the urethra are the
most frequently observed. Vesical wounds are
met with either associated with lesions of the
neighboring organs or separately.
Associated bladder wounds are almost in-
variably combined with fractures of the bony
pelvic girdle, more particularly fractures of the
pubis, or with Intestinal perforations; and in
these cases the wound in the bladder is merely
secondary, for the peritonitic ssrmptoms which
accompany intestinal injuries create such an
alarming condition that the vesical lesions are
relegated to the background. In other cases,
the intestinal injuries are much less serious and
the patients may survive. Adhesions develop
and the patient may void his urine thru points
at a great distance from the bladder. Of three
patients under my observation, one passed near-
ly all his urine thru an opening in the upper
part of the right thigh, and the two others
passed their urine thru an orifiice situated on
the posterior aspect of the buttock.
Wounds of the bladder may sometimes re-
main undetected, and they should be very care-
fully looked for. Thus, when a patient com-
plains of having had no natural micturition,
while a catheter introduced thru the urethra
shows the hladder to be perfectly empty, and at
the same time there is a suprapubic swelling,
there is reason to assume the presence of a
vesical lesion, and in this case immediate in-
tervention becomes imperative. Hypogastric
section should be performed at once as offering
the only prospect of a successful outcome for
the patient.
The most Important rule for the guidance
of the operator in the treatment of the bladder
wounds thru war injuries is primarily the o6-
solute necessity to insure a good drainage of
the urine, first by freely exposing the wound
and next by securing easy evacuation of the
urine thru vesical drainage. This also adds to
patient's comfort by preventing wetting of the
bed.
The diagnosis of a wound of the bladder hav-
ing been established, it is necessary in the first
place to locate the opening into the bladder so
as to Introduce a drainage tube which guaran-
tees the complete evacuation of the urine. It
does not suffice, however, simply to insert a
drainage tube into the wound, but we should
assure ourselves that it is properly introduced
into the bladder itself. In order to comply with
this imperative indication, surgical intervention
is usually required, with free exposure of the
wound under local anesthesia, so as to ascer-
tain that the drainage is thoroly established.
After a good vesical drainage has been al-
lowed to exert its effect for a fairly consider-
able time (often a month or two), the borders
of the wound may be seen gradually contract-
ing, the suppurating tracts drying up, and the
perivesical fistulas closing, while the neighbor-
ing wounds heal. It now becomes easy to re-
establish the normal course of the urine by
means of a properly functioning permanent
catheter.
Primary suture of a bladder wound seems to
be hardly ever practicable in cases of war In-
jury, on account of the associated lesions.
Drainage is all that is left to do. the best drain-
age being by the anterior median route.
Wounds of the lateral walls of the bladder do
not necessarily call for a median cystotomy;
the surgical treatment of the entrance wound
and its tract guarantees a sufficient drainage
in the majority of the cases; the later applica-
tion of a permanent catheter will facilitate the
closure of the urinary fistula.
The Physician Under Prohlbitlonr— The in-
auguration of prohibition thruout the United
States affects the physician not only as a cit-
izen, but also as a professional man ( Chicago
Med. Recorder, Aug., 1919). Necessarily, the
law provides some exceptions in the use of
alcohol and various liquors containing alcohol
for medicinal purposes. In a circular of in-
structions to internal revenue collectors and
agents the commissioner of internal revenue
states that Section 1 of the' Act of November
21, 1918 (War Prohibition Law), provides that
after June 30, 1919, unUl demobilization is
proclaimed by the President, no distilled spirits,
beer, wine or other intoxicating or vinous liq-
uors shall be sold for beverage purposes. It
also provides that the commissioner shall pre-
scribe regulations for the sale of distilled spirits
for sacramental, medicinal and other than bev-
erage purposes. The commissioner directs that
physicians may prescribe wines and liquors for
internal use or alcohol for external use as stated
previously. Such prescriptions must be in du-
plicate, both copies signed in the physician's
handwriting. Not more than one quart of any
liquor may be prescribed for a single patient
at a given time and in no case shall a physician
prescribe alcoholic liquor unless the paUent is
under his constant personal supervision. Pre-
scriptions must show the name and address of
the patient, including the street or apartment
number, if any, the date when the prescripUon
was written, the condition or illness for which
prescribed and the name of the pharmacist to
whom the prescription is to be presented for
flUIng Physicians should note carefully this
provision: The prescription must designate a
certain pharmacist and no other pharmacist
can fill the prescription than the one designated.
The physician must keep a record in which a
separate page is allotted to each patient for
whom alcoholic liquors are prescribed and must
enter thereon, under the paUent's name and
address, the date of each prescription, the
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AMERICAN Medicine
NOTES AND ANNOUNCEMENTS
Se2>tbmber^ 1919
617
amount and kind of liquors dispensed by such
prescription and the name of the pharmacist
filling it. Licensed pharmacists or druggists
may fill such prescriptions, provided the drug-
gist's name appears on the prescription in the
physician's handwriting and provided the drug-
gist has received a permit (Form 737). and
provided he has qualified as a retail liquor dealer
by the payment of a special tax. No prescrip-
tions for alcohol or alcoholic liquors may be
refilled. Druggists filling such prescriptions
must preserve, in a separate file, one copy of
each prescription filled and once a month must
send to the collector of internal revenue in the
district in which they are located a list showing
the name of physicians prescribing alcohol or
alcoholic liquors, the names of the patients and
the total quantity dispensed to each patient
during the month. If these reports show that
a physician is prescribing more than normal
quantity or that any patient, thru the prescrip-
tions of one or more physicians, is procuring
more than the normal quantity, the facts shall
be reported to the commissioner of internal
revenue and the United States attorney. Phar-
macists are instructed to refuse to fill prescrip-
tions if they have reason to believe that physi-
cians are dispensing for other than strictly
legitimate medicinal uses or that a patient is
securing, thru one or more physicians, quanti-
ties in excess of the amount required for legiti-
mate purposes. If the prescription is medicated
or denatured so as to be unfit for internal use.
non-beverage alcohol tax paid at the rate of
$2.20 per gallon may be used in filling the pre-
scription, but if it is not so medicated or de-
natured, liquor tax paid at the rate of $6.40
per gallon must be used. Physicians preparing
or dispensing their own medicines or desiring
alcohol for strictly scientific and medicinal pur-
poses must file an application for a permit with
the collector of internal revenue of the district
in which they live. This application must be
accompanied by a bond furnished by a surety
company or signed by two individuals as sure-
ties. Both the application and the bond must
be in duplicate. On receipt of the application
and bond, the collector of internal revenue will
issue a permit to the physician authorizing him
to have on hand or in transit a certain amount
of alcohol or alcoholic liquors, the amount de-
pending on the size of the bond. A bond for
$100 allows the physician to have on hand or
in transit 20 gallons of alcohol or liquors. The
physician must keep an account of all alcohol
or alcoholic liquors purchased and on hand and
must be ready at any time to produce his records
and satisfy the internal revenue inspectors that
any amount used has been for legitimate, me-
dicinal, scientific and non-beverage purposes.
Alcohol or alcoholic liquors purchased by a
physician under these circumstances cannot be
used for his own consumption. The instruc-
tions of the commissioner of internal revenue
to all government officers is that the law and
the regulations regarding alcohol and alcoholic
beverages must be strictly enforced. Physi-
cians should . familiarize themselves with the
instructions under the law and should carefully
and rigidly comply with all requirements. In
case of doubt, it is best to secure a ruling or
an opinion from the collector of internal revenue
rather than to run any risk of violating the
law.
Shall Opiam be Proscribed ?— There is good*
reason to believe^ says Dr. Wm. Rittenhouse in
A/Ws Jour, of Clin. Med,, Aug., 1919, that the
attempt will be made to get Congress to pass
a law that will deprive the medical profession
of one of its most valuable remedies, or rather
two of them; for, it is sought to prohibit the
importation, manufacture, and sale of every
form and derivative of opium and cocaine. If
the attempt is made, we may be sure that it
will be done as quietly as possible, and that no
effort will he made to ascertain whether the
great mass of the profession want such a law
or not.
So, it behooves us to be watchful, not alone
for this attempt, but for others that are likely
to be made. We must make our influence felt
It is simply a question of every man doing his
duty.
The interdiction of opium and cocaine is too
large and important a question to be dismissed
with a few words. A good many doctors, when
the subject is mentioned, are disposed to treat
the matter lightly. They say: "Surely, no one
will ever attempt such an absurd thing." It
does seem incredible that suQh a thing should
be seriously proposed. Yet, we must not lull
ourselves into a false sense of security, on the
ground that the thing is absurd. A good many
absurd laws have been enacted before now, and
a lot more will be.
Watchfulness is our only security. It may
be trite to say that eternal vigilance is the
price of liberty, nevertheless, it is sadly, pro-
foundly true. If we must fight for the liberty
to relieve human suffering in the way that
experience teaches us to be best, then let us
not lose the fight in advance by an ill-founded
confidence, that 'the thing is too absurd to be
true." Is anything too absurd to be attempted
by our modem reformers?
NEWS NOTES""
ANNOUNCEMENTS
Honorary Degree for Llentenant-Commander
Bainbridge* — At the annual commencement ex-
ercises of Coe College, Cedar Rapids, la., held
on June 11th, the degree of LL. D. was conferred
upon Lieutenant-Commander William Seaman
Bainbridge, Medical Corps, United States Naval
Reserve Force. This was given in abscencio.
Doctor Bainbridge not being able to be present
on account of his official duties in the navy.
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September. 1919
NOTES AND ANNOUNCEMENTS
American Msdicine
Nnrsing Schools Opened In Bnffalo.— A post
graduate course for public health nurses is to
be given in Buffalo for sixteen weeks beginning
September 29, under the auspices of the Buffalo
University, the Buffalo Chapter of the American
Red Cross, the Department of Health, the Dis-
trict Nursing Association, and the Department
of Hospitals and Dispensaries.
An excellent teaching staff has been secured.
A certificate will be given to all students satis-
factorily completing the course, which will cost
$25.00. The class will be limited to thirty, and
applicants must be registered in New York
state or states having equivalent standards.
Application blanks will be supplied by the Uni-
versity of Buffalo, College of Arts and Sciences,
Niagara Sq., Buffalo, New York.
Red Cross Supplies Nitrons Oxide Gas.— The
American Red Cross supplied great quantities
of nitrous oxide gas to the American hospitals
in France. To the United States Army hospitals
699,429 gallons were sent, to the Red Gross hos-
pitals 495,629 gallons and to different hospitals
251,110 gallons, between September, 1917, and
October 23, 1918.
Nitrous Oxide was first introduced into Europe
by Col. G. W. Grile at the American Ambulance
Hospital at Neuilly. The British learned the
technic and used it in their dressing stations.
The Red Cross ordered a complete plant for
the manufacture of Nitrous Oxide gas from the
Ohio Chemical Company and this was estab-
lished at Montreau, about fifty miles from Paris.
A Frenchman, experienced in the making of
the gas was secured to direct the work, .the
government permitting his release from the
army.
The especial effects of the gas are said by
surgeons to cause no lowered vitality, less tox-
emia, less post-operative respiratory complica-
tions and the patient enjoys a quick return to
consciousness.
The Oldest Man in the M'orld.-— It is claimed
that '*Uncle Johnny" Shell who has just cele-
brated his 131st birthday at Lexington, Ky., is
the oldest human being in the world, having
been born, according to his belief, in Tennessee
September 3, 1788. His eyesight and hearing
are only slightly affected and he is still fairly
active. His eldest child is a daughter ninety-
seven years old.
Typhii8 Raging in Europe.--An epidemic of
typhus is raging in Europe and the Red Cross
is taking an active part in the effort to stamp
out the disease.
Henry P. Davidson reports that 275,000 cases
have been found in the belt extending from the
Baltic to the Black Sea and there is appalling
distress in Poland, Lithuania and the Balkans.
The Red Cross has sent 200 representatives
to Poland in response to a pathetic appeal from
Paderewski. Edicts calculated to stop the
spread of the disease have been published in
that country, one of them being an order that
every person shave and bathe. About 100,000
cases have been reported and the death rate
is high.
At the conference held in Games, recom-
mendations were made to enlist Red Cross So-
cieties to establish a permanent committee of
medical experts of the allied countries to deal
with the typhus problem.
GoTemment Wants Workers in Tenereal Dis-
ease Campaigiu— The recently created Interde-
partmental Social Hygiene Board of the United
States Government is in need of a number of
specially trained men and women to complete
its organization. The United States Civil Serv-
ice Commission has announced examinations
for the following positions: Chief of division
for scientific research, $3,500 to $4,500 a year;
chief of division for educational research and
development, $3,500 to $4,500 a year; educa-
tional assistant, $2,800 to $3,600 a year; chief
of division of relations with States, $3,500 to
$4,500 a year; chief of division of records, in-
formation and t>lanning, $3,500 to $4,500 a year;
supervising assistant and inspector, $2,800 to
$3,600 a year; field agent, $1,800 to $3,000 a
year. All positions are open to both men and
women.
Applicants for these positions will not be
given scholastic tests in an examination room
but will be rated upon their education, experi-
ence and writings. Published writings of which
the applicant is the author will be submitted
with the application. For most of the posi-
tions a thesis on one of a number of given
subjects will be accepted in lieu of published
writings. The receipt of applications will close
on November 4. Detailed information and appli-
cation blanks may be obtained from the United
Stotes Civil Service Commission, Washington,
D. C, or from the secretary of the United SUtes
Civil Service Board at the post office or cus-
tom house in any of 3,000 cities.
The law creating the Interdepartmental So-
cial Hygiene Board provides for the coopera-
tion of the War and Navy Departments and
the Public Health Service of the Treasury De-
partment for the prevention, control and treat-
ment of venereal diseases. The duties of the
Board as set forth in the act are (1) to rec-
ommend rules and regulations for the expendi-
ture of moneys allotted to States for the use
of their respective boards or departments of
health in the prevention, control and treatment
of venereal diseases; (2) to select universities,
colleges, or other suitable Institutions which
shall receive allotments for scientific research
for the purpose of discovering more effective
medical measures for the prevention and treat-
ment of venereal diseases; (3) to recommend
such general measures as will promote correla-
tion and efficiency in carrying out. the purpose^
of the act; and (4) to direct the expenditure
of certain moneys appropriated by the act.
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IBMEMtrMBDKK
PUBLISHED liONTHLY
BdltorUl (MffioM • 18 Bast 41 at St.. N«w York City. Publieation OffioMi 180 ColUi* St.. BarllnAtoa, Tt.
OompUto 8wlM» YoL XXY. No. 10
H«w SeriM, YoL XIY. No. 10
OCTOBER, 1919
$2.00 '""•'
la Advaneo
CONTENTS
BDITORIAIi COMMENT SIO
MBN AND THINGS 630
ORIGINAL ARTICLBS 635
PHYSICAL THBRAPY 668
RATIONAL ORGANOTHBRAPY 671
CORRBSPONDBNCB 674
BTIOLOGY AND DIAGNOSIS 67S
TRBATMBNT 676
GBNBRAL TOPICS 679
NEWS NOTES AND ANNOUNCEMENTS .. . 682
(OoilUllll4d on 9*C0 i)
CONTRIBUTORS
IRVING \iriLSON VOORHEES, M. S., M. D.,
New York City.
MARK L KNAPP, M. D., LL. B., LL. M., New
York City.
BEVERLEY ROBINSON. M. D., New York City.
CAPT. H. W. HILL. M. D.. C A. M. C. St. Paul,
Minn.
HYMAN L GOLDSTEIN. M. D.. Camden, N. J.
WILLIAM W. GRAVES. St. Louis, Mo.
Bntored as ••eond-eUst auttor Uanuj S8, 1006, at ibe Poat Offieo ai BnrlingtoB, Vi.. under Act of Conrreaa, March 8, 187B.
Hand
Disinfection
can be easily and
conveniently accomplished by the
use of
SYNOL SOAP
This efficient liquid soap en-
ables the physician and surgeon to
cleanse and disinfect the hands
with gratifying freeilom from th©
irritating effects of caustic soaps
and antiseptics. It is particularly
serviceable to those who have to
cleanse the hands many times each
day* Invaluable in the office, op-
erating room and sick chamber*
ANTISEPTIC-
CLEANSING—
DEODORANT
(wivv\Aow<^^^
N0W Bmnswick, N. J.
U. 9. A.
So many cases of
Pruritus, Chafiii^
and Irritations
are relieved by applying
K-Y Lubricatmg Jelly
that we feel we owe it to our patrons to
direct their attention to the usefulness
of this product as a local application,
as well as for surgical lubrication.
No claini is made that K-Y Lubricat-
ing Jelly will act with equal efficiency in
everv case; but you will secure such
excellent results in the majority of
instances that we believe you will con-
tinue its use as a matter of course.
NO GREASE TO SOIL THE CLOTHING !
Collapsible tubes, 25c. Samples on repast!
(]xifi4^^
New Brunswick, N. J.
U. S. A.
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VWftnvkanoflier
qAkndc of influenza?
A RE we to hmve a recurrence of die plague wkich destroyed liatf a
/^ million lives in this countiy a year ago> In all probabilily. yea.
A review of the records of previous epidemics warrants tlie
assumption that the scourge will reappear this (all and next winter.
In the event that this theory proves corrects how can die medicai
profession cope with the disease?
Pkophj^actic vaccination is die rational procedure, fai suppott of due
contention we dte two illustrations:
In one, locality, during the recent epidemic, 3437 persons were
immunized with Influenza-Pneumonia Vaccine (Prophs^actic). Of this
number only six died, and these had but one injection. Among du>se
who received two or three injections there were no deaths.
In another locality 800 persons were immunized; 481 received one
inoculation, 224 received two, 95 received three. Only tvrenty cases of
influenza developed among those who had one or more inoculadensii
But two deadis occurred, and these were of persons tudio had only one
inoculation.
As a prophylactic the vaccine is administered in diree graduated
doses at intervals of three or four days. The first dose is two and (
half billions ( I /2 mil); the second, five billions ( I mil); the third, i
and one-half billions (11/2 mils).
Influenza-Pneumonia Vaccine
(Prophylactic)
Bio. 632. ThM bulbs (f/2 mil 1 mil I 1/2 nib).
one prophylactic treatment.
Bio. 633. Three syringes ( f/2 nil, I miL I 1/2 niU).
Bio. 634. One 5-mil vial.
Bio. 635. One 20.mil vial
We commend this vaccme to the consideration of pi
Parke, Davis & G>mpany
DETROIT
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American Medicine
H. EDWIN LEWIS, M. D.. Managinz Editor
IRA 8. WILE, Associate Editot
PDBUBHID MONTHLT BT THl AMBBIOAH HBDIOAL PUBU8H»0 Compant
Copjriffhted bj the Amerlcsn Medieal PnbUsliiiiff Co., 1919
Complete Series, Vol. XXV, No. 10
New Series, Vol. XIV, No. 10
OCTOBER, 1919
to on YEARLY
Congenital Syphilis. — Studies of the
prevalence of congenital syphilis among
children are of particular importance both
in connection with the work of lessening
infant mortality and from the standpoint
of racial betterment. Blackfan, Nicholson
and White reported the examination of 101
infants in a foundling hospital with only
two positive reactions to the Wassermann
test. Holt has reported the testing of 178
hospitalized children with no definite signs
of syphilis, with an approximate percentage
of 6.1 adjudged to be syphilitic. Churchill
and Austin, in connection with a study of
persons in the Children's Memorial Hos-
pital, Chicago, concluded that the inci-
dents of hereditary syphilis must vary
greatly, considering that estimates have
been made of from two to fourteen per
cent, in Europe and America, their own
figures being 3.3 per cent. The percentages
of positive Wassermann reactions have been
demonstrated to be notably higher in institu-
tions for mental defectives, epileptics and
children suffering from various other nerv-
ous conditions. One of the difficulties with
the different reports lies in the variability of
the results with the Wassermann test, due
in part to the fact that the Wassermann
reaction is more strongly positive in early
syphilis than in tertiary or so-called latent
syphilis.
Because of this conflicting testimony the
investigation of DeBuys and Loeber to de-
termine the incidence of congenital syphilis
in a foundling institution, Journal of the
American Medical Association (October 4,
1919) deserves comment. They studied
106 infants and children, 57 males and 49
females, of whom 41.6 per cent, were under
one year ; ZZ per cent, in children from one
to two years; 11.3 per cent, children from
two to three years; 9.4 per cent, children
from three to four years ; the remaining 4.7
per cent, in children from four to seven
years. The Wassermann reactions were
supplemented by luetin tests. The un-
common feature of their report lies in the
fact that the Wassermann reactions were
uniformly negative, but this was probably
due to the fact that as part of the routine
medical care, each child received twelve
powders of one grain each of mercury with
chalk, three daily for four days, followed
by castor oil. All children with any skin
eruption received treatment with mercurial
ointment. At the conclusion of the oint-
ment application or of the powders of mer-
cury and chalk, syrup of ferrous iodide in
five-drop doses, three times daily, was given
to all children under six months of age.
This fact probably may explain why the
Wassermann reactions were negative, de-
spite the fact that the luetin test showed
itself to be a most valuable diagnostic agent.
Their results, however, do not constitute
any criterion for estimating the compara-
tive values of the two tests in connection
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620
October^ 1919
EDITORIAL. COMMENT
Ambrican Mkdxcins
with the determination of congenital syph-
ilis, tho they do suggest marked differences
in their value in the determination of con-
genital syphilis during early life, particu-
larly in view of the fact that congenital
syphilis is such a great source of infant
mortality that only the milder infections
permit children to survive.
Skin eruptions were present in many
of the inmates, and 40 per cent, of the skin
eruptions were syphililitic. Fortunately,
the skin eruptions, together with other clin-
ical findings, were of the greatest diagnos-
tic value when the value of the luetin test
was at its minimum, namely, during the
first few weeks of life. The administration
of iodides affected the luetin reaction, altho
the lesion is sufficiently characteristic to be
distinct from the normal positive luetin
reaction. Congenital syphilis was found
to be relatively more frequent in the so-
called illegitimate children than in those
born in wedlock.
The incidence of congenital syphilis, as
determined by the study, was 83.96 per
cent, of which 74.53 per cent, were revealed
by means of the luetin reaction, and only
9.43 per cent, were diagnosticated by means
of the clinical findings and syphilitic erup-
tions.
It is difficult to draw conclusions from
an investigation made from a selected group
of children, particularly such as are found
in a foundling asylum. The constitutional
inferiority of children of this class is evi-
denced in the fact that with few exceptions
all of the inmates were below the normal
averages in weight, height, development
and nutrition. It is impossible, therefore,
to deduce any statistical values that might
be applicable to the general infantile popu-
lation. The facts, however, are sufficiently
important to point out the necessity for
routine testing of children in foundling in-
stitutions, with a view to the proper admin-
istration of anti-syphilitic treatment as
early as possible. The necessity for such
a course is further accentuated in those
institutions where extra-mural or boarding-
out service is maintained. It is esential for
the protection of families with which chil-
dren are to be boarded, as well as for se-
curing the greatest assurance of adequate
medical care for the children thus placed.
A further item which merits continued
investigation is the comparative use of the
luetin and Wassermann tests among young
children, with a view to fixing with greater
exactness the relative values of each in the
determination of syphilis during early life.
Are Pottage Stamps Dangerous? — ^The
ubiquity of microorganisms is part of com-
mon knowledge. The mere presence, how-
ever, of bacteria does not necessarily con-
stitute a menace. Numerous organisms are
of inestimable service in assuring the puri-
fication of streams, the fertilization of the
soil and the destruction of undesirable ma-
terial. The abundance of pathogenic bac-
teria forms the essential problem underly-
ing the spread of disease.
From time to time, attention is drawn to
many of the simple acts of life which con-
tain a slight hazard to health and, unfor-
tunately, such items are too frequently over-
stressed. In the complexity of modem liv-
ing, the high development of social inter-
course, the growth of transportation, the
increased contacts of human beings, it is
impossible to live without some degree of
exposure to a vast variety of incidents
which might be productive of bacterial con-^
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AMBRIOAN MBDIOUIB
EDITORIAL. COMMENT
October, 1919
621
tamination. It is unfortunate, however, to
have life consist of a series of fears. There
are sufficient real dangers from bacterial
carriers to appreciate the minimum dangers
which may be said to lurk in various rou-
tine performances of daily life.
Another example of suggesting a danger
is to be found in the discussion of "The
Postage Stamp as a Possible Source of In-
fection'' by J. Diner and G. Horstman, The
Medical Times (October, 1919). Postage
stamps were secured from fifty diflferent
places and note was made as to whether
they were kept exposed on the desk or were
held for sale in a drawer or cash register.
Laboratory tests were then made to deter-
mine the bacterial content of the stamps by
shaking them out in a saline solution and
then plating one cubic c.c. on an agar medi-
um and counting the colonies after 48 hours
incubation at 37 c. No stamp was free
from germs. Twenty contained colonies too
numerous to count. There appears to be very
little diflference in the growth secured from
stamps which were exposed on the desk and
those held in the drawer. The estimation
of the different colonies, however, is by no
means significant. More suggestive is the
fact that there were recovered and deter-
mined thru the use of differential media
and the examination of stained smears colon
bacilli, staphylococci, streptococci, pneumo-
cocci and diphtheroid bacilli.
Unfortunately, no tests were made to de-
termine the virulence of any of the bacteria
recovered, wherefore it is difficult to de-
termine what degree of danger was pre-
sented by the presence of these various or-
ganisms.
While it is undoubtedly true that had
these stamps been moistened with the
tongue, as is the all-too-common practice,
the possibility of such organisms entering
the mouth would have been increased. It
must not be forgotten that most oral cavi-
ties will reveal the existence of most of
these organisms without making use of a
postage stamp. Were stamps a grave source
of infection, a very large percentage of the
population would undoubtedly be suffering
from some infection due to this cause be-
cause of the commonness of the method of
licking postage stamps.
The gum utilized for making the stamp
adhere constitutes a favorable medium for
bacterial growth, and for this reason, pos-
sibly, it may be said that stamps are more
dangerous than scwne other articles to which
the tongue may be applied. If one con-
siders, however, the vast numbers of or-
dinary stamps daily wetted by the saliva,
and then thinks also of the number of fin-
gers that go into mouths, and the vast num-
ber of only partially clean eating utensils
which similarly enter the buccal cavity,
there is a grave question as to whether there
is a sufficient degree of possibility of infec-
tion from* this source to warrant viewing
it with any great alarm.
The month is a significant channel of
entry for pathogenic bacteria and the un-
clean mouth is a potent source of danger to
health. A large variety of disease produc-
ing organisms have been found in the
mouth, some of which are dangerous to
the individual and others of which appar-
ently do him no harm. The sterile mouth
probably does not exist, and a certain de-
gree of protection has been developed by
the mucous membrane so that there is more
or less general success in overcoming the
large proportion of the supposedly infective
bacteria. Under these circumstances the
mere demonstration of the bacterial content
of postage stamps does not serve as an
indictment against them from the stand-
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622
OCTOBBR, 1919
EDITORIAL COMMENT
American Mbdicinb
point of public health. The hygienic les-
son that people should not lick postage
stamps is certainly sound ; but, nevertheless,
this practice is scarcely to be construed
as a potential danger compared with the
eating and drinking which are so essential
for sustenance, but, nevertheless, are re-
sponsible for a large measure of bacterial
contamination of the oral cavity.
A Program of Mental Hygiene^ — ^The
demand for an improvement in mental hy-
giene as part of the Child Welfare Move-
ment is being met in various ways thruout
the country. For some, the word "segre-
gation" appears to suffice as an answer to
all the questions relating to feeble-minded-
ness. This solution, however, is inadequate
to solve the manifold difficult problems
which are bound up in dealing with the
mentally handicapped. Dr. C. Macfie
Campbell, addressing one of the conferences
of the Children's Bureau upon the subject,
"Standards of Child Welfare," outlined a
program which, for the time being, repre-
sents an ideal method for attacking the
problem in the interests of the state. His
scheme includes "The mental examination
of backward school children; the mental
clinic ; the traveling clinic ; the special class ;
directed training of individual defectives in
country schools; instruction of parents of
defective children ; aftercare of special-class
pupils ; special training of teachers in nor-
mal schools ; census and registration of the
feeble-minded ; extra-institutional supervi-
sion of all uncared-for defectives in the
comrpunity; selection of the defectives who
most need segregation for institutional care ;
increased institutional facilities; parole for
suitable institutionally-trained adult defect-
ives; permanent segregation for those who
need segregation; mental examinations of
persons accused of crime and of all inmates
of penal institutions; and long-continued
segregation of defective delinquents in spe-
cial institutions."
The significant features of this most ex-
cellent plan involve a form of cooperation,
the need of which grows more apparent in
public health work. Feeble-mindedness is
not regarded as a health problem, or as an
educational problem, or as a challenge to
our courts or institutions, but is recognized
as a complex condition demanding team-
work on the part of psychiatrists, psychol-
ogists, teachers, normal schools, parents, so-
cial workers, institution officials, parole of-
ficers, court officials, prison officers, etc.
The very breadth of this vision is refreshing
and stimulating. The great difficulty lies
in the harmonizing of conflicting opinions
so as to secure the adoption of even a small
part of this complete program which at
present is merely an ideal, and finds no
expression in its fulness in any state of
the Union.
All delinquents are not defectives, nor
are all defectives potential delinquents. Some
are educable, others are unfitted for ordin-
ary academic training. The problem of
ascertaining mental defectives in a com-
munity, particularly those of the moron
group, calls for earliest attention. The
greater the number of children that can be
reached during the formative period of their
lives, the more satisfactory will be the out-
come of our eflForts in their behalf and in
the interest of the community. While it
is true that all children theoretically are
under the control of school authorities, large
numbers manage to escape this jurisdiction.
In extensive areas of the country no effort
is made to include a mental examination of
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American Mjbdicinb
EDITORIAL, COMMENT
October, 1919
623
school children and, in consequence, many
school systems suffer from the presence of
children in the regular grades who might
better receive their training in special
classes either in or out of the regular school
or, indeed, by transfer to special types of
institution where their complete welfare
might receive greater consideration.
The development of our probation and
parole system, the institution of juvenile
courts, reflects a desire to deal fairly with
juvenile delinquents, but this work cannot
be satisfactorily administered without a
more complete cooperation between legal
authorities, probation officers, and psychol-
ogists, psychiatrists, and school teachers,
truancy officers, and others having personal
knowledge of the life, the heredity and the
environment of particular children.
The necessity for mental clinics is ap-
parent. The difficulties of instituting clinics
in rural communities are numerous, but by
no means insuperable, as the armamenta-
rium of such clinics is exceedingly limited
and lends itself easily to transportation.
The adaptation of such traveling mental
clinics to the needs of the various states is
well within the powers of state departments
of health. The essential factors are the
recognition of the problem and the respon-
sibility for its control being vested in a
single state department, preferably the de-
partment of health, thru the establishment
of a subsidiary division designed to care
for feeble-mindedness in its general aspects.
The fundamental work to be accomplished
and the methods of dealing with feeble-
mindedness necessarily are dependent upon
a full knowledge of the problem such as
may be secured thru the medium of a sur-
vey, such as has been made in various sec-
tions of the country.
All the advantages which might be se-
cured for the defective child of wealthy
parents should be made available for all fee-
ble-minded persons in the community. When
education is necessary, or the correction of
physical defects, or segregation to prevent
procreation, or hospital care, or probation,
the needs of the community demand that
equal opportimities and advantages be af-
forded without distinction to every type of
family in the community. It is patent that
this becomes possible only under a highly
centralized form of administration, prefer-
ably under state auspices and direction,
with a careful designation of phases to be
cared for by individual communities. It is
because of this that Dr. Campbell's pro-
gram appears to be particularly meritorious
and to commend itself for adoption by all
states that recognize feeble-mindedness^ as
a serious problem that too long has been
neglected or indifferently regarded.
Physical Examinations of Recruits. —
The results of the physical examination of
the first million draft recruits have been
compiled in Bulletin Number 11 of the War
Department, emanating from the office of
the Surgeon General. The conclusions
point out specifically various contrasts be-
tween conditions noted in draftees from ru-
ral and urban centers. While the ratios
of rejections differ in the various states for
various reasons, and the interpretation of
standards of examination did not possess
at all periods the same degree of rigidity,
the facts ascertained are none the less valu-
able.
Sundry questions arise as to the influence
of city life upon the growing population,
and some of them find their answers in the
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624
October, 1919
BDITORIAL. COMMENT
AMDUCAJf MBDXCINS
results of the physical examination of re-
cruits. Hernia, actual or incipient, is more
influenced by the urban factor than by any
other. Men from the cities show about 30
per cent, more defective vision than men
from the rural districts. Otitis media is
about 60 per cent, commoner in the cities.
Flat foot, which, incidentially is the great-
est defect, having been found in nearly one-
fifth of the men examined, is maricedly ccwn-
moner in both the severer and slighter
grades, in city men than rural men. As
might be expected, chronic alcoholism and
drug addiction were far more frequently
present among those coming from cities
than among those living in rural districts.
Myopia and varicose veins similarly are
more frequent among city men. Strangely
enough, rejections for underweight showed
a preponderance of city reared young men.
The prevailing defects existent among
recruits from rural areas are infectious dis-
eases; all forms of tuberculosis; venereal
diseases, except syphilis; benign tumors;
arthritis; nearly all nervous diseases, ex-
cept paralysis of muscle and tabes dorsalis ;
all mental diseases except alcoholic psy-
choses; conjunctivitis of all forms; cata-
ract; pterygium; retinitis; amblyopia and
nystagmus; most diseases of the nose, ex-
cept nasal polypus ; respiratory defects, ex-
cept pleurisy; ankylosis, and non-union of
fractures.
The variation of defects in very large
cities is exemplified, for example, by the
diseases and defects noted among recruits
from New York City. These men showed
an excess of drug addiction, constitutional
psychopathic states, otitis media, acute and
chronic endocarditis, hernia, contracture of
joints, hammer toe, loss of part of foot,
underweight and cryptorchism. Strange as
is may seem, among conditions strikingly
uncommon among recruits from New York
City are pulmonary tuberculosis ; hyperopia ;
conjunctivitis other than trachoma; hyper-
trophic tonsillitis; mitral insufficiency; var-
icocele ; fibrinous pleurisy ; hydrocele ; bony
ankylosis ; deformities of the hand resulting
from injury or infection; malunion of the
lower extremities; curvature of the spine;
hypospadias, and bullet and other recent
wounds. That the above named conditions
are not wholly dependent upon density of
population is evident from the fact that in
Chicago the exceptionally common diseases
and defects were chancroid; simple goitre;
exophthalmic goitre; arthritis; hyperopia;
hemorrhoids ; varicose veins ; varicocele ;
loss of fingers ; curvature of the spine ; de-
fective physical development; overweight;
hypospadias and bullet and other recent
wounds. There was, on the other hand,
less than the average of constitutional psy-
chopathic states, eye and heart defects;
hernia; flat foot and pronated foot.
These variations in defects are indica-
tive of numerous interacting factors such
as climate, racial variations in the popula-
tion, the nature of industries, the character
of patients, housing and methods of rec-
reation. The conditions due to defective
heredity do not stand out with great prom-
inence.
Among some of the conclusions of partic-
ular interest, one may mention that defect-
ive physical development was found in ex-
ceptionally high proportion in the New Eng-
land States. Mitral insufficiency was in ex-
cess of nearly 60 per cent, in recruits from
the rural districts. Considering generally
large and small cities in rural districts, the
amount of pulmonary tuberculosis and ven-
ereal diseases is inversely correlated to the
denseness of population. Defects of vision
are directly correlated to the size of cities.
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AMBRICAN MBDIGUIB
BSDITORIAIi COMMENT
October, 1919
625
Valvular heart diseases are roughly and in-
versely correlated to the density of popu-
lation.
Much may be learned from an analysis
of the figures presented to assist state health
officers in formulating programs designed
to meet the specific needs of their citizens
as reflected in the figures for rejection.
Varicose veins, for example, constitute a
problem in Minnesota and Wisconsin, while
trachoma is of far greater significance and
importance in Kentucky, Illinois, ' Indiana
and Missouri. Goitre is particularly com-
mon in the territory adjacent to the Great
Lakes. Drug addiction requires serious
consideration in the cities of Kansas.
It is a rare experience to have an op-
portunity to weigh the problems of the
young men in the United States in the man-
ner made available thru the examination of
recruits. The statistical analysis of these
examinations under the direction of the Sur-
geon General constitutes a most valuable
addition to our knowledge of men as they
are to be found during a period of greatest
virility and strength. Further reports that
are to be issued will supply further statis-
tical material which will serve to correct the
errors that may have been made in the
earlier examinations and establish reliable
figures representing the imperfections of
those called to the colors.
It must not be forgotten that the mere
fact of rejection for military service does
not connote complete unfitness for civil or
industrial life. The trials of the soldier
are far more severe than those experienced
in civil life. While possibly one-quarter to
one-third of males, 20 to 30 years, are
physically unfit to fight, their handicaps may
not be such as to materially interfere with
their successful living under the ordinary
conditions of civil life. Even if onlv fifteen
per cent, of males 20 to 30 years old pos-
sess a serious physical handicap against
normal civil activities, the mere number is
sufficient to indicate the necessity for de-
creasing them insofar as may be possible.
Probably comparatively little can be done
for the existent generation, but everything
remains to be attempted for the protection
of the growing generation.
Typhoid Contrd* — In a discussion of
typhoid fever in New York City during
1918, Monthly Bulletin, The Department
of Health (August, 1919), L. I. Harris calls
attention to one or two items which are
of the utmost importance in connection with
typhoid prophylaxis.
"We have found it difficult to secure the
cooperation of private physicians in educat-
ing the members of this community to the
tremendous value of the protection against
typhoid fever, which can be secured thru
immunization." Despite various efforts at
publicity thru utilization of placards extol-
ling the virtues and advantages of typhoid
immunization, the number of immuniza-
tions made by the Department of Health
during 1918 was very much smaller than
during the preceding year. It is obvious
that any campaign of public advertising in
support of a theory of preventive medicine
requires substantiation and support by the
medical profession. It seems almost unbe-
lievable that family physicians should be
adjudged guilty of a lack of interest or of
a failure to properly participate in support-
ing the efforts of the community in lower-
ing the typhoid morbidity and mortality
rate.
While it is true that the morbidity rate
from typhoid fever in New York decreased
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OCTOBBR, 1919
B2DITORIAL. COHMBNT
AunucAN MBDICIMa
from 68 per hundred thousand in 1898 to
21 per hundred thousand in 1918, and the
case mortality rate fell from 30 per cent, to
16 per cent., the results can scarcely be
regarded as satisfactory. Typhoid fever
is one of the best examples of preventable
disease whose continued existence casts
serious reflections upon public health ad-
ministration and municipal sanitation. The
typhoid fever rate has been properly re-
garded as an index of the attitude of com-
munities toward public health and sanita-
tion. The reduction of this single disease
to the vanishing point is desirable, not mere-
ly because of its own seriousness, but be-
cause of the manifold advantages that will
accrue to the community thru the efforts
to overcome it. To have any measure of
the blame for failure on the part of public
health authorities fastened upon the medical
profession is unfortunate, because physi-
cians are in possession of all the facts rela-
tive to the benefits of typhoid immuniza-
tion, and know full well the benefits which
are to be derived from an extension of its
practice.
• A second criticism which merits consid-
eration lies in the statement "In a relatively
large proportion of the cases admitted to
general hospitals, supervision for the pur-
pose of enforced sanitary precautions and
for other purposes does not seem to have
been as rigidly exercised as in the supervi-
sion of cases treated at home." Particular
reference is made to the fact that general
hospitals have discharged patients who have
survived typhoid fever without referring
their records to the Department of Health
prior to their discharge, so that a labora-
tory examination might be made to deter-
mine the presence or absence of typhoid
bacilli in the intestinal tract. It is patent
that such individuals discharged from hos-
pitals without proper safeguard constitute
a group among whom there may be nu-
merous bacilli carriers free to go about and
serve as a menace to those with whom they
come in contact.
The importance of coDtroUing tsrphoid
carriers is beyond argument. The practice
of releasing patients who have suflfered
from typhoid fever only after two stools
have been found to be negative for typhoid
baciUi is of great importance. The experi-
ence of the Health Department has indicated,
however, that public safety is better assured
by a requirement that all individuals who
recover from typhoid shall ''for a period
of from six months to a year be required
to submit specimens of stools at regular
intervals, so as to make certain that we are
not releasing carriers who may move about
freely and prove to be a source of infection
to others." Some municipalities demand
that suspected carriers enter a hospital un-
der the jurisdiction of the health department
for a day, at stated intervals, so that stools
may be obtained under proper supervision
with a view to preventing the substitution
of a stool obtained from a normal person
for that of the suspected carrier. In this
direction, hospital authorities should freely
cooperate. Their responsibility to the com-
munity is not ended when the typhoid suf-
ferer leaves the institution. From the
standpoint of public health, the individual
is not cured until his body is freed from the
typhoid bacilli that may lurk in the intestinal
tract. Incidentally, it may be remarked
that hospitals might be more rigid in de-
manding the immunization of all persons
who come in contact with typhoid sufferers.
This applies particularly to internes, nurses
and orderlies, whose protection is essential
not merely for the sake of their own health.
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AMERICAN MBDIOZNa
EDITORIAL COMMENT
October^ 1919
627
but in the interests of the entire hospital
and the community it serves.
During 1918 less than one per cent, of
the total number of typhoid cases reported
gave a history of having received immuniz-
ing doses of typhoid vaccine. While these
figures cannot be fully interpreted without
a knowledge of the relative proportion of
the population already immunized, at first
glance they are highly suggestive of the
dangers existent from non-immunization.
The history of the military and naval forces
during the war attests the tremendous ad-
vantages conferred thru the protective inoc-
ulation. There is no reason why similar
advantages should not obtain during times
of peace.
The two main factors today, outside of
sanitation, for the prevention of typhoid
fever are personal immunization and the
control of typhoid carriers. The responsi-
bility for securing both of these, while pri-
marily resting upon health departments, is
no less an obligation of the medical pro-
fession. Where sanitation is particularly
lax, the necessity for immunization is tre-
mendously increased. It is impossible, how-
ever, without mandator}' public health prac-
tice to succeed in immunizing a community
without the heartiest support and coopera-
tion of the medical profession. If it were
possible for each individual physician to
recognize in himself a small but powerful
cell of the public health organism, he would
function more vigorously for the benefit of
the entire community. The least that can
be said is that criticisms of the medical pro-
fession for failures to carry out sensible
provisions of modern hygiene and medicine
should serve as a stimulus to greater activ-
ity. If physicians fail to support the re-
sponsibility of health authorities, one can
scarcely blame laymen for objecting to pro-
visions of law in their own behalf concern-
ing whose value they are in doubt. The
best medium for advertising the benefits
of public health measures should be the
profession itself, which stands as the ex-
ponent of modern preventive medicine.
Rural Health Administratioii. — The re-
cent study of Rural Children in Selected
Counties of North Carolina (Rural Child
Welfare, Series No. 2) is highly suggestive
of the numerous problems confronting
county health officers or State departments
of health interested in raising health
standards. The population of the areas
studied is uniformly native born American
of native percentage, so that the question
of foreign influences is not involved. The
main difficulty apparently is one of sanita-
tion, with a lack of pure water and the more
pronounced deficiency of privies, render-
ing soil pollution almost inevitable.
The most striking finding is the high ma-
ternal death rate from causes pertaining to
child birth in the lowland county, 41.5, and
in the mountain county 21.9 per hundred
thousand population as compared with the
rate of 15.2 for the entire area of death
registration. The high figures are largely
due to the significantly high rate of 93.9
among negro women. Patently, facilities for
protecting the life and health of mothers
during childbirth are totally insufficient. In
the lowland county, one-third of the white
mothers and nine-tenths of the negro moth-
ers were attended by midwives. Few women
had received any prenatal advice or atten-
tion, while nursing care at confinement con-
sisted largely of the services of untrained
relatives and neighbors. Trained nursing
during confinement is totally lacking in the
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October, 1919
EDITORIAL. COMMENT
Amwucan Mbdxouis
mountain county, and inability to secure
medical attention at childbirth is not rare,
and even where the physician was in attend-
ance, post-natal visits were rarely made.
The demand for rural nurses for prenatal
education and obstetrical care is obvious and
immediate.
Fortunately, the infant mortality rate is
not very high, probably because of the al-
most universal breast feeding of infants,
frequently continued well into the second
year. Nearly half of the infant deaths oc-
curred within the first two weeks after birth,
probably from causes incidental to dystocia
or disease during pregnancy. The reduction
in this mortality rate may best be offset by
further, prenatal care.
The nind dEstricts ol the country are
suffering from ignorance even more than
from poverty. The education of citizens,
however, is distinctly within the range of
state function, and, in consequence, the re-
sponsibility for existent deficiencies lies at
the doors of the State departments of health.
The need for public health nursing, based
upon a plan of county nursing service and
community nursing, is manifest. To many,
public health nursing ?s still r^;arded as an
interesting experiment, bom of a charitable
interest in various classes of society. It is
time that nursing service was removed from
the category of charitable enterprises and
placed among the public health necessities
and essentials where it belongs.
Recognition of the right of individuals
in rural districts to a type of health pro-
tection equal to that afforded to residents
of urban districts should not be further
ignored. Large cities possess the means of
supplying the health needs of their own
communities. The scattered population,
however, in rural sections makes it difficult
to provide the necessary agents without the
cooperation and support of larger units of
the population such as the county, a group
of counties, or the State. Medical inspection
of school children, the provision of prenatal
care and adequate obstetrical attention, edu-
cation in the home in matters pertainii:^ to
hygiene and sanitation are equally if not
more important, in rural communities than
in urban sections.
The conditions revealed by the studies in
Kansas and North Carolina clearly indi-
cate the dire necessity of increasing appro-
priations for education in rural sections, but
education in itself, valuable as it may be,
does not suffice. Some follow-up scheme
must be devised which makes it possible to
give direct instruction in the home thru the
use of varied types of public health agencies
essential for carrying out the principles and
plans enunciated in bulletins, pamphlets,
posters, monographs and lectures.
Physicians practicing in rural sections are
greatly handicapped in prophylactic work
owing to the distances that must be
traversed in reaching the various homes and
because of the lack of facilities for main-
taining healthful conditions in them. The
lack of sanitary homes, overcrowding, in-
sufficient food of the right sort, poor water
supply, and unsanitary privies complicate
the situation. The real necessities of the
rural communities are not met thru books,
papers and magazines, county fairs and the
establishment of institutions for defectives,
delinquents and dependents. There is an im-
perative necessity for socializing and hu-
manizing public health work in rural com-
munities, in a fashion that only becomes
possible when the machinery of public
health work is enlarged so as to afford every
opportunity for health to the normal part
of the population whose worth to society
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AMDUCAN MBDICINB
EDITORIAL COMMBNT
October, 1919
629
is of the maximum importance. Difficulties
are numerous and obstacles great, but these
do not suffice to excuse or condone a state
of hygiene and sanitation which reflects
most seriously upon the present state of
public health administration in the sparsely
populated sections of the country.
IntematioiMiliring the Fight Against
Venereal Diseases^— At the Medical Con-
ference of the Inter-Allied G>mmittees of
Red Cross Societies, various sub-conunittees
discussed specific topics and presented
plans of organization for combating par-
ticular conditions, whose conquest is neces-
sary for the advancement of public health
and child welfare.
The Section on Venereal Diseases, in its
report, embodies various principles which
involve: (1) Measures for the protection of
individuals not yet infected; (2) Measures
for the elimination of conditions of environ-
ment favoring the dissemination of venereal
diseases; (3) Measures for the discovery,
treatment, control of individuals already in-
fected ; (4) Measures for accurate observa-
tions and recording of data relative to ef-
forts to combat venereal diseases on lines
already established; (5) Measures for
furthering research upon venereal disease
infections and the demonstration of new
methods for combating venereal diseases;
(6) Measures for education.
It is patent that the activities involved
depend upon education, research and an in-
crease in the number of centers of activity
against venereal diseases. It is difficult to
arrange these three in the order of impor-
tance but, obviously, education must be
emphasized fundamentally in order to stim-
ulate public opinion, rouse lethargic con-
sciences, and awaken a powerful desire to
work cooperatively on the part of doctors,
nurses, legislators, social workers, moral
and religious workers, as well as the vast
group of un-thinking and high-thinking in-
dividuals termed "the general public." It is
manifestly necessary that a comprehensive
program be adopted if results are to be
achieved commensurate with the physical,
social, and economic importance of vene-
real diseases. The necessity for popular
propaganda for the control of syphilis,
gonorrhea and chancroid, no longer re-
quires argument.
The Aid of the Red CroM.— The
importance of having the backing and
active assistance of the Red Cross So-
cieties thruout the world is apparent. The
direction of the huge forces gathered to-
gether for emergent war work will require
guidance into new channels of effort, and
the massing of the Red Cross forces in an
attack upon any problem is bound to re-
sult in a wide degree of popular education
with valuable results.
A comparatively few years ago a mere
handful of physicians and laymen were in-
terested in attacking the venereal diseases.
Despite the fears of many that this subject
was too dangerous for public discussion, a
constructive plan of propaganda and organ-
ization was devised and fostered. A new
impetus was given to the movement by
large exhibits, particularly that held in con-
nection with the International Congress of
Hygiene and Demography at Washington.
Growth was slow, but adherents to the
cause took on a new determination and thru
the activities of the American Federation*
of Sex Hygiene and its publications, the
movement increased in intensity and worth.
The Great War marked a critical time in
the evolution of social hygiene. The Na-
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October, 1919
UEN AND THINGS
Amducan 1Is>icinb
tional Government early recognized the im-
portance of protecting its soldiery insofar
as might* be possible from the hazards of
venereal infections. The united efforts of
the Departments of War and Navy, the
commission on Training Camp Activities,
and the United States Public Health Serv-
ice brought about a tremendous wave of
activity and reform looking toward the es-
tablishment of a higher moral standard at
home and abroad. The National efforts
have been crystallized by the establishment
of a Division on Venereal Diseases under
the able leadership of Colonel C. C. Pierce,
which is today a most active force in stimu-
lating public opinion, in promoting national
publicity, and in organizing state and local
action.
The achievements of the past two years
bear witness to a vast amount of construc-
tive effort, supported by the interest and
enthusiasm of a war-swept state of mind.
For the continuation of the lines of develop-
ment thus far established, and their exten-
sion in various directions, it is essential to
keep together all sections of the body politic,
whose interests were first secured thru the
exigencies of war work. It is, for this
reason, therefore, that the advent of Red
Cross Societies into the field of social hy-
giene must be hailed and encouraged.
The International Conference marks the
completion of efforts at initiating new ma-
chinery for fighting the black plagues thru-
out the world. The vastness of the forces
aligned must be construed as an indication
of the seriousness of the problem. Behind
all the machinery, however, there is the
hand and mind of man, and it is the human
effort, thought, and power, which must be
relied upon to support the comprehensive
program devised at Cannes, if success, how-
ever relative, is to be obtained within the
next decade or generation.
MEN AND
THINGS
Widening the Doctor's Sphere. — It was
extremely interesting, and at the same time
illuminating, to read the newspaper reports
of the surgical congress. In almost ever}'
case they emphasized the simple, easily un-
derstandable nature of the address. The
reporter, expecting to be buried under an
avalanche of technical verbiage and fearful
lest his ignorance of things medical and
surgical render the subject discussed en-
tirely unintelligible, found to his utter
amazement and pleasure that he could un-
derstand and appreciate almost everything
that was said, in fact that he could follow
the meaning of the speaker as easily as the
professional men present. Commenting on
Dr. William J. Mayo's opening address, one
newspaper remarks : "He escaped from the
realm of the technical and discussed a num-
ber of highly important topics in a ' way
that anyone could understand and appreci-
ate." That, the writer explains, was due
to the fact that Dr. Mayo treated his au-
ditors not mere as fellow surgeons, but
also as citizens concerned in the solution of
all the problems that confront the general
public. The newspapers have been quick
to appreciate the new attitude that is being
assumed by both surgeon and physician.
Hitherto they had been accustomed to rele-
gate reports of such conventions to some
obscure page, feeling that it did not con-
stitute news of wide interest; but now, for
the first time, both the surgical congress
and the convention of women physicians
were not only reported minutely from day
to day, but were made the occasion for illus-
trated articles and popular interviews. That
the daily papers shoult adopt the intricate
and highly specialized subjects of medicine
and surgery as matter for their columns is
a most gratifying comment on the new
character these callings have assumed, the
altered attitude the professional man has
assumed. No longer is medicine shrouded
in a veil of mystery, no longer does the
physician hand down his diagnoses and
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MEN AND THINGS
October, 19 Iv
631
judgments from an altitude. He has de-
scended into the midst of his fellows, he
speaks their language, he appeals to his pa-
tients as a human to humans. What has
happened to conventions has happened to
the publications of the profession: ad-
dressing themselves primarily to profes-
sional men, they are nevertheless read and
understood and often enjoyed by the laity,
who are no longer confounded by a degree
of technicality which was a form of snob-
bery and a deliberate weapon against the
admission of the untutored masses. Now
the physician and the surgeon deliberately
court the masses, deliberately make their
appeal in language simple and non-techni-
cal enough to be understood by the vast
public ; for both physician and surgeon have
come to realize that their sphere has broad-
ened enormously in recent years, that their
mission is something more than writing pre-
scriptions and cutting live tissue, that their
calling is an invitation to a wide usefulness
and a wide social service of which they are
availing themselves in greater and greater
numbers.
Hence it is that the recent conventions
have given themselves over so uniquely and
admirably to the larger problems of medi-
cine and surgery — the social, industrial and
moral problems, rather than the strictly pro-
fessional problems. Particularly was this
true of the convention of women physicians.
A list of the subjects that were discussed
at this convention is extremely illuminating
and shows the changing nature of the gen-
eral attitude toward the public on the part
of the profession. Disease was discussed,
but it was discussed almost entirely from
its social side. Sanitation came up numer-
ous times, but sanitation as a community
responsibility, rather than as a problem in
medical science, was the point at issue. A
resolution was passed urging that "provision
be made in the covenant of the League of
Nations for an Industrial Bureau of Hy-
giene." It was recommended that persons
of both sexes be urged to undergo physical
examination before marriage and also that
there should be regular physical examination
of children up to the time they leave school.
Authorities were advised to take measures
for provision of good food at reasonable
prices and that the public be educated in
food values. Physicians were urged to
make themselves familiar with condi-
tions under which workers were employed
and to work for the removal of those re-
sponsible for ill health. A unanimous sen-
timent in favor of accident insurance for
workers, as well as insurance against sick-
ness, neither at the expense of the employee,
was expressed. And in addition there were
a host of kindred subjects with which hith-
erto the profession has concerned itself lit-
tle or not at all.
It has been the policy of American Med-
icine in the past, and it will remain so in
the future, to encourage this broadening of
the doctor's sphere, to report and stimulate
any effort to identify the practice of medi-
cine with the larger, more vital, more ur-
gent social tasks. If at times it may have
seemed that we were going far afield in
discussing industrial, social or ethical prob-
lems, it was with the studied and deliberate
purpose of attaching one more interest to
the ever-widening, ever-expanding useful-
ness of the doctor. It is for this reason
that what Miss Jane Addams had to say
at the convention of women doctors as-
sumes such great importance. And it is
for this reason that Dr. Anna Moutet*s ad-
dress on the French attitude toward illegiti-
mate children seems of such great moment.
Depopulatioii and lUegitiinacy. — It is
significant that it was a French doctor,
Mme. Moutet, of Lyons, who arose at the
convention as the champion of the illegiti-
mate child. The circumstance merely em-
phasizes the familiar observation that
France has always led the other nations
in its enlightened attitude toward the un-
married mother, but it serves to emphasize
also the oft-repeated assertion that morality
is merely a matter of geography. The dif-
ference between our attitude and that of
the French toward illegitimacy is merely
one of population demands. The French
have as lofty an ideal of marriage and of
the family as we, and their attitude toward
illegitimate children is not a frivolous one.
In comparing the two nations, the deter-
mining factor, however, is that here the
population is growing rapidly and constant-
ly, while in France the population is di-
minishing rapidly and constantly. Hence
we can afford to maintain our severe
condemnation of the bearing of children
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ICBN AND THINGS
Ambrican Mbdicinb
out of wedlock, while the French can-
not do so. Their need of children is so
great that they are constrained to waive
moral considerations and to strain their
ethical code in order to add to their dimin-
ishing numbers. It was, therefore, a French
woman who dared to say : "It is important
above all to favor the rate of birth by all
means, to do away with all obstacles in the
protection of all children indiscriminately.
The procreation of a child must no longer
be held as a disgrace or as a burden. The
girl mother must be lifted, the prejudice
which makes her an object of censure must
be combated and if irregular birth is no
longer a disgrace to the child, neither must
it be a dishonor to the mother. She must
find in society for herself and her child the
support which in the past was refused her."
Without doubt Mme. Moutet's remarks
found a ready and sympathetic response in
the hearts of her audience. They were
physicians, but they were women first of all ;
and they probably felt that Mme. Moutet's
viewpoint was humane, generous and en-
ligrhtened. But that the general public of
this country will accept her attitude or ap-
prove of it is questionable. Anglo-Saxon
morality is inflexible, stubborn, unduly
harsh even, and it will be a long time be-
fore we in this country learn that there
may be better places for an erring girl than
the reformatory or the house of correction.
It will be a much longer time before we
sink so low as to feel gratitude to a woman
for bringing a child into a world sorely in
need of children and pay her for her con-
tribution, as the French are doing. The
morals of a race change very slowly, and it
is only the threat of a national calamity that
can precipitate a quick change. The dan-
ger of depopulation, even with the pros-
pect of extensive emigration in the future,
is not very great in the United States ; and
it is only such a threat that could alter our
attitude toward illegitimacv. To the aver-
age American, what the French are doing,
what they plan to do on a more generous
scale in the future, is nothing less than an
encouragement to immorality. But the
French, who are shrewder than we in such
matters, know that the principle of gener-
osity where children are concerned is not
an encouragement to immorality, but an
alleviation of it. They frankly acknowledge
the inevitability of error and they coura-
geously make the most and the best of it. We
have yet to learn in this country that our
corrective and punitive measures are of lit-
tle, almost no, avail, and that we are merely,
thru a mistaken policy, adding to our liabil-
ities when we might be augmenting our as-
sets.
Fatigue and Its Moral Dangers. — Miss
Jane Addams, speaking at the Conference
of Women Physicians, called attention to
the moral danger involved in fatigue. Miss
Addams, always a careful and dependable
observer of industrial conditions, spoke
briefly and scarcely emphasized an observa-
tion which brings to a light a situation of
momentous importance: the unprecedented
number of women who have entered the
industrial world permanently as a conse-
quence of the demand for labor during the
war, and the danger of lowered moral re-
sistance accompanying the increased de-
mand on their energies. "We have much
to learn on the psychologic as well as on
the physiologic side of the labor problem,"
she said. "The connection between fatigue
and the lowering of moral resistance has
not yet been fully worked out, but there is
an appalling connection between them. I
wish very much some connection would be
made between moral health and the unnatu-
ralness of women working in factories with-
out stimulus to their intellects or affec-
tions." Miss Addams' observation of the
relationship between fatigue and lowered
moral resistance disturbs the conventional
belief that idleness is one of the most
frequent inspirations to mischief. Work
has always been prescribed for those who
fell into evil ways because they had not
enough to keep them busy. It never oc-
curred to the well-meaning advisors of work
that such work might itself involve as great
a temptation to mischief as idleness. It
has always been a commonplace belief that
hard labor, with the consequent fatigue,
rids a man or woman of his or her inclina-
tion toward lewd or immoral diversion.
Physically, that is true enough; but psy-
chologically, the reverse is often the case.
In England, where women in large num-
bers flocked to the munition factories early
in the war, a serious situation developed in
a short time. It was almost immediately
apparent that the women, who hitherto had
led conventional, circumscribed lives, were
indulging in appalling excesses — excesses of
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drinking, smoking and immoral practices.
In fact, the immorality of the women muni-
tion workers became a serious concern thru-
out the country. At the end of a difficult
day's work, exhausted as they were with
their labors, they did not return to their
homes. They congregated in the cafes and
centers of diversion, spent their money
freely and conducted themselves with alarm-
ing freedom in their association with men.
In the light of Miss Addams' observations,
this is easy to understand. Their physical
energies were at low ebb, but so was their
moral resistance. Physically they were not
disposed to moral weakness, but mentally
they were more than ever so disposed. And
it is the mental element that is the more
important of the two. The old adage, in
view of later experience, may be altered
to read: "The spirit was willing, tho the
flesh was weak." Hard work, tho it may
exhaust the body, often acts as a stimulent
to the senses.; and, if these senses are not
properly directed, havoc is bound to result.
In this country, unless proper measures are
taken, the same problem will confront us
as it did in England. Countless women are
still occupied in factories and the various
industries. For these women there must
be found an outlet which will direct their
natural desire for relaxation and recreation
into approved channels. At the end of a
hard day's work they must not be left to
their own tired resources. As Miss Addams
briefly hints, they must be supplied with
some stimulus to their intellects and their
affections which will serve to strengthen
their moral resistance. Music, literature,
municipal dances and entertainment of a
wholesome, instructive type should be ac-
cessible at all times. What these working
women are to do with their leisure should
be made the concern of the community. If
it is not, their leisure will become the very
vexing problem of the community in a short
time. The problem is a serious one, one
in which the doctor may be a very helpful
factor, in cooperation with the social
worker.
Morality and the Nude.^ — Some time
ago a scientist was prosecuted for having
in his possession a number of photographic
plates of the nude female figure. These
plates were only part of a collection which
this scholar employed to illustrate his
theories about race traits. There was
among them a great number of photographs
which revealed only facial characteristics,,
but the few which showed the figure seemed
to be ample evidence to the public censors
that the man who owned them was a lewd
and immoral collector of lewd and immoral
photographs. It was inconceivable to them
that these vicious plates could be prized for
anything but their provocative sexual
nature. They were confiscated and, if we
recall correctly, destroyed. The incident
emphasizes only too clearly the amazing
misconception of our moral censors con-
cerning the significance and influence of the
nude on the average, healthy mind, a mis-
conception which, one is tempted to think,
borders very close on degeneracy. It may
seem a mere trick of verbiage thus to accuse
the moral mentor of himself being guilty of
the fault for which he persecutes his vic-
tims, but the theory of the moral instability
of most censors of morality is founded more
in fact than in fancy. Indeed, one may say
that nine times out of ten the moral censor
is more completely the victim of a dis-
torted and perverted attitude toward sex
than the morally censored. Every man and
woman has some degree of experience with
the nude, whether he be artist, physician,
scientist, or layman ; and the writer has yet
to find a single individual of normal, intel-
ligent, honest attitude toward life who does
not acknowledge that the nude has always
been a chastening influence in his life. The
association with the nude is always a pure
one. Some are impelled to purity by the
ugliness of the nude human form. Some
are thus influenced by its beauty. If there
is any difference, that is the only one to be
found. Perhaps the most common and
most eloquent example of the influence of
the nude may be found in the art school
classes. There a group of students will be
busily engaged in drawing from the nude
figure without seeing anything in that figure
but the beauty which they are trying to
capture and transfer to paper or canvas.
The model is not a human being: she is
merely an inanimate example of art. And
the best proof that it is clothes and not
nudity which stirs adventurous, romantic,
perhaps wicked motives, is the fact that as
soon as the model dons her clothing she at
once (and not till then) becomes a lure to
the men students. If nudity were more
compelling sexually than the clothed figure,
then the Metropolitan Art Museum would
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draw larger crows than the burlesque
houses of New York. Which is the more
disturbing influence, in a moral sense, the
Venus de Milo or the scantily garbed bur-
lesque favorite? There can be but one
answer. Yet the burlesque houses con-
tinue unchallenged by the moral censors,
while the Venus de Milo is tolerated as a
dangerous influence merely because the
prestige of generations of admiration pro-
tect it.
If the moral censor feels that the nude
has a vicious, harmful influence on the
public, he thinks so because the nude has a
vicious, harmful influence on himself. He
judges the effect on others by himself — a
very mischievous and misleading procedure.
For, as has been stated, on the average
healthy, normal individual, the eflfect of the
nude figure is completely disarming of all
vicious inclinations. The average moral
censor thus reveals himself as not the
normal type. And, in fact, a close study
of the activities of moral censors, reveals a
tendencv toward the abnormal in them:
either they are sexually hypersensitive and
imagine all other people to be like them-
selves, or they are sexually perverted and
are victims of reflexes of attraction or re-
vulsion which are not within the experience
of the normal type. Above all, they cannot
be happy individuals. A contented person
is rarely found on a committee of persecu-
tion. Such committees when they are
voluntary are generally made up of an ele-
ment that is either unsatisfied or sated. It
has had either too much or too little of the
experience it is trying to suppress in others.
It is not the normal type. It would be in-
teresting if some day a psychoanalyst would
reveal the unconscious motive which guides
a moral censor toward the release of his
libido by the extreme and unintelligent
measure of persecuting those who are
normal enough to release their libido in a
natural, normal, innocent manner.
Theodore Roosevelt. — As we -go to
press, meetings commemorative of the birth
of Theodore Roosevelt are being held all
over the country. Universal is the regret
felt by the American people that this great
man has been taken from us, that we are
denied his counsel and inspiration in these
troubled times. It is true, his teaching, his
splendid patriotism and his fine interpreta-
tion of Americanism constitute a legacy that
cannot fail to enrich every one of us and
enable us to better realize the worth of our
citizenship in this, the best country on earth.
But how much it would mean if the Nation
today could feel the influence of his sane
and sober thought, the inspiration and
patriotic glow of his spoken word, the love
of this country he could make so real and
worth while!
Many and various have been the tributes
paid to Theodore Roosevelt. All have told
of the worth of the man and the poignant
sorrow caused by his death. But none has
better expressed the place he filled, or the
part he played than the words of appreciar
tion by Curran Pope in a recent issue of the
Indianapolis Medical Journal. We are un-
able to print these in their entirety but the
following sum up so well the life and works
of this great American citizen, that we
esteem it a privilege to reproduce them.
"He was an American, man, citizen and
soldier. Democratic to the core, he loved
his country and its people above everything
else. No one seemed ever to question (suc-
cessfully?) this. No matter what mistakes
he may have made, and they were many,
for Theodore Roosevelt was human, we all
agree they were the mistakes of wisdom and
not those of intent. Not even his bitterest
enemy questions his Americanism, his love
of his flag and his undying patriotism. He
was a born leader of men. Few in America
can or have been able to rally a hundred
thousand men to a standard, ready to do or
die, because he whom they loved and re-
spected was ready to lead them, they cared
not whither, even though it be to the carol
of the great guns. In my opinion, this one
incident in a career so replete stamps him
with attributes of courage, power and per-
sonality no other in this broad land of ours
has ever possessed. And history will in
time give him his rightful place as a great
American. When the passage of time cools
the ardor of men, when just judgments can
be formed, the intellectual gifts, the quali-
ties of hand and heart will be truly appre-
ciated. His friends will remain staunch and
true ; embittered partisan feelings will fade ;
in his death enmities will cease, and the real
American will estimate him for what he has
been and remember him for his rich con-
tributions to this country's cause."
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^ORIGINAL
TICLES
CAUSES, DIAGNOSIS AND TREAT-
MENT OF CHRONIC COUGH.^
BY
IRVING WILSON VOORHEBS, M. S., M. D.,
Assistant Surgeon, Manhattan Eye, Ear
and Throat,
New York City.
Every practitioner of general medicine
is quite familiar with a rather large group
of patients who consult him because of a
persistent troublesome cough. Sometimes
such cough is of many years standing and
is associated, consequently, with very
marked pathologic changes in certain body
structures; but quite often the cough has
been present for only a few weeks or
months, and yet gives every sign of becom-
ing permanent since it does not yield to
any of the ordinary remedies prescribed
in such conditions. There is a history of
frequent colds, of asthma or hay fever or
some severe acute illness such as influenza
from which the patient recovered in every
detail except this distressing symptom which
"seems to hang on" as the vernacular puts
it.
These patients are not very welcome in
the physician's waiting room because they
disturb and drive away other patients who
think that everyone having a cough must
be a victim of tuberculosis. Moreover, it
*Read before the Greater N. Y. Med. Ass'n,
April. 1919.
requires much time and study in some in-
stances to establish a diagnosis, much more
time and study than the hard-driven gen-
eral practitioner can spend, and therefore
the "expectant method" of treatment is
the one most commonly adopted.
The causes of chronic cough fall con-
veniently under three heads, altho the
classification might doubtless be extended,
but for present purposes these three will
suffice :
A. From mechanical irritation of
vagus.
B. From bacterial infection somewhere
along the path of the airways.
C. From "sensitization" to proteid
toxins and to pollens.
It is well known that almost any irrita-
tion of a peripheral organ will produce re-
flex cough. For example, in examining
the auditory canal, or in removing cerumen
the patient sometimes coughs quite vio-
lently for a minute or so. Pressure against
the lingual or faucial tonsils likewise brings
on a spasm of coughing, and there are cases
of diseased tonsils, that is disease of the
tonsillar crypts, associated with cough which
are entirely relieved by tonsillectomy.
Pressure upon the vagus thru new
growths or enlarged glands sets up this
same cough reflex. Aneurysmal cough is
well described in the symptom-complex of
the older writers on medicine as well as by
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the more modern authors. Goitre and
cervical glands are occasional causes, altho
pressure here tends more to the paralytic
than to the stimulative or irritative lesion.
Elongated uvula with a constant sensation
of tickling in the throat is responsible for
irritation of the vagus fibres supplying the
epiglottis, and the latter is also influenced
in turn by the pressure of an hypertrophied
lingual tonsil at the base of the tongue.
New growth of the esophagus in the early
stage irritates the vagus and causes cough,
while pressure symptoms at a later stage
may cause the usual paralysis. Foreign
body in the trachea, bronchi or lungs may
set up very great irritative cough which
later on is associated with the expectora-
tion of large amounts of pus due to the co-
incident bacterial invasion. The cough of
chronic passive congestion of the lungs due
to heart, kidney or liver disease has been
often described in the text books and has
been corroborated clinically.
There are doubtless many other mechan-
ical causes but it is quite unnecessary to
multiply them here. It is sufficient to in-
sist that every peripheral source must be
investigated in order that nothing be over-
looked; for an accurate diagnosis is indis-
pensable to any system of rational and ef-
fective treatment.
The second group of causes and by far
the commonest is that in which there is
bacterial infection somewhere along the
airways. It is with this group that we are
chiefly concerned in this essay.
Any chronic infection of the respiratory
tract must have been at one time acute, and
hence at that period of the individual's his-
tory was curable since the patient did not
succumb to it. The reason why no cure
was effected is either because the body re-
sistence was inadequate to rout the enemy
entirely, or because the aid afforded by med-
ication or general management of the case
was likewise inadequate. Neglected or
improperly treated "colds" are the com-
monest causes of chronicity of mucous
membrane disease, for it is commonly con-
ceded now that so-called colds are infec-
tious and communicable, and as such are a
menace to public health. Says Rosenau:
"Could the. sum total of suffering, incon-
venience, sequelae and economic loss result-
ing from common colds be obtained it would
at once promote these infections from the
rank of the trivial into the rank of serious
diseases."
Bacteria capable of causing the clinical
entity described as "a cold" are probably
always present on the respiratory mucous
membrane, especially in the upper tract.
These are the exciting cause; the predis-
posing causes being chilling of the body
surface, exposure and fatigue. Not only
rhinitis but many other infections may fol-
low chilling of the body or wet feet, no-
tably pneumonia and that vague thing which
we call "rheumatism". Just so soon as the
body resistance falls below normal the bac-
teria are ready to do their work and will
succeed unless there are sufficient anti-
bodies to offset even an overwhelming num-
ber of bacteria. Emery says that when the
surface of the body is chilled, the phago-
cytes circulating thru the skin are alter-
nately subjected to the excessive interior
warmth and the excessive exterior cold
which render them less efficient function-
ally. He found that immunity is a purely
relative term, and that even in the otherwise
immune, susceptibility may be superinduced
by experimental means. For instance,
fowls are immune to anthrax, but are ren-
dered susceptible if kept for some time
standing with the feet well immersed in cold
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water. It has also been found that cold
and wet are much less likely to produce
disease during muscular exercise, but
fatigue must be avoided. Exercise in-
creases the heat of the body, increases heart
action and accelerates the movement of the
blood thru the skin, raising the internal
temperature of the body ; therefore, during
exercise the temperature of the leucocytes
never falls much below normal and their
function is not reduced.
There is some ground for belief in the
old dictum that "a fever patient never
catches cold" which is, perhaps, explainable
on the basis that there is always ^ hyper-
leucocytosis when the temperature is high,
old leucocytes being constantly destroyed
and new virile leucocytes being born out of
the bone marrow constantly. In any case
we know that in the presence of any serious
disease where the number of leucocytes is
not increased or where they fall below
normal, the prognosis is not good unless we
succeed in stimulating the growth of new
white blood cells. This is such a simple
and important factor in body resistance
that its value should never be overlooked.
The recent influenza epidemic bore witness
to the fact that there was both a relative
and actual decrease in leucocytes, especially
in cases which succumbed quickly to the in-
vading army of virulent micro-organisms.
When thinking of the patient's resistance
to disease one does not always remember
that the micro-organisms also have a well-
developed line of defense against both the
body fluids and any agent which we may in-
troduce from without the body. Bacteria
become more or less tolerant to antiseptic
agents, and even in vitro it is not always
easy to kill certain types such as the spore-
forming group. The encapsulated bacteria
are also very hard to kill because a lipoid
envelope protects them against the action
of body fluids. Moreover, micro-organ-
isms . show almost human intelligence in
ensconcing themselves in the cell recesses
of the body where they may remain strongly
entrenched and maintain their virulence
over a period of months or years. It is
for this reason that relapses are so com-
monly met with in acute disease. Upon
the same grounds, too, one can explain the
so-called ''carriers" of active organisms
which have apparently become habituated
to the individual in such a way that he may
remain in an apparently good state of health
while harboring them in the various organs
and tissues of the body thruout a period of
years. •
Further, there is a general alkaline or
acid reaction of the body fluids which en-
courages or makes possible the tenure of
certain bacteria. Recent work on the in-
testinal flora has shown that in chronic
infection of the lower bowel with well-
known symptoms of putrefaction, forma-
tion of gas, numerous fluid stools, etc., the
dejecta are acid in association with certain
pathogenic bacteria, and alkaline in asso-
ciation with certain other bacterial groups,
so that rational treatment of the lower
bowel depends upon a knowledge of the re-
action to litmus. Therefore, where bac-
teria are growing readily in an acid medium
the bowel is flushed frequently with an alka-
line wash; and, conversely, where bacteria
are propagating in the presence of an alka-
line medium, an attempt is made to acidu-
late the medium so that the organisms will
find it more difficult to live, thrive and
grow.
Another factor which influences the
resistance of the patient is the "acidosis"
element. Normally the blood is alkaline,
and when this alkalinity is reduced the ac-
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tion of antibodies is lessened, giving to
micro-organisms and their toxins the
greatest opportunity for unrestricted prop-
agation and devastation of tissue. Alexins
and opsonins work best in alkaline media;
and, therefore, the therapeutist has an op-
portunity to favor this condition by medi-
cation and by diet. Ingestion of acid
fruits which are converted into alkaline
citrates, tartrates, malates and the like when
they reach the blood are certainly of value
in combating acidosis. This may help to
explain the great faith of the laity in the
use of lemons during acute illnesses, and
in the light of recent studies this faith may
have a foundation in fact.
The lower respiratory tract is sometimes
infected from the upper airways. For in-
stance, pus from a sinus infection drops
down into the hypo-pharynx, sets up a
laryngitis and tracheitis, ultimately a bron-
chitis which for one reason or another never
gets entirely well. Adenoid tissue in the
vault of the pharynx probably exerts a like
influence, since it is almost constantly a
culture medium for bacteria. And thus it
comes about after some acute, severe ill-
ness such as influenza or scarlet fever that
the patient seemingly recovers, but in some
part of his body there lurks the micro-
organisms of the original infection, now
apparently harmless to the host who has
established his immunity and a tolerance
for the presence of such germs, but de-
cidedly pathogenic and harmful to the in-
nocent, unsuspecting person who happens
to make a "contact'* with the carrier.
This question of "carriers" is especially
important in considering chronic infections
of the airways. As may be inferred from
the above, a carrier is one who harbors
pathogenic micro-organisms in his body
without exhibiting any personal manifesta-
tions of the disease. Diphtheria bacilli,
streptococci, diplococci, meningococci and
many other organisms may live in the air-
ways without giving any definite signs or
symptoms of their presence. It is well
known that physicians and nurses go about
their work in the hospital wards in an ap-
parently good state of health carrying vari-
ous dangerous bacteria in the mouth and
throat. Such are termed temporary car-
riers ; for once they are outside of the locus
of infection for a few days the bacteria can
no longer be found by culture. An acute
carrier is one who has had some disease
and who harbors the micro-organisms thru-
out convalescence and for a few days there-
after. A chronic carrier is one who has
recovered from an infection, but carries
the germ for months or years thereafter.
The study of carriers has shed new light
upon the spread of communicable diseases,
and emphasizes the necessity of taking at
least two negative cultures from all cases
before discharging from quarantine. The
difficulty of sterilizing the respiratory tract
is obvious, but it must be done if public
health is to be safeguarded, and the newer
teaching of medicine must demand and see
that it is done. Says Rosenau, "The cure
of carriers is one of the pressing problems
of preventive medicine, but one hopeful
feature is that their number may be dimin-
ished by isolating the cases. Thus, the
number of typhoid carriers falls oflF sharply
as a result of any successful measure di-
rected against the clinical case." In the
first weeks that America was at war with
Germany this carrier question came up
very prominently because of the develop-
ment of cerebro-spinal fever. Govern-
ment pathologists visited many of the hos-
pitals in our cities and took cultures from
the naso-pharynx and throats of patients
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in the waiting rooms in order to find out
what proportion of the civil population is
carrying infectious diseases and thus
spreading them far and wide. I have not
seen the report on this work, but Great
Britain has rendered hers and the investi-
gators concluded that every case of cerebro-
spinal fever is an instance of some carrier
developing the disease, the same type of
meningococcus being found in the naso-
pharynx and spinal fluid.
For purposes of convenience we may
classify the chronic infections of the
larynx, trachea and bronchi into tubercular
and non-tubercular. So much has been
written about the tubercular variety that it
would be superfluous and likewise impossi-
ble to go into that in a paper of this length,
but it would seem that the intensive study
of tuberculous lesions of the lungs has
overshadowed the non-tubercular to such
an extent that this latter very large and
very important group has been overlooked.
After all that has been said, written and
done in the diagnosis, pathology, sympto-
matology and prognosis of pulmonary
tuberculosis we are in about the same rel-
ative position regarding treatment as we
were fifty years ago. There is as yet no
specific general treatment, and the hygienic
management such as regulation of diet, in-
take and output, exercise, fresh air, etc.,
has been worn quite threadbare. As for
local treatment this is not even attempted
except when the tuberculous process at-
tacks the epiglottis or larynx, seemingly be-
cause it is believed that the tubercle bacil-
lus cannot be killed in the lung in sufficient
numbers to make any diflFerence in the
course of the disease ; for in many instances
the constitutional symptoms outweigh all
others. Is it too much to believe or hope
for that in the not distant future someone
is going to make the attempt to treat the
lungs directly by organizing against the
tubercle bacillus a campaign so destructive
as to make its persistent habitat in the
lungs untenable? Such treatment would
make use of all the hygienic and dietetic
methods now recognized as helpful, and
combine them with the application of
methods worked out from a study of the
physiologic chemistry of the body metab-
olism in the presence of tubercular infec-
tion. At the present time it is difficult to
get an intelligent laboratory report on the
sputum sent to most Health Board Labora-
tories. It is deemed sufficient to report on
the presence or absence of tubercle bacilli,
but the specimen may be swarming with
long or short chain streptococci, streptococ-
cus mucosus, streptococcus viridans, diplo-
coccus pneumoniae, and all possible vari-
eties of staphylococci. The absence and
continued absence of tubercle bacilli from
repeated specimens, and the constant pres-
ence of other micro-organisms speak
favorably for a lung infection of non-
tuberculous origin. Many patients suffer
for years from the latter condition, and in
some cases are finally convicted of having
tuberculosis an)rway even tho no tubercle
bacilli have ever been found. One such
case has been under my observation for
almost two years. For the past twenty
years he has been examined by some of the
best physical diagnosticians in this country
who report a wide difference of opinion.
During this period he has always coughed
up considerable pus, occasionally some
blood, but at no time has the tubercle bacil-
lus been found. The sputum has, however,
always shown long chain streptococci,
staphylococci, diplococci, etc. At one time
he spent six months in a tuberculosis sani-
tarium to which he was ordered by a lung
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specialist with a diagnosis of pulmonary
tuberculosis, but after repeated attempts
to prove the diagnosis correct, the sani-
tarium authorities sent him away with the
opinion that no pulmonary tuberculosis is
present. It does not seem reasonable to
suppose that in the countless sputum speci-
mens he has submitted during the twenty
year period, the tubercle bacillus would not
have been found at some time had it really
existed in the lung. This is undoubtedly
a chronic infection of the lungs caused by
the organisms above enumerated. The out-
look for cure is remote at this late date be-
cause it is fairly impossible to remove the
diseased lung tissue and so destroy the
nidus of infection. Nevertheless, he has
improved greatly under treatment by vac-
cines and antiseptic medication dropped di-
rectly into the trachea. One should add
that an X-ray picture of the chest disclosed
no foreign body, but merely the usual mot-
tled appearance of the lungs and enlarged
peribronchial lymph nodes.
The non-tubercular conditions of the
lungs which exhibit the expectoration of
considerable quantities of foul pus are lung
abscess, empyema of the pleurae with rup-
ture into a lung, and foreign body in a lung.
Since the bronchoscope has come into ex-
istence such cases are being investigated
more and more by the bronchoscopist, and
some surprises have burst upon the eyes of
the internist especially in the matter of un-
suspected foreign bodies. Dr. Sidney
Yankauer of New York City has reported
several such cases which he diagnosed both
in hospital and private practice, and he
has been a pioneer in washing out the lung
after removal of the foreign body.
A third group of diseases characterized
by distressing chronic cough is the anaphy-
lactic or ^'sensitized" group. This is an ex-
ceedingly difficult field for investigation,
but some surprising things are being dis-
covered which will bring comfort to a large
number of suflferers from pollinosis, hay
fever, hay asthma, and various protein sub-
stances. There are persons who cannot
ride behind a horse without being seized
with a fit of coughing, sneezing and lacry-
mation. Others suffer from the peculiar
substance given off from the hair of cats,
mice, dogs and rabbits. Chicken feathers
are anathema to certain patients, while
others are much affected by sheep's wool
or goose feathers. In determining which
of these is active for a given patient it is
sometimes necessary to go thru a large
number of skin tests especially for the food
proteins — strawberries, grapefruit, pine-
apple, lobster, veal, etc. Naturally this
must be done by a laboratory expert who
can give the necessary time and attention
to this problem of diagnosis.
All that has gone before is a necessary
and important background for the treat-
ment of chronic cough.
It is well understood, I think, that cough
is only a symptom, that it has no real sig-
nificance apart from the underlying cause;
and therefore, the successful treatment of
chronic cough resolves itself into the ques-
tion of diagnosis. Ruling out the purely
mechanical causes under group A and the
causes associated with anaphylactic or sen-
sitization phenomena under group C, we
have to deal chiefly with the activities of
pus-forming micro-organisms. First in
importance is to determine exactly if possi-
ble the kinds of bacteria present, their num-
ber and virulence, the culture media on
which they grow best, their behavior to
various stains and other data which the
laboratory expert must be relied upon to
furnish us with. It is a standing rule with
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my laboratory man to make an autogenous
vaccine from every pus specimen unless
otherwise ordered. How much can we ex-
pect from vaccines in these chronic infec-
tions? This is still a disputed point and
many good clinicians put forth excellent
arguments on both sides of the question.
Regarding the specific action of vaccines
there is some doubt, for surprising results
have at times been obtained by using ordi-
nary proteid substances which have noth-
ing to do with bacteria. Possibly it is the
bacterial proteins which bring about the
helpful eflFects. We are still quite in the
dark about this whole vaccine question, and
it is, therefore, not surprising that some
men have failed utterly to see anything
good in it, since the matter is so empirical
that no one has any rule to guide him in the
dosage, frequency of administration, etc.,
save his intuition. It falls out that in some
hands vaccines are not only useless but even
harmful. One very important item is that
the vaccine be carefully made and counted.
In killing the organisms I prefer that no
heat be used as it seems to make the vac-
cine inert or brings about some lipoid change
which may be harmful. It is much better
to use some chemical antiseptic such as
cresol or phenol in proper dilution. The
vaccine is then counted as 500 million to
one c. c, and the first sensitizing dose is
put at about 50 million: This is doubled
every third day if the reaction is entirely
worn off, until we are giving two or even
three c. c. We must not pile up our eflFects
too rapidly or the patient will show symp-
toms of anaphylactic shock and his resist-
ance will then be lowered instead of in-
creased.
Two desirable eflFects accrue from the
use of vaccines : First, they make the patient
sleepy, thus securing good solid rest at
night ; second, they make the patient hungry
thus helping to build up the body resist-
ance.
We must do everything possible to build
the patient up, for in these chronic infec-
tions he is always badly in need of an entire
change of regimen. One must study his
daily habits and needs with respect to
fresh air, exercise, food, out-of-door sports,
change of climate, etc., and must prescribe
these in writing after a proper course has
been determined upon.
The possible presence of acidosis must
be investigated. In that event we must ad-
minister sodium bicarbonate, sodium ci-
trate and other alkalis in large doses plus
the acid fruits. Alkaline waters must be
imbibed exclusively, and frequent examina-
tions of the urine must be made to deter-
mine the degree of acidity, and the presence
or absence of acetone and diacetic acid.
Having fortified the patient in a general
way we must get the mucous membranes
clean, tone up these membranes and finally
apply our local antiseptic in such a way as
to make the habitat of bacteria no longer
tenable. We must blast them out of their
trenches but keep the trenches intact, a
problem quite as difficult as any which con-
fronted the Allied engineers.
To cleanse the surface one may use
alkaline washes thru the bronchoscope.
Potassium iodide and expectorant drugs
may be given to stimulate the mucous
glands so that at least some of the bacteria
may be thrown out by this mechanical ac-
tion. It must be remembered that we have
to do not only with surface but subsurface
infection, the bacteria being intrenched
deep down in the submucosa in many in-
stances. Consequently, most surface appli-
cations will kill only those bacteria which
happen to be exposed.
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General tonics may be employed with
good effect. Of these, strychnine is es-
pecially useful since it acts almost specific-
ally upon relaxed mucous membranes.
Finally, we must employ antiseptic agents
with skill and sound judgment. Salts of
silver — argyrol, protargol, silvol, solargen-
tum are all helpful if applied directly to the
diseased area. They must be dropped di-
rectly into the trachea once or twice daily
and coaxed into the affected bronchus thru
gravity, the patient lying down on the af-
fected side immediately after the instilla-
tion. The oily antiseptics are at times
very helpful: Menthol in oil, thymol, oil
of cloves, etc., in from five to twenty-five
per cent, solution, about one c. c. being in-
troduced at each sitting.
Recently we have had given to us thru
the work of Carrel and his associates the
so-called dichloramine-T in chlorcosane
oil. This is one of the most active anti-
septics for chronic infections and the only
precautions one needs to follow are that the
liquid be fresh, neither acid nor alkaline,
uncontaminated by foreign matter, and
that it reach the free exposed surface where
bacteria are assumed to be. One should
then control the progress of the case by
making frequent bacteriologic examina-
tions of the sputum to note what changes
have taken place in the numbers, virulence,
etc.. of the bacteria.
One will fail in the treatment of these
cases if he does not explain in the very
beginning what he proposes to do, that the
time of treatment will extend over many
weeks, possibly several months, that one or
two treatments must be given daily, and
that only thru the most strenuous and
painstaking work can one hope to eradicate
the bacteria and heal the lung. Treatment
of such cases **by the visit" is hopeless.
We must take the case as a problem to be
solved and must demand that the patient
be ready to submit himself to all the vari-
ous laboratory, X-ray and other tests and
procedures cheerfully and immediately
whenever requested. Naturally a physician
with a large practice of varying cases can-
not give either the time or attention that
these patients must have. He must aim to
specialize in this type of case so that he can
give his entire time and attention to them
just as he would to a serious surgical con-
dition. He must, in consequence, be paid
a fair inclusive fee. He must not try to
cut down on the number of visits, the
necessary examinations and the like.
If the routine herein outlined is followed
in detail it will bring no end of satisfaction
to the patient, the physician and all others
concerned.
THE sucx:essful treatment of
ASTHMA.
BY
MARK I. KNAPP, M. D., LL. B., LL. M.,
New York City.
The topic for discussion concerns a sub-
ject, the conception of which has remained
unaltered and unchallenged for the many
centuries past. Asthma, we are taught, is
a condition of spasm of the bronchial tubes
which is brought about by various causes.
If I differ from such teachings and chal-
lenge their correctness, it is not because I
lack the due reverence, which everyone of
us owes to our forefathers in medicine, but
because my accidental discovery of the cause
of asthma has forced me to forsake the an-
cient conception and to substitute for it a
theory, the correctness of which has been
substantiated by an experience in over four
hundred cases.
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The watchword of medicine must be
progress and the test of the correctness of
any theory must be the result obtained when
following the dictates of such theory. True
science demands that we examine and, with
unbiased mind, analyze every new theory
which promises improvement on our old
ideas. Just because the newly propounded
teaching markedly differs from our accepted
views is no reason why one should lay it
aside contemptuously. Quite the contrary.
The theory which I here propose to elabo-
rate on, not only is in marked contrast with
the present ideas, but the results obtained,
because of this theory, border on the mi-
raculous. May I ask the reader to suspend
his natural aversion to and prejudice against
innovations until he has finished reading
this paper and that he may pay close atten-
tion to my remarks and my reasoning.
My object is, first, to prove that the pres-
ent understanding, that asthma is produced
by a spasm of the bronchial tubes, is abso-
lutely erroneous ; and, secondly, it is my de-
sire to establish the correctness of my con-
ception, that asthma is the oflf-spring of a
pathologic gastrointestinal condition. To
prove either and both my contentions I shall
have to call to my assistance the well-set-
tled and well-proven laws, as are embodied
in physical examinations. I must have re-
course to this just because the direct proof
is unavailable and, so far, impossible. I
shall attempt to prove that the old teaching
is based upon nothing more fundamental
than speculative imagination, as no one as
yet has been able to directly observe the
presence of the assumed spasm. To do
this it would be necessary to open the lungs
and look at the bronchial tubes during their
supposed spasm. For excellent reasons this
has not yet happened. No asthmatic has as
yet permitted his chest to be opened in
order that we may learn of the actual con-
dition of the bronchial tubes when he wran-
gles for air. Nor has anyone died during
an attack of asthma and had an autopsy
performed immediately after. Nor could
an autopsy have availed us any, as a spasm
is the expression of a vital function and
death suspends vital functions. For like
reason the opening of the chest under an
anesthetic would fail to show a spasm;
complete anaesthesia would overcome a
spasm. The X-ray, to my knowledge, has
not yet been attempted, and during the
spasm the patient is not in a quiet condition,
but moving violently and, therefore, the em-
ployment of the X-ray is precluded. In
order to prove the fallacy of the present
teaching by indirect proof, I shall rely upon
the clinical evidence as manifested by the
sufferer's behavior during an asthmatic at-
tack. Whether the patient is seized while
in bed or out of bed, he always assumes
during the attack a position which is most
favorable to expiration. We also observe
that it is not the inspiration which is labored,
but the expiration. These are facts which
are not and cannot be disputed. The pic-
ture of the chest is that of fulness in all
of its diameters. These facts are not only
not in consonance with the theory of an
existing spasm of the bronchial tubes, but
are diametrically opposed to such an as-
sumption. What does a spasm mean? A
spasm means a muscular contraction which
is much more violent and forceful than is
a normal contraction, and also is of longer
duration'than is a normal muscular contrac-
tion. In a contraction of the muscular
structure of a tubular organ, the lumen of
such tubular organ is lessened. This lessen-
ing of the lumen is in direct proportion to
the force of the contraction ; the more force-
ful the muscular contraction, the lesser is
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the lumen. A spastic contraction is synony-
mous with an amplified contraction and an
amplified circular contraction of a tube
means that the lumen becomes much less
than it would become on normal contract
tion. Accordingly, the physiologic eflFect of
a spastic contraction of the bronchial tubes
would be a circular contraction, therefore
a constriction of the bronchioles. Since
the physiologic function of the bronchial
tubes is to aflFord a passage for the entrance
of air into the lungs, a constriction of such
tubes must have as a consequence a les-
sened quantity of air passing thru a lessened
lumen. The smaller the lumen thru which
the air can pass, the less is the quantity of
air which can reach beyond the constriction.
If a quantity of air, less than normal,
reaches the air vesicles, the air vesicles will
respond in distention to a lesser degree, the
air cells will distend less and the aggregate
distention of all the air vesicles will natu-
rally bear upon the entire distention of the
lungs as a whole. In fewer words, a con-
striction of the bronchioles must produce
a diminished expansion of the lungs. In
the condition of hyperdistention of the tho-
racic cavity, due to whatever cause, we see
on inspection not only a larger chest, but
especially a distention, a bulging out of the
intercostal spaces. Conversely, a retrac-
tion of the organs of the chest becomes man-
ifest by the retracted condition of the in-
tercostal spaces. The intercostal spaces are
the index of the state of the relative disten-
tion of the thoracic organs. If the inter-
costal spaces are filled out, distended, bulge
out, then, in the absence of ony other con-
dition within the chest wall, such bulging
out is due to distention of the lungs. But
if, on the other hand, there is a check to the
quantity of air which can enter the air cells,
the lungs cannot distend to their normal
capacity and, whatever else may happen, the
bulging out of the intercostal spaces cannot
happen. Thus, the element of the disten-
tion of the lungs being dependent upon the
quantity of air which is supplied to the air
cells, it is immaterial at what particular
point the air supply is shut oflf or interfered
with, in order to produce a retraction of
the intercostal spaces. All that is neces-
sary is that the air supply be shut oflf or
diminished before it can reach the alveoli.
Certain pathologic conditions which are open
to our inspection do cause a constriction of
the air passage right at the beginning of
the respiratory system. I refer to spasms
of the larynx and trachea, to swellings of
these structures, due to inflammatory or
edematous changes and to growths. Un-
der any of these conditions a less quantity
of air enters the lungs. What is the clinical
phenomenon we observe herein? The pa-
tient struggles in inspiration, the inspiration
is very much prolonged and labored, the
supra- and infra-clavicular and the inter-
costal spaces are not only not bulging out,
but are retracted. In other words, the clin-
ical picture we here find in the actual de-
monstrable obstruction to the passage of air
fully conforms to the reasoning followed
out above and with which we have all been
familiar since our student days. But the
clinical picture of the chest during an asth-
matic attack is in marked contrast to the
one just portrayed. The asthmatic has no
difficulty in inspiration; it is the exipration
which embarrasses so much. During the
asthmatic attack the supra- and infra-clavic-
ular and the intercostal spaces are distended
and bulge out. How could we be guilty
of assuming two diametrically opposite man-
ifestations to be due to the self-same cause!
If obstruction to the entrance of air into
the lungs produces retraction of the inter-
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costal spaces, how can we allege that bulg-
ing out of such spaces is also due to ob-
struction ? In the demonstrable obstructions
of the larynx and trachea there is difficulty
in the inspiration; in asthma the difficulty
is in the expiration. Also auscultation con-
firms the proper interpretations of the in-
spection. The inspiration is free and rela-
tively much shorter than the expiration, and
the asthmatic rales are heard in expiration.
It is impossible to affirm, without doing
violence to one's logic, that two opposingly
contrasting phenomena are the result of the
same identical cause. If, as we know,
obstructions to the larynx and trachea cause
difficulty in inspiration and retraction of
the chest, then free inspiration with diffi-
culty in expiration in connection with bulg-
ing out of the chest cannot possibly be as-
cribed to obstructed inspiration, to the pres-
ence of a spasm. Two different phenomena
must have two different causes. Asthma
has been known for centuries and the as-
sumption of a bronchial spasm as its cause
apparently appeared plausible enough to the
first writer, whose teachings were copied
for centuries. Such teaching has thus ac-
quired a sacred solemnity which no one
dared dispute or challenge. There is no
spasm of the bronchial tubes in asthma.
The proper understanding of the nature
and cause of the asthmatic spasm requires
the proper understanding of the nature,
cause and mechanism of coughing. Here
again we meet with time-worn and errone-
ous assumptions from which we cannot
easily extricate ourselves. Unfortunately,
ordinarily the layman and the physician un-
derstand by cough the synonym of ^*catch-
ing a cold." This "cold" is rather a very
unscientific and very highly misleading ex-
pression, but for the sake of convenience
and brevity I will retain this expression,
giving it the same meaning as the laity.
A person coughs and goes to the physician
with the self-made diagnosis of having a
"cold," and the physician not only adopts
this diagnosis, but also prescribes for it.
Why, then, wonder at the many failures in
the attempt to cure such "colds" ? It is true
that cough is one of the symptoms in bron-
chitis and pneumonia. Yet it is not true
that all coughs are due to these causes.
From my own experience I feel justified
to assert that only a very small minority
of "coughs" are caused by the so-called
colds. On recollection we know of many
cases where a slight irritation of the throat
by a very fine hair, or morsel of food, or
some powder was sufficient to cause a most
violent fit of coughing, which persisted until
the irritant was dislodged. Spraying and
swabbing the throat always excite cough-
ing. Again, we are not unfamiliar with
the so-called stomach cough, something we
know does exist, altho its exact nature is
still a matter of speculation with most of
the profession. The several instances just
enumerated give us a variety of elements
distinct from each other, yet calling forth
one and the same effect, namely, the cough-
ing. Strict adherence to scientific reason-
ing will not permit us to hold one and the
same result as the effect of various and
distinct causes. If, nevertheless, the same
result is obtained from apparently different
agencies, then the implication must be that
all these various and distinct agencies have
somewhere one element or one point which
is common to them all. From the illustra-
tions just cited as producing cough, an ele-
ment or point which might be common to
them all does not appeal as a plausible as-
sumption. But, since to produce cough, we
must have not only the irritant, but also
the necessary anatomical structure upon
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which the irritant shall act, and since the
irritants alluded to seem not to have a com-
mon element might we, perhaps, find that
the enumerated irritants all converge their
irritating action upon one and the same
anatomical structure? If the latter propo-
sition can be established, then the solution
of the nature of the cough is made. That
a hair which lodged on the posterior pharyn-
geal wall and that swabbing of the posterior
pharyngeal wall do excite coughing is a mat-
ter of common knowledge. If we pass thru
an atmosphere which is charged with nox-
ious powder particles and cough as a conse-
quence, we would not be justified in cate-
gorically denying the possible lodgment of
some powder particles upon the pharyngeal
wall. The irritating particles could have
gotten on to the pharynx either thru the nose
or the open mouth. The first two illustra-
tions as of a positive fact and the latter
illustration as a possible fact — certainly not
a deniable fact — are sufficient to point out
the pharynx as being at least one structure
which, when irritated, will excite coughing.
Vomiting is quite often succeeded by a spell
of coughing. We might, perhaps, in this in-
stance call the coughing an expression of a
reflex action. However, we could not deny
that the gastric contents, in order to be vom-
ited up, had to pass the pharynx. If the gas-
tric contents were irritating enough for the
stomach to be ejected by it, were they less
irritating when they reached the pharynx?
Irritants proceeding from the stomach, es-
pecially when they are of a gaseous nature,
can and do easily reach the pharynx and
if they irritate the stomach they also irri-
tate the pharynx, and hence the coughing.
The cough is, therefore, not due to a reflex
action from the stomach but to the direct
irritation of the pharynx by irritants of the
stomach having reached the pharynx. But
also irritants located or generated in the
intestines can reach the pharynx if the
pylorus permit the passage. In other words,
if the pylorus is insufficient, if it is relaxed,
if it does not close, no obstruction is offered
to the intestinal irritants on their way up
from the intestines thru the stomach and
esophagus upon the pharynx. Whether
this is the genealogy of all of the so-called
stomach coughs is immaterial. It certainly
may be the genealogy of some stomach
coughs. Let us now proceed in our attempt
to explain, upon the same basis, the cough
of bronchitis and pneumonia. I will adhere
to my principle of leaving out of question
the nervous system and reflex actions. Can
we assume a direct irritation of the pharynx
also in these pathologic conditions? Aside
from the fact that we find mostly the phar-
ynx also affected in bronchitis and pneumonia
we know that mucus is being decomposed
in the bronchial tubes and lungs and that
there are present here chemical irritants
which are forced out thru the mouth. Again
we see the pharyngeal irritation not as a
possibility, but as a fact. Reasoning from
these premises, would it not be advanta-
geous to tracheotomize all patients in whom
we find abscesses or pus-filled cavities in
the lungs so as to prevent the exhausting
cough and the necessary irritation of the
larynx with its fatal consequences? Either
upon inquiry, or volunteered by the patient,
we get the history that the patient feels a
sense of choking in the region of the larynx
before he starts coughing. To assume the
presence of chemical changes of the green-
ish or yellowish or rusty mucus, which cause
acrid, irritating gases to ascend previous
to the throwing up of the mucus, need not
tax or overburden our powers of imagina-
tion. If a hair or the swabbing of the
pharynx may cause coughing, why could not
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the chemical irritants which were produced
from the chemical changes of the bronchial
or pneumonic mucus be responsible for a
like effect ? So far there seems to be noth-
ing in the way to hold out the pharynx as
perhaps the chief, if not the only, struc-
ture which must be irritated in order to
evoke coughing. In the discussion of asth-
ma we will find it most essential to recog-
nize the pharynx as the anatomic struc-
ture whose irritation is responsible for the
severe spasms of coughing.
Having to the best of my ability at-
tempted to explain the cause of the cough
the question now is, what is the mechanism
of the cough? This depends upon two
factors: respiration and muscular contrac-
tion. A deep inspiration is taken and the
ordinarily following expiratory movement is
voluntarily modified by the action of all
the expiratory and the pharyngoglossal
muscles. The former muscles attempt ex-
piration and the latter obstruct and check
it. The greater the obstruction of the phar-
yngoglossal muscles the greater the force
and violence of the expiratory muscles.
When both sets of muscles act simultane-
ously, the air held between these sets of
muscles is put under great tension and acts
solidly in one body as a piston. This is the
pneumatic piston. Under the force of the
expiratory muscles this pneumatic piston,
not only drives any matter which can be
dislodged before it, but also excites peris-
taltic action in such organs as are capable
of it, mechanically stimulates glandular se-
cretion and milks the glands. The expira-
tory muscles are sufficiently known and un-
derstood by all the physicians. I wish to
dwell somewhat on the action of the phar-
yngoglossal muscles, which are most con-
cerned in the act of coughing. These are
the inferior and the middle constrictors of
the pharynx and of the glossal muscles it
is especially the geniohyoglossus. The
inferior constrictor is attached to the sides
of the thyroid and cricoid cartilages and
the middle constrictor is attached to the
hyoid bone and stylo-hyoid ligament. The
geniohyoglossus is attached to the jaw and
to the hyoid bone, and the hyoid bone is
united by ligaments with the thyroid car-
tilage. The fibres of these muscles are so
arranged that when they act all together
the tongue is drawn backward and down-
ward, the pharynx is drawn forward and
downward and the larynx is drawn upward
and backward. The combined action of
all these muscles closes up the entrance
into the esophagus and to the larynx.
Under the influence of an irritation the
pharyngoglossal muscles contract and the
escape of air from the larynx and esoph-
agus is prevented. Preceding Ae action
of these muscles the patient takes a deep
breath and the inspired air is prevented
from escaping in the manner just cited.
Now the expiratory muscles b^gin their
action. A series of convulsive expiratory
contractions follow every inspiration, the
expiration is broken up into a series of con-
vulsive contractions of the expiratory mus-
cles which act on the pneumatic piston pre-
viously mentioned. If the offending mate-
rial is of a mechanical nature and not firmly
imbedded, the concussions of the pneumatic
piston and, in the case of the esophagus,
also aided by peristalsis, will soon eject the
offending matter. But if the irritant is of
a chemical nature the coughing spasms will
continue until the irritant is diluted or neu-
tralized by the secretions and is then ex-
pelled. Another illustration of the action
of the pneumatic piston may be found in
the normal act of "blowing the nose." A
deep breath is taken, the nostrils are oc-
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eluded with our fingers and then we "blow"
the offending matter out. When the irri-
tant which excites the coughing is of a me-
chanical physical nature the violent cough
contractions will soon expel the offensive
matter. Likewise will the responsive cough-
ing soon cease when the irritant is a chem-
ical, introduced from without the body. But,
when the chemical irritant proceeds from
within the body and is constantly being gen-
erated, the coughing will persist so long, un-
til no more irritant is generated. This may
continue for hours. But with the persistence
of the cough other corollary effects follow.
Because of the continuous and violent con-
tractions of all the muscles concerned, not
only do these themselves weaken, but they
produce soreness and pain of the bones
there, where they are attached. With the
persistence of the chemical irritation and
therefore, with the persistence of the cough
that is, with* the persistence of the expulsive
efforts, the contractile force of the muscles
gradually weakens. The result is that as the
muscles weaken, yet the irritation persists,
the efforts of the sufferer to expel the irri-
tant are much more augmented with the
consequent greater weakness and exhaus-
tion of the patient. Given on one hand the
unimpeded full inspiration and, therefore,
the full distention of the air vesicles of the
lungs together with the occlusion of the
esophagus and larynx and, on the other
hand, the hammering contractions of all the
expiratory muscles acting upon the fully
distended lungs, the result must be the in-
sidious, gradual attenuation of the fine walls
of the distended air vesicles. The necessary
result can easily be foreseen. The distended
and attenuated air cells sooner or later must
lose the elastic contractile power of their
walls. This condition is responsible for the
development of emphysema, which is such
a frequent concommitant of asthma.
After the foregoing remarks I am ready
for the discussion of asthma itself. The
reader has already gathered from the pre-
ceding remarks that I deny, and most em-
phatically so, the present conception of the
nature of asthma. I have attempted to
argue and to convince the reader that the
present understanding of asthma is abso-
lutely barren of any underlying facts and
that it is merely an inheritance of ground-
less and unproven speculation of centuries
past. In our due reverence for our past
teachers and in the absence of any different
ideas, the old and ingrained precepts went
by unchallenged. I have attempted to rea-
son with the reader and to convince him
of the fallacy of the present dominant
views. I shall now endeavor to spread be-
fore the profession my own reasoning as
to the cause of asthma and as confirmed
by upward of 400 cases.
My association with the treatment of
asthma came to me not because of any
infatuation with the subject, the why and
wherefore of which I had set out to inves-
tigate. I never intended to do any original
research work in that mysterious malady.
My interest in asthma came to me unex-
pectedly and the cure of it as a mere dis-
covery. Not until I had cured the fourth
consecutive case have I begun to search
for the connection between asthma and dis-
eases of digestion, my specialty. It hap-
pened in the following manner: Some 16
years ago a woman came to consult me
about her stomach trouble. In giving me
her history she also remarked that she had
been suffering for many years from asthma,
which fact was evident enough without her
mentioning it. "Doctor," she said to me,
"if you can only give me a little relief from
my stomach trouble I shall be very glad.
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Don't bother about my asthma. Doctor J.
is treating me for it and I know that there
is no cure for asthma." Indeed, I felt very
happy that the patient did reHeve me of
possibly having to take care of her asthma.
The patient suffered from Insufficientia
Pylori and required daily treatments. After
the tenth or twelfth treatment the patient
told me that her asthmatic attacks were
not so bad as they used to be. Gladsome
as the news was I paid no attention to
it and continued my treatment of her stom-
ach trouble. Several weeks after the pa-
tient surprised me by telling me that she
had no more asthma. Being interested in
her welfare I was certainly very pleased
to hear it, but what did I have to do with
it? An accident, I thought, and dismissed
the incident from my mind. The second
asthma case came some time after. Here
again the patient suffered from insufficiency
of the pylorus and the second asthma cure
was accomplished in the course of a few
weeks. Another accident I thought. A
third asthma patient came in due time in
which the gastric diagnosis was insufficiency
of the pylorus, and after some few weeks
of treatment the third asthma miracle was
worked. This rather puzzled me. I now
had three consecutive cases of asthma and
all three got well. However, I did not
think of it in any other light, but that I
merely had good luck and made up my mind
to take advantage of it the next time. So
that when the next asthma case came I
very cautiously held out a slight hope to
the patient of possibly being able to cure
his asthma. This promise involved no risk
for me as the patients came to me only for
the cure of their stomach troubles. For
the fourth time there was the association
of insufficiency of the pylorus with asthma,
and the cure of both. I now began seriously
to think over the matter. The undeniable
facts were : First, that all four patients had
insufficiency of the pylorus. Second, that
all four patients had suffered from asthma,
and third, that all four patients were cured
of their asthma. Furthermore, I was sure
of one thing; that Deity had not selected
me to work miracles thru. Reflecting over
these facts I came to the conclusion that
there must be a relation between the asthma
and the insufficiency of the pylorus. What
was it?
Let me now give a brief summary of
Insufficientia Pylori, which I have de-
scribed for the first time in the Phila. Med.
Jour. (May 24, 1902). The diagnosis of
insufficiency of the pylorus is to be made
when one hour after the test breakfast either
no contents at all are aspirated from the
stomach, or very little and that little is usu-
ally imbedded in mucus. Altho I have pub-
lished about a dozen articles on the subject I
would advise those who are interested in the
subject to read the first paper here men-
tioned. (In parenthesis I wish to make these
following remarks: If the examining physi-
cian find no contents one hour after the
test breakfast, he must make sure that the
stomach tube entered the stomach and not
possibly an esophgeal diverticulum, which
was empty of contents.) According to
the degree of the insufficiency the ingested
food leaves the stomach sooner or later, and
either not digested at all by the stomach
or a good deal of the ingesta pass into the
duodenurri undigested. Medicine assumes
the existence of "vicarious action;'* but
if this hypothesis hold good anywhere in
the body it finds no application in gastro-
enterology. A cursory reflection on the
mere elements of digestion is sufficient to
stamp such an assumption of vicarious di-
gestion as an impossibility. Gastric diges-
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tion is acid ; intestinal digestion is alkaline.
The food articles are only chemical com-
pounds and chemical compounds cannot be
acted on alike by acids and by alkalies.
We know that the stomach digestion is acid
and we also do know that food is being
digested by the acid stomach. How can
we assume that the chemical elements of
the food which nature intended to be di-
gested by an acid medium, could be digested
by the alkaline secretions of the intestine?
The clinical proof is that it cannot. The
chemical elements which nature intended to
be digested by the acid stomach cannot be
digested by the alkaline intestine. When,
in insufficiency of the pylorus, the ingested
food or part of it passes out into the intes-
tine without first having been digested by
the stomach, such parts as have not been
digested undergo in the intestine fermenta-
tion or decomposition, or some other chem-
ical processes with the production of gasses
and of volatile acids. The result of this
is increased intra-abdominal pressure, which
is clinically evident by compelling the suf-
ferer to loosen his or her clothing. This
latter phenomenon is familiar to all of us.
Just let us pause now and think over this
increased intra-abdominal pressure. Is this
pressure exerted only against the abdominal
wall? May we not correctly assume that
the pressure is not limited to the abdominal
wall, but that it acts with unabated force
in every direction and, therefore, also
against the diaphragm ? Surgeons meet with
this condition and find even the liver, the
heaviest of our organs, occasionally pushed
into the thorax by the strong intra-abdom-
inal pressure. The pressure thus exerted
upward against the diaphragm and, there-
fore, against the thoracic cavity not only
puts a formidable obstacle to the normal
excursions of the heart and lungs which
these have to overcome, but also very much
diminishes the breathing capacity of the
lungs. The lungs thus shut in in the bony
cage which the ribs represent and, there-
fore, cannot escape the forceful pressure
from below, must suflFer compression. Un-
der such conditions the actions of these
most vital organs, the heart and lungs, are
violently interfered with. It stands to rea-
son that the longer the thoracic organs are
prevented from functioning normally, the
greater will be the damage. The lungs
attempt to expand and at each attempt
they meet with obstruction from below.
This happens eighteen times in a minute
and persists not for one minute, nor for
one hour, nor for one day, but for days,
weeks, months and years. That such state
of affairs cannot have a salutary effect upon
the lungs will hardly be disputed. Herein,
I thought, I had to look for the cause of
what is clinically seen as asthma. After
I had assured myself of the correctness of
this reasoning, the relationship between
asthma and the insufficiency of the pylorus
became manifest. Also, I understood now,
why the four patients got well, namely, with
the cessation of the increased intra-abdom-
inal pressure. With the cessation of the pres-
sure upward against the lungs, these were
permitted gradually to function normally.
We thus find the explanation for the first
element in the production of the asthmatic
constitution. The second element is the
cough and the cause of the cough. I have
already alluded to the formation of acid
gases in the intestines as the result of un-
digested gastric contents getting into the
intestine and here undergoing decomposi-
tion or fermentation. These acids are irri-
tants and act as irritants upon any surface
with which they come in contact. As these
acids ascend they cause irritation along their
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tracks. The irritation of any mucous mem-
brane calls forth contraction of the under-
lying muscularis and the contraction of this
is in direct ratio to the degree and duration
of the irritation. The acid gases as they
rise from the gastrointestinal canal to the
esophagus and beyond cause irritation all
along the esophagus and of the pharynx
as well. As the consequence of this the
corresponding and irritated muscles of the
pharynx do contract. Contraction of the
glossopharyngeal muscles, cited above, close
the lower part of the pharynx and with it
prevent the escape of the irritating acid
gases. These accumulate below the con-
striction and cause here distention. This
the patient feels and describes as "choking,"
or as a "lump/* or as "something sticking
there.'* There is now an irritant which
continues to be generated in th^ intestines
for perhaps several hours, during all of
which time the patient tries vainly to rid
himself of by coughing. As mentioned be-
fore, the continued coughing gradually
weakens and dilates the alveoli. Thus
weakened the lung tissue becomes easily
susceptible to various attacks.
Etiology. — I have already sufficiently
dwelt on what I consider the cause of asth-
ma. However, I wish to discuss very briefly
what the books allege to be the cause of
asthma. Let me speak first of heredity.
It is true that we find asthma in several
succeeding generations and in several mem-
bers of the same family. Does that prove
heredity? By heredity I mean something
which we cannot possibly escape, which has
been implanted upon us during uterine life.
Perhaps a little anecdote will not be out of
place. Very often after our daily clinics at
the Augusta Hospital, Berlin, Professor
Kutner, the late assistant to Ewald, would
assemble all of us when we would discuss
whatever appeared worth while discussing
of the clinical material. So it happened that
once I mentioned the fact that I have been
treating the father, the mother and several
children for achylia gastrica, a disease, the
existence of which I now deny. Here was
something to talk about. Doctor Kutner
then turned to the first assistant and asked
his opinion. The gentleman addressed
thought it was rather strange and suggested
that it would tend to point to heredity. The
other gentlemen also were of this opinion.
Now Dr. Kutner turned to me and asked
me what I would suggest. Whereupon I
began to laugh. "Why do you laugh?"
asked Dr. Kutner.
"Well," I said, "do you want to know
what I think is the matter?"
"Of course, yes," was the answer of Dr.
Kutner.
Whereupon I replied : "The trouble here
is a bad cook. If we are to admit heredity
at all, and arg^e that the children inherited
the disease from their parents, how could
the spouses inherit the disease from each
other? It is true that asthma may run in
the family, but not because that the one
inherited it from the other, but because they
were all brought up on the same faulty diet.
A father and mother are presumed to love
their child. If the parent believes in a
certain food, not only will he eat it, but he
will also insist that his child eat of it ; believ-
ing that this particular food is good for him,
he wants his child to also have the benefit
of such food. If now, in the course of
years, that particular food caused disease
to the parent, how could the child escape
it?"
Neither age nor sex has any influence
upon asthma. My youngest patient was
six months and my oldest 84 years old. Both
sexes are equally affected.
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There is a very widely entertained belief
that asthma is due to some nasal disease.
I have lately had a patient who told me
that she had no less than 15 nasal opera-
tions. To be conservative, I believe to have
had at least one-third of my cases in whom
one or more nasal operations have been per-
formed for the cure of asthma. Had they
been cured they would never have come to
me. This, however, does not argue that
if a nasal operation is necessary, that it
should not be done. While nasal conditions
may have their influence upon asthma they
are not the cause of asthma.
The most common conception is that asth-
ma is caused by the inhalation of some pol-
lens. But the fact is that only a very in-
significantly small number of people who
suffer from asthma have ever been in the
neighborhood of such plants. Further-
more, the majority of asthmatics begin to
suffer in winter, at a time when there are
no pollens to inhale. Animal odors are
also accused as being the cause of asthma;
I have not yet met any of such cases in my
practice.
Many hold the climate as responsible for
asthma. My patients have come from all
parts of the country and from all altitudes
and from all climates. I am just now treat-
ing a patient who several times was sent
to the mountains by his previous physicians,
and had to leave there after a few days
because his asthma became very much ag-
gravated. Others went thru a like experi-
ence when they went to the seashore on the
recommendation of their attending physi-
cian. And, while climate has no bearing
at all in the etiology of the asthma, atmos-
pheric conditions do exercise an influence;
some patients get worse in damp weather
and others are distinctly benefitted by it.
Cardiac and renal diseases have also been
made to carry the burden of responsibility
in the causation of asthma. There is no
denying that there are many cases of asthma
associated with either heart or kidney dis-
ease. But where is the proof that they are
causally correlated? I had such combina-
tions in my practice, but the number of
these is very small. I fear that the diagnosis
of cardiac asthma was based chiefly, if not
altogether, on the clinical sjrmptom of pain
and distress in the region of the heart. I
have seen those cases time and again when
patients came to me with the diagnosis of
cardiac asthma, made by the physician, when
the heart was perfectly well and which had
ceased to give any symptoms once the asth-
ma was being treated. In these cases the
patients will sometimes continue to evince
anxiety about the condition of their heart,
altho neither the asthma nor the heart causes
them any trouble. The assumed heart dis-
ease, which was based on the history of
pain in the cardiac region, was due to the
intra-abdominal pressure forcing the dia-
phragm up against the heart and throwing
the heart forward, upward and outward.
This condition can easily be visualized by
the fluoroscope and recorded by the X-ray.
Under this condition the heart is pressed
against the ribs which procedure is painful.
There is no reason why asthma should not
possibly co-exist with any other disease, be
the disease an affection of the heart, or of
the kidneys, or of any other organ. We are
no more justified in calling, in a specific
case, the asthma heart asthma, or kidney
asthma, then we would be justified in calling
the asthma thyroid asthma, if the thyroid
• happened to be affected at the same time.
The co-existence of other affections besides
the asthma does not permit us to associate
them as interdependant on each other. In
my experience there is but one asthma and
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this is bronchial asthma, and the bronchial
asthma has the gastrointestinal conditions,
mentioned before as the etiologic factor.
The foregoing discussion applies to the
etiology of the asthmatic constitution. The
asthmatic attack, the asthmatic spasm may
be initiated by many other agencies. It is
this fact which has been misleading the
profession heretofore. The asthmatic con-
stitution is the offspring of a pathologic
condition of the gastrointestinal tract. Given
this underlying condition and different irri-
tants may bring on the spell of asliuna.
In the one case the inhalation of pollen,
in another the emanations of some animal,
which is especially irritating to that indi-
vidual; in another an excitement or some
other psychically violent circumstances.
Thus we must distinguish the asthmatic
constitution from the asthmatic spell.
Sjnnptomt. — ^The symptoms of the
asthmatic constitution can be summarized
xmder the heading of gastrointestinal pneu-
matosis. Pneumatosis not only has a set
of symptoms of its own, but so far has
proved the greatest stumbling block in our
divine science in the matter of diagnosis.
Pneumatosis means gas distention. There-
fore, it means that the stomach and the
intestines are distened. A distended gastro-
intestinal canal reacts both on itself and
upon the circumlying adjacent structures.
In reacting upon itself it is bound to produce
an effect which must be contrary to the
one which a contracted canal will produce.
The two symptoms which are the result of
muscular contraction and which are mainly
in the minds of the patients are, appetite
and peristalsis. I have repeatedly discussed
the question of appetite, especially in my
papers: "Organacidia gastrica, Med, Rec,
Sept. 6, 1902; Additional Notes on Organ-
acidia gastrica, Phila. Med. Jour., March
28, 1903, and The Nature and Cause of Ap-
petite Hunger and Anorexia, Amer. Med.,
Aug. 26, 1905," and have maintained that
appetite is the result of muscular contrac-
tion. This has been proved by Cannon and
published by him seven years later, which
publication has caused other physiologists
to study the same question with like result.
Since appetite is something which concerns
everyone, it will be worth repeating that
appetite is a sensation which is the result
of muscular contraction of the pyloric re-
gion, or of the duodenum, or of both. (In
parenthesis I should like to ask the physi-
ologists who do mention my name not to
quote me as saying the very contrary of
what I actually did say, as did Carlson.)
In the absence of contraction, i. e. in relaxa-
tion and in distention there is no appetite.
Movements of the bowels are caused by
the peristaltic action of the intestinal mus-
cularis. As peristaltic action is synonymous
with contraction of the muscularis, the dis-
tention of the muscularis, which is the oppo-
site of contraction, also has the opposite
effect of peristalsis, %. e. no peristalsis, there-
fore no passage, constipation. The disten-
tion pressure against the adjacent organs
and structures causes pain of greater or les-
ser degree and should not be interpreted as
reflex pain. The pressure upward against
the heart, which forces the heart upward,
forward and outward, interferes with the
heart's action. The patient becomes con-
scious of the pulsations of his heart, and as
the heart has to beat against an obstruction
the pulsations become distressing and pain-
ful. The dislocation of the heart necessarily
impinges upon the normal excursions of the
left lung and the respiration on the left side
also becomes painful. The distention of the
stomach is felt by the patient as bloating,
fulness, or weight, and the escape of the
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gas thru the mouth is responsible for the
belching. The irritating gases reach the
pharynx and cause constriction of the phar-
yngeal muscles, the gases cannot escape and
accumulate behind the constriction until the
muscle spasm ceases. This causes the pa-
tient to complain of choking, or of a lump
in the throat. This, im fortunately, has been
misinterpreted as the globus hystericus.
The distention of the intestines is felt by
the patient as fulness or weight in the abdo-
men. Asthma does not set in suddenly; it
begins with what is usually called dyspeptic
symptoms. Perhaps a good rule would be
to warn every patient who chronically com-
plains of fulness after meals accompanied
by shortness of breath, pain in the left side
on inspiration, palpitation and difficulty in
going uphill or up a flight of stairs, of the
likelihood, that asthma may be developing.
There may be supraorbital and frontal head-
ache, or the patient may recall having had
them years ago. Quite a frequent symptom
is pain in the back of the head and in the
nape of the neck. This latter is probably
due to a mechanical cause of the nattire
of traumatism. During the violent spasms
of coughing, the muscles of that region are
violently, suddenly and sharply contracted.
This exerts a violent pull upon where the
muscles are inserted ; this, I believe, is the
cause of the pain in the nape of the neck.
Very often the patients complain of buzzing
in the ears. The appetite varies and may
be even fair between the attacks. But dur-
ing the time that the patient suffers from
the asthma there is no appetite. There is
palpitation, the patient cannot go upstairs,
or uphill, he is short winded and does not
dare undertake long walks, he tires very
easily and is incapable of any exertion. He
gets up tired in the morning, even when
when he is free from attacks. He hates
to go out alone for fear he may be
seized with an attack on the way. Con-
stipation is the rule. This is a symptom
which the physician must be careful in elicit-
ing. When the patient tells me that his
bowels are good my next question is, "what
do you take for them?" In the majority of
cases the patient will then mention either
the routine use of some drug or of such
fruits which are known to produce move-
ments. In the first years of asthma the
patient may feel perfectly well between the
attacks or during the non-asthmatic season.
But later the patient is full of apprehension
and fears to go out alone or any long dis-
tance. Coughing may be a prominent symp-
tom; the dry, hacking, tiring cough. The
patient usually dreams much, the dreams,
as a rule, being quite unpleasant. As the
disease wears on the patient becomes apa-
thetic, especially so when he can get his
sleep only in the sitting posture. Withall the
patient need not look bad. Quite the con-
trary. Between the attacks the patient ap-
pears in perfect health, which deceives his
family and friends.
The clinical appearance of an asthmatic
attack can be summed up under the head-
ing of air hunger and the violent, but in-
effective attempt by the patient to remove
an irritant, located somewhere in the
chest. Quite often, the patient who has
gone thru many attacks, knows by certain
prodromal symptoms, that an attack is
coming and such premonitory sensations
are peculiar to each individual. Usually,
the patient goes to bed, perhaps even, in
an exuberant frame of mind ; he feels quite
well and happy. But, somewhere, around
two or three in the morning the patient be-
gins to have difficulty in his breathing and
begins to wheeze, of which the patient has
only hearsay knowledge, as he himself is
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still asleep; he knows only what his family
tells him. Quite suddenly he wakes up
and throws himself into the characteristic
asthmatic posture, which is one, most
favorable to forced expiration. There is
quite a similarity between this posture and
the posture one assumes in defecation. In
both instances one seeks expulsion, pent
up air in the one and pent up fecal matter
in the other. The patient sits in bed with
legs flexed and thighs drawn towards the
abdomen, while the trunk is inclined for-
ward. The chin rests upon the hands and
the elbows on the knees ; the shoulders are
raised and the head is fixed. In this posi-
tion the patient labors with respiration. At
intervals there is the cough, which con-
tinues in a somewhat staccato manner, be-
ginning strong and loud and then diminish-
ing in force with each successive concus-
sion. The lips become cyanotic, the mouth
is open and the eyes bulge out; the body
is bathed in cold perspiration. Suddenly
the patient jumps out of bed and runs to
the open window gasping for air. The be-
havior of those, who cannot sleep in bed,
but take their sleep sitting in a chair is
somewhat different. When the asthmatic
spasm seizes them, they get off the chair
and brace against a piece of furniture with
the entire body bent, or rather curved for-
ward and the head thrown back. In either
case the patient brings up a considerable
quantity of mucus at the end of the attack
and also gases are expelled. The attack
may last only a short while or several
hours. Some patients have only one at-
tack in 24 hours, others have two or more.
Once more let us reflect upon the manifes-
tation of an asthmatic seizure. This hap-
pens, as a rule, sometimes past midnight,
around one or two o'clock in the morning.
that is, about 7 or 8 hours after the last
meal. At this time the ingested food
is in the small intestine and has already
undergone considerable chemical changes
with the production of irritating volatile
gases. But the production of such gases
has not yet been completed ; they are being
constantly generated and forced upward
by the normal contractions of the ab-
dominal muscles, which at every contrac-
tion increases the intra-abdominal pressure.
The noxious gases, reaching the pharynx
cause violent and spastic contraction of ite
muscles and of the muscles forming the
back of the tongue. The spastic contrac-
tion of these muscles seals the larynx and
the esophagus and their irritation by the
noxious chemicals provokes the effort to
expel these by the violent act of coughing.
All muscles of expiration are called into
violent contractions because of which they
gradually weaken. The more these mus-
cles weaken, the more inadequate becomes
the expulsive force and the greater be-
come the efforts of the patient. These
struggles exhaust the patient. As the ex-
pulsive force weakens the air cells are not
only inadequately emptied, but are sur-
charged with CO2 which incites still deeper
inspirations, causing still greater distention
of the air vesicles. Under these circum-
stances the cell walls weaken and lose their
resiliency, which causes the dilatation of the
air cells; in the* course of time this dilatar
tion becomes permanent. The enlargement
of the chest and the bulging out of the in-
tercostal spaces evidence the dilatation of
the air cells. Because of the enlargement
of the air cells while the bronchioles re-
tain their normal size, the relation in size
between the bronchioles and the air cells
changes, that is, the bronchioles are now
relatively smaller. This has its effect up-
on the sound; air is forced from a wider
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space thru a narrower space. This gives a
higher pitched sound and, as this happens
with the expulsion of the air from the
lungs, we therefore hear these asthmatic
rales in expiration.
Diagnosis. — ^The diagnosis of asthma
is not always an easy matter. In my earlier
experience I have sent patients away and
told them, they had no asthma, for which
they came to consult me, because at the time
of the consultation there was no evidence
of asthma on auscultation. I have since
learned this not to be the right practice.
When a patient comes to consult about
asthma, the presumption is very strong
that he has asthma. If we hear no asth-
matic rales at the time when the patient
presents himself for examination it is be-
cause the patient happens to come during
an interval. The interval between attacks
may last only a few hours or it may last
for days and weeks. It so happened that
the patient came when his chest was free
from rales and wheezing. The rule should
be, that when a patient comes to consult
about asthma, he should be treated for
asthma, whether at the time there are
asthmatic rales or not. The diagnosis
rests mainly on auscultation. Indeed, one
need not even see or come near the patient.
I can very often make the diagnosis of
asthma by hearing the patient's breathing,
when the patient is yet in the waiting room.
It is the change of rhythm, which so char-
acterizes asthma. It is the fully free in-
spiration followed by the deep, labored and
prolonged expiration. One other condi-
tion gives that rhythm and this is pneu-
monia. But in pneumonia the respirations
are increased in number, while in asthma
they are not.
The patient should be stripped and set
down in an easy position for the ausculta-
tion. We will hear that peculiar sound,
known as wheezing. This is made up of
dry rales of all sizes and of varying pitch.
These sounds are heard in expiration.
Should this position of the patient yield no
auscultatory signs, then the patient is
placed on his back and again examined and,
should this position also prove negative
then the examining chair is tilted to an
angle of approximately 45 degrees, the pa-
tient's head being down and his legs up.
It is remarkable how much this posture
will bring out. I use this position not only
for the examination of the chest, but also
for the palpation of the abdomen, when it
gives most excellent results. Again and
again no other than the inclined position
would bring out the asthmatic rales. It is
also significant, that the asthmatic rales, if
heard only in the inclined posture, are apt
to be heard mostly, if not altogether, over
the lower lobe of the right lung. This fact
again seems to confirm by view, that asthma
is due to pressure upward from the ab-
domen, as in the inclined position the ab-
dominal viscera crowd against the dia-
phragm, and the heavy liver exerts its pres-
sure against the right lower lobe of the
lung.
On inspection we will find, that the chest
is full, the intercostal spaces are filled out
or bulging and that the supraclavicular
fossae are prominent. For the inspection
of the abdomen the patient is placed on his
back. We now note, that there is a promi-
nence over the region of the stomach and
very often we will see here a wavy tremula-
tion. This phenomenon is due to the trans-
mission of the pulsations of the abdominal
aorta to the gas filled bowel and stomach.
In taking the history of the case we will
always find, that the patient has had di-
gestive troubles; he may have them at the
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time of the consultation, or has had them
some time before and thought he was cured.
In no case should the test meal examination
be omitted. The test meal examination
should be conducted with the object to at-
tain practical, yet scientific facts. And for
this purpose there is no better test, than
the Ewald test breakfast. This consists of
35 grams of plain white bread, that is,
bread made of white flour and water and of
300 c. c. of plain water. The patient should
come to the physician's office fasting about
14 hours after he had had a full meal the
evening before. The patient's fasting
stomach is first examined by means of the
stomach tube and the condition of the
stomach is ascertained. After this the test
breakfast is given him in the office of the
physician and the patient waits in the wait-
ing room for one hour. The patient should
be perfectly quiet during this hour after
which the stomach tube is again introduced.
We will now find insufficiency of the
stomach, that is we will find no contents or
perhaps only a trace. Fanciful modifica-
tions of the test meal have been devised,
but they have proved good apparently only
in the hands of the one who devised them.
Prognosis. — ^The prognosis in uncom-
plicated cases is most excellent irrespective
of the length of time the asthmatic condi-
tion had continued. My youngest patient
was six months old and my oldest 84 years,
and both got well. The baby's case would
certainly dispel the belief, that asthma
is of a nervous nature. First, because no
one would care to impute nervousness to a
6 months' old nursling. And, secondly, I
did not treat the baby, but treated the
nursing mother. The child remains well
and is now a little happy girl of over five
years, whose grateful mother continues to
send me asthmatic patients. The 84 year
old patient had been suffering from asthma
since he returned from the army in 1867.
Not only do the patients get well, but they
begin to feel better within 36 or 48 hours
after treatment has been instituted. This
often proves a drawback rather than a
blessing for the following reason. Em-
boldened by the rapid turn for the better,
the patient soon begins to experiment with
the diet which was forbidden him. I have
very numerous instances of this occurrence.
The physician must always have in mind,
that the patient is very apt to eat and drink,
what he should not. If after the patient
had begun to feel better and kept on feel-
ing better for the first 10 or 12 days and
then begins to complain, the suspicion is,
that he disobeys. Patients, who for months
had been obliged to sleep in chairs can go
to bed after a few.days of treatment. How
encouraging is this to the patient! The
attacks begin to lessen in severity and fre-
quency right from the beginning of the
treatment. But the physician must tell the
patient the exact truth, that the patient
must expect more spasms, which will gradu-
ally disappear. Otherwise a recurrent at-
tack, no matter how mild and of how short a
duration will have a depressing eflfect upon
the patient. The greatest patience and
perseverence is required of both the patient
and physician ; the patient always needs en-
couragement. The physician must be stead-
fast in his positive promise of cure. The
treatment requires on an average four
months. The word cure must be used in asth-
ma in the same sense as it is used in every
other curable disease. Pneumonia is curable,
so is pleurisy, so is measles, so is scarlet fe-
ver, etc. Will the patients, once cured of
these diseases ever get them again? Of
course, they may get them again. Should this
knowledge stop us from treating these dis-
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eases? We all wish, that when we once
went thru one disease, we should never get
this disease again; but it remains only a
wish. So it is with asthma. If a patient
gets cured of asthma he also may get it
again. But there is this difference between
asthma and the other curable diseases : one
can never tell when he may again fall victim
to pneumonia, pleurisy, etc. But the pa-
tient who gets asthma after he once was
cured, has himself to blame. The asth-
matic patient is told and knows what is go-
ing to provoke ^sthma. And if, in spite
of this knowledge he nevertheless continues
to abuse himself, whose fault is it? But
the rule is, that after the patient had experi-
mented a few times and got some slight at-
tacks he complies with the few restrictions
in his diet and remains well. Asthma is
absolutely curable, but the patient may get
asthma again, if he so choses. The pa-
tient is taught to know his enemy. If not-
withstanding this he nevertheless disobeys
and again knowingly contracts the same
gastric condition which originally brought
on asthma, whose fault is it, that he has
again to suffer? Perhaps an illustration
will not be out of place. Some years ago
a patient came to me from Arizona and was
cured. Months after his cure I was called
in haste to see him in his hotel. I found
him suffering severely and asked him what
happened. Between gasps for air he told
rne not to mind anything, but make him
better. He was well again in two days
and he then told me the following. He
had come to New York on an important
deal. "I had to go out with the boys," he
said, "and eat and drink with them. I knew
I was going to get asthma and I took the
asthma as part of the deal. I knew that
you were here and that I will get well."
Now this is exactlv the frame of mind the
patient wants to be put in. What a differ-
ence between the patient believing himself
lost, incurable and doomed for life and the
patient's taking another attack merely in
the same light as contracting an attack of
tonsillitis or some similar slight indisposi-
tion. Once the patient has been cured he
knows what struck him, if he again gets an
attack. But, as a rule the patient can and
will ward off the actual attack; he knows
the premonitory symptoms. He knows
where he has transgressed and he will cor-
rect himself before the real attack would
come. Of this I have many instances-
After the patient had remained well for a
certain time he will long for and eat some
of the forbidden food. For a little while
he will feel no distress. Encouraged by
this result he eats more and will have to
pay the penalty. Of all these possible hap-
penings the patient should be forwamed.
Where complications exist the cure will
be influenced by the complication. Es-
pecially distressing is a complicating em-
physema, which is of frequent occurrence.
Treatment. — For the treatment of
the paroxysm a long list of medicines has
been tried and recommended. They ac-
complish nothing more than a temporary
amelioration of the spasm, they do not
cure. But the patient, once used to it, will
abstain from the use of his specific drug
with difficulty. The quickest relief is
given by the hypodermic use of adrenalin.
But in mentioning this I warn against its
use. A patient of mine had used an
ounce bottle in 24 hours. Also, I have
seen one fatal result. The inhalations of
the fumes of nitre paper or of stramonium
leaves is not so dangerous as is adrenalin.
The stramonium leaves are used either as a
powder, the leaves being pulverized, or in
the form of cigarettes, which are smoked
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by the patient. The nitre paper is made by
saturating blotting paper in a saturated
solution of potassium nitrate and then
drying the paper. Also chloroform in-
halations are used and amyl nitrite. How-
ever, the most commonly used drug by the
physician is the hypodermic injection of
morphine. This may or may not relieve
the spasm; as a rule it does. A patient
of mine had used before I began treating
her one and a half grains of morphine at
a dose which she injected herself. I took
the bottle of morphine away from her and
she had never used any morphine after
this. I never use or advise any of the
drugs here mentioned except the morphine
or its equivalent and this only in the treat-
ment of an intercurring bronchitis. In the
treatment of asthma itself I never use any
opiate.
Remembering that asthma has as its
cause the insufficiency of the pylorus our
efforts must be directed to the cure of this
condition. Insufficiency of the pylorus de-
mands alkaline treatment which Is intended
to aid the intestinal digestion. The alkalies
have to be administered at a time when the
chyme is out of the stomach. This is to
be ascertained by the repeated examination
of the test breakfast; that is, if the pa-
tient has no contents in the stomach one
hour after the test meal, the test is repeated
the following day and the aspiration of the
stomach is attempted one-quarter of an
hour sooner. If then the stomach yields no
contents, the test is again repeated the next
day and the aspiration attempted again one-
quarter of an hour sooner. In this way we
acquaint ourselves with the precise time
during which the stomach empties itself.
The alkalies are to be given after the stom-
ach had emptied itself so as not to interfere
with whatever gastric digestion may yet be
left. Most often I use the bicarbonate of
soda, the oxide of magnesia and the car-
bonate ©f calcium. But also the potassium
carbonate and bicarbonate and the chloride
of calcium may at times be found very use-
ful, so also the chloride and carbonate of
ammonium. The plain rhubarb and soda,
nux vomica, strychnine, the mydriatics,
cascara and the salicylate of soda are all
drugs which m$iy have to be combined with
the alkalies. In many cases I add colchicum
and strontium bromide to the alkalies.
Which combination and what doses are to be
used is entirely a matter of each individual
physician's experience. For the constipa-
tion, which is one of the commonest symp-
toms I have used for very many years the
following combination : aloin and podophyl-
lin, of each 34 g»*ain, phenolphthalein from
one to one and a half grain and atropin one
hundred and twentieth of a grain at a dose,
to be made into pills of which one pill is
to be taken every night. Also potassium
iodide and ammonium iodide may have to
be used to loosen the mucus. Of these'two
I prefer the ammonium iodide. Of the
saturated solution we start with a few drops
well diluted in water and bring it up to the
point of tolerance.
Of most importance in the treatment of
asthma is the diet. Unfortunately no set
rule can be laid down which would apply
in every case. Each case must be studied
individually. The following principle
should guide us in the selection of the food.
No acids, no gas containing or gas form-
ing foods or drinks, no spices, no tea, no
coffee and no yeast containing beverages.
We must bear in mind that each nation-
ality, nay, each locality has its own foods
and its own food combinations and its own
kind of dishes to which the inhabitants of
this special locality have been used and
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which they do prefer. What may be a
highly prized delicacy in one locality may
be looked upon with great disfavor in an-
other. My procedure is the following: I
have the patient submit to me a list of the
food which he usually takes and I then go
over with him each article and make such
changes or erasures as seem to me indicated.
In this way the patient gets a diet list to
which he has been used and which he likes.
Neither vegetables nor cereals are tolerated
at first and should not be allowed for sev-
eral weeks, until the patient's case is well
in hand. The same holds goods with re-
gard to meats. One soon finds out that
meat is not always meat. That is, that
there is a diflference in the various kinds
of meat, and in the various cuts of meat.
Some patients get along best on beef while
others require lamb; some eat chicken
without any harm and others veal. No
uniform rule can be applied. The meat which
is doing good to one may have violent ef-
fects on the other. Our experience is the
only guide. Foods rich in starches should
not be given for a long time. After five or
six weeks treatment we may begin gradually
with cereals, vegetables and fruits. I pro-
ceed in the following way: I allow one
cereal one day and then the patient is not
to have any cereals for two days after this.
If there is no bad effect upon the patient
within this time, then the patient is allowed
to have it again. The same way I proceed
with the vegetables and fruits. Only one
kind is permitted at a time and then there
is a rest of two days between, so that the
effect may be watched. The vegetables
should always be cooked and the fruit
should be taken raw. However, the phy-
sician must be on his guard. The patients,
eager to have fruits or vegetables, may re-
port that the eating had no eflFect upon
them and in their anxiety to have them will
withhold from the physician the fact that
they had distress. After a few days they
will begin to complain of the distress and
will insist that the fruit or the vegetable, as
the case may be, was not the thing that has
harmed them. The physician should not
mind this but stop the fruit or the vegetable
which he suspects.
At the beginning of the treatment the
following should not be allowed: Tea,
coffee, cocoa, beer, wine, fruits, acid foods
and salads, oat meal, graham bread, whole
wheat bread, shredded wheat and other
cereals, all fats except moderate quantities
of sweet butter and olive oil, beans, peas,
cabbages, radishes, onions. Salt should
not be permitted. Instead of the common
salt the sodium bromide may be given to
be used the same as the common salt, i, e.,
without regard to any dose.
The patient should not go to bed early.
It is best that he go to bed about midnight.
The reason for this is that if he goes to
bed, say about 9 and then wakes about 2
or 3 in the morning, he may stay awake
for a few hours, which has a very depress-
ing influence upon the patient. The patient
fails to note that he has already slept 5 or
6 hours. In most instances the patients get
up in the morning with a spell of coughing.
This I believe to be due to the fact that the
mucus accumulates in the esophagus while
the patient is in the recumbent position,
instead of going downward into the stom-
ach or being cleared by the patient, as it
would naturally do when he is about. Tak-
ing one or two cups of hot water just be-
fore going to bed will greatly alleviate this
distressing symptom.
Sununary. — ^There exists but one kind
of asthma: bronchial asthma. The fact
that diseases of other organs co-exist with
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661
asthma establishes no causative relation be-
tween such other diseases and asthma. The
nature of asthma does neither preclude nor
forbid the presence of diseases of other
organs. No proof has ever been adduced,
nor can there be adduced, that the asthmatic
spasm is due to spasm of the bronchial
tubes. The proper interpretation of the
physical sig^s in a paroxysm makes such
an assumption impossible. Asthma must
be recognized as the pulmonic symptom of
a gastrointestinal condition and, while
various causes may provoke an asthmatic
spasm, the cure of asthma depends solely
upon our ability to cure the gastrointestinal
condition. Neither climatic, nor atmos-
pheric conditions or changes cause asthma,
but they do exercise some influence in the
progress of the cure. Asthma is not con-
fined to either sex or age ; male and female,
young and old suffer alike. The prognosis
in uncomplicated asthma is excellent.
Asthma is curable in about four months.
A DOUBTFUL DIAGNOSIS OF PUL-
MONARY TUBERCULOSIS WITH
REMARKS ON TREATMENT.
BY
BEVERLEY ROBINSON, M. D.,
New York.
A few weeks ago, a young engineer fire-
man came to see me professionally. He
had been under the care previously, of a
physician who had examined and cared for
him according to approved modern methods.
At first, he was uncertain as to the diagno-
sis. The patient had lost considerable
weight and on physical examination of the
lungs showed apparent signs of tuberculo-
sis. The patient had no cough or expector-
ation and no fever. He had never spat any
blood. He did not feel ill, but about as
usual.' His family and friends, however,
thought he looked badly and said he was
pale. The blood and urine examinations .
were negative. A Wassermann test was
made. It also, was negative. There was
no venereal history. An X-ray picture was
taken and as interpreted, confirmed the
diagnosis of pulmonary tuberculosis.
There was a somewhat large, single ulcer
in the middle of the pharyngeal wall. A
scraping was taken from this ulcer and only
streptococci were shown. There were no
laryngeal symptoms. It was thought that
the ulcer on the pharynx might be due to
pemphigus, altho there were no evidences
of this disease elsewhere. The patient had
been given mixed anti-syphilitic treatment
of mercury and iodide of potash with no
apparent benefit.
Personally, I found no signs of pulmo-
nary tuberculosis upon physical examination
of the chest, but in view of the previous
diagnosis, confirmed by the translation of
the X-ray picture, I thought it possible, or
even probable, that the patient had begin-
ning pulmonary tuberculosis. Therefore,
I advised giving up his work for a time and
going to a healthful country resort inland
and moderately elevated. In a4dition, I
gave the patient a tonic of iron, quinine and
strychnine, and told him to paint the ulcer
of the pharynx daily with tincture of the
chloride of iron and glycerine, one dram
to the ounce.
After a few weeks absence from the
city, he sends me a most encouraging
report. He has gained ten pounds in
weight, the ulcer of the pharynx is almost
cured, he has no pain in the throat, his
family notes his much improved condition
and he feels well.
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I advise persistence of the same treatment
for a while, to remain in the country also,
for a time and to report me again, in *a few
weeks.
This case seems to me interesting and
important. First of all, physical examina-
tion and diagnosis of chest disease are not
infrequently incorrect, simply because the
examiner considers certain signs as evi-
dence of disease, when really they are not.
They are merely somewhat unusual signs in
the aggregate.
As to the X-ray picture: Unless it is
properly translated, it is most misleading,
as I have already found in quite a number
of cases of different kinds.
Hitherto, it has not been my fortune to
have to do with pemphigus of the throat,
so far as I know. On the other hand, I do
not recall having seen a single ulceration of
the pharynx like the one mentioned and
with no concomitant ulceration of the
larynx.
Has the patient incipient tuberculosis and
will he again lose weight, show another
ulceration of the pharynx and perhaps de-
velop other symptoms of disease, when he
returns to the city? I do not know. I
hope not. The future alone will settle it.
So far as the mere loss of weight is con-
cerned, ai)d taken by itself, it may mean
one of many things and these are often ob-
scure for awhile and it must simply be
labeled: rundown — ^need of a change of
air, scene, food, occupation. When these
conditions are attended to, weight will often
return and the patient again be wholly
normal and in excellent shape.
I feel I should report the preceding case
because I do not wish others to be misled
by mere physical examinations, or X-ray
pictures. Today too much importance is
attached to both and too little to a fair ap-
preciation of the history, the absence of
symptoms and the rational interpretation
of the facts of the case, all of which should
be carefully considered. Of course, in the
case reported, if the patient had been per-
mitted to continue his work and remain in
the city, he might surely have shown all the
signs and symptoms of pulmonary tuber-
culosis. Fortunately, I did not allow it.
Again, I advised against the use of tuber-
culin to fix the diagnosis further, if possible.
My reason for so doing was that I fear
the use of tuberculin, as being uncertain
and often decidedly, harmful.
I wish to add that in my experience, the
most valuable application in many forms
of throat trouble, is the one I used in this
case. Not only is it astringent and healing ;
it is also an admirable disinfecting agent.
In diphtheria, it is sometimes, almost
sovereign. Sir Morell Mackenzie, my
former great preceptor in his throat clinic
at Golden Square, London, England, made
use of it far more than any other throat ap-
plication and praised its value. It was from
him that I first learned to rely upon it and
have rarely found it failed me. After its
use one must be careful to rinse the mouth,
especially if there has been any contact
with the teeth. The corrosive action of the
tincture of iron on the teeth, particularly if
there are any fillings, is very marked and
injurious. As to the mere discoloration of
the teeth which may follow its use, when
employed frequently, that may be gotten
rid of by the use of tooth paste, or powder,
or the orris root points, or cleansers.
Bed-sores. — ^Try prolonged immersion
in hot water baths for indolent bed-sores
and large, slowly healing burns. You will
be surprised how grateful such treatment is
and how often it is highly advantageous. —
Urologic and Cutaneous Review,
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663
THE ATTITUDE OF THE MEDICAL
OFFICER OF HEALTH WITH RE-
SPECT TO TUBERCULOSIS.
CAPT. H. W. HILL, M. D., C. A. M. C,
Late Medical Officer of Health, London, Ont,
now Exec. Sec, Minnesota Public Health
Assn., St. Paul, Minn.
Tuberculosis should be handled on the
same public health lines as those of any
other infectious disease, that is by dis-
covering the sources and by preventing
further spread therefrom; by blocking the
routes of infection from unidentified
sources so far as our present knowledge
will permit; by such a general enlighten-
ment of the public that everyone as a matter
of course, may be led to avoid all these
sources and to block all these routes of in-
fection, identified or not; and finally, by
aiding in the search for any system of pro-
tection procedures which may enable the
human body to resist the disease.
In surveying the field, let us classify cases
of tuberculosis. It is known that two main
types affect the human subject, human
tuberculosis and bovine tuberculosis. Both
of these types are produced by germs which
bacteriologically are distinctly diflferent, al-
tho doubtless closely related. However,
the diseases themselves are clinically quite
distinct. For instance, human tuberculosis
is chiefly active and prevalent in subjects
over the age of sixteen. Bovine tuber-
culosis occurs but very seldom in individu-
als over that age, the vast majority of cases
being in young children. Again human
tuberculosis is for the most part, at least
eight-ninths of it, a disease of the lungs.
Bovine tuberculosis on the other hand is
found very rarely in the lungs, but is prac-
tically confined to bones, joints, intestines.
brain and so on. Moreover, and this point
is most important to the health officer,
human tuberculosis is spread by means of
consumptives themselves, that is, from open
cases of tuberculosis of the lungs. On the
other hand, bovine tuberculosis is almost
invariably disseminated by infected raw
milk. Just as soon as we cease to use raw
milk or other raw products from cattle,
bovine tuberculosis in the human being will,
to all intents and purposes, disappear.
Pasteurization, or boiling of milk, will put
an end to this particular phase of the prob-
lem, and the sooner we are civilized enough
to carry out that method uniformly and un-
failingly the better it will be for the public
health.
Human tuberculosis, however, will con-
tinue despite all other measures we may
take against it, until we either immunize
the whole human race, and at present we
have little reason on which to base the hope
of such a happening, or until we watch the
tuberculous members of the human race
so closely that spread from them must
cease.
The primary duties, then, of the health
officer with regard to tuberculosis are,
first, and least important, to secure uni-
versal pasteurization of milk for whatever
purpose it is to be used, in order to elimi-
nate bovine tuberculosis ; second, and most
important, to secure early diagnosis and
prompt radical treatment of human tuber-
culosis, especially of the lungs, so that the
patient may be prevented from reaching
the open infectious stage, and to obtain the
prompt isolation and radical treatment of
all who have reached that stage, so as to
prevent the infection of others. I am con-
vinced that the view commonly held that
tuberculosis is usually contracted in child-
hood by no means always holds good, and
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it is my firm belief that a good many people
do not become infected until past the age of
sixteen.
Any health officer who assumes that in
dealing with adults he need not take into
account the fear of infection being spread
among them is making a terrible mistake.
Suppose that we were to handle the army
cases on that plan and were to allow all
army cases to mix with the other soldiers.
From this point of view, consider how
senseless it is to disregard the danger to
adults from open infectious cases, as well
as to say that it does not matter as long as
they are not associated with children.
Our plan for handling cases is as follows :
Someone suggests that so-and-so has tuber-
culosis and the course we pursue is this:
We decide whether it is an "open" or
a "closed" case* by careful and repeated
sputum examinations. One positive sputum
result will of course decide that the case is
open. Decision as to a "closed" case is
reached on the basis in effect both in army
and civil practice. If we get six consecutive
negative results within a week, or two
weeks, we are satisfied that the case is not
"open," at any rate, at that time.
As for the logical distinction with regard
to treatment between the open and closed
cases: in the first place, there is no ques-
tion that "open" cases must be isolated at
home, in a hospital or in a sanitorium, and
for the protection of the public at large,
such isolation should be rightly enforced.
With the "closed" cases, which are evidently
not infectious, advise in the way you think
most fitting, endeavor to assure proper
treatment at home, in the sanatorium or in
the hospital as circumstances permit, and
watch those cases carefully. By having
these patients report at frequent intervals
or by having a nurse see them frequently,
the health officer knows whether any par-
ticular case is improving or failing. If a
case of this kind becomes "open," it is at
once isolated as occasion warrants and per-
mits.
With respect to children, who very
fortunately seldom become open cases,
the best policy is to bring the matter to the
parents in this manner: "Your child has
tuberculosis ; he is not dangerous to others ;
he can go to school so far as the health
authorities are concerned because he won't
transmit the disease, but he is in a delicate
condition, and for the sake of the future
he should be well cared for." In many in-
stances the wisest plan would be to remove
that child from school and send him to the
preventorium or to take steps calculated to
most quickly bring about recovery. If the
child continues to attend school he must re-
port every two or four weeks as may be
thought advisable.
One of the points we most strenuously
insist on is this; when we find an open
case of tuberculosis in a family or a closed
one, for that matter, we do not stop with
that case. We examine all the other mem-
bers of the family, and often too, close as-
sociates outside. The line is being drawn
very sharply between open and closed
cases. If the case is a closed one and the
patient is recommended for free treatment
in the sanatorium, all the routine usual in
such cases is gone thru and it may be two
or three weeks ere the sanatorium is
reached. But if it is an open case, we
simply despatch it forthwith to the sana-
torium or hospital, and it matters not an
iota whether the city authorities are in-
clined to pay for it or not ; they have to.
The important distinction, therefore, is
that the open case is usually the adult case
and consequently the greatest menace. Two
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hundred years ago, one-quarter of the en-
tire population of Europe died from tuber-
culosis. If cases of chicken pox can be
isolated, why cannot the same be done with
tuberculosis and syphilis, and why cannot
we get rid of disease and not concern our-
selves so much with a lot of things that
really are of no consequence?
In the present inorganized state of civil-
ian medical service, our efforts must neces-
sarily be spasmodic and uneven, must fail
in comprehensiveness and fall far short of
the ideal. Only annual, or semi-annual or
even more frequent medical inspection of
all citizens can achieve the really early and
efficacious diagnosis of tuberculosis. Until
our civilian medical service is remodelled
and made compulsory, we shall have to face
a continual development of early cases into
cases which next week, or next month or
next year, will be infecting new subjects,
which in turn, may be new sources of in-
fection for days, or weeks, or months or
years before they are recognized at all.
Hence we shall probably secure our most
immediate results by being constantly and
carefully on the lookout for the "open"
cases, and by promptly isolating them pre-
vent further damage.
I am perfectly convinced that our sana-
toria should be so designed that "open"
cases should never mix with "closed" cases.
Further, I am strongly of the opinion that
sanatoria for "open" cases should be so
designed that the open cases need not mix
with each other, at any rate while they are
running a septic temperature. Everyone
who has had experience in the treatment of
tuberculosis is convinced that upon the dis-
covery of an "open" case in a household,
every other member of that household and
all those who have been in the custom of
frequently visiting that household should
be registered, examined and watched for
months.
To do all these things as they should be
done, is not at the present time practicable,
but to accomplish them some day is ab-
solutely necessary if the race is to emerge
from its existing terribly infected condition.
It is, therefore, the bounden duty of every
health officer to work, whenever he has the
opportunity, for the day when medical in-
spection of every citizen at frequent inter-
vals, and prompt action on the findings, will
be an accepted and natural routine. Then,
and only then, will tuberculosis disappear,
and not tuberculosis alone but all our severe
infections as well. The army is doing an
immensely valuable service in the direction
of educating the public in what a civilian
medical service can and should achieve,
and I believe one good result of the great
war will be the ultimate abolition of the in-
fectious diseases of which group tuber-
culosis is so prominent and direful a mem-
ber.
GONOCOCCEMIA AND METASTATIC
GONORRHEA.
BY
HYMAN I. GOLDSTEIN, M. D.,
Camden, N. J.
Samuel P., 21 years, white. Fruit and
produce dealer. Single. Jewish. Had
measles when a child. Influenza, during
October, 1918. Received an injury to chest
(left) and contusion of left hip in an auto-
mobile accident, December, 1918. Had
his first attack of gonorrhea September,
1918. The second attack ( ?) began Jan. 2,
1918, two or three days after exposure.
In the third week of the specific ure-
thritis he was seized with pain in left hip
and some pain in right wrist. Complained
of no difficulty on urination, no dribbling,
etc. Urethral discharge present. Had
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been treated for past few weeks for his
gonorrhea by a Philadelphia doctor.
During this period, and until about a week
previous to my seeing him, he was out all
night and exposed to sexual excitement and
intercourse (while having an active dis-
charge). A few days later this arthritis
began in wrist and hip. Denies ever having
had a chancre or rash at any time. Never
had rheumatism, malaria, typhoid fever, and
never had any trouble with joints, teeth,
eyes, ears or sinuses; did have some sore
throat when younger.
Father died of carcinoma of the breast.
Mother, brothers and sisters living and
well. No tuberculosis or lues traceable in
family.
Some fever present ; the pulse and respi-
ration varying accordingly. Temperature
ranged from 99j4° to 103 ^ Had chills and
chilly sensation; insomnia; dry coated
tongue, parched lips, crying with pain ; rest-
less, nervous, and slightly delirious at night
during sleep. Patient was septic in ap-
pearance.
The gonorrhea blood complement fixa-
tion tests were all positive (several dif-
ferent laboratory reports).
Urethral Smear. — Positive for gono-
cocci.
Syi^ilU. — Blood, Wassermann and No-
guchi tests all negative (three different
laboratory reports).
Malaria. — Negative blood smears.
Typhoid Fever. — Negative Widal reac-
tion (several times).
Blood Culture.— On early blood cul-
tures, no growth was obtained. Recent
blood cultures have not yet been reported
to me.
Bloodi— Secondary anemia of mild
grade present. Due to the general gonor-
rheal infection (septicemia) and metastatic
involvement. Hemoglobin, 75% ; (2/3/
19) ; W. B. C. 16,400; Pmn. 84; S. M. 13,
L. M. 1, Eosin. 2, R. B. C. 4,160,000.
Urine.— (1/27/19). Trace albumin.
All qualitative tests negative — for indican,
sugar, diacetic acid, acetone, etc. A few
R. B. C. ; a few pus cells ; ammonium
urates ; total solids 35 gms. per litre. Urea
1.14%. S. G. 1.015. No casts. Some
squamous cells.
Reaction alkaline (due to medication).
(2/3/19 P. M.) ; Amber. 1.015 S. G. Some
indican, very faint trace albumin. Some
W. B. C. Some bladder epithelial cells.
Many cylindroids. Few uric acid crystals.
Urine specimen, 2/4/19 A. M. Amber;
1.013 S. G. Acid. Trace albumin. In-
dican + many W. B. C. Few R. B. C.
Some bladder epithelial cells. Very few
hyalin casts and many cylindroids. Some
amorphous urates.
Blood Pressure.— Systolic 110-112 to
108. Diastolic 74.
Heart. — Sounds weakened tone, and at
times a very faint murmur heard, esp>ecially
after deep breathing and then holding
breath. Possibly due to the anemia or a
beginning acute endocardial or myocardial
involvement.
Lungs^ — Except for a few scattered
rales, were negative. A slight cough, due
to an associated tracheobronchitis, or the
myocardial weakness.
TreatmenL — Dial-Ciba, or barbital, and
morphin one-eighth to a quarter of a
grain and bromides, given on several occa-
sions as required. The patient has received
complete and absolute rest in bed for three
weeks with Blaud iron pills for the anemia.
Pure ol. Santal in capsules and argyrol in-
jections for the local condition, which was
clearing up nicely. Plenty of water to
drink. A natural laxative water for the
bowels. Also heavy mineral oil, etc., and
alkaline rectal enemas — ^both evacuating
and irrigating. Polyvalent antigonococcic
serum intramuscularly and intravenously.
Gonococcus vaccine hypodermically and in-
tramuscularly. Small doses of mercury and
large doses of syrup ferri iodide for dif-
ferent periods. The most satisfactory and
most rapid relief of pain and improvement
was noticed after the combined use of the
vaccine and one large intravenous injection
of the antigonococcic serum (50 c. c), given
when he was very septic and suffering
greatly. The relief and improvement were
almost magical. Dr. Alfred C. Wood, of
the University of Pennsylvania, saw the pa-
tient with me and believed that cause and
effect in this case, would indicate the fur-
ther use of specific serum (vaccine) thera-
py. No other medication received at the
time could possibly have had such beneficial
effect.
A few days ago, X-ray examination was
advised to decide whether there is an
arthritis, an osteo-arthritis, or effusion in
the joint, etc., and his removal to the hos-
pital urged for this purpose, and for the
possible relief of pain by Buck's extension
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or plaster of Paris splint, etc., or any pos-
sible operative interference, that may later
be necessary, in the opinion of the surgeon.
About a week after the initial administra-
tion of the polyvalent antigonococcic serum,
patient had some urticaria with marked
itching, which passed away after a few
days. Before he received the large serum
doses, he had received a small injection of
the serum as a desensitizing dose. This
prevented any marked anaphylactic serum
reaction. After the large intravenous in-
jection of the serum, he received 15 min. of
adrenalin solution and a very small dose of
atropin, to ward off any possible after-
effects. However, the patient took the
specific therapy without any untoward re-
sults and with considerable improvement
until lately, when his pain returned after
the specific treatment had been discarded
for several days, and when he was advised
to go to the hospital for the X-ray studies,
etc.
Careful measurement was made of the
urine output and of the intake of all fluids.
The urinary output was quite satisfactory
and his kidneys at no time gave us any con-
cern. Locally, for the relief of pain in the
joint I ordered hot water bottle, hot tur-
pentine stupes, tincture of iodine painted on
the affected area, and the old, reliable oint-
ment containing, ung. belladonna, ung.
hydrargyri, and ichthyol, at different times.
I did not use calcium sulphide nor any of
the other supposedly efficient internal
remedies. Early in the treatment he did
receive some urinary antiseptic (urotropin)
and mild alkaline diuretics.
Later on, while in the hospital, he de-
veloped an arthritis of knee which gave
him considerable trouble. I believe this may
have been prevented had the use of serum
and vaccine been continued. Failures are,
at times, due to inadequate dosage of sera
and vaccines or because they are not poly-
valent preparations and of the proper
strains.
It is very important to know whether
there is an arthritis or an osteo-arthritis
with bone and cartilage destruction or
rarefaction, because the second type will
demand longer rest and more careful fixa-
tion of the affected joint, whereas in the
first, earlier massage and passive motion
will help to prevent formation of adhesions
and give him early use of his leg.
Leeches and blisters over affected joints
may give some relief.
CONCLUSIONS.
In regard to gonorrheal arthritis, first be
sure that your arthritis is of gonorrheal
origin. This can be ascertained by the his-
tory, the age, the sex of the patient, by the
complement fixation test for gonorrhea, and
of course, smears from the urethra and
smears after prostatic massage will help.
All of these cases have a focus of infection
some place and this is usually in the pros-
tate or the seminal vesicle in the male and
in the tubes and ovaries of the female. The
gonorrhea cannot be eliminated unless you
treat these foci of infection. The best
method of treatment other than the rest and
local treatment is the administration of large
doses of anti-gonococcic serum, say up to
50 c. c. This is given best, ordinarily, in
doses of 10 or 15 c. c. on successive days.
The action of the serum is enhanced by the
combined administration of mixed poly-
valent vaccines in doses varying from a
quarter of a billion to two, three or even
four billions. In the more subacute or
chronic cases, the careful administration of
fresh vaccine in large doses seems to do
more than the serum alone. The pre-
ferred method of treatment is a combina-
tion of the two. Occasionally on the eighth
or tenth day following the administration of
the serum there is an anaphylactic reaction.
Thi^ can best be controlled by the adminis-
tration of adrenalin, 1 to 1,000 in 15 minim
doses every 4 to 6 hours, and a 100th to
150th of a grain of atropine hypodermically.
Large doses of alkaline remedies, especially
alkaline waters, can be given until the reac-
tion subsides.
If the gonorrheal rheumatism does not
then improve, one must keep on with the
local treatment, prostatic and vesicle mas-
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sage, etc. Then again, failure in improve-
ment may be due to inadequate dosage of
anti-gonococcic serum and anti-gonococcic
stock vaccine; the intravenous administra-
tion of the serum may act more promptly in
severe cases. Finally, don't forget the ton-
sils, bad teeth and infected sinuses are the
most frequent cause of an arthritis, and that
this source of infection may be overlooked
even if there is a urethritis present.
Under the Editorial Direction of Albert C.
Oeyser, M. D., New York.
SOME DEDUCTIONS CONCEBNINe CANCER
OF THE UTERUS.
Dr. J. F. Baldwin, in an interesting arti-
cle in the Ohio State Medical Journal a
short time ago, points out that high am-
putation by the cautery as practiced by
Byrne of Brooklyn, has given good results,
but that most surgeons still prefer panhys-
terectomy. The original Wertheim gives
the best results, but the primary mortality
has been so high that the operation has
never become a favorite one. Lately two
methods of treatment have been advanced :
one, the "cooking" of the cancer, in which
the vitality of the growth is destroyed by
means of an electrode heated to a tempera-
ture several degrees below that which de-
stroys normal tissue ; and the other, the use
of radium, which is especially of value in
inoperable cases.
High amputation is and remains high am-
putation. Whether the knife, the cold
snare, the electric cautery or whatever other
method is used, the end results are practi-
cally the same. If the surgical technic is
correct there ought to be just as little loss
of blood with the one as with the other.
When a radical removal of the uterus and
the adnexa is undertaken, however, the
sudden removal of so much important tis-
sue often causes too much physical shock ;
hence the undesirable primary mortality.
In the cooking method, the object to be
attained is to destroy the cancer cells in
situ. If these cells were located all in one
certain region, if there was no such thing
as constitutional susceptibility, or if one
could be sure that cancer was a local dis-
ease, then the removal or the destruction
of cancer cells in situ would be the ideal.
The particular method employed is of little
consequence. If the knife removed all of the
diseased tissue, left a clean, healthy wound
and healing took place promptly, all ends
would be served. In the cooking process
the cancer cells are killed and the system
throws them off in the form of a slough.
In analyzing the benefits of this method
it should be pointed out that the less the
physical destruction and the more is left
for nature to do, the better it obviously is
for the patient.
The application of radium to a cancer
of the uterus, as in many other affections,
has much to recommend it, but like most
of the other methods that have been used
in cancer it also has much to condemn it.
When radium is applied to any living
tissue there ensues as the result of its em-
anations, a very pronounced cellular dis-
turbance. It is really an ionic disturbance
of the vibratory rate of the cells, which
essentially results in cellular disharmony.
The system promptly reacts with a localized
inflammatory process. Between the ionic
cellular disturbance and the attempt on the
part of the inflammatory process evolved,
a cell change occurs. This change is fre-
quently of a beneficial nature. The cancer
cells are either slowly absorbed or, what
is of greater imlportance, their unphysio-
logic function is interfered with. As a re-
sult a localized cancer, especially of the su-
perficial variety will frequently be more or
less permanently eradicated. . If, on the
other hand, the original lesion has already
invaded the system, then, of course, failure
must be anticipated. Neither is it possible
to judge the dose to be administered cor-
rectly in each case, since the personal equa-
tions of the patient's reaction and the
physician's acumen play an important role.
On general principles it may be stated
that any method which depends entirely on
destroying the cancer cells in situ by some
system of complete removal, as by the knife,
cautery, cooking, caustics or radium, can-
not, and does not, take into consideration
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669
the systemic relations of cancer. If cancer
was always a local disease, then local opera-
tive procedures might be expected to pre-
vail. The moment that cancer is considered
a constitutional disease, from that moment
on the treatment must be more or less con-
stitutional or, at least, physiologic.
It is true, of course, that some cancers
are and remain a local disease. Removal
or destruction of the mass in these cases
should be followed by complete recovery
and permanent cure. Some cancers are
local only during their early stages, but be-
cause of constitutional dyscrasia sooner or
later become constitutional. Early removal
by any proper method produces a large per-
centage of permanent cures. It is this class
of cases that furnish the foundation for the
various claims of cure by knife, cautery,
radium, caustics or the X-ray. The later
the operation, the more susceptible the pa-
tient, the greater the percentage of recur-
rencies.
In some cancers the constitutional symp-
toms are more pronounced than the local
from the first. There are usually two para-
mount reasons for this : Either the patient
did not discover the lesion during the purely
localized stages, or when the lesion was
discovered, it was because the constitutional
symptoms were more prominent than the
local lesion. Here exclusively local opera-
tions, except for temporary cosmetic or
symptomatic reasons, are contraindicated.
They not only almost always fail to effect
a cure of the disease for which they are
undertaken, but as a rule do not contribute
to the longevity of the patient.
The Cancer Function. — It is not the
anatomical formation nor the mere pres-
ence of a tumor which destroys the life of
the cancer patient.
Cancer cells, no matter where located, are
not in harmony with the physiology of the
system. Every living cell, as every living
individual, must perform a dual function;
one is an individual function, performed
mainly for selfish reasons. It includes indi-
vidual existence, maintenance and the
propagation of the species. As far as the
cancer cell is concerned we have no fault
to find with this one function. The second
function is a sort of communistic or social
function. By the performance of this func-
tion the system as a whole is benefited,
each cell is in harmony with all the other
cells of the body ; in short it is physiologic.
In order to perform this physiologic func-
tion in a physiologic manner, each cell must
assist and be assisted by each neighboring
cell. In other words, it must be in harmony
with the entire constitution of the individ-
ual. Cancer cells are not in harmony with
the system, they do not assist, nor are they
assisted by their neighboring cells. What-
ever function the cancer cell does perform,
it is unphysiologic and, therefore, detrimen-
tal to the body as a whole. The secretion
or the excretions of a cancer cell are not
only detrimental, but they compel the rest
of the system to guard and defend itself
against them. As long as the system is
able to perform this defensive function in an
adequate manner, so long will there be a
balance maintained. Failure in this on the
part of the system means defeat, cachexia
and death.
When we speak of maintaining a bal-
ance we simply mean that the two opposing
forces are for the time being equal to or
equalized by each other.
IVhat Are the Opposing Forces? — The
cancer cells give off an excretion or a secre-
tion which is not in harmony with the sys-
tem; it is unphysiologic, a foreign sub-
stance, a veritable poison. This toxic ma-
terial being manufactured within and by the
living cells of the body, sooner or later
comes in contact with and exerts its malign
influence on some of the normal cells. When
such an abnormal influence is manifested
there is an interference with the normal
physiologic function of the affected cells,
followed by bodily cachexia and death of the
individual.
The Anti-toxin, — In order to neutralize
this toxic material the system possesses the
power of manufacturing an anti-toxin. As
long as this is furnished in adequate amounts
there will be no cachexia, because the at-
traction is greater between the two chemical
compounds than between either of the com-
pounds and the cells. Since then the anti-
toxin neutralizes the toxic effect of the can-
cer toxin, it follows that the strength of
each bears a definite relation to the other.
Again, since the anti-toxin like the toxin,
is manufactured by the cells of the same
system, it must also possess the same power
of reaching and influencing the normal tis-
sue cells. Such an influence must be
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PHYSICAL THBRAPY
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equally unphysiologic. Let us see what
probably happens if such a combination does
take place. The cancer cell produces a
toxin. The system, probably the endocrine
organs particularly, is activated into pro-
ducing something not usually present. To
do this some cells are obliged to assume a
new function, perhaps a new anatomical
formation. All of this comes about as a
result of the stimulation or irritation of
the cancer toxin. Let us suppose now that
suddenly the original cancer cells are re-
moved, yet the anti-toxin is still present in
large amounts, what office or function will
now be performed by it? Since it has ad-
mittedly no function now to perform, it
like the toxin, must be neutralized or de-
stroyed. What is going to destroy it ? Log-
ically there is only one substance capable
of doing this and that is the cancer secre-
tion. Where is this now suddenly to come
from? Could not this free and useless
anti-toxin cause certain normal cells to take
upon themselves the function now of pro-
ducing the toxin? If this is so, then we
can imder stand why a cancer, after it has
become constitutional and is completely re-
moved locally, still tends to recurrence and
metastasis. Again and again it may be re-
moved and as many times it may recur.
This recurrence need not be at the site of
the original lesion ; it may be anywhere
where susceptible or responsive cells are to
be found. In the one instance such cells
may be found along the course of the
lymphatics, in the other along the blood
vessels.
The local removal of a cancer which has
become constitutional in character, no mat-
ter which particular method is employed,
cannot, therefore, be looked upon as a cura-
tive measure. To cure a cancer it is neces-
sary to remove the cause. Cancer cells,
like other cells, functionate best within a
certain temperature radius. Experimentally
it has been determined that when cancer
cells are subjected to a long continued tem-
perature of 104° F. they cease in the per-
formance of their function, which function
is so inimical to the life of the patient. Let
this cancer function cease and the patient
lives, because there is no reason to do other-
wise.
Physiologic Therapy. — Heating the
cancer cells to a temperature of 104° F.
and over interferes with the unphysiologic
cancer activity. The quantity as well as
the quality of the toxin is gradually changed.
The general system responds by lessening
and changing the production of the anti-
toxin. When neither toxin nor anti-toxin
is formed, there is no longer a malignant
condition present. The tumor per sc is, as
before stated, of little consequence. It may
be left or it may be removed for cosmetic
or other reasons the same as any other
benign growth.
Technic. — A high-frequency apparatus is
required which must possess a rather high
rate of alternations, a low voltage and a
comparatively high amperage. A diather-
mic apparatus gives a wide range of varia-
tion and is particularly suitable for this kind
of work. It is essential that the malignant
growth is so situated that it can be placed
between the two electrodes of the appara-
tus. When the meter gives a reading of
1000 milliamperes, the temperature in the
uterus will indicate about 106° F. with an
ordinary fever thermometer. In cases of
breast tumors a reading of 2000 — 2500
milliamperes will produce a temperature un-
der the active electrode over the tumor of
106° F. Such a temperature must be main-
tained for at least one hour, either daily or
on alternate days.
After a few treatments the heat is re-
tained in the parts from two to eight hours
following each treatment. The harder the
mass the longer the heat retention.
After about one month to six weeks the
patient usually shows a decided general im-
provement. Sometimes the tumor disap-
pears entirely, sometimes it simply becomes
smaller. If the uterus was firmly adherent
this becomes freely movable. If prior to
the treatment there was no uterine dis-
charge, there is now an almost constant
"beefwashing" discharge; if there was an
offensive discharge it is changed to a non-
odorous one. Pain ceases early and, as a
rule, permanently. All clinical manifesta-
tions of the disease disappear, the patients
gain in weight and become to all intents
and purposes normal individuals.
Old cases treated as far back as 1910 are
alive and well ; in some there are still traces
of a tumor, in others there is no sign of
foreign growth. The treatment can be rec-
ommended as painless, bloodless, efficacious
and in most cases permanent.
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671
RATIONAL
ORG^OTHERAPY
Endocrine Dysfunction. — More and
more have we come to appreciate the great
importance of the glands of internal secre-
tion— the endocrine system — in maintaining
normal health says an editorial writer in
the Jour, of the Indiana State Med. Assn,
(July 15, 1919). As our knowledge of the
function of the various members of this
system increases the more do we realize
how profoundly they influence the animal
organism.
Many, if not most, of the normal bodily
activities and functions are directly or in-
directly controlled or regulated by this en-
docrine system. In fact, in many ways it
seems to be the regulatory system of the
animal body. The growth, the development,
the metabolism, the catabolism, the sex char-
acteristics and functions, all these and ap-
parently many more of the vital activities
of the body are dependent on the properly
coordinated function of the ductless glands.
When these function properly, normal health
results; when there is improper function
— dysfunction — of this system, abnormal
processes appear in one form or another.
As a result of the increase of our knowl-
edge along these lines we have learned that
many symptoms which hitherto formed
vague, obscure, or indefinite clinical com-
plexes can now be explained, to a certain
extent at least, if not altogether, as due to
a disturbance of the function of the duct-
less glands, i. e., endocrine dysfunction.
Over (hyper) activity or under (hypo)
activity of one or more glands of this sys-
tem can give rise to symptoms that may be
pathognomonic of such perverted function
or not. There are certain well-defined
symptom complexes that are characteristic
of perverted function of certain definite
glands of this system. They have been rec-
ognized for some time, and are already quite
well known. But we are now learning further
that many of the so-called vague functional
disturbances are not merely imaginary, but
have as their basis disturbed endocrine func-
tion.
Among the functions that are regulated
by this system is menstruation. The inter-
nal secretion of the ovary, in coordination
with the internal secretion of the pituitary
and the thyroid, regulates the function of
menstruation. When this system functions
normally menstruation is normal, but when
there is dysfunction, menstruation is ab-
normal. Heretofore disturbances in the
latter process were blamed on the uterus,
and that organ was unhesitatingly subjected
to dilatation and curettage. Whenever
there is a definite pathologic process within
the uterus, such a procedure can remedy
the menstrual disturbance by removing the
obvious cause. But in the vast majority
of cases the cause is not within the uterus.
The abnormal menstrual process is simply
a manifestation of abnormal activity of some
of the endocrine glands, and the rational
way to correct such menstruation is by
proper endocrine therapy.
In view of this newer knowledge it has
become self-evident that the operation of
curettage is not only not indicated in a great
many, perhaps nearly all, cases in which
it has been and is even now being done, but
is absolutely useless. Such an operation
cannot reach the cause of the trouble. The
gynecologist has found out that he must
attack this trouble not with his curette, but
with the proper medicines. This idea is
quite frankly expressed by one of our lead-
ing gynecologists (S. W. Bandler) in these
words: "I hope that some day there will
be a law that before we curette a patient we
must get a license or permission from some
central authority to use it in a particular
case, and then only after giving genuine
reasons therefor."
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Mammary Extract in the Treatment
of Uterine Fibromyomata« — ^After giving
a record of his individual experience with
mammary therapy in the treatment of uter-
ine fibroids, Briggs, in the California State
Journal of Medicine, says that it indicates
the remarkable, but perhaps not invariable,
influence of mammary extract on uterine
fibroids and menorrhagia, their most fre-
quent and distressing symptom. Mammary
extract, even with prolonged use did* not
seem to produce any untoward results. In
some of the cases he combined it with hy-
drastis and ergot and occasionally, tho rare-
ly, the combination produced more or less
gastric disturbances which subsided, how-
ever, on the suspension of these two drugs.
Other untoward results, either from the
combination or from the mammary extract
alone, Briggs had not observed even after
prolonged use. On the contrary, there
was generally a distinct improvement in
the physical health as well as in the morale
of the patients, probably chiefly attributable
to the arrest of the menorrhagia, the relief
of pressure symptoms, and the relief of
mental strain due to fear of operation. The
mammary hormone probably antagonizes
the follicular hormone or inhibits its pro-
duction and thus moderates or prevents an
excessive menstrual molimen and its con-
sequent hyperemia, menorrhagia and local
nutritive disturbances. The effective dos-
age, therefore, would seem to depend on
the degree of excessive ovarian activity —
the greater this functional activity the larger
the quantity of mammary extract required
to inhibit or antagonize it. A daily quan-
tity of the extract representing from twenty
to fifty grains of the fresh gland was used
in the cases here reported. The dosage in
several of the cases was too small. This
accounts, perhaps, for the comparative or
even absolute failure of the treatment in
a few of the cases and possibly also for the
absence of gastric irritation occasionally
noted by others. At present Briggs says
he usually prescribes thirty to forty grains
daily and, in refractory cases, increase to
fifty or sixty. Pregnancy seems to be the
only positive contraindication to the use of
mammary extract. In two of the cases re-
ported, however, its continued use did not
prevent pregnancy. In both of these cases
mammary extract was given for some time
before and for three months after concep-
tion and in a third case (in consultation)'
for the last four months of pregnancy with-
out provoking interruption.
Saline Solution with Organ Extracts
in Shocks — Descomps and Qermonthe
(Presse Medicate, August 22, 1918) present
thirteen cases of shock, hemorrhagic or
toxic, treated within from 6 to 24 hours
after injury by intravenous injection of a
hypertonic solution of about the same
composition as Ringer's solution — ^to which
was added a few mils of soluble extracts
of thyroid, hypophysis, adrenals, testicles
and spleen and a little strychnine and digi-
talin. This was administered to supply the
temporary deficiency in the blood of the
secretions of the endocrine glands, which
exert a controlling action on the functional
activity of the sympathetic and maintain
the action of the vasomotor centers. Cir-
culatory disturbances are a conspicuous
feature of all shock.
Eight of the patients thus treated re-
covered and in five the measure was a
failure.
The successful cases showed a regular
and forcible pulse within six or eight hours.
Blood pre5sure rapidly increased. Persist-
ent diuresis and increased daily elimination
of urea were noted. Urea output increased
above the average to twenty-nine up to
forty-two grams, suggesting an action on
the liver. Chlorides were low. The spe-
cific gravity of the urine was always nor-
mal or above.
In some cases there was a diminishing of
delirium, restlessness and mental disturb-
ances.
The Use of Pituitary Extract in Ob-
stetrics.— While extract of the hypophy-
sis, according to Schwaab {Presse Medicate,
1919, XXVII, page 299), is of value in
the treatment of uterine inertia in the course
of labor, its use to provoke labor is abso- •
lutely improper. It has no effect in activat-
ing an abortion in progress nor does it as-
sist in the expulsion of a retained placenta
in abortion. In all of these cases the uter-
ine musculature is too weak to be influenced
by the extract.
The author is of the opinion also that .
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RATIONAL. ORQANOTHBRAPY
October^ 1919
673
pituitary extract should not be employed
during the period of delivery at term. Gen-
erally it has no effect when delivery is
delayed because of uterine atony without
hemorrhage ; in such cases it even tends to
disturb normal contractions and to produce
instead contractions of Bandl's ring with
incarceration of the placenta. When th^re
is hemorrhage at the time of delivery, pit-
uitary medication should yield to other
methods.
In caesarean operation the author is of
the opinion that ergot is preferable to pit-
uitary extract to stimulate uterine contrac-
tion.
In urinary retention after childbirth, how-
ever, the indication for the use of pituitary
extract is clear. In numerous cases the
contractions of the bladder are stimulated
and catheterization is avoided.
Schwaab has never observed any incon-
venience with the use of weak subcutaneous
injections of pituitary extract, but heavy
doses and intravenous injections are apt to
cause nausea, delirium, circulatory lipothy-
mia, etc., in the patient and circulatory dis-
turbances and apnea in the fetus. An-
other effect which many authors ascribe to
pituitary extract is tetanization of the uterus
either during labor or delivery. In
Schwaab's opinion, however, this complica-
tion is exceptional when the doses given
are weak.
The Stimulatioii and Inhibition of the
Gastric Secretion Which FoUows the
Subcntaneoiu Administration of Certain
Organic Elxtracts. — Rogers, Rahe and
Ablahadian, in the American Journal of
Physiology for Feb., 1919, give the fol-
lowing conclusions :
1. A slightly alkaline saline solution, or
alcohol, extracts from the thyroid some non-
coagulable material which is a vigorous
stimulant for the gastric secretion.
2. This material produces its effects at
least in part by intensification of the func-
tions performed by the terminal filaments
of the (gastric) vagus.
3. Extracts similarly made from the
pathologic tissue of adenomatous or hyper-
thyroid human glands are inert.
4. Extracts of the adrenal gland vigor-
ously inhibit gastric secretion.
5. These extracts of the adrenal gland
all contain more or less adrenalin, and there-
fore it is presumable that their effect is pro-
duced by intensification of the inhibitory
function which is ascribed to the (gastric)
sympathetic.
6. Adrenalin is not as active a gastric in-
hibitor as the adrenal nucleoproteins ob-
tained from extracts of the whole gland.
These adrenal nucleoproteins contain only
traces of epinephrin.
7. Extracts of the pituitary gland also
inhibit gastric secretion, but only about one-
half as vigorously as do extracts of the
adrenal.
A Thought on the Internal Secretions*
— Ghedini {Gazzeta d. Ospedali, Jan. 5,
1919) says that the true internal secretion
of an organ is contained in the venous blood
issuing from that organ, and he insists that
instead of using organic extracts we should
employ this venous blood. The cells of the
organ cease to secrete when they are dead,
hence removal from the body to make the
extract not only arrests production of the
internal secretion, but probably modifies es-
sentially the delicate secretion already on
hand in the tissues of the organ. Instead
of a living secretion we get only a dead and
possibly decomposed product. The efferent
blood contains the secretion in its maximum
vital potency. He published in 1911 re-
search on the thyroid secretion thus obtained
in the efferent blood, and in 1913 and 1915
similar research on the venous blood from
the suprarenals, pancreas and testicles.
Manfredi announced in 1913 that the effer-
ent blood from the pancreas inhibited cer-
tain actions of .epinephrin. The difficulty
of obtaining the efferent blood or lymph
hampers and limits the research in this line,
but this is the goal to be aimed at by inves-
tigators.
The Ductless Glands in Oironic Tuber-
culosis^ — Bobeau {Presse medicale, Febru-
ary 24, 1919) having determined in guinea-
pigs succumbing to slowly progressive
tuberculosis, marked impairment of all the
ductless glands, came to look upon poly-
glandular opotherapy as an advantageous
auxiliary to any of the usual methods of
tuberculosis treatment. Patients actually
treated with ductless gland products were
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CORRESPONDENCE
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markedly improved. Attention is called to
the fact that the ductless glands do not
function separately, but in mutual harmony.
This is especially true of calcium metabo-
lism, the endocrine secretions constituting
one of the mordants indispensable for the
fixation and utilization of calcium by the
organism. Polyglandular opotherapy is thus
to be considered an adjuvant measure in
the remineralization cure of tuberculosis.
Disappearance of dental pain, which in the
author's cases always took place when ura-
nalysis showed that demineralization had
been arrested, is an excellent clinical sign
of improvement. It may even prove feasi-
ble, with the aid of the X-rays, to formu-
late a convenient scale for better apprecia-
tion by the physician of the process of re-
mineralization in tuberculosis cases.
Leucocyte Elxtract for the Treatment
of Undetermined Infections^ — Dr. G. F.
Leonard of New Brunswick stated in an
interesting paper before the Med. Soc. of
N. J. that it was not claimed that leucocyte
extract was a specific for any disease, nor
that it was a panacea. From the clinical
evidence available, however, he had arrived
at the following conclusions: (1) Leuco-
cyte extract was harmless in localized in-
fections, superficial and deep. (2) Its use
had proved beneficial, many cases being
cured, and others improved. (3) In pneu-
monia other than type 1, it improved the
general condition, made the patient more
comfortable, probably shortened the course
of the disease, and decreased the mortality.
(4) In any undetermined infections it was
the sole biologic product indicated. (5) In
infections attended with high * leucocytosis,
such as was found in measles and influenza,
the administration of leucocyte extract re-
sulted in an increase in the number of leu-
cocytes, and was therefore indicated. The
author stated that in cases in which there
was a specific serum, that alone should be
used ; but that in cases in which there was no
specific serum, and in those in which the in-
fection was not known, the use of leucocyte
extract was particularly of value.
Arteriosclerosis. — ^The most potent fac-
tor in arteriosclerosis is overfeeding. The
most universal factor is gastrointestinal au-
tointoxication.
CORRESPONDENQ
Is Compnlsory Health Insnranee Inevitablet
To the Editor
American MEa>icisE:
This is the first question that the Committee
on Public Information of the Medical Society
of the County of Schenectady had before it
when we undertook the investigation of the
subject of Compulsory Health Insurance.
We had heard for several years the often re-
peated statement that Compulsory Health In-
surance was inevitable and that the medical
profession had better make the best of it When
we came to study the actual data at hand we
found several very interesting facts which are
briefly as follows:
Ninety per cent of the "inevitability" talk
can be traced directly to Mr. Andrews and a
few other propagandists for Compulsory Health
Insurance. It is part of the propaganda.
Only an overwhelming popular demand will
make inevitable a law which will reverse the
very history of the State and substitute for a
policy of individual liberty and self help a
policy of control of the individual and State
help. There is in this State almost no popular
demand for any such change.
The only persons who are alleged to benefit
from this distinct class legislation are the labor-
ing people. It is well known that the farmers,
the merchants, the manufacturers and the com-
mon people are against Compulsory Health In-
surance. Even labor is not in favor of Com-
pulsory Health Insurance.
In California last fall the whole stage was
set in favor of Compulsory Health Insurance.
The legislature had passed a constitutional
amendment in favor of it. Hiram Johnson was
in favor of it. The so-called commission to in-
vestigate the subject, composed chiefly of Ameri-
can Association for Liabor Legislation propa-
gandists, had reported in favor of Compulsory
Health Insurance. The professional labor
leaders were for it. There was an intense edu-
cation campaign extending over the entire
State. When the question came to a state wide
popular vote Compulsory Health Insurance was
defeated by a vote of nearly S-1 and labor did
not support the measure.
In XJtica last spring there was a campaign of
education on the subject followed by a popular
vote on the subject. Thirteen thousand factory
employees voted on the subject Did they vote
for it, or 2-1 against it, or even 10-1 against it?
No, they voted 12,875 to 112 or 100-1 against
Compulsory Health Insurance.
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ETIOLOGY AND DIAGNOSIS
October, 1919
675
Any law which is fundamentally unjust;
which demands that industry pay fifty per cent,
of the costs when industry is responsible for
less than one per cent; which teaches the
doctrine that it is unhealthy to work; and which
substitutes a policy of control of the individual
and forced charity for the policy which has
made this country what it is— such a law is not
in our opinion inevitable.
Very truly yours,
Committee on Pubuc Information,
Medical Society of the County of
Schenectady.
An Appeal for Human Embryologic Material.
To the Editor
American Medicine:
In 1906 I observed certain malformations of
the human shoulder-blade, and in contributions
to current literature I have given them the col-
lective name, "the scaphoid type of scapula,"
and pointed out some of its hereditary, clinical
and anatomical significance.
Probably the most important observation con-
nected with this type of scapula in man is its
age incidence, that is to say, it occurs with great
frequency among the young and with relative
infrequency among the old. There appear to
be two possible explanations of this fact:
either
A — One form of shoulder-blade changes into
the other during development and
growth.
B — Many of the possessors of the scaphoid
type of scapula are the poorly adapt-
able, the peculiarly vulnerable, the
unduly disease susceptible — the in-
herently weakened of the race.
I have attempted to answer these questions
by seeking evidence in various directions and
one of the most important of these has been a
study of intrauterine development of shoulder-
blades. My investigations in this direction
have been limited by the material at my dis-
posal, which has been inadequate for a definite
solution of this phase of the problem. I am,
therefore, appealing to physicians for fetuses in
any and all stages of human development.
It is desired that the material, as soon as
possible after delivery, be immersed in 10%
formalin in a sealed container, and be forwarded
to my address; charges collect. Due acknowl-
edgment will be made to those forwarding
material.
Respectfully yours,
WnxiAM W. Graves.
727 Metropolitan Bldg.. St. Louis, Mo.
m
ETIOLOGY
AND
lAGNOSI
The Etiology of Appendicitis. — Selberg
(Munchener medizinische Wochenschrift, Mar.
21, 1919), contrary to certain writers, believes
that appendicitis has not decreased either in
frequency or in gravity since the war. The war
alimentation seems rather to have increased
the number of cases, '^he infectious estival
enteritides bring about an increase of appen-
dicitis.
The Etiology of Migraine^— Reviewing the
various theories that have been advanced in the
attempt to find an explanation of the origin
and nature of migraine, Drs. Mary P. S. Rupert
and Blizabeth E. Wilson (Amer, Jour. Med.
8ci., March) conclude that the symptoms of
migraine arise from stimulation of certain areas
in the central nervous system and that this
stimulation may be provoked in many ways:
by pressure, by reflex stimulation or by circula-
tion of certain toxic substances in the blood.
In their attempt to determine the nature of
the toxin, or toxins, the authors undertook
careful studies of the gastric contents and of
the feces of patients afflicted with migraine. It
was found that many of these patients register
an abnormally high blood pressure during the
attack. Furthermore, patients having frequent
and severe attacks of migraine exhibit, during
the latter, some abnormality of the stools,
usually putrefaction with alternations in the
blood pressure, and these usually are accom-
panied by a depression of the renal function in-
cluding some disturbance of the nitrogen out-
put.
The variation of blood pressure between at-
tacks corresponds with the findings in the stool.
For instance, a persistently low blood-pressure
reading is likely to be associated with an occa-
sional putrefactive movement and, as this con-
dition is corrected, the attacks become less in
frequency and severity. In some cases, there
then occurs an improvement in the blood pres-
sure between attacks.
It still is to be determined where and what
is the source of the irritation and the authors
are extending their investigations in this direc-
tion, namely, the attempt to discover the prob-
able caustic toxin.
Tabercnlosis of tbe Anus and Bectnm.—
Symptoms— The local symptoms of tuberculous
ulceration, if of the sigmoid or rectum, are lum-
bar or sacral pain and rectal tenesmus accom*
panied with diarrheal evacuations of pus, blood
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and mucus. The diarrhea is slight at first but in-
creases as the ulceration spreads until thirty or
forty evacuations occur daily and the associated
coloproctitls disturbs digestion in general. The
discharges have a gangrenous odor. Bleeding
is not profuse but as the oozing is persistent the
blood may accumulate and be retained in the
rectum and when voided may be fresh, or tar-
like or mixed with the feces.
DingnosU — Drueck {Med. Bummary, Sept.
1918), claims that tuberculous ulceration of the
bowel should be looked for in every tubercular
patient when diarrhea occurs that cannot be
accounted for by overeating of Improper food,
or by other dietetic errors and which, does not
promptly yield to treatment The presence of
tubercle bacilli in scrapings from the ulcer is
strong evidence of the nature of the trouble,
altho the possibility of accidental deposit of
tubercle bacilli on a non-tubercular ulcer must
be remembered. The clinical picture is, how-
ever, somewhat characteristic (1) The pres-
ence of tuberculosis elsewhere, as in the lungs,
lymphatics or the genito-urinary system. (2)
Ulcers which follow the course of the blood
vessels and in the rectum spread out irregularly
in every direction. (3) Diarrhea, discharge of
mucus, blood and pus with rectal tenesmus.
(4) General emaciation of the patient with
great loss of body fat This may be expressed
locally by the consumption of the perirectal fat
and a shrunken or fiftinel-shaped anus.
It is essential that workers be able to recog-
nize the disease which they are studying. They
should know its history and distribution,
whether it occurs in pandemic, epidemic, en-
demic or sporadic form; its relation to the
physical, biologic, or climatic features of the
countries where it occurs, whether Immunity
or difference of susceptibility has been recog-
nized, its symptoms, theories of causation and
dissemination, and suggested treatment
Certain insects should be investigated with
especial care, particularly insects which come
in contact with the blood of the patient or the
food or feces. Before transmission experiments
are begun, It is necessary to know the normal
conditions of life of the Insect its food, methods
of reproduction and the proper conditions of
the soil or water in which it is to be. The study
of the causation of disease is receiving consid-
erable attention today. It is to be hoped that
the suggestions offered in this article may lead
to greater effort in locating the possible inter-
mediate hosts and invertebrate carriers.
REATMENT
Insect Transmission or Causation of Disease.
— Pierce, in a recent issue of Bcience, has stated
that insects may be involved in disease trans-
mission either by transmission of an organism
or the inoculation of a toxin; or there may be
an intermediate phase in the life cycle of an
organism, the insect not coming in direct con-
tact with the final host. Insects can carry bacte-
ria, many types of protozoa and many species of
parasitic worms. Insect toxins may be introduced
into the system by means of the mouth, claw, cau-
dal appendage, or ovipositor of the insect. Some
insects live as parasites on the bodies of men
and animals; sometimes insect larvae are in-
gested as food and continue to develop in the
intestines or other organs, often at the expense
of the tissues. Insects may obtain the organ-
isms which cause disease directly from the
blood of an infected host from infected surfaces
of the body, or from the excretions of an in-
fected host The organism may then be trans-
mitted by the insect by direct inoculation thru
the proboscis or by the passive transmission of
the parasite in the reflex actions which take
place in the sucking of blood ; the organism may
be regurgitated by the insect on the body of
its host and obtain entrance by its own activity,
or it may pass thru the insect and out in its
feces, or in malpighian excretions. If the or-
ganism is taken up by the insect In its larval
stage it may pass thru a number of insects
before finding a vertebrate host
Trench Month*— This condition, according to
Merkeley (Orca Health, Aug., 1919) is well de-
scribed by the designation as ulcerative inter-
stitial gingivitis. A lack of oral hygiene is
generally conceded as a contributing factor, and
badly kept table utensils undoubtedly help in
the distribution of the infection. Streptococci
and a very few staphylococci have been found,
as well as anaerobes in the form of the bacillus
fusiformis and its spirochaete, said to be a spore
form of the bacillus fusiformis. Certain other
ultra-microscopic forms are regarded by the
author as chlefiy responsible. The infection
spreads with great rapidity and then assumes a
stubborn chronic character. The clinical picture
presents a slough closely approximating in gen-
eral appearance that of an arsenic necrosis.
The fioor of the mouth, tongue and cheeks are
rarely involved, altho there is a considerable
rise in temperature of the cheeks in acute ex-
acerbations. There is also a general rise in
temperature of a couple of degrees, due no
doubt to the absorption of ptomaines and toxins.
Pain may be severe enough to produce insonmia.
The chief aim in the treatment being the re-
moval of the cause and all contributing factors,
the slough is best cleaned away by applying ^y
crystals of copper sulphate on a small pledget
of cotton to each interproximal space where
slough is present The bactericidal application
is allowed to remain three or four minutes, then
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677
washed out with a water syringe, this treat-
ment to be repeated daily for three or four days,
or if pain be intense, twice daily. As a mouth-
wash, undiluted Dakin's solution should be
prescribed, with instructions to the patient to
hold the solution in the mouth for some min-
utes and use the cheeks to forcibly wash out
the interproximal spaces. When the pain has
disappeared and the slough has been cast ofT,
which should be in four to five days, a thoro ex-
amination should be made for all irritants ^nd
these should be removed even to the removal
of all shell crowns and extraction of the third
molars, if badly involved. It is noteworthy
that the tissue flap covering a partially erupted
third molar may form a pocket and thus be-
come the seat of trouble. In fact, fifty per
cent, of cases treated to date point to this origin.
Treatment by irrigation and wash should be
continued until granulation-tissue has a good
start, then iodine and violet ray massage well
may be employed, keeping up the Dakin solution
as a mouth wash intermittently. The destroyed
gingival tissue will slowly regenerate and give
a fairly good effect even in extensive necrosis.
Milk Diet in Diabetes MeUltns^^P. Le Noir
(Bulletin de VAoadimie de m^decine, July 1,
1919) reports his experiences during past few
years with brief "milk cures" in diabetes, either
to overcome complications or severe symptoms,
or for purposes of alteration with the custom-
ary protein and fat diet. The author believes
even a mitigated protein fat diet has various
drawbacks and in the long run may lead to
harmful results in diabetics predisposed to
visceral disease, arteriosclerosis, and often al-
ready suffering from gout and obesity. For
temporary detoxication, therefore, he subjects
his patients to five day cures in which the food
taken is restricted to from two to three litres
of milk — usually two and a half litres — given at
equal but rather short intervals. Slight diminu-
tion of the body weight occurs, but hunger and
lassitude are not marked. The milk cure is re-
peated at intervals dependent upon the severity
of the disease, the tendency to visceral lesions
or arterial changes, and the patient's willing-
ness to undergo it. In the periods between
milk cures the ordinary antidiabetic diet is or-
dered, avoiding unnecessary strictness as well
as any excess of total intake. Among seven-
teen cases of "arthritic" diabetes of interme-
diate severity, without emaciation, four showed
complete disappearance of glycosuria after the
first "cure," the sugar reappearing only in
traces or not at all for several months. In
nine cases the sugar was markedly reduced,
often by two-thirds or one-half, after each milk
cure, while in four the measure was unsuccess-
ful. In one instance the sugar output, already
reduced from eighty to twelve grams by strict
antidiabetic diet, fell to four grams under the
milk diet In another patient passing forty-
nine grams, glycosuria disappeared, and 100
grams of saccharose given in three litres of
milk failed to cause its reappearance. The milk
cure is formally indicated in cases with renal,
cardiac, or hepatic disease or advanced arterio-
sclerosis, not only to dispel skin and gastro-
intestinal symptoms but to secure rapid reduc-
tion of glycosuria. Milk cures should also be
used regularly as a corrective of the customary
diet and are especially advisable in obese, gouty
and bulimic cases.
Serum Treatment of Typhoid Feverr— In
treating patients exclusively with antityphoid
serum Rodet and Bonnamour (Bulletin de
VAcad^mie de medicine, June 3, 1919) claim
that the administration of serum should be
begun as soon as possible, but should be em-
ployed even in patients received late, always
producing at least some favorable effect. The
first injection consists of fifteen or twenty mils.
If a reduction in temperature follows within
forty-eight hours, no further injection is given
as long as defervescence continues. If, how-
ever, the reduction fftils to occur or the tem-
perature reascends, a second dose of ten to
fifteen mils is given forty-eight hours later.
The third dose is similarly regulated and con-
sists of only five to ten mils. Generally, three
injections suffice, frequently but two, and occa-
sionally one. In a few instances, fourth and
fifth injections at the usual two-day intervals
are required. More frequently, serum is re-
peated for recrudescence or relapse after a more
prolonged period of improvement The serum
acts both on the temperature and the symptoms.
It never causes the immediate rise in tempera-
ture which often attends vaccine or colloid
metal injections. Often the temperature shows
a marked drop within twenty-four hours after
the first injection. Even If it soon reascends
a favorable prognosis is indicated, the tem-
porary drop often being the forerunner of an
early reduction by lysis. Sometimes the first
injection is followed by a progressive, perma-
nent effect on the temperature. Absence of
effect on the temperature after three injections
points to a different or superadded infective
process. Toxic manifestations are reduced to
a minimum by the treatment which is contra-
indicated neither by hemorrhage nor an already
grave condition of the patient.
The Treatment of Malaria.— Nocht (Wiener
medizinische Wochenschrift, Feb. 22, 1919)
gives a summary of his principles of treatment
of paludism and considers also some other
questions related to them, such as becoming ac-
customed to the drug, the mode of action of
quinine (this is not a direct toxic for the Plas-
modium), the drawbacks of quinine treatment
when too intense or when uselessly prolonged.
Nocht follows the treatment outlined: Quinine
is given for eight days in the daily quantity of
one gram divided into three, four or even five
doses, then a pause of four days, then three
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days of quinine, next a pause of four days.
This is continued for six to eight weeks at the
maximum. Intramuscular or intravenous in-
jections of quinine only do away with the
digestive disturbances and are only indicated
when these arise. Arsenic preparations (sal-
varsan, neosalvarsan, etc) are to be re-
sorted to as alternating drugs only. They are
especially indicated when the young parasitic
forms of the disease or febrile paroxysms occur
during quinine treatment. Methylene blue and
other drugs which have been proposed offer no
advantages. From the viewpoint of prophylaxis,
the writer is most interesting in his remarks.
Prophylaxis is of value, especially from admin-
istrative and military aspects. It has the ad-
vantage of distributing the patients more
uniformly, thus preventing massive and simul-
taneous contaminations. But the writer be-
lieves that subjects who have been given pro-
phylactic treatment are very prone to suffer
from aggravated forms of malaria and a pro-
longation of the disease if they eventually con-
tract it.
mand it the alkaloid should be griven per oa in
pill form.
Strychnine in Nenrasthenla and Anxiety
Neuroses* — The use of heroic doses of nux
vomica and strychnine in nervous collapse is
well enough known to neurologists, and re-
cently Heckel in a monograph on neuroses of
anxiety has recommended the alkaloid in those
states as well, says an editorial writer in the Med.
Record (Aug. 31, 1918). Hartenberg regards
strychnine as almost a specific in the nervous
asthenia of neurasthenia and gives it in increas-
ing doses — always in excess of 6 milligrams
(1/10 grain) daily dose. By reason of the fact
that strychnine is not retained in the body cer-
tain individuals can acquire a tolerance of
several centigrams a day. In anxious states
this high dosage is not indicated and by the
mouth a tenth of a grain daily dose need not be
exceeded, while a fifteenth suffices by the hypo-
dermic route.. To give larger doses would very
likely increase the severity of the anxious state.
The remedy is indicated, according to Harten-
berg, in secondary neurasthenia due to or-
ganic disease and wherever there is a somatic
substratum. In endogenous cases with obses-
sions and phobias the results are less happy.
When the drug is given per os it exerts an ac-
tion on the digestive apparatus as shown by
acceleration of the food passage. Given sub-
cutaneously a nervous reaction soon follows and
if this is in excess the patient is irritable and
restless. To strike the ideal dose it is well to
begin with a milligram by the mouth. On the
ninth day Hartenberg would change to 2 mil-
ligrams in two daily doses, one on waking in
the morning and the other during the day. One
may or may not increase the dose further, but
3 mg. daily should not be exceeded. After three
periods of treatment the patient should rest a
fortnight, after which the treatment is begun
again with daily doses of 2 mg., which may be
gradually increased until ])enefit arrives or the
limit is reached. If the digestive organs de-
BemoTftl of Tonsils. — ^Tho many surgeons re-
move only tonsils that are a menace to their
possessor, it is certainly true that several men
(and particularly the young and enthusiastic
just leaving special training) remove many
harmless, innocent victims and believe in so do-
ing they have removed the source of all Ills.
Faville (Virginia Medical Monthly, Sept.. 1919)
states that most modern surgeons are in accord
with an eminent New York specialist in his
summary of a paper on the subject written over
four years ago in which he says:
1. That the tonsils have a definite function
in early childhood.
2. That tonsils should not be removed un-
less there is some especial indication before
four years of age.
3. That small, buried tonsils associated with
enlarged cervical glands should always be com-
pletely removed unless some other definite
cause is found for the condition.
4. That tuberculosis is often found to be of
tonsillar origin.
5. That one of the most important points to
be considered in judging whether a tonsil
should be removed or not, is the size of that
tonsil in relation to the individual throat
6. All tonsils, large or small, which seriously
interfere with respiration should be removed.
7. That many local pathologic conditions are
caused by diseased tonsils.
8. That many cases of middle ear catarrh
could be prevented by removal of the tonsils.
9. That there is a distinct relationship be-
tween the tonsils and many general diseases.
10. And, finally, that the promiscuous re-
moval of the tonsils of children, without the
finding of some associated pathologic condition,
is pernicious; and that all cases demanding
operative interference should be carefully
selected.
Treatment of Whooping Conglu— Barilari
(Reviata del Inatituto Bacteriologico, Aug.,
1918) gives a report of his various experiences
in treating whooping cough with the patient's
own sputum, or with asthma sputum, with an
autovaccine, with sputum from healthy persons,
and with various preparations. Charts are
given showing the abrupt drop in the number
of paroxysms after injection of an autovaccine
or a preparation made from the patient's spu-
tum. The latter is generally called Kraus' anti-
tosina. One young man with violent paroxysms
and vomiting, the tenth day of the disease, was
improved by a single injection of autovaccine.
no vomiting occurring thereafter. The second
injection two days later was followed by a drop
from twenty to eight paroxysms a day, all im-
measurably milder, in less than a week. A
young woman with whooping cough for a month
was given two injections of 5 c c of a prepara-
tion from whooping cough sputum, and in a
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AMERICAN MEDICINS
GENERAL. TOPICS
October, 1919
679
week the paroxysms had dropped from twenty-
eight to nine, much less severe. No effect was
apparent In some cases, but on the whole,
Barilari extols this antitosina method- as effi-
cient. The sputum for the antitosina must be
from persons who have not previously been
treated with it. The cough loosens up and be-
comes less spasmodic and vomiting ceases.
Thirteen charts are given; they demonstrate the
superior efficacy of this whooping cough spu-
tum therapy, at least over the other substances
tested.
Management of Acute Anterior Gonorrheas-
There are such wide variations in the reported
results of treatment of acute anterior gonor-
rhea in the male with the various silver prep-
arations at our disposal, that a study of the
elements which combine to give success, the
causes of failure and an attempt to standardize
a treatment offering the strongest hope of good
results seems pertinent Adams (N. Y. Med.
Jour., Oct., 1918) claims that only freshly pre-
pared solutions of argyrol made directly from
the crystals, employing a strength of ten per
cent, to fifteen per cent., should be used. No
injections should be entrusted to the patient for
personal use as long as discharge or cloudy
urine is present. All the prepared solution the
anterior canal will hold without distress should
then be slowly injected with a plunger or bulb
urethral syringe, as the patient is lying on his
back, after he has urinated and the glans has
been cleansed — care being taken that the
urethral folds are fully distended. Two drams
to half an ounce is the quantity required. Then
the meatus should be gently but firmly closed
with the fingers and the injection retained in
the canal for twelve to fifteen minutes, after-
ward being allowed to fiow into cotton or other
waste. The meatus should be covered with
dressing until the next urination, to protect the
clothes from being stained. Such injections
should be used once daily, the classic restric-
tions in diet and activity ordered, giving in-
ternally only sufficient favorite medication to
render the urine neutral or faintly alkaline.
This routine should be continued for two or
three days after the disappearance of discharge
and free pus in the urine, as indicated by the
appearance of the first urine in the two glass
test.
It is well to consider the pathologic condition
of the canal at this time. It is incontestable
that upon the appearance of pus at the meatus
gonococci are present in intercellular spaces —
possibly in the submucosa in some portion of
the canal. Injections do not kill these bacteria.
There is also a greater or lesser area of des-
quamated mucosa — ulcerated area — if that
term is preferred, and possibly deep infection
of some of the mucous follicles or glands of
Littr€. The plan for treatment of such a con-
dition must be directed toward two aims: 1. To
prevent reinfection of the canal from gonococci
in the tissues and, 2, to assist in reforming the
mucosa destroyed. This is the time for mildly
stimulant medication and injection^. Now may
be used, with cautious introduction, sandal-
wood oil or the balsams. The patient may be
entrusted with a mild injection of protargol,
one quarter per cent, (five grains of protargol
in four ounces of solution), to be used one to
three times daily and retained for ten minutes.
The fact should be borne in mind that the mar-
gin between mild stimulation and irritation is
narrow; and symptoms of overtreatment should
be looked for, i. e., first a return of cloudy
urine, and later, discharge. If no such symp-
toms appear, the protargol may be doubled in
strength ; but that should be the limit.
Then the more frankly astringent agents may
be employed in the reverse order of their Irritat-
ing qualities: zinc sulphate up to one grain to
the ounce; lead oxide up to one grain to the
ounce; zinc and lead combined to the same
strength; zinc permanganate up to one grain
in four ounces; nitrate of silver from one grain
in two ounces up to two grains in one ounce.
In no case should nitrate of silver be injected
oftener than once in four days. The other solu-
tions may be used daily or every other day.
Should shreds and flakes persist in the third
week of treatment, in a patient responding
promptly and progressing without reinfection,
it is almost positively an indication of deep in-
volvement of some of the mucous follicles. Here
again injections and internal medication are
valueless except for prophylaxis against rein-
fection, the anterior endoscope offering the only
efficient means of attack.
Patients should be under observation for a
total period of from five to six weeks and the
urine free from fiakes and shreds before dis-
charge. After such a period it can be safely
assumed that the virulence of gonococci in the
submucosa is spent and that they are safely
buried, except in the event of most severe
traumatism which is not of frequent occurrence.
So potent is the assistance given patients by the
treatment outlined that a reinfection caused by
the thoughtless drinking of beer five days after
institution of treatment has subsided and clear
urine again been passed twenty-four hours after
the injection following the reinfection.
kNLUAL
TOPICS
How to Make Water Safe. — An editorial
writer in the Critic and Guide calls attention to
the fact that sparkling clear water is more apt
to be a disease carrier than grossly contam-
inated water, for the reason that all surface
waters are more or less subject to dangerous in-
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680
OCTOBBB^ 1919
QBNBRAL. TOPICS
Ambeican Mkdicins
fection. Typhoid bacilli may live thirty days
in water of ordinary temperature and much
longer in colder waters. Boiled water is the
safest when boiling is practicable. When boil-
ing is not feasible, tincture of iodine, three
drops to the quart of clear water is an efficient
bactericide. If the water is cloudy or contains
much sediment, six drops should be used per
quart, or enough to produce a very faint brown-
ish discoloration. After the iodine has acted
for fifteen minutes, a pinch of ordinary photo-
graphic *'hypo" (sodium thiosulphate) clears
the water and removes the last traces of iodine.
The fifteen minute interyal is important and
also the brown color. In this strength there
is no disadvantage from the chemicals used.
Do I Btriye to keep public health matters out
of partisan politics? Do I keep abreast jf
progress in public health?
If not, why not?
Obligation of the Physician^ to the Public
Healths— The physician's obligation to society
should induce him to apply his special knowl-
edge to the study of community health prob-
lems and make himself one of the leaders in the
inauguration of measures to promote public
health and welfare, states Rupert Blue in
the May issue Modem Medicine.
To do this he must maintain active contact
with the agencies engaged in the promotion of
health and welfare; keep informed regarding
recent important activities and achievements in
the field of public health and state medicine; in-
terest himself in the interrelation of health and
social and economic conditions; and cultivate a
broader outlook on the relation of medicine to
public health and welfare; constitute himself
a health educator, always to his patients, and
as occasion offers, to the community; seek to
discover the causative factors in disease and
direct attention to their correction or removal;
cooperate whole-heartedly with the health
authorities by promptly reporting all births and
deaths and all cases of notifiable disease; by
assisting in the maintenance of quarantine, by
promoting preventive measures for the control
of disease, and by utilizing the diagnostic lab-
oratory facilities and specific therapeutic agents
offered by the health authorities.
It is almost inexcusable for a physician to be
ignorant of the sanitary condition of his com-
munity. With the extensive social and eco-
nomic adjustments now going on thruout the
world, the time has come for physicians gen-
erally to take a more active interest in deter-
mining the relation of medicine to the public
health and welfare. Let each physician ask
himself:
Do I fully instruct patients in controlling the
spread of communicable disease?
Do I stimulate the people of my community
to Initiate community health work?
Do I always seek to discover the underlying
social and economic causes of patients' ill-
nesses?
Do I place self-interest above community wel-
fare by failing to report communicable disease
to the health officer?
Food Yalne of Meat^Nies, who is associate
editor of the Hotel Gazette, says in a recent
issue of If, 7. Med, Journal that there are a
thousand and one dishes of which each one is in
itself a well balanced meal, and in addition is
appetizing and nourishing. They can, even at
the present high costs, be prepared for a reason-
able price. They are made by a combination of
a small portion of meat with a larger quantity
of grain, cereal, or other farinaceous substances
or vegetables. They are flavored from their
essential ingredients so that their preparation
requires no high order of culinary skill. With
a judicious use of the ordinary fireless cooker
they can be prepared in the morning, put in the
cooker and taken out ready to serve when the
family returns in the evening; thus releasing
poor women from the bondage of the cook stove
and, in addition, providing the family with
better food than could be prepared by the old
hurry-up way, which is so wasteful of material,
and consumes so much time. These dishes are
prepared so that all the substance of each in-
gredient is conserved for consumption. The
shrinkage instead of evaporating into the air is
absorbed by the parts of the combination and
saved to the consumer. The pleasure which is
derived from eating is established first by sight,
second by taste and smell, and lastly by the
feeling of satisfaction after eating which brings
with its relaxation of mind and body. If food
can be so prepared that it brings about all these
things, and that with the homely means at the
command of every housewife, much can be
saved by thus abolishing the necessity of din-
ing at restaurants and spending money which
economized, purchases many better and per-
haps more needed things. Stews largely com-
posed of potatoes and various vegetables with
only enough meat used to flavor them are better
than meat stews. Potatoes cooked k la Bou-
langdre with bacon, and sliced unions constitute
a meal in themselves. A small part of meat or
fish will give relish or fiavor to the satisfying
and nourishing cereal. The farinaceous or vege-
table dinner will save money and health.
Pregnancy and Childbirth Among Siberian
AborigineSiT— Miss M. A. Czaplicka, a Russian
lady who lived for some years in Siberia among
the primitive people, according to a writer in
the London Lancet (Aug. 10, 1919). has shed
a good deal of light on the mode of life, habits,
customs and superstitious practices in a book
entitled "Aboriginal Siberia, a Study in Social
Anthropology" (Clarendon Press. 14*. net).
Among other things she has collected data re-
lating to pregnancy and childbirth, some of the
more interesting of which are here given with
names of the tribes concerned: —
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American Medicinb
GENERAL TOPICS
October, 1919
681
The Kamchadal. — ^According to Krasheninnl-
koff, an eighteenth-century traveler, a woman
gave birth to a child kneeling and in the pres-
ence of all the villagers without regard to sex
or age. The newly-born child was wiped with
and wrapped in a species of grass called tow-
chitch; a stone knife was used to cut the um-^
bilical cord, and the placenta was thrown to
the dogs. A woman who wished to become
pregnant had to eat spiders; some women for
this purpose would eat the umbilical cord to-
gether with a grass called kiperi. On the other
hand, if a child was not desired there was a
widespread custom of causing abortion by shock,
or by killing in utero. The old women "spe-
cialists" who carried out the operation frequent-
ly caused the death of the mother. In order
to induce sterility concoctions made from cer-
tain grasses were taken.
The Yukaghir. — ^All cases of childbirth among
the Yukaghir were very difficult, and the bar-
barous practices attendant on them produced
nervous diseases and premature age in the
mothers. The foundation of these practices is
the belief that difficult labor and unfortunate
birth are caused by the entry of an evil spirit
into the woman. Difficult labor is also attrib-
uted either to the failure of the mother to
observe certain taboos or to the ill-will of the
child itself. Therefore, two pregnant women
are not allowed to live in the same house in
case the two unborn children should communi-
cate and decide which mother should die. Some-
times the husband helps his wife who is in
difficult labor by placing his arm around her
abdomen. The taboos connected with childbirth
affect not only the mother, but also the rest
of the household. Some of these taboos are: the
pregnant woman must not eat the fat of the
cow or reindeer, or larch-gum, as these things
are believed to "freeze" or thicken in the stem-
ach and^to fasten the child to the inside of the
uterus; but butter of the cow or horse's fat
may be eaten. She ought not only to be active
and energetic during the puerperium, but ought,
in walking, to raise her feet high and also to
kick away stones or lumps of earth in her path,
thus symbolizing the removal of obstructions
at childbirth. At the first attack of labor-pains
not only the wife, but the husband and mid-
wife, must loosen all their garments, so that
the child may not be hampered in any way.
The Chukhee.—ThiB tribe is one of the most
prolific in Northeast Asia, and the women are
delivered with little trouble. Custom forbids
the mother receiving any help at childbirth —
help may only be given in cases of absolute
necessity. She must not groan, and has to at-
tend to her own needs as well as to those of
the new-bom infant. She cuts the cord (With
a stone skin-scraper) and pulls away the pla-
centa. Accordingly, a large pelvis— because it
eases delivery— is considered one of the chief
features of womanly beauty.
The GiZyafc.— The Gilyak woman never dares
to give birth to a child at home; she must, in
spite of the severity of the weather, go out of
the hut for this purpose. In the late fall or
winter a special hut is built for the woman, but
it is a very uncomfortable affair, so that mother
and child suffer from exposure to cold and
wind. To help the woman in labor a wooden
figure is carved, representing a woman in the
act of delivery, and to it are sacrificed different
kinds of foods, with a view to placate the evil
influences which are at work. Special knives
are used to cut the cord. The woman returns
home on the eighth or ninth day. A woman
who wishes to have a child wears various amu-
lets, such as a dog's tooth, etc.
The Buryat — ^Among the Buryat of Alarsk
during delivery the women of the family are
gathered near the mother and take the child
a^d drop it in a horizontal position on the floor,
which has been made soft for the purpose, after
which it is washed and wrapped up. Two or
three days later a feast is held at which the
ceremony of wrapping up the child begins. A
boy or girl present is chosen to reply to ques-
tions put by a temporary "mother," who holds
in her hands an arrow and a right haunch of
bone of an animal. After the questions have
been asked and answered three times a name
is given to the child. The feast ends with the
making of a fire in the place where the birth
occurred; the guests, including the father, sur-
round the fire and squirt into it from their
mouths a mixture made from meal and oil, all
in one voice exclaiming "Give more happiness!
Give a son!" — repeated three times. General ex-
citement prevails and they vie with each other
in smearing their friends' faces and clothes with
oil, ashes and fresh animal excrement.
The Yafcttt.— Yakut marriages are generally
fruitful, averaging ten children to one woman,
but becoming less so towards the northern dis-
tricts, altho the Yakut are everywhere more
prolific than the Tungus. The lack of children
is ascribed solely to the woman. According to
the explorer Jochelson, women from the north
have very difficult delivery. The Yakut regard
the pangs of childbirth as sickness caused by
evil spirits, and therefore if the assistance of
a midwife or the goddess of fertility, Ayisit« is
of no avail, a shaman is called in to fight the
spirit. A Yakut woman is always delivered on
the bare earth, for the Yakut believe that the
"earth-soul" is communicated to the infant from
the earth at the moment of birth. No considera-
tion is shown to mother or child, for women
possessed of evil spirits are regarded as no less
perilous to society than those infected with
epidemic disease. This accounts for the cruelty
manifested by the Yakut towards women suf-
fering the pains of labor. Cases have been
known where the woman has died as a result
of such cruelty. To hasten delivery two posts
are driven into the ground and a third one is
fastened across the top of them. The woman
kneels and places her arms over the cross-piece
far enough to bring the latter under the arm-
pits. One man from behind holds her shoulders
and another in front holds her hands to pre-
vent any possibility of her resisting the opera-
tions of the midwife. The latter kneels in
front of the patient and presses upon her abdo-
men, at the same time imploring the aid of the
benevolent goddess. Aylsit, who is believed to
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682
October, 1919
NOTES AND ANNOUNCEMENTS
Amsrican Hbdicinb
be present at childbirth and to assist the pa-
tient. Certain food taboos are observed before
childbirth: the expectant mother must eat
neither swan's flesh nor wild birds' eggs, be-
cause the child might otherwise be deaf and
imbecile.
The customs collected by Miss Czaplicka are
found among aborigines more or less all over
the world. The custom mentioned as existing
among the Yukaghir of the spectators loosen-
ing their garments is in one form or other very
old. It was a belief of ancient Roman and
Greek folklore that the goddess of delivery,
Lucina or Ilithyia, could hinder delivery ac-
cording to the attitude which she took up, a
belief referred to by Herrick, who says, "At
thy birth Lucina cross-legged sat."
NEWS NOTES "»
ANNOUNCEMENTS
American Students In French Universities* —
More than 5,000 American officers and private
soldiers have pursued courses in French univer-
sities during the past few months. The Ameri-
can soldier-students have recently given expres-
sion, in a delicate manner, of their gratitude
to their French instructors. They have raised
by subscription among their number more than
70,000 francs. This sum is to be divided among
the fourteen French universities that have re-
ceived American students. At the opening of
school in the fall, fourteen French students
sailed for the United States, where they will pur-
sue a course of study for a year at some Ameri-
can university.
Europe Lacks Soap. — Europe is menaced by
a lack of soap, according to the London New
Statesman. Lack of soap and of its aid to
cleanliness is said to be the main cause, after
underfeeding, of the appalling death rate from
disease in Central Europe generally. Typhoid,
typhus, dysentery, scurvy and tuberculosis have
increased in Austria, Hungary, Poland, Bohe-
mia, Russia and Germany, and these diseases
cannot be fought successfully because of lack of
disinfectants, linen and soap.
Legislation for Study of Mentally Defeetire*—
The study of feebleminded, backward and
otherwise mentally handicapped school children
by the Bureau of Education is provided for in a
bill introduced by Congressman L. C. Dyer of
Missouri. (H. R. 8479.) The measure provides
for the establishment of a new bureau in the
Bureau of Education to collect information re-
garding feebleminded children and for a mental
laboratory to determine standards. A psycho-
educational clinic is also provided. The sum of
$30,000 annually for the maintenance of this
bureau is appropriated. A director is to be ap-
pointed at a salary of $4,500.
The Care and Treatment of Drug Addicts* —
A measure appropriating a total of $5,000,000
for federal assistance to the state health agen-
cies for caring for and treating drug addicts has
been introduced by Senator Joseph I. France,
chairman of the Senate Committee on Sanita-
tion and Public Health. The Secretary of the
Treasury is authorized to divide the appropria-
tion among the states, to be payable only if the
respective states by official or private subscrip-
tion raise a similar amount The sum of
$3,000,000 is authorized to be expended before
July 1, 1920, and $2,000,000 is made available
for ihe following year. One-fifth of this amount
may be expended to collect and spread infor-
mation regarding the care and treatment of
drug addicts. Any hospital equipment held by
the army and navy which is not in use is to be
transferred to the Treasury Department for the
use of drug addicts. The Secretary of the
Treasury is charged with the enforcement of
the act.
French and American Physicians.— It has
been announced in Le Temps that an organiza-
tion has been formed for the purpose of estab-
lishing permanent relations between American
and French physicians and surgeons. Commis-
sions have been appointed to take charge of the
establishment of a course of teaching for Ameri-
can physicians visiting France, to found a bu-
reau of information and to examine into means
of organizing an exchange of articles on medi-
cal and surgical subjects between the Journals
of the United States and France.
Fighting Typhas In Serbia.— The American
Red Cross has appropriated $65,000 to enable
the American Women's Hospital Association to
send a mobile hospital unit to Serbia for relief
work in connection with typhus and other epi-
demics. Of this amount $25,000 Is a cash dona-
tion, the balance representing supplies to be
provided from existing stocks in Europe.
The Women's Contrlbatlons.- Surgical dress-
ings to the number of 300,896,071 and valued at
$13,922,292 have been turned out by the vol-
unteer women workers in Red Cross Chapters
in the United States during the eighteen months
preceding January, 1919. They also produced
29,422,390 hospital garments and supplies,
valued at $26,818,943. The total value of the
work of the 8,000,000 women volunteers is
placed at $81,499,997.
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DEC ?0 1919'
HMERlCafrMEDlGINE
PUBLISHED MONTHLY
B4ll«*rUl>OfflM«t 18 BmI 41 at St.. Ifvw T«rli City. PabliMtUa Offi«««« 189 C*I1««« St.. B«rila«t«a. Tt.
OmBpM* StriM, Tol. ZZY. No. 11
N«w 8MfM. Yok XJV. No. 11
NOVEMBER, 1919
52 nn YEAiLT
CONTENTS
BDITORL/UU COMMBMT 088
MBit AND THINGS 888
ORIGINAL ARTICLB8 898
RATIONAL ORGANOTHBRAPT 781
BY-WAYS AND HIGH-WAYS 7SS
BTIOLOGY AND DIAGNOSIS 788
TRBATBIBNT 788
GBNBRAL TOPICS 748
NBW8 N(»TBS AND ANNOUNCBMBNTS 741
(OOBtla88d 88 PMr8 •)
CONTRIBUTORS
G. FRABTK LYDSTON, M. D^ and ML J. LATI-
MER. M. Dn Cbicaso, IlL
A. B. VIPOND. M. D.. Montreal. P. Q.
H. LAVE80N, M. D.. New York City.
W. H. RAND. M. D.. Washington, D. C.
B. 8. GOODHUB, M. D.. LL. D.. PukOO-MolQjcal.
Hawaii.
GBORGB M. GOULD. M. D.. Atlantic City, N. J.
R. G. BOWMAN. New York City.
PBRRY MARSHALL. M. D.. New Salem. Mass.
D. H. GALLOWAY.- Ph. G.. M. D.. Roswell. N. 1&
^V. B. KONKLB. M. D.. Montoursville. Pa.
CLARA LOUISB CARLBTON.
laltrti M MMBd-tlMt MlUr Juvaif ». 1908. ■! Um PmI OSm ■! BwUsfWa. VL. osdmr Art of CongreM. March t. IKTB.
Hand
Disinfection
can be easily and
eonrenleiitly aeeomplished b j the
nse fd
SYNOL SOAP
This efficient liquid soap en-
ables the physician and surgeon to
cleanse and disinfect the hands
Mth gratifying freedom from the
irritating effects of caustic soaps
and antiseptics. It is particularly
serviceable to those who haye to
deanse the hands many times each
day. Inyaluable in the office, op-
erating room and sick chamber*
ANTISEPTIC-
CLEANSING—
DEODORANT
(jxXv^vkfv\/^^^
So many cases ot
Pruritus, Chafiiig^
and Irritations
ars reKeved by applying
K-Y Lubricating Jellj
that we feel we owe it to our patrona to
direct their attention to the usefulnesa
of thia product as a local application^
as Will as for aurgical lubrication.
No claim ia made that K-Y Lubricate
ing Jelly will act with equal efficiency in
every case; but you will secure such
excellent results in the majority of
instancea that we believe you will coa»
tinue its use as a matter of course.
NO GREASE TO SOIL THE CLOTHINGI
CoBapsibli ivbsSf 25c. SampUs on rsfmsL
nmw Bnuiswlek, N. J.
U.S. A.
(l^yC4l4CMA|i^^
N.J.
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Pneumonia Phykcogen
ID the treatment of
Influenza
DURING die winter of 1916-19 Pneumonia Phylacogen
was extensively used in influenza for die prevention
and treatment of the complicating pneumonia. It had a .
pronounced effect, not only in the pneumonic cases» but
also in cutting short the influenauJ attack.
In one large city it became a routine measure to treat
all influenza casesb on the first visit» with Pneumonia Phy-
lacogen. Not only did improvement follow, but in a great
minority of the cases pneumonia did not develop.
Tedmiqae
Administer at once one mil (Cc) of F^eumonia Phylao
ogen, the second day give two mils, the third day three
mils, and so on, as a preventive of pneumonia and to check
the influenza. Do not allow more than 24 hours to elapse
between doses. In some cases the interval should be
shortened to 12 hours, or even to 8 hours in severe cases.
Bio, 605. BoUm of 10 milt, one ia a peckaga
Bio. 607. Bulbs of I mi], five ia a package.
Parke, Davis & Company
DETROIT
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American Medicine
H. £DWIN LEWIS. M. D., Manrnging Editor
PUBUSHBD MORTHLT BT THK AVXBIOAH MlDIOAL PUBUBHIRG COMPANT
Cosjriffhtod b7 the Ameiiean Medical PabliBbinff Co.. 1019
lEA 8. WILB, Associate Editot
Complete Series, Vol. XXV, No. 11
New Series, Vol. XIV, No. 11
NOVEMBER, 1919
to €^ YEARLY
9^.UU In Advance
Two New Organisms.^— The necessity
for discovering the etiologic factors of dis-
ease as the basis of rational prophylaxis
and therapeusis is constantly being empha-
sized ; and the growth in our knowledge of
the causation of disease is due largely to
the impetus growing out of this need. With-
in the past generation the bacterial origin
of disease has been developed more com-
pletely than during any century since the
beginning of time. The foundation studies
of Pasteur and Koch have been built upon
by numerous investigators who have suc-
ceeded in unraveling many of the secrets
of affliction, thus making possible a stronger
defence of mankind against bacterial inva-
sion.
Recently Surgeon Edward Francis, of
the United Public Health Service, has de-
termined the bacterium tularense, first iso-
lated by McCoy and Chapin, as the causa-
tive agent of "deer-fly fever." This con-
dition is not widely spread and practically
all of the cases reported have occurred in
Utah, most particularly in Millard County.
The disease itself is comparatively new,
the first fatal case having been noted in
1919, tho its existence has been known
since 1917. As far as is known the infec-
tion develops from a fly bite, as the result
of which neighboring lymph glands become
swollen and inflamed and usually sup-
purate. A fever of a septic type ensues,
lasting from three to six weeks. Tho symp-
toms appear to be most severe and threat-
ening, the prognosis is favorable.
It is probable that the bacterium tula-
reuse is spread thru the medium of rodents
in which it causes a plague-like disease. In-
formation is still lacking as to the mode of
communication to human beings, nor is
there knowledge concerning the degree to
which "deer-fly fever" exists in other sec-
tions of the country.
The relation of insects to the spread of
disease is assuming increased importance.
The fly, the mosquito, the body louse and
the tsetse-fly are responsible for tremen-
dous losses in life and for even greater
amounts of invalidity and social and eco-
nomic distress.
The role of the mosquito in the causa-
tion of malaria and yellow fever is well
known. While discovery of the Plasmodium
gave complete information regarding the
etiology of malaria, the mode of transmis-
sion was not determined until many years
later. In the case of yellow fever, how-
ever, the growth of knowledge has been
reversed and the Stegomyia has long been
held guilty as the disseminating agent of
the readily controllable disease. The actual
invading agent has eluded the laboratory
workers for many years, altho several or-
ganisms have been described as the respon-
sible cause of the disease. Recently Nogu-
chi has recovered an organism to which
has been given the name leptospira icte-
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November, 1919
EDITORIAL. COMMENT
Ambhican Medicins
roidcs, which promises to satisfy all of
Koch's postulates. If this new organism,
upon further investigation, proves to be the
actual origin of yellow fever, the possibility
of a vaccinal treatment will add to our
method of cure. Under these circumstances
the entire life history of yellow fever, con-
sidered as an epidemic, will have been
worked out successfully and another pre-
ventable disease will be placed with greater
definiteness in the category of curable dis-
eases.
The far-reaching importance of the dis-
covery of new microorganisms is attested
in the prompt application of present day
knowledge concerning active and passive
immunity in securing a mastery over the
agencies of disease. The greatest develop-
ments of the past decade have been based
upon the knowledge of the habits, method
of growth and dissemination of microscopic
animals and plants pathogenic to man.
The magnificent results of medicine in
connection with warfare, may be attributed
to the patient researches of innumerable
workers, whose enthusiasm and interests
have led them to find man's invisible foes.
From the assault upon tuberculosis to the
victory over trench fever, the leaders have
been those wielders of test tubes and Petri
plates, versed in the law of bacteriology,
serology and immunology. The Accom-
plishments of present day discoverers are
due to the progressive advances of labora-
tory science and their prompt testing in clin-
ical medicine. Francis and Noguchi achieve
the triumphs of discovery by virtue of their
own capabilities and their successful build-
ing upon the accumulated data of the past
generation. Their work, however, will be
tested in the realm of general experience
and their revelations will become valuable
thru the observations and controlled appli-
cations of the medical profession.
A Minutry of Health.— On July 1, 1919,
the English Ministry of Health Act went
into effect. The first Minister of Health is
Dr. Christopher Addison, who brings to
the office a vast amount of experience
gleaned from service in high office. He has
served as a Parliamentary Secretary of the
Board of Education and the Board of Mu-
nitions. Since 1917 he has acted as Min-
ister in charge of Reconstruction. In ad-
dition his medical training has had a wide
scope of effectiveness as a lecturer, a writer,
a publicist and teacher. By training and
the practical test of experience he is ade-
quately fitted to assume the important du-
ties with which he is now charged.
The general powers of the Minister of
Health are thus defined in the Act as
printed in Public Health Reports, October
10, 1919. "It shall be the duty of the Min-
ister, in the exercise and performance of
any powers and duties transferred to or
conferred upon him by or in pursuance of
this Act, to take all such steps as may be
desirable to secure the preparation, effective
carrying out and coordination of measures
conducive to the health of the people, in-
cluding measures for the prevention and
cure of diseases, the avoidance of fraud in
connection with alleged remedies therefor,
the treatment of physical and mental de-
fects, the treatment and care of the blind,
the initiation and direction of research, the'
collection, preparation, publication and dis-
semination of information and statistics
relating thereto and the training of persons
for health services."
The significance of the new Ministry of
Health may be appreciated from the fact
that there are transferred to it all the pow-
ers and duties of the Local Government
Board, the Insurance Commissioners and
the powers of the Board of Education, with
respect to attending to the health of ex-
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AMERICAN MBDXCINB
EDITORIAL COMMENT
November, 1919
685
pectant mothers, nurslings and children
under the school age, as well as medical
inspection of school children. He is
charged with the administration of the Mid-
wives Acts and the Children's Act of 1908.
His jurisdiction includes also Wales and
Ireland.
This step in the unification of medical
functions under national auspices is the
most important administrative step that has
been taken in many years. Its importance
cannot be overestimated and the results to
be attained will justify its existence. The
value of nationalization of procedure under
a single administrative head is recognized
in the United States, where health functions
are so widely distributed among the various
states and several departments of the gov-
ernment.
There has been considerable agitation
for the establishment of a Federal Depart-
ment of Health, with a Secretary in the
Cabinet, but this seems to be remote, inso-
far as its accomplishment is concerned. The
necessity for a Cabinet officer is not on a
parity with a necessity for a single effective
administrative organization to inaugurate,
supervise and control the administrative
measures suitable for the maintenance and
protection of public health.
At the present time various health func-
tions are distributed among the departments
of the Treasury, Interior, Labor and Agri-
culture, together with the unusual power
granted to the War Department, the Navy
and, indeed, to the Interstate Commerce
Commission and Congress itself. Added to
these diverse departmental influences are
the numerous powers and duties of the
State Departments of Health thruout the
country. It is patent to any administrator
that complete harmony cannot be secured
without the establishment of a consolidated
department to deal with the problem of
health.
Public health in the United States has
made remarkable progress, but its fullest
development is hampered by reason of the
divided responsibility manifest in health
administration thru all too numerous chan-
nels. The English government has set an
example in administration which merits the
flattery of imitation. The United States
needs a unified ministry of health under
national auspices.
Whether the United States Public Health
Service should be expanded so as to be-
come the center of national health func-
tions is worthy of investigation and con-
sideration. Its peculiar position of ac-
tivity during epidemics and calamities has
resulted in wealth of confidence in its ability,
sanity and thoroness. The general public
believes in it and trusts it implicitly. The
wide range of activities entrusted to it is
indicative of its potentiality for larger serv-
ice.
As Lee K. Frankel, President of the
American Public Health Association, prop-
erly suggests, it is time that steps were
taken to build up a coordinated and har-
monized health organization for the coun-
try. Thus only can there be avoided the
waste in effort, money and effects that are
constantly handicapping public health serv-
ice.
If there is no place for a Minster of
Health, there is ample need for an admin-
istration of health activities by a single or-
ganization that will reach and affect every
portion of the United States.
A Promising Gift.— The General Edu-
cational Board of the Rockefeller Founda-
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November, 1919
EDITORIAL. CX>MMENT
American Mboicine
tion has announced a gift of twenty mil-
lion dollars, the income of which is "To
be currently used, and the entire principal
to be distributed within fifty years, for the
improvement of medical education in the
United States."
The purpose of the fund is to build up
worthy medical schools by improving their
clinical resources, raising salaries and mak-
ing such provision as may be necessary to
raise the standard of medical education in
this country. The effectiveness of this gift
will be reflected in the improvement in edu-
cational facilities and in the type of physi-
cians to be developed by mean^ of it.
A war experience pointed out numerous
short-comings in our medical education and
created numerous standards for evaluating
our traditional system of medical training.
The necessity of securing an ample supply
of highly trained and efficient physicians
capable of coping with problems of public
health and sanitation, revealed some degree
of our weakness. Public health work has
been advancing particularly in attacking
epidemic diseases, tuberculosis, cancer, men-
tal diseases, industrial and occupational dis-
eases, but none the less medical schools
have given inadequate attention to these
fields of medicine to provide a sufficient
corps of trained workers. It is for this
reason that one finds an increased interest
in medical problems on the part of social
workers, nurses, psychologists, engineers
and sanitarians.
The fact that large portions of the pub-
lic health field will be split oflF from the
general fold of medicine unless medical
colleges make the necessary alterations in
the curriculum to provide capable men and
women, trained to take up those phases of
public health, claims increasing attention.
The sociologic aspects of medicuie may
not appeal to the profession at large, but
the possibilities of growth and development
in this direction are far greater than have
been appreciated. If the medical profes-
sion rejects its present growing opportuni-
ties it will be because of the failure of our
medical institutions to appreciate the prob-
lems of the future or their unwillingness to
alter their present plans so as to adapt their
educational methods and subject matter to
the demands of the coming generation.
It is to be hoped that the vision which
gave rise to the gift of twenty million dol-
lars will affect those responsible for the
advancement of medical education. If
grants are made to institutions that will
widen the calibre of their training and will
organize their teaching staff on the basis
of full-time professorships, with full clin-
ical opportunities, and daily contact with
living problems, it is safe to say that the
educational conscience will be stimulated in
no uncertain way.
The Carnegie Foundation for the Ad-
vancement of Teaching, in its reports on
medical education conferred untold benefits
upon our colleges and led to numerous
reconstructions and gains in medical edu-
cation. The Rockefeller Foundation has
similarly given the profession and the pub-
lic the benefit of its advice, counsel and ex-
ample in various ways. One need but refer
to its accomplishments in attacking hook-
worm, tuberculosis ; its efforts in behalf of
social hygiene and mental hygiene; its as-
sistance to medical colleges in Baltimore
and St. Louis, and its organization of a
modern medical plant in China, as well as
its establishment of that most excellent Re-
search Laboratory, the Rockefeller Insti-
tute. With the support and cooperation of
these large Foundations, medical practice
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American Medicine
EDITORIAL. COMMENT
November, 1919
687
and research have received a tremendous
impetus. This fact is but another evidence
of the intelligent recognition of the funda-
mental value of sound medical training, as
a pre-requisite for a high standard of med-
ical practice.
The gift has been made, but its results
belong to the future. The main element
in its widest usefulness lies in the broaden-
ing of the sympathies and understanding
of our medical colleges with the aims and
purposes of the medicine of the future.
There may be fewer institutions, but they
will be of a grade commensurate with the
seriousness, dignity and responsibility of
modem medicine.
Vocational Re-education. — Thru the
passage of the Smith-Bankhead Bill a par-
tial enactment for the relief of persons
disabled in industry or otherwise has been
effected. This legislation provides for an
extension of the facilities offered to war
cripples to secure vocational retraining so
that equal opportunities may be granted
all those maimed in industrial life. The
permanent casualties of each year exceed
eleven thousand persons, and their potential
value to the community has been neglected
because of the lack of system and organiza-
tion designed to rehabilitate them to their
maximum powers. The gain to communi-
ties thru the direction of efforts to increase
the fitness of the handicapped workers is
reflected not merely in economic benefits,
but in terms of improved health, renewed
vitality, greater nervous stability and a
higher degree of health morale.
Under the terms of the bill, as passed by
Congress, it is necessary that individual
states provide dollar for dollar, the money
granted by the Federal Government for the
benefits of the industrial cripples. The
full effect of the new legislation, therefore,
depends upon state ratification of the fed-
eral scheme thru supplementary legislation.
It is to be hoped that the necessary action
will be taken and that vigorous leadership
will assert itself, that promptness may be
ensured.
There is always a danger that reparative
legislation will interfere with constructive
policies, seeking to decrease the necessity
of money grants. Re-education is not a
substitute for accident, prevention. Voca-
tional retraining cannot take the place of
workmen's compensation laws, nor can it
serve as an argument against the need for
health insurance. The very existence of
legislation of this character should serve
as a financial argument for the more com-
plete installation of safety devices in in-
dustry and the establishment of wise
schemes for the increasing of industrial
safety. The ability to use the left hand
cannot compensate for the loss of the right
hand. It is undoubtedly true that the hu-
man factor cannot be removed by legisla-
tion and in consequence accidents will con-
tinue while men work. Because of this
new possibility of restoring the handicapped
to positions of independence and self-sus-
tenance, it represents a gain to social action.
The functions of hospitals in securing
the complete restoration of those cared for
by reason of injuries should include not
merely physical restoration to health, but
functional restoration. Hitherto resources
and facilities have been inadequate, but
under the new law their efforts may be
properly supplemented to accomplish the
desired results. For this reason the inter-
est of physicians, particularly industrial
physicians, should be enlisted to the end
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NOVEMBBR, 1919
BDITORIAL. COMMENT
American Mkdiciks
that State laws may be enacted to make pos-
sible in every state the application of the
provision for vocational rehabilitation with
state and federal assistance. Recognizing
the importance of this measure the medical
profession, thru its county and state so-
cieties, might well adopt resolutions calling
upon their respective legislatures to facili-
tate the passage of the law, making possible
this wider plan of educational re-education
in the interest of social, moral, economic
and physical health.
SUte Health Centers.— H. Chamberlin
in Modern Medicine, October, 1919, dis-
cusses The University of Iowa as the State
Medical Center. According to his descrip-
tion the University Hospital has become
the health center for the entire state. A
Child Welfare Research Station, a Dental
Infirmary and a Bacteriological Station are
included in this center for the purpose of
investigation into and the application of
the various principles essential for the ra-
tional development of preventive arid cura-
tive medicine. Under the state law indi-
gent patients are accepted at the hospital
and cared for at the expense of the state.
The faculty of the medical college serves
as the medium of extending health educa-
tion among the people of the state, thru
personal efforts and the use of pamphlets
and bulletins. Particular effort is to be
devoted to rural sanitation and hygiene,
with emphasis upon the prenatal care of
the mothers, the nutrition of children, the
correction of deformities and the stimula-
tion of education.
This step in the utilization of large and
established medical institutions under state
auspices is a distinct advance in health ad-
ministration. Every state hospital might
well become a center from which a variety
of attacks could be made upon communal
health problems. Colleges which exist by
reason of state charters, should serve the
entire state as well as satisfy local needs
or provide a place of training for a limited
number of individuals. State Agricultural
Colleges have set a pattern as to the manner
and extent to which facilities may be af-
forded to all sections of a state.
Recent developments in health methods,
worked out particularly in connection with
conditions that arose during the war, have
demonstrated the possibilities and advan-
tages of a far richer organization for the
control and supervision of conditions hos-
tile to public health. The use of mobile
ambulance units, traveling dispensaries,
itinerant lecturers and health councils have
justified their further employment in con-
nection with the establishment of fixed
centers for health activities.. With the in-
creasing employment of public health nurses
and the improvement of transportation
facilities, it is possible to make the hos-
pitals function more vigorously and more
effectively than has been the practice of
the past.
With a full time teaching staff in our
medical colleges, possessing their own hos-
pitals, there is a wealth of opportunity for
raising the educational standards of the
state, so as to provide for a higher degree
of intelligence upon the problems of health.
If to this possibility be added a system for
bringing into contact with hospital facili-
ties the large number of persons having
need of them, a tremendous gain will have
been achieved.
The form of organization employed in
military work, based upon Base Hospitals,
Evacuation Hospitals and First Aid Sta-
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AMSRIGAN ICSDXOINB
EDITORIAL. COMlfBNT
October, 1919
689
tions, supplies a type readily adaptable to
the peace needs of medical administration
in times of ordinary living. There has been
much loss of effectiveness and much waste-
fulness and extravagance due to the failure
to coordinate hospital and dispensary facili-
ties in one harmonious plan. Some sec-
tions of a state will abound in hospitals,
while large areas are lacking in essential
and necessary aids to medical welfare.
Certain diseases are amply provided for,
while other conditions are woefully lacking
in the requisite facilities for their care and
control. Emergencies are provided for
under private auspices in many industries,
while other industries employing fewer
workers are lamentably weak in provisions
for emergent cases.
The development of group diagnosis,
specialized clinics, health classes, convales-
cent homes, and the growing emphasis
placed on mental hygiene, occupational ther-
apy and vocational re-education indicate a
portion of the newer developments in public
health medicine, requiring coordination and
unification in order to achieve the maximum
benefits.
If state institutions could serve as the
basic centers, around which might be or-
ganized all health movements, an incalcu-
lable gain would be affected. A single
scheme or program is becoming imperative.
Whether the Iowa plan is the one best fitted
to effect the needs of the various states or
not, is a question for further investigation.
It is highly suggestive, however, and com-
mends itself to all interested in improving
the health and welfare of the country. Or-
ganization along this line would in no wise
interfere with the growth of a further cen-
tralization of public health affairs, while
it would offer a splendid opportunity for
the stabilizing of preventive methods and
of perfecting them for the greater advan-
tage of urban and rural population, regard-
less of distinctions or social and economic
status.
Infant Mortality and the Social Status.
— Knowledge concerning the causes of in-
fant mortality continues to increase and
additional data appear to corroborate the
importance of an adequate income as a
factor in lowering the infant mortality rate.
The recent Bulletin of the Children's Bu-
reau (;JPublicaiion, No. 52) deals with in-
fant mortality, considered in the light of
an investigation of the births during one
year in Saginaw, Michigan. This study is
of particular interest because the families
included had a higher economic status than
those in other cities studied and reported
upon by the Bureau. Three-quarters of
the population were native and there were
few recent immigrants among the foreign
born residents.
The births during the year ending No-
vember 30, 1913, formed the basis for the
study, thus making the period one unin-
fluenced by the effects of war, or the con-
gestion or pressure incident to military and
industrial changes. The mortality rate of
84.6 was comparatively low, tho there were
marked variations between the section of
the city with good sanitation and high eco-
nomic standard of the residents, as com-
pared with a less fortunate area. For ex-
ample, the rate on the east side was only
67.5 compared with 106.2 for the west side.
Three-quarters of the births studied were
to native mothers and the infant mortality
rate was only 70.5, while for the infants
of foreign mothers it was 127.6. Of the
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NOVKMBER, 1919
EDITORIAL. COMMENT
Ammican Mk»icins
total births 92.6 per cent, were to English-
speaking mothers.
The mortality rate among breast fed in-
fants was approximately one-half the rate
that was found among artificially fed in-
fants. This, of course, is a constant finding
in every investigation of this character. The
economic influences are particularly notice-
able in the consideration of the fathers'
earnings. The highest mortality rate, 179.5,
was found among the infants whose fathers
were in the lowest earnings group, $450.
There is a marked contrast in the infant
death rate for the group of births in fam-
ilies where the father earned under $850
(116.4), and the group where the paternal
earnings were over $850 (33.9). This
fact is of importance in studying the prob-
lems of nativity, because a larger proportion
of the infants of foreign bom mothers were
in the low earnings group.
It is significant insofar as treatment is
concerned, that over one-half of the infant
mortality consisted of still births and deaths
under two weeks of age. Prenatal causes
were responsible for over two-third& of the
total infant deaths.
The Urgent Necessity for Birth Regis-
tration.— ^The conclusions of the investi-
gators emphasize the necessity for complete
and prompt birth registration, the introduc-
tion of adequate prenatal care and the ex-
tension of instructive public health nursing
during pregnancy, the puerperium and in-
fancy. The local problems involve an im-
provement of municipal sanitation as ap-
plied to the water and milk supply, the col-
lection and disposal of refuse and garbage,
an improved housing code and the abolition
of yard privies, except in the distinctly
rural sections. Attention is drawn to the
necessity for a well paid, full time health
officer, supported by a sufficiently large
health crops of full time assistants with
adequate compensation.
It is patent that the suggestions are by
no means radical and simply include those
measures which experience has demon-
strated to be effective in bettering the physi-
cal environment of the people and of assist-
ing in combating ignorance. It is interest-
ing to note that the bulk of the mortality
was due to prenatal care as of the max-
imum importance in counteracting this
large part of the infant death rate.
There is a question for investigation in
the fact that still births were proportion-
ately far more numerous among foreign
bora mothers, than among native mothers,
while the general infant mortality rate was
forty per cent, lower among the children
of native mothers than of foreign born
mothers. It is equally striking that the
infant mortality rate in families who own
their homes was considerably lower than
in the families where the homes were not
owned. The industrial problem evidences
itself in the fact that the infant mortality
rate was only 74.6 when the mother was
not employed in gainful work during the
year following the birth of her infant as
compared with the rate of 154.5 of infants
whose mothers worked during the year fol-
lowing their birth.
There was evident no relation between
still births and the earnings of the father,
tho there was a marked decrease in the
infant mortality rate as the income ad-
vanced. The extremes are found in the
infant mortality rate of 179.5 for the in-
come group earning under $450, and only
22.2 for the income group earning $1,250
and over.
Here again is obvious the influence of
poverty with all its concomitants upon in-
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American Mbdioxnb
EDITORIAL. COMMENT
November, 1919
691
fant mortality. In the light of industrial
unrest and the efforts of workers to secure
wage advancement, the influence of low
earnings upon the death rate, particularly
of infants, merits careful consideration. This
public health aspect of earnings should
receive more practical consideration by
health officials. It would be a splendid
advance in administration policy if, among
the conclusions of investigators into the
cause of death, one were to find the sugges-
tion that all legitimate steps should be
taken to raise the standard of wages in a
community with a view to lessening the
dire effects of poverty upon infant mor-
tality and the diseases and handicaps of
children.
Tke Prevention of Influenza. — ^Altho
influenza in epidemic form disappeared
from the country some time ago, it is proper
to inquire as to the extent of our knowl-
edge of preventing its spread in event of
a re-occurrence. The vast extent of the
epidemic gave abundant opportunity for
study and experimentation along various
lines, but the sum total of our knowledge
has been enriched very slightly.
The Public Health Committee of the
New York Academy of Medicine, report-
ing upon methods of prevention of influ-
enza (Medical Record, Mar. 29, 1919) sum-
marizes most of the evidence which has
been gathered. The etiologic factors con-
cerned in the causation of the disease ap-
pear to be unknown, and the view that the
influenza bacillus alone is responsible ap-
pears to be untenable. Some unknown
factor or factors, possibly a filterable virus,
initiate the infection and are responsible
for the lowering of resistence, enabling
secondary organisms to overcome the de-
fensive mechanisms. Obviously, until the
X-factor is determined, a rational system
of prevention is impossible.
While there is a strong probability that
droplet infection plays a role in the propa-
gation of the disease, experiments serve to
indicate that some unknown factor is also
concerned, thus accounting for the rapidity
of spread of the epidemic in communities
less sparsely populated and where closeness
of contact is apparently a less important
factor. While direct infection undoubtedly
is a factor, a cofnplete description of the
modes of dissemination becomes impossi-
ble until the causative agencies are entirely
known. An astonishing and discouraging
fact is found in the incidence of the infec-
tion among the strong and vigorous, as
well as among those undernourished and
enervated.
According to the report, a relative im-
munity is produced by a single attack, but
there is a great question as to whether those
who suffered most in the recent epidemic
were those who were too young to have
had the disease during its appearance in
1890, a matter of 28 years ago. Altho the
largest number deaths in New York City
occurred among persons 28 years of age,
the mortality rate of all the groups above
25 years of age amounted to 61.6 per cent,
of the total mortality. Children under fif-
teen years of age constituted only 21.2 per
cent, of the total mortality. It is obvious
that the percentage of mortality is far lowe-
among the young exposed during this epi-
demic than among the large group who
were alive at the time of the earlier epi-
demic, altho it may be argued that these
older groups had not been exposed during
the earlier ravaging epidemic. It can hard-
ly be said to be proven "that those who
suffered most in the present epidemic were
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EDITORIAL. COMMENT
Amsucam MM>innf
persons now too young to have had the
disease in the epidemic of 1890."
As far as preventive measures are con-
cerned, they are of nowise different char-
acter than the measures that would be
adopted for combating the spread of any
other epidemic of infectious diseases not
controllable by prophylactic innoculations.
The avoidance of overcrowding, the pro-
tection against droplets, the general sani-
tary improvement of conditions are as valu-
able for preventing one infectious disease
as another. There are, in fact, no general
principles for preventing influenza which
are not equally applicable to all other in-
fectious diseases. As far as specific pro-
tective agencies are concerned, such as the
use of masks, evidence is adequate to state
positively that the general masking of the
population is a satisfactory procedure. The
difficulties in this direction are obvious, but
without frequent changing and steriliza-
tion of masks, it is doubtful if their
efficiency warrants their mandatory adop-
tion.
The use of sprays and gargles in the acute
stages as a means of cleansing the respira-
tory passages is a line of treatment that re-
quires the utmost care. While material re-
duction of the bacterial flora of the nose
and throat may be effected by the use of
mild antiseptic sprays and gargles, there is
also the possibility of lowering the resisting
power of the mucosa, and even of injuring
the mucous membrane, not to mention the
possible danger of creating difficulties in the
Eustachian tube and middle ear as the re-
sult of careless methods.
Vaccines and serums are judged to be
still in the experimental stage. It is be-
lieved that more success attends efforts at
preventing secondary infections due to or-
ganisms such as streptococci and pneu-
mococci than can be secured thru the util-
ization of alleged specific vaccines to pre-
vent purely influenzal infections.
Thus far experience has demonstrated
conclusively that rest, promptly secured at
the first manifestation of the disease, is of
the greatest value in assisting the disease
to pursue a mild course and to be free from
devitalizing pulmonary complications. This
procedure merits emphasis, not merely be-
cause of its effects in connection with in-
fluenza, but because of its general appli-
cation during the course of all other in-
fectious diseases.
In a sense, protecting the community
against influenza, as at present understood,
amounts to the utilization of the same com-
mon sense principles that underlie modem
sanitation and public health administration.
There is no panacea for influenza, nor is
there any guaranteed method of safeguard-
ing individuals or communities from its re-
appearance. This is but another illustra-
tion of the importance of an understanding
of the underlying causes of disease as a
preliminary to promulgating a rational pro-
gram for its prevention or cure. It is true
that empirically, a few methods were dis-
covered for the control and prevention of
malaria and syphilis, but even their rational
application awaited the discoveries of Lav-
eran, and Schaudinn and Hoffman.
Until all the causative factors in the pro-
duction of influenza are revealed, the medi-
cal profession is hampered in offering a
satisfactory scheme for preventing its ap-
pearance in epidemic form. There is am-
ple need for diligent research to determine
the causation of so-called epidemic influ-
enza.
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AMBHICAN MSDICINB
MEN AND THINGS
November, 1919
693
MEN AND
THINGS
Death of A WeU-known Medical
Editor. — It was with the deepest sorrow
and regret that the medical profession of
the country learned of the death of Dr.
Charles F. Taylor, the well-known editor
of The Medical World. Few medical men
could claim a wider circle of friends or a
greater following among those of his own
calling. Earnest, straightforward and well
possessed of the courage of his convictions,
Dr. Taylor nevertheless had a gentle, kindly
manner that enabled him to advance and
stand by his honest opinions without af-
fronting or antagonizing those who held
contrary views. Dr. Taylor was a clear
and erudite thinker not only along lines of
medical thought, but also in regard to so-
ciologic, political and humanitarian prob-
lems. He was always abreast and often
ahead of the times, but never indulged in
bizarre or ill-founded theories. Progress-
ive and broad- visioned, he still was con-
servative and cautious in his recommenda-
tions. In his community he was a faithful
leader who never shirked a duty or dodged
an issue. The good he did will long re-
main as a monument to his whole-hearted
efforts to help his fellowmen.
Dr. Taylor was best known to the medi-
cal profession of the United States as the
editor and publisher of The Medical World,
a monthly medical magazine of extensive
circulation and wide influence. He was
also a brilliant and prolific writer on local,
national and international governmental
problems and published many books and
pamphlets on these questions. He also pub-
lished a quarterly magazine known as
Equity, which attracted not only national,
but international attention among public
men and students of governmental prob-
lems. Dr. Taylor's work as a publicist was
conducted at great expense for what he con-
sidered to be the public good and without
thought of financial or other personal re-
ward for himself.
Charles Fremont Taylor was born at At-
tica, Indiana, on July 3, 1856. He gradu-
ated from the Central College of Physi-
cians and Surgeons, of Indianapolis, in 1880.
He practiced medicine in Indiana for sev-
eral years and then came to Philadelphia
and established The Medical World. After
this publication was on a profitable basis,
he gave most of his attention to sociologic,
political and economic subjects. In 1892
he married Estelle Foreman, of Philadel-
Db. Chables Fbemont Taylob.
phia, who died in 1894. In 1899 Dr. Taylor
married Amelia Orr Cameron, of Fort
Wayne, Indiana, who survives him.
For many years Dr. Taylor was a mem-
ber of the Philadelphia County Medical So-
ciety, Pennsylvania State Medical Society,
the American Medical Association, the
American Medical Editors' Association and
the Philadelphia Medical Club; also the
Art Club, City Club, Trade Press Qub,
Economic Club, American Academy of
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MEN AND THINGS
Ambbican Medicinb
Political and Social Science and the- Ethical
Culture Society. He was a past president
oi two of these organizations, the American
Medical Editors' Association and the Eco-
nomic Club.
In the death of Dr. Taylor the people at
large, as well as the medical profession,
have sustained a great loss. We shall miss
his warm handshake, his genial smile and
the genuine interest he always evinced in
the affairs of his friends and associates. In
mourning his passing, tho our hearts are
sad and heavy, there is yet a deep and abid-
ing sense of gratification in the recollections
of his friendship. Fortunate, indeed, are
those of us who knew the charm of his
personality and can treasure the memory
of the hours spent with him. The world
is a better place to live in to every one of us
who have been fortunate enough to have
known him.
Dr. Lorenz's AppeaL — Recently Gen-
eral Sir Frederick Maurice, one of the
soundest military critics in Europe and a
man whose high position is a guarantee of
his patriotism, published an article appeal-
ing for a more humane treatment of the de-
feated Germans. He criticized the "bitter-
enders" who persisted in their truculence
long after the occasion required it and said
their conduct was like the conduct of a man
who has cut a snake to ribbons and then
proceeds angrily to trample it under foot.
This article was vigorously challenged by
several public organs, and it is doubtful
whether the American public responded to
it as Sir Frederick had perhaps hoped. Not
so long ago there was another appeal issued,
this time by Dr. Lorenz, of Vienna. It was
an appeal for the starving, underfed, and
disease-ridden women and children of
Europe. The appeal was directed to the
public in general, but it must have had par-
ticular significance for the medical men of
this country. Dr. Lorenz is well remem-
bered here, not only for his bloodless opera-
tion on Lolita Armour some years ago for
congenital dislocation of the hip, but for his
splendid service to both humanity and the
profession thruout his long and honorable
career. Such an appeal, coming from such
a source, could not fall upon deaf ears ; and
many doctors no doubt, wishing at the same
time to respond to a humane appeal and yet
not fall short in their patriotism, must have
found themselves in a trying dilemma. On
the one side, they were aware of the persis-
tent and spirited desire on the part of a
large part of the public, and even among
many leaders, to exact the last measure of
punishment from the defeated enemy; and,
on the other side, they were conscious of
the repeated appeals by men in high places
on the Allies' side who have for a long time
been pressing for a generous and sports-
manlike treatment of a crushed foe. Which
are they to obey?
Dr. Lorenz's appeal adds nothing to the
information those who have been watching
the current of events in Europe already
possess. They know that starvation on a
colossal scale prevails in the defeated coun-
tries. They know that the sick are insuffi-
ciently provided for and that they are dying
by the thousands. They know that mothers,
underfed themselves, are unable to feed
their young. They know that the genera-
tion that will come to manhood and woman-
hood twenty years hence will be a weak,
neurotic, broken, feeble race. The doctors
of this country know all this, and they know
what it means in terms of race progress.
They are not politicians, and their impulse
is to respond promptly to avoid the catas-
trophe that threatens. But checking this
impulse is public opinion, which recalls the
atrocities which were laid at the door of the
Germans during the war and which is re-
luctant to forgive and forget so soon. And,
when it is pointed out that a refusal to help
means the condemnation to death and star-
vation of innocent women and children who
had nothing to do with the making of war,
the answer comes that Germany did not
consider innocent women and children when
she let loose her submarines and bomb-
throwing airplanes. Such a contention is
mischievous for two reasons: first, that we
are committing ourselves to a course of con-
duct which we condemned in the Germans ;
and second, that we are fighting the enemy
with his own weapons long after the fight-
ing has ceased and the weapons have been
discarded. Surely, this resolute purpose to
punish the Germans for their sins must come
to an end some time. At some time in the
future the world will have to bury its ani-
mosities and extend a helping hand to the
enemy's suffering population. When is this
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MEN AND THINGS
November, 1919
695
to be ? Clearly, the proper time for forgive-
ness is the end of hostilities, and in the
present instance this is particularly true. If
Germany had come out of the war unbeaten,
if she remained strong* and still constituted
a threat to the peace of the world, it would
be not only fair but necessary that her pun-
ishment continue until she were rendered
harmless. But Germany is thoroly beaten,
she has been rendered impotent to do
further harm, and she is burdened with
obligations which reduce her to the rank of
a fourth-rate power. She has been com-
pletely disarmed and discredited. Her pun-
ishment has been complete.
Healing the Wounds of the War^— It
is contrary to the spirit of American man-
hood to hit an opponent when he is down.
It is particularly repugnant to think that
the "bitter-enders" are hitting now, not at
the soldier who fought against them, but at
the women and children and the aged of the
defeated populations. The desperate ap-
peals that have come from Germany and
Austria have not been for the men who have
returned to civilian life, but for these who
suffered themselves during the war and who
are suffering more acutely now. It is against
these that any effort to perpetuate the bit-
terness that was bred during the war is be-
ing directed. How long is this bitterness
to be maintained? There have been wars
before this. Less than sixty years ago this
country was in the throes of civil strife.
The bitter struggle lasted as long as the re-
cent war, and the charges of inhumanity
that were laid at the door of the South were
numerous. They committed innumerable
atrocities. Feeling in the North was acute.
But when peace came at last, these differ-
ences were promptly buried. In a few they
persisted, but these few were not the
wisest ; and in a short time the past was for-
gotten. It was inevitable that it should be.
The differences of the recent war will have
to follow the same course. They cannot be
perpetuated forever, and the sooner they
are forgotten, the better for the progress of
the world.
And, in this task of healing the wounds
of the nations, the doctors of the world can
play a large part. It may be difficult for
the statesman to reach a hand to his fallen
fellows, it is difficult for the soldier to shake
off the hostility which was a part of his edu-
cation, but it is easy for the doctor to re-
spond to an appeal for humaneness in
lightening the burden of the sufferers. His
calling is an unselfish, magnanimous one,
and his magnanimity does not cease at the
frontiers of his country. It reaches beyond
them. Wherever there is suffering, there
his duty lies. He knows that, to help an
individual, whatever his race, is to help hu-
manity. That is the larger view, the view,
we hope, the doctors of this country will
accept. But even the narrower view points
to rewards which the average individual
seems to lose sight of. Germany has been
crushed, she is on the verge of bankruptcy
and dissolution. But she has an enormous
obligation to fulfill. She owes the world
reparation and indemnities that reach into
the billions. This reparation and these in-
demnities are necessary to the Allies, who
were brought to the point of exhaustion by
the war, and unless they are forthcoming
the Allies will themselves face bankruptcy.
To refuse to help the Germans at this time
would be utterly visionless and suicidal. It
would be robbing the Allies of their just
reparation. Germany cannot pay unless she
is helped to her feet, unless her industries
are revived, unless her population is re-
stored to normal conditions of Hving. If
Germany is to have the money to pay the
Allies, her people must work. If her people
are to work, they must have food and proper
medical attention. Refusing humane as-
sistance to Germany at this time is refusing
aid to the Allies. Those who persist in their
determination to keep the Germans helpless
are indulging in the familiar but pathetic
pastime of "cutting off their noses."
Doctors vs. Legislators. — Exchange of
opinion with a number of doctors revealed
their quick responsiveness to an appeal such
as Dr. Lorenz's and indicated how simple
a thing it would be to bridge the gap that
has grown between the warring nations if
the matter were left in the hands of the
medical men. But, unfortunately, doctors
do not make war and they do not make
peace. It is the legislators who make both
— and they make them both badly. Ehiring
the war, the gentlemen in Washington ob-
structed and bungled almost every measure
that came up before them. Now that the
war is over they betray the same incompe-
tence to bring it to an end promptly and sat-
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MEN AND THINGS
Ambrican Mbdicikb
isfactorily. A year after the armistice
came into effect, they find themselves buried
underneath a mountain of verbiage and
vain eloquence — and we are still at war.
The treaty of peace has not been signed,
the League of Nations proving an insur-
mountable obstacle, and the reason given is
that the Covenant, which not so long ago
was the hope of the world, is a threat to
"Americanism." It is as "Americans** that
they object to the Covenant, and their ap-
peal to the country has been consistently on
the ground of "Americanism." This mere-
tricious appeal, which is as trivial and un-
imaginative as the waving of the flag at the
curtain of an otherwise poor play to get a
little applause, is an almost convincing sign
that the peace bunglers have a bad case on
their hands. It is the appeal to which every
losing cause resorts. This country did not
go to war on account of "Americanism,"
and that principle is not the determining
factor in the making of peace. A high na-
tional spirit and loyalty to one's country is
a valuable asset which it would be folly to
deprecate, but such a spirit is valuable only
within one's own borders. "Americanism"
is a matter of primary importance within
our own borders, where the national interest
is concerned ; but it retires to secondary
importance, and rightly so, where the in-
terest of the world at large is concerned.
When this country went to war, it definitely
broke away from the provincialism and
isolation which was one of its petty virtues
and definitely took its stand beside other
nations as a member of the international
family, as much concerned as any other
member for the peace and progress of the
world. It helped achieve the peace it
sought. Will it now withdraw from any
share in the progress that is to follow if
this peace is pursued to its logical end?
That, certainly, was not the intention of the
nation when it entered the war, it was not
the intention of President Wilson when he
outlined the aims of the Allies, it is not the
spirit of the men who offered their lives and
gave them in large numbers to secure per-
manent peace and understanding.
. The enemies of the peace treaty are mak-
ing their fight on the ground that it is an
imperfect thing. Surely, they are not so
elemental as to believe the choice, in any
difficulty, is simply and solely one between
the perfect and the imperfect. Perfection
is the most elusive thing in the world, per-
haps it is unattainable. And the present
treaty is by no means a perfect instrument
of peace. Its friends do not claim perfec-
tion for it. President Wilson has at no
time maintained that it is a cure-all and a
finality. Again and again he has insisted
that it is the best thing the brains of Europe
and America have been able to devise in
circumstances that have defied solution. Be-
fore the war was won, the league idea was
universally accepted. Now it is suddenly
discovered that "Americanism" is at stake,
and the patriotism of the masses has been
appealed to. The sensitive public, always
alert when there is any question of its
loyalty, is in a quandary. But it is one which
it should be an easy matter to relieve.
Theodore Roosevelt was a good American,
a man of the stanchest patriotism, yet less
than a decade ago he worked for something
that was very like a League of Nations. Ex-
President Taft, whose Americanism is cer-
tainly indisputable, negotiated a score of
treaties with foreign powers which prac-
tically brings them together into what is in
every respect but the name a League of Na-
tions. Both Ex-Presidents were inspired
in their efforts to attain an understanding,
not by their Americanism, but by their
sense of responsibility for the peace of the
world. Despite their strong natioiialism,
they found a place in their outlook for a
strong internationalism. If the gentlemen
in Washington could cultivate such an out-
look, it would be possible to put a prompt
end to the numerous wars which have suc-
ceeded the war that came to an end a year
ago. Failing of this, the chaos that threatens
Europe will become a chronic and perma-
nent state abroad.
Motherhood and Maternity. — There
are few things about which we are more
sentimental than motherhood. From time
immemorial, the poets have sanctified the
honored title of Mother, and even the shab-
biest and least imaginative individual has
always been able to respond freely and
quickly to the glamor which attends the
name. And yet, despite all this, is it not
strange that we have remained so utterly
unsentimental and unresponsive in the mat-
ter of maternity ? The world has ever paid
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MEN AND THINGS
November, 1919
697
lavish tribute to motherhood, but it has al-
ways shown the most amazing indifference
to maternity. At the recent International
Congress of Working Women, a plan for
systematic government aid for mothers was
thoroly discussed, but it is doubtful if the
plan will gain any greater headway now
than it has in the past! It is a sad com-
ment on the interest shown in this subject
that the newspapers gave but the scantest
notice to the proceedings of the Congress,
and the public remained as apathetic as
ever. Yet what can be of more vital im-
portance to the race than its survival under
the most favorable conditions? And its
survival under favorable conditions is de-
cidedly threatened by the march of events
which, if they are not prc^erly met, will
constitute a very real and very grave dan-
ger.
From the time women rose from all fours
and began to walk erect, maternity has been
a problem, growing more and more trouble-
some from era to era, until now it is dis-
tinctly one of the concerns that must be
met soon and adequately if the race is to
go on. When woman's place was in the
home and motherhood, however, indiffer-
ently accepted, was a more or less leisurely
thing, the problem was not so acute. But
now woman's place (at least that of a large
and increasing proportion of women) is no
longer in the home. Hundreds of thou-
sands have drifted into shops and factories,
into business and the professions, and for
these maternity is an obstacle which they
must consider seriously before they agree
to accept it. But chiefly the problem of
maternity is an acute one for the women
in industry. These women, if they accept
maternity, do so at the risk of losing their
jobs and interrupting their careers. They
cannot undertake the risk of remaining
away from their jobs for four or five
months and exposing themselves to the com-
petition of their fellows. And it is not
likely that an employer, under present con-
ditions, will be willing to hold a place open
for so long a time. Furthermore, the cost,
in actual dollars and cents, of childbearing
is an almost forbidding consideration. Even
among the better classes one frequently
hears the remark that "of course we would
like a family, but we can't afford it." And
the working woman can afford a family
even less. The situation is a very serious
one, but nothitig is being done in this coun-
try to relieve it. In Europe several coun-
tries have passed legislation practically en-
dowing motherhood and securing the race
against the danger of suicide. The recent
Congress agreed that an expectant mother
should be granted six weeks' leave before
and six weeks after maternity and that her
compensation, by the state or by industry
and the state together, should not be less
than the minimum wage paid in the in-
dustry in which she is employed. This is
a modest enough plan and it would be a
sad comment on the vision of our states-
men if the project does not win their ap-
proval. Miss Julia Lathrop, chief of the
Children's Bureau of the Department of
Labor, speaking at the Congress, urged a
more practical and sensible attitude toward
motherhood to replace futile sentimentality.
That better counsel may prevail in the near
future than in the past is to be hoped for
in view of the closer attention that is being
given to the question of maternity and
childbearing. Whether there is to be a
more intelligent treatment of the problem
in the future will be judged from the fate
of the bill before the Committee* of Pub-
lic Health Quarantine, providing for the
cooperation of the Public Health Service,
the Commissioner of Education and the De-
partment of Labor in reducing the number
of deaths every year from causes connected
with childbirth. Concerning the problem
of maternity, it should be borne in mind
that two powerful instincts are in conflict
in woman : the instinct of self-preservation
and that of motherhood. It should be the
duty of the state to make the instinct of
motherhood free by making the other a
less pressing consideration.
Public Health and Telephones. — Dr.
Royal S. Cof>eland's rebuke to the telephone
companies and his criticism of the deplor-
able service as a danger to the public health
is welcome for more than one reason; not
only has he spoken publicly the thought
that has been in the minds of countless citi-
zens (a thought which has not infrequently
found private expression in words that
could not be reproduced here), but he has
had the courage to attack a powerful cor-
poration openly and in undisguised terms.
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American Mbdicinb
a course which hitherto political considera-
tions have too often made the Health De-
partment, if not too timid, at least too dis-
crete, to follow. After twenty-five inspectors
of the Health Department had spent two
weeks studying the situation and had made
a report to the head of the department, Dr.
Copeland ordered a thoro investigation on
the ground that conditions were "preju-
dicial to public life and health." The utterly
inadequate, often incompetent, service
which the telephone companies have ren-
dered of late is unquestionably a menace
to the public health, not to mention a
menace to the public temper. It is easy to
conceive the danger, always present, in the
use of a public telephone booth after it had
been occupied by an individual suffering
from some contagious or infectious disease.
Normally, such a person would occupy the
booth but a few minutes. With the present
service, he would occupy it at least three
times as long, multiplying the danger of
contagion by that number. Besides, as Dr.
Copeland points out, a man with high blood
pressure or weakened arteries, tried beyond
endurance by the long and indefensible de-
lays of Central, is likely to break a blood-
vessel and suffer from cerebral hemor-
rhage. These reasons alone are ample on
which to build a case against the companies,
but there are others equally potent. The
telephones are a public utility, largely em-
ployed by individuals as a means of getting
into immediate touch with their physicians
in case of necessity. It is imperative that
this seryice be not only adequate but
prompt. How much physicians have suf-
fered from the bad service it is not easy to
say, but they probably have suffered as ex-
tensively as the other callings. And the
loss to the physician implies a much more
serious loss to the individual in need of his
services. The present deplorable service
is indefensible, and in numerous instances
has every appearance of being deliberate.
A very busy man, in his office all day, was
told by a friend that he had tried to get in
touch with him all afternoon on one occa-
sion and that the operator had each time
told him there was no response. This man
was in his office all the time, and at no time
did his telephone bell ring. Another man
of consequence in the business world called
a number and was repeatedly told that the
line was busy. After several vain efforts.
he insisted that the operator connect him.
She once more announced a busy wire, and
he insisted on speaking to the manager. He
made his complaint and the manager
promptly replied that the operator was right
and that the single wire in the office he was
trying to reach was being used. Knowing
that there were eighteen wires leading into
that office, the man persisted until he finally
obtained the number. He asked the office
operator if at any time all the wires had
been occupied that afternoon and she told
him that at no time were they occupied,
reaffirming his information as to the num-
ber of wires the switchboard commanded.
He was right; Central was wrong, decep-
tive and impudent. Yet there was nothing
f6r the man to do but suffer and pay his
bill when it came. The same condition can
no doubt be reported in physicians' offices.
In pursuing his investigation. Dr. Copeland
probably recognized this serious menace
to the public well-being. And meanwhile
the telephone companies might be prevailed
upon to give prompter service when it is
stated that it is a doctor's number that is
being called. It the service must be bad, it
should be as good as it can be — at any rate
in urgent cases.
The Major and the Minor in Medical
Practice. — Many minor men try for the
major places in practice, and many of them
fail. Such failures take all of the ambition
out of a doctor. Few of us can attain to
the major places and no beginner in prac-
tice really knows in advance whether or not
he has it in him to attain to a major place.
So it is wise to begin practice in a minor
place and try it out for a couple years.
Some will do well to take a minor place in
an important city. In either event one will
come to realize whether he is best fitted for
a major or a minor practice. There is no
disgrace in deciding to be a real success in
a minor role; the real disgrace is failure
from misdirected ambition. Many minor
practitioners who stubbornly try to main-
tain an untenable position make less than a
thousand dollars a year, whereas they might
readily make five thousand dollars yearly
if they had the good sense to start fresh in
a practice to which they are naturally
adapted, and their final honors would be
greater. — Medical Coun^iL
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Amsrican Medicxns
ORIGINAL ARTICLES
November. 1919
699
ORIGINAL
<VRTICLES*j
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THE ETIOLOGY OF HYPER-
TROPHIED PROSTATE.
BY
G. FRANK LYDSTON, M. D.,
Formerly Professor of Genito-Urinary Surgery,
College of Medicine, University of Illinois.
and
M. J. LATIMER, M. D.,
Genito-Urinary Surgeon, St. Anne's and Nor-
wegian Hospitals, Chicago, 111.
"Hypertrophy of the prostate'' is
pathologically inaccurate nomenclature, but
its meaning has become so definite from
long usage that it probably is the best
available. The term implies an enlargement
of the prostate, almost always first brought
to the surgeon's attention after middle life,
which enlargement cannot be explained by
neoplasm, tuberculosis, or simple or specific
inflammation.
Hypertrophy of the prostate is the most
important morbid condition of the organ
coming under the observation of the gen-
eral practitioner. A large proportion of
individuals past middle age are subject to
it, and are more likely to come primarily
under the notice of the medical man than
under that of the surgeon. Upon the
management of the case when it first comes
under observation depend the patient's
safety and future comfort. Apparently
simple measures of exploration and pallia-
tion at the hands of some general practi-
tioners are far more dangerous on the aver-
age than radical operations undertaken
under like circumstances by the specialist,
because of the rougher manipulations
and less conscientious technic from the
aseptic standpoint. It is obvious, there-
fore, that the physician should thoroly un-
derstand the disease and, more especially,
appreciate the relation of bacterial infec-
tion to the morbid conditions incidental to
prostatic enlargement. It should no longer
justly be said, as the senior author so fre-
quently has expressed it to his classes, that
the prostatic's greatest danger often begins
with his first visit to the doctor.
Etiology. — ^Very few pathologic condi-
tions have been the subject of so great
variance of opinion as to their etiology as
has enlargement of the prostate. Opinions
have varied from the agnostic view that,
in the present state of our knowledge, we
are unable to determine positively the cause
of the disease, to assertions as dogmatic as
could be imagined. It is noteworthy that
most modern theories are more open to
criticism than are some of the more ancient
views. There was much logic in the opinion
of Home, who, nearly a century ago, pro-
mulgated the theory that the principal
cause of prostatic disease was slow return
of blood from the vesical neck, due to dis-
advantageous situation of the veins in re-
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lation to the heart, which favors habitual
congestion of these vessels. This tendency
to congestion he held to be enhanced by
high living or any other circumstance that
increased the circulation in this region.
Home believed that traumatism — ^such as
that produced by horseback riding — some-
times produces in the deeper parts of
the prostate rupture of blood-vessels, sub-
sequently followed by hypertrophy. This
rupture of vessels he believed to be analo-
gous to apoplexy. He also assigned to old
age a prominent role. Home's theory is
very suggestive in the light of modern
views on bacteriology. Congestion under
certain circumstances favors bacterial in-
vasion and, as later will be noted, invasion
of the prostate by micro-organisms prob-
ably is a very important factor in the etiol-
ogy of prostatic hypertrophy.
Wilson, writing in 1881, endorsed the
opinion of Home so far as the tendency to
the disease on the part of high livers is
concerned. He claimed that strict celibacy,
on the one hand, and venereal excess on the
other, alike are productive of the disease,
tho admitting exceptional cases in persons
who live abstemious and temperate lives.
Sir Charles Bell asserted the existence of
a special predisposition to prostate enlarge-
ment, but did not define it. Admitting this
predisposition, he believed the exciting
causes to be associated with irritation of the
bladder, with resulting frequent contrac-
tions of that viscus. As a consequence of
these contractions of the bladder, he be-
lieved the urethral muscles to be the seat of
overaction, resulting in a drawing back of
the so-called median lobe so as to elevate it,
thus causing urinary obstruction.
Samuel Cooper confessed ignorance of
the causes of prostatic hypertrophy. He
seemed to think from his experience, how-
ever, that people who led sedentary lives
were most susceptible to the affection.
Astley Cooper arbitrarily stated that
hypertrophy of the prostate was the conse-
quence of old age alone, and not of disease.
Brodie also believed that enlarged prostate
was a matter of course in old men. He
held that prostatic hypertrophy never be-
comes manifest until the development of
plainly-marked evidences of senility —
which obviously would not prove that the
enlargement was caused by senility.
Gross, the elder, expressed the opinion
that prostatic hypertrophy resulted from
habitual engorgement of the organ inci-
dental to (1) protracted and repeated sex-
ual intercourse; (2) irritation from vesical
calculus; (3) the free use of stimulating
diuretics and alcohol or malt liquors; (4)
exposure to cold; (5) the suppression of
cutaneous diseases; (jS) gout and rheuma-
tism; (7) traumatism; (8) frequent cathe-
terization; and (9) habitual straining at
stool, as in chronic diarrhea and other af-
fections of the bowels.
Mercier classed as predisposing causes
all conditions and influences favoring cir-
culatory sluggishness. According to him,
men of lymphatic habit with plenty of cel-
lular and adipose tissues generally have a
lax and unresisting venous system. Such
subjects, he claimed, are most frequently
the victims of prostatic enlargement. He,
too, believed that sedentary habits favored
the disease.
Amussat stated that syphilis, a foreign
body in the bladder, and stricture of the
urethra were the most common causes of
prostatic enlargement. It is observed, he
claimed, chiefly in elderly persons who have
for a long time used sounds or bougies up-
on themselves.
Desault claimed that enlarged prostate
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was due to old age, being found only in
elderly men, and those who had experi-
enced numerous attacks of gonorrhea. He
believed, also, that the disease might result
from "scrofula" and other cachexias.
Civiale "put the cart before the horse"
and placed vesical calculus first in the
order of etiologic prominence. He re-
garded organic stricture of the urethra as
etiologically second only to vesical calculus.
He denied the relation of venereal excesses
to chronic prostatic disease.
Coulson contents himself with* the pre-
sentation of the views of others and has
no definite opinion of his own.
Thompson expresses unequivocally his
belief that prostatic enlargement often is
seen in relatively young patients as a re-
sult of interstitial plastic eflfusion, due to
inflammation, the enlargement occurring
in old age being an unnatural development
of the prostatic tissue proper, t. e,, true
hypertrophy,. According to him, inflam-
mation and its products do not favor over-
growth, but are directly antagonistic to
such a process. He believes, therefore, that
a prostate enlarged by inflammatory eflfu-
sion probably is less likely subsequently to
become hypertrophied. Nutrition is im-
paired, not encouraged by inflammation.
In brief, Thompson excludes inflammation
from the etiology. Urethral stricture and
calculus are not considered by him to be
important etiologic factors. He does not
believe that habitual engorgement of the
prostate and hemorrhoidal plexuses has
much to do with the etiology of the disease.
He says:
"True hypertrophy, in any situation,
never has venous congestion for a cause;
venous congestion impairs structure, and
predisposes to ulceration of the tissues af-
fected by it, but never augments vital force
or stimulates growth."
Upon this ground Thompson denies con-
gestion as a possible cause of hypertrophy
of the prostate. He further disputes the
possibility of rheumatism, gout or syphilis
playing any part in the pathologic process.
As to the effect of sexual excesses, he says :
"Much importance has been attributed
to the effect of habitual indulgence of this
kind; but, from the fact that the affection
has been observed to occur in individuals
known to have been remarkable for chas-
tity, the opposite extreme of continence
has been regarded as exercising a similar
influence. In regard to the first, it appears
reasonable to believe that repeated use
might induce hypertrophy here as else-
where; while, without entering upon the
question of the prostatic function, it is im-
possible not to associate the organ with the
sexual act, and admitting this, it is not easy
to escape the inference that hypertrophy
is likely to result from sexual excess; yet
facts do not favor this view. Hypertrophy
does not exist when the function is in
greatest vigor and is not called into im-
mediate existence by the most licentious ex-
cesses indulged in during the prime of life,
and it must be admitted that in any part of
the body hypertrophy develops itself coin-
cident with or, at all events, immediately
follows the increased action which induces
it."
Altho Thompson disputes the view that
the prostate is truly a secreting gland, he
admits it for the sake of argument, and
claims that no other gland offers a patho-
logic parallelism with hypertrophy of the
prostate, all of its component tissues not
being increased in their normal relative
proportions. An enlargement of the gland
may be due to increase of glandular ele-
ments ; or, on the other hand, to a change
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in Structure and increase in bulk of the
"prostatic tissue proper". Thompson log-
ically enough does not believe, further-
more, that enlargement of the prostate is a
simple ^'muscular hypertrophy" induced by
increased action. He calls attention to the
close similarity between the uterus and the
prostate and believes that:
'7ust as during the latter part of the
period of reproductive activity the uterus
is prone to develop new growths identical in
structure with its own, a similar tendency
will be found to develop new growths in
the prostate iat a corresponding period of
the life of the male."
Thompson's tables apparently support
this, by showing that hypertrophy of the
prostate is a disease incident to old age,
but he fails to indicate the precise connec-
tion between the disease and advancing age.
Even granting that old age is the chief
etiologic factor, there yet is much to be ac-
counted for. Why should so large a pro-
portion of elderly men present a condition
so distinctly pathologic, affecting an organ
which, in old age at least, should be prac-
tically of no importance from a physiologic
or functional standpoint? Thompson him-
self admits that prostatic hypertrophy is
not .necessarily or even usually present in
old age, but is rather exceptional. Accord-
ing to him, a slight tendency to hypertrophy
undetermined during life may exist in about
one in three individuals after 60 years, and
marked enlargement may affect one in
seven or eight after that age. Among 40
prostates of elderly men dissected by
Thompson only 32 per cent, were appre-
ciably enlarged, and but 2 per cent, suffi-
ciently to have produced symptoms during
life.
Considering the function and period of
greatest functional activity of the organ.
atrophy, rather than hypertrophy, should
be expected in old age. Indeed, atrophy
is the normal "old man's prostate."
The modern French school, following
the distinguished Guyon, entertains the
peculiar view that prostatic enlargement is
not a local disease and due to local causes,
but that all the urinary organs, particularly
the bladder, undergo analogous changes,
the origin of which should be looked for in
structures bearing absolutely no anatomic
relation to the urinary system, implying,
in short, that enlargement of the prostate
is dependent upon general atheroma. Thus,
this school claims that the walls of the blad-
der become weakened, with resulting ac-
cumulation of residual urine, followed by
cystitis prior to the enlargement of the pros-
tate. Guyon even went so far as to assert
that chronic retention of urine was due,
not to prostatic obstruction, but to impair-
ment of vesical contractibility produced by
the general atheroma, of which both the
enlarged prostate and the associated blad-
der conditions were merely local expres-
sions. The obvious corollary of this posi-
tion was that operation for the removal of
the prostatic obstruction was irrational and
foredoomed to failure. Guyon, however,
finally adopted prostatectomy, performing
his first operation — a partial one via the
perineal route — in 1889.
Reginald Harrison asserts that the habit
of partial retention frequently precedes
the vesical signs of prostatic enlargement,
the depression of the posterior wall of the
bladder being a primary change. In this
the author heartily concurs. Belfield long
ago called attention to the fact that a small
amount of residuum was quite common in
old men with normal prostates and advised
that pains be taken to completely empty the
viscus during micturition. Harrison
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further holds that depression of the pos-
terior wall of the bladder results in com-
pensatory hypertrophy, which determines
the development of a strong muscular band
or buttress at the base of the trigone, and
finally enlargement of the prostate itself.
Even tho we admit that in certain cases
depression of the floor and alterations in
the walls of the bladder precede perceptible
pathologic change in the prostate, it is ob-
vious that this condition may in no way be
causative of the prostatic disease. Such
cases are no argument against what appears
to be the correct view, viz.: that serious
pouching of the bladder generally is a
secondary condition. For example, gen-
eral atheroma with resulting alteration of
the structure and power of the bladder
might occur and subsequently become as-
sociated with hypertrophy of the prostate,
the latter condition being due to the same
causes as in other cases in which prostatic
hypertrophy is unassociated — ^primarily at
least — with disease of the bladder.
Much of the etiologic obscurity of pros-
tatic hypertrophy probably is due to the
clinical fact that the primary condition that
precedes true hypertrophy is rather excep-
tionally brought to the attention of the
surgeon. A certain amoimt of diffuse
hyperplasia from prolonged hyperemia, in-
cidental to various causes of irritation,
undoubtedly exists in many men under mid-
dle age. It is not, however, until distinct
"hypertrophy" or hyperplasia has occurred
that definite S3miptoms are complained of.
In operated and in fatal cases the process
is so far advanced as to bear very little
resemblance to the chronic engorgement
and simple hyperplasia that constituted the
initial stage in the so-called hypertrophic
process. As for Thompson's views re-
garding the ctiologic importance of inflam-
mation and circulatory disturbance, this
much may be said, vi^, : chronic congestion
and inflammation do not produce genuine
hypertrophy, it is true, but they do cause
hyperplasia, especially where the circula-
tion is impeded by the relatively dependent
position of the part. The hyperactivity of
the organ induced by the resulting irrita-
tion will explain the pseudo-hypertrophic
element of the disease, which really is sub-
ordinate to the hyperplasia. This argu-
ment is especially applicable to the prostate,
which is a glandulo-muscular organ. An
important point is that prolonged conges-
tion, with or without hyperplasia, favors
germ invasion, which is of especial moment
in view of ihe glandular nature of the pros-
tate,
Ciechanowski recently has committed
himself to the theory that prostatic enlarge-
ment after middle life is due to inflamma-
tion which has existed for years with few
or no symptoms. He believes that chronic
inflammation involves the gland stroma.
If the stroma immediately surrounding the
urethra and the principal gland ducts of the
prostate are involved, the ducts are con-
tractured. As a result of this obstruction
the acini of the gland are dilated. Simul-
taneously there occurs proliferation and
desquamation of the epithelium. Ciechanow-
ski believes that the gland enlargement is
chiefly due to dilation of the tubuli of the
gland. He claims that if the inflammation
affects chiefly the periphery of the gland,
atrophy of the prostate results from com-
pression of the acini.
Racial peculiarities seem to have a
marked influence in the etiology of hyper-
trophy of the prostate. It rarely is met
with in the negro. Our distinguished
countryman, the late Dr. Hunter McGuire,
stated that he never had met with an ex-
\
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ample of it in the pure-blooded negro, but
had seen several cases in mulattoes. Other
surgeons claim to have met with the disease
in pure-bloods. Such cases as the author
has seen have been "enlargement" from in-
flammation.
The causes of the disease, according to
the views of the author of this paper, may
be classified as follows:
General causes:
Individual predisposition.
Senility.
The gouty or rheumatic diathesis.
Syphilis (?).
General atheroma.
Local causes:
Chronic irritation and hyperemia due
to urethral or bladder disease.
Early gonorrheal prostatic infection.
Colon bacillus infection at any period
. of life.
Remote causes:
Masturbation.
Coitus interruptus.
Sexual excesses.
Prolonged and ungratified sexual ex-
citement.
(It is obvious that the local and general
etiologic factors are most effective when as-
sociated).
The foregoing causes are not all recog-
nized by most modem authorities, yet
would appear to be based upon sound
physiologic reasoning, taking into consid-
eration the structure and function of the
organ. The prostate is one of the most
important of the sexual organs. It is par-
ticularly important because the prostatic
urethra is the seat of sexual sensibility and
the entire organ is involved in the venereal
organism and because its secretion adds to
the bulk of the semen.
One of the most important elements in
the sexual act is active hyperemia of the
prostate and it seems plausible from this
fact alone, that excessive indulgence may
produce permanent injury, especially if
the coUiculus becomes irritable and in-
flamed. Should sexual excess be alternated
with prolonged and ungratified sexual de-
sire, a permanent impression is still more
likely to result. Constant overstimulation
of the glandular function of the prostate
is a very important element for considera-
tion. If infection be superadded, the con-
ditions found in prostatic hypertrophy
should not be surprising.
Of ail the etiologic factors in prostatic
hypertrophy, none, in the authors' opinion,
is more potent than the abuse of the pros-
tate incidental to coitus interruptus.
Enlargement of the prostate produced
by chronic hyperemia usually is of no par-
ticular importance during youth or early
adult life. This probably is explicable by
the relief afforded by free secretion, the
elasticity of the tissues themselves, and the
fact that the bladder retains its normal
tonus: When, however, the individual
passes the prime of life and his tissues be-
come less resilient and secretion in general
less active, there is scantier secretion, with
diminished activity of the return-circula-
tion, and the hyperemia is not relieved.
Few modern authorities attribute so much
importance to prolonged irritation and
habitual engorgement of the prostate
from various causes as did the elder
Gross, but it is the authors' opinion that
in some respects the views of this dis-
tinguished surgeon were based upon ac-
curate observation and sound reasoning.
Any condition of the urethra giving rise to
prostatic irritation and hyperemia, or to
actual inflammation, may lead to perma-
nent irritability of the vesical neck, with a
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ORIGINAL. ARTICLES
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resulting increase in frequency of urination,
which may become permanent, especially
if infection be superadded. It seems rea-
sonable that this may produce hypertrophy
of the "overworked" prostate later in life
when, as is likely to be the case, undue
sexual excitement or indulgence co-exists
with the urinary irritation. The gouty and
rheumatic diatheses probably bear a sub-
ordinate relation to the etiology of hyper-
trophy of the prostate in certain cases by
increasing irritability of the tissues in gen-
eral. In this connection it must not be for-
gotten that rheumatism often is due to
prostatic infection and a result, not a cause,
of prostatic disease.
In a general way it may be said that the
various etiologic factors outlined are pro-
ductive of what the senior author long ago
described as "prostatic overstrain", yrhich
bears the same relation to prostatic hyper-
trophy that a long-forgotten strain, experi-
enced during early life, sometimes does to
a stiffened and thickened joint in the aged.
It is a matter or common experience that
when the tissues begin to lose the elasticity
of youth, when joints begin to grow less
mobile and a tendency to rheumatoid pains
and other senile difficulties develops, special
complaint is likely to be made of so-called
rheumatism or rheumatoid arthritis, limited
to some joint that suffered an injury at
some remote period. Many injuries ex-
perienced in youth and long forgotten are
called to mind by some pathologic condition
supposedly incident to senility. It hardly
is conceivable that so large a proportion of
men would develop prostatic hypertrophy
if there were not some such special causes
for the condition as those above mentioned.
Prostatic hypertrophy certainly is not a
natural concomitant of advanced life, and
it is probable that the causes outlined bear
the same relation to it that frequent child-
bearing does to certain pathologic condi-
tions of the uterus. It is noteworthy that
the majority of authorities, who do not
frankly acknowledge their inability to as-
sign the disease to any particular cause,
dwell with greater or less emphasis on the
dependence of the disease upon conditions
that produce irritation and hyperemia of
the organ.
Prostatic enlargement, as shown in the
resume of etiologic opinions, has been at-
tributed to urethral stricture. Stricture
undoubtedly is capable of producing chronic
congestion and hyperplasia of the prostate —
i. e., overstrain with resulting circulatory
disturbance and associated infection. Para-
doxic as it may seem, however, the danger
of resulting prostatic hypertrophy is in-
versely to the degree of obstruction and
back pressure. Strictures of large caliber
in the penile urethra produce proportion-
ately greater reflex disturbance of the pros-
tate than do deep strictures of small cali-
ber. A man who, at the age of from
thirty to forty, develops a tight stricture in
the deep urethra is likely to be perfectly
protected from enlarged prostate in after-
life. Irritation and congestion of the pros-
tate occur, it is true, but hyperplasia of the
portion of the organ most likely to produce
urinary obstruction is prevented by the
pressure of the urine in the prostatic
urethra during micturition. The authors'
experience in the performance of perineal
section upon tight strictures in the mus-
culo-membranous region is that the pros-
tatic urethra often is greatly dilated, ap-
parently at the expense of the prostate it-
self, or at least of that portion immediately
contiguous to the mucous membrane lining
the prostatic urethra. The effects of pres-
sure in producing relative prostatic atrophy
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are well shown in cases of calculi that have
become lodged in the prostatic urethra.
There may be, it is true, compensatory
hypertrophy of the remaining muscular
fibers of the prostate, but we must not for-
get what seems to be a logical analogy,
viz.: cardiac hypertrophy followed by ex-
treme dilation resulting from obstructive
valvular lesions.
The role of infection in the etiology of
prostatic "hypertrophy" is, in the authors'
opinion, of primary importance. The most
important part of the prostate being es-
sentially glandular in structure, it is neces-
sary only to recall various factors which
produce h3rperplasia of gland tissue in
other localities to comprehend the possibili-
ties of infection in their relation to prostatic
overgrowth. The point of departure in the
so-called senile enlargement of the prostate
is, in the senior author's long-held and often-
expressed opinion, glandular hyperplasia,
and to him it always has seemed logical to
infer that an infection of some kind — super-
added or not to prostatic hyperemia, active
or passive — is the starting point of most if
not all cases of prostatic hypertrophy.
Gonorrhea earlier in life leaves its mark
in a low grade of irritation and infection
which. leads primarily to hyperplasia of the
glandular prostatic elements and later to
more marked hyperplasia and a greater or
less degree of fibrosis.
But how shall we explain on the basis
of infection, the occurrence of prostatic
hypertrophy in men who never have been
infected -by gonorrhea? The senior author
of this paper long has contended that this is
easily explained by infection with the colon
bacillus, to which in every individual the
prostate especially is exposed. The prostate
is immediately contiguous to the bowel, and
the intimate relations of the prostatic and
hemorrhoidal plexuses of veins, afford a
special facility for infection of the prostate
from the bowel. Congestive and inflamma-
tory conditions of the lower bowel produce
hyperemia of the prostatic plexus of veins
and not only favor transmigration of micro-
organisms but, by evolutionary adaptation,
so change the properties of the colon bacil-
lus that it becomes actively infectious and
most pernicious in its eflfects. Should slight
lesions of the rectal mucosa coexist, the
transmigration of the bacillus coli is likely
to occur at any time. Once the parapros-
tatic tissues are invaded it is but a step to
infection of the glandular tissue of the pros-
tate. A low grade of inflammation result-
ing, glandular hyperplasia follows, its
progress being very slow and requiring
a long period for its development to the
point? of producing symptoms. Indeed, un-
less more or less acute exacerbations occur,
and in the absence of such form of develop-
ment as will produce obstruction of the
urinary way, the attention of the patient
may never be called to his prostatic over-
growth. Urinary symptoms often occur
suddenly from more or less acute hyper-
emia of the prostate. Retention occurs, the
doctor is called and the catheter is passed.
Infection of the bladder is likely to follow,
which infection usually, and often justly,
is charged up to a dirty catheter. If,
however, these cases be carefully stud-
ied, the majority of them will be found to
be bacillus coli infection from transmigra-
tion or some accidental auto-infection —
often with superadded mixed infection.
This may occur under the most careful and
aseptic manipulations. Whether or not the
bacillus coli primarily is responsible for a
single case of prostatic hypertrophy, the
fact remains that prostatic disease of what-
ever kind is a constant invitation to colon
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bacillus infection, and few cases of primary
prostatic enlargement run their course with-
out its development. Irrespective of its
etiologic importance, it is obvious that the
effect of intercurrent colon bacillus infec-
tion must be an increase of the enlargement
and of the obstructive effect of the prostatic
disease. As bearing upon the etiology of
prostatic hypertrophy, in the authors' ex-
perience, superadded colon bckcillus infec-
tion of the prostate and bladder is suggest-
ively frequent in sub-c^ute and chronic
deep-seated gonorrhea, A very large pro-
portion of cases of chronic so-called gonor-
rheal cystitis and prostatitis really are colon
bacillus infections in which gonorrhea
merely hcts prepared the soil and plays a
distinctly subordinate role.
Apropos of "individual predisposition"
the peculiar tendency of some subjects to
fibrotic conditions is worthy of note.
THE BELLADONNA TREATMENT
OF EPILEPSY AND OF OTHER
SPASMODIC DISEASES.
BY
A. B. VIPOND, M. D.,
Formerly M. O., First Brigade, C. F. A. and
Captain to Third Field Ambulance, France.
Montreal, P. Q.
For some years past I have felt dissatis-
fied with the usual methods of treating
epilepsy. For the many cases I have seen,
both in private practice and in my large
clinic for children, I have formerly advised
the mothers to regulate the child's diet,
keep the bowels open, avoid all mental ex-
citement, and have added to this the me-
dicinal treatment of so many grains of potas-
sium bromide, or of the triple bromides,
three times a day. I then felt * satisfied
that I was doing all that could be done with
our present knowledge and obtained the
same results as other physicians who treated
epilepsy by the same methods. About five
years ago, however, I felt convinced that
something more could be done and that a
treatment which tried to eliminate the per-
ipheral irritant and thus prevent a nervous
discharge or spasm from the unstable grey
matter of the brain was the most important
element in the treatment for this disease.
We all know how one fit predisposes to
another and how readily the unstable grey
matter of the cortex gets into the habit of
discharging nervous energy. For some
years past I have adopted the plan of asking
the mother or friend of the patient whether
there is noticed any peculiarity about the
child before it develops the fit or convul-
sion. I am frequently told that the mother
knows when a fit is coming on and the fol-
lowing may be noticed : For some time be-
fore the fit the little patient is feverish and
constipated, or may be nervous and cross,
others flushed and forgetful. These are
premonitory signs and are quite distinct
from the aura and demand prompt treat-
ment. I have proved that if the peripheral
irritants can be got rid of, such as tem-
perature, constipation, etc., in such cases
where a history can be obtained, we are in
a position by proper treatment to prevent
the fit taking place. The first epileptic fit
makes its impression on the brain; it may
have required a considerable irritant to
produce it, but the next is produced much
more readily and it is not long before the
brain gets into what may be termed, the
epileptic habit.
There are a great many other cases where
a history of premonitory signs cannot be
obtained. Here the treatment must be that
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which you adopt for epilefpsy. I fail to
see the difference between the convulsion
in an infant and the epileptic fit in the older
child or adult. The cry may be absent in
the infant, but how frequently is it absent
in older children or in adults. In the infant
we get the same tonic spasm as in an adult.
This may be of short duration followed by
clonic spasm, as well as frothing from the
mouth, biting the tongue, relaxation of the
neck of the bladder, etc. We lay great
stress upon peripheral irritants, but per-
ipheral irritants will not act upon the brain
of a healthy child. The child who has a
normal brain will not develop convulsions,
no matter what peripheral irritant hai^ns
to be present. We advise the removal of
adenoids, circumcision, etc., to remove any
possible irritants in cpnvulsicMis, and this
is good advice, but no peripheral irritant
will act as a direct cause of convulsions or
epilepsy in a healthy brain. The direct
cause is congenital weakness or irritability
of the grey matter — without these we do
not get convulsions. What percentage of
children, for instance, who require circum-
cision, or who should have adenoids re-
moved, suffer from convulsions or epilepsy?
The percentage is very small indeed. On
the other hand, how many children who
have this congenital lack of nerve tone are
relieved by the removal of these peripheral
irritants? This unstable condition of the
brain structure is an inherited condition.
I am inclined to believe that this inherited
brain deficiency is one of nutrition of the
grey matter or of the cortex. Sir William
Gowers found that in over 50% of 1450
cases there was an inherited tendency to
epilepsy or of some other nervous disorder.
Most of these children belong to nervous
families. It frequently happens that one
member of the family will suffer from ep-
ilepsy and another from insanity. I would
not classify epilepsy as a functional disease
because I fully believe that cases of epilepsy
must be accompanied by an organic brain
ccMidition or deficiency and that in most
cases of idiopathic epilepsy this peculiar
structural condition is an inherited one and
most likely •» deficiency of nutrition.
The classification of idiopathic epile|>sy
into major and minor forms, to my mind,
is not complete and would suggest that we
add to this classification, mental epilepsy.
I have met with several epileptic children
who presented peculiar mental attacks. For
instance, a short time ago a mother brought
a child of about 14 months of age to the
clinic and gave the following history: For
some time past the child had been having
"peculiar turns"; it would cry under slight
provocation at the top of its voice for sev-
eral minutes and could not be quieted, its
lips would become blue and then he becomes
unconscious ; there is.no spasm of the limbs.
While I was examining this little patient
he had one of these turns. He cried lustily
for a couple of minutes, then his lips be-
came blue and he went quite unconscious.
This condition lasted for one or two min-
utes then he woke up suddenly, stared
around him and seemed dazed, tho did not
cry. In other words, the fit of mental ep-
ilepsy was over. This child had many at-
tacks like these during the day. He pre-
sented no signs of rickets or of larxn-
gismus stridulus, or of any other spasmodic
condition. Another case is that of a little
girl of about five years, whose mother stated
that she was quick-tempered and is con-
stantly on the move and had "peculiar
turns." Without any apparent cause the
child's face flushes, she then gets into a
violent temper and does not know what she
is doing. She gets over this mental condi-
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tion in about three minutes time when she
is quite well again. Another case was that
of a boy of about ten years of age, who
takes epileptic fits and between the fits is
constantly talking about killing Germans
and prays for an hour at a time. I look
upon this as mental epilepsy alternating with
the major form of that disease. In these
mental types of epilepsy I imagine that the
nervous discharge nmst come from one of
the prefrontal convulsions of the brain.
Another example was the case of a young
girl of about fourteen years of age, who
had been taking major epileptic fits for
some time past. Between the fits she also
takes "peculiar turns." She will look dazed
and stupid for a short time, then suddenly
makes an effort to climb a post or a tree,
after which she will sleep for some time.
This is not a case of hysteria, but one of
mental epilepsy.
Treatment of Epilepsy and Gmviil-
sioiis« — ^The universal treatment of epi-
lepsy during the past forty years has been
the bromide treatment. Some use the po-
tassium bromide, others the triple bromide.
Some patients are given small doses, others
receive heroic doses. One author states
that the attack must be suppressed, if nec-
essary, by the exhibition of as large a dose
as 45, 60 and even 90 grains per day to a
child of five years, and 120, 150 or 180 to
a child of ten years, to effect a cure or even
to produce a moderate improvement. I
would state that it would not take long for
this author to fit his little patients for the
lunatic asylum. He also states that this
dose must be continued indefinitely, perhaps
with occasional short interruptions. Again
he states that under proper medical super-
vision there is no danger and that further
this is the unanimous opinion of all compe-
tent physicians. These doses, to my mind,
are not only dangerous, but also are fatal
as regards the child's intellect. Sachs states
that in epilepsy the only symptom that we
can find in the interval are the effects of
biting the tongue. The acne results from
the bromide treatment and the general stu-
por and indifference are as often due to
the drugs administered as to the disease
itself.
I maintain that many cases — what per-
centage I cannot say — of epileptic insanity
in children and adults are due to the pro-
longed use of large doses of the bromide
salts. How does potassium bromide act on
the brain? Sajous asserts that the primary
eflfect of potassium bromide is to depress
the functional activity of the vasomotor cen-
ter and thus to cause relaxation of all the
vessels provided with a mtlscular coat, the
large central vascular accommodating more
blood. The capillaries of all organs, partic-
ularly those of the brain and skin, are more
or less depleted and the functional activi-
ties more or less lowered as well as its
quieting influence on cerebral excitement. I
may add that for a long time past I have
held the view that potassium bromide causes
cerebral anemia and that this anemia de-
presses the motor and intellectual centers,
especially in the young child, with a corre-
sponding amount of loss of brain develop-
ment. Albertini states that it so obtunds
the sensitiveness of the cortex that its elec-
trical excitation can no longer provoke epi-
leptiform convulsions. Another author
states that larger doses of bromides cause
anemia of the brain and anemia means loss
of or diminished function of the organ.
Schonten and DeFleury have found that
even small doses of bromide lower the
blood pressure and thought it was charac-
teristic of the disease. Now I am convinced
that the lowered blood pressure is produced
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by the potassium , bromide which has been
given ; the diminution of blood in the capil-
laries of the various organs impairs func-
tional activity. Weir Mitchell and others
have reported that the bromides produced
melancholia. For some years past I have
held the view that the bromides produced
an anemia of the brain and thus a deficiency
of oxygenated blood cwnes into contact
with the structures of the brain. Now if
the delicate and immature brain of the child
with its sensitive centers and grey matter
does not receive a sufficient supply of pure
oxygenated blood, what may we expect?
These centers are receiving thousands of
impressions daily which are stored up for
future use and I am certain that the devel-
opment of the brain is interfered with by
giving the child repeated and large doses
of potassium bromide.
Granted that with this drug we can in
a large number of cases of epilepsy arrest
the fits, or produce a great improvement in
their frequency, what about the develop-
ment of the child's brain ? Potassium bro-
mide may stop the fits, but at what a great
expense in many cases! I claim that the
loss of memory and indiflference and in
some of insanity, is produced by the pro-
longed exhibition of the bromides.
Some years ago I realized that epilepsy
and convulsions did not call so much for
a sedative with its brain anemia, as for an
antispasmodic, which would give a rich sup-
ply of oxygenated blood to the grey matter.
The question now arises, which of the anti-
spasmodics would be suitable for these
cases? We all know what a valuable anti-
spasmodic belladonna is in enuresis and in
the spasm of whooping-cough. I look upon
enuresis as nothing more than a "habit
spasm" of the neck of the bladder followed
by dilatation. This is central in origin. If
belladonna helps enuresis and spasms such
as we find in whooping-cough, what eflfect
would it have in the so-called habit spasm,
such as blinking the eyelids, shrugging the
shoulders, moving the lips, etc. ? I may state
that I have given belladonna to many pa-
tients who have had such habit spasms and
they got perfectly well or were markedly
improved in a few weeks time. However,
I will refer to this later on.
I tried belladonna for the incoordinate
movements of chorea and it cured many
cases of the acute condition and I have
treated two or three cases of the chronic
condition with complete cure in every in-
stance. In these cases I generally give it
combined with sodium salicylate and soda
bicarbonate. Many physicians stop the
rheumatic treatment when chorea develops
or when endocarditis supervenes, but I
could never understand the reason why this
is done.
Before leaving the spasmodic diseases,
such as enuresis, habit spasm chorea with
its incoordinate movements, I would like
to say a word or two on the complexion of
these little patients. Referring to my notes
I find, where I have noted the complexion
of these little patients, that in fully 80%
there is blue eyes, fair or medium light skin
and the hair light or medium in color. Dr.
Still, of the Great Ormond Street Children's
Hospital, London, noted the same in regard
to rheumatism ; in fact the lighter the com-
plexion of the child who has rheumatism
the more serious is the attack. In my own
experience I have found that the most se-
rious cases of rheumatism with grave car-
diac troubles are found in red-haired chil-
dren. In fact I have had three children
die under my care during the past three
years from rheumatism endocarditis and
they all had red hair. Rheumatic nodules
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always denote a serious condition with grave
cardiac disturbance.
These children who have habit spasm or
an enuresis are, as a rule, exceptionally
bright in school. The pigment in the darker
complexioned child would seem to have
some influence in steadying the nervous sys-
tem. I may further add that enuresis is
more common in girls than in boys.
If belladonna can cure or help local spasm,
what effect does it have on the general
spasm of epilepsy or of convulsions, and
how does it act ? For some years past I have
claimed that belladonna in medicinal doses
gives a rich supply of oxygenated blood to
the brain and Sajous states that by its ac-
tion on the sympathetic center it enhances
the blood-propelling power of the arterioles.
As a result the capillaries of the entire or-
ganism are traversed by a super-normal
quantity of arterial blood, blood usually ac-
tive in oxygenating properties. Spasms
such as that of rheumatic torticollis, enu-
resis, etc., may be due to hypocatabolism
in many instances by promoting the dis-
tribution of spasmogenic wastes, cause mus-
cular relaxation (Sajous). Belladonna in-
creases nutrition of the nerve cells and thus
adds tone to the spongy grey matter from
which the motor discharge arises. Sir Wil-
liam Gowers states that we must regard the
function of the nefve cells as nutritional
only and that we must regard the spongy
grey matter as the part of the brain in
which the nerve impulse arises under the
incidence of other impulses to it and we
must, therefore, look to this, and to this
alone, as the place in which any alteration
exists that underlies the phenomena of
epilepsy.
I am inclined to believe that idiopathic
epilepsy is due to a congenital deficiency
in the nerve cell whereby its nutrition is
lessened and thus the nutrition of the grey
matter and this denotes an unstable condi-
tion or molecular change in the grey matter
of the brain. In a child the highest of con-
trolling centers are the last to develop and
add to this a congenital or hereditary de-
ficiency, one can readily see it would not
require a strong peripheral irritant to pro-
voke a nervous discharge.
The Treatment of Idiopathic Epilepsy.
— This resolves itself into two classes:
(1) The preventive treatment and (2) the
treatment for the fit proper.
(1) The preventive treatment consists
in removing all peripheral irritants, such as
adherent prepuce, tape worm, adenoids, etc.,
and also treats premonitory signs, such as
high temperature, constipation, etc. I look
upon this as the most important part of
the treatment provided we do away, or can
do away, with the peripheral irritants and
obtain a history of premonitory symptoms.
The following history explains what I mean :
Some time ago I was called in to see a
child about eight months of age; he was
taking convulsions daily. He was given
potassium bromide, chloral, belladonna, etc.,
with no improvement. He required to be
circumcised. This was done, all medicine
stopped, and h« has never had a convulsion
since the operation, eighteen months ago.
In this instance a peripheral irritant acted
upon an unstable condition of the cortex
and there was a nervous discharge ; in other
words, a vicious cycle was produced. In
many cases we found a history of premoni-
tory signs or symptoms, such as flushed
face, a dull appearance, twitching of the
facial muscles, with facial irritability in
others, high temperature or constipation. I
always inquire for premonitory symptoms
such as the above, especially in children,
and in over 50% have they been present.
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If the child is feverish or constipated I pre-
scribe for a child one year old, phenacetine
iy2 grains, calomel 1 grain, white sugar 20
grains, divided into three powders, one to
be taken every hour in milk, the child to be
kept quiet in a dark room. For a child
of five yearsj phenacetine 6 grains, calomel
1 grain, divided into three powders as pre-
scribed. This treatment reduces the tem-
perature, quiets the nervous system and pro-
duces a free movement of the bowels; in
other words, the child is brought to a nor-
mal condition and the result is that the fit
does not take place. I have many histories
among my notes proving that this treatment
has arrested convulsions or an epileptic fit.
If one can accomplish this it is a great gain
to the child as it tends to break up the
habit. Every convulsion or fit which is
arrested when the cortical structure was
on the point of setting free a motor dis-
charge, tends to the recovery of the little
patient.
(2) In the belladonna treatment for the
fit proper, the following brief histories may
be of interest:
Case I. Gertrude P., aged 10 years,
came under my care on August 16, 1913,
having had five fits during the past two or
three weeks, four of the attacks being
minor, the other a typical major attack. She
was given belladonna at once and up to the
present the child has had no recurrence of
the trouble.
Case II. I saw Margaret D., aged four
years, on November 27, 1914, having suf-
fered from several epileptic fits. Here the
results were exactly the same.
Case III. M. P., another case under my
care, after treatment with belladonna has
been quite free for the past two years.
Case IV. Another interesting case was
that of an infant of 10 months who de-
veloped convulsions, was given potassium
bromide, chloral hydrate, with no eflFect, the
fits continuing some 50 or 60 daily. After
the administration of belladonna it was per-
fectly well in a short time.
Case V. Another case was that of a
child of two years and three months who
came to my clinic on July 31, 1913, having
had two fits, one in June and the other on
July 18. He was placed on belladonna
treatment and altho he had two more fits,
one on August 25 and another in about
eleven months time, he has had none since
and is bright and intelligent.
Case VI. Charles E., aged two years and
seven months, developed a fit on August 10,
with a temperature of 103**. I adminis-
tered phenacetine and calomel in addition
to the belladonna treatment and up to the
present time no recurrence has taken place.
Case VII. The following case is of in-
terest as it demonstrates how a young girl
of 12 years of age showed all the premoni-
tory signs and was treated with phenacetine
and calomel with the result that the fit did
not take place. She had been quiet all day,
then flushed with facial irritability; there
was a marked tremor of the orbicularis
muscle, slight twitching of the left arm and
no doubt a nerve storm was pending. I
put this child on phenacetine 8 grains, cal-
omel 2 grains, divided into three powders,
one to be taken every hour, the first powder
being given be*fore leaving the clinic. The
result was the attack was entirely checked.
Later on, by the same preventive treat-
ment, the fit was again arrested so that the
child escaped having two epileptic fits, which
meant a great gain as every nerve storm
arrested tends to break up the bad habit.
Case VIII. The next case is one in
which I did not have a recovery ; however,
there was a marked improvement. E. K.,
aged six years, has been taking epileptic
fits for over two years following an attack
of whooping-cough. The attacks were fre-
quent, one taking place every seven to ten
days. In a short time the frequency les-
sened under treatment, but the child was
not cured. I can imagine that the whoop-
ing-cough produced some change in the cor-
tex, probably a slight hemorrhage took
place and one could hardly look for a cure
in this instance. In most other instances,
where we have no known organic lesion
such as hemorrhage in whooping-cough, we
get a complete cure by giving the belladonna
and if it does not act I arrive at the con-
clusion that the cause of the epilepsy may
be due to some brain injury such as whoop-
ing-cough might produce, a slight hemor-
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rhage into the brain, or the hemorrhage
may date, from birth. Altho these cases
may not be cured I have had a marked im-
provement in many instances by the admin-
istration of belladonna.
At the present time I am treating a little
girl of about four years of age who is men-
tally defective and who has been having
fits every day. As long as she takes bella-
donna the fits are completely arrested. Some
time ago I was called in consultation to see
a child of about eight months old who had
been having many fits during the past few
days. I placed the child under the bella-
donna treatment and they stopped at once.
Some time later the child developed laryn-
gismus stridulus and the belladonna ar-
rested this in about twenty-four hours.
The last case which I will mention is that
of a young soldier who was under my care
while medical officer with the First Quebec
Regiment. This young man developed epi-
lepsy, the fits being frequent; he had been
taking large doses of the bromides without
producing any effect and was discharged
from the army as being unfit for service.
I placed him under the belladonna treat-
ment and he subsequently passed for the
Navy and has had no fits since. Many
other cases of cure by this belladonna treat-
ment might be mentioned, but the above is
sufficient to advocate its use.
Now the question may be asked, will bel-
ladonna cure all cases of idiopathic epi-
lepsy ? The answer is, "No." I have tried
it in cases of chronic epilepsy of ten to
fifteen years standing and have succeed-
ed in reducing the fits, but these cases
are not cured. I have also tried it in
cases of epilepsy following injury to the
brain at birth. In these cases the fits
are lessened in frequency, but as we have
destruction of a part of the brain we cannot
expect to cure them. Belladonna lessens
the frequency of the fits and improves the
memory and the patients become more
cheerful and brighter. One cannot over-
come the effects of chronic epilepsy plus
the baneful influences exerted by large,
prolonged doses of potassium bromide; it
will not cure these cases.
Belladonna effects a cure in most cases
of convulsions in children provided we do
away with all source of peripheral irrita-
tion and that the convulsion is not caused
by hemorrhage into the brain.
Further, belladonna will effect a cure in
most cases of idiopathic epilepsy provided
we get the case under our care before it
becomes chronic and before the brain be-
comes saturated with bromides.
In every instance we should look for
some premonitory sign or symptom which
can be corrected in time to prevent a fit
coming on. I have a young man under my
care who suffered from epilepsy for about
a year. He did well under the belladonna
treatment, but about once a week. a fit would
come on in the morning while dressing. I
added about 10 grains of potassium bro-
mide, to be given only at bed time, and the
result was that he had not one fit during
the past year. The dose of belladonna in
this instance cut off the baneful influence
of the potassium bromide.
What are the effects of the potassium
bromide treatment? First, it depletes the
smaller vessels of the brain and produces
anemia; second, bromide acne and other
bromide rashes may be produced; third,
loss of memory takes place, not produced
by the epilepsy, but by large and continued
doses of potassium bromide ; fourth, a stu-
pid look is noticed in many instances and,
fifth, insanity is produced. It is generally
held that this insanity is caused by the epi-
leptic fits, but I am inclined to the belief
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that it is induced by giving large and con-
tinued doses of bromide. So we can see
that the bromide treatment has its disad-
vantages.
How does belladonna act ? First, it gives
a pure, rich supply of oxygenated blood to
the brain as well as to the surrounding grey
matter. It also, by increasing the circula-
tion, does away with the toxines which may
be present. Second, no acne is produced.
We may have belladonna poisoning, but we
do not require doses large enough to pro-
duce this. Third, the memory is improved.
Fourth, the child is bright and shows in-
creased intelligence. The mother tells me
that the first thing she notices is that the
child is so much brighter. Fifth, insanity
is never produced in using this treatment
in the proper doses.
I am not alone in treating epilepsy by
belladonna, for several of my confreres in
Montreal are using it at my suggestion and
are having the same results. I generally
use the tincture of belladonna as it is easier
to handle and the dose can be regulated
better.
In a child of six months I give one to
three drops every four hours, or three times
daily.
In a child of one year, two to five drops.
Two to five years, four to eight drops
three times daily. This can be increased
if necessary.
I have used belladonna for other spas-
modic conditions with gratifying results.
Thus I have treated many cases of habit
spasm with success. For example, E. T.,
a bright, blue-eyed girl of seven years, came
under my care on July 24, 1914, with blink-
ing of the- eyelids, twitching of the mouth,
etc.; I placed her on belladonna and by
September she was quite well again. P. C,
a child of twelve, had a persistent blinking
in both eyelids; this got quite well in a
month's time. Vera I., blinking, of both
eyelids, moving of frontal muscles, con-
stant for two or three months, got practi-
cally well in a short time.
Many of these children live in homes
where they are constantly under irritating
conditions and here the treatment is not so
successful as long as they remain in an
unfavorable environment.
With regard to the cases of chorea
treated with belladonna, Lizzie E. devel-
oped three or four attacks of rheumatism
complicated with chorea, under treatment
with belladonna soda salicylates and entire
rest was cured in six weeks. Another case
was that of a boy of fifteen who had several
attacks of rheumatism and chorea, the last
attack continuing for many months. When
I saw him the left arm, leg and face were
involved and he had been taking arsenic
up to thirty drops without improvement.
In four weeks after starting the belladonna
he was quite well with no recurrence. The
third case was also a lad of fifteen who had
several attacks of chorea, the last for a
period of twelve months ; arsenic had no ef-
fect. He took belladonna and was quite
well in about four weeks time.
Dr. G. F. Still states that there are few
diseases of children for which the medical
attendant is likely to gain less credit than
in these cases. Freedom from mental ex-
citement and worry, including school work,
a change of scene and air, will add materi-
ally to the obtaining of a good result. Fully
75% of these cases can be helped or cured
provided the child can live in a quiet en-
vironment. Poor children do better in the
hospitals and for those in better circum-
stances the child should be isolated.
During the past few months I have treated
several cases of laryngismus stridulus with
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tincture of belladonna and the little patients
without exception were well in a short time.
Two children developed convulsions some
days before the laryngismus, one had albu-
min in the urine and four others had sup-
pression, in one case persisting for twenty-
four hours; this might be produced by a
tonic contraction of the vessels of the kid-
neys. Belladonna is also useful in children
who are habitually irritable and cross and
who sleep poorly. In tetany also the infant
will be quite well in a few days.
I claim that belladonna is the rational
treatment of all spasmodic conditions such
as epilepsy, convulsions, enuresis, habit
spasm, whooping-cough, spasmus-nutans,
tetany and laryngismus stridulus. It is of
use. also in the treatment of chronic irri-
tability of infants and in older children as
well in incoordinating conditions depending
upon lack of tone in the cortical centers
and the grey matter of the brain, such as
chorea, etc.
SOME REMARKS ON APHASIA.
BY
H. LAVESON, M. D.,
New York City.
Aphasia is a general name for diseased
conditions of the brain which aflfect the
patient's consciousness of words. In sensory
aphasia the subject's hearing or reading
of words is aflfected; in motor aphasia
he is unable to speak or to write. In
either case he may or may not know the
meaning of words. The patient's speech,
for example, may be unaffected and he may
read perfectly, yet spoken words may seem
to him like mere inarticulate sounds, or he
may hear words and even understand them,
he may speak and write and he may yet be
unable to read printed and written words,
even those which he himself has written.
These forms of sensory aphasia are named
word deafness and alexia, respectively,
motor aphasia also has two main forms,
inability to speak and to write. The latter
is called agraphia and the former is named
pure motor aphasia. In agraphia the pa-
tient reads and speaks understandingly ; he
can even read what he himself has earlier
written, but he cannot write. In pure mo-
tor aphasia, a man understands what is said
to him, reads printed and written words
and can even write, but his speech is more
or less seriously disturbed. He can laugh,
cry and sing, but either he misuses words,
one place or another, or he has no words at
all or he speaks incoherently in what has
been called a broth of unintelligible sylla-
bles. He may recognize his mistakes and
be tormented by them, but he cannot avoid
them. Sometimes it happens that the in-
ability to speak affects only objects of a
certain sense-class. For example, a man
may be able to name the visual and tactile
qualities of an object, but unable to name
sounds of any kind; or he may be able to
name colors and sounds, but not tactile qual-
ities. Pure motor aphasia is known as au-
ditory, tactile or visual, according as it af-
fects one class of sensations or another.
It has been abundantly established that
word-blindness or the loss of the meaning
of words, is due not to the derangement
of articulatory or word-hearing centers, but
rather to the loss of connection between
such word-centers and the visual, auditory
or tactile centers of concrete images. The
man who is unable to tell the meaning of
the word "brush," tho he writes and artic-
ulates the word and rightly uses the object,
no longer associates the motor or visual
image of the act of brushing with the sight
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ORIGINAIj ARTICLB8
Amkucam Mbdicinb
of the word. This absence of the habitual
association may be due either to the injury
of visual or motor centers or to injury of
the fibres connecting word-center with other
centers. Normally the articulation center
is closely connected with the brain-centers
for concrete imagery, but sometimes the
us, a slight excitation of the sense-cells in
the articulation center. This shows the im-
portance of the Broca and Wernicke cen-
ters, and it indicates that the Broca cen-
ter in the lower frontal convolution is not
merely a motor center ; in other words, that
it is not concerned merely in the use of
SENS0RY4i»e
Flmanl
Pio. 1. Scheme of Localization in Cortex of Convex Surface of Hemisphere.
rUNEUS
Fig. 2. LocaUzation on Inner Surface of Hemisphere.
connection is utterly broken and again it is
curiously altered.
The verbal image includes at least two
parts : the sound of the word as heard and
the consciousness of articulating the word.
Even when we merely listen and do not
actually speak aloud there is, for most of
speech, but that it is a sense center as well,
excited during the word-consciousness of
persons of the tactile-motor image type.
Language by an educated person is read
and written as well as spoken and heard.
The word-sound often, therefore, suggests
the image of the written or printed word
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Amsrican Mkdicins
ORIOINAL. ARTICLES
November^ 1919
717
and it may suggest the movement of writ-
ing. The complete percept of a spoken
word must thus include fused elements of
sound and articulation.
Report of cases :
Case I. "What is the reason, Doctor,"
she said, "that everything in a book or
newspaper is illegible to me? Last eve-
ning I sent an advertisement to the Herald
for a waitress and when the girls came this
morning I could not read their references.
I then took up the Herald and found that
I could not read a word in it. At first I
supposed my eyesight had failed, but I
Case II. An example of the total loss
of the power of recognizing words occurred
in a hospital patient, but in him it was
words that came thru the ears which he
could not recognize, so that he had what is
termed word-deafness. He was naturally an
intelligent young man under thirty, a clerk
in a mercantile establishment, and was sup-
posed to have become insane because
he talked only gibberish and, moreover, he
did not seem able to understand what was
said to him. It was soon found, however,
that he could read and write as well as
ever so that to all questions that were put
to him in writing he wrote correct an-
,,AOT0R A^^,^^ .
Pictrhtat
Fig. 3. Scheme of Position of Fiber-tracts descending from the various areas.
could see everything around the room as
well as ever, and so also with my crochet
work. I then opened the Bible, but could
not read a word. What is the matter with
me?" I at once recognized that she had
been struck with word-blindness, as this
affection is technically termed, and from
that day to her death, two years later, she
never saw a word. She had no other dis-
order of speech and none of vision. She
heard every word that came to her ears and
she could speek as fluently as evef, but no
word could reach her consciousness thru
her eves.
swers. The reason he talked so incoherently
was because he could not hear his own
words and for the same reason all words
addressed to his ears reached his con-
sciousness only as sounds, but were other-
wise as unintelligible to him as the words
of a language which he had never heard.
Case III. A man retires to bed in good
health, but is found in the morning utterly
unable to speak a word. It is soon ascer-
tained that he has no word-deafness, for
he evidently understands everything that is
spoken to him and that he has no word-
blindness because he can read, but he may
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NOVBMBER* 1919
ORIOINAIj articuds
Amsbican Mbdicins
not be able to utter a word, still less a sen-
tence. In his distress he- may make signs
that he would like to write; it is usually
found that he cannot find the words to ex-
press himself by writing any more than he
can by speaking.
150 CASES OF OCCUPATIONAL DIS-
EASE REPORTED IN NEW YORK
IN 191&
BT
W. H. RAND, M. D.,
Washington, D. C.
According to the returns made by the
hospital authorities and private medical
practitioners of New York City, there was
an incredibly low incidence of occupational
diseases during the year 1918 in that munic-
ipality with its population of 5,047^1
(See World Ahnanac, 1919). The entire
number reported to the City Health De-
partment for that period was only 150 —
probably not a centesimal part of the cases
actually occurring.
There are 6,379 physicians in New York
City (Medical Directory). Hence, on an
average, it required the cooperation of 42
physicians to report each case of industrial
disease. But how is. it possible to account
for this wholly inadequate exhibit? There
is but one candid explanation. The law is
not executed.
Section 92 of the New York City Sani-
tary Code reads as follows:
''It shall be the duty of the manager or man-
agers, superintendent or person in charge of
every hospital, institution or dispensary in the
City of New York to report to the Department
of Health, in writing, the full name, age and
address of every occupant or inmate thereof
or person treated therein, affected with any
one of the occupational diseases included in
the list appended, with the name of the disease,
within twenty-four hours after the time when
the case is diagnosed, and it shall be the duty
of every physician to make a similar report to
the said Department within the same period
relative to any person found by such physician
to be affected with any one of the said oocnpa-
tional diseases, stating in each instance the
name of the disease:
"Arsenic poisoning, bisulphide of carbon
poisoning, caisson disease (compressed air ill-
ness), carbon monoxide poisoning, dinitroben-
zol poisoning, lead poisoning, mercury poison-
ing, methyl alcohol or wood naphtha poison-
ing, natural gas poisoning, phosphorus poison-
ing."
Eleven distinct kinds of occupational dis-
ease are enumerated in the forgoing official
category. Too many or else too few!
The list is not an exhaustive one, tho it
purports to be a complete inventory of the
recognized diseases of occupation. Yet
with the text of this Code there is published
a table of occupational diseases (certified
to the City Health Department in 1918) in
which were reported six varieties of in-
dustrial diseases that are not included in
the Code schedule. The Code schedule,
therefore, is inadequate, even for cataloging
local occupational health hazards. In fact,
it is impossible to make a complete list of
occupational ailments, since their character
is not well defined and their number is un-
known.
The Weekly Bulletin of the Department
of Health, City of New York, for April 5,
1919, records the fact that one hundred and
fifty cases of occupational disease were re-
ported to the Department during the year
1918. The cases were distributed as fol-
lows:
Disease.
5R
Of)
5R >
►»
^
9
Anthrax 0 15
Dinitrobenzol poisoning 0 1
Caisson disease 107 0
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AMBRICAN MBDICINS
ORIOINAIj articlbs
NOVBMBBR, 1919
719
G)pper poisoning
Lead poisoning
Picric acid poisoning.
Occupational neuritis
Sewer gas poisoning
TNT poisoning
Wood alcohol poisoning
1
6
2,
0
1
0
1
118
0
13
0
2
0
1
0
32
From January 1 to March 31, 1919, the
record stands thus:
^a
^
eO
^'oS
"S
"E ^
t- IB
Disease.
1^
II
"«
i
-"I
09 >.
CD -t^
i£
O 0}
S ^
Co H4
^
Anthrax
1
. 3
2
Lead poisoning
2
Mercurial
poisoning .
. 1
1
5
5
Concerning these data the Health Officer
offers the trenchant comment, "The cases
are so few as to indicate that many cases
of such maladies are not reported as re-
quired by the Sanitary Code."
'The Bulletin adds this importunity:
"Physicians and institution superintendents
are urged more fully to cooperate with the
Department in future, and to promptly re-
port all cases of industrial diseases coming
to their attention."
Such appeals are impotent and unavail-
ing. Something more virile than verbal re-
monstrance is requisite to meet the case of
physicians who are guilty of laches and
non-compliance with the law. Severe
penalization of such negligence is impera-
tively demanded. To tolerate open viola-
tion of the statute is "worse than a crime ;
it is a blunder."
In order to render the Code effective it
should be amended in two important par-
ticulars: First, a provision should be in-
corporated in the text for the payment of a
nominal fee (25 cents, perhaps) to the
physician for every case of occupational
disease reported by him. This fee would
reimburse him for postal expenses in mak-
ing written returns to the Health Depart-
ment.
Then the Code should impose penalties
(fine and imprisonment) for wilful disre-
gard of its requirements.
It is conceded that, in its present form,
the Code is "a thing of beauty", the ethereal
embodiment of transcendental morality and
altruistic benevolence.
But compliance with its requirements
levies tribute on the reporter by extorting
from him the cost of postage, tho no penalty
is incurred by ignoring the law. Thus the
Code virtually offers a premium for its
own nullification. It holds out no induce-
ments and inspires no incentives to obedi-
ence, while it lacks the punch that ensures
cooperation and penalizes dereliction of
duty. .
Purgation of Patients Before Opera-
tion*— ^Alvarez (Surg., Gyn, and Obs., xxvi
6) considers this question and concludes
that the body is weakened by the upset of
the balance of salts, particularly where there
will be vomiting and hemorrhage. There
is an increased growth of bacteria and some
evidence of an increased absorption of
toxins and a tendency to flatulence and dis-
tention. The loss of sleep prjor to opera-
tion is undesirable. The resumption of
colonic activity is delayed and more difficult.
It is suggested that food should be g^ven
as late as possible before operation and
even enemas avoided, and purgation avoided
after operation a:s well as before.
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NOVBICBBR, 1919
ORIOINAIj articuds
AMBBICAN MBDICINI
FREE MEDICAL ATTENDANCE AS A
PUBLIC UTILITY— AN EX-
PERIMENT.
BY
E. S. GOODHUE, M. D., LL. D.,
Pukoo-Molokai-Hawaii.
The maintenance of public health and the
best method of promoting it, are receiving
a great deal of attention not only among
medical men but outside in lay communities.
Floyd Parsons says in a recent magazine
article: "Tho the leaders of medicine to-
day fully recognize that the doctors of the
future must deal very largely with per-
sonal hygiene and preventive medicine
rather than emergency treatment, this im-
portant change, like most revolutions in
policy, will be brought about not by the
medical profession, but by business men to
satisfy the urgent needs of industry.
The new power of the working people
alone makes it necessary that our present
health ideals be changed. Only a few years
ago there was not one employer in ten who
believed that a company would be held
legally responsible for each and every ac-
cident occurring to an employee in one of
its plants. But this dream of idealists came
true."
The medical profession here and abroad
has long recognized the disadvantages of
charging and collecting fees for services
rendered those who are so unfortunate as
to be obliged to call in the services of a
doctor.
The present system is expensive, time-
consuming, annoying and to the ethical
physician, the hardest and most distressing
part of his work. It brings him up against
base ingratitude inherent in so much of
humanity; it sometimes obliges him to
charge for services he would gladly render
free of charge; it makes enemies, subjects
him to the shafts of witless witticisms; it
is wholly inadequate in securing for the
doctor the money he has earned.
Most physicians, if not poor, are more or
less troubled by financial matters, and they
should not be expected to do for nothing
a large amount of practice their sense of
sympathy will not allow them to refuse.
The state should see to that. Nor should
a physician have to accept a humiliating "re-
muneration" for his work- fees often less
than those paid a plumber or an electrician.
A physician will do an immense amount of
medical and surgical work for a salary
ranging from $75 to $150 a month, while
the manager of a plantation may draw from
$6,000 to $10,000 a year, or the bookkeeper
and overseer, $200 or more, a month.
The qualified physician should be paid
by the state, county, corporation or the
philanthropic associations. Not for work
at $1 per, but at a salary which a physician
can accept without loss of self-respect.
Hospitals should be provided free to all.
Not county or other eleemosynary institu-
tions with the stigma of patronage about
them, but places where all sick persons
whether rich or poor, may receive medical
treatment without money and without price.
Dispensaries for indigents should be elim-
inated as such and maintained upon another
footing.
As it is, patients with money seek the
dispensaries, shamefacedly as it were, cheat-
ing the physician out of his fee ; or the in-
digent come in proud necessity with a loss
of self-respect.
A beginning has been made in England to
subsidize medical service for the public
good, but the error was committed at the
start of demanding of the physician much
work for small pay. It is true that the
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AliWtlOAN Mbdxczns
ORIQINAL. ABTICLJSS
November, 1919
721
best and most skillful physician works with
enthusiasm in his routine of duty, and not
for pay ; but no physician can live and prac-
tice adequately without spending a great
deal of money. It costs to qualify for the
practice of medicine. It costs to secure and
fit up an office. It costs to wait for patients.
It costs for a car, expensive apparatus, good
drugs, for journals and books, books, books.
Even if patients fail to settle their accounts
for a year, or do not pay at all, the doctor
must pay promptly or lose his standing in
the community.
Keeping accounts is an irksome part of
pected to so limit his practice. As a matter
of fact, others "sponge" on him in one way
or another. And the fact that he is a gov-
ernment physician induces a large number
of persons to believe that he should not
charge any one at all. As he must provide
for his own living expenses, transportation,
drugs and equipment for private practice,
he cannot well live on his salary which does
not take into account the small income de-
rived from his private work. In some dis-
tricts, plantation practice and pay help him
out.
Upon consideration, one cannot blame the
Pig. 1. Home of Dr. Goodhue, the Leper Settlement's Resident Physician.
the physician's work. He hates it. The
country doctor's wife often has to be the
bookeeper and share the blame of sending
bills, while in the offices of city doctors who
have large practices, an accountant or secre-
tary may be kept — but he is not much of a
camouflage. After all, the doctor does the
work and makes the charges — he is the one
to get his fee out of the rich, or temper the
wind to the "shorn" lamb.
To some extent the Hawaiian Territorial
system meets the need for free medical
service, limited, however, to indigent per-
sons only. At least, the physician is ex-
people for feeling that a doctor should
answer a call from physical distress any-
way, at anytime, without expecting pay.
While in one sense he is no more obliged to
do so than the grocer should be made to
supply the hungry family free, yet, in an-
other, he is, and the human, altruistic factor
comes in. It will always come in so long
as sickness and death abide. This is one
great reason why a physician's work and
relations to his people should not be placed
upon a common "business" basis.
The physician who expects to get rich or
even well-to-do out of the practice of medi-
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NOVBMBBR, 1919
ORIOINAIj articuds
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cine, is not a physician qualified well to serve
his patients; he is a medicated drummer.
That so many physicians become side-
tracked financially is due largely to the fact
that they have not cared to get rich; that
they have given money matters little
thought and therefore are not business men ;
that, in later years when their families and
have lived only to get the world rid of that
evil upon which their material success de-
pends— sickness.
In some district;^ where there are planta-
tions or other corporations paying men at
regular intervals, nearly everybody is able
to pay the doctor well. But in isolated
places like the island of Molokai, where few
Pig. 2. A Part of the Leper Settlement on Molokai. The Village of Kalawao.
living expenses make heavy demands upon
their resources, they find themselves obliged
to invest in some outside business (generally
wild-cat) in a desperate attempt to meet
their obligations. Had they qualified for
and given attention to business, they would
have been as successful as any others de-
voted wholly to the pursuit of selfish com-
petency; but they did not. Instead, they
persons make more than is necessary to meet
the ordinary living expenses, the present
writer has realized that his services should
be subsidized wholly. I felt that if I did
not have to charge anyone at all, my work
among those whom we are seeking to en-
courage in their care of their sick, would be
enlarged, and my influence for good ex-
tended. It would save annoyance on both
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Ambrioan Mbdxoxnb
ORIOINAIj jlRTICUBB
N0VBMBEB4 1919
723
sides. It would eliminate complaints due
.largely to unpaid and unpayable bills. Peti-
tions against him are the Hawaiian govern-
ment physician's bugbear. A patient gets
along very well with his doctor until he owes
a bill which he feels that he cannot pay.
He begins by avoiding the doctor, then he
fears, then hates him, and, finally, ends by
sending in a complaint on some other
ground, of course, than his indebtedness.
It's quite a logical sequitur.
Thru the generosity and public spirit of
the Board of Supervisors of Maui County,
the Molokai Ranch, together with govern-
ment appropriation for Territorial physi-
cians, I have been able to eliminate entirely
all charges for medical attendance or drugs.
Of course my work has increased, but this
I am gUd to do. And personally to secure
this freedom for myself and the. people, I
have been glad to bear my part of the cost
of free service. It was felt that a few
"able" to pay ought to pay, but I have in-
sisted (and I think time has justified this
insistence), upon the principle for all-free
medical care for rich and poor If the fact
that they reside in this district and cannot
pay for necessary services rendered them
by the physician, disturbs them, they are
free voluntarily to assist the doctor in his
public charities, or, rather, duties.
On the whole, while necessary calls are
greater, I find that every one is even more
considerate of the doctor than he was
before. The fact that the doctor himself
is bearing a part of the burden of maintain-
ing public health when he might be earning
more in almost any other island field; that
he stays here because he likes his work and
people, meets with response. The officers
of the county went in at the last election
with good majorities ; they will again. The
ranch management is regarded not only
with trust as to fairness and consideration,
but with affection by "all the boys." And
it is expected that the Territorial bonus will
be increased as to drugs and actual expenses
of carrying on the "medical business," in
good time. The county maintains free tele-
phone service for all on the island. On the
other side, between us and which rise the
inaccessible cliffs of Molokai Leper Settle-
ment, there are no charges for medical
service administered by Dr. W. J. Good-
hue. Here the lepers are wards of the
Government, carefully guarded, treated,
clothed, housed and fed.
Perhaps a word regarding the specific
field of my endeavors might be interesting.
Molokai, like its sister islands, lies within
the tropics, with an area of 261 square
miles. It is shaped like a shark, its face
east, its dorsal fin due north. Upon this
fin separated from the rest of the island by
steep cliffs over 2,000 feet high, are situated
the two villages comprising the Leper Set-
tlement. Oahu on which Honolulu stands
is about 50 miles distant and may be seen
on a clear day. The island of Hawaii, also,
southeast, Maui in the same direction about
17 miles distant, Lanai, south, and Kahoo-
lawe, all clear and beautiful, cloud-capped
and serene, from any point you look at
them along the leeward side of Molokai.
Halawa at the far eastern end is a beautiful
valley with a famous waterfall and river.
A good road winds down ft nerve-thrilling
grade to the few houses here. On west,
over a splendid automobile road, we reach
Pukoo, where the resident physician lives.
Here are wharf, postoffice and a few stores.
Mountains rising to a height of over 4,000
feet, and cut into by numerous picturesque
valleys and ribboned by waterfalls, back the
villages and road all the way to Kaunakakai,
the principal port, situated about 28 miles
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November, 1919
ORIGINAL. ARTICLBS
Amebic AN Medici wb
from Halawa. An automobile may travel
the whole distance over a good road, thru
lovely kiawe forests, by beaches and small
homesteads, always in sight of some island,
unutterable sea-colors and groves of palms.
A little hamlet by the beach is where Presi-
dent Tyler's son lived and died. Old stone
ruins are here and there, the ruins of a tem-
ple of stones built by Kamehameha the
First, a cocoanut grove set out by Kame-
hameha the Fifth. From Kaunakakai the
road turns inland to Kualapuu where the
Molokai Ranch buildings stand. Farther
on, is Kalae with its prosperous farm colony
of one family of brothers, their wives and
children. Here at an elevation of about
2,000 feet the air is delightful. There is a
school as well as at the other villages. It
is a part of the doctor's duty to see that
these schools are sanitary and their chil-
dren kept in health. A subsidized dentist
and oculist make periodical visits. The
numerous children of these hamlets I love,
and they appear to be glad to see me at any
time. I speak to them on various matters,
now and then, health, their American citi-
zenship, Lincoln, Roosevelt. It was my
privilege to deliver a personal message to
them (on another island) from James Whit-
comb Riley a few n;ionths before he died,
and some songs my daughter and I wrote
have been set to music by a Hawaiian com-
poser of local fame. One, The Self-Same
Star, is very sweet and quite popular on
all the islands ; while another, Our Hawaii,
is sung and played by the Leper Orchestra
at the Leper Settlement. The schools, then,
constitute an important part of my work.
The climate of the whole range from
Kalae to Halawa is very salubrious and
agreeable. Trade winds blow almost con-
stantly, gentle showers fall, the nights are
invariably cool. Fish are abundant in the
sea and ponds stretching from Maonui to
Kaunakakai, the latter built by Hawaiians.
of unrecorded times. These ponds are en-
closed by rocks following the reefs and con-
tain mullet of fine quality. Cattle range
upon a thousand hills. Where there is
water, fruits and vegetables abound, and on
the whole, residents of the island are greatly
blessed by nature.
The homes are rather widely separated,
and while the most of our residents are
Hawaiians, there are a few Chinese, Japa-
nese, Portugese and Whites. Honolulu is
reached in four or five hours ; Lahaina and
Wailuku in two, by regular steamers.
Catholic and Congregationalist churches
are numerous, and one or two Mormon so-
cieties. A live Civic Improvement Associa-
tion attends to the public needs of the com-
munity. Plans are ahead for a free library,
high school, hospital, band, baseball fields, a
district nurse. My daughter is humane
officer, and a special officer for child- welfare
has just been appointed. The Tack of money
is the only thing that prevents our rapid
development along such lines as I have in-
dicated.
Cervical Ssmtpathectomy in the Cure
of Facial NeunJgia. — In the treatment
for facial neuralgia deep injection of al-
cohol had given Pleth (Amer. Jour, of
Surg., May, 1919) the best results, tho pain
returned in from nine to twelve months. In
a few cases keratitis or even the loss of an
eye had been observed. In performing the
operation of cervical sympathectomy alco-
hol had been injected at all points of exit
of the trigeminal from the skull ; the inside
of the foramen ovale had been avoided. It
usually takes about three months before any
definite relief is manifested. In one case
where the injection had been made for
facial neuralgia a previous neuralgia of the
radial and ulnar disappeared.
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AMBRICAN MbDICINB
ORIOINAIi ARTICLBS
November, 1919
725
THE PERSONAL, ARTISTIC, AND
PUBLIC TRAGEDIES OF AN
ARTISTS EYESTRAIN,
BY
GEORGE M. GOULD. M. D..
Atiantlc City, N. J. .
When the tragedy of the painter Blake-
lock was brought to the attention of
artists and art-lovers, I said to several
friends and physicians that the clouding of
his mind was undoubtedly caused by his
eyestrain. And I awaited the proof of a
second case whereby in some way I might,
at least for myself, put the theory to the
test.
I was recently surprised by the appear-
ance in my office of a friend and patient
accompanied by an elderly man, a distin-
guished painter, whose mind, it was evi-
dent, was. in an abnormal condition. Early
in life the man had typical migraine, with
binding up of the head for headache, etc. ;
and there was the customary history of
nausea and vomiting, "neuritis," and the
rest. Several oculists were mentioned as
having been consulted, and "others." There
had been "little or no reading for years."
The ophthalmoscope showed floating opaci-
ties and results of old hemorrhages in the
vitreous. He "broke down" two and a
half years ago. Altho he had not read for
years, he had diligently painted many mas-
terpieces that commanded high prices from
connoisseurs. If his mind had permitted
him to act the part of a good and obedient
patient I might have given him more cor-
rect spectacles. I did the best I could to
tide him over, hoping for some mental quiet-
ing and rest from work until I could make
the refraction tests in the silent Woods-
Home several hundred miles away. In the
meantime he should rest, avoiding all work.
and sleeping, if possible, twenty hours a
day.
So soon as I could I made the long jour-
ney, by automobile, to the patient's home
and more accurately measured his errors
of refraction. The distance-correction was
found to be:
Right eye: -fCyl. 0.75 Ax. 30.
Left eye: -fSph. 0.62, -fCyl. 1.25 Ax.
180.
The usual presbyopic addition of Sph.
3 was made and bifocal spectacles ordered
for constant use except when painting. But
it was, of course, the eyestrain from paint-
ing that had produced the artist's ill health
and to cancel this it was necessary to find
what presbyopic lenses would be required.
This would depend upon the habitual dis-
tance of the artist's eye^ from the canvas,
the landscape, sketch, the model, or the
sitter, etc., and would demand the correc-
tion of his ametropia for distance by the
same power-lenses that had been ordered
for general use. But in painting this dis-
tance from his eyes to the canvas was sev-
eral times greater than in reading, writing,
etc. The combined length of the arm and
brush would require a much less powerful
lens than for ordinary reading, writing, etc.
The conclusion was, therefore, that instead
of an addition of 3 diopters, 1.25 would be
found best to give clear vision and relieve
strain. The upper or distance-parts of the
bifocals were ordered smaller than the usual
presbyopic segments and the lower or paint-
ing segments considerably larger than cus-
tomary.
Soon came letters from the painter's wife
and son that the man was "well — well and
happy, and devoted to his art-work." The
threatened disasters of several kinds — indi-
vidual, family, public, art — were, and re-
main matters of the sad past.
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AN AMERICAN MAKE-SHIFT: THE
NUCLEUS OF FUTURE PUBLIC
HEALTH HOSPITALS IN MONTE-
NEGRO.
BY
R. G. BOWMAN,
New York City.
One of the most serious obstacles that
confronted the American physicians and
nurses engaged in civilian relief work in
the Balkans was the lack of suitable build-
ings wherein they might establish hospitals
of some permanency.
The building which was assigned to them
at Kolachin, Montenegro, for instance, was
a deserted Austrian "hospital," if it could
be designated as such. It was a two-story
cement house with few windows, with slab
floors, thru which sifted chilling winds,
with sanitary conditions unfit to mention,
and with a pile of manure banked on the
side. The patients who lay on the floor
were pitiably and unspeakably filthy.
This was the "hospital" to which Miss
Henriette Wiltsius was appointed as head
nurse, ward nurse, surgical assistant and
matron, and this was the condition which
confronted her when she arrived at Kola-
chin, after a fourteen-hour trip by Red
Cross camion, by horseback, by cart and by
foot, in a blinding snow storm.
^ But Miss Wiltsius, being an American
nurse, was equal to the emergency. She
called on the interpreter to get women for
cleaning and a carpenter, then things began
to buzz. The walls were patched, new
floors were laid, additional windows were
cut in each room and an inside staircase
built. Having accomplished that much she
turned her attention and the carpenter's
energy to the furnishings.
An old iron operating table, much too
low, and a few iron cots represented the
entire stock in trade. Plank slats were laid
across the cots and straw mattresses
fitted to them, after which they were made
up with Red Cross sheets and blankets and
so became the acme of comfort to the na-
tives who were accustomed to sleeping on
mud floors.
But Miss Wiltsius did not stop there;
washstands, bedside tables, linen closets and
even chairs were designed by her and ex-
ecuted by the carpenter.
The operating room, which promised to
be a stumbling block, developed into the
pride, not only of the American unit and
Kolachin, but of all the Balkan States, for
it is the most perfect model in the country
and the most unique, all the furnishings
having been made entirely of Red Cross
packing boxes. The old operating table
was raised on a wooden stand and placed
conveniently near were two tables for dress-
ings; to supplement these were wall cab-
inets, stools and a clever three-decked stand
for washing, all made of white pine and
glaringly clean. And then there were
the screens. "Fm really proudest of the
screens," said Miss Wiltsius. "I couldn't
make the interpreter understand what I
wanted, so I hunted thru three magazines
we had. In one I found the picture of a
hinged photograph frame with three sides,
I showed that to the carpenter. These reg-
ulation hospital screens with muslin panels
are the result."
So today the little twelve-bed hospital at
Kolachin stands as a beacon light in the
heart of a country steeped in superstition
and ignorance of medical science. To the
Montenegrins, used to living in wooden
slab lean-tos and stone huts without win-
dows, its immaculate condition is a wonder,
while the cures aflfected by the one doctor
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727
and two nurses are looked upon as nothing
short of miracles. On horseback and in
carts, sufferers pour in for treatment from
the surrounding country from as great a
distance as fifty miles and patients on foot
from nearer neighborhoods are regular vis-
itors.
It may be that this make-shift hospital
will be the inspiration of future public
health hospitals in Montenegro. A Ser-
bian general, who visited it recently said,
"It is a remarkable example of American
ingenuity. We must take this as an ex-
ample. Our people are always complaining
that they can't get materials. We have the
wood, but we apparently haven't the sense."
But before the Montenegrins can estab-
lish worthwhile hospitals they must of ne-
cessity train doctors and nurses to man
them. A country with 100,000 inhabitants
with but four doctors and practically no
trained nurses is a serious proposition and
it seems as if outside supervision will be
imperative for some time.
Before the American Red Cross went into
the Balkans neither the practice of medi-
cine nor nursing was taken seriously. Un-
skilled women of the lower class clattered
about their hospital duties without any kind
of supervision or training and were never
in any way encouraged to become efficient ;
while native "flochers," men and women
who had picked up a smattering of medi-
cine as they went along, and were little
more than healers, treated the most serious
cases.
From this it appears that the most vital
factor in the work of the American Red
Cross unit in Montenegro is not the dress-
ing of a certain number of wounds or the
treatment of a certain number of medical
cases, but the awakening of these unskilled
workers and others interested in medicine,
to a realization of the necessity of medical
training. It is only in this way that the
mass of people will be reached and edu-
cated to the need of better sanitary condi-
tions, as the first step in the prevention of
disease.
The same problem, tho in milder form,
of unhealthy sanitary conditions exists in
isolated districts of our own country, where
doctors are scarce and nurses are almost
entirely absent. The Red Cross proposes
to combat this by the establishment of the
Public Health Nurse in all rural districts
as she is now established in all cities of
50,000 or more inhabitants. The nurse will
cooperate closely with the over- worked
country doctor, making regular rounds
among the farmers, helping their wives with
the care and nourishment of their children,
planning simple home hygiene methods and
when necessary nursing members of the
family back to health. It is hoped in this
way that thousands of infants, and mothers
who die in childbirth each year will be
saved, and that great strides will be made
against tuberculosis and other diseases.
DRINK, AN EFFECT, OR A CAUSE,
OF CRIME?
BY
PERRY MARSHALL. M. D..
New Salem, Mass.
Some parts of an able article on "Science
and Alcohol" in the May number of Ameri-
can Medicine, struck me a little strangely.
And at the risk of being thought foolishly
presumptuous in questioning both specialism
and other well-proved ability, may I call
attention to two of them? First, the sug-
gestion that "drink is more a blessing than
a curse," preventing worse evils as "over-
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ORIOINAIj abticuds
eating" and the "use of drugs," which do
not appear to most of us to be worse evils.
When we read in the papers that a man has
been beating his wife, committing arson, or
murder, or has got into jail or prison, we
do not commonly read that he had been
over-eating, or had been eating hashish or
opium, but that he was under the influence
of liquor. The government is now greatly
inconveniencing every doctor in the land
over the matter of drug addiction, which
hardly has any relation to crime, but which
governments are organized to prevent. Med-
icine supports the government in this, but
when it strikes at alcohol, as it should strike
if alcohol is the criminal, then it is said
government is not minding its own busi-
ness.
Justice Field, of the U. S. Supreme Court,
in the case of Crowley v. Christensen, 137
U. S. 86, 11 Sup. Ct. 13, recently found as
follows :
"By the general concurrence of opinion
of every civilized and Christian community
there are few sources of crime and misery
to society equal to the dram shop The
statistics of every state show a greater
amount of crime and misery attributable
to the use of ardent spirits obtained at these
retail liquor saloons than to any other
source.
"The injury, it is true, first falls upon
him in his health, which the habit under-
mines ; in his morals, which it weakens ; and
in the self-abasement, which it creates. But,,
as it leads to neglect of business and waste
of property and general demoralization, it
affects those who are immediately connected
with and dependent upon him."
If the supreme court is correct in this
statement, then is there scarcely anything
else so important for it to do as to deal
with "the alcohol jag." And if for this
should be substituted the "food jag" which
mostly ends with self, instead of misery
inflicted on others and self, by crime, it
would seem to use, unsophisticated folk to
be a lesson, and not a worse evil.
When we take alcohol into the system
we ingest a liquid utterly different from
any fluid in the body or in any ordinary
food. The liquid of the blood, of milk, of
coffee, tea, lemonade, etc., is one; it is
water, chemically HjO, three atoms to the
molecule.
Ethylic alcohol is CjHeO, nine atoms
to the molecule. Its specific gravity or
weight compared with water — 1000, is 792.
It boils at 172** R, water at 212° F. It
bums in air, water does not. It can change
to acid, its taste is biting. It circulates in
the blood and is eliminated mainly as alco-
hol, about as foreign to our physical econ-
omy as any liquid can be.
"Attack the vicious use of alcohol and
preserve its harmless employment." Is
not this latter just what governments do
when they allow its use in medicine ?
Second, the idea that the hard drinker
is usually of natural criminal tendency
seems to me a hard saying. The naturally
criminal people are comparatively few and
are defective. "Hamby," on trial in New
York last June, was declared by experts to
be a natural criminal, a defective. Many
of us have personally observed the gradual
growth of appetite, beginning with indul-
gence and going on till it becomes a dom-
inating disease, a tyrant that degrades and
then destroys its victim.
I have personally known authors of abil-
ity, physicians, business men, lawyers and
a few judges even, on their way down-
wards toward the rapids, in their advanced
life. Some have been temporarily rescued
by some "cure."
The sight, smell or taste of liquor again
wakens the demon of desire in them. "Ex-
cellency leaves them, to re-enter when rum
is out."
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"When the wine is in, the wit is out,"
the proverb says. Have the great of the
world been all mistaken in supposing that
crime was the effect and not the cause of
drink ?
Shakespeare said: **0 that men should
put an enemy in their mouths to steal away
their brains! That we should with joy,
pleasure, revel and applause transform our-
selves into beasts!"
"O thou invisible spirit of wine, if thou
hast no name to be known by, let us call
thee devil."
AN INTERESTING CASE OF RE-
MOVAL OF THE APPENDIX
THRU THE VAGINA.
D. H. GALLOWAY, Ph. G., M. D.,
RoBweU, N. M.
This patient was a woman 37 years old
and the mother of three children. She was
referred to me by her physician because of
an intractable uterine flow. For this con-
dition no explanation has been found, there
was no indication of cancer. A curettage
had been without any effect. After getting
the history of the case, of what had been
done medically and surgically for her re-
lief, from the fact that she suffered a great
deal of pain, that her health was being
undermined by the frequent and great loss
of blood, I advised hysterectomy.
This advice was accepted and the opera-
tion decided upon, but as there was no
bleeding of consequence at this particular
time, the patient wished to postpone the
operation. About a month later, however,
she developed a very severe pain in the pel-
vis. On examination I found the uterus
excruciatingly tender, the least movement or
touch caused the greatest pain. As no ex-
planation could be found for this condition,
immediate operation was advised. The op-
eration was begun and very little difficulty
found in getting the organ out, but on care-
ful examination before we finished the op-
eration we could find no explanation for the
pain. I made a further investigation and
found a very large appendix, highly in-
flamed, full of pus and evidently it had been
in contact with the uterus. By a little
manipulation I was able to bring it down
until I could see the cecum, when, by the
aid of two clamps, it was ligated. A clamp
was then put on the base and the appendix
was excised and removed without ruptur-
ing it. It was very long, probably seven
inches, and at the distal end as large as the
end of a man's index finger. There was
no bleeding, the mesentery was very small,
so that one ligature controlled it all, the
stump was released, the clamps put in posi-
tion and a packing put in.
The patient made a perfect and uninter-
rupted recovery and has never since had
any trouble from either the appendix or
anything in the pelvis. I have not been
able to find in the literature any account of
the removal of the appendix by this route.
A SANITARY CORDON TO CHECK
THE SPREAD OF TYPHUS IN
POLAND.
One of the prime recommendations of the
Inter-Allied Medical Commission sent to
Poland late last summer by the League of
Red Cross Societies, was the establishment
of a "sanitary cordon" to prevent the typhus
epidemic which is ravaging that country
from spreading to western Europe and even
to America. Famine, overcrowding and
the continued influx of infected returning
refugees and prisoners of war have sown
typhus all over the country ; even during the
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ORIOINAIi ARTICLES
Amwican Mbdzcinb
summer months the epidemic has not
ceased ; and with the return of winter, with
bad living conditions and increased oppor-
tunities of infection, a much more serious
situation is to be faced.
In the ordinary sense, the term "sanitary
cordon*' is used to signifiy an attempt, by
strict military and police methods, to main-
tain a comprehensive medical control over
the entry of every person thru the frontier,
to secure as a routine the medical examina-
tion of every such person, and his disinfec-
tion, detention in quarantine, certification,
etc. Such a cordon is not advisable in
Poland at the present time, principally be-
cause the disease was already spread
practically all thru Poland west of the pro-
posed line, and is also widely prevalent in
regions to the south of the country.
There is a sense in which the establish-
ment of a cordon would be of the greatest
advantage, and indeed almost indispensable
for the handling of the situation. This con-
sists in the establishment, on the main
routes from the East on which refugees
arrive en masse, of stations where they can
be individualy examined, disinfected and
when necessary sent to hospitals or detained
as "contacts*' — meanwhile being fed and
cared for. From such a point of view the
sanitary cordon resolves itself into the estab-
lishment of only some half dozen main ob-
servations to deal with the main stream of
refugees. Other developments of the sys-
tem, such as supplementary disinfecting
, stations, may be added if necessary. A
useful check might be afforded by the issue
of "sanitary passports," or certificates to
those who have passed the medical tests
and have been cleansed and disinfected.
These would be demanded by the authori-
ties at the ultimate destination and those
without passports would be placed under
observation.
The conditions are in some respects very
favorable to the proposed system. West of
the proposed line of observation are a con-
siderable number of foci over a wide area,
with two or three small areas of intense in-
fection. These occur in a nation which al-
ready possesses organized civil and military
sanitary departments which are being as-
sisted by such agencies as the American
Red Cross. On the other side of the line
is a vast area without any civilized form of
government or health organization, incident-
ally containing one or two million people
trying to get into Poland. There is a state
of war and the frontier is guarded by a
large and efficient military force, distances
between cities are great and lines of com-
munication few. Refugees and prisoners
arrive in a destitute condition and are con-
sequently attracted to places where food and
clothing may be secured; and while in-
dividuals may pass thru undetected, it
should not be difficult to direct all the prin-
cipal streams toward equipped stations on
lines of communication.
In the countries north, south and west
of Poland the conditions are not so much
worse than those in Poland as to encourage
immigration, even if the military situation
allowed of such a drift; on the other hand,
it is estimated that in Russia there are from
one and a quarter to one and a half million
Poles and Russians who will cross the pro-
posed cordon within the next few months,
and it is probable that the drift, tho dimin-
ished, will continue for years.
The risk to other countries from a severe
epidemic condition, if serious, is encourag-
ing. In spite of the fact that the country
has been free from invasion and organized
only a short time, and that she is without
resources and engaged in warfare to pre-
serve her existence, there is an excellent
health organization in both civil and military
areas. She needs only a small amount of
additional material and personnel to make
this organization what it should be.
Realizing this, the American Red Cross
has recently appropriated $2,000,000 for
relief operations in Poland till spring. It
has now a commission of over one hundred
persons at work in its large bases at Lwow,
Warsaw, Bialystok and Cracow, and with
the eleven mobile relief units in the field.
"I do not know what we would have done
without the Americans," said Premier
Paderewski recently, in discussing the joint
operations of the American Red Cross and
the American Relief Administration. "I
thank you from the bottom of my heart."
Hemorriioids. — Acute hemorrhoids de-
veloping in women during pregnancy are
often cured by moderate, careful dilation of
the sphincter at the time of delivery. —
Drueck, Medical Standard,
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RATIONAL ORGANOTHERAPY
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731
RATIONAL
ORGANOTHERAPY
The Pituitary in Diabetes Insiindus. —
Extracts of the posterior lobe, or pars
nervosa, of the pituitary structure provoke
an unmistakable change in the secretion of
urine when they are introduced directly in-
to the circulation, says an editorial writer
in the Jour, A. M. A. (Nov. 22, 1919).
This renal effect has been compared to the
secretion-promoting effect exerted by ex-
tracts of the duodenum on the pancreatic
cells. Because of such experimental ob-
servation the pituitary has been assumed to
exercise a regulatory influence on the func-
tions of the kidney. Such reasoning, often
applied in connection with the ductless-
glands, has grave limitations and is rarely
conclusive. As a recent writer has re-
marked, it is by no means logical to assume
or infer that the functional importance of
an organ is demonstrated by the properties
of an extract of it. If one applies such an
argument to the galactagogue substance in
the pituitary of a fish, the absurdity is ob-
vious.
Other evidence for the functional inter-
relation of kidney and pituitary has been
sought in the domain of pathology. In the
chronic polyuria most frequently referred
to as diabetes insipidus, involvement of the
pituitary, particularly of its junction with
the brain, has been demonstrated repeatedly
at necropsy; in fact, there are no records
in which the pituitary was examined and
found to be perfectly normal. Experimental
pathology, by damaging the structures in
the neighborhood of the posterior lobe of
the pituitary, has frequently produced ab-
normalities in the flow of urine. Polyurias
lasting from one to six months have fol-
lowed the artificial lesions; yet such results
have been exceptional and attained only by
chance, apparently.
Kennaway and Mottram of the Middle-
sex Hospital, in London, have added clin-
ical evidence to the problem of pituitary
function in connection with the kidney. The
antidiuretic effect of pituitary extract given
by subcutaneous injection was demonstrated
both in a normal subject and in a case of
diabetes insipidus. Administration of such
preparations by mouth is ineffectual. It
has been suggested that the antidiuretic ef-
fect is due to diminished absorption from
the bowel so that less water is available for
secretion thru the kidneys. If we may
trust the evidence of Konschegg and Schus-
ter, however, the effect is rather attribut-
able to direct action on the kidneys. Kenna-
way and Mottram maintain that the imme-
diate restoration of a normal state of the
urine when pituitary extract is adminis-
tered in diabetes insipidus provides the
strongest evidence for the normal activity
of the gland in regulating the secretion of
urine. We must confess, however, that in
view of the contradictions in the literature
of the subject and the indirect nature of
both clinical and experimental evidence, it
would be far-fetched to maintain without
reserve that disorder of the pituitary is in
all cases the cause of chronic polyuria. In-
jection of pituitary extracts now appears
to be the most effectual mode of treatment.
However, every day obvious examples of
the limitations of such a procedure are en-
countered.
Action of Strychnine upon the Output
of Epinephrine from the Adrenals. —
According to Stewart and Rogoff (Journal
of Pharmacology and Experimental Thera-
peutics, May, 1919) strychnine causes a
marked increase in the output of epinephrine
from the adrenals. Outputs ten times the
original amount were observed in a series
of experiments on dogs and cats. The in-
crease persisted for a considerable time.
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American Mbdicinb
When the last adrenal sample was taken,
usually an hour to an hour and a half after
the strychnine injection, the epinephrine
output was still, as a rule, notably aug-
mented. Indeed with the smaller doses the
output was sometimes greatest at this time.
Doses of strychnine well within the thera-
peutic range, which caused little or no ex-
aggeration of reflex excitability, produced
a considerable increase in the output. The
animals being necessarily well anesthetized,
it is supposed that still smaller doses would
suffice in non-anesthetized animals. Indica-
tions were obtained in some experiments
that the stage of prolonged increase of the
output, which constitutes the principal action
of the drug, may be preceded by a transient
diminution; this was best seen with the
smaller doses and upon subcutaneous ad-
ministration. No evidence was found that
under strychnine the possible normal max-
imum concentration of epinephrine in the
plasma — something like one in 500,000 —
can be increased. In spite of the greatly
increased output caused by strychnine, there
was no evidence that th^ epinephrine store
of the adrenals is distinctly diminished even
by the prolonged action ot the drug in large
and repeated doses. The accumulation of
epinephrine in the glands is therefore in-
creased as well as its liberation. This is
what occurs during stimulation of the
splanchnic nerve, except when intermittent
stimulation is continued for very long
periods. It corroborates other evidence
that the strychnine effect is produced by
an intensification of the secretory process
thru the nervous mechanism which normally
governs it, and not by a direct action on
the adrenals.
Suprarenal Insufficiency. — S e z a r y
(Presse Medicate, Sept. 22, 1919) classifies
suprarenal insufficiency under three head-
ings: the fulminating, rapidly fatal form;
the monosymptomatic form (myasthenia or
amyotrophy), and the form inducing a
whole set of symptoms : acute (syndrome of
Sergent-Bernard) ; subacute and slow (Ad-
dison's disease and its varieties). Tuber-
culosis may induce any one of these "syn-
dromic forms" of suprarenal insufficiency,
and syphilitic processes often locate in the
suprarenals, as also those of diphtheria, ty-
phoid and other acute infections. Specific
treatment should be given when such is pos-
sible, antitoxin with diphtheria, for exam-
ple, or quinine with malaria. Rest and
suprarenal treatment are useful whatever
the infection, but he prefers the extract of
the whole gland, and given by the subcuta-
neous route. He reserves epinephrine for
acute disturbances with collapse of the
heart, and recommends the subcutaneous
route. He gages the dose by the thera-
peutic results obtained with the first doses
and by the signs of intolerance. A rise in
the blood pressure is a good index of the
efficacy of the opotherapy, but the fact that
it does not rise does not prove that the treat-
ment has been ineflfectual. A still more in-
structive index is th^ finding with the dyna-
mometer showing the variations in the
strength of the muscles tested fifteen and
thirty minutes, one hour, three hours and
so on after the injection of the suprarenal
extract. When these two tests show a
favorable influence from the suprarenal
treatment, he keeps up this dose, not in-
creasing it until the effect grows less pro-
nounced. The appearance of tremor calls
for caution ; glycosuria, albuminuria, circu-
latory disturbances require suspension of
this treatment. In some cases the doses
have to be high and kept up for several
weeks or even months before a good result
is obtained. Signs of intolerance should be
watched for with special care in these cir-
cumstances. Sometimes addition of pitu-
itary will give surprisingly fine results when
the suprarenal treatment is a failure. With
cheesy tuberculosis and cancer, the knife is
still the ideal treatment, possibly resecting
only the pathologic tissues and leaving the
rest intact. But in order that this can be
done the disease has to be diagnosed early,
and it is to be hoped that the progress of
medicine will soon render this possible.
Antithyroid Treatment of M^orrfaa-
gia. — ^Weil reports a case in the Bui de
la Societe Medicale des Hopitaux (July 4,
1919) in which uterine hemorrhages had
kept up for twenty-five days each month for
a year. The woman who was 30 years old
had only 2,000,000 erythrocytes and 40 per
cent, hemoglobin, while the blood took ten
minutes to clot. The gums also bled readily
but there were no personal or hereditary
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733
hemorrhagic antecedents. The woman had
a small goiter but no other signs of exoph-
thalmic goiter. He gave tentative organo-
therapy with thyroid, suprarenal, pituitary
and other organ extracts, and tried iron and
arsenic — ^all to no avail. Then he changed
to what he calls antithyroid treatment, and
a complete cure soon followed. He used
for this three teaspoonfuls a day of a glyc-
erin preparation of the blood of goats thy-
roidectomized over a month before. The
literature records the cure by this means
of a persisting and recurring hemorrhagic
pleurisy in a case of exophthalmic goiter,
and the arrest of severe menorrhagia in one
woman, a virgin. The hemorrhage-reduc-
ing power of this antithyroid treatment
seems to be restricted to the genital sphere
and complex endocrine disturbance, Ra-
mond has reported a case in which thyroid
treatment improved myxedema in a woman
of 48, and seemed to cure completely a tend-
ency to multiple-recurring hemorrhages.
Pancreatic Extract in Gastric Cancer. —
Loeper (Progres Medical, Aug. 30, 1919)
has been giving pancreatic extract intrave-
nously in the treatment of gastric cancer,
and he reports five out of the series of
cases in which this has been done, discuss-
ing the theoretical bases for it. The i-
suits seem to indicate that this treatment
has a decidedly favorable action on certain
of the s)rmptoms from gastric cancer — "I
do not say on the cancer itself." The weight
increased in all, the number of erythro-
cytes increased and the antitryptic index
showed higher values in two of the four
patients tested. In the cancerous it acts
the same as in healthy subjects and in dogs,
increasing the antiproteolytic power of the
blood serum and the resisting power of the
blood corpuscles. The general condition
improves and the resisting power of the
organisms is enhanced, including the special
defensive reactions against the cancer prod-
ucts.
The Treatment of Thyroid Intoxica-
tion.— In a case of goiter, reported by Dr.
Joshua H. Leiner (N. F. Med, Jour,, Au-
gust 2) in a Russian woman, thirty- four
years of age, the Forchheimer's treatment,
with quinine hydrobromide and ergotin,
caused a slight improvement in the thyro-
toxicosis. It is needless to state that the
dietetic and hygienic surroundings received
suitable consideration.
When this treatment was stopped a re-
lapse occurred, the symptoms of which as
far as they were manifested in hot flushes
and tremor, yielded to ovarian extract.
When decided symptoms of relapse became
manifest this patient was given five-grain
doses of thymus extract three times daily
thru which a decided improvement had be-
come evident two weeks later.
Doctor Leiner mentions that, in case of
exophthalmic goiter, the thymus likewise
undergoes a hyperplasia; and altho theo-
retically the feeding of this gland is con-
traindicated, clinical experience teaches that
benefficial results have followed its admin-
istration.
PARAGRAPHIC REFLECTIONS.
By
W. B. KONKLE, M. D.,
MontoarsYille, Pa.
Medicine That Knows Its Place. —
"Nature can do more than the doctors",
said Cromwell on his death-bed, according
to his secretary, Thurlo, as cited by Vol-
taire. Moliere makes a sly old fox of a
doctor say to his colleagues, "Let us be in
accord around the sick, that we may at-
tribute to ourselves the fortunate outcome
of disease, and cast upon nature all the
blunders of our art". Again, a cynical lay-
man he has declaring, "Almost all people die
of their remedies, and not of their mala-
dies". So from hieroglyph to stereotyped
page, thruout literature criticism and satire
have thus differentiated recovery, from
cure, assigning to the latter a relationship
auxiliary and subordinate. In spite of this,
however, a certain class and proportion of
physicians perennially persist in maintaining
toward disease states a general spirit and
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November, 1919
BY-WAYS AND HIGH- WAYS
American Medicine
manner of officiousness which, plainly and
frankly, is sheer meddlesomeness. Med-
icine that knows its place and powers, how
fine, how efficient ! But medicine that pre-
sumes and trespasses and usurps, how im-
pertinent and pernicious! The invariable,
routine procedure of "pulling patients thru",
as frequently manifest, would be ludicrous
were it not perilous. How some doctors
save life is superlatively staggering! Even
in childbirth, a process simple, natural, uni-
versal, the same tendency and practice are
too often evident. Not a rarity is the doc-
tor who performs as tho he considered
child-bearing an operation incumbent on
himself and the woman jointly; who simul-
taneously with her goes into labor, rivals
her efforts, and carries off the lion's share
of the credit and glory. Contemplating the
case as it progresses, one might inly repeat
the appeal of Henry V to his soldiers —
'*Once more into the breach (breech), dear
friends, once more". In the name of great
Hera, let the woman have the baby. "Baby-
bearing" doctors are a farce and a nuisance.
How Muck Should the Patient Be
Told? — ^The end of medical treatment is
to get one's patient well — 'Huto, celeriter ac
juci$nde", after the aphorism of Asclepiades
of Prusa as paraphrased by Celsus — ^**only
this and nothing more". The pathfinder
Bartholow was wont to distinguish and em-
phasize the idea by reiteration of his own
clearly coined and deeply relevant phrase,
"therapeutic diagnosis". The expression
reveals peculiar force and pregnancy as used
in contradistinction to the academic diag-
nosis of the Skoda school. No; not to
vindicate one's judgment nor to exalt one's
self as a medical scientist, not to exhibit and
illustrate professional proficiency and con-
sistency, not to demonstrate personal com-
petency and dexterity, not even to avoid 'Ue
crime de Use Faculte, qui ne se pent assez
punir" of Doctor Purgon, not primarily for
any of these purposes, but to help his pa-
tients get promptly and thoroly well, should
one manage his cases. This the attendant
should be courageous enough and magnani-
mous enough to do. In pursuance of such
a course one will learn to keep his own
counsel. You can never get a sick man well
by telling him he is likely to die. Thomp-
son of New York some years ago gave a
sane word of warning and advice along this
line with reference to heart disease. The
caution is especially significant now-a-days
as directed toward blood pressure findings.
To discover in a person a critical blood pres-
sure, and then subject the person to extra
risk of apoplexy by an oracular, unvar-
nished, solemn, portentous announcement
of the fact, is, to say the least, short sighted
and reprehensible practice.
Neglecting the Pulse^ — ^The sphygmo-
manometer having been brought into ques-
tion, it may be stated that the instrument is
not an unqualified boon. It does, truly,
furnish a delicate and precise test that en-
hances exactness and certainty in the de-
termination of abnormal conditions and in
the diagnosis of disease processes. It is an
acquisition of real value, and its importance
in the field of investigation of body states
and body functions should not be underesti-
mated. A flagrant misuse, however, is its
indiscriminate, ostentatious, ominous em-
ployment in the case of sick people. A posi-
tive evil is routine, mechanical, absolute,
servile dependence upon it to the exclusion
or neglect of study of the pulse by palpation.
To the deft, keen physician the pulse tells
much more than the sphygmomanometer
can tell. Says Galen, "The science of the
pulse is difficult; it exacts of him who
wishes to acquire it a great attention of
mind and an extraordinary talent for obser-*
vation". This is eminently true. And al-
tho Galen authorized in the science results
undue, even preposterous, in his enumera-
tions and classifications clearly verged upon
the fanciful and whimsical extremes reached
by the Chinese savants, yet, nevertheless,
the pulse does, indeed, show many phases
and many combinations. In fact, no two
pulses are exactly alike.
The Pertinency of Common Terms. —
Quite noteworthy is the degree of correct-
ness and pertinency ofttimes pertaining to
the classical names in common use for
pathologic and physiologic manifestations.
Not infrequently such designations are
ideal. There is the term "lung fever", for
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BY-WAYS AND HIGH- WAYS
November, 1919
735
instance. It is old — older than bacteriology.
Still it stands accurately and forcibly for an
acute infection as definite and specific as
typhus or typhoid. Then, again, take in ex-
ample the expression "change of life". How
graphically, how pointedly the phrase indi-
cates and accentuates those profound modi-
fications and alterations occurring at the
climacteric equally in the circulatory and in
the nervous system of a woman, those two
of the component parts of the corporal
organism so intimately connected with, and
so wholly essential to, life its very self!
might be reasonably urged, still the extreme
lengths advocated, altho feasible, cannot
logically be necessary to effectual action.
Sears, following Schick, maintains that the
dose of diphtheria antitoxin should be
graduated to the standard of body weight.
That proposition has the ring of good sense.
It simply implies the application of a gen-
eric principle. In short, there is a "too
little" and a "too much" involved in the
antitoxin problem. A key that ever fits
and never fails is the Ovidian legend,
"Medio Tutissimus ibis".
Have We Mastered Dii^theria.— We
thought that thru antitoxin we had the
mastery of diphtheria — that we had con-
quered, subjugated the disease beyond per-
adventure. And the confidence was most
satisfactory and comfortable. Then along
came certain leaders with an assertion and
a protestation. We were told that we had
been using doses of the specific unreliably,
if not impotently, small; that amounts as-
toundingly larger were not only permissi-
ble, but actually demanded — amounts really
prohibitive in general practice from consid-
erations both of availability and cost. These
utterances have borne the hall mark of
authority, truly — carry the sanction of
special study favored by unexcelled oppor-
tunity. But there is involved in the ques-
tion a logic inevitable, inflexible, inexorable.
And dialectics constitutes no specialty in
medicine. Indubitably fruitful is the ex-
perimental method. To be fully trusted,
however, it must be of the character of
'U'empirisme rationnel ou philosophiqtie"
of Renouard. Now applying the rule of
reason to antitoxin dosage, it would ap-
pear that, if the enormous quantity sug-
gested is indispensable to therapeutic eflFect,
then are the amounts ordinarily adminis-
tered ineflFectual, futile, in which case either
our observations have been faulty, or we
have been again led astray by that arrant
false guide, "post hoc ergo propter hoc'\
And, if such downright error may have
been accepted with reference to the smaller
dose, why may it not likewise occur in the
estimation of the results of the huge dose ?
But, if not radically wrong as to the potency
of the usual treatment, then, while some en-
largement or reenforcement of the same
The Traditional Ilk of ChilAood.—
A violation of the traditions of childhood
that smacks of profanation is the warfare
waged by preventive medicine against child-
hood's own diseases so called. A picture
of those early days minus mumps and
measles and whooping-cough, if not dis-
torted and denaturalized, at any rate could
not be reckoned orthodox! Seriously
viewed, the acute infections more peculiar
to the age of growth can, of course, be
headed oflF and kept within bounds. But
can they be completely and finally rounded
up? Can they be eradicated? And, for
obvious reasons, the milder the malady, the
more difficult its repression and suppression.
Chicken-pox and small-pox are ungovern-
able respectively in inverse ratio to their
respective virulency. Then there is the
further question of the wisdom of the
policy of assisting to protract liability to
these minor infections into mature life,
where they are likely to be more severe
and where days spell dollars, when with
small risk, at a time that in no way
presses, enduring immunity to their re-
currence may be acquired by squarely fac-
ing them instead of evading them. Does
the adult regret having had mumps and
measles in childhood ? A hardship, a handi-
cap, a plague — is it to be dodging mumps
and measles when duty urges and fortune
beckons ? Still another consideration should
not be overlooked. May it not be that the
very mildness of type characterizing these
diseases of childhood under discussion, and
which reduces to the minimum their im-
portance as to suflFering and danger, may it
not be that this marked mildness is due to
partial immunity gained by the process of
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BTIOLOOY AND DIAGNOSIS
Ameeican Medicine
transmission from generation to generation
of a lowered or declining susceptibility?
May we not thus be the beneficiaries of an
hereditary attenuated liability? The rav-
ages wrought by certain ordinarily not fatal
infections among races to whom they had
priorly been unknown lends color to the
theory. If partial immunity can be pro-
gressively attained, why could it not be re-
trogressively influenced and modified?
Some day there may be told a mournful
tale of immunity won and lost.
THE DOCTOR MUSES,
I am the first
To welcome you
Into the world.
I listen anxiously for
Your first feeble wail
Announcing your arrival.
As you grow, and develop.
All your baby ills
Are carefully considered
By me.
Even the first
Little tooth
The pride of fond mothers always,
Needs my skill
And care —
Something more than
Fond pride —
To welcome it!
I supplement the
Mother love
Which often
Does not know,
I am at your
"Beck and call"
Always.
To whom do you turn
In the greatest crisis
Of your life?
The Doctor!
When you stand
At the Gates of Death —
You, or one of your loved ones —
I am summoned
And I come.
Mayhap thru wild winter storms
Or summer's fierce heat
I answer the call of Duty.
I try again to put your feet
Onto the
Highroad to Health
And success.
Straightway, if I succeed
You forget.
If, being fallible, and human
I make one mistake,
I am cast aside, all
Benefits forgot!
I grow gray in
Your Service.
Always, always, I stand beside
The bed of pain,
To soothe and succor.
That is my life.
My bitter cup,
That you so soon
Forget.
What say you? Another call to duty
From one who suflFers
Dire distress?
(Farewell brief moment of my leisure!)
I will come.
From one who never pays me
Sav you?
Ah!' Well!
Still answer,
I will come.
Clara Louise Carleton,
m
ETIOLOGY
AND
IA6NOSI
"^
Etiology and Treatment of Ennresls*— Grover
(Jour, A, M. A., Aug. 24, 1918) bases his con-
clusions upon a study of about 200 cases in
children between four and twelve years of age.
He believes that the condition is never a dis-
ease entity, but is merely a symptom of an
underlying, general neuromuscular fatigue. The
fatigue is chronic and the patients are all of
the overactive, nervous type. There is often
an element of marked mental strain from too
prolonged school work. The treatment is ex-
clusively dietetic and hygienic. All food be-
tween meals is forbidden, even bread and but-
ter and milk, and the following foods are ex-
cluded from the diet: Soups, coffee, tea, cocoa;
sweet, salty and highly seasoned food; ice
cream, candy, cakes and pastry; jellies, jams,
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ETIOLOGY AND DIAGNOSIS
NOYBMBER. 1919
737
etc.; condiments, bananas and raw apples. To
simplify the digestive work at night meat, eggs
and vegetables are forbidden at supper. The
diet consists of milk, butter, eggs, meat, fish,
breadstuffs, cooked cereals, macaroni, vege-
tables, orange, stewed fruits and simple, un-
sweetened desserts. No fluids are given after
four p. m.; the child must be in bed by seven
p. m., and no active play is allowed after four
p. m. If very nervous, school is temporarily
prohibited and a nap required every afternoon.
Moving pictures, music lessons and evening
study are prohibited. Absolutely regular hours
are established for urination at night, namely,
seven and ten p. m. and six a. ul; and in some
cases with small bladders, two a. m. for a
while. The day wetters are made to urinate
at regular times by the clock, the intervals be-
ing lengthened to increase the capacity of the
bladder until a satisfactory r^ime is estab-
lished. Rewards are offered for following the
directions. The results of such treatment are
surprisingly good as shown by the fact that
nineteen per cent, of the patients did not wet
again after their first visit, twenty-three per
cent did not wet once after the first few weeks
or months, thirty-one per cent, were reduced
to a maximum of wetting once a week, and only
twelve per cent, were not benefited at all.
The Cerebral Complications of Miimps«—
Mumps is generally considered a benign infec-
tion; but during epidemics it may increase in
virulence and severe complications arise, states
an editorial writer in the Jour, of the Amer-
Med, Assn. (Sept 20, 1919). Of the complica-
tions, orchitis, pancreatitis and meningitis are
the most important. Meningeal reactions may
appear two or three days after the appearance
of the swelling, or later as th^ parotitiB is sub-
siding. Frequently orchitis also develops. The
meningitis may manifest itself by increased
fever, headache, insomnia, general discomifort
and, according to Acker, exceptionally by nau-
sea, vomiting, rigidity of the neck, Kemig's
sign, and pupillary changes. The spinal fluid
usually is clear, but is under increased pres-
sure and shows a lymphocytosis. Before the
advent of spinal puncture, these meningeal
symptoms were spoken of as a meningismus of
parotitis; but now the occurrence of actual men-
ingitis in the course of mumps is accepted. In
a recent study, Haden remarks that many fea-
tures of the nervous complications point to an
* encephalitis, and not simply to a meningitis,
and that in most cases the cerebral symptoms
are out of all proportion to the meningeal re-
action as reflected in the spinal fluid. The
occurrence of symptoms of cerebral irritation
was noted by Acker, who also records cases
with convulsions, monoplegia, hemiplegia or
aphasia. Other recent reports seem to conflrm
the view that the ssonptoms are due to an in-
volvement of the brain substance; but in the
absence of anatomic study of such cases the
question remains open. It may be well to re-
call that, in acute infectious diseases, edema of
the brain may produce cerebral symptoms with
or without signs of meningeal reaction and that
the spinal fluid in such cases may show no
cellular changes. The association of orchitis
with meningitis in mumps is of interest in view
of the recent report by Latham of epididymitis
as a complication of epidemic meningitis. He
states that some of the mildest cases of men-
ingitis may show marked epididymal involve-
ment On the basis of Latham's report that in
70 per cent, of the cases with epididymal in-
volvement the meningococcus was found in the
blood, we might assume that analogous inva-
sion of the blood takes place in mumps and that
close study of the blood may throw light on
its cause.
Warts* — In explanation of the etiology factor
in the production of common warts Wile and
Kingery (Jour, of the Amer. Med. Assn., Sept
27, 1919) state that there have been advanced
at various times the opinions that they are
caused by an infecting organism, trauma or a
foreign body. There are many clinical exam-
ples which stand out in favor of each of these
hypotheses. The frequency with which ver-
rucae occur at points of trauma^ notably on
the hands and feet, would, at first glance, speak
strongly for trauma as the causative agent In
favor of a foreign body as a possible cause are
the numerous clinical examples of localized hy-
perkeratosis following accidental implantation
of thorns, thistles, bits of glass and steel. That
localized hyperkeratosis of a warty type un-
doubtedly occurs following such foreign body
implantation is, however, in no way conclusive
proof of the etiologic moment of the foreign
body itself. The injury incident to the en-
trance of the foreign body can as readily be
accepted as the portal of entrance for an in-
fecting organism. The clinical evidence in
favor of an infectious agent in the causation
of warts is extremely suggestive.
RoTslng's Sign in Chronic Appendicitis*—
Among the provoked pains of chronic appen-
dicitis, says an editorial writer in the New
York Med. Jour. (Aug. 16, 1919), a special place
should be given to pain produced by the forc-
ing back of gas in the cecum and appendix.
To this phenomenon the name of Rousing has
become attached, because he apparently was
the first to study it But the paternity of this
sign does not in reality belong to the distin-
guished surgeon of CJopenhagen. He unques-
tionably was the first to advise to search for
pain by progressively pushing back the gas in
the descending colon from below upward, then
continuing to slide the hand, still pressing
deeply from left to right along the transverse
colon and finally sliding it from above down-
ward into the fiank and right iliac fossa to-
ward the cecum. This procedure, which is dif-
ficult to carry out properly, is due to Rovsing
and to it his name rightly belongs, but three
years before he published his method in 1907,.
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TREATMENT
Amkricam Mkdicink
Walther of Paris demonstrated that free and
deep abdominal palpation over areas other than
the right iliac fossa provoked a pain in the
appendix by gas distention of the cecum.
In all doubtful cases of appendicitis it is well
to look for this appendicular pain by distention
of the cecum, which will generally give valu-
able data. With the right hand applied flat
on the middle and left part of the abdomen,
deep pressure is made, forcing the intestinal
gas back toward the right segment of the colon.
Then the left hand is progressively pushed
into the area of the right colonic angle whereby
the cecum becomes distended. By this technic,
pain in the appendix from cecal distention is
more readily realized than by Rovsing's method.
Not only is this sign very accurate, but it
possesses another great advantage. In nerv-
ous subjects, direct palpation of the right iliac
fossa — a region spontaneously painful — is ren-
dered more difficult on account of the patient's
apprehension, who instinctively contracts the
abdominal wall. On the contrary, palpitation at
a distance does not awaken this distrust, so
that an exploration can be carried out which
would otherwise be impossible.
Drug Addlctioii. — In a recent number of the
American Journal of Public Health, Ernest S
Bishop discusses the subject of drug addiction
and points out that this is a disease which
should be studied and treated primarily from
a scientific instead of from a social and legal
point of view. Drug addiction is recognized
as a problem involving nearly as many persons
as tuberculosis, people who should not be re-
garded purely as mental degenerates. Dr.
Bishop asserts — and probably no one in America
can speak with greater authority — that drug
addiction exists in mentally, morally and physi-
cally normal individuals as well as among the
lower classes with whom it is generally asso-
ciated. Bishop believes that the phenomena
which attend withholding opiates in the ad-
dicted may best be explained by the presence of
some antidotal substance developed and circulate
ing in the blood. In order to deal more ade-
quately with the drug situation, the author
recommends organized scientific, medical or pub-
lic health activity directed towards the clinical
and laboratory investigation of this disease.
REATMENT
-in
^L
Gonorrheal Arthritis*— In regard to gonor-
rheal arthritis, first be sure that your arthritis
is of gonorrheal origin. This can be ascertained
by the history, the age, the sex of the patient,
by the complement-fixation test for gonorrhea
and, of course, smears from the urethra and
smears after prostatic massage will help. Gold-
stein (Med. Brief, Nov.. 1919) sUtes that all
of these cases have a focus of infection some
place and this is usually in the prostate or the
seminal vesicle in the male and in the tubes
and ovaries of the female. The gonorrhea can-
not be eliminated unless you treat these foci
of infection. The best method of treatment
other than the rest and local treatment is the
administration of large doses of antigonococcic
serum, say up to 50 c. c. This is given best,
ordinarily, in doses of 10 or 15 c. c. on succes-
sive days. The action of the serum is enhanced
by the combined administration of mixed poly-
valent vaccines in doses varying from a quarter
of a billion to two, three or even four billion.
In the more subacute or chronic cases, the care-
ful administration of fresh vaccine in large
doses seems to do more good than the serum
alone. The preferred method of treatment is
a combination of the two. Occasionally, on the
eighth or tenth day following the administra-
tion of the serum, there is an anaphylactic re-
action. This can best be controlled by the
administration of adrenalin, 1 to 1,000 in 15
minim doses every hour to five hours, and
V,ot to V,5»th of a grain of atropine hypoder-
mically. Large doses of alkaline remedies,
lemonade and kalak water can be given until
the reaction subsides. If the gonorrheal rheu-
matism does not then improve, one must keep
on with the local treatment, prostatic and vesicid
massage, etc. Then again, failure in improve-
ment may be due to inadequate dosage of anti-
gonococcic serum and antigonococcic stock vac-
cine— the intravenous administration of the se-
rum may act more promptly in severe cases.
Finally, don't forget the tonsils, bad teeth
and infected sinuses are the most frequent
cause of an arthritis, and that this source of
infection may be overlooked even if there is
a urethritis present.
Cutaneous Cancer,n-Reporting on dermatol-
ogy in Boston Medical and Surgical Journal
(May 30, 1918), Bowen says that cauterization
is by some considered to be better than the
knife or curette for cutaneous cancer, because
it does not open up the lymphatic and blood
vessels, and also claims for it a selective
action on the pathologic tissue and that an
inhibitory action is produced on the malignant
cell by the copious outpouring of serum.
1. If the lesion is in the earliest stages of
evolution, a local cure may be expected as a
result of adequate treatment with arsenic paste,
actual cautery. Roentgen ray, or radium fulgu-
ration and excision. It is advisable, even in
these early cases, to apply the Roentgen rays
to the treated area and the neighboring lym-
phatics when the lesion has been destroyed by
some agent other than radium or the Roentgen
ray. Speaking comparatively of the Roentgen
ray and radium, there are instances when the
latter is of greater value, namely, in Roentgen
ray cancer and the growths that occur in
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AMIRICAN MBDIOUOI
TREATMENT
NOVBMBBR^ 1919
739
xeroderma pigmentoBum. Radium is also pref-
erable in epitheliomas developing on leuko-
plakia, not only on account of the location, but
because the results are superior.
2. If the growth is advanced beyond the
very early stages, it should be removed by ex-
cision and the roentgen ray applied as a pro-
phylactic agent, as already outlined.
3. If, for various reasons, the lesion cannot
be excised, it can be removed by the actual
cautery or with arsenical paste, and the Roent-
gen ray used as a prophylactic.
4. Finally, there are cases in which, on ac-
count of certain complications and difficulties,
none of these methods can be utilized. In such
instances we can resort to Sherwell's method.
Diet During the Pverperiam^— The diet ad-
vised for the puerperal woman in the average
textbook on obstetrics is irrational, states
Rucker in the May issue of the Virginia Med,
Monthly. One should bear in mind that the
milk flow is largely influenced by the diet and
can be largely controlled at will by the char-
acter of food given, and especially by the
amount of fluid allowed. Certain articles of
food are partly excreted in the milk, or modify
in a manner prejudicial to the infant — espe-
cially acid fruits and vegetables with a decided
flavor such as cabbage, turnips, carrots and
sweet potatoes. Both the old method of starv-
ing the puerpera for the flrst week and the
newer ' procedure of forced feeding — ^which
means forced liquids — are cruel and unneces-
sary. Under the latter procedure the breasts
become greatly engorged and very painful, ex-
pert nursing becoming necessary for their re-
lief. A more rational plan is to place the pa-
tient at once on a general diet and then modify
it according to the behavior of the breasts.
If the milk proves inadequate the fluids can
easily be augmented or the patient even placed
on a liquid diet. The general diet obviates the
loss of weight so common in former times, as
well as the more recent painful breasts. It
is more pleasant for the patient, allowing her
a greater variety of food and is less constipat-
ing, an occasional enema being usually all that
is required. Since the author adopted this plan
of feeding, several years ago, no patient has
had engorged, painful breasts. The milk flow
has been more gradual in onset, but longer
sustained. In most cases it has been abundant,
even in highly nervous, frail women. The over-
abundance of milk often followed by agalactia
because of inability of the infant to empty
the breasts, was never met with.
Amebic Dysentery: Treatment by Bismnth.^
Yorke (British Med. Jour,, April 12, 1919)
draws attention to the value, in the treatment
of acute amebic dysentery, of bismuth subni-
trate in massive doses, as recommended by
Bates from experience gained in the Panama
zone. A combination of large doses of bismuth
by the mouth, combined with hypodermic in-
jections of emetine, gives much more constant
and satisfactory results than emetine alone.
A preliminary saline purge is given unless
the acute dysentery has already persisted for
several days, in which case it is unnecessary.
Emetine hydrochloride, one grain, is injected
subcutaneously, and bismuth subnitrate, 120 to
180 grains, suspended in milk or water, is
given by the mouth three or four times daily
for a period of twelve days.
Occasionally a morning saline may be neces-
sary if the bismuth causes constipation.
This treatment invariably clears the stools of
entamebae — a result which can by no means
be claimed for emetine alone — and causes the
disappearance of the symptoms of acute dysen-
tery, the stools speedily becoming less frequent
and free from blood and mucus.
Ambnlatory Treatment of Tarlcose Ulcer and
Edema of the Leg.— Audibert and Fouquet
(Presse mMicale, May 8, 1919) recommend a
treatment based upon firm bandaging of the
limb with gauze impregnated with the follow-
ing paste:
Gelatin, \
Zinc oxide, \ of each 10 grams
Starch, )
wS""' l^'^^l^ ^(^^^m^
Potassium silicate 100 grams
Before use the gauze bandage is softened in
warm boiled water and subjected to pressure
to drive out any excess of the paste. The ulcer
and surrounding tissues are carefully cleansed
with boiled water, the ulcer dusted with a
bland powder, and its margins protected with
strips of leucoplast to prevent subsequent tear-
ing away of new epidermis when the dressing
is removed. The prepared bandage, which
should consist of rather stiff gauze, is then
applied about the foot and leg in circular fash-
ion, beginning at the root of the toes. In cases
with edema, some degree of pressure should
be exerted over the lower portion of the leg.
The dressing Is renewed every four days at
first; later, when suppuration has ceased, at
weekly intervals. This form of dressing is ab-
sorbent and antiseptic; mercury bichloride, one
in 1,000, or salicylic acid, may be added to the
formula to enhance the latter property. The
treatment was applied with notable success in
120 cases. Its efficiency is illustrated in the
case cited of an ulcer of ten years' standing
which healed in thirty-one days — after six
dressings.
Pain disappears in a few hours after appli-
cation of the dressing and the patient is urged
to walk about, the resulting activation of local
circulation, now supported by the bandage
which acts as an artificial covering fascia, pro-
moting the processes of repair. Granulation
is often so active that application of silver ni-
trate becomes necessary. After recovery, re-
currence should be prevented by means of an
adjustable elastic bandage. The treatment is
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October^ 1919
QBJNBRAL TOPICS
Amirican Mbdxcinb
serviceable also in syphilitic leg ulcers as an
auxiliary measure.
Treatment of Epithelioma by Badliim,n-A
writer in the International Clinics emphasizes
the fact, with many photographic illustrations,
that in each case the proper form of radiation
and dosage for each case must be carefully
determined.
Four classes of epithelioma are to be con-
sidered:
First, the lesion which can be cured by one
application of radium with the proper dosage.
Second, the lesion which is so situated that
glandular involvement is likely to take place
or has already occurred and the Roentgen ray
should be employed as an adjunct to treat ad-
jacent glands.
Third, those cases in which the local appli-
cation of radium supplemented by the Roentgen
ray will only act as a palliative measure.
Fourth, those cases in which excision is Justi-
fied to be followed by radiotherapy.
Professor Boggs {Therapeutic Record) be
Heves that radium and the X-ray should always
be considered first in the treatment of epithe-
lioma because, when properly applied, prac-
tically all epitheliomatous tissue can be made to
disappear and there are fewer recurrences than
by any other method. In order to apply the
method, however, the operator must have the
requisite clinical experience with these growths
as well as a knowledge of the use of the agents
employed.
Inoperable cases in which the tonsil is in-
volved, are often markedly improved so far as
symptoms are considered.
The Treatment of Taginal Discharge*— Chan-
dler (New York Med. Jour., Oct. 11, 1919) ad-
vocates treating ordinary discharges of the
vagina by a so-called dry method. Six treat-
ments were given in the cases reported. The
first three treatments consisted of swabbing
the cervical canal with pure carbolic acid and
painting the entire vagina mucous membrane
with a weak solution of iodine, after which the
vagina was packed with dry sterile gauze in
sufficient quantities to straighten out all the
folds. The last treatments consisted of the
application of a powder made of equal parts of
stearate of zinc, starch and boracic acid, and
packing the vagina with sterile gauze. The
advantages alleged were that this treatment
cured more quickly than any other method.
Treatment of Wonnds By Paraffin*— Pratt as-
serts that he knows {British Medical Journal,
March 1, 1919) of no. other treatment in which
the constitutional symptoms so quickly disap-
pear, in which the pain so rapidly subsides and
in which healing is so uninterrupted, as in
wounds and burns treated by soft paraffin.
The wound or bum is first thoroly
cleansed with sterilized water; the paraffin is
then melted and either sprayed by a special
spray or painted by a sterilized brush over the
affected area. One layer of gauze is th^
placed over the injured part and then another
layer of melted paraffin is either sprayed or
painted over the gauze. On the top of this a
cotton-wool pad in placed and then the part
is bandaged. The dressing is left undisturbed
for twenty-four hours, when it is removed and
a fresh application made. A third dressing is
applied In ordinary cases the next day and.
when necessary, a fourth dressing two days
after.
The Student's Health Creeds— The Indiana
State Board of Health has issued the following
"Health Creed" to the school children of their
state. It contains so much splendid advice in
brief, terse form that it should be sent all over
the country:
I believe my body and good health are sacred.
If I am sick it will very probably be because
I have violated some one or more of nature's
laws of health.
I will study nature's laws of health and will
obey them for my own sake.
I will not suck my fingers or pick my nose
or wipe my nose on my hand or sleeve, for
these practices are unsanitary and very Im-
polite.
I will not wet my fingers in my mouth when
turning the leaves of books.
I will not put pencils in my mouth or wet
them with my lips.
I will not put pins or money In my mouth.
I will only use my mouth for eating good
plain food, drinking pure water and milk and
for saying good and kind words.
I will always chew my food thoroly and
never drink whiskey or wine.
I will strive against the habit of ^clearing
my throat" because it is nearly always unnec-
essary and may be disagreeable to others.
I will not cough or sneeze without turning
my face and holding a piece of paper or hand-
kerchief before my mouth. Polite people never
cough in public if they can prevent it.
I will keep my face, hands and fingernails
as clean as possible.
I will not spit on the floor, stairways or
sidewalks, and will try not to spit at all;
ladles and gentlemen do not spit.
I will wash my mouth every morning on
getting up and at night on going to bed, and
will use a tooth brush if I can get one.
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American Mbdzcins
NOTES AND ANNOUNCEMENTS
November, 1919
741
I will be clean in body, clean in mind, and
avoid all habits that may give (^ense to others.
I will get all the fresh air I can and will
open wide my bedroom windows when I go
to bed.
The Poisoned Air of Industrial Sections^—
Pine trees die in industrial cities, especially
where much soft coal is used, and they die be-
cause they cannot breathe, says a writer in the
Medical Council. Deciduous trees that shed
their leaves or breathing apparatus once a year
may live there, for they renew their respiratory
systems every spring. Coniferous trees, espe-
cially those with needle leaves, are easily choked
by the carbon and sulphur products in the air.
and they gradually die.
If man could shed his respiratory mucous
membranes and cells once a year he would
rarely get catarrh, bronchitis, pulmonary tu-
berculosis, bronchial asthma or influenza. But
man is Just as much biologically unfited to live
in a poisoned atmosphere as is the pine tree,
for he is of the perennial type, not the decidu-
ous one, and his respiratory system is very
sensitive.
In addition to this, man is peculiarly sensi-
tive to organisms that gain entrance to the
respiratory tract; and the chemical irritation
caused by the acids generated in the air of
industrial sections renders him all the more
susceptible. Indeed, with man, nearly all of
the respiratory diseases, including catarrh, are
more or less infectious; and if there is a great
incidence of respiratory disease In an industrial
city, with the gradual generation of peculiarly
malignant strains of common catarrhal organ-
isms, the persons in the surrounding country
are apt to be Infected, even if the air at their
homes is pure. The great consumption of gaso-
line in the cities is also greatly adding to air
contamination.
The lesson from all of this is obvious and it
is becoming increasingly evident that smoke
and gases resultant from combustion must be
more intelligently handled and a way found to
eliminate this menace to public health.
NEWS NOTES "»
ANNODNCEMENTf
Boylston Medical Prizes*— These prizes, which
are open to public competition^ are offered for
the best dissertation on questions in medical
science proposed by the Boylston Medical Com-
mittee.
At the annual meeting held in Boston in 1916
a prize of three hundred dollars was awarded
to an essay entitled ''Studies of the Streptococ-
cus of Smith," by Wilson G. Smillie, M. D., of
Cambridge, Mass.
For 1919 there is offered a prize of three hun-
dred dollars and the Boylston Prize Medal, for
the best dissertation on the results of original
research in medicine, the subject to be chosen
by the writer. The Boylston Prize Medal will
be added to the money prize only in case the
winning essay shows special originality in the
investigations detailed.
Dissertations entered for this prize must be
in the hands of the Secretary, H. C. Ernst,
M. D., Harvard Medical School, Boston, Mass.,
on or before December 31, 1919.
In awarding these prizes, preference will be
given to dissertations which exhibit original
work, but if no dissertation is considered
worthy of a prize, the award may be withheld.
E^ach dissertation must bear, in place of the
author's name, some sentence or device, and
must be accompanied by a sealed packet, bear-
ing the same sentence or device, and containing
the author's name and residence within.
Any clew by which the authorship of a dis-
sertation is made known to the Committee uHll
debar such dissertation from competition.
Dissertations must be printed or typewritten,
and their pages must be bound in book form.
All unsuccessful dissertations are deposited
with the Secretary, from whom they may be ob-
tained, with the sealed packet unopened, if
called for within one year after they have been
received.
By an order adopted in 1826, the Secretary
was directed to publish annually the following
votes: —
1. That the Board does not consider itself
as approving the doctrines contained
in any of the dissertations to which
premiums may be adjudged.
2. That, in case of publication of a success-
ful dissertation, the author be consid-
ered as bound to print the above vote
in connection therewith.
The Boylston Medical Committee is appointed
by the President and Fellows of Harvard Col-
lege, and consists of the following physicians:
William F. Whitney, M. D., Chairman; Harold
C. Ehnst, M. D., Secretary; William T. Porter,
M. D., Edward H. Nichols, M. D., Reid Hunt,
M. D., Henry A. Christian, M. D., John Warren,
M. D.
The address of the Secretary of the Boylston
Medical Commi^te is Harold C. Ernst, M. D.,
Harvard Medical School, Boston, Mass.
That Precious American Soap«— Tou pay
thirty-five cents for an ordinary piece of coarse,
brown laundry soap in Prague, Bohemia, and
toilet soap costs six times as much. Some soap
has been sent in by the American Red Cross
but sending in soap enough to wash a nation is
a big Job, and this new republic of Czecho-Slo-
vakia has few animals left from which to obtain
soap fats. Neither does it have trees that pro-
duce vegetable oils.
In Rumania, too, soap is more to be desired
than rubies or fine gold. A Red Cross worker,
inspecting the hospitals in Bucharest, was met
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742
November. 1919
NOTES AND ANNOUNCBMBNTS
Amhucan Mkdioinb
everywhere with accounts of the cures effected
thru the use of American soap. Two thousand
cakes had been distributed at a military hos-
pital at Aradea Mare and the doctors in charge
declared that 600 cases of sore eyes had been
cured principally thru the use of this soap. At
Bekes Csaba, soap again was praised as a
remedy which had abolished skin diseases
among hundreds of patients.
Caring for Dmg Addicts In Louisiana^— Vis-
iting physicians who have specialized in the
treatment of the drug habit said some interest-
ing things to the State Board of Health at a
recent meeting in New Orleans says a writer in
the Item, One of the most pleasant was that
the clinic for drug addicts, operated under con-
trol of Doctor Merrick Swords, is the best and
most sensibly managed in the country because
it handles the sufferers as it would any other
persons afflicted with disease and because it
safeguards their identity from prying eyes and
relieves them alike of the extortions of the drug
peddlers and the exaction of "institutions" and
"experts", most of which do them no good. It
is gratifying to know that here is one thing the
State of Louisiana is doing for its unfortunates,
and doing well and competently.
The visitors also remove the mysterious hor-
rors in which rumor has enveloped victims of
the drug habit. The addict, said one of them
is not a liar or a criminal. The percentage of
crimes and untruthful persons among them is
about the same as among ordinary humanity.
Drug-taking does not cause, nor is it an evi-
dence of degeneracy. The victim of drugs is
merely one who is ill and who will cooperate
with the physician if he knows that his advisor
is honest and competent.
Another interesting point made was their
warning against the professional reformer who
wants to remake humanity with a few slogans
and catchwords and would heal the sick by
passing laws to harass or imprison them. Hu-
manity may be coaxed into the right path, it
may be weaned away from disease and habits
that cause disease, but not by "drives" and
"professional propaganda." And dear Lord,
how weary the country is getting of them!
Genito-Urlnary Clinics* — Physicians are cor-
dially invited to the geni to-urinary clinics given
by Dr. Abr. L. Wolbarst on Thursday eve-
ning, at 8.30 o'clock, November to March in-
clusive, at the West Side Dispensary and Hos-
pital, 328 West 42nd Street, near 8th Avenue,
New York. Interesting cases may be brouj'ht
for diagnosis and conference.
VfhSLt We Know Abont Cancer*— The Ameri-
can Society for the Control of Cancer an-
nounces the publication, thru the Council on
Health and Public Instruction of the American
Medical Association, of a new handbook for
practitioners entitled "What We Know About
Cancer." The handbook has been prepared by
a special committee consisting of Dr. Robert
B. Greenough, director of the Harvard Cancer
Commission; Dr. James Swing, professor of
pathology at Cornell University Medical C(^-
lege, and director of cancer research at the
Memorial Hospital, New York, and Dr. J. M.
Wainwright, of Scranton, Pa., for many years
chairman of the cancer commission of the
Pennsylvania State Medical Association. In
addition the manuscript has been reviewed and
criticized by a number of prominent surgeons
and other students of cancer and revised in
accordance with the suggestions thus obtained.
The handbook 'atten4>ts to provide in a brief
compendium the essential facts about cancer
in general and its manifestations in the dlffei^
ent locations where it most commonly occurs.
Organiiatlon Against Health Insiiniiice.^
The New York Federation of Physicians an-
nounces that the Kings County Professional
Guild will call a mass meeting in the near
future for the purpose of organizing the medi-
cal profession in opposition to compulsory
health Insurance. Persons desiring further in-
formation may communicate with the organiza-
tion committee at 207 East Tenth Street, New
York.
Dr. Garvin Decorated for Servlees In Frasee.
— Major Albert H. Garvin, chief of the Bureau
of Tuberculosis, Medical and Surgical Depart-
ment with the American Red Cross' forces in
France, has been decorated with the Medallle
d'Honneur de Vermeil of the French govern-
ment in recognition of his services to that
country. Major Garvin, who went to France in
September, 1917, was superintendent of the
New York State Hospital for Tuberculosis for
ten years. He returned to America late in
June.
IT ISN'T YOUR TOWN— IT'S YOU.
If you want to live in the kind of a town
Like the kind of a town you like.
You need't slip your clothes in a grip
And start on a long, long hike.
You'll only find what you left behind,
For there's nothing that's really new.
It's a knock at yourself when you knock your
town.
It isn't the town — it's you!
Real towns are not made by men afraid
Lest somebody else gets ahead.
When everyone works and nobody shirks
You can raise a town from the dead.
And if while you make your personal stake
Your neighbors can make one, too,
Your town will be what yon want to see.
It isn't the town — it's yon!
— Exchange.
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Complete Series. Vol. XXV. No. 12
IS'ew Series, Vol. XIV. No. 12
jJAN oU lyZO
DECEMBER, 1919
$2.00 ^^ARLY
In Advance
PUBLISHEII MONTHLY
Editorial Offices: 18Ea8t41»l8t.,NewYark €i(j. Publlcatioii Offkes: 189 Colleir<^ St., Burlington, Vi
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The Longest Therapeutic Way Round
is sometimes the shortest way to satisfactory results.
Bronchial irritation and inflammation is often most
quickly and efficiently influenced by administration
of oil per os, which stimulates secretion, soothes and
promotes expectoration, without upsetting digestion.
TERRALINE
(FETROLEIM PIRIFK ATION)
is medicinally pure petroleum oil, bland, palatable
and supplied either Plain, with Heroin, or with Cre-
osotes.
TERRALINE is soothing, relieves cough, promotes
expectoration. It is also mildly laxative, soothing
and healing when used as an intestinal lubricant.
It is an ideal vehicle for many medicinal agents.
TERRALINE is intended for physicians prescribing
only. Old friends are apt to be best friends — Terra-
line has been tested and proven.
For practical and efficient administration of mercury
and KI, regarded as essential to the successful use of
arrhenic compounds, PIL MIXED TREATMENT
(Chichester) has won the confidence of, and is used
by thousands of physicians.
Sold in bottles only~never in bulk. Price $1.00 per
bottle.
HILLSIDE CHEMICAL COMPANY
>KMR( K<J». >. Y., r. S. A.
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American Medicine
H. EDWIN LEWIS, M. D., Manrnginz Editor
IRA 8. WILE, Associate Editot
PUBUSHID MORTHLT BT THB AmBICAH MlDICAL PUBUSHIKQ COMPAKT
Covyrifflited by tbe Amerioan Medioal PabUBhinc Co., 1919
Compete SeriM, Vol. XXV, No. 12
New Series, Vol. XIV, No. 12
DECEMBER, 1919
%f> on YEARLY
^^•UU In Advance
Reforming Medical Teachings — Recon-
struction in Medical Education was the
basis of the presidential address of George
D. Head, before the Minnesota State Med-
ical Society. His constructive arraignment
of medical teaching {Minnesota Medicine,
E>ec., 1919) is stimulating and suggestive,
constituting the practical reflections of a
teacher of medicine of twenty years' expe-
rience, after completing his observations of
the results of medical teaching as evidenced
in the military service.
His criticisms are not leveled at all medi-
cal schools, nor do his remarks cover all
individual students. He reviews the tend-
encies of medical colleges and sympathet-
ically makes interrogations concerning the
types of practitioners that are being devel-
oped at the present time. His estimate of
the nature of the graduate in medicine is
based upon certain qualities which he deems
essential. "He should possess: (1) Ade-
quate knowledge; (2) an analytical mind
capable of weighing evidence and drawing
conclusions; (3) a love of truth continually
urging him to make investigations and re-
cord observations; (4) a realization of the
limitations of his knowledge, which prompts
him to seek by diligent study and post-
graduate instruction to perfect it; (5) an
acquaintance with the art of the practice
of medicine secured by close association
with men of experience and personal quali-
fications; (6) a calm and equitable tem-
perament and a large fund of human sym-
pathy; (7) a lofty conception of the ideals
of his professional work, which lifts it
above the standards of business and civil
life."
From an analysis of current practice in
teaching, he concludes that there is a lack
in development of initiative, a tendency to
an overstoring of the mind with facts, a
lack in virility, in power and growth, and
insufficient attention to the development of
powers of analysis and keen observation.
In his words : "Our system of modern med-
ical education is now creating a type of men
with less initiative, weaker powers of ana-
lytical reasoning and, observation, and the
ability to differentiate clearly between fact
and theory than any generation of medical
graduates which has preceded him in the
last quarter of a century."
He demands some re-adjustment in the
relation of professor and student, so that
personal contact may be closer and so that
the realities of medicine may be presented
more directly than thru subordinate in-
structors. ' He advocates the development
of research work during the period of medi-
cal training as a means of fostering the
spirit of the investigator, arousing initia-
tive and cultivating the powers of observa-
tion. Particularly does he stress the ne-
cessity of creating a broad point of view
with reference to the human side of medi-
cine and a recognition of a greater degree
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744
Dbcbmbbr^ 1919
EDITORIAL COMMENT
Amhucan Mkdicinb
of humanity in the face of current prob-
lems. He wisely comments, **Men and
women are not test tubes and retorts," and
as a result he advocates more attention be-
ing placed upon the humanitarian side of
medicine, which he regards as having been
more in evidence two decades ago than at
the present time.
As a means of stimulating patience, op-
timism, human interest and understanding,
he suggests that some advantages are to be
found in a readaptation of the old pre-
ceptorial system.
In his philosophic comments, one notes
a greater appreciation of the humanities
than of the laboratories, and more belief
in medical idealism than in emphasizing
financial returns.
There is a wealth of suggestion in his
ideas concerning the reconstruction of un-
dergraduate education. He is not blind to
the dangers of an overweighted curriculum,
nor does he require medical omniscience as
the prerequisite to securing a diploma. For
this reason he calls for a greater effort on
the part of the profession to develop our
institutions of post-graduate instruction.
It is highly significant to find the reac-
tions to war experiences evidencing them-
selves in dissatisfaction with the general
plan of medical teaching. It is most hope-
ful to find the highest and the finest criti-
cisms arising in the medical profession and
from the lips and pens of teachers of long
experience and broad vision. It requires,
however, the backing of the rank and file
of the profession to sustain the efforts of
the leaders and to guarantee the reforms
in medical instruction that they boldly an-
nounce and unhesitatingly demand.
Supervised Pregnancy. — ^The effect of
a decade of efforts in behalf of infancy is
manifested in the mortality statistics. Ac-
cording to the figures of 1917 and preceding
years, it is apparent that infant deaths form
a smaller part of the total deaths. Certain
factors, such as diarrhea and enteritis, are
growing less important while other factors
as premature birth and birth injuries are of
increasing significance.
In 1917 the total deaths under one year
of age constituted only 15.7% of the total
deaths in the registration states, as com-
pared with 19.4% in 1910. It is striking
that the total deaths of infants less than
one day old increased from 9.8% in 1910
to 15.8% of the total deaths under one
year of age in 1917. The relative per-
centage of deaths under one week was
practically stationary. There was a small
decline for infant mortality under one
month of age, with a marked decline for
children between the ages of one month
and one year.
As might be suspected from the age dis-
tribution of mortality during infancy, there
is a pronounced increase in conditions lead-
ing to death during the first few days.
Whereas diarrhea and enteritis caused
28.6% of the infant mortality during 1910,
it was accountable for only 22.5% during
1917. On the other hand, malformation
increased from 5% to 7,2i%, premature
births from 14.3% to 20.5%, and injuries at
birth from 2.4% to 4.4% during the same
period of eight years.
There is cause for reflection in the in-
crease of the death rate from premature
births from 17.5% in 1910 to 21.1%c in
1917, as well as the rate of injuries at
birth from 3.2% to 4.6%. Possibly a part
of the answer lies in the intensity of ac-
tivity for infant welfare thru the* medium
of milk stations, improved health admin-
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AMIRICAN MBDIOINa
BDITORIAI. COMMENT
Dbcembeb^ 1919
745
istration and increased attention to health
education relative to the facts of infant
care. In all probability a certain measure
of responsibility rests upon the medical pro-
fession for the increase of death from birth
injuries, possibly due to the too frequent
and improper use of forceps. The increase
in syphilis is not marked in the death rate,
so . it possibly does not play a large part
in affecting the death rate from malforma-
tion or premature births; and this conjec-
ture is further supported by the fact that
deaths from congenital debility have sharp-
ly declined.
Mortality figures strongly suggest the
importance of extending facilities for
better obstetric attention and particularly
for the advancement of administrative meas-
ures leading to an improved hygiene of
pregnancy, with the accompanying benefits
of prenatal care. The methods thus far
employed are valueless for effecting a de-
crease in the mortality at birth or during the
first week, unless recourse is had to some
administrative measure such as maternity
clinics and instructive nursing for pregnant
women. Results thus far available indicate
that this course of action is most valuable
for diminishing the number of premature
births, lessening the number of still births
and for obviating many of the difficulties
incident to childbearing. Under these cir-
cumstances there is a powerful argument
for a wider introduction in baby-saving
campaigns, of the activities centered upon
pregnancy and labor.
A Sanitary Index*— In 1916 W. R.
Batt, Registrar of the Pennsylvania State
Department of Health, suggested a means
of securing a single figure which might
correlate health and sanitary conditions.
This ratio which he called *'the sanitary in-
dex" consisted of the sum of all the deaths
from causes number one to number fifteen
in the Abridged International Classification
of Causes of Death, plus all infant deaths
divided by the total population. The ratio
of all other deaths to the population he
called the residual death rate. The general
death rate consists of the sum of these two.
In the Tenth Annual Report of the Com-
missioner of Health of the Commonwealth
of Pennsylvania, the sanitary index is dis-
cussed as a method of measuring the effi-
ciency of public health work. The death
rate is merely an index of the ratio of the
number of persons dying in any fixed pe-
riod of time to each unit of one thousand
persons. Its reduction is most desirable,
but such a reduced death rate is not an
evidence of the effectiveness of efforts to
bring it about, nor does it suffice to indicate
wherein sanitary failure was responsible
for a larger mortality than should have oc-
curred.
At times the presence of specific diseases,
such as typhoid fever, tuberculosis, and
diphtheria, have been considered as a basis
for presenting statistics relative to sanitar}'
progress, but they fail to present a suffi-
ciently composite picture to indicate the
complete accomplishment of sanitation
along prophylactic lines.
A large group of diseases has been rec-
ognized as preventable thru direct sanitary
efforts, while another group has been rec-
ognized as being amenable to the helpful
influences of educational efforts to promote
personal hygiene. Such diseases as typhoid
fever, typhus, relapsing fever, malaria,
smallpox, measles, scarlet fever, whooping-
cough, diphtheria, cholera, dysentery,
plague, influenza and the various conditions
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Decbmbkr^ 1919
EDITORIAL COMMENT
Ambrican Mbdicikb
giving rise to infant mortality require and
absorb the bulk of the efforts and resources
of public health officers and the results of
grappling with them may be considered as
a reasonable index of efficiency in protect-
ing life and health.
These, therefore, are the diseases and
deaths from which are estimated, with re-
lation to the general population, the statis-
tics to establish a sanitary index.
The Pennsylvania experience during the
ten years, 1906-1915, evidences that the
principal reduction in the general death
rate has been due to the declining in deaths
from the diseases that are the. objects of
sanitary attack. The residual death rate
which includes the evidence for the need
for greater efforts to improve personal hy-
giene, safeguard industrial workers, and
improve racial vitality, does not evidence
the marked decline so patent in the sanitary
index.
A high sanitary index is the result of in-
adequate or ineffective efforts at sanita-
tion. Other factors entering into it are
the nature and character of the population
as reflected in age, sex, color and nativity,
and the presence or absence of uncontrolled
epidemics. In order to make the maximum
use of the sanitary index, a state or munici-
pality should be divided into several units
of population, possessing sufficiently nu-
merous basic common characteristics to
make comparisons possible and fair. The
numerical distribution need not be similar;
to illustrate, in Pennsylvania, population
groups consist of (1) 4 municipalities hav-
ing more than 100,000 population, (2) 8
municipalities of between 50,000 and 100,-
000 population, (3) 9 municipalities of be-
tween 25,000 and 50,000 population, (4)
41 municipalities of between 10,000 and 25,-
000 population, (5) 877 municipalities each
having less than 10,000 population. (6)
1,556 townships constituting the rural pop-
ulation.
The State Department of Health had the
direct responsibility for the sixth group
which comprised only 31.5% of the total
population of the state. By the use of these
various groups it was possible to study the
efficiency of the numerous administrative
agencies responsible for the maintenance of
sanitation.
This method of comparing the sanitary
indices provides a form of measurement,
which enables the student or investigator
of public health methods, to scrutinize the
results accomplished in terms of the ex-
penditure of money and effort. It is equally
valuable in pointing out sections wherein
sanitation has advanced or in which it has
failed to achieve the best result.
The use of measures of this character is
distinctly advantageous and while the san-
itary index is not to be regarded as the
final word in measurements of this type,
it does afford a practical and useful "yard
stick" when applied to wards in a city, coun-
ties in a state, or to the general work of
the various states within the nation.
The Metric System. — ^The standards of
weights and measures used in Great Britain
and America are out of harmony with the
metric system in its world-wide usefulness.
The difficulties incident to this lack of
harmony were emphasized during the pe-
riod of warfare, when the United States
War Department was obliged to adopt the
metric system for use in France, **for all
firing data, for artillery and machine guns,
in the preparation of operation orders, and
in map construction." This unified stand-
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EDITORIAL COMMENT
Dbcbmbbb, 1919
747
ardization was called forth because of the
numerous difficulties arising from endeav-
oring to secure unanimity in action while
discussing different units essential for war
measures.
As the Arabic numerals are now gener-
ally employed in mathematical computation,
so there is a need for a single standard of
measure. To this end there is renewed
agitation for the adoption of the meter-
Hter-gram standard in the United States and
Great Britain. Thirty-four nations now
employ the metric system exclusively, while
two hundred and twelve countries make
partial use of metric units or have adopted
standards equivalent to metric units.
When one recalls the vast number of
units of measure now employed for dry
measure, wet measure, Troy and apothe-
cary weight; and then contemplates the
different kinds of gallons and quarts, pecks,
bushels and ounces, the complexity of our
present system is at once apparent. The sim-
plicity of the metric system commends it-
self and the faciHty with which this decimal
system is acquired and used argues for its
adoption.
Whatever advantages the meter-liter-
gram standard possesses for commerce, in-
vention and scientific investigations also ap-
ply in the sphere of medical practice. The
tendency to write prescriptions in the metric
system is increasing despite the fact that
American practice labors under the dis-
advantage of having two systems which are
only interchangeable thru the use of a
simple mathematical formula. The phar-
macist has more service from the metric
measures than from the current standards
for dry or liquid measurement, and the use
of the apothecaries scale is more cumber-
some than the simple use of the metric
table.
The difficulty in introducing a single
system lies merely in tradition and con-
servatism. The decimal coinage in this coun-
try reflects an interest in the value of the
metric system. Had the advice of Thomas
Jefferson been followed, America would
have adopted the complete system more
than one hundred and twenty-five years
ago. It is not unreasonable to believe that
in our present-day efforts to secure some
relief from various phases of international
confusion, a new trial will be made to
adopt a universal plan for the expression
of quantity and that in this connection the
metric system will probably emerge trium-
phant. There is, assuredly, hope that the
example set by the United States Pharma-
copeia in adopting the metric system will
be followed in the near future thru the
national approval of the so-called French
system — which as a matter of history was
invented by an Englishman.
Venereal Suspects. — ^The various meth-
ods being employed to secure the control of
the venereal diseases raise numerous legal
questi(Mis. Vague regulations have been in-
stituted in various communities providing
for the detention of persons suspected of
having venereal diseases. In order to ascer-
tain the existence of syphilis, for example,
the employment of the Wassermann reaction
is frequently necessary. In this connection,
the opinion given by the Supreme Court of
Iowa shows the imperative necessity for
definite laws authorizing action by boards of
health. In connection with the detention of
persons suspected of having venereal dis-
ease, the following abstract from Public
Health Report, March 21, 1919, is of the
utmost importance.
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December^ 1919
EDITORIAL. COMMENT
American Mbdicinx
"One Wragg was arrested charged with
lewdness. Bail was fixed, subject however
to the order of the local board of health,
which board subsequently issued an order
detaining the accused until it could be ascer-
tained whether he was afflicted with a
venereal disease. Wragg then sued out a
writ of habeas corpus for his release. The
stipulated facts showed that petitioner
would be compelled to permit an expert to
extract approximately 5 cubic centimeters
of blood from petitioner's veins to deter-
mine whether he was afflicted with syphilis,
such test being known as the *Wassermann
reaction,' and that the petitioner would be
further restrained if the expert should re-
port a positive reaction.
"The Supreme Court of Iowa, in an opin-
ion by Judge Weaver in Wragg v. Griffin
(170 Northzvestern Reporter, 400) , after de-
termining that neither under the statute law
nor under the rules of the board of health
could a person merely suspected of having a
venereal disease be compelled to submit to
such an examination, says: 'Even when
charged with the gravest of crimes, one can-
not be compelled to give evidence against
himself, nor can the State compel him to
submit to a medical or surgical examination,
the result of which may tend to convict him
of a public offense; and, if there be any
good reason why the same objections are
not available in a proceeding which may
subject him to ignominious restraint and
public ostracism, it is at least a safe and salu-
tary proposition to hold that, before the
courts will uphold such an exercise of pow-
er, it must be authorized by a clear and
definite expression of the legislative will.'
"The writ was therefore sustained."
The justice of this decision, in the light
of present regulation, is not open to ques-
tion, but it is patent that public opmion,
crystallized into law, will make adequate
provision for securing the scientific infor-
mation desired. The tendency of the day is
to recognize the force and merit of pro-
cedures designed to protect the public
health, and, incidentally, to protect indi-
viduals from the dire results of their own
ignorance or neglect.
The existence of methods for determin-
ing dEsease carriers carries with it a cer-
tain responsibility for securing their appli-
cation in a practical manner in the interests
of the community. The determining of
venereal diseases, unfortunately, still mani-
fests a reflection of the attitude of the pub-
lic regarding venereal diseases in their
moral aspects. From the public health stand-
point, it is obvious that the moral and eth-
ical problems are secondary to public health
values. If the power of public opinion has
been eflfective in establishing a moral plane
which has permitted the concealment of
menacing diseases, a redevelopment of the
public conscience will suffice to counteract
this attitude. Thus will be established a
more powerful opinion concerning the dan-
gers of venereal disease, and the necessity
for their control in the interests of the com-
munity. A freer knowledge of the essential
medical and social facts will transform
some of the social energy now devoted to
the protection of individuals from possible
stigma and ostracism to the rational position
that is held towards those unfortunate
enough to be eflFected by non-venereal dis-
eases of a contagious nature, which do not
involve moral turpitude, but, nevertheless,
constitute the sufferers as potential sources
of danger to the public health.
A typhoid carrier, it is true, cannot be
held responsible for his condition, altho the
general public cannot escape the accusation
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AMBUOAN ICBDIOXini
EDITORIAIi COBOfBNT
Decbmbbr« 1919
749
of moral indifference to the continued ex-
istence of such a preventable disease. A
venereal disease carrier may be guility of
an infringement of the moral law, but the
public is not free from the criticism that its
general attitude toward venereal diseases
has been responsible to no small extent for
the degree to which veneral diseases
exist. Insofar as public effort seeks
to mitigate the surroundings and en-
vironment, the attitudes of mind, the in-
tentional disregard of the facts and evidence
of the essential truths bound up in sex lore,
it is aiming to counteract the pernicious con-
ditions conducive to venereal infection. In
the attempt to control venereal infections,
the public mind is being awakened to its
own blindness and neglect in a most en-
couraging manner.
The desire to control carriers of venereal
disease is laudable, but dependence cannot
be placed upon this method in order to
achieve satisfactory results. The promulga-
tion of laws for the detention and examina-
tion of venereal suspects is but a trifling
item in the campaign against venereal dis-
eases. It possesses, however, a valuable edu-
cational message, far above the slight effect
that such a procedure would have upon de-
creasing venereal diseases. It represents at-
tacking the problem on the basis of indi-
viduals, whereas accomplishment can only
be secured thru a wholesale revolution in
ideas, ideals, methods of administration, and
provision for the education and recreation
of the public. The venereal disease carrier
is assuredly a public health menace, but
one may properly ask whether the greater
menace is not to be found in the failure of
communities to realize their responsibility
for the existence of venereal disease in all
its manifestations, and in their origin in
a social laxity due to the widespread ignor-
ance and purposeful neglect.
The Births of a Nation. — ^The registra-
tion area for births in 1916 comprised the
six New England States, New York, Penn-
sylvania, Michigan, Minnesota, Maryland^
and the District of Columbia. This registra-
tion area comprising only about 25% of
the population of the United States sup-
plies the statistical material utilized in sup-
plying the second report on birth statistics
compiled by the Bureau of Census.
The most significant fact developed by
the study of the birth rates and infant mor-
tality is the marked excess of births over
deaths, particularly in those localities in
which the proportion of foreign born of the
population is the largest. The birth rate 24.8
per thousand population was 10.1 per thou-
sand higher than the death rate, 14.7 per
thousand. It is obvious that if the birth
and death rates of 1916 were to remain con-
stant and migration played no part in the
development of the areas concerned the
general population would increase annually
by a little more than one per cent.
A study of the native and foreign ele-
ments of the population makes patent the
fact that far more births occur annually to
white foreign born married women, aged
15 to 44, proportionately to their number
than to native white married women of
corresponding ages. In New York State,
for example, the per cent, of foreign bom
mothers to total white mothers in 1916 was
52.84, tho in 1910* the foreign born married
females, 15 to 44, constituted only 42.71%
of the total number of white married fe-
males, 15 to 44. As the relative proportions
of the female population probably did not
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December. 1919
EDITORIAL. COMMENT
Amsucan MBioma
change greatly between 1910 and 1916 it
is evident that the fecundity of foreign
born mothers in New York State was con-
siderably greater than that of native bom
mothers.
While war has achieved a certain degree
of national solidarity in the United States,
the various expressions of national sym-
pathy evidence the fact, fully recognized,
that the population of the United States is
far from homogeneous in character. The
elements of foreign blood entering into the
growing generation warrant consideration
in connection with any plan for the com-
plete Americanization of the present grow-
ing population, now in, or soon to enter, the
public school systems of the country. In
1916 in the birth registration area 52.4 per
cent, of the white children had fathers born
in foreign lands, while 56.6 per cent, of
their mothers were born outside of the Uni-
ted States. The non-American nature of the
stock is further evidenced by the fact that
11.3 per cent, of the fathers, and 11.9 per
cent, of the mothers were born in Germany,
Austria and Hungary. Italy gave 11.6 per
cent, of the fathers, and 10.6 per cent, of
the mothers. Russia and Poland yielded
10.7 per cent, of the fathers, and 9.7 per
cent, of the mothers. Canada and England,
Scotland, Wales and Ireland, together were
represented by only 7.2 per cent, of the
fathers, and 7.4 per cent, of the mothers.
Teutonic, Italian and Russian parentage
constituted the main generative forces giv-
ing rise to the American born children of
foreign parentage.
The inter-relatioii of birth rates andmor-
tality rates largely determines the growth
of population. The war has brought about
profound alterations in both sets of figures.
It is true that complete figures for the Uni-
ted States are lacking, but, nevertheless, it
is possible to gain some idea of the com-
parative position of the United States and
other countries in- the matter of the pro-
tection of infancy. A high birth rate is by
no means significant of rapid increase of
population, because a high mortality rate
may oflFset the apparent gain from new
lives.
The Australian Commonwealth of 1915
had a birth rate of 27.3 and an infant death
rate of only 10.7; in consequence, there
were 256 births per himdred infant deaths.
The German Empire, 1913, had a birth rate
of 27.5 and a death rate of 15.0 with a rate
of births per hundred infant deaths of 183.
New Zealand, 1915, had a birth rate of 25.3,
but a death rate of only 9.1 and the high
rate of 279 births per hundred deaths un-
der 1 year. The United Kingdom, 1915, had
142 births per hundred infant deaths. The
birth registration area of the United States
in 1916 had a birth rate of 24.8, and an
infant mortality rate of 14.7, and the num-
ber of births per hundred infant deaths was
168.
These conditions varying markedly are
strongly contrasted by the French figures
of 1912, when the births per hundred in-
fant deaths numbered only 108. While the
infant mortality rate of the United States
is fairly creditable, it is by no means as low
as that of Australia, Denmark, New Zea-
land, the Netherlands, Norway, Ontario,
Sweden, or Switzerland. Its birth rate is
lower than that of Australia, Chile, Finland,
Germany, Hungary, Italy, Japan, the Neth-
erlands, New Zealand, Norway, Roumania,
Russia, and various other countries as Aus-
tria, Italy, Germany, Hungary, Prussia,
Roumania during pre-war years.
While the highest birth rates remain
among foreign born parents, the infant
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AMCRICAN MBDIdNB
EDITORIAL COMMENT
December^ 1919
751
mortality rate similarly is found among the
same group of the population, altho the
relative infant mortality rates vary among
the different nationalities.
Again, the lesson is driven home of the
importance of a more complete system of
birth registration for more complete and
accurate mortality statistics as the basis
of organized work for the conserva-
tion of childhood. The year of re-
construction now opening should be marked
by renewed efforts to establish pub-
lic health work upon a firm basis. Vital
statistics are by no means dried and use-
less compilations of figures. They are force-
ful indications of the assets and liabilities
of the race. They are sign posts along the
road of racial progress which must be
numerous and easily read if nations are
to proceed freely along paths leading to in-
creased national health, prosperity and
happiness.
Artificial Limbs. — ^Up to September 19,
1919, there were exactly 1,200 claims for
artificial limbs, says a recent report of the
War Risk Bureau. Of these, 621 were ar-
tificial legs and 579 were artificial arms.
While the artificial limb was well known
to the ancient Egyptians and was issued by
Julius Caesar to the forces who captured
Gaul and invaded England, in its modem
application it is essentially the product of
American inventive genius. The type of
leg which Rameses used to order for his
men and which was in general use by the
niutiles of Pericles, consisted of a peg sur-
mounted by a hollow wooden cone lined
with leather, which was affixed to the body
by means of a pair of homely suspenders.
It was stiff and it was impossible, there-
fore, to "bend the pregnant hinges of the
knee." This was remedied by a French
gallant who, in 1853, discovered that the
emulation of "Hick, Hick, with his hickory
limb" was unpopular in French society. He,
therefore, inserted a hinge at the knee.
While, in the process of active perambula-
tion a strong metal pin prevented flection
of the limb, but when seated the gallant
beau would pull the pin and bend the hick-
ory limb with his hand, thus removing the
danger of tripping some fair Duchess. On
rising, the leg was straightened out, the
pin reinserted, and the process of "dot and
carry one" recommenced.
We have progressed far from that crude
apparatus. The close of the Civil War
necessitated the manufacture of large num-
bers of artificial limbs and American in-
genuity has succeeded in producing an ar-
tificial leg which is little short of marvelous.
The limbs are made of wood, covered with
rawhide which is shrunk on. They are
very light, comfortable and useful. Many
persons call them cork legs in the belief
that they are made of cork. They forget,
however, that the cork leg received its
name from a famous city in Ireland, cele-
brated for its artificial limbs.
Artificial hands are, however, not quite
so satisfactory. The arms themselves
really function very well. Several enterpris-
ing manufacturers have, however, succeeded
in producing fairly efficient artificial hands
which function reasonably well when used
with discretion and patience. The intelli-
gent men who are willing to train them-
selves carefully are able to use these with
a considerable degree of satisfaction. The
present war has stimulated very greatly in-
ventive genius along the lines of artificial
limbs and it is believed that before very
long an absolute satisfactory hand and arm
will be placed upon the market.
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MEN AND THINGS
AaiBRICAN Mm>igimb
N AND THINGS
Teachers' Salaries. — Medical interest in
the extension of education arises from the
fact that physicians are not merely practi-
tioners of the healing art and advocates of
public health education, but also because
they are citizens and parents. The neces-
sity for adequate school training is con-
stantly accentuated. Stress is placed upon
school houses, books and apparatus, but in-
sufficient thought is devoted to the two
most vital elements that go to make a school
— the pupils and the teachers.
In a recent report upon "Teachers' Sal-
aries and Salary Schedules in the United
States, 1918-19," prepared by E. S. Even-
den, for the Commission on the Emergency
in Education of the National Educational
Association, appear some striking state-
ments from which we select the following:
'There are more than 5,000,000 persons in
the United States over 10 years of age
(about one in every twenty) who cannot
read nor write." "Of the 3,208,446 men
examined by the draft boards of the United
States, 949,419 were declared physically
unfit for general military service. Con-
sidering that these men were in the prime
of life and assuming that even the same
proportion would hold for younger and
older men and for women, it would indi-
cate that there are 30,000,000 persons in
the United States who are to a greater or
less degree physically inefficient." "About
4,000,000 children are taught by teachers
less than 21 years of age, with little or no
.high school training, with no professional
preparation for their work and who are,
in a great majority of cases, products of the
same schools in which they teach." "The
average number of year's (200 days) at-
tendance at public schools for each indi-
vidual, as indicated by the school statistics
for 1916, was only 5.96%, or less than the
completion of the sixth grade for an aver-
age education for the citizens of the great-
est democracy of the world." "The total
high school enrollment for 1916 was only
8/4% oi the enrollment of the elementary
schools."
These statements are of the utmost sig-
nificance and should appeal particularly
to the medical profession whose mem-
bers represent a standard of education
and training far above the average. There
is every indication that Americ^a must
awaken to the necessity of developing and
securing a larger supply of adequately
trained teachers to enable our public school
system to prepare children for intelligent
citizenship. Regardless of the mental
capacity of children every scheme of edu-
cation requires efficient teachers. Money
may be "the root of all evil," but it is
equally true that it is essential for much
good. Competent teachers cannot be se-
cured at a rate of compensation that can
attract only the incompetents. According
to the report mentioned, an average yearly
salary of $630.64 prevailed, or less than
$55.00 per month. This figure is scarcely a
living wage and it is offered for the finest
type of constructive work in the direction of
training the young. What possibilities are
there for a rich Americanization with poor
teachers, poorly trained and poorly paid?
In such large cities as New York and
Chicago the salaries of school teachers are
far less than those paid in occupations
wherein relatively little training is required.
It is worth more to carry bricks, to ham-
mer iron, to mould dough, to wipe a joint,
to putty a window, or put on a horse's
shoe, than to lead the bodies and minds of
children to a high degree of health, power,
usefulness and loyalty. Street cleaning is
a highly paid occupation compared with
teaching, if the figures of New York form
a criterion, the initial salary of a street
cleaner being $400.00 more than the initial
salary of a school teacher.
It is time that the profession in its triple
guise of physician, parent and citizen.
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MEN AND THINaS
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753
awakened to a sense of professional public
and private responsibility toward matters
of this nature. We offer no apology for
urging medical men to take a practical in-
terest in educational affairs. There is no
subject more closely allied with the inter-
ests of medicine than education, and the
Doctor-TeacheF fully appreciates that the
laborer is worthy of his hire and that capa-
ble service can best be secured by the
granting of a wage in some measure com-
mensurate with ability, interest and enthu-
siasm and the desired highest type of end-
result.
How rarely, however, does one find a
medical society passing a resolution urging
upon the city father the necessity of grant-
ing a reasonable and deserved salary sched-
ule for the teachers of their children, those
excellent public servants who are charged
with the duty of making the next generation
a better, a healthier and a more ideal group
of efficient citizens.
Health Centers.— The United States
Public Service is urging a plan for the
nation-wide conservation of health and is
seeking to secure the cooperation of all
health agencies in a unified program. It is
patent that without a uniform program
there is great danger of duplication of effort
and waste of time, effort and funds.
. The benefit of a systematic attack upon
diseases is evidenced in the reduction of
the typhoid fever death rate from 33.8 per
one hundred thousand in 1900 to 13.4 in
1917, and tuberculosis from 190.5 to 146.4,
and diphtheria from 35.4 to 16.5 during the
same period of time. This evidence is
highly suggestive of the possibilities of co-
operation in public health administration
and demonstrates the possibilities of future
efforts in this direction.
The machinery of the American Red
Cross, now letting up its war-time activi-
ties, is to be transformed into health energy
on a peace-time basis. The benefits which
are to accrue to the country in the poten-
tials are most valuable, tho the actual ex-
tent of accomplishment will depend upon
the establishment of a definite program
with a distinct understanding as to the parts
which must be played by public and private
health agencies. It is obvious that various
sections of the country have distinct prob-
lems of local interest in addition to the
general problems common to all sections
of the country.
The greatest advantages now being real-
ized in the field of preventive medicine de-
pend upon cooperation, education, and the
development • of interest in personal and
familial hygiene. In these directions are
moving the great forces of public health
administration as well as the concentrated
energies of private organization, interested
in the control of tuberculosis, cancer, vene-
real diseases, the decrease of infant mortal-
ity, medical inspection of schools, and vari-
ous types of centers for the dissemination
of knowledge concerning the principles of
health.
The American Red Cross is seeking to
crystallize a part of its energy in the direc-
tion of assisting communities to establish
health centers. Without any idea of en-
croaching upon the 'fields of other accredit-
ed public or volunteer health agencies, it
aims to stimulate their eflForts and, when
possible, to coordinate them so that the en-
tire field of public health work may be
properly covered. As a new phase in this
effort its influence is to be cast on the side
of health centers which are to represent
not merely the physical headquarters for
communal health work, but the concrete
expression of the practical interest of the
community in the health and welfare of
the entire community. These are to func-
tion in the interest of health and the pre-
vention of disease thus differentiating
them from the regular type of dispensary
so well knov/n. They will serve as places
for the unification of dispensary facilities,
as clearing houses of health information
and in smaller communities may properly
take the form of community houses or
social centers.
While the chief activities of such health
centers would concern themselves with the
conservation of infants and children and
the prevention of tuberculosis, there would
be ample opportunity for directing energy'
along the lines of mental hygiene, industrial
hygiene, social hygiene, as well as oflfering
a center for dental work or the aftercare
services growing out of epidemics such as
influenza and poliomyelitis.
The aim of the health center should in-
clude the promotion of a better understand-
ing and cooperation between physicians in
private practice and those responsible for
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lODN AND THINGS
Ambbican Mm>icins
public health activities. In smaller com-
munities it might well become the head-
quarters of the county medical society, a
repository of the medical library, and the
location for consultations and diagnostic
clinics. It may become the recognized
source of centralized efforts for health
education and physical guidance, having
as an end the prevention of disease.
Thus constituted it would develop into a
neighborhood station affording construct-
ive suggestions for the promotion of the
general betterment of neighborhood life.
The recognition of health as a positive
virtue to be developed possesses a tremen-
dous advantage over the customary policy
of recojgnizing disease as a liability. The
health center idea is positively constructive
and curative of many community ills that
hitherto have grown out of the existence of
preventable accidents, diseases and defects.
Herein is an opportunity for an excellent
peace program in which may be enlisted the
activities of the medical profession and lay
workers in private organizations as well as
the direct interest of health administration
in cities and villages, in counties and states.
If the American Red Cross and the United
States Public Health Service can secure
the adoption of their plans a great step in
advance will have been taken toward assur-
ing mankind a larger opportunity for
achieving and maintaining health and of
improving the vitality and morale of the
race.
Surgeon, Soldier-President? — It is the
custom, with the approach of a presiden-
tial election, to put forward one's chosen
candidate with the assurance that he is
uniquely suited to a unique situation. If
he is a business man, the prediction is ven-
tured that an era of prosperty and big
business is looming ahead and that the can-
didate is the only one who could guide the
ship of state thru the hazardous waters.
If he is a lawyer, then it is legislation that
is needed and his long experience is ines-
timable. If he is a scholar, then statesman-
ship is the paramount issue. As often as
not these presidential barkers have gone far
afield to prove the indispensability of their
special choice. It is with caution, then,
that at any time a conscientious individual
will undertake to recommend a candidate
as the choice par excellence when there are
other candidates of notable worth and
achievement in the field. Yet this seems
to be an occasion when a medical journal
feels itself privileged and free, without fear
of seeming unoriginal merely, to recom-
mend one of its own brotherhood as sin-
gularly fitted for a responsibility which it
is becoming daily more convincing to many
that he could shoulder with credit both to
himself and the country. In numerous
quarters of the country the name of Gen-
eral Leonard Wood, surgeon, soldier and
builder, is coming forward as a presidential
candidate, and American Medicine consid-
ers it an honor to record its approval of a
choice which it considers admirable in
every respect. And if, despite forbidding
precedent, it is said that General Wood
seems uniquely the man for the occasion,
we hope it will not be thought that we are
resorting merely to rhetoric. We have in
mind his qualifications as soldier, surgeon
and builder.
Mr. Albert Rhys Williams, an amiable
radical of no mean discernment, recently
said: "They fought this war to end all
war. Now they are making a peace to end
all peace." Those who have been watching
the stubborn, misguided, muddled eflforts of
Congress, who are aware of the disorder
and chaos in Europe, who know that there
are half a dozen meaningless little wars
still going on abroad, are coming more and
more to agree with Mr. Williams. The
successful termination of the war has re-
moved definitely and perhaps forever a dan-
gerous enemy of order and peaceful prog-
ress, but the unsuccessful termination of
peace is perpetuating international suspi-
cions and misunderstandings which it will
not be easy in the next generation or two
to allay. International peace is still a tenta-
tive, uncertain thing, and the consequences
of the war are not all that were hoped for.
The unity of the Allies, so solid during the
war, shows disquieting marks of instability ;
and, in the effort to resume normal life and
normal business, there may occur more than
one delicate incident to try the harmony of
nations which, only a little while ago, had
but a single aim. Peace is still in the bal-
ance, the issue is still clouded, the position
of this country in the family of nations
still obscure; and, tho we are sure that
never again can such a hideous tragedy be
enacted, we feel, nevertheless, that a soldier
at the head of the country will give an
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assurance, the lack of which no few feel.
Leonard Wood, as a soldier, is not a chau-
vinist ; he is not a bigot, and he carries no
chip on his shoulder. He has the reserve of
a diplomat, the reticence of a student, the
modesty that goes with genuine ability, and
these are qualities that would make for in-
ternational understanding.
Many Wounds to HeaL — But above all,
the excellence of the choice is emphasized
by the fact that the late war has left the
world with many wounds to heal, and it
is as a surgeon that General Wood is espe-
cially fitted to play an important role in
this universal healing. It is not legislation
that the world needs most now, it is not
commercial arrangements that it requires.
Europe is in need of food, it is in need of
medicines and a period of convalescence.
The four years of war have left a mark
on the youth of Europe and the generation
to come will be an undernourished, nerve-
worn, delicate generation at best, and un-
less America comes to the rescue there may
be no generation at all. What Europe will
need most urgently during the next four
years — perhaps during the next twenty
years — will be ambassadors of mercy much
more than diplomats: the Red Cross, with
its splendid efficiency and vision, and the
various organizations for succor and aid
that sprang up during the exigencies of
war. A journalist of distinction, writing
from Vienna to a friend in New York and
asking for a Christmas present, begs pathet-
ically for a few cans of condensed milk,
none being permitted to adults, and children
getting too little of the paltry supply. In
the East thousands are dying daily because
of a lack of drugs and medical supplies.
Whole races on the fringe of civilization
are in danger of extinction for lack of prop-
er care. Disease is rampant. Tuberculo-
sis and venereal diseases are menacing the
lives of hundreds of thousands. Abraham
Lincoln declared the country could not ex-
ist half free, half slave. If he were alive
now he would declare with equal convic-
tion that the world cannot exist half wfell,
half sick. This country escaped the ravages
of the war. It should feel the obligation
to rid Europe of the ills which it was
fortunate enough to escape. Such an obli-
gation is now upon the country, and with
a man trained and experienced in medicine
at its head, it would fulfill this obligation
adequately and intelligently. The ever-
widening sphere of the doctor makes him
particularly fitted for an executive trust
that carries so many responsibilities with
it. His profession has given him the
acumen of the busness man, the tact of the
statesman, the humaneness of the reformer,
the vision of the legislator ; and these quali-
ties will stand him in good stead in an of-
fice which demands such a versatility of
talent as no other office requires. Major-
General Wood is a man whom the American
people can trust to lead them humanely,
wisely and well in this hour of the world's
travail.
Starving Armenia and the WorldTs
Duty. — Starving Armenia, its people driv-
en from pillar to post by the relentless Turk,
its population reduced to a mere fraction
of its original numbers, the survivors
starved, homeless, suflfering, is a case in
point. But it is a case which cannot wait
upon the fortunes of political change in a
far-oflF country. It is a case that demands
immediate attention. For it is not the fate of
a single nation or people that is in the bal-
ance. It is civilization that is up for judg-
ment. If the world should fail Armenia
at this stage, then confidence in the teach-
ings of humaneness, in the prestige of cul-
ture is reduced to a cipher. The basis of
all modem civilization is the respect for
human life. From our infancy we are
taught that it is wrong to kill, that it is
just as wrong to countenance the destruc-
tion of life even if we are not accomplices.
Yet, in its indiflference to the fate of un-
happy Armenia, the world is a tacit accom-
plice of the Turk. It holds aloof while the
victim of the most heartless crime in his-
tory is in the throes of death. This alone
would be ample grounds on which to im-
peach humanity, but it is not only a ques-
tion of human life — it is a question of human
intercourse, of morality, of the laws that
govern the fraternity of man and man. The
spectacle of Armenia is not alone of a race
dying, but of a race driven to desperate
measures to safe itself from annihilation.
Eye witnesses, fresh from scenes of that
wretched country, bring back accounts that
are ghastly in the extreme. Death has be-
come so ordinary a spectacle that children
may be seen playing at their games on the
highway with the corpses of other little ones
only a few paces away. A father was seen
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walking toward the market-place in the
company of his young daughter. A few
minutes later he was seen returning alone,
a sack of flour slung across his shoulder.
He had traded his child to a Kurd for the
sustenance of a few days. He was not
ashamed, he was not downcast. He took
the only measure he knew, a measure grow-
ing more and more commonplace, to save
himself from starvation. He had merely
imitated his fellows who, in their despair,
had grown dull to the dictates of common
morality. The wrong, in a larger sense,
was not his. It was that of a world which
permitted such things to happen without
any thought of the ultimate consequences
to itself. What will be the outlook of these
children playing on the highway when they
grow up? What micrometer will measure
the social conscience of the race bred by
a father who is driven to barter his daughter
for a bag of flour ?
It is not a local question, affecting only
the Armenians directly concerned. It is a
question affecting immediately the contigu-
ous countries, one which is bound to poison
the civilization of far-off countries. Thou-
sands of miles away nations tremble in fear
of the virus of Bolshevism that is coursing
in the veins of Russia, but they feel them-
selves secure against the taint of a poison
more destructive than the most deadly polit-
ical heresies. Are we so sound that we
can expose ourselves to the contagion of
such moral lassitude? And, if we are, can
we stand aside and indifferently look on
as the texture of morality is torn to shreds?
The world cannot allow such indignities to
be perpetrated against its self-respect. It
cannot allow fellow-humans to be driven to
measures that destroy all the careful build-
ing* of centuries of civilization. In self-
defence, if for no other reason, it must
come to the aid of Armenia.
Politics and Medicine. — Coincident with
the findings of Jeremiah F. Connor, More-
land Act Commissioner, in his investiga-
tion of the State Industrial Commission,
comes a memorandum handed down by
Justice Guy which is of special interest to
the profession. Sitting in a case in which
a man brought suit for injuries sustained
when a brewer's wagon ran over him, Jus-
tice Guy made it a special point to refer
to the services of two physicians in the
case in scathing terms. "Each of these
witnesses," reads the memorandum, re-
ferring to the physicians, "after testifying
to material facts learned by him in the
treatment of the plamtiff, admitted on
cross-examination that he had been em-
ployed previous to the trial by the defend-
ant to testify as a medical expert for hire
at the trial. Such an utter regard of the
ethics of the medical and legal professions
cannot be passed by without serious con-
demnation by this court. The relation of
physician and patient is peculiarly confi-
dential and is safeguarded by law in the
interest of the patient by forbidding dis-
closures by physicians of material and
necessary facts, the knowledge of which
was gained in the treatment by the physi-
cian of his patient without an express
waiver of the patient as provided in the
statute."
In a word, both of these doctors, after
treating the injured man and obtaining his
confidence, offered their services as wit-
nesses to the man their patient was suing
and betrayed the trust of their patient in
return for the reward they expected to get
for their services to the brewer. We can
hardly recall a more flagrant case of the
violation of the dignity of two callings in
a single instance, and we feel that Justice
Guy is well justified in his belief that it is
a question which the Bar Association and
the medical societies ought to take up. This
is but an individual instance, but there are,
unfortunately, numerous cases of the same
nature that come up in the courts every
week. The practice of medicine lends it-
self less easily than any other profession
to the shrewd and unscrupulous methods
of the fortune hunter. In its origin sci-
entific and humanitarian, it has been the
custom since the beginning of time to keep
it within the bounds prescribed by its dig-
nified origin. It is the one profession which
men and women enter for more than the
mere reason that they can get their living
by it. It is regrettable, therefore, that here
and there an individual, with less respect
for the profession than has always been
felt by both the community and the doctor,
makes an adventure of his career as a physi-
cian and introduces methods which in some
callings are not regarded as altogether cul-
pable. But the methods of no profession
correspond to that of the physician, cer-
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tainly the tactics of the stock exchange and
politics are out of place in it, and it is neces-
sary that the public understand that these
practices are nowhere condemned so com-
pletely as they are by the legitimate prac-
titioner. Yet, despite all precautions, there
arise instances such as that which Justice
Guy anathematized so justly, and it is high
time that the authorities united in a thoro
effort to stamp them out of a profession
that is perhaps the cleanest profession of
all. It is with deep regret that a physician
reads of the doubtful dealings of a brother
practitioner and, if it depended solely on
the members of the profession, such mal-
practitioners would be promptly driven
from the ranks. Unfortunately, the physi-
cians are powerless to achieve this without
the cooperation of the civil authorities, and
this cooperation has never been a perfect
thing.
It is encouraging, however, to read the
report of Mr. Jeremiah F. Connor on his
investigation of the State Industrial Com-
mission, the outstanding circumstance of
which, in his words, is that "injustice and
frauds" have repeatedly been practiced on
injured employees. These injustices and
frauds have their basis in the fact that doc-
tors with little more than political influ-
ence to recommend them come into posi-
tions in which they control a monopoly of
the cases of injured employees and they
exercise this monopoly with little concern
for the interests of the injured. To remedy
this situation, Mr. Connor suggests that
these men be supplanted by a *'panel of
physicians" appointed upon the advice of
recognized medical societies, to be revised
from time to time, and only men of prom-
inence and of unquestioned probity to be
employed thereon. Such a course, he sug-
gests, would eliminate definitely the "run-
ner" and the "ambulance chaser," and he
suggests further that it be made a mis-
demeanor for anyone to receive a fee in
connection with the presentation or collec-
tion of a claim for compensation unless a
fee has been authorized by the Compensa-
tion Committee. The course Mr. Connor
suggests seems a highly commendable one
and can be approved by every physician
with the faith that it will go a long way
to solve one of the problems that has con-
fronted and disquieted the profession for
a long time.
Motor Accidents and Defective Laws.
— Broadway pedestrians were startled
one night recently to see a taxicab, beyond
control, suddenly swerve toward the side-
walk, mount the curb and fling itself thru
a plate-glass window. The driver was in-
stantly killed and two passersby were se-
riously injured when they could not get
out of the path of the rampant cab. It
developed, on investigation, that the driver
of the calD had an artificial right eye and
it was judged that this was the cause of
the accident. The machine had a right-
hand drive and the chauffeur had to lean
far out of his car to observe the traffic be-
hind him. Thus another fatal accident was
added to the long list of preventable motor
accidents and, as in many instances, blame
is not to be laid at the door of the driver
of the car: it should be attached to the
loose regulations which make it possible
for men to assume the responsibility of
pursuing a profession or a pastime which
they are physically unfitted to pursue. At
best, there is enough carelessness in driving
on the part of those who have no handicaps
to overcome; but the amazement of the
authorities at the mounting figures in motor
accidents is hard to understand in view of
the carelessness which permits men and
women to expose the lives of pedestrians
to danger who are physically unfitted to
be trusted with the guidance of a car. If
a statistician were to examine the circum-
stances surrounding a given number of ac-
cidents of this sort, he would discover that
a large proportion of them is due to in-
capacity rather than carelessness. The
cursory examination to which applicants for
a driver's license are submitted is inade-
quate. During the war the air-fighters, tho
it was only their own lives that were in
question, were obliged to pass tests so se-*
vere that only a small proportion came
thru successfully. The civilian driver, with
lives of others in his care, is dismissed with
a trifling examination. It is altogether pos-
sible for a man with a weak heart, or an
epileptic, or a man with inadequate vision,
or one with the poorest muscular coordina-
tion, to obtain a license with ease, provided
these defects are not immediately percepti-
ble. So long as conditions remain as they
are, there should be little surprise and cer-
tainly little indignation on the part of the
authorities if accidents seem to multiply
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rather than decrease. All the modem in-
ventions to prevent railroad accidents are
valueless if the human element is at fault
and all the caution at the command of traf-
fic officers is impotent in the face of in-
competent drivers, drivers incompetent less
because of ignorance than because of physi-
cal defects. Unless precautions are taken
against these physical disqualifications, it is
not to be expected that the epidemic of mo-
tor accidents will subside.
respite from their sufferings. That this
was possible was due in large part of course
to the generosity of numerous benefactors,
but in no small measure credit goes to those
who do not forget, who, despite the repeti-
tion of the daily contact with suflFering, have
never grown callous — the doctors and nurses
in hospital service. Their efforts to make
Christmas a happy occasion for their pa-
tients is an eloquent contradiction that
nurses and doctors, from their constant as-
duristmas in the Hospitals. — ^What man
or woman has ever left a hospital, after a
'serious illness, without feeling that here-
after it will be impossible to pass any such
institution without bowing his head in hu-
mility before the splendid and faithful serv-
ice that is to be found within its doors,
without giving an affectionate thought to
the many suffering ones who are lying there
without any of the privileges and liberties
of those outside? And how many men and
women remember their vow one year later ?
It is extraordinary how quickly the human
brain forgets. Christmas was celebrated at
the hospitals recently. It was celebrated
joyfully and many ailing ones enjoyed a
sociation with illness and death, grow cal-
lous and indifferent. Such a charge, tho
often repeated, is a perversion of the fact
that they merely remain level-headed and
cool on occasions when the average person
loses his head, and it is fortunate for the
patient that this is so. It makes it possible
for him to receive the care and the precise
treatment which an hysterical sympathizer
would be incompetent to offer. But that
both physicians and nurses remain always
sensitive to the plight of their charges must
have been evident to the thousands of sick
who spent Christmas in the hospitals of the
country. Thanks to the doctors and nurses
few *'shut ins" were forgotten.
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ORIGINAL
TICLES
EXPERIENCES OF A MEDICAL RE-
SERVE OFFICER WITH THE
AMERICAN EXPEDITION-
ARY FORCE.
LEO B. MEYER, A. M., M. D., F. A. C. S.,
Late Major, M. C, U. S. A..
New York City.
Medical men with the U. S. Army who
had conviction as to what would be re-
quired of them, or to put it less forcibly,
who had ideas as to what they would do
when they became part of the A. E. F. soon
found that nothing happened as expected.
I left New York in February, 1918, as a
member of the surgical staflF of Base Hos-
pital No. 3 (Mount Sinai Hospital Unit,
New York City). We all hoped, tho we
hardly expected this hope to be realized, that
we would functionate as a unit within rea-
sonable distance of the firing lines (say 25
miles), in other words as a unit similar to
some of the less advanced casualty clearing
stations of the English, the advanced units
of which were within five or six miles of
the front. To our surprise and chagrin at
the time, we were assigned to a place about
40 miles northeast of Bordeaux — as far
from the firing line almost as it was pos-
sible to put us. Add to this disappoint-
ment the fact that when we arrived at our
destination we found a place only partially
completed, without a satisfactory water sup-
ply or lighting arrangements such as might
be expected in a large rear hospital, the
grounds littered with rubbish, and it is not
difficult to picture a very disgusted set of
men. The enthusiasm with which we set
out, dampened somewhat by what seemed
to us a very severe overland trip from
Havre to our destination, fell to the vanish-
ing point.
A few words about the trip may prove of
interest. We set out February 6, 1918,
and were agreeably surprised in finding our-
selves on board the large trans-Atlantic
liner "Lapland" (18,000 tons). Our trip
was very rough and stormy, so rough, in
fact, that half a dozen of our life boats were
smashed, our protecting gun put out of
commission — ^and the ship's hospital flooded.
About 250 Serbian volunteers who were
returning from the United States to enter
the Serbian Army thought their last hour
had come and were with difficulty re-
strained.
However, after losing most of our convoy
we finally reached the neighborhood of Ire-
land, where we cruised aimlessly about, not
daring to enter the Irish Sea because of
wireless warnings (so I learned later) that
submarines were very active in the neigh-
borhood of Liverpool, our destination.
After three days we were met by seven very
welcome 'destroyers who convoyed us to
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Glasgow. We were told later that the
destroyers had been on the lookout for us
for two days and that it was rumored that
our ship had been lost.
Something of submarine activity at this
time may be imagined when the reader is
reminded that we left New York about the
time the Tuscania was sunk, ^rrived at
Glasgow about the time the Calgaria was
torpedoed and crossed the Channel from
Southampton to Havre the day after an
this time we lived in our clothes, slept (or
tried to) sitting up — froze, ate tin rations
and drank French wine or coffee prepared
with little alcohol stoves some of us had
had the foresight to bring along (ag^ainst
orders).
We- finally arrived at the Monastery of
Vauclaire, built in the 13th century by the'
Chartreuse Monks, and converted by the
French Government some years before into
an insane asylum. (Fig. 1.) It was, how-
Fio. 1. The Chartreuse Monastery of Vauclaire near Monpont — as it was before its conver-
sion into a hospital. — Built in the 13th century under the protection of the Talleyrand family
whose coat of arms are still in the entrance hall of the refectory.
English hospital ship was sunk with the
loss of many lives (rumored 100).
We arrived at Havre one afternoon, left
the rest (?) camp in the midst of an air
raid at 4 A. M., walked to the railroad
station about two miles away in a drizzling
rain and boarded a typical French com-
partment train. Orders as to our route and
destination were handed to our command-
ing officer with the cryptic remark of "Good
luck to you — God knows you need it" — and
we did, for it took two days to make a trip
that should have taken eight hours. During
ever, left for us to complete the job and our
enlisted men, among whom were carpenters,
plumbers and electricians, did yeoman work,
preparing the place for the reception of pa-
tients, the first convoy of whom were re-
ceived in the middle of April, about six
weeks after our arrival. (Fig. 2.)
During these six weeks the medical offi-
cers were not altogether idle, for the coun-
try for miles around was absolutely bare of
physicians and they were called upon to do
all manner of work, from the handling of
sick infants and pneumonia cases to offi-
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761
ciating at difficult obstetrical cases, treating
fractures and doing operative work of all
kinds.
Our first convoy consisted of about 360
cases that had been operated upon at ad-
vanced hospitals. Subsequent convoys fre-
quently consisted of patients who received
their first operation at our hospital. Espe-
cially was this the case during the second
battle of the Marne and at some stages of
the Argonne battle, during which the ad-
vanced hospitals were at times swamped.
assistant surgeon, anesthetist, two nurses
and two operating orderlies, there was quite
a loss of personnel at the hospital.
Surgical work at the base differed greatly
from that at the front. The base had the
complications to handle : innumerable com-
pound fractures, secondary chest and joint
infections and at times secondary operations
for the removal of retained foreign bodies.
In addition there was surgical work similar
to that in civil hospital, for base hospitals
(and this was especially true of Base 3)
Fig. 2. Base Hospital 3 almost completed. Note that the monks' cells on only one side
of the quadrangle remain. Oh the side opposite the cells, buildings similar to those at the
end were erected before we arrived. — The building in the center was the main kitchen.
At the height of the Argonne fight our
hospital, originally organized to handle 500
men, took care of over 2,800 at one time.
Of course additional medical men, nurses
and enlisted personnel were assigned, but
the staff was never adequate, which meant
that every one was over-worked, for pa-
tients were never neglected. What made
the problem still more difficult during the
height of the fighting from June to the
armistice, was the temporary (a very in-
definite and convenient army term) detach-
ment of operating teams for service at the
front where the need for them was urgent.
As each team consisted of a chief surgeon.
are in the center usually of large training
camps. One who has had experience both
at a base and at the front can consider him-
self extremely fortunate.
I was lucky enough to see some work at
the base before being sent forward in charge
of an operating unit and was doubly fortu-
nate in that I was able to return after the
armistice and see the result of the work done
in the forward areas. When one has worked
under pressure at an advanced operating
post for twelve (often many more) hours,
day after day, one marvels at the remark-
able results obtained. American surgeons
were fortunate in being able to profit from
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the three years' experience of French and
English surgeons — ^many a doughboy owes
his limb or life or both to the fact that we
entered the war in 1917 instead of 1914.
A word as to the French people among
whom our lot was cast. The village was
the center of a thriving agricultural and
wine district ; it had its market day once a
week to which peasants within a radius of
ten miles brought things for sale — eggs,
butter, all manner of food stuffs, live stock,
Fig. 3. The Author.
products of the loom, etc. During such
times the town was lively enough — at other
times it was like any typical small village.
However, it can truthfully be said that after
the arrival of the Americans the place
livened up considerably and became quite
prosperous. The people were very hospitable
and many a pleasant hour was spent by a
number of us at the various homes. It is
curious to note the peculiar views of
Americans held by many of even the edu-
cated French living distant from the large
centers. I happened to be visiting a family
one afternoon and noticed an open Chopin
score on the piano. The young lady of the
house, who spoke English, mentioned that
she didn't care very much for the American
type of music (she had been entertained
with rag-time and jazz) and asked me if
we Americans had ever heard of men like
Chopin and Liszt !
After a short stay at the base I was or-
dered to American Headquarters with a
team and from there to Paris. At Paris
we expected to be ordered to Chateau
Thierry, but the need for surgeons at
American Red Cross Hospital No. 1 at
Neuilly, near Paris, was so great that we
were sent there and remained at that point
about ten weeks. This was the hospital
in which Mrs. Wm. K. Vanderbilt was in-
terested and where she might have been
seen every day actively at work among the
wounded. It was the hospital of which
Colonel Blake was in charge at the begin-
ning of the war. After he left it, he was
placed in charge of American Red Cross
Hospital No. 2 in Paris proper.
We arrived at the hospital about 2 P. M.
and were put to work at once, operating
until midnight. On our arrival there were
about 200 unoperated men lying in the cor-
ridors of the hospital, the number increas-
ing every minute. This was June 6th,
while the severe fighting at Chateau Thierry
and Belleau Woods was in progress. We
relieved men who had been operating day
and night for five days, some of whom had
not had their clothes off during this time.
The first batch of men operated upon by
us were from the famous 5th and 6th
Marines. Many of them were badly
wounded but all had plenty of pep left.
Their usual greeting was "How long do
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you think TU be laid up," or "Fix me up
quick." Patients reached the hospital from
8 to 24 hours after being wounded, altho
the actual trip was only 2 hours (40 miles).
However, the wounded were so numerous
in this fight and the congestion so great,
that there was considerable delay. During
the German offensive of July IS, 1918 and
the Allied counter-offensive of July 18,
1918, the interval between the time the
soldier received his wound and his arrival
at the hospital, was much less.
By this time the profession is familiar
with the methods of handling war wounds
and the importance of removing every bit of
foreign matter and of damaged tissue — what
is technically known as a wide and thoro
debridement — and of leaving the wound
wide open. Fractures of lower extremities
were treated whenever possible by exten-
sion, with the aid of a Thomas or Hodgen
splint, suspended from a Balkan frame or
some modification thereof. Most wounds
were Carrel-Dakined. While the end re-
sults of our compound fractures might not
be all that could be desired, most of them
will eventually get well, with serviceable
limbs (albeit the convalescence may be
long) ; considering the severity of many of
these injuries, that is saying a good deal.
Mention has been made of the dough-
boy's desire to return to duty as quickly as
possible. Some, in fact, were so keen about
this (tho evidently suffering from severe
wounds) that they would say that their
wounds didn't amount to much in the belief
that this statement would mislead the doctor
and induce him to return the soldier to duty
the more quickly. Occasionally one would
say "I guess I'm done for" — and he usually
was when he said this. Each one had to
be handled differently from a mental stand-
point; some you jollied and joked with,
while with others you almost agreed. My
policy with a badly wounded man was to
talk first — ^beat him to it, s;o to say, for one
could usually see the look of worry in his
eyes. I'd smile, but, as Sam Bernard or
Lou Fields might remark, only "from the
face out" — ^and say — "Well, Buddy, they
tried hard to get you this time, but they
didn't quite succeed ; we won't let them get
away with it." Then we'd have a little
argument about it and end up by agreeing
that we were going to fool the Dutchmaa
and give Buddy another whack at him. No
time was wasted during this confab, for the
nurses and orderlies were getting him ready
for operation while we were talking and the
assistant was starting the anesthetic, so that
the last thing the boy thought of was how
he was going to get even, and this was fre-
quently responsible for some very violent
dreams.
At the Neuilly Hospital we also operated
upon Frenchmen. They were much older
than our boys; in fact, it was nothing un-
usual to have men from 50 to 60 years of
age on the table. (It had been a long war
for the French and every available man was
on the job.)
I can add nothing to what every one
knows about the air raids over Paris and
the work of the long range German gun,
Big Bertha. I looked forward to my first
experience with an air raid and was con-
siderably mortified one morning to learn
that I had slept thru one, tho the barrage
was, according to my colleagues, a very
violent one. (We may have worked hard
and not always had enough sleep, but when
we had the chance, we certainly cotdd
sleep 1)
Big Bertha bothered no one very much.
It was a little uncanny to be working at the
operating table, hear a crash and know that
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in exactly twenty minutes, there would be
another messenger that would strike Paris
somewhere and do damage — ^no one knew
how much — nor where ; one always figured
that the chances were against it striking the
exact neighbood in which one happened to
be. This was a sort of fatalism that was
common and was regularly present with the
men at the front — ^after their baptism. It
seemed that Big Bertha always got busy
when the Germans started a big offensive,
exemplifying a phase of German psychol-
ogy, for the German war leaders figured
he said was the feeling of the Frenchman in
the street when the Americans arrived ; and
this was, contrary to generally accepted
opinion, a feeling of regret; for it was
thought that we had come too late and that
the war could only be prolonged with that
much more unnecessary suffering; in fact,
the stage was reached where they felt it
made little difference whether they lost or
won, for they were war- weary after three
years of intense suffering. However, after
the brilliant work done by our boys at Cha-
teau Thierry, the feeling changed to one of
Fig. 4. What is left of Selcheprey. Before the Battle of St. Mihiel, this was No Man's Land.
that by shelling Paris while making a big
offensive they would scare the Parisians
(and this would mean all France) into be-
lieving that Paris would soon fall. But
Germany was as woefully mistaken in this,
as in most if not all her interpretations of
the effects of her acts upon the allied na-
tions, especially the French.
One day at Neuilly we had as guest an
American who had lived many years in
Paris and whose children were bom there.
In an informal talk, he gave voice to what
hope, and after July 18th, to one of
certainty that the enemy would be beaten.
It must not be forgotten that this was only
the opinion of one man, albeit one who was
trained at judging mass feeling. He also
mentioned what may be of interest to those
who want everything German in the United
States relegated to the scrap heap, that his
children who were being educated at a pri-
vate school in Paris, were being taught Ger-
man without any request on his part or
notification to him that this was being done.
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All during August, 1918, we heard of
preparations being made for a big American
drive in the neighborhood of Verdun. On
August 21 we were ordered to Chaumont
(G. H. Q.) and from there to Evacuation
Hospital No. 1, north of Toul, about eight
miles south of Seicheprey (Fig. 4), the lat-
ter being the front line in this sector. En-
route we were held up a few hours at Neuf-
chateau, the train running true to the usual
schedule by being a few hours late. Waiting
at the station were many First and Second
around us were full of fighting men. Those
adjacent to the hospital held the 5th and 6th
Marines. All night long, guns, munitions
and men were going forward; during the
day all signs of activity were gone. This
continued till The Day, which proved to
be September 12th, arrived.
In the interval between our arrival and
the beginning of the Drive, many of us, not
being very busy, went forward on explora-
tion trips to the front, making general nui-
sances of ourselves. We went forth fully
Fio. 5. Enlisted men of the Medical Corps U. S. A., assigned to look after mustard gas
cases, clothed in anti-mustard gas suits.
Division boys joking one another as to who
really did the work during the fighting at
Chateau Thierry in May and June, 1918,
each group insisting that had it not been
there, the other would have "knuckled
under."
When we arrived at Evacuation Hospital
No. 1, near which Lufberry, the Amer-
ican Ace, met his death, we found very
little to do, but soon realized that we
were part of the preparation necessary for
some big movement rumored to occur early
in September. (Of course the Germans
knew nothing about this!) The woods all
armed with tin hats and gas masks and
without Sam Browne belts, all of which
precautions were obligatory. Sam Browne
belts were discarded because they labeled
the wearers as officers, for whom German
sharpshooters were always on the lookout.
We explored ruined towers at and just be-
hind the front lines, saw monster camou-
flaged guns hidden in the yards of what
once were dwelling places (Fig. 6), peeked
thru the periscopes of lookouts, and saw the
German lines and the smokestacks of Metz.
We saw and felt the mud, walked and
slipped on the duckboards in the trenches,
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chatted with the lookouts and were told by
them that they didn't understand why so
much fuss was made about taking Mont Sec
(which was right in front of us — one-half
mile northwest of Seicheprey) ; they were
ready to take it any time ! (I was told that it
cost the French 60,000 casualties to hold it
15 minutes the year previous, but the
doughboy, as we all know by this time, had
supreme confidence in himself, and this
confidence was rarely misplaced — certainly
not on this occasion, for on September 12th
he took Mont Sec with little trouble and
relatively few casualties.)
and four in the afternoon and that it was
fairly safe to walk about at other times.
However, it did not pay to be too cock-sure
about this as things did not always happen
according to schedule. There were many
wire entanglements here which were toys
compared to those of the main resistance
lines of the Germans in the neighborhood
of Varennes, to be mentioned later.
On our way to Beaumont, the village
next to Seicheprey, the road makes a wide
curve known as "Dead Man's Curve," which
we were told to avoid as it was under enemy
observation all the time and was frequently
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Fig. 6. Main Street — Beaumont. Before the commencement of the St. Mihiel Drive these
shells of French houses sheltered large calibred guns carefully camouflaged.
Some idea of what must have taken place
in the neighborhood of the hospital during
the period before our battle line became
more or less stabilized (sometime during
the latter part of 1914) can be imagined by
the condition of the ground, which was rid-
dled with shell holes, most of which had
been there for years. Of course there were
also new shell holes, for not a day passed,
even in this so-called "quiet area" without
a fair number of shells being sent over.
At the time I took my first trip over this
area I was informed that the German
"strafe-time" was usually between three
shelled. We avoided it going forward but
not returning, as to avoid it meant going
thru entanglements and brush.
Every American soldier with whom we
talked expressed the conviction that the
American Army would be in Metz before
winter. We all know how well this pre-
diction was verified.
One did not have to go to the battle line
to get some of the excitement of war, for
enemy aeroplanes were constantly over us
and we occasionally saw air fights, or more
commonly, near air fights, as neither side
at this time seemed anxious to lose aero-
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planes. At one time we saw three of our
sausage balloons which were anchored about
five hundred yards behind the lines go down
in flames as a result of clever work by a
German aeroplane, which darted out sud-
denly and unexpectedly from behind a
cloud and did the work before any of our
men could get near him. However, we had
the satisfaction of learning later on that
this man was brought down as he was try-
ing to get his fourth balloon. Of course it
was not pleasant for us to see our own
balloon brought down in this way, but we
all night long supplies were going forward
along the road in front of the hospital.
This traffic was so heavy as frequently to
keep us awake. The majority of the guns
going forward were the famous 75s and
155s of the French, but there were rumors
of much larger guns in the forward areas,
such as 14" naval guns. We were even
told that there was a 22" gun, a tale that
was never verified and probably not true.
There were none of these at this time, so
far as we knew, tho after the armistice was
signed I was in a gun factory where I was
Fig. 7. A German dugout Just captured by American trooiw.
the taking of measurements of the dugout.
American officer directing
had to look upon it as part of the game and
we know that German balloons which were
too far away for us to see were being
similarly brought down.
We were also made aware that the Ger-
man is a pretty good shot with his long
range guns, for we saw an ammunition
dump, situated about two miles immediately
in front of our hospital and the same dis-
tance behind one of our field hospitals, put
out of business by three well directed shells.
Mention has been made of the fact that
told that one of these monsters had just
been turned out (it took one year to manu-
facture).
During the day time everything was hid-
den and it looked as if nothing could hap-
pen, tho the woods all around were full of
soldiers and the famous 5th and 6th Marines
were in the woods adjoining the hospital,
awaiting orders to go forward. The men
of the hospital dropped in to pay these boys
a call and the boys reciprocated by coming
over and giving a fine minstrel show a few
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nights before they went into line ; we oper-
ated upon many of these very boys between
September 12th and 20th.
On September 12th at 1.30 A. M., while
we were all peacefully sleeping, *'Hell broke
loose!" We were awakened by terrific
shell fire and the horizon to the north of us
was one mass of flame. This continued
until the morning. At 8 A. M. the wounded
began to arrive and from them we learned
that the boys had gone over the top at
5.30.
There were many Germans brought in
and views, tho of course this was not
strictly according to rules. Also we realized
that the answers these men gave were prob-
ably more or less such as they felt we might
want to hear. One German lieutenant who
had been wounded once before, when asked
whether he had been told that prisoners
would be badly treated by the Americans
(we had heard that such rumors had been
spread) answered in the negative, and that
he, for one, was glad he was with us. An-
other said that the German people were
satiated with war and that the people had
Fio. 8. Wounded German prisoners.
wounded. (Fig. 8.) To show how little a
private in the ranks knows of his where-
abouts, one of these prisoners told me that
he had been taken prisoner at a place which
I now know remained in German hands up
to the time of the armistice. Naturally we all
felt elated at hearing that our boys had
advanced so far, but we soon learned that
the man was mistaken ; however, it had been
a great day.
It was but natural that we should question
our German prisoners as to their feelings
nothing to say or it would have been long
since over. These prisoners were well
dressed and shod, and looked well fed,
very different from some I had seen in
April, six months previous, which shows
the difficulty of drawing conclusions from
isolated instances.
We had at this time visual evidence of
just how hard put the Germans were to
obtain rubber, for a captured German am-
bulance brought to the hospital had iron
wheels in place of rubber tires ; each wheel
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was really a wheel within a wheel, the two
being separated by heavy spiral springs.
By the end of September the battle line
in this neighborhood had again became more
or less fixed and the pressure of work at
the hospital had subsided. I made use of this
quiet period to visit many of the towns
just taken by the Americans, among which
were Essey, Nonsard, Thiaucourt, etc. Our
trips forward were always interesting as we
were dependent upon whatever transporta-
tion happened to be going forward at the
time. Most frequently it was a lorry which
was carr3ring food or some other material.
"Lorry-hopping" was the term applied to
seekers of excitement such as we were at
that time. Sometimes we were fortunate in
getting a lift on an ambulance or a Ford
car. Occasionally a motor cycle with a
side car would help out and on one occasion
we went forward on a little narrow gauge
railroad taking ammunition to the front.
I can well remember with what peculiar
feelings I heard the story of the driver of a
Ford ambulance, which was our taxi at that
time and without a windshield. He told me
that the windshield had been taken away by
a piece of exploding shell the day before
while making the same trip, the shell at
the same time killing the driver.
The roads were in terrible shape, shot
up and muddy, but we were told that com-
pared to their condition on the day after
the offensive started they were wonderful,
for on that day it took eight or more hours
to go about five miles and one was never
sure that his car wouldn't end in a ditch.
Engineers followed the attack closely, try-
ing to make the roads passable as rapidly
as possible, using the stone from the ruined
houses for roadbeds.
Going thru the houses in Thiaucourt we
were struck by evidences of rapid German
evacuation such as tables upon which un-
eaten food remained.
In spite of the grim business of war, the
doughboy loses no opportunity to get a
little fun out of his work. I saw one clean-
ing his mess outfit while wearing a plug
hat, salvaged no doubt from one of the
rapidly evacuated homes.
At Norroy I participated in the excite-
ment of seeing. a town within the German
lines in the process of being blown off the
map by some artillery six miles to the rear,
the fire of which was being checked up by
French artillery ofiicers in the dugout in
which we were. This town was being
treated in this way because it was suspected
of sheltering the guns which were shelling
Pont-a-Mousson. As we had just passed
thru the shelled area of Pont-a-Mousson to
reach Norroy, it was with some satisfaction
that we saw the houses of this town go up
in the air.
On October 15th I was ordered forward
to an evacuation hospital in the neighbor-
hood of Verdun. This hospital was planted
in the mud. It seemed to rain all the time
and boots were a necessity. The operating
room here was a long hut containing
eighteen operating tables placed side by side.
Each surgical team had three tables. The
teams worked in twelve hour shifts, six
teams by day and six by night, the shifts
changing every ten days or so.
No matter how rushed we were the work
here had been so systematized, and the en-
listed men and nurses so thoroly trained and
so willing, that the work could be done very
rapidly and satisfactorily and witfiout con-
fusion. In spite of the number of people
working in this big operating room it was
surprising how quiet everjrthing was. It is
remarkable how little all this affected the
wounded doughboy, who might be lying on
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an operating table awaiting his turn, for the
on turning his head to the right he might
see one surgeon operating upon an ab-
domen, and to the left another upon a shat-
tered limb, nothing seemed to bother him
much as long as he had a cigarette. As a
matter of fact, he felt that for some time
at any rate he would have a comfortable
bed to sleep in and be free of the dirt and
mud and strain of the trenches.
I had heard so much of the famous Citadel
at Verdun that during one of the quiet
periods I obtained leave to visit it. and while
walking thru the streets of the city ex-
perienced the sensation of shells exploding
hospital dropped some leaflets which told
the American soldiers how foolish it was to
continue the war when the German people
were anxious for peace and ready to make
it and that they should stop fighting to avoid
further unnecessary bloodshed. About the
only effect this propaganda had on the boys
was to make them feel that they had the
Germans "on the run."
While we felt rather secure in our loca-
tion we occasionally were reminded that
there were possibilities of excitement inas-
much as an evacuation hospital near us had
been hit by a shell, severely wounding sev-
eral of the personnel.
Fig. 9. First aid station in the woods.
near me, as it was a habit of the Germans to
throw some gas shells into the place every
day at four o'clock. They were a little
ahead of their schedule that day for it was
only three when they sent them over. The
Citadel is really a large underground city
which has existed many years and is capable
of accommodating ten thousand people at
a time. It has a hospital, theater, church
and everything necessary to make that num-
ber of people comfortable.
About October 26th a German aeroplane
circling about in the neighborhood of the
A few weeks before the armistice was
signed I made my last move forward to a
mobile hospital pitched at the foot of Hill
240 in the Argonne Forest, around which
some of the severest fighting of the war
had taken place in the month previous. One
could see plenty of evidences of this, for
the ground was full of shell holes ; in fact it
was impossible to pitch a tent without en-
closing a shell hole.
All about us were German built dugouts ;
those in the woods were filled with the
souvenirs dear to the heart of the doughboy
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— casings of exploded shells, German rifles,
bayonets, caps, coats (from which most of
the buttons had already disappeared), can-
teens— in fact, all material now generally
described by the term "German hardware."
One saw graves innumerable. Buried
Germans and Americans in twos and threes
and singly. One saw wrecked aeroplanes
and it was not difficult to sense the terrific
struggle that must have taken place.
It was so cold here that we were forced
to operate with sweaters on. When we
went to bed we had more clothes on than
everything had suddenly become almost un-
comfortably quiet.
I remained at this advanced station for
two weeks after the armistice was signed
and there being practically nothing in the
way of surgical work, I did a little Cook's
touring of the front. This was encouraged
by the authorities even before the signing
of the armistice, for in published orders
they recognized the fact that the officers
wished to take advantage of opportunities
which would probably never recur.
During my journeys of exploration I was
Fig. 10. American soldiers camping in the woods.
when we were up and about. As a matter
of fact we had to undress in the morning.
We were busy here until the signing of
the armistice and for a few days thereafter.
The night of the armistice was celebrated
by us in a rather quiet way. One of the
boys had gotten hold of some bottles of
champagne and after drinking a few toasts
we worked all night, for tho the shooting
stopped the wounded kept coming in for a
few days after the fighting ceased. All
about us colored flares which during the
fight were used as signals were being sent
up by the boys, celebrating the finish. In-
stead of the noise of the previous days
able at first hand to see the remarkable de-
fense system in the neighborhood of Va-
rennes, which the Germans had painstak-
ingly built up for over four years and which
they considered impregnable. There were
elaborate dugouts (connected by under-
ground tunnels) electrically lighted, with
cement floors, windows with window-panes,
good home-made furniture, flower gardens,
bowling alleys, music halls, and overhead
miles of barbed wire. Elach lookout sta-
tion had a comfortable seat and was ab-
solutely protected. The entire defense was
something at which to marvel. The Ger-
mans evidently expected to remain there
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permanently. I visited Monfaucon, the
place from which the Crown Prince watched
in safety the battle for Verdun; the only
thing left in the whole town is the tower
from which he viewed this battle.
I visited Dun-sur-Meuse (north of Ver-
dun), situated on a high hill, the roofs of
the houses on one level forming the yards
of the houses on the level immediately
above. The graveyard of the town shows
the scars of battle ; the "Rest in Peace" on
some of the remaining tomb-stones looked
queer amid the wreckage where exploding
shells had disinterred bones that had been
at rest for many years.
At the beginning of the war I had heard
a good deal of the expression "Gott strafe
England," but it wa3 something of a sur-
prise to me to find this sentence chalked
on stable doors and other places at this
time.
Standing on the heights of Dun-sur-
Meuse one could look north for many miles
over beautiful fields showing few of the
ravages of war, for after Dun-sur-Meuse
there was little artillery fighting, the Ger-
mans retreating faster than the artillery
could be brought up.
My touring trip was cut short by an order
returning me to Base 3, where could be seen
some of the final stages of war wounds.
Of the work done here I am in no position
to write as most of it was done during my
absence. When I left, the hospital was
caring for about 500 patients and could ac-
commodate 1,200. On my return on De-
cember 2nd, there were still 1,000 patients
under treatment and the place was able to
handle about 3,000. We had actually under
treatment at one time 2,800 patients.
From then until our return there was
little to do, as the hospital had been taken
over by another unit and we were awaiting
orders to return to the States. We greeted
the Statue of Liberty exactly thirteen
months after saying good-bye to her, and
I can truthfully say that it was the liveliest
and most eventful thirteen months I have
ever spent. I am thankful to have had the
chance of being "over there," but pray that
the opportunity of doing my bit in this
way shall never again offer itself.
2178 Broadway.
CONTAMINATED AND INFECTED
WOUNDS— PRINCIPLES OF
TREATMENT— WITH ADDENDA
ON ANTISEPTICS AND TERMI-
NOLOGY.^
BY
DAVID C. HILTON, A. M.. M. D., F. A. C. S.,
Lincoln, Neb.
Perspective. — In this field of changing
methods, perspective is needed.
To view at short range the passing show
of old and new methods and materials ap-
plying to the treatment of infected wounds
is bewildering. Judgment as to how to
think and what to do in the matter of treat-
ment is difficult. A study of the history of
medicine and of the principles underlying
treatment is a valuable corrective for errors
of viewpoint and judgment. It corrects the
perspective, and sets earmarks of differ-
entiation between the glittering new and the
soberly progressive in our art. It is to
furnish a degree of perspective that prompts
the author to write this paper. Time will
apply to it the test of historical judgment.
Principles vs. a Detail. — ^A new era
has come in the treatment of infected
wounds. A new surgical specialty is here.
He replying "There is no new surgery,
^ Read before the Nebraska State Medical As-
sociation meeting, May 19-21, 1919.
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merely another microbe killer," has the
short range viewpoint. He is absorbed in
a mere detail and is unmindful of the under-
lying principles on which it rests. Funda-
mentally the newer treatment of infected
wounds is not one of antiseptics, but rather
of bacteriologic and surgical problems.
System of Treatment. — Few of the
principles and methods of treatment herein
set forth are distinctly new. The combina-
tion of these principles, and methods, old
and new, into a therapeutic system with a
technic adapted thereto, having thoroly
modified our surgical methods, the clinical
course and the results of treatment has
forced the category of contaminated and
infected wounds into a new surgical spe-
cialty. The one principle, that of bacterio-
logic control, is new in general surgical
practice. This principle is as a compass
without which we are lost in a sea of
difficulties. The results of treatment are
decidedly new. Successfully applied it gets
union in the wound by primary intention,
and fibrous scar is disallowed. It is supe-
riority of achievement in degree and in
kind, that has opened the new era.
Training and Organization. — ^To sur-
mount the difficulties of carrying on the
treatment demands special training in sur-
gery, bacteriology, antiseptics, nursing, and
in organization, as well as patient industry
to mobilize these coordinated branches into
an effective therapeutic unit. Without
special training and unit-control, failure
awaits effort ; and discredit, the surgeon and
his staff.
Wound History.— This paper covers
the treatment of the open wound. The
periods in the history of such a wound har-
boring pathogenic organisms are :
(a) the period of contamination,
(b) the period of infection,
(c) the period of closure.
Principles of Treatment.; — ^The princi-
ples of wound treatment in the pre-inflam-
matory period or the period of contamina-
tion are:
(a) mechanical cleansing,
(b) closure, and
(c) immobilization.
For cases constitutionally and anatom-
ically unsuited for perfect cleansing by
mechanical means as for instance in com-
pound fractures, th.e principles applying
are:
(a) approximate mechanical cleansing,
(b) chemical cleansing ("Prophylactic
antisepsis of Lister"),
(c) closure, and
(d) immobilization.
Purpose.— The inclusive purpose of
wouiid treatment during this period is to
shorten the time of healing by :
(a) disallowing the formation of a cul-
ture medium for septic organisms in the
wound.
(b) disallowing gross scar with union by
secondary intention. Thus the treatment
is essentially prophylactic against infection
and curative by inducing union of the
wound by primary intention.
Bacteriogenesis. — Bacteriogenesis in
the wound determines the time limit of con-
tamination and the incidence of infection.
The period of election for operating the
contaminated wound is the first twelve
hours following traumatism. The results
of Policard's study of war wound bacteri-
ology may be taken as average findings.
They are as follows:
(a) At three hours after contamination.
Shreds of clothing. Blood infil-
tration. Many leucocytes. No
bacteria or pol)rmorphonuclear
leucocytes.
(b) At nine hours after contamination.
Polymorphonuclear leucocytes
prevalent. Tryptic digestion of the
exudate. Dead lymphoc)rtes. No
bacteria.
(c) At twenty hours after contamination.
Increased leucocytes. Bacteria ob-
served. Bacillus Welchii is the
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first to appear, showing the wound
at twelve hours.
Mechanical Qeansin^w — Mech a n i c a 1
cleansing involves preparing for an opera-
tion as in aseptic work, in doing "debride-
ment" or the removal of the entire wound
surface in one piece cutting to a depth of
from three to ten millimeters, and then in
changing instruments and gloves prelimi-
nary to aseptic closure. "Debridement"
must be economic, having due respect for
important structures to avoid increasing
disability by operative trauma. Each im-
portant tissue receives necessary first aid
repair, nerves are resected, and sutured,
tendons approximated and vessels ligated.
There should remain freely bleeding sur-
faces uncontaminated with soil by technical
errors in the performance of the work.
Failure is due to piecemeal dissection, to
carelessness of asepsis, and to insuperable
anatomical difficulties such as compound
fractures, considerable loss of substance, or
the "anfractuous" nature of the wound. To
stain the surface with a dye such as brilliant
green, is a valuable guide to accuracy in
"debridement."
Closure. — Closure of the wound surgi-
cally is pursuant to "debridement." The
wound may be closed by :
(a) Primary suture,
(b) Primary delayed suture, or by
(c) Secondary suture.
Primary suture is immediate closure by
suture.
Primary delayed suture is immediate
suture and delayed closure. The wound is
lightly packed with gauze for a few days
awaiting final judgment as to the cleanliness
before tying the sutures.
Secondary suture is closing by delayed
suture on or before the eighth day. Clean
wounds closed before the eighth day heal
without gross scar.
Results of Primary Snturew— As to the
results of primary suture in contaminated
war wounds after "debridement" Moynihan
gives a fair statement for the British serv-
ice, and the work of Pierre Duval and
Lamaitre gives a good idea of what the
French were enabled to accomplish. To
quote from Moynihan, "If the operation is
carried out with scrupulous exactitude and
with something near to technical perfection
in cases of small 'contamination' wounds
where there is no loss of substance, prob-
ably not less than 80 per cent, will heal by
first intention. The failure occurs in those
cases where a piecemeal removal of the in-
fected wall has been carried out, where, that
is to say, there has been a frequent reinfec-
tion of the newly made raw surfaces."
Pierre Duval, one of the cleverest operators
of the French is said to have worked under
ideal conditions as to equipment and per-
sonnel. Of his primary suture cases, ninety-
two per cent, of the soft tissue wounds and
fifty per cent, of the compound fracture
cases healed by first intention. The average
period of hospitalization for his primar>'
suture cases was three weeks, and for his
primary delayed suture cases about one
week longer. On the service of R. Lamaitre
at the Boulouse Evacuation Center, August
2, 1917, to February 3, 1918, there were one
thousand nine cases. Of these, sevent\'-
nine per cent, were returned to duty during
this period (including February). The
average time of hospitalization was twenty-
nine days. Eighty per cent, were cases of
primary suture, and nine per cent, were of
secondary suture. Lamaitre used only dry
dressings — no antiseptic. Leriche advo-
cates fixation of the wound surfaces with
tincture of iodine after careful hemostasis.
Postoperative Course. — ^The usual post-
operative course is characterized by the ces-
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sation of pain in the wound after twelve
hours. Spontaneous pain and a rising pulse
are the most reliable indications of undue
closure. This circumstance should lead to
an examination of the wound for tender-
ness away from the stitches and if progres-
sive to their removal. Tenderness may be
due to hematoma as well as to inflammation.
The temperature may rise to 101 degrees
for a few days. Without concomitant de-
velopments it should not cause alarm. To
bury the end of a silkworm gut in the
wound is good practice. At the end of
twenty- four hours it may be removed and
cultured. If a culture of virulent organ-
isms is discovered, more especially of an
anaerobe or of streptococci, the stitches
must be removed forthwith and the wound
opened.
Rules of Practice. — Experience has
shown that for primary closure to be safe
and successful a few special rules must be
obeyed in pursuing the general plan of
treatment. Among them are the following :
(1) The surgeon must have continuous
oversight of his cases for fifteen
days after operation.
(2) Do no primary closure if the general
condition of the patient is bad.
(3) Do no primary closure if doubtful of
the primary cleansing being suf-
ficient.
(4) Do no primary closure in ordinary
or aggravated cases of compound
fracture.
(5) Depend on inspection in tracing a
wound, never use a director.
(6) Hemostasis must be so perfect that
hematoma will not form.
(7) Tension on the sutures is to be
avoided. Vaucher by cultural
methods sets forth the bacteriolog-
ic situation as related to wound
closure.
(a) If the wound is sterile it is safe to
close. ■
(b) If the cultures show no anaerobes or
streptococci, and only the commoner
aerobes, the closure is a safe condition.
(c) If the cultures in milk show an-
aerobes with or without aerobes but no
streptococci, the local and general condition
of the case must be watched closely as the
clinical condition is the best guide in this in-
stance for safety.
(d) If the cultures show both anaerobes
and streptococci never close a wound. It
is reasonable to suppose that the practical
rules of wound closure from a bacteriolog-
ic standpoint will be formulated for one
section and another, and from time to time,
according to the incidence and relative
virulence of microorganisms producing
wound infections.
Immobilization. — Immobilization to in-
sure rest of the part by fixation, by ex-
tension, or otherwise must obtain after
thoro mechanical cleansing, reconstruc-
tion of the tissues, perfect hemostasis,
and accurate coaptation without tension
on the sutures. For bed cases, immobiliza-
tion with posture to favor return circulation
is best secured by an overhead suspension
apparatus. The so-called "Balkan Frame"
as constructed for the "War Demonstration
Hospital of the Rockefeller Institute for
Medical Research," New York City, and
adopted by the War Department for the
use of the army, is unexcelled for the pur-
pose.
Chemical Qeansing. — Chemical cleans-
ing in the contamination period of wound
history is "prophylactic and therapeutic
antisepsis." Many wounds incompletely
cleansed by mechanical measures can be
rendered "clinically sterile" by invoking
this phase of chemical cleansing. Disinfec-
tion in this instance is staging a clean fight
between organisms distributed over the
wound surface and the antiseptic. In this
period the victory is prone to be immediate
and in favor of the host, whereas the reverse
is true in the period of infection, wherein
organisms are entrenched within the tissues
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and are disseminating themselves on the
ebbing and flowing streams of blood and
lymph. In the ordinary routine of surg-
ical practice, the choice of antiseptics is de-
termined by availability, stability, efficacy
in vivo, and harmlessness to the tissues
from a single application. In general the
tincture of iodine fills these requirements
well. To get the most effective action from
iodine the wound surfaces must be dry. It
precipitates in an aqueous medium as in
blood and lymph, and weakens in antiseptic
power. Its antiseptic power is greatest if
the tissues are so dry that it will fix them.
INFECTED WOUNDS.
Principles of Treatment. — ^The princi-
ples of treatment in the inflammatory period
or the period of infection are :
(a) mechanical cleansing,
(b) chemical cleansing (therapeutic anti-
sepsis of Lister and other prop-
erties),
(c) immobilization,
(d) bacteriologic control, and
(e) closure.
Purpose. — ^The inclusive purpose of
treatment as it is in the period of contami-
nation, is to shorten the time of healing by :
(a) arresting all infective processes,
(b) "clinically sterilizing" the wound,
and
(c) making surgical closure to get union
by primary intention.
A notable feature is to abolish from the
clinical history of the case, union by the
slow, dirty and dangerous process of granu-
lation and second intention, thru superior
surgery.
Application. — ^The application of these
principles varies with the infective state of
the wound whether it be that of
(a) gas gangrene,
(b) phlegmon, or of
(c) suppuration.
And it ako varies with the type of organ-
ism whether it be
(a) aerobic or
(b) anaerobic.
Incidence of infection. — ^Altho extra-
limital to our subject, it is revelant here to
discuss the question "When is a wound in-
fected?" A definition of infection com-
monly promulgated among the profession is
as follows: "Infection is incident to the
implantation of organisms in the living tis-
sues, and their multiplication.*' This defini-
tion tho valid is half revealing and half
concealing. It impresses the mind with the
idea of the germ being the active agent, and
of the tissues as being passive in the mat-
ter. It leaves the theory of infection germ-
biased and tissue-blinded. To perceive
when a wound is infected is to understand
the tissue agencies at work in relation to
traumatism and to the invading organism.
When organisms are implanted in a wound
they begin to die, as they do when first
placed in an artificial culture medium. The
tissues, the blood, and the sera are not
favorable media for germ life, and definite
chemical changes must have converted the
leucocyte ladened influx of serum from an
inhospitable and hostile environment into
a culture medium. Serum in the wound is
antiryptic at first, and remains so until,
with the breakdown of leucocytes, tryptic
digestion of it into peptones supervenes.
Not until this has occurred is there a re-
ceptive culture medium provided for infec-
tion to set up in the wound. The chemistry
of the living body is such that bacterial in-
vasions thrive only if tryptic digestion has
converted the fluids and contused or nec-
rosed parts into a favorable culture medi-
um. A free flow of serum into the ^i^ound
early after traumatism tends to inhibit the
infective process. The salt treatment of
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Sir Almroth Wright induces a serum flow.
A wound felting over with fibrin becomes
"lymph bound" in the ordinary course of
events and is highly favorable to rapid in-
fection. The organisms that endure an un-
changed serum best have been termed as a
class "serophytes." They include among
others, staphylococci and streptococci.
Suppumting Wounds. — 1. Mechanical
cleansing is the first principle to be applied.
It takes into account the wound and the ad-
jacent integument. The integument is al-
ways a carrier of infection, and from it the
wound may be reinfected, repeatedly unless
sufficient devotion to cleansing it from the
start is continued. Mechanical cleansing
is applied in four particular ways: First
foreign bodies and gross tissue waste are re-
moved, as for instance, sequestra of bone,
sloughs, hematomata, and gangrenous tis-
sues. These harbor the invading organ-
isms, until cast off by natural processes or
by artificial means. Second, all wound
parts are opened up to the end that liquid
infectious waste may be discharged freely
and promptly. That is, to make the wound
relatively self-cleansing by the establishment
of drainage and of counter drainage in pro-
portion to the needs of the case. Third, un-
restricted exposure of all wound surfaces is
provided for intimate chemical contact, in
order that chemical cleansing may effect
"clinical sterilization" in the shortest possi-
ble time. Fourth, in case of anaerobic
infections no focus is left unexposed or
viable. For the elimination of foreign bod-
ies and of tissue outcast, and for drainage,
the most radical work short of anatomic er-
rors and overreaching constitutional limita-
tions, makes for the most ideal cleansing,
the shortening of hospitalization, and the
conservation of life. Into the special sur-
gery of the anaerobic infections, the limita-
tion of our topic forbids entrance. In pre-
paring the wound for chemical cleansing the
surgeon uses a special technic. He must
go further than the simple requirements of
extraction, excision and incision for drain-
age. The old way of operating anticipated
healing by the slow, dirty process of granu-
lation or of healing by second intention.
The new way contemplates preparing the
wound by a further step, in such a manner
as to facilitate continuous chemical action
on all wound surfaces, and to conclude heal-
ing by primary intention. To operate in-
fected wounds for chemical sterilization re-
quires the highest type of surgical skill
guided by a new viewpoint, accompanied by
a new technic and anticipated by a knowl-
edge of the practical difficulties besetting the
days or the weeks in which universal and
continuous chemical contact must obtain in
the wound. It is the refusal to appreciate
that a new surgical specialty is here and to
anticipate the difficulties of infected wound
sterilization that frequently leads to failure
and brings the practice into disrepute.
2. Chemical cleansing in its antiseptic
phase is therapeutic antisepsis in the in-
fected wound as against prophylactic anti-
sepsis in the contaminated wound. To
carry chemical cleansing to the point of
"clinical sterilization" and accomplish sur-
gical closure and union by first intention is
an ambitious* undertaking beset with numer-
ous pitfalls that only the specially trained
surgeon and an organized force of helpers
can circumvent, case by case. One has
merely to recall the care, the skill and the
organization of forces at his command in
doing aseptic surgery to appreciate this in
some measure. Furthermore he has to win
proficiency in this new work, to know by
how narrow a margin success is won — ^by
how much more skill and organization are
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sloughing, inflamed wounds made clean,
than are aseptic wounds kept clean.
For the chemical sterilization of infected
wounds, the antiseptic, the method, and the
apparatus are to be studied and mastered.
As to the antiseptic none has as yet been
introduced which will cleanse the wound in
a few applications. It must, therefore, be
so thoroly nontoxic at a uniform therapeutic
potency that it can be repeated as long and
as often as necessary with impunity. Also
it must be efficient in vivo. It must be more
than a bactericide or antiseptic. It must
be a cleanser in the full meaning of the
term. Wound disinfection ever awaits
wound cleansing. Mechanical cleansing
falls short in matters aside from bacterial
contamination. More or less of solid or
semi-solid exudated sloughs, and shred's
not removable by physical means are to be
voided by chemical agency. The chemical
cleanser must be a solvent so powerful that
it will constitute a chemical drain. It must
complete the cleansing of the wound from
the point at which mechanical methods have
left it unfinished. The most invulnerable,
the deepest and the last refuge about the
wound for bacteria must be melted away.
The mere bactericidal power of an anti-
septic is only one phase of its activities in
the wound. In fact, many substances acting
antiseptically are not direct bactericides.
The advantages and the disadvantages of
any antiseptic agent have to be measured
by its effects on the tissue cells, the sera, the
blood, the discharge and the oflf-castings of
disease, the by-products of bacterial growth,
etc.
As to the method, it must be standardized
and be susceptible to close analysis, so that
if the process of sterilization becomes sta-
tionary or retrogressive on a day, the fault
can be located. It must provide for the
delivery of the requisite amount of anti-
septic to the wound surfaces in the desired
strength, and with the regularity which will
render the wound sterile in the shortest pos-
sible time. It must also insure against del-
eterious side effects of treatment.
As to the apparatus, whatever is adopted
must carry on with the method the essentials
of treatment, and serve the fundamentals of
success.
The fundamentals in the use of an anti-
septic are :
(a) time,
(b) contact, and
(c) concentration.
If one considers the multiplicity of rela-
tionships between these three fundamentals
of success and the three factors in chemical
cleansing :
(a) the antiseptic,
(b) the method, and
(c) the apparatus —
it will be evident that errors leading to
failure are avoidable only thru specializa-
tion in training and organization in person-
nel.
3. Immobilization of the affected part is
a principle of treatment to be observed both
in the period of chemical sterilization and
of closure. Motion in the wound during
the process of sterilization disseminates
bacteria along sliding planes of tissue and
with the ebb and flow of sero-cellular cur-
rents in and about the wound. It also dis-
turbs dressings, disarranges the facilities
for carrying on universal chemical contact
of the antiseptic over all wound areas.
These bad effects of motion apply particu-
larly to wounds in joints, bones, aponeu-
roses, muscles, and the sheaths of nerves
and vessels with their contents. During the
process of repair by primary union, after
sterilization of the wound, immobilization
is a prerequisite of success. Nothing tends
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more effectually to break down the healing
process than neglect of preventing gross tis-
sue movements. There is a balance of
forces during repair, the one working for
and the other against union. The wound is
never made bacteriologically sterile. Infe^:-
tion is minimized to a degree that invites
surgical closure with safety under favoring
conditions. One of these conditions is im-
mobilization. Rest to relieve inflammation
and to promote healing is an old and much
neglected principle of treatment. The full
force of its benefits is nowhere better util-
ized than in the new surgery of contami-
nated and infected wounds. Some training
in orthopedic methods of fixation and in
the use of overhead extension and sus-
pension devices proves to be requisite.
However, it is the result and not the per-
sonal whim in obtaining immobilization that
counts.
The. general surgeon unlike the ortho-
pedist is not a stickler for immobilization.
They, as a class, break over to mobilization
in season and out of season. Any surgeon
to succeed in this work must leave all prej-
udices against immobilization behind or
failure will be his portion. It is for these
reasons, theoretical and practical that the
simple doctrine of immobilization is placed
here as a principle of treatment.
4. Bacteriologic control is an index of
the relative infectivity of the wound. It is
had by three processes:
(a) by the smear count,
(b) by cultures, and
(c) by measurements of the surface area
of the wound.
Practically the smear counts are the rou-
tine indicators, and they are reliable guides
after the first twenty- four hours following
contamination of the wound. Cultures and
measurements are adjuncts for selective use
as occasion arises. Experience is requisite
for accuracy in counting bacteria in a smear
of wound secretion. Every unit of the
organism counts for one, as for instance
each coccus in chain formation and the pair
in diplococcus. Intracellular bacteria are
also counted as being viable. A smear is
taken every forty-eight hours from the
worst infected part of the wound and at the
maximum period after treatment with the
antiseptic. If the count shows one bacteri-
um in an average of five fields on two suc-
cessive days, the wound may be safely
closed. Some are closing wounds with a
fair degree of success showing five bacteria
per field, providing the cultures are negative
to streptococci and to anaerobes. No doubt
bacteriologic indications for wound clo-
sure will be found to vary with times, with
regions and with circumstances, but the
general basis for closures has been well
founded on broad experience and thoro
scientific research. The recorded and the
charted data of bacteriologic control dis-
play the infectivity of the wound and at a
glance indicate the course of sterilization,
whether progressive, retrogressive or sta-
tionary. This record faithfully kept and
charted day by day is the surgeon's guide in
all cases, and without it he is lost and pro-
gressive sterilization becomes a myth in his
work.
5. Closure is surgical rather than ex-
pectant because the wound can be made
ready far short of the time necessary for
closure to be effected by gpranulation. It is
not conformable with the intent of the treat-
ment to use chemical sterilization methods
week in and week out, month in and month
out, until the wound finally closes by its
own accord. Such a consummation is ri-
diculous and rightly puts the efforts to
scorn. One should beware of masquerad-
ing a pretense of new surgery in the guise
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of antiseptics and appliances; the whole
adding heavily to the patient's expense and
inconvenience to deliver nothing in return
except the old surgical results as heretofore.
Results must be new in kind. Union by
secondary intention must be forestalled.
Closure by suture with primary union must
supplant it, with a material shortening of
the time of healing.
Phlegmon. — ^The principles to be car-
ried out in the treatment of phlegmonous
inflammation are:
(a) limited mechanical cleansing,
(b) complete exposure, and
(c) chemical sterilization.
No extensive operation should be under-
taken in a case of phlegmon. Thoro-going
incisions, multiple in character, laying open
the entire phlegmonous area for the benefits
of drainage and of chemical contact are in-
dicated. The most radical surgery for the
purpose of exposure, and the most limited
surgery of a general operative type meet
the crisis at hand best.
• Gas Gangrenew^Gangrene is mentioned
here for the purpose of classification only.
It is beyond the purpose of this paper to re-
view the treatment of special infectious dis-
eases. The principles of treatment as men-
tioned under "suppurating wounds" obtain
here, except that "closure" does not apply
under any circumstances in the course of
gangrene. A gangrene is never "clinically
sterile" until it is unquestionably bacterio-
logically sterile.
ADDENDUM ON ANTISEPTICS.
The new surgery of contaminated and
infected wounds has developed in connec-
tion with "tryouts" of antiseptics, and close
study of the problem connected with their
successful use. When successfully em-
ployed, when wound healing was satisfac-
tory, it has been presumed to be incident to
therapeutic value in the antiseptic. In some
instances this inference has been altogether
wrong, and in others partially true. These
successes have been due wholly or in part
to a more intelligent and a more intensive
application of the principles of surgery, of
bacteriology, of physiology, and of nursing
in their practical bearing on the treatment
of infected wounds. The antiseptic in ques-
tion has never been more than a contribut-
ing factor in the final outcome. However,
it has been fully demonstrated that the anti-
septic is often indispensable to the result.
Those who propose to sterilize infected
wounds without antiseptics may succeed in
many cases, but not in all. Their failures
will be the most convincing argument in
favor of the intelligent application of the
principles of "chemical cleansing." On the
other hand, those who anchor their hope of
success in antiseptic treatment to a degree
that blinds them to the necessity for thoro
"mechanical cleansing" on a new surgical
basis, will fall short of the most uniformly
good results within their grasp. The ideal
of the surgeon in this new field should be to
make the utmost use of every great princi-
ple involved in the therapy and not to allow
himself to be drawn from the main issue by
pitting one principle against another to see
How narrowly he may be able to escape im-
pending disaster.
Requirements of Antiseptics* — ^The re-
quirements of any antiseptic for progpressive
chemical cleansing are :
(a) antiseptic power,
(b) nontoxicity, and
(c) efficiency in vivo.
The older antiseptics fail in one or more
of these particulars. To meet these require-
ments diligent research has been conducted
and as a result many new antiseptics have
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been introduced into practice. Some of
them have had a transitory popularity while
others have come to stay. Among the
newer antiseptics that have been well
championed are :
Hypertonic salt solution accorded to
Wright.
Salt ointment, 5%, accorded to Sargent.
Bismuth subcarbonate, iodoform, paraf-
fin ointment, "Bipp" accorded to Mor-
rison.,
The flavine compounds, accorded to
Browning,
Eusol, accorded to Edinberg, and
The chlorine group antiseptics, in the
forms of
(a) Dakin's solution, of sodium hypo-
chlorite,
(b) Chloramine T in neutral soap
paste, and
(c) Dichloramine T in chlorinated
liquid paraffin, "chlorcosane,"
accorded to Dakin.
Dakin's Solution. — Of the new antisep-
tics, those of the chlorine group stand out as
preeminently useful, and of them all, Da-
kin's solution deservedly ranks first. Its
action on the wound is:
(a) antiseptic,
(b) solvent, and
(c) oxidizing.
It is also antitoxic to toxin of bacillus
Welchii and possibly to the toxips of other
organisms. It is superior as a chemical
cleanser. It cleans the wound quickly of
necrotic tissues and of sloughs, and cleans
where others fail. Chloramine T and
dichloramine T are to be preferred in am-
bulant cases where wounds are fairly free
of necrotic elements, and superficial.
''Carrel-Dakin'' Tcchnic— The "Carrel-
Dakin" technic in the use of Dakin's
solution is the criterion by which other
methods of using it must be judged. The
exhaustive researches and broad clinical ex-
perience of Carrel and Dakin and of their
co-workers have established the value of
Dakin's solution and standardized the tech-
nic of wound sterilization by it. This is
so true that their methods will be the pat-
tern for others to • follow in the steriliza-
tion of infected wounds for some years to
come. Their technic is a systematic
eflfort to adapt every feature of instillation
timing of universal contact, and of chemical
concentration, to the progressive steriliza-
tion of wounds in the shortest possible time.
The instillations are timed the same, day
and night, for infection will progress as
rapidly at night as in the day. They are
given at intervals of not more than two
hours. The contact of all wound surfaces
is effected by adapting the preliminary sur-
gery to the requirements of the treatment
to be followed by the appropriate use of ap-
paratus, and by immobilization with the pa-
tient in bed. The concentration of the Da-
kin solution when it reaches the surfaces to
be sterilized is required to be the same as
it is in the reservoir. To attempt to carry
out the "Carrel-Dakin" treatment with the
patient ambulant or with miscellaneous
nursing and assistance is ridiculous.
Princii^es vs. Antiseptics. — "Chemical
sterilization" is only one feature of the
''Carrel-Dakin" treatment for it compre-
hends all of the other principles of the new
surgery of contaminated and infected
wounds as set forth by numerous surgeons
and set into practice by each in his own
way. Antiseptics may come and go, methods
and technic may be revolutionized or dis-
carded altogether, but the principles of the
new surgery of contaminated and infected
wounds will abide and with them a better
future for the affected.
ADDENDUM ON TERMINOLOGY.
Principles. — ^The principles of treat-
ment are variously grouped. There is a
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tendency to place them under two heads,
(1) surgical methods and (2) progressive
chemical sterilization. But this is in reality
a grouping of the methods of procedure. It
is not a statement of the principles underly-
ing those methods.
Surgical Methods and Princii^es. — Sur-
gical methods are invoked with the applica-
tion of all of the principles except with
that of bacteriologic control. Mechanical
cleansing is effected by methods that are
both surgical and otherwise. They are in
part operative, in part common manual
such as any intelligent person can apply,
and in part physiologic methods as by
free bleeding and the early exudation of
serum in the wound. Immobilization brings
in the methods of orthopedic surgery.
Chemical cleansing appeals to a special sur-
gical knoVledge and skill as a preliminary.
Closure in this line of treatment always re-
fers to surgical closure with the removal of
any scar tissue that may have grown into
the wound.
Chemical Qeansing and Sterilisation. —
The term "Progressive chemical steriliza-
tion" is not an equivalent for the principle
of progressive chemical cleansing. The
word "sterilization" calls attention to the
antiseptic power of the cleanser only. As
pointed out the cleanser must be more than
an antiseptic. It is called on to finish the
cleansing of the wound from sloughs,
necrotic tissue, etc., which mechanical
methods leave incomplete.
immobilisation. — Immobilization is a
principle as well as a method of treatment.
It is here placed among the principles of
treatment by right of being a unique and in-
dispensable element of success, and of being
applied for reasons fundamentallly different
from those attaching to the other principles.
THE PHYSICIAN AND THE NEW
YORK STATE INCOME
TAX LAW.
EUGENE M. TRAVIS, State ComptroUer,
Albany, N. Y.
Doctors must devote so much time in the
study and practice of their calling that it
is quite impossible for them to give par-
ticular attention to matters outside of the
profession. This situation was considered
by the framers of the New York State In-
come Tax Law and a law has been framed
taxing personal income which meets the
exigencies demanding the enactment of the
law, and is in simple language capable of
interpretation without deep study. All that
is required for filling out a return is atten-
tion to records of income and expenditures.
The increasing cost of government, and
the loss of approximately twenty million
dollars excise revenue brought about by
the ratification of the National Prohibition
Amendment presented an alarming situa-
tion in the financial condition of the state
and its political sub-divisions. The prob-
lem was rendered more difficult when it
was considered that real property was al^
ready carrying a heavy burden and that
system of personal property taxation was
being inefficiently administered. Recognized
taxation experts pi national prominence
were consulted by the legislative ccwnmit-
tees and it became evident that a tax on in-
comes must be levied. Not only was this
conclusion inevitable, but the method was
generally recognized as the most evenly dis-
tributed form of taxation.
The State Act is similar to the Federal
Income Tax statute, but the rates are lower
and it does not impose surtaxes. The rates
are one per cent, on the first $10,000, two
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783
per cent, on the next $40,000 and three per
cent, on all sums over $50,000. The New
York State law affects residents and non-
residents who have income from sources
within the state, and certain estates and
trusts.
Income to be Reported b^ a Physician*
— Fees for professional services whether
received in cash or other property are to
be reported in gross income. Other returns
should be included, such as dividends, in-
terest and profits from sale of real and per-
sonal property. Interest on bonds issued
by the U. S. Government, the State of New
York or any of its political sub-divisions,
as well as gifts and devises should be ex-
cluded in computing gross income.
Gain or loss on property acquired before
January 1, 1919, is found by the difference
between the amount received and its mar-
ket value on January 1, 1919. If the prop-
erty were acquired after January 1, 1919,
gain or loss is shown by the difference be-
tween the amount received and its cost.
For example, a doctor bought an automo-
bile in 1918 for $2,000 and on January 1,
1919, its market value was $1,500. On
June 1, 1919, he sold it for $1,800. His
gain or net income from this transaction
is $300. Cost of permanent improvements
should be added to the market value or cost,
as the case may be, to determine the profit
or loss on the sale.
Deductions for Expenses. — ^The items
which appear to be most troublesome to the
doctor are expenses which he may deduct
from income. This is true especially when
his office and residence are in the same
dwelling, and when he uses the same auto-
mobile for professional calls and for his
family.
The Comptroller has ruled that a doc-
tor may subtract the cost of supplies used
in the practice of his profession, expenses
paid in operating and repair of an auto-
mobile used for professional calls, dues to
professional associations and subscriptions
to professional journals. In addition to
these, the doctor may charge off ordinary
and necessary expenses of his business,
such as light, fuel, telephone, cleaning and
hire of office assistants. There is a distinc-
tion between business expenses and certain
other expenditures which are not deduct-
ible. Books, professional instruments and
equipment of a permanent nature are cap-
ital investments and are not allowed as
business expenses. However, deductions
may be made for their depreciation.
This, in a general way, outlines deducti-
ble expenses incurred by a doctor and the
same principles apply to all other profes-
sions. Briefly, all expenses connected di-
rectly and solely with the conducting of
an income producing business, trade, pro-
fession or vocation are allowable deduc-
tions.
A doctor rented a house and used a por-
tion of it for his office and laboratory, and
he and. his family occupied the other part
as a residence. According to the rule, he
may deduct as an expense the proportion
of the rent paid for use of office room and
laboratory, but the balance which repre-
sents the rent for use of part of dwelling
occupied by the family is not a deductible
item, as it is a personal, family or living
expense. The same principle applies to
the cost of maintenance of the automobile,
which the doctor uses for making profes-
sional calls and also for the convenience of
his family. That is, he may deduct such
a proportion of this expense as can be prop-
erly set aside to its use for professional
purposes. Likewise, expenditures may be
deducted for light, fuel, telephone, etc..
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which can be allocated to their use for
purely professional purposes.
Personal Exemptions. — Recognition is
made of certain expenses payable by in-
dividuals and these payments are offset by
personal exemptions to be deducted from
net income.
An unmarried man is allowed $1,000, as
a personal exemption or if he is married
and living apart from his wife. A married
man living with his wife or with wife in
a sanatorium, is allowed $2,000 exemption.
Each taxpayer, whether married or not,
is allowed an additional exemption of $200
for each dependent under eighteen years of
age, or incapable of self-support by reason
of mental or physical disability, and solely
dependent upon him for support. The
State Comptroller has ruled that the exemp-
tion shall be granted in the highest class
to which he would have been entitled dur-
ing the year. For instance, a doctor is mar-
ried on New Year's Eve, hence his status
as a married man entitled him to $2,000
personal exemption or the division of it
between himself and his wife, if she make
a separate return. If during the following
year a child is born, his status that year
would entitle him to $2,200 personal ex-
emption. Suppose on December 31 his wife
and child died, this would not effect his
personal exemption for that year.
Army Pay not Taxed. — ^A number of
physicians served in the U. S. Army dur-
ing the year 1919, and a number are en-
gaged in making examinations for the Bu-
reau of War Risk Insurance. This income
is excluded from taxation, but the amount
received from the government must be set
off against the personal exemption allowed
the taxpayer.
A doctor receives $2,000 from the U. S.
Government and is entitled to $2,400 per-
sonal exemption. His U. S. salary was
$2,000. He is entitled to deduct but $400
frcmi his net income.
Doctors are called upon frequently for
gifts to charitable institutions. These con-
tributions are deductible to the extent of
15 per cent, of the net income and the de-
ductions are limited to contributions made
to corporations organized under New York
laws. "Gross Income," "Net Income" and
"Taxable Income" refer to the steps taken
in omitting and including items to deter-
mine the amount on which the tax is to
be paid. The meaning of these terms can
be best explained by the following illustra-
tion: A doctor received, during 1919, an
income of $12,000, which included $2,000
interest from liberty bonds. His gross in-
come is $10,000. He has deductible busi-
ness expenses of $2,000 and an uninsured
fire loss of $500, both totaling $2,500, which
subtracted from gross income leaves $7,500
net income. The doctor is married and has
three dependent children under eighteen,
which entitles him to $2,600 personal ex-
emption. The balance, $4,900, is taxable
income, the rate being one per cent. The
doctor pays the State Comptroller $49 tax.
Administration of die Tax. — ^Tax re-
turns must be filed and the tax paid at
any district office of State Income Tax Bu-
reau or the State Comptroller at Albany,
not later than March 15, 1920. An exten-
sion of time to file the return' may be grant-
ed in the discretion of the Comptroller un-
der certain circumstances. Penalties are
imposed for failure to make a return and
for evasion of the tax. Employees of the
Comptroller's office are forbidden under
penalty to divulge contents of a return.
Further information may be obtained from
the District offices of the Income Tax Bu-
reau, located at Ajlbany, New York City,
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Brooklyn, Bronx, Jamaica, White Plains,
Buffalo, Rochester, Syracuse, Utica, EI-
mira, Binghamton and Kingston.
THE TREATMENT OF PNEUMONIA.
BY
M. FORD MORRIS, JR.. M. D..
Instructor in Medicine in the School of Med-
icine of Emory 'University, Visiting Physician
to the Anti-Tuberculosis Association.
Atlanta, Qeorgia.
Probably ever since time began, pneu-
monia has claimed a dreadful toll of lives.
Even tho, during these many centuries,
much progress has been made in the treat-
ment of this very fatal disease, pneumonia
still remains the "Captain of the Men of
Death." Therefore it behooves us to keep
ourselves thoroly familiar with every ad-
vance in therapy, as well as the older symp-
tomatic treatment Since the publication
of a previous paper(l), there has not been
any great addition to our therapeutic
knowledge. However, with the approach
of winter, it is advisable to review the best
of the present-day methods of treatment.
It seems best to discuss the subject as fol-
lows:
1. Prophylactic^ — Good food, plenty
of sleep, an abundance of fresh air, proper
ckrthing, a cool sponge bath every morning
— in short, all measures which keep indi-
vidual resistance at a high level — ^are of
value. The administration of a vaccine
composed of pneumococci of types I, II,
III, and of hemolytic streptococci seems to
be well worth while. Kolmer and Stein-
feld(2) recommend a prophylactic mouth-
wash of ethylhydrocuprein (1 to 10,000)
solution in liquor thymolis and the same
drug or quinine itself in Dobell's solution
as a nasal douche. The administration of
antistreptococcus serum to all cases of
measles will prevent many of the dreadful
pneumonic sequelae of this very common
disease. When absolute isolation of each
pneumonia patient is impossible, the plac-
ing of screens, at least eight feet in height,
around each patient will aid materially in
stopping the spreading of this disease.
2. Hygienic — ^The patient should be
isolated in a light, airy room which is de-
void of all unnecessary furniture and which
has the temperature of the outside air. The
patient should have just enough bed-cover-
ing to keep him comfortable, and he should
have no draught blowing on him. Absolute
mental and physical rest, as well as expert
nursing, are imperative. The diet should
consist of easily-digested, easily-assimi-
lated, non-fermentative foods of high
caloric value, given in small amounts every
two or three hours. The patient should
drink freely of water, and he or she should
have an abundance of fresh air.
3. Ssmiptoiiiatic. — An initial chill may
be lessened by the administration of hot
drinks and the application of hot water
bottles. Three or four gprains of calomel
should be given soon after the patient is
first seen. The fever usually requires no
treatment ; but if the temperature is above
104**F., a cool sponge bath is in order. In
case the patient has any serious cardiac dis-
turbance, he will react better to a warm
sponge bath. A frequent painful cough
calls for the administration of either heroin
or codeine. In bronchopneumonia, the
use of expectorants is of much value; this
statement holds true sometimes also in the
third stage of lobar pneumonia. Probably
the best drug for this purplbse is ammonium
chloride, which is best given with licorice
or the syrup of citric acid. Strapping the
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affected side with adhesive plaster and the
administration of codeine or morphine will
control the pain of an accompanying pleu-
risy. The application of mustard plasters
or kaolin to the skin of the chest is appar-
ently of no value ; in fact, "the notion that
the course of an acute infective inflamma-
tion in the alveoli can be modified by doing
something to the skin of the chest is path-
ologically untrue and . physiologically im-
possible" (3). The toxemia can be partly
overcome by plenty of fresh air and water ;
at least three pints of water should be taken
daily by the patient, either by the mouth,
by the rectal drip, by hypodermoclysis, or
by intravenous administration.
Abdominal distention is best relieved by
the hypodermic administration of pituitrin
or eserine sulphate and by the use of tur-
pentine stupes and asafetida enemata. Of
course, the omission from the diet of any
food that is causing distention is necessary.
The mild types of delirium call for the ap-
plication of the ice-cap to the head and for
the administration of a bromide in 20 grain
doses every three hours. The more severe
types of delirium require the use of mor-
phine. The cyanosis of some cases can be
overcome by the inhalation of oxygen for
five or ten minutes each half hour; at the
same time, the heart should receive atten-
tion.
The heart muscle early becomes affected
by the pneumonia poisons, with the result
that cardiac medication is practically al-
ways necessary. Digitalis is the drug
usually indicated ; and the tincture seems to
be about as good as any other preparation.
It is necessary to use an active solution;
and if no effect is obtained, the dose is
either too small or else the preparation is
inactive. A dose of 20 or 30 drops every
four hours will soon get the pulse rate
under control. However, one should not
hesitate to give larger doses, if such doses
are necessary. Digitalis should be stopped
when the pulse rate gets down to 80, or
with the onset of sudden anorexia, vomit-
ing, diarrhea, a decrease in urinary output,
or extra-systoles. Caffeine and sodium
benzoate is an excellent stimulant ; also the
compound spirit of ether and the aromatic
spirit of ammonia are rapidly diffusible
stimulants. Camphor in oil is slower, but
quite powerful. In collapse, atropine is
very valuable. Strophanthin, or ouabain,
given intravenously, is probably the most
powerful stimulant of cardiac muscle; but
it is dangerous to give this drug soon after
digitalis therapy. When the heart is labor-
ing against increased peripheral resistance
occasioned by the contraction of the arteri-
oles, or when the blood pressure in an ar-
teriosclerotic patient is ascending to unsafe
heights, nitroglycerine should be given.
The blood pressure should be taken regu-
larly and frequently. Hypotension calls
for the administration of adrenalin and
pituitrin, in addition to digitalis.
Empyema, altho it is not a symptom, oc-
curs frequently enough to warrant its con-
sideration here. It seems best to aspirate
the pus daily, and at the conclusion of each
aspiration, to inject into the pus cavity one
or two ounces of a surgical solution of
chlorinated soda (4) ; and to do a late in-
stead of early operation, when operation is
necessary.
4. Immunotherapeutic — (a) Lobar
pneumonia. — Cole and Dochez(5) have
found that pneumococci are of four dis-
tinct types (I, II, III, IV) and that, so
far as specific therapy is concerned, pneu-
monia is caused by four different organ-
isms ; the Types I and II are the most prev-
alent, and that each of these types yields a
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protective antipneumococcus serum, that of
Type I being much more potent. These
two scientists found it impossible to treat
pneumonia caused by either Type III or IV,
because in one type the organisms are of
distinct varieties and the other type does
not yield an immune serum. But there is
much consolation in the fact that infection
by either Type III or IV is relatively slight
and rarely fatal. In all cases studied by
Cole and Dochez, "the serum had an ulti-
mate favorable effect in lowering the tem-
perature and shortening the course of the
disease." In all cases, one injection was
sufficient to render the blood sterile.
The particular type of causative organ-
ism is determined by the agglutination test
or Blake's precipitin test (6) on a culture
obtained either from the blood, sputum
coughed from the lung, or directly from the
lung by means of a needle inserted into it.
If the causative organism belongs to either
Type I or II, the treatment, with the appro-
priate serum in doses of 50 to 100 c. c.
diluted one-half with normal saline solu-
tion, injected into a suitable vein, is begun
immediately. The condition of the patient
is used as a guide to further treatment,
the total amount of serum used is from 190
to 700 c. c. and the dose should not ordi-
narily be repeated within 12 hours of the
preceding one.
(b) Bronchopneumonia. — As soon as
the causative organism can be determined
by culture of the blood, sputum, or by lung
puncture, immunotherapeutic treatment
may be advisable. If the streptococcus is
the cause, the intravenous administration
of antistreptococci serum is in order. If
the pneumococcus is the cause, serum of
that kind should be given. In influenza
pneumonia, the use of serum obtained from
convalescent influenza-pneumonia patients
has been tried, but did not yield much suc-
cess. In the treatment of bronchopneu-
monia, the use of sera has been of far less
value than in lobar pneumonia.
**The status of vaccination in pneumonia,
both prophylactic and curative, is still very
doubtful — and the evidence of clinicians in
favor of vaccination as a therapeutic meas-
ure is insufficient to overthrow the general
scientific arguments against the procedure."
Hiss (7) reports very good results in the
treatment of pneumonia with an extract of
leucocytes obtained from rabbits, in doses
of 20 to 60 c. c. q 4 h.
5. Chemothempyd — ^At the present
time, quinine and its derivatives are the
nearest approaches to a specific chemical
remedy, in pneumococcus pneumoniae. In
1901, Petzold (8) used quinine hydrochlo-
rate hypodermically and considered it a
specific. . Later, Henry (9) enthusiastically
reported using quinine hydrochlorosulphate
on account of its greater solubility, hypo-
dermically.
In 1912, Cohen (10) reported his use of a
50 per cent, solution in water of quinine
and urea, given into the muscles, in doses
totaling 90 to 150 grains within 48 to 60
hours, without cinchonism. As a result of
this form of treatment, the symptoms are
favorably changed, but the physical signs
are uninfluenced. In a later paper (11),
this same author asserts his belief that qui-
nine and its congeners are antitoxics or anti-
dotes to the pneumococcic toxins; that
often one dose is sufficient to insure re-
covery. In other cases, however, he says
that the quinine and urea must be supple-
mented by heart stimulants. When the
temperature is over 103° F., he gives, either
orally or intramuscularly, 7j/2 to 15 grains
every 3 hours until the temperature is re-
duced to 102.2° F. Commenting oh this
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quinine and urea treatment, Billings (12)
says the effect is solely from the quinine,
which, if given in sufficiently large doses,
will lower febrile temperature, but advises
against combating high temperature in
pneumonia with antipyretics.
At present ethylhydrocuprein, a synthetic
quinine-like substance, seems to be the best
chemical agent in treating lobar pneumonia.
Ethylhydrocuprein was probably first used
by Morgenroth and Levy (13) while they
were working with various derivatives of
quinine. Cole (14) says that this sub-
stance is 150 times as strong as quinine,
and that it has the power, even in the dilu-
tion of 1 to 5,000,000, of killing pneu-
mococci in the test tube, and that it seems
to be effective against all types of pneu-
mococci.
Both Wright (15) andFrankel(16) noted
several cases of transitory amblyopia fol-
lowing its use, and the former was imable
to observe any therapeutic effects what-
ever. Also Stuhmer(17) has reported a
case of transitory total amaurosis following
a total of 2.25 grams administered within
48 hours. These ill effects are probably
due to the facts that the therapeutic dose
is very near the toxic dose, and that these
patients received too large a dose.
In a series of 20 cases, Becher(18) ob-
tained most excellent results. He found
that, when the drug was begun on the first
day of the disease, the average time until
the disappearance of fever was lyi days;
when begun on the second day, it was a
little over 3j4 days — the time growing
longer the later in the disease the adminis-
tration of the drug was started. In addi-
tion to the prompt reduction of fever,
Becher notes that the drug lessened the
number and frequency of complications
and averted serious cardiac manifestations.
The untoward symptoms affect the eyes
and ears particularly, and sometimes mani-
fest themselves in nausea and vomiting.
Baerman(19) who gave the drug in an
oily suspension, thinks that this agent has
an unmistakable curative action in pneu-
monia, especially when combined with im-
mune serum.
Chesn.ey(20) declares that a bactericidal
action for pneumococci can be secured in
the blood stream of patients if the patients
are given 0.024 gram of ethylhydrocuprein
per kilogpram of body weight, per 24 hours.
If at first a large dose is given and followed
at intervals of not more than three hours,
by smaller doses, the appearance of this
bactericidal action may be hastened.
Both Chesney and Cole recommend an
initial dose of 7 or 8 grains, followed every
two hours by 2 J4 grain doses. Becher gives
4 grains every four hours. The oral ad-
ministration of the hydrochloride has given
the best results.
"Of things, some are in our power, and
some are not" beginneth the Enchiridion
of Epictetus. Surely this is true in the
treatment of pneumonia. When we have
done so much, we have about exhaused all
our therapeutic resources. Then, all we
can do is to watch and wait, and hope that
the fateful summons to cross the dreary
river of death will not come to her or him
o'er whom we watch.
Rkfebencbs.
1. Morris, M. P., Jr.: Medical Record, Octo-
ber 6, 1917.
2. KoLMER and Stein felp: JowmaX A. M. A.,
January 5, 1918.
8. Pye-Smith and Beddard: In Allbutt and
Rott€8ton*8 System of Medicine, 2nd £3di-
tlon. V, 241.
4. Mann, A. T.: Transactions of 8o. Dakota
State Medical Asso., 1918.
5. Cole and Doohez: **Pneumoooccic Infec-
tions''* in Forchheimer's Therapeutics,
Volume V.
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789
6. Blake, F. O.: Journal of Experimental
Medicine, July, 1917.
7. Hiss, W.: Journal of Medical Research,
1913, XIX 385.
8. Petzold: Deutsch, Arch, fur klin. Med,,
Band 70, Hefte 30-31, 1901.
9. Henbt: Phila, !Medioal Journal, February
14, 1903.
10. Cohen, S. Sous: Smer, Jour, of the Med.
Sciences, January, 1912.
11. : N. Y. Medical Journal, June 3,
1916.
12. Billings, F.: Practical Medicine Series,
1917, I. 100.
13. MoBGENBOTH and Levy: Berliner-klin.
WocK, 1911, II. 1660, 1979.
14. Cole: Penn. Medical Journal, February,
1917.
15. Wright, A.: Lancet, 1912, II. 1633, 1701.
16. Frankel: Berliner-klin. Woch., 1912.
17. Stuhmeb, a.: Medizinische Klinik, De-
cember 3, 1916.
18. Becheb, E.: IJM., October 29, 1916.
19. Baebhan: Zeitsch. f. exper. Path. u.
Therap., 1914, I. 476.
20. Chesney, a. M.: Jour, of the Amer. Med.
Asso., January 13, 1917.
MULTIPLE ARTHRITIS OF OB-
SCURE ORIGIN.'
BY
VIRGIL E. SIMPSON, M. D..
Louisville, Kentucky.
The subject of this report is a man thirty-
eight years of age, the father of three liv-
ing children. For the past fifteen years he
has had on his mind the responsibility of a
large business enterprise to which he has
devoted close attention and in consequence
has taken little or no recreation.
In March, 1919, the patient had what was
supposed to be a mild attack of influenza.
He was not under my observation at that
time, but the probability is he was not in a
highly resistant state. His attack of influenza
was presumed to have been mild in char-
acter, but examination by an eve, ear, nose
and throat specialist revealed that some of
the accessory sinuses were involved accord-
ing to the patient's statement. However,
early in May he consulted another eye, ear,
nose and throat specialist who was certain
his sinuses were clear.
During the latter part of May, he began
* Case report before the Society of Physicians
and Surgeons, of Louisville, Kentucky, Novem-
ber 20. 1919.
to suffer pain and swelling; about the meta-
tarso-phalangeal joints of both feet. The
process extended rather rapidly and suc-
cessively involved the ankles, the lower
legs, the joints of the hands (particularly
the right) and wrists ; he also* had pain in
the dbow and shoulder joints but no swel-
ling. He was at different times under the
care of two prominent physicians in Louis-
ville with no improvement.
His condition became sufficiently serious
in July as to cause him to quit work, at
which time he came under my observation.
He had then been away from his business
about a week. His temperature and pulse
were about normal; blood pressure 130
mm. Hg. Blood examination showed leu-
cocytes eight thousand, hemoglobin eighty
per cent., er)rthroc)rtes four million plus.
At my first visit the additional history
was obtained that the patient had suffered
from some gastrointestinal disturbance in
1916; that he had been operated upon by a
Louisville surgeon for gastroptosis the
stomach having been "hitched up in correct
position"; that at the same time his ap-
pendix which was perfectly normal had
been removed, and strange to relate he sur-
vived the surgical insult !
I examined this man carefully, and noted
that several of his teeth were sensitive to
touch with a probe. Attention had not
hitherto been attracted to his teeth ; he had
not suffered from toothache altho pyorrhea
alveolaris was marked around several lower
and one or two upper teeth. Some of his
teeth had been filled and others needed
dental attention. On this basis I suggested
that the arthritis was in all probability due
to focal infection, and that it was my belief
his teeth were responsible as no other pos-
sible source of infection could be found.
I therefore advised that he have the mouth
and jaws examined by an expert roentgenol-
ogist. He was accordingly taken to the
office of a dentist who makes a specialty
of exodontry and roentgenologic work. The
Roentgen ray showed abscesses at the roots
of the fifth, sixth and seventh molars on
the right side, and two teeth under these
three were similarly involved. The right
upper incisor tooth showed what the dentist
called a "granuloma" at the root. Extrac-
tion of the diseased teeth was recommended
and done a few days later at the Norton
Infirmary with thoro curettage of the ab-
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ORIGINAL ARTICLB8
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scess cavities. Recovery was uneventful
from the extraction and curettement, the
wound being kept open for five weeks be-
fore it was allowed to heal.
Since that time the sinuses have again
been examined with negative result; his
blood has been again cultured with an ab-
solutely negative result ; the Widal reaction
is negative; Wassermann negative; ex-
amination of the genitourinary tract nega-
tive and the man has a negative venereal
history.
Five weeks ago, for the first time, one of
the joints began to fill with fluid, i. e., the
left knee. It filled rather rapidly, and
three days later several cubic centimeters
of fluid withdrawn by aspiration was sub-
mitted to the laboratory for examination
hoping the responsible microorganism might
be located. Again to our surprise the cul-
ture was negative.
Since July this man has spent two weeks
at Martinsville, Indiana ; he has grown pro-
gressively worse and is at present again at
the Springs on his own volition. Dr. C. W.
Dowden saw him with me in consultation
two weeks ago, and he suggested possibly
there was an underlying gouty condition.
We accordingly made another examina-
tion of the blood for urea and uric acid,
with negative results.
I do not know the cause of the multiple
arthritis in this case. The man's tonsils
are apparently normal ; there seems no rea-
son for suspecting the tonsils as the focus
of infection as they are not enlarged nor
are there any adhesions at the pillars. Cer-
tain joints which are painful and swollen
today may two days later be free from pain
with absolutely no impairment of function.
In fact, functional impairment occurs only
during an acute attack of pain. As soon
as pain subsides joint function is com-
pletely restored. The joints have been re-
peatedly examined by the Roentgen ray and
the bones found normal. The man's tem-
perature thruout has remained about QP^'F.
Of course it is well recognized that mul-
tiple arthritis may have its origin in focal
infection. It is also true that the primary
cause of the trouble may be completely re-
moved and yet pathology in one or many
joints may persist. However, it would
seem that in a case such as this, where the
joint pathology has persisted since removal
of the primary cause which was presum-
ably located in the teeth, 'there should be
impairment of function in the involved
joints. I cannot conceive of any disease
which might act as a secondary focus with-
out impairment of function.
So far as metabolic disturbances are con-
cerned I can conceive of but one condition
which might result in multiple arthritis and
that is gout. Any disease due to faulty
metabolism which manifests itself primarily
in the joints of the feet, with subsequent
involvement of other joints and persisting
for six months, must eventually show some
evidence on blood examination, such as in-
crease in the amount of urea and uric acid,
and there will also be angulation from uric
acid deposits which can be clinically demon-
strated.
This patient has no uric acid deposits,
and blood examination shows the excretion
of urea to be practically normal in percent-
age. Roentgen-ray examination shows
that the joints are perfectly normal.
The Work of American Physicians in
Local Ezaminating Boards* — ''In the
work done by the medical profession in
the war, one cannot pass by that accom-
plished in examining the young men drafted
into the army. This work of the local
boards was not done by picked specialists
or by men previously trained for it. The
physicians of the boards were at first usu-
ally the county and city physicians appointed
by the local sheriflF, and the figures form an
interesting study. Of the 10,000,000
(9,952,735) called and registered, 6,750,-
000 (6,744,289) were not examined. Of
the one-third who were examined — ^that is,
of the 3,208,448—70.4 per cent, were found
to be fully qualified, while 29.6 per cent,
were found physically to be totally or par-
tially disqualified. Of the 2,124,293 who
were sent by the local boards to the camps
and were there subjected to the careful and
minute examination of experts, 91.9 per
cent, were accepted and only 8.1 per cent,
rejected. It is interesting to note that in
the draft of 1917 the local boards rejected
29.1 per cent, and in 1918 they rejected
29.6 per cent. The more this work is
studied, the more one appreciates its extent,
its far-reaching influence and the high value
of the work performed." — Col. Alexander
I^mbert.
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RATIONAL. ORGANOTHERAPY
December, 1919
791
RATI O N AL
ORGANOTHERAPY
The Adrenalin Test* — Goetsch {Med.
Record, page 780, Nov. 8, 1919) reports
the results of a clinical study of approxi-
mately 300 cases of thyroid disease in the
human subject with special reference to the
sensitiveness of these patients to hypoder-
mic administration of adrenalin; to show
that in clinical states of hyperthyroidism
there was an increased tolerance for adren-
alin hyperdermically administered; and to
indicate the practical application of this
knowledge to the study, diagnosis and treat-
ment of thyroid disease in the human sub-
ject. With the abundant physiologic evi-
dence that increased thyroid secretion
caused a hypersensitiveness of the sympa-
thetic nervous system to the action of ad-
renalin, he thought it would be of interest
to test the reaction of human patients suf-
fering with hyperthyroidism to the subcu-
taneous administration of adrenalin. His
thought was that if thyroid secretion sen-
sitized the sympathetic endings to the ac-
tion of adrenalin it was reasonable to sup-
pose that a sudden increase of adrenalin in
the circulating blood would call forth ac-
tive responses thruout the domain of dis-
tribution of the sympathetic nervous sys-
tem. This result he had found to be re-
markably constant. The work was begun
five years ago while he was in the surgical
clinic of Professor Gushing and continued
during the past four years in the clinic of
Professor Halsted at Johns Hopkins Hos-
pital. To his great surprise and satisfac-
tion the first patient exhibiting hyper-
thyroidism, a case of exophthalmic goiter,
gave a sharp reaction to the injection of
adrenalin, and since that time he had per-
sonally carried out or supervised the carry-
ing out of the test in 300 cases of thyroid
disease and in approximately 100 conditions
simulating in many respects hyperthyroid-
ism. In a so-called positive reaction there
was usually an early rise in systolic and a
fall in diastolic blood pressures. In a very
mild reaction the fall in diastolic pressure
might occur alone. There was a rise in pulse
pressure of at least 10 and sometimes as
much as 50 or more millimeters of mercury.
In the course of 30 to 35 minutes there was
a moderate fall of the pulse and blood pres-
sure, then a characteristic secondary rise
and a second fall to the normal in about
one and a half hours. Together with these
changes one saw an exaggeration of the
clinical picture of Graves' disease or hyper-
thyroidism brought out, especially the nerv-
ous manifestations.
The Di£Ferential Diagnosis of Hyper-
thyroidism by Basal Metabolism and Ali-
mentary Hyperglycemia. — ^There seems to
be quite general agreement, asserts Mc-
Gaskey {N. Y, Med, Jour,, Oct. 11, 1919),
as to the causal relationship of overactivity
of the thyroid gland to increased metabol-
ism. In fact, it seems to have been proved
that there is a close quantitative parallel-
ism between the thyroid secretion and the
metabolic rate, and that the estimation of
the latter by means of the oxygen con-
sumption may, therefore, be relied upon,
with certain reservations, as an accurate
index of the activity of the thyroid gland.
The isolation and identification of thyro-
toxin and its complete chemical study by
Kendall, together with its physiologic and
therapeutic study by Plummer, have placed
this entire subject upon an accurate, almost
mathematical basis. These discoveries, in
the opinion of the writer, have relegated
to the domain of obsolete pathologic con-
ceptions the always dubious hypothesis of
dysthyroidism, at least in so far as it refers
to perversion, rather than a quantitative
variation of thyroid secretion. From the
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RATIONAL. OROANOTHSRAPY
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Strictly clinical aspects of the question one
may confidently proceed on the following
assumptions: (1) That the symptoms of
hyperthyroidism and hypothyroidism are
due to quantitative variations of thyrotoxin
in the body cells. (2) That the funda-
mental phenomenon which dominates the
entire clinical picture from cretinism to
•^'Basedowism" is perversion of the meta-
bolic rate. (3) That this metabolic rate
has its absolute equivalent, in accordance
with fully established physical laws, in the
heat production of the entire mass of body
cells. (4) That this heat production is es-
sentially a process of oxidation and is
equivalent to the quantity of oxygen con-
sumed, the latter being regulated by, and
dependent upon, the metabolic rate. (5)
That it is now possible with the compara-
tively simple Benedict portable respiration
apparatus to determine clinically the oxygen
consumption over a sufficient period of
time, say ten to fifteen minutes, with suf-
ficient accuracy for all clinical purposes.
(6) That if food metabolism is eliminated
by twelve to fifteen hours' starvation (the
usual normal condition in the morning),
and the metabolism of voluntary muscular
effort is eliminated by absolute rest in the
recumbent position (one-half to one hour
is sufficient), there remains only the energy
output — the heat production — the metabol-
ism of the circulatory and respiratory
mechanism, with small and probably negli-
gible additions for the phenomena of se-
cretion and the intracellular chemical
changes of the cells of the body while at
rest, which is called basal metabolism.
This so-called basal metabolism is very con-
stant, not only in the same individual, but
in all individuals when calculated in pro-
portion to the area of body surface, varying
in health, in a large majority of people,
probably less than 10 per cent, from the
average normal rate. The clinical estima-
tion of basal metabolism is thus a very
practical and reliable guide (and compara-
tively easy, altho requiring the utmost care
and accuracy) to the functional activity of
the thyroid gland in health and disease, and
without which thyroid disease cannot be
adequately and scientifically studied. Be-
fore making a final decision as to the func-
tional state of the thyroid, there are certain
important limitations and reservations
which must receive careful attention. The
first and perhaps most important question
is : What other causal conditions, aside from
variation in thyroid activity, may produce
the fluctuations of basal metabolism which
form the basis of this clinical study? For
while quantitative variations of the thyroid
hormone produce these changes to an ex-
tent and with a promptness and certainty
that nothing else can equal, it does not fol-
low that other and independent factors exist
with which one must reckon. In reality
such factors do exist. Among these may
be mentioned fever, severe cardiorenal dis-
ease, pernicious anemia, and age, all of
which the writer discusses more or less in
detail. With due attention to the precau-
tions and exceptions suggested, the rate of
basal metabolism must be regarded as an
altogether dependable index of thyroid ac-
tivity at the time of observation. With re-
gard to alimentary hyperglycemia in its rela-
tion to hyperthyroidism the writer states:
(1) That alimentary hyperglycemia follow-
ing 100 grams of glucose is present in prob-
ably every case of thyrotoxicosis. (2) That
it is rarely, if ever, present at the end of the
first hour in normal persons, altho it may
have occurred at the end of about thirty
minutes. (3) Its presence, therefore, in
one hour and especially in two hours al-
ways indicates abnormal carbohydrate met-
abolism unless gastrointestinal function is
delayed. (4) It occurs in latent, and of
course in manifest, diabetes, in alcoholism,
malignant disease, arthritis, and very prob-
ably in a considerable number of infections,
acute, subacute or chronic in the same cate-
gory with arthritis. (5) Before attaching
a positive diagnostic value to alimentary
hyperglycemia in suspected hyperthyroid-
ism, these conditions and possibly others of
which we are now learning must be ex-
cluded. (6) While its positive value can
only be considered corroborative, its nega-
tive value in excluding hyperthyroidism is
very great and probably exceeds 90 per
cent. (7) In hyperthyroidism there is no
constant direct ratio between its intensity
and the height of the alimentary hyper-
glycemia, altho in general the blood sugar
values in severe cases are high. (8) Too
much importance should not be attached to
alimentary blood sugar values below 140
mgm. of sugar in 100 c. c. blood, altho
sharp lines of demarcation cannot yet be
drawn.
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RATIONAL ORGANOTHERAPY
December, 1919
793
The Hyperthyroid Theory of Basedow's
Disease. — Cumston {N. Y. Med, Jour.,
Aug. 30, 1919) emphasizes the fact that the
thyroid gland receives its impulses from
the nervous system by way of the laryngeal
nerves, and by its activity produces a sub-
stance which in turn reinforces the activity
of the nervous system by increasing its sus-
ceptibility. A normal nervous system would
perfectly well support a reinforcement of
its excitability and would not react by any
apparent symptomatology. There would
be a disproportion between cause and eflFect,
this being made evident at points particu-
larly sensitive to thyroglobulin, that is to
say in the domain of the sympathetic and
cerebrospinal system.
The clinical symptoms can be readily sur-
mised. They consist of cardiovascular
symptoms (tachycardia, palpitation, vascu-
lar erethism, sensation of heat), polyuria,
polydipsia, bulimia, emaciation, profuse
sweating, nervous disturbances (nervous-
ness, insomnia, tremor, headache). How-
ever, while in constitutional iodic subjects
a predisposed nervous system is attacked
by thyroid intoxication (provoked by
iodine), in patients with exophthalmic goi-
ter it is on the contrary the seriously
changed nervous system which acts on the
thyroid gland by the intermediary of the
laryngeal nerves, causing hyperfunctioning
which reacts on the nervous system. Thus
a vicious circle becomes established. Sur-
gical treatment breaks this vicious circle,
but does not cure the diseased nervous sys-
tem. A morbid change of the nervous sys-
tem and an increase of the thyroid secretion
are the two conditions sine qua non of the
morbid symptomatology. In the first, iodic
thyroidism, the nervous changes preexist;
iodism gives rise to thyroid intoxication;
both conditions being manifested.
In true exophthalmic goiter, the nervous
system, more profoundly changed, is the
only primam movens which starts up thyroid
hyperactivity and creates the vicious circle
in which the nervous system excites the
thyroid secretion, rendering the nervous
system more excitable, and so on.
Finally, in the third, Basedow's disease,
thyroid hypersecretion preexists, and it is
this which creates the nervous lesion by a
long continued irritation. One of the best
arguments in favor of the theory of thyroid
hypersecretion is the success obtained by
various serotherapeutic measures based up-
on this hypersecretion.
Corpus Luteum Extract in the Vomit-
ing of Pregnan^. — ^J. K. Quigley {Amer.
Jour, of Obstetrics, Aug., 1919) gives his-
tories of several cases in which this freat-
ment was applied. The total number of
patients treated by him was seventeen;
twelve were permanently benefited by the
treatment, and four others were benefited
but relapsed, not enough of the drug having
been given. In one case, of the pernicious
type, there was complete failure. The corpus
luteum extract was often injected intra-
muscularly, e. g., in the deltoid muscle, in
doses of one mil, repeated every four days,
daily, or even oftener. In some cases five
grains of extract were given by mouth
three times a day. The average number
of injections given was seven. In the four
relapsing cases only three to five doses had
been given. Had these patients been given
more of the drug at the onset as a routine,
permanent benefit would probably have
resulted. The one mil ampoules of extract
employed in administering the intramuscu-
lar injections each contained 0.2 gram of
desiccated corpus luteum substance.
D
I Physical Therapy
The Treatment of Rheumatoid Arthri-
tis.— ^An editorial writer in the Amer.
Jour, of Electrotherapeutics and Radiology
(Sept., 1919) concludes his very compre-
hensive article as follows :
(1) Patients suffering from rheumatoid
arthritis received marked benefit and have
been clinically cured by the action of the
static current in relieving local inflamma-
tion and tissue infiltration, restoring^ circu-
lation and metabolism, both local and gen-
eral.
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December, 1919
PHYSICAL. THERAPY
American BIsoicine
(2) In no case in the light of the pres-
ent knowledge of the causes of the condi-
tion should diet and high colonic flushings
as a routine method be omitted.
(3) In no instance should these patients
be restrained from exercise ; but on the con-
trary, exercise should be encouraged during
the treatment, short of commencing fatigue.
(4) The treatments by radiant light and
heat, either local or with the light bath, two
or three times weekly add very much to the
relief of these cases, promoting as they do
increased metabolism and elimination.
(5) Mechanical vibration plays a very
important role in the treatment of this dis-
ease, for the relief of muscular tension,
overcoming the stiflFened joints and improv-
ing to a degree local metabolism and elim-
ination.
Under the condition indicated only the
most advanced cases resist an improvement
of the condition, and in all other cases un-
der the indicated regime and routine treat-
ment these cases are uniformly cured. Fail-
ure only results from a careless technic or
indifferent attention of careless patients to
treatment and diet, or the destruction of
joint structures which had taken place prior
to the institution of treatment. All structures
or parts of joints that have undergone or-
ganic change will remain permanently im-
paired with the inflammatory process
abated.
Radiam Treatment of Cancer — ^The
effects of and efficacy of radium have been
very widely discussed of recent years, says
an editorial writer in the Medical Record
(Nov. 8, 1919). As a therapeutic agent
it has been extolled to the skies and con-
demned without reservation. Soon aft6r its
first introduction it suffered severely from
the exaggerated and indiscrete praise of
its too enthusiastic advocates. In the re-
action which followed it was freely stig-
matized as absolutely useless and even
harmful. The medical profession is now
coming to a fair estimate of its worth,
avoiding excessive praise on the one hand
and equally foolish condemnation on the
other. The conclusion has been arrived at
that radium is neither a "cure all" nor a
useless or harmful means of combating
certain diseases, but when employed prop-
erly, that is in correct dosage and with
exact knowledge as to its application, is a
most valuable remedy.
W. H. B. Aikins of Toronto read a paper
on radium at the meeting of the American
Radium Society, Atlantic City, Jime 9,
1919, which is published in the Medical
Press for October 8, 1919. In this paper
it is explained how necessary it is to rec-
ognize the limitations of radium and not
to expect too much from its employment.
Aikins reviews the history of radium in
the treatment of cancer and states it holds
a firm, almost unassailable position as re-
gards the treatment of cancer of the face.
It may be relied upon in a large proportion
of these cases to bring about a permanent
cure without leaving the disfiguring and
contracted scars which so often result from
surgery, and which so frequently are the
site of recurrence of the trouble. In such
cases there is no other treatment which can
compare with radium in the excellence of
its cosmetic results. Further, Aikins says,
radium may be recommended in this con-
nection because of the ease and painless-
ness with which it can be applied. Not
only in malignant, but also in benign dis-
eases of the skin radium has proved its
value.
Surgeons for the most part regard ra-
dium as chiefly useful as an adjunct rather
than a substitute for the knife. As to this,
while Aikins does not admit that its main
value rests in its post-operative efficacy, he
does regard it as peculiarly useful in this
field. He quotes from the Report of the
London Radium Institute, issued at the end
of 1918, in which it is stated that between
1911 and 1914 a large number of cases of
cancer were operated upon by surgeons of
high standing, and the operations were so
extensive that in the opinion of the opera-
tors recurrence was inevitable. After post-
operative treatment with radium, recurrence
took place in less than 20 per cent, of the
cases, a result which is believed to be un-
equaled even in the records of selected cases
operated upon by surgeons of extensive ex-
perience. One of the most beneficial ef-
fects of radium is the manner in which it
will often, perhaps generally, relieve the
distressing features of incurable cases and
thus modify the unpleasant symptoms char-
acteristic of the final stages of the disease,
and render the last days of the patient at
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PHYSICAL. THERAPY
December, 1919
795
least endurable. This precious action of
radium has been notably demonstrated in
advanced cases of cancer of the uterus.
Aikins does not in any way overstate the
case when he says that the present position
of radium therapy is very encouraging and
that radium has amply justified its use by
its palliative properties in these hopeless
cases.
Radio-Therapy in Inflammation. — ^Ac-
cording to the American Journal of Electro-
therapeutics and Radiology, in the very
early stage of inflammation the application
of radiant light and heat or thermal pene-
tration with the high frequency current, or
the administration of dry heat by dilating
the superficial vessels and capillaries, en-
larging the channels of circulation thru the
capillaries and small blood vessels, may
make possible the escape of the inflowing
blood and arrest or prevent the establish-
ment of stasis. When the induction of such
hyperemia, however, has been delayed and
the stasis is already well established, more
active measures will be required — energetic
means which will act sls a vis a tergo, and
force out the accumulations in the lymph
spaces thru the lymph channels, and so dis-
engorge the tissues.
In a paper read at Buffalo in 1901 (The
Effects of Electrostatic Modalities upon
Hyperemia and Pain), at the annual meet-
ing of the American Electrotherapeutic As-
sociation, Adami first called attention to
this principle, which has since been recog-
nized and employed by a large number of
medical men with the same success that has
always attended their use by the writer. In
this paper it was stated that the previous
dictum of the medical profession, that elec-
tricity should not be employed in the treat-
ment of acute inflammatory conditions in
the earliest stages, was an error because its
proper employment effects an early dissi-
pation of the inflammatory exudate, softens
the involved tissues and brings about
promptly a restitution to normal of the cir-
culation and metabolism in a manner that
cannot be accomplished so effectively by
other measures.
In the case of a sprained ankle or knee,
referred to by Adami, the systematic, prop-
er application of the static current at the
first administration will soften the exuda-
tion, relieving the pressure, with relief from
pain, relaxation of mu&cular tension and
restoration of motility and utility to the
joint. The patient who comes for treat-
ment on crutches will walk out without
them with little or no pain, and unrestrained
in his directions as to rest. An individual
in such condition should return for daily
treatments, with the result of a complete
restoration of the affected part within a
week, without an evidence of having had an
inflammatory trouble. This will be the re-
sult in all cases in which there has been
no solution of continuity or fracture of the
ligamentous or bony structures of the joint,
when they come under observation within
24 or 36 hours after such accident has oc-
curred. The same principle applies to the
treatment of every similar inflammatory
condition not the seat of an infectious
process.
The best means to be employed for the
relief of local inflammation in which infec-
tion does not enter as a factor is the appli-
cation of the static wave current, the static
sparks, the static brush discharge or the
direct vacuum tube static current, singly
or conjointly. Any one of these modal-
ities is capable of removing superficial in-
flammation. If, however, the deep struc-
tures of an enlarged joint are involved, or
other deep-seated structures, the best
means for relieving it is by inducing tissue
contraction of such deeply located tissues
with the application of long static sparks.
The static brush discharge is applicable for
the relief of all superficial inflammations
including sprains of the hands and fingers,
and other small joints, and to all inflamma-
tory conditions involving the skin, face and
scalp. The static wave current is adequate
for relieving all moderately deep inflam-
matory conditions. The size of the metal
electrode for internal or external use and
the length of spark gap should be regulated
to bring about the requisite degree and
depth of tissue contraction, while, as stated
above, the static spark is indicated in deep-
seated inflammation. The direct vacuum
current administered with a vacuum tube
connected, and operated as the static wave
current is with the static machine, is capable
of producing similar effects of diffuse tissue
contraction, but is generally confined to the
treatment of the cavities of the body and
superficial inflammation.
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TREATMENT
Ambwican Medicine
REATMENT
Treatment of Influenwu — General manage-
ment: Wetmore (The Canadian Med. Aaan.
Jour. Dec. 1919) rightly states that the things
that count in the general management of a case
are absolute rest in bed from the first, fresh air,
and good nursing. The bad cases are those
that persist in being around, or who are com-
pelled to look after other members of the fam-
ily, after they are themselves affected. Prophy-
lactic and therapeutic inoculation may be un-
able to save such a one from the dangerous
pneumonia.
Fresh air: Let the windows be kept open from
the first. And if there is any suspicion of lung
complications, order the patient's bed brought as
near to the open window as possible, and see that
the order is carried out before you leave the
house. When possible, put the bed in a corner
of the room between two windows, kept wide
open from top to bottom day and night. Of
course see that the patient is provided with
plenty of bed-clothing, with artificial heat in-
side the bed. As in ordinary pneumonia and
tuberculosis, so here, absolutely fresh air is
life-saving.
Good nursing: Put a nurse in charge of a
case early so as to conserve the resisting power
of the patient, and besides, prevent other mem-
bers of the family from becoming overfatigued.
Without a nurse, one never knows whether or
not their orders of vital importance such as
clearing out of the prim^e viae, and the keep-
ing up of proper nourishment will be promptly
and efficiently attended to. All honor to the
nurse, who thruout the recent dangerous pan-
demic was not afraid to work day and night,
hand in hand with the physician, in their life-
saving mission, to prevent the patient from
drifting on and on, into hopeless, helpless, sep-
ticemic cyanosis!
When called to a case, isolate the patient,
arrange masks and hand washing for the at-
tendants, and see that the sputum is properly
taken care of. This last can be done by having
bits of rags or paper, and a paper bag as a re-
ceptacle pinned to the bedside and later burned.
See that a bed-pan is available.
Diet: Give liquids entirely at first. A mix-
ture of milk and lime-water is good, one part
lime-water, two parts milk, of which the patient
may take from six to eight ounces every two
hours; or milk and raw eggs may be taken,
an egg to a pint of milk, half the quantity
every two hours. If the case is serious, see
that the patient has nourishment at night as
well as during the day.
Medical treatment: Clear out the digestive
tract early with a saline cathartic, such as
Epsom salts, preceded by fractional doses of
calomel in case of vomiting, and repeat the
saline each day unless contraindicated. Acido-
sis being usually present, alkaline treatment,
I think, does as much good as any other, with-
out doing harm. Some give both bicarbonate
of soda, c.p., and citrate of potash, giving from
seven to ten grains of each drug separately and
alternately each hour. A third form of alkali
is the lime-water and milk. The treatment
generally agrees well with the digestive system
and the bicarbonate of soda has a tendency to
gradually lessen the pains. When alkalies are
administered, a somewhat smaller dose of the
therapeutic vaccine is required. In view of the
oncoming toxemia and tendency to vasomotor
paresis, we must avoid the coal-tar products
as much as possible. Aceto-salicylic acid is
usually given for the pains. For the cough,
moderate doses of heroin (1-12 gr.) are given.
Insomnia also may be treated by heroin, or a
stronger opiate.
Circulatory failure: Some autopsies having
shown disorganization of the adrenals, one
would be inclined to recommend adrenalin
chloride solution for cases showing vasomotor
paresis, and lowered blood pressure; and in two
or three cases where used, I found it helpful
in tiding over a weak spell. To combat the
circulatory failure accompanying pneumonia,
tincture of digitalis in five to fifteen drop doses
every four, six or eight hours has been used a
good deal, with or without alcoholic stimulants
in half ounce doses. As in other diseases, so
here, a dangerous toxemic condition would
appear to be an indication for free alcoholic
stimulation.
Treatment of Muscular Atrophy by Artificial
Stimulation.— Cooper, in the London Lancet
(Dec. 13, 1919) points out that treatment may
be regarded as preventive or restorative, ac-
cording to the stage of the injury. The pre-
ventive treatment of. atrophy of the tissues of
an injured limb is necessarily a difficult prob-
lem, and must be largely circumscribed by the
nature of the injury; but even when the exigen-
cies of surgical treatment have been fully con-
sidered, it is deplorable to find so many patients
sent at a late stage to the department of physio-
therapy, the wholesale atrophy of whose tissues
bears eloquent testimony to the fact that the
suspension of the functional activity of every
tissue of the limb was considered a sine qua non
of surgical treatment. Fortunately, there were
many surgeons who treated the injured limb
as well as the injury itself, and even under the
most difficult circumstances managed to secure
sufficient functional activity to prevent the atro-
phy that attends absolute disuse.
There is no doubt that too much attention
has been given to restorative treatment as com-
pared with preventive treatment, and the sur-
geon who has conquered sepsis and secured a
perfect alignment has but little reason to be
proud of the result if the joints of the limb
are immovable, and the muscles hopelessly
atrophied. For the atrophy of such muscles
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is frequently hopeless, and in many cases has
proceeded so far that a large proportion of the
muscle cells have perished and have been re-
placed by fibrous tissues. No amount of sub-
sequent stimulation can restore such a muscle
and "permanent disability" too often marks the
measure of the surgeon's skill.
For the treatment of muscles by artificial
stimulation two methods are available: stimu-
lation by massage and stimulation by electri-
city.
Massage. Bearing in mind that our object
is to produce contraction in muscle fibres with
a view to determining exchange between the
fibre and the surrounding lymph it does not
appear that In massage we have an agency of
any considerable value in restoring the size
and tone of a wasted muscle whose response
is limited to direct stimulation, as is the case
in muscles suffering from reaction of degenera-
tion. Where the nerve-supply is intact contrac-
tions in response to manipulations are largely
the result of stimulation of the muscle fibre
thru the muscle plate, but where the nerve-
supply is interrupted contractile response to
manipulation must correspond to the irritabil-
ity of the muscle fibres to direct stimulation,
and in most cases this response to direct stimu-
lation is very feeble. I am inclined to regard
massage as effective to a large extent in such
cases on account of its action on the vasomotor
system, and this result will be largely brought
about by mechanical action, as the vasomotor
reflexes are also affected in peripheral nerve
lesion.
Contraction Produced hy Means of Electrical
Stimulation. In electricity we have an agency
which is peculiarly effective in producing con-
tractions of muscle fibres, and, as is well known,
by utilizing this form of energy we can obtain
the most complete contractions of individual
muscles or muscle groups.
For the production of contraction in muscles,
we can use either the faradic or the interrupted
galvanic current. The stimulation caused by
the electrical current is due to the displacement
of the ions in the nerve or muscle and the more
sudden the displacement the more stimulating
is the effect. A constant current is therefore
incapable of producing contractions in muscles,
and it is only at the make and break of the
current that stimulation takes place. It has
been suggested that muscles probably contain
two kinds of contractile material, the striated
portion and the sarcoplasm. The striated por-
tion responds to brief stimuli and contracts
rapidly, the sarcoplasm responds to longer stim-
uli only, and contracts slowly. * A sluggish
contraction would represent a contraction of
the sarcoplasm. Muscles suffering from re-
action of degeneration, as is well known, will
not react to the currents of brief duration set
up in the ordinary induction coll of faradic
battery. They will, however, react to the in-
terrupted galvanic current, and muscles suffer-
ing from reaction of degeneration would there-
fore appear to have sustained a loss of striated
elements with survival of the sarcoplasm alone.
This appears to have been borne out by the fact
that when reaction of degeneration is fully
established, the character of the contraction be-
comes sluggish. For the treatment of muscles
suffering from reaction of degeneration the gal-
vanic current alone is effective. The faradic
current is ineffective unless its voltage Is enor-
mously increased, in which case the Intensity
would be great and the excitation very painful.
It is thus ineffective as a practical method of
producing contractions. It is necessary to re-
member that several factors are concerned In
the production of contractions in muscle by
electrical stimulation; the current must have
a minimum of intensity, and this minimum cur-
rent, in order to be effective, must last for a
definite time, this representing the velocity of
excitability of the muscle. In normal muscles
this is about one-thousandth part of a second;
in paralyzed muscles velocity of excitability is
much slower, and a current may have to act for
one-twenty-flfth of a second to produce con-
traction in a degenerate muscle. Hence the
ordinary faradic current is ineffective for pro-
ducing contractions in paralyzed muscles. The
practical problem in the treatment of muscles
by electrical stimulation would appear to con-
sist in the selection of that particular type of
current that will give the best contractile re-
sponse.
Cooper concludes his excellent article as
follows :
1. Excluding the muscular dystrophies and
injury due to trauma and toxins, all muscular
atrophy is of the disuse type — that is, it Is
caused by suspension of the normal function
of contraction and relaxation.
2. The condition and tone of a muscle are
largely dependent on their function — inter-
change between, the cell and surrounding lymph
taking place during contraction and relaxation.
3. Prevention of atrophy and restoration of
atrophied muscles by rhythmic contractions Is
therefore a reasonable line of treatment.
4. Artificial stimulation of muscle conserves
the nervous energy of the patient and in most
cases of injury is the only method that can be
employed.
5. Of methods of artificial stimulation elec-
trical is the most valuable.
6. Treatment by electrical stimulation is
governed by the consideration of two factors:
(1) The degree of contraction produced; (2)
degree of pain caused by the stimulation.
7. Pain is largely a matter of the length of
waves employed and the uniformity of the in-
terruptions.
8. Apparatus devised to give a uniform type
of interruption yields the best results.
9. Fatigue is a toxic phenomenon due to ac-
cumulation of lactic acid. There is no risk of
fatigue if a proper blood-supply is ensured and
a short interval allowed between the contrac-
tions.
10. Practical experience has demonstrated
the value of artificial stimulation in restoring
the condition of wasted muscles and in prevent-
ing atrophy.
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TREATMENT
American Medicine
Mall^ant Measles* — Rest in bed, warmth,
good ventilation, and light, stimulating,
nourishing diet suitable to the individual case
is essential says O'Shea (The Practitioner, Dec.
1919) in this grave malady. The special point
to be noted in connection with the malignant
forms is the treatment of the pyrexia, nervous
disturbances, and the eruption. With regard
to the high temperature, the best method of
reducing it and thereby relieving the headache
and great discomfiture present, is sponging the
skin, small surfaces at the time, with tepid
water. This method is fraught with less dan-
ger than the tepid bath or tepid pack. In cases
in which there is sudden retrocession of the
rash, the patient must be placed in a warm
mustard or ordinary hot bath, and warm drinks
given. The eruption may possibly be brought
out thus, but both procedures are attended by
a certain amount of risk, and cannot be carried
out in every case — for instance, when the
patient's temperature is already higher than is
safe. In connection with this point, it may be
mentioned that some writers advocate treating
the hyperpyrexia of typhoid fever by hot spong-
ing. The explanation is that it has as its object
the dilatation of the superficial vessels to cool
the blood in quantities; it is used when the
temperature approaches 105*" F., and the heart
is so depressed that cold or tepid applications
will not lead to a favorable result. To be suc-
cessful the water used must be as hot as the
patient can comfortably endure, and the spong-
ing must last only four minutes. With the ex-
ception of the lower extremities, the patient,
as a rule, is afterwards covered only with a
sheet for a half an hour.
As regards the nervous disturbances, they are
caused by the high temperature and toxic con-
dition of the blood. When these are of a mild
character, namely, headache, restlessness, and
slight delirium, they usually disappear under
the remedial measures taken to reduce the
fever and bring out the rash. The more seri-
ous manifestations, namely, meningitis and its
attendant symptoms, assume a grave aspect
and, unless quickly and successfully treated,
end the case fatally.
The head must be shaved, an ice-bag applied,
and leeches put over the temples or behind the
ears. The patient must be kept very quiet, and
the room darkened. Bromides or chloral can
be given by the mouth or rectum, and, in some
instances, it may be necessary to give frequent
inhalations of chloroform to ease the convul-
sions which occur towards the end of fatal
cases. Bronchopneumonia is usually present
in these cases, which are invariably fatal.
In bad cases saline infusions should be given,
to dilute the poison and to help the failing cir-
culation, due to the diarrhea and troublesome
vomiting which sometimes occur in toxic cases.
This procedure also alleviates the anguishing
thirst always present. Pallor, pinching of the
face, and a small, weak pulse are indications
for immediate saline infusion. Oxygen is also
indicated at this stage, when the cyanosis be-
gins to tell on the heart. Abdominal distention
may be present in cases complicated by broncho-
pneumonia, and may be a source of great anx-
iety to the physician. This requires immediate
attention, and 5-15 mm. of turpentine, accord-
ing to the age of the patient, may be given
orally if there Is no renal trouble, or Sii-Ji of
turpentine per rectum in one pint of starch
mucilage, and a little ice to the abdomen. When
the kidneys are diseased, intestinal antiseptics
should be administered, instead of turpentine,
and, of these, bismuth salicylate is the best.
Tonics, cod liver oil especially, are indicated
during convalescence.
Camphor in Acute fiiflnenial Bronehltls and
Bronchopneumonia.— Giuseppi, in the British
Medical Journal of December 28, 1918, discuss-
es the recent outbreak of infiuenza at Felix-
stowe. England. He treated 250 cases with
camphor, with a mortality of one — a man who
died after three days' illness from broncho-
pneumonia.
The incidence of bronchopneumonia in the
250 cases was 26, or 10 per cent.; in another
series of 200 cases during the same outbreak,
and untreated with camphor, the incidence was
8 per cent., but the number of deaths was 4, a
mortality of 2 per cent. The outbreak was
very severe, and the cases treated ranged in
severity from very acute to mild. The tempera-
ture varied from 105.5 ** to 100** F.
The treatment adopted was the administra-
tion of pills containing four grains of camphor
made up with soap, in mild cases three times
daily and in the very acute cases every three
hours. The treatment was continued until the
temperature dropped and the signs of bron-
chitis or bronchopneumonia cleared up. A
typical case may be of interest.
A boy, aged ten, was suddenly taken ill on
September 6 with acute pains in the back an^d
head. When seen the temperature was 105.6°
F., pulse 120. There was slight cyanosis, and
marked and widespread signs of bronchitis and
patches of bronchopneumonia were found over
both lungs. On September 7 the boy became
unconscious. The camphor pills were begun
on September 8, after the unconsciousness had
lasted thirty-six hours. Pulse 130. temperature
104.8'' F. Within twenty-four hours the boy
recovered consciousness. The signs in the
lungs slowly cleared up, and the chest became
normal on September 12.
There was no doubt in the minds of those
who watched the boy that his recovery was
entirely due to the camphor. The only other
treatment was a diaphoretic mixture, which
was stopped on September 9.
The effect of camphor in large doses is very
marked, and tho the number of cases treated is
too small to allow GiuseppI to describe it as a
specific he thinks there jcan be no doubt, from
the difference in the mortality in the two series of
cases treated during the same outbreak with
and without camphor, that the curative action
of camphor is remarkable. Certainly its effect
in clearing up the lungs and lowering the tem-
perature far surpasses that of any other drug
that has been tried by this writer.
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Dbcbmbbb^ 1919
799
The Modern Treatment of Empyema hj Anti-
8epties« — Stoney, in The British Medical Jour-
nal, says that acute empyema is easily cured
by simple surgical methods. Thru neglect
or Inefflcient surgical treatment the lung and
diaphragm, become covered by granulation tis-
sue which by its further development into fi-
brous renders the cavity non-collapsible and
chronic empyema results. This condition is
difficult or impossible to cure even by extensive
Estlander or Schede thoracoplasty.
Most if not all cases can be cured without re-
sorting to such dangerous and mutilating opera-
tions, because it is not necessary to obliterate
the pleura space but merely to render its walls
sterile, and this is possible by frequent wash-
ings with hypochlorite solution. The treat-
ment is not dangerous if a free exit for the
fluid is provided.
The earlier the treatment is instituted, the
sooner and more surely will a cure be obtained.
The opening is most suitably made by removing
one inch of the eighth rib in the scapular line.
Three illustrative cases are reported.
Treatment of Bites^^In the treatment of
the bites and stings of poisonous insects, slices
of raw onion placed over the parts, binding it
on firmly and changing it once in two or three
hours, has been found very efficacious. — Practi-
cal Med. & Surgery (Nov. 1919).
Treatment of Heart Disease^— We rarely treat
heart disease, says Shattuck, in a recent issue
of the Boston Medical and Surgical Journal,
We may use salicylates in rheumatic endocardi-
tis, potassium iodide for a syphilitic heart, or
rest and time for a weak heart, but aside from
these cases we usually treat patients who have
diseased hearts. If compensation is good and
the lesion apparently not progressive, the
patient should live so as to maintain myocar-
dial nutrition. He is more likely to do this if
he knows why, so it is usually best to be frank
and to tell him when his heart is affected.
When compensation is inadequate the patient
appreciates better his need of help. The major
marks of myocardial failure are edema, pain
and shortness of breath. To meet the edema,
we reduce the load on the heart, mainly by rest,
or stimulate its power. When the right ventri-
cle is greatly over-distended, venesection up to
a pint or more may have an almost miraculous
effect, and this may pave the way for digitalis,
which would be of no use until the right ven-
tricle was relieved. A patient subject to an-
gina should never be without a nitrite ready for
use. but the all-important therapy is a regula-
tion of the mode of life.. The innocent and the
grave cases vary more in prognosis than In
treatment. Every effort should be made to
avoid bringing on pain. Sometimes it is well
to put the patient to bed for a week or two.
Usually it is enough to limit activity to that
which is compatible with comfort. The details
of medicinal treatment depend on the origin of
the angina. We can add years of comfort and
activity to life by inducing patients to adapt
their lives to their powers.
Treatment of Acute Gonorrhea in Women«r—
The treatment of acute gonorrhea in the early
stage before pus formation is, according to Kem-
per (Eclectic Med, Jour,, Dec. 1919), to put the
patient to bed, keep bowels open, and apply
lotions of lead water and alcohol. As soon as
pus is detected it should be evacuated by a free
incision made on the inner surface of the great
lip. The cavity should be curetted, washed
with a 1 to 1,000 bichloride solution and packed
with iodoform gauze, which should be changed
frequently. The cavity must be made to heal
from the bottom.
The chronic form is very difficult to cure, it
often being necessary to dissect out the entire
gland.
Gonorrheal salpingitis and oophoritis fre-
quently follow gonorrheal metritis by conti-
guity of tissue. The infiammation of the tubes
and ovaries is not characterized by any pathog-
nomonic symptoms, endometritis producing
about the same symptoms — painful, irregular,
profuse menstruation, attacks of pelvic perito-
nitis, and often a rapid loss of health.
The tubes may become filled with pus and
this pus escape into the uterus, or it may make
a way into the bowel and the case make a spon-
taneous recovery. It may escape thru the
fimbriated extremity or ulcerate tiiru the
tube and produce a very severe or fatal case of
peritonUtis.
The involvement of the tubes nearly always
causes the ovaries to become diseased, first a
parovaritis, followed by atrophy and cyst forma-
tion of the ovary.
The diagnosis is best made by bimanual ex-
amination with the patient well under a general
anesthetic.
Treatment of the acute stage is rest in bed,
hot vaginal douches, free movements of the
bowels until the acute stage has passed. When
the disease becomes well localized an abdominal
operation should be done to remove the diseased
parts.
Acute Perimetritis. — This complication is
more likely to occur during pregnancy or after
childbirth. The symptoms are those of acute
pelvic peritonitis and septic absorption — ^pain,
tenderness, vomiting, fever — and in a few days
may terminate fatally. Usually resolution takes
place.
The chronic form is characterized by persist-
ent pain and tenderness. Every jar, strain or
coitus is very painful or unbearable.
Treatment is rest in bed, antiseptic vaginal
douches, bowels kept open with salines until
the acute stage is past. If it is found that pus
tubes are the cause of the trouble they should
be removed.
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December, 1919
GENERAL. TOPICS
American Medzcins
Maternal Impressions in New MexIeo« —
In the November number of Man Elsie Clews
Parsons gives an account of the customs re-
lating to childbirth as practised In the Indian
town of Zufii» New Mexico. If a child has a
rash it is due to the fact that before its birth
the mother tested the heat of her oven by
sprinkling bran in it. To cure the rash the
mother soaks some bran in water and rubs it
over the baby. If the baby has sores, which
look like the spots of paint on a mask which
the mother has seen worn by the father during
her pregnancy, the rash is said to be cured oy
putting spots of paint on the baby and, at the
same time, on the mask, like curing like being
a characteristic of Zufil thought Masks seen
by the mother in her pregnancy may also cause
disfigurement in the baby, in which case the
father puts on the mask, dances till he sweats,
and with his sweat the baby Is anointed. If a
baby cries a great deal it is because its father
sang a great deal before it was born, and for
such crying there is no remedy. Other curious
beliefs are the changing of the unborn girl into
a boy should a man be present in the lying-in
chamber; movement of the fetus on the right
side the sign of a girl, and on the left side the
sign of a boy; and the swallowing of a bean to
produce easy delivery. The Idea in the latter
case is that Just as the bean slips down with
ease so the delivery will be easy.
Marriage Laws and Ensrenles.— Does the
average layman understand the real intent and
purposes of the constructive legislation regulat-
ing the marriage of the "unfit" or diseased per-
son, asks an editorial writer in the Southern
Med. Jour. (Dec. 1919). Is it that the scope
of their comprehension limits the thought mere-
ly to gonorrhea and syphilis? In truth, do the
laws that have been enacted by several states
strive for eugenic marriages, or are these
special laws a mere weapon in the hands of
the veneral disease antagonist? Any step that
tends to promote a high standard of the human
species should be endorsed by all. In order
that the reaction following the evolvement of
such radical measures should be wholesome and
cooperative, it seems to The Journal of prime
importance to insist upon enlightenment and
upon placing the basic principles of such move-
ments upon a liberal and substantial basis.
No set of men in the whole world sees more
vividly the fearful and far-reaching conse-
quences of the union of units than the physician.
The annals of penitentiaries, reformatories,
asylums for the insane, institutions for the
feeble-minded, hospitals for epileptics, homes
for the blind and for the deaf mute, alms-
houses, county jails and work-houses are fruit-
ful for medical investigations among the unfor-
tunates taken from the daily walk of life. It Is
evident that the medical profession has been
somewhat remiss In urging ways and means
for protecting society against the degenerate,
whether unrestrained or In an institution.
As an instance of the cost of supporting a
family that may spring from a degenerate, the
following is presented by Dugdale in his classic
Investigation, "The Jukes, A Study of Crime,
Pauperism, Disease and Heredity." From the
early half of the eighteenth century to the end
of the nineteenth century the known descend-
ants of Jukes numbered 1,200. The aggregate
cost of this family to the State of New York
was known to have been $1,308,000.
The physician views the problem of marriage
as one for the propagation of the species. He
realizes the immutable laws of heredity and
therefore assumes that the character units of
one or the other parent are transmitted to the
offspring in whole or In part. There are two
varieties of character units — the agenlc units,
those that tend to destroy or to deteriorate the
race; and the eugenic units, those that tend to
Improve the race. Under the agenic units may
be found defective physiques, feeble-mlndedness,
epilepsy, insanity, pauperism, alcoholism and
' drug habitues, syphilis, criminality, certain nerv-
ous diseases, defects of speech, including deaf-
mutism, etc. Under the eugenic units may be
mentioned strong physique, mental ability, apti-
tude for the arts and sciences, memory, moral-
ity and temperament
From the foregoing it is apparent that the
problem as presented In recent laws dealing
specifically with venereal diseases may fail to
be solved unless augumented by the concerted
efforts of the physician and the public health
educator. It Is well to emphasize the impor-
tance of venereal diseases, but what of bring-
ing facts concerning reproduction Into homes,
before societies and leagues devoted to a study
of the great question? What of moulding pub-
lic opinion, which is but the father of public
action?
The marriage laws as they stand are good,
but fall far short In furnishing the solution.
Charles Reed, in his book on "Marriage and
Genetics," concludes: "A theme that thus deals
with the deepest sentiment and the profoundest
welfare of the human individual and with the
family considered as the unit of society, here
and now as well, must be approached in full
appreciation of ascertained facts and be dis-
cussed in the light of natural laws underlying
the problem."
May It not be asked, do our legislators, our
courts, our officials of the law, our Institutions
and our profession deal with the question as
presented? Should concentration be made on
one phase of the problem, or should attempts
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NOTES AND ANNOUNCEMENTS
December, 1919
80]
be directed to strengthening the germ plasm of
this and future generations?
A Simple and Practical Method of Catheterfisa-
tIon« — Those who have taught pupil nurses to
catheterize, and who have watched their work
closely, will, states Ida Gaeley (Modem Hospi-
tal) ^ agree that the points in the procedure most
difficult for the -average pupil nurse to grasp
are, i. e.: (1) How to keep their hands from
conveying infectious materials into the meatus;
(2) to be able to find easily the meatus urin-
arius, especially in puerperal patients, where
the labiae are swollen. To remedy this I have
adopted the technic outlined in the succeeding
paragraphs :
Equipment
One sterile tray containing:
1. One sterile pan, containing two perfect
glass catheters, each having five inches of rub-
ber tubing attached to its distal end.
2. One sterile pitcher containing one quart
of sterile antiseptic solution of proper strength
for flushing.
3. One sterile wide-mouth glass bottle, capac-
ity at least one quart, of special design for this
purpose only.
4. One package of three sterile towels.
5. One pair of good sterile gloves.
Additional supplies: Douche pan, draping
sheet, and screen for bedside.
Procedure.
1. The pupil takes tray and other supplies
to bedside and places screen around bed.
2. She washes her hands carefully and dries
them on clean towel.
3. Puts patient on douche pan, drapes with
clean sheet, folding bed covers to foot of bed.
4. Places the tray at patient's feet.
5. Opens sterile packages — puts on sterile
gloves.
6. Places one sterile towel over pubic region
and one over thigh next pupil.
7. Picks up handle of pitcher with extra
sterile towel with right hand. With thumb and
forefinger of left hand separates labiae at the
uppermost point, and holds them well separated.
8. The solution is poured from pitcher in
right hand with some force, so that the flow
strikes against the meatus, thereby opening it,
and at the same time washing infectious
material downward from it, thus cleansing the
orifice.
9. Still holding the labiae apart— not letting
them fall together for one instant — ^the pupil
sets the pitcher on the tray, picks up the cathe-
ter at the rubber end, and kinks the rubber as
she inserts the catheter into the meatus.
10. Then releasing the thumb and forefinger
of left hand, with them she holds rubber end
of catheter closed until, with right hand, she
places the bottle in douche pan, directing rub^
ber end into it, allowing the urine to flow direct-
ly into a sterile container, thus providing a
sterile specimen if same is wanted for examina-
tion.
The rest of the technic is the same as is us-
ually taught; pressure over the suprapubic re-
gion, and reaching recesses of the bladder by
gentle turning of the catheter to facilitate the
flow of urine.
The catheter must always be inspected before
insertion for cracks or imperfections, and for
that reason or in case of accident I instruct
pupils to sterilize two catheters for each cathe-
terization.
After the urine ceases to flow the pupil flushes
the labiae, removes patient from the douche
pan, dries the buttocks, and makes the bed
toilet.
NEWS NOTES "»
ANNOUNCEMENT/
Samuel D* Gross Prise«— The Philadelphia
Academy of Surgery announces that essays will
be received in competition for the Samuel D.
Gross prize of $1,600 until January 1, 1920.
The conditions annexed by the -testator are
that the prize * 'shall be awarded every five
years to the writer of the best original essay,
not exceeding one hundred and flfty printed
pages, octavo, in length, illustrative of some
subjects in surgical pathology or surgical prac-
tice, founded upon original investigations, the
candidates for the prize to be American citi-
zens."
It is expressly stipulated that the competitor
who receives the prize shall publish his essay
in book form, and that he shall deposit one
copy of the work in the Samuel D. Qross
Library of the Philadelphia Academy of Sur-
gery.
The essays, which must be written by a single
author in the English language, should be
sent to the "Trustees of the Samuel D. Gross
Prize of the Philadelphia Academy of Surgery,
care of the College of Physicians, 19 S. 22d St.,
Philadelphia," on or before January 1, 1920.
Nutritional Besearclu— The National Research
Council has formed a special committee on food
and nutrition problems which will devote its
attention to important problems connected with
the nutritional values of food, for both human
and animal use.
The committee, with the support of the coun-
cil, is arranging to obtain funds for the support
of its researches, and will get under way. Just
as soon as possible, certain speciflc investiga-
tions already formulated by individual commit-
tee members and subcommittees. These include
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802
December, 1919
NOTES AND ANNOUNCEMENTS
American Medicine
studies of the comparative food values of meat
and milk and of the conditions of production of
these foods in the United States, together with
the whole problem of animal nutrition ; the food
conditions in hospitals, asylums and similar in-
stitutions; the nutritional standards of infancy
and adolescence; the formation of a national
institute of nutrition, and other problems.
The members are: Carl Alsberg, chief of the
Bureau of Chemistry, Department of Agricul-
ture; H. P. Armsby, director of Institute of
Animal Nutrition, Pennsylvania State College;
Isabel Bevier, director of department of home
economics. University of Illinois; E. B. Forbes,
chief of the department of nutrition, Ohio Agri-
cultural Experiment Station; W. H. Jordan,
director. New York Agricultural Experiment
Station; Graham Lusk, professor of physiology,
Cornell University Medical College; C. F. Lang-
worthy, chief of office of home economics, De-
partment of Agriculture; E. V. McCollum, pro-
fessor of biochemistry, School of Public Health
and Hygiene, Johns Hopkins University; L. B.
Mendel, professor of physiological chemistry,
Yale University; J. R. Murlin, professor of
physiology and director of department of vital
economics, University of Rochester; R. A. Pear-
son, president of Iowa State Agricultural Col-
lege; H. C. Sherman, professor of food chem-
istry, Columbia University; A. E. Taylor, Rush
professor of physiological chemistry, University
of Pennsylvania, and A. F. Woods, botanist,
president of Maryland State College of Agri-
culture.
Destruction of Bedbugs. — Bertrand, Brocq-
Rousseau, and Dassonville (Preaae mSdicale,
September 18, 1919) found that bedbugs were
destroyed by amounts of chloropicrin sufficient-
ly small to permit the practical use of the com-
pound for this purpose. The proper quantity
per cubic metre of room space Is from four to
ten grams. Destruction of the ova is not in-
sured by a single exposure to the agent. Con-
sequently, the hatching period for these ova
being about a week, a second exposure should
be made about two weeks after the first.
Army Medical Corps Keep Effective 1^94;
Out of 195,000 Wonndedy 182,000 Have Recov-
ered.— The record of the Army Medical Depart-
ment in dispatching its duties of war stands
out in bold relief as one of the greatest accom-
plishments in the records of medicine.
BECORD OF DISEASES COMBATED
Statistics show beyond all dispute that the
American Army was the healthiest and cleanest
army that ever fought. By far the greatest toll
of deaths from disease was taken by pneumonia
and influenza during the general epidemic that
at the time was world wide. Deaths in the
Army from this cause are placed at 8,000. There
were only 1,000 cases of typhoid, fifty of which
were fatal; venereal cases never exceeded 4 per
cent, an exceedingly low figure in an army in
the field. Dysentery was present at one time,
but this was checked before it reached the epi-
demic stage.
When the American troops arrived in France,
there was great difficulty In securing hospital
space and the first wounded found themselves
housed in all manner of buildings, from choice
edifices of imperial foundation down to humble
and none too clean municipal halls in the
French villages. There were, at the close of the
war, 153 base hospitals, sixty-six camp hospitals,
and twelve convalescent camps in France alone.
One of the best known hospitals was that estab-
lished in the Ecole de la L«egion d'Honneur, at
St. Denis, quite close to Paris, where many of
the wounded from Chateau-Thierry were
brought.
IMPROVING YANK HOSPITALS
The great Haviland china factory at Limoges
was turned over to the Americans for hospital
purposes and the library of Orleans was stripped
of 100,000 books to make room for the narrow
cots and operating tables. In Vichy, hospitals
were established in eighty-seven hotels, while
seventy other hostelries were similarly con-
verted in and around Vittel and Contrexville.
Two of the outstanding features of American
hospital work in France were the greatest hos-
pital centers such as Mesves with 25,000 beds
and the mushroom 1,000-bed "Type A" hospitals,
that standardized all American-built hospitals
in France.
Summing it up, the Army Medical Corps and
the Red Cross were able to keep 93% per cent
of the fighting forces effective for duty at all
times and of the remaining 5.7 per cent only
3.4 per cent, were incapacitated thru disease.
This is a record on which the Army and the Red
Cross can look back with satisfaction.
German Money in Bushel Lots* — It took a
bushel of Gei'man paper money to enroll the
boys of Company A, Eighth Infantry of the
American Army of Occupation during the recent
Red Cross Roll Call. With the rate of exchange
standing at thirty marks for a dollar, the phys-
ical detail of counting and sending the collec-
tions was no small task.
Before the official date for opening the drive
in the United States the company, consisting of
250 men, enrolled one hundred per cent ^
This unit was the first organization in the
Army of Occupation to be paid on that day.
It had previously been announced that the Roll
Call would start that evening.
"Let's beat 'em to it" said a lieutenant.
"Atta boy," responded the company, and
forthwith at Fort Constantino, on the west side
of the Rhine, there was a shower of marks like
the fall of autumn leaves. When the names
were all checked off, a large bale of marks was
left over and many men had two and three
memberships coming to them.
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AMBRICAN MBDICINB
Watch the Teeth
Cleaned With Pepsodent
You will meet them con-
stantly^ for millions of teeth
are now cleaned with it.
Note how Pepsodent reduces
the tartar formation — how it
combats the plaque.
The use of Pepsodent means
this:
The daily application of ac-
tivated pepsin to the protein
plaque — particularly in the
interstices.
Efficient daily polishing with
tricalcic phosphate, the chief
tooth constituent. It is unique-
ly effective, yet the most ex-
haustive tests prove it harm-
less.
An alkaline mouth condition.
Pepsodent is add in reaction.
It contains no soap or other
alkali. Therefore it stimulates
the flow of alkaline saliva.
Every doctor who tests it or
watches the results will ap-
prove it and urge its general
adoption.
Ask us for a tube to try.
Dental Mudn Digestant
Based on activated pepsin.
Contains no soap, no chalk
a48
THE PEPSODENT COMPANY,
5115 Ludington Bldg., Chicago^Ill.
Please send me, free of charge,
one regular 50c size tube of Pepso-
dent, also literature and formula.
Name
Address
Eneloae eard or letterbead
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▲IfBRICAM MBDIdNB
Why is a Gall Stone
■
Although authorities differ,
certain fundamental facts
are pretty well known.
Our little brochure, with
above tide, emphasizes
the important pathologic
factors, and indicates a
rational treatment for
Gall Stone Disease.
It is brief and to the point.
A postal will bring a copy.
r. H. STRONG COMPANY
56 WaiTM St, New Tojrk
CholoiMtia TabloiMtia
INFLUENZA IS STILL
A MENACE
A rettim of the epidemic in some
form or other is expected the
coming winter and duty demands
that the profession should
BE PREPARED
No remedy, judged by the num-
ber of cases treated with it, won
a higher percentage of good results
than
PROTEOGEN NO. 12
(FORMULA OF DR. A. 8. HOROTTTS)
Get in touch with us at once for
information or arrange for sup-
plies thru your local druggist.
thewhsMeRRELLcomb^w
1 " CIMC1I«?IATL U S. A.
Scalp Diseases
especially dandruff, or seborrhea, and local circulatory derangements-^-
utually require systematic shampooing.
The special formula and unique character of
PACKER'S TAR SOAP
give it a specific utility, not only for cleansing the scalp, but also for increasing
the physiologic activity of the scalp tissues that nourish and enliven the hair.
Many physicians have learned this from practical experience, and as a
consequence have been using and recommending Packer's Tar Soap for over
forty-five years. The prompt and satisfactory results obtained in the hygienic
care and treatment of the hair and scalp, readily Account for its general ac-
ceptance today as the standard shampooing agent
We have just issued a second edition (revised) of our manual on 'Tha
Hair and Scalp— Their Modem Care and Treatment,*^ free on request
The Packer Mfg. G)., New York City.
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AMERICAN MBDICINB
Glykeron and GIp- Heroin
ARE SYNONYMOUS APPELLATIONS AND ARE
NOW KNOWN AS SUCH TO ALL DISPENSING
PHARMACISTS
THESE designations may now be used interchangeably by
the physician when prescribing the preparation originaUy
known only as Glyco-Heroin (Smith).
As a safeguard against having worthless imitations of the prep-
aration dispensed, it is suggested that the physician use the
name
GLYKERON
which is non-descriptive and more distinctive, when prescribing
GLYCO-HEROIN (SMITH) for Cough, Asthma, Phthisis, Pneu-
monia, Bronchitis, Laryngitis, Whooping-Cough and kindred af-
fections of the respiratory system.
DOSE — The adult dose is one teaspoon- ^^--— —————— ——^—
ful every two hours, or at longer inter-
vals as the individual case requires. Th« composition of GLYCO-HER-
For chndren of ten years or more, the OIN (SMITH) has not been modi-
dose is from one-quarter to one-half tea- fied in the slightest degree.
spoonful; for children of three years or
more, five to ten drops. •
MARTIN H. SMITH COMPANY
New York, U. S. A.
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AMERICAN MEDICINE
THE STORM BINDER AND ABDOMINAL SUPPORTER
PATENTED
The Storm Biader it io a class of its own. It is not an ordi-
nary belt. It is a Washable, Abdominal Supporter; adapted to
the use of men. women and children for any purpose for
which an abdominal supporter is needed* It is elastic without
rubber elastic and vrithout leather. It supports with com-
fort.
The Storm Binder is two supporting Belts in one — a body
part and a reinforcing band attached to the body belt at the
median line. Years and experience have proven that the
Storm Binder has many times the efficiency of the ordinary belt.
It raises up and gives a support to the lower middle abdomen and inguinal regions. It lessens the jarring
of the viscera in automdbile riding and in all athletic exercises.
For General Sapport as in pregnancy, visceroptosis, obesity, etc
For Special Sapport as in hernia. sacro»iliac. relaxations, etc.
For Post Oparative support for incisions in upper, middle and lower abdomen.
Every Storm Supporter is made to order.
Let us send you our 86 page illustrated folder with samples of materials and physicians' testimonials.
Mail orders filled at Philadelphia only — in 24 hours.
*^ KATHERINE L. STORM, M. D.. 1541 Diamond St.. Philadelphia. Pa.. U. S. A.
Peacock's
BROMIDES
assure your patients a pleas*
ant, pure and uniform solution
of the neutral bromide salts,
that may be used for prolongs
ed bromide treatment of the
chronic neuroses with maxi^
mum results and minimum
tendency to disagreeable
effects. Peacock's Bromides
are without a superior as a
safe and effective antispasmod-
ic, nerve sedative and hypnotic*
DOSE:
One to four
teaspoonfuls.
w C?
CHIONIA
places at the physician's com"
mand an exceptional prepara-
tion of CfiioTUinthus Virgimca
that can be relied on to stim-
ulate the liver without unduly
increasing bowel activity. In
sluggish liver conditions in
which the biliary secretion is
depressed, Chionia will be
found a remarkably efficient,
satisfactory and acceptable
cholagogue.
DOSE: One io two tea-
spoonfuls three times a day.
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PeACOC K Ch E M ICAL Co., St. Louis>Ma |
AMBRICAN MBDICINB
From Puberty to Menopause
THROUGH this period
most women suffer from
uterine neurosis, and as
Godell so aptly describes it,
"the intangible,
imponderable,
invisible pelvic
pains of neurotic
women/'
pregnancy call for the admin-
istration of HAYDEN'S VI-
BURNUM COMPOUND,
presenting its well-known an-
tispasmodic and
calmative action
as a preventive
and as a treat-
ment in neurosis.
Anticipated
monthly attacks of Dysmen-
orrhea, the exhausting effects
of Menorrhagia, and the
nervous symptoms of early
It should be given
in teaspoonful doses, three
times a day, administered in
hot water. Literature, form-
ula and samples upon request.
NEW YORK PHARMACEUTICAL COMPANY
BEDFORD SPRINGS, BEDFORD, MASS.
after 30 years
of genuine and valuable use by physicians
BOVININE
The Reconstructive Tonic
has proved its helpfulness to young and old
For Children
where they do not assim-
ilate a usual diet — ^the
modem method is to pre-
scribe Bovinine.
For the Old
where digestion is weak-
ened and who are not'
graining under any other
treatment, try Bovinine.
SAMPLES and literature giving examplee
and quoting leading speoialiets,
sent to phyetcvane
For Treatment
of diseased tissues, ex-
ternal or internal, Bovin-
ine is especially adapted.
ON REQUEST
THE BOVININE COMPANY, 75 Wist Houston St., Now York
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6
AMBBICAN MBDICIMB
JImerican medicine
PUBLISHED MONTHLT
Editorial Ofii««i 18 East 41 at St.. If aw Tark CI«t
PabUaaUaa OfBeat 189 CaUa«a St.. B«riia«toB.Vt.
Intored m MCOBd-clsM matter Juidkit SS. IMS, mt tli* PMt OflUr*
at BarliBfton. Vt.. under Art of CongrMt. Marcli S. 1179.
TABLE OF CONTENTS
T%m Imtar-valAtiaB af Birtk Rataa aad Mar-
taUtr Rate* 78#
Artlflelal Llatba 7S1
MEN AND THINGS
CoTfT PictiMe— FIrat Amariean Hoapltal la Paiia
Teackera^ Salariea
Healtk Ceatera
SarsaoB* Saldlar^PrealdeatT
Maay 'Wmuk^m to Heal
Starrfac AnneaU aad tke W^orld'a Datx
Polltlca and Medlciaa
Motar AcddieatM aad I>cfc«tl\*a Laws . . .
CkriatoHia la the Haai^tala
7S2
753
754
755
755
75C
757
758
EDITORIAL COMMENT
Reformlair Medical Teachlair 748
Sapervlaed Prevnaacr 744
A Saaltarr ladex 745
Tke Metric Srateat 746
Veaereal Snapeeta 747
Tke Bxlateaoe of Metk€»da for DetenalalBs
Dlaeaae Carrieva 748
Tke BIrtka of a Natloa
749
ORIGINAL ARTICLES
BxpeHeacea of « Medical Reaen-e Officer
IITItk tke Aaaerloaa Bxpedltloaarx F*oree
— By Leo B. Meyer, A. M., M. D.. F. A. C.
S., Late Major, M. C, U. S. A., New York
City 759
Coatamlaated aad lafeeted 'Wooada— Prla-
dplea of Treatment— WItk Addead* oa
Aatlaeptlca aad Termlnolorr— By David
C. Hilton, A. M., M. D., F. A. C. &, Lin-
coln, Neb 772
(Contlnuad on iMiff« 8)
FOR INFLUENZA AND SEQUELAE
ANGIER'S EMULSION
Angler's Emulsion Is particularly adapted to the treatment of
the catarrhal symptoms, whether Respiratory or Intestinal, which
generally follow the more acute stage of influenza.
It relieves the harsh troublesome cough, while it also allays the
dangerous symptoms of congestion and inflammation of the
respiratory organs.
It overcomes Intestinal Intoxication ; Promotes Nutrition ; Ha-
stens Convalescence,
3 Emuls Angier J^vi
or ,^xii
Sig: 2 teaspoonfuls every 2 or 3 hours.
AN6IER CHEMICAL COMPANY, BOSTON, MASSACHUSETTS
FOR PROTECTION USE THE GLYMOL ATOMIZER AND GLYMOL
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AHXRICAN ICBOICINII
The problem raised by the
question~What will the
after-effects be?~finds its
solution in
NEUROSINE
The Safe Soporific
Wherever the effect of a hypnot-
ic-sedative is desirable but great
caution in its use necessary, Neu-
rosine is pre-eminently the quali-
fied remedy.
Protect Your Patients
AGAINST
Golds . Influenza . Pneumonia
USE SHERMAN'S No. 38
Write for Literature
r KANUFACriNltll |
Deiroit/Hck.
ai.s.A
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8
AJCDRICAN MBDIdNa
The PkxaicUn uid the New Yoric State In-
come Tax Law — By Eugrene M. Travis,
State Comptroller. Albany, N. Y 782
The Treatment of Pneamonia— By M. Ford
Morris, Jr.. M. D.. Atlanta, Ga. T86
Multiple ArthrltUi of Obacnre Oriffia — By
Virgril E. Simpson. M. D., Louisville, Ky. 789
RATIONAL ORGANOTHERAPY
The Adreaalln Test 791
The Differential DlasmosUi of HrP^rthyroid-
Uim by •Baaal Metabollam and Alimen-
tary Hyperrlrceatia 791
The HyperthTDold Theory of Basedow** I>1»-
798
Corpus I^vtenm Extract la the Vomiting of
Presmancy 793
PHYSICAL THERAPY
The Treatment of Rheumatoid Arthritis . . . 798
Radlnm Treatment of Cancer 794
Radlo-Thempy In Inflanunatlon 795
TREATMENT
796
Treatment of Inflnensa
Treatateat of Mnscniar Atrophy by Artl-
flelal Stimnlatloa 796
Mallgaaat Measles
796
Oamphor In Acute Inflaensal Bronchitis and
BronchopnevaM>nta 798
The Modem Trcatatent of E:aapyenMi by An-
tiseptics 799
Treatment of Bites 799
Treatnieat of Heart Disease 799
Treatment of Acute Goaoirhea In Women . . 799
GENERAL TOPICS
Maternal Impressions In New Mexico 899
Marriairc Laws and Bnsenics 890
A Simple and Practical Method of Oathe-
terlsation 801
NEWS NOTES AND ANNOUNCE-
MENTS
Siamuel D. Gross Prise 801
NntTltional Rescui^di 801
Destruction of Bedbass 80S
Army Medical Corps Keep BffcctiTC 9S%t
Oat of 195,000 l^ounded, 18X000 Have
RecoTcred 80S
Gennan Money In Bushel I^ots 808
Chronic Invalidism is a very frequent sequel of
Influenza.
FellojjTS* Syi^ the
supplies the indispensable mineral s^^^:r^quired by
the system togetHerv^^Ptl^^lS^TWS^tSit^^^ agents,
strychnine ^rj. quinine. cJt accelerates convalescence
The si^nd^^Tonic for OverJ^fif'^ntury'
SAMPLES>m>^UX«^R Alii (^ElJPOU REQUEST
FELLOWS MEDICAL MANFG. CO., Inc.
26 Christopher Street New York
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AMBRICAN MBDICDnD
9
tmm/////^^
P
Announcing
the Production of
-St
neumo-k3irep-»;3erum
(Antipnenmoooocio and Antistreptoooooio Semm)
Reports from Army Gamps indicate that the strepto-
coccus hemolyticus and other streptococci are frequently associa-
ted with pneumococci as causative factors in pneumonia. When
it is determined that the pneumonia is complicated by the strep-
tococcus, the conjoint use of Antipneumococcic Serum Polyva-
lent and Antistreptococcic Serum Polyvalent is indicated.
The Difficulties and
Inconvenience of Sep-
arate injections of Anti-
pneumococcic Serum
and Antistreptococcic
Serum may be avoided
by using Mulford
Pnenmo-Strep-
Serum, which is pre-
pared by injecting
horses simultaneously
with the fixed types 1,
II and III of pneumococ-
cus, also some strains
from group IV pneumo-
coccus, and 15 key
strains of streptococcus.
Pnenino-Strep-
Semm, therefore, pos-
sesses the combined ad-
vantages of antipneumococcic and antistreptococcic serums. It contains
antib<xlies against all the various strains of jpneumococcus and streptococ-
cus employed, and, by standardization agamst type I pneumococcus, it is
equally as potent against type I pneumonia as the type I and polyvalent
antipneumococcic serums.
InJectlDK Cultures Into Serum-Producing Horse
^OWFO^^
An Injection ot 100 mils Pnen mo- St rep- Serum is
equivalent to 100 mils Antipnenmocoooic Semm
and lOO mils Antistreptoooooio Semm.
Supplied in 50-mil packages, with the Mulford perfected
Intravenous Apparatus.
^^^SS^^*^ B« ^* Mnlford Company, Philadelphia, U« S. A.
4H12
mmm^ms^M£mm^^^^m//^^^mimmmmii!ii^
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10
AMBBICUN lOBDIdMB
ERCOAPIOL (SMITH)
Its Utmty in the Treatment of
AyENORRHEA. DYSMENORRHEA AND OTHER
DISTURBANCES OF MENSTRUATION
Despitft the fact that Brffoaplol (Smith)
exerts a pronounced anals*elo a-nd eeda-
tlve effect upon the entire reproduotlTe
system. Its use Is not attended with the
objectionable bjr^effeets associated with
anodyne or narcotic drurs.
The unTarlable certainty, asreeableness
and slnsuUtr promptness with which
Ersoaplol (Smith) relleres the sereral
▼arletles of amenorrhea and dysmMior-
rhca has earned for It the unquallflcd en-
dorsement of those members of the pro-
fsssion who have subjected It to exactlns
clinical tests.
DOSAGE: Ordinarily, one to two capsules should
be administered three or four times a day,
MARTIN H. SMITH CO.
HBW TOBK - - V. S.'a.
h: Pills
What are the underlying causes of
gall-stone formation?
Infection of the gall-hladder.
Bile stasis.
Increased cholesterin formation.
Duct swelling and inflammation.
Probilin Pills are pharmacologically
so planned as to meet all of them.
A fifteen year reputation proves it.
made in u.s.a.
Furnished sixty in amber vial
with green label and red seal
at before-the-war price.
SCHERING GGLATZJNcNiwYoRK
prrUITARY LIQUID (Aimour) is ftandardized physio-
logically, free from chemical preservatives and is sold in
dated packages. Dating the packages shows the physician
whether or not he is getting a fresh product.
Pituttary Liquid I c. c. ampoules, 6 in a box.
ARMOUR A COMPANY
ARHEOL
(CPBHMO)
THE ACTIVE PRINCIPLE OF SANDALWOOD OIL
Used with conspicuous success in
Gonorrhea,Cystitis, Vesical CatzirrhyEtc.
DIRECTIONS: JO f 12 eaptuht dmily Soli by all Retail DrmuUU
ASTIER LABORATORIES
45, Roe da Dodear Blaachc, Paris, Fmacc
E. FOUGERA & CO.
90 B«elauB Str««C Mew York
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AMERICAN MBDldNB
11
Morrhuol Creosote
(Cbapoteaut)
INDICATIONS: Wherever Cod Liver Oil and Creosote are
prescribed. Cod Liver Oil contains Vitatnihes and these have been
separated by Chapoteaut of Paris in the form known as Morrhuol
(Extractum Morrhuse Alcoholicum), representing the vitamines
''morrhuine, nicomorrhuine, amylamine, dihydrolutidine/'
oxycoUidine, aselline and morrhuic acid.
Each capsule of Morrhuol Creosote contains:
R Morrhuol 20 centigrammes
Creosote (beech wood) — 5 centigrammes
Dose: Four to eight cap-
sules daily.
<CM A FOTSA trw
m^HjUI
Write for literature and samples
to the U. S. Agents
E. rOUGER A & CO.. Inc.
New York
Prevent Needless Fatigue
Walking with hard leather heels on still harder floors, stairways and
sidewalks is bound sooner or later, to cause excessive nerve tire and fatigue.
9/
HEELS
through their remarkable resiliency and shock-absorbing properties, substantially remove the harsh
impact and jar from each of the 8,000 or more steps the average individual takes daily, and thus
prevent much nerve tire and exhaustion- '^
Medical men have come to appreciate the great hygienic value of O'SuUivan's Heels » for
personal experience has shown them conclusively how much these high grade rubber heels
contribute to physical comfort, well-being and efficiency.
O'Sullivan's Heels assure maximum resiliency and durability, and arc guaranteed to wear
twice as long as ordinary rubber heels.
NEW YORK CITY
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12 AMERICAN MEDICINE
In the Treatment of the Acute Infections
— ^particularly septicemia, pyaemia, severe inflaenza, the secondary and
septic pneumonias, tuberculosis, and septic processes generally —
BANNERMAN'S
Intravenous Solution
has given results of the most prompt and grratifying- character in many cases that
have failed to respond to any other therapeutic measure. In numerous instances it
has proven a veritahle life saver, through its exceptional capacity for stimulating
and reinforcing latent forces of bodily resistance and recuperation.
It is not claimed that Bannermann's Intravenous Solution is a miracle worker,
but no physician who has observed its beneficial effect in some grave case of infection
with the prompt drop in the temperature and pronounced improvement in the pulse,
respiration and every other symptom, can fail to be impressed with its therapeutic
value.
If you have some case that has failed to respond to all other lines of treatment
why not write for clinical data and full information?
Wm* S* Bannerman Co.
82 North State Street 607 -C Reliance Bldg. Chicago, 111.
BROMIDIA
(BATTLE)
Sedative Antispasmodic Hjrpnotic
A true synergistic remedy, each of whose
constituents aids and reinforces the therapeutic action
of the others, thus affording a degree of
efficiency not obtainable from any single remedy.
The care used to select ingredients of the
highest chemical purity and to combine them in the
most akillful manner, assures a maximum of
sedative, antispasmodic and hypnotic effect
BROMIDIA has been the remedy of choice of many physidans
for many years. In conditions of nervousness and sleepUsssness.
BATTLE & CO., ChemMU' Corporation, ST. LOUIS, MO.
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AllSRICAN MEDICINE
13
THE
MEDICAL
BULLETIN
THE LUIKART CHILDREN
Carter's Mercury Antidote
The recent publicity given the Luikart chil-
dren of Detroit, poisoned by corrosive subli-
mate administered by their mother, and saved
from death through the timely help of Dr.
Thomas A. Carter, of Chicago, must impress
on every physician the advisability of having
a supply of Doctor Carter's antidote on hand
for such emergencies. The administration of
Carter's antidote is very simple— one tablet
being given for each tablet of the poison taken.
It is supplied in bottles of 100 and 500 tablets
by The Abbott Laboratories.
Incidentally, the too-numerous cases of
poisoning with bichloride must lead one to
consider the use of an antiseptic having all
the virtues of bichloride, phenol, and such
substances without their
poisonous qualities. Such
an antiseptic is Dakin's
stable, water-soluble, non-
irritating synthetic Chlora-
zene.
The latest form in which
Chlorazene has been pro-
duced, and we believe ulti-
mately the most popular, is
AROMATIC
CHLORAZENE
POWDER
A FREE
TIUAL BOTTLE
or
AROMATIC
CHLORAZENE
POWDER
The coupon below will
bring it to you.
This is a combination of 5 per cent, of Da-
kin's Chlorazene with sodium bicarbonate, so-
dium chloride, saccharin, and eucalyptol. A tea-
spoonful of this powder dissolves instantly in
a glass (about 6 ounces) of water and pro-
duces a delightful aromatic antiseptic solu-
tion, which is 2% times as strong as pure car-
bolic acid. It makes an agreeable and power-
fully germicidal mouth-wash, spray for nose
or throat, gargle, or douche. It is cooling,
refreshing, and of gn^eat germicidal power. It
may also be used for general antiseptic pur-
poses, such as applications to cuts, wounds,
skin diseases, etc.
AIDS TO SUCCESSFUL SURGERY
The development of remarkably improved
germicides — Dakin's Chlorazene and Dichlora-
mine-T together with a new type of non-stick-
ing wax-impregnated dressing — Parresined
Lace-Mesh Surgical Dressing — ^makes possible
a procedure for wound treatment which is giv-
ing remarkable results.
First: CLEAN OUT by excision of all devi-
talized tissue and by removing all dirt with
Neutral Sodium Soap, Abbott, the non-irritat-
ing, alkali-free liquid soap made from vege-
table oil.
Second: CLEAN UP all existing infection
by irrigating with Chlorazene, Dakin's power-
ful, non-irritating, water-soluble antiseptic.
The wound is then dried and sprayed witii so-
lution of Dakin's Dichloramine-T in Chlorco-
sane, the most powerful
germicide known to science,
accomplishing in M minute
the same degree of sterili-
zation which it takes 7
hours for bichloride or 24
hours for phenol, to pro-
duce. The antiseptic action
of Dichloramine-T-Chlorco-
sane is prolonged over 18 to
24 hours, requiring dress-
ings only once daily, and
cleaning up infection at a
very rapid rate.
Third: KEEP CLEAN—
Prevent reinfection by daily
dressings with Dichlora-
mine-T-Chlorcosane and protect with Parre-
sined Lace-Mesh Surgical Dressing. This wax-
impregnated woven lace DOES NOT STICK
and is painlessly removed without disturbing
the healing processes.
RETUBN THIS COUPON
The Abbott T^&boratories, Dept. 6. Chloaco, lU.
You may send me. without charge, a trial bottle of
AROMATIC CHLORAZENE POWDER. Also Infor-
mation reerardiner Dichloramine-T. Parresined Lace-
MeHh Surfirical Dressing, and Neutral Sodium Soap.
Dr
AddreM
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AMERICAN HBDICINB
In Neurasthenic
G>ndition8
Hysteria Anxiety
Worry Brain Fag
Insomnia Overwo»
Indigestion (Nervous)
Recovery from the after*
^ectsof
Colds, La Grippe, etc.
Alcoholic Excess
Rum Stomach
R CELERINA
Domof Cekrtna: TeaspomM ikrm
a day befwm or after maali
Efficient
Mucous Astringents
Kmedy'sUglitPiDuCuMdeMb nkkkl
ABICAN
(Kennedy's LUht Pfaius Ciniiffiii)
AND
Konedy'sDark Pins Canadensit it kWM
DARPIN
QCamedy's Durk Pfaius Canadensis)
To obriate confusion with any of the
other ^Pinus Group*' and to more
readily differentiate between the Light
and Dark varieties of Kennedy's
Pinus Canadensis, the changes as shown
have been suggested.
Narootic Law doM nat applj to CakflMa
RIO CHEMICAL CO^ 79 Emnow Street, New York
Help the Heart Help the Kidneys
Circulatory stasis induced by impaired cardiac force and deranged
filtering function of the kidneys, brings about and maintains
effusion of serous fluid into the tissues.
Anasarca, Ascites, Dropsy is more than a symptom.
It is a condition that demands careful effective treatment.
Anasarcin Tablets strengthen the heart and regulate its rhythm.
Anasarcin Tablets increase urinary output, both of fluid and salts.
Anasarcin Tablets do not disturb digestion, produce arteriole con-
traction, or exert cumulative effect.
Anasarcin Tablets can be regulated in dosage to meet the indications
present in each individual case.
Sample and literature to physicians on request
THE ANASARCIN CHEMICAL CO., Winchester, Tenn.
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AMBRICAN MBDICINB
15
Your Perennial Problem:
INFLUENZA
{La Grippe)
Is a grateful field of activity for ATOPHAN.
Gives ATOPHAN a chance to broadly display its superior
pain-relieving and anti-inflammatory properties.
Seven and a half to fifteen grains (one or two tablets) help
readily to alleviate the respiratory inflammation, the congest-
ive headache, the pain and stiffness of limbs and ba-ck.
And ATOPHAN acts without cardiac depression, constipation,
or kidney irritation.
High and persistent fever, of course, calls for a few doses of
a more active antipyretic to round out the good work of
ATOPHAN.
Literature and Information from
SGHERING & GLATZ, Inc., 150 Maiden Lane, New York
LIQUID - POWDER - OINTI^ENT
CAMPMO-PHENIQUE LIQUID- •
A powerful Antisepic Germicide used successfully by surgeons in minor
and major operations. Exerts a healing influence and induces rapid
granulation* Soothing in burns- -healing in wounds.
CAMPHO'PHENIQUE POWDER- A Dressing De Luxe
Possesses all the Antiseptic and Germicide properties
of the liquid. It is a dry treatment for tores, wounds,
cats and abrasions of the skin.
CAMPHO-PHENIQUE OINTMENT
Indicated in various diseases of the skin
and scalp*
PRiCES
Liquid, i ox. 30c: 4 os. - $1-00
Powder, Sifter Top Canm 30c and . 75
Ointment, 4oMt Canm • • 1.00
If your druggist is not
supplied order direct.
Campho-Phenique Co.
ST. LOUIS. MO.
Physicians* Samples
and Literature
on Request
ijk^j^j^SlJII^
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16
▲MBRICAN MBDICINB
The Natural Coagulant
of Blood
ThromboplaatlM Solntlon (Armour) is a specific
hemostatic and is made from the brain substance
of Kosher killed cattle. This brain tissue of c&ttle
killed according to Mosaic law is uninjured and by
the Armour process this ''principle" which causes
coag-ulation is extracted and supplied to the med-
ical profession in standardized and sterilized form.
ThromboplMstlB SolvtUMi (Armour) is useful in the
treatment of hemorrhagre especially that from
oozing: surface, scar tissue and the nose and throat.
25 c. c. vials, in dated packagres.
PItiiltary I^l^vld (Armour) is the most trustworthy
solution of the Posterior Pituitary Substance. It Js
free from preservatives and is standardized phys-
iologrically by the Roth method. % c. c. and 1 c. c.
ampoules.
Thyroida (Armour) runs uniformly 0.2 per cent
organic iodin in Thyroid combination. Thyroid
Tablets (Armour) %» %, 1 and 2 grain. When
Thyroids is indicated specify Armow's.
Wt ciffw all th0 ^ndoerine gland prpyaraHomt in votrdtr amd ttibl«t». A U drying
of 0*0 gbifd* if don0 in paruttm ormnm at a low t«mperatMrt. Thim intmnem nnin-
JMttd thtt-aptutic ralae.
Circulars on request.
ARMOUR^COMPANY
CHICAGO
The combined Treatment of SYPHILIS by
SUPSALVS
STABLE SUPPOSITORIES OF
"fiflli" (OF FRERCH
OVV MANDrACTDRE)
AND MERCURIAL INUNCTION (BIERSALY)
The«e Suppositories contain 0.10 ffrm. of
*'606" for rectal administration (also made with
0.03 srr. dose for children) in box oontainins 6.
Price per box of 6, 15.00; children's dose, $1.00.
Simple in Use. Rapid and Bfleetive AtssgpU—
Arsenic beinv found in the blood and urino
12 hours after administration.
Produce No UBdeslrable BITeets
At the International Congrress of Hodidno
Ehrlich stated that the biochemical action of
•«606" on spirochaetes is not direct but indirect,
a third factor found in the body fluids beinff
necessary.
This success is explained by the well-
known experiment of Levaditi: "^f living treponemas be placed in a eolntion of Arseno-
bensol (606) they continue to live in it. But if a trace of extract of liver be added to the
mixture the treponemas are destroyed."
"If 606 has to be taken up and transformed by the liver in order to become toxic to
the treponema, there is no better mode of absorption of the druv than hj way of tke
tete«tlsew since all the Tetna of tke Intestiiiee Join the portal toIb. If this be the case no
route could be more indirect and more unsatisfactory for active treatment than one that
is not intestinal or not intravenous (i. e. prehepatic), since some of the druv must neces-
sarily become flxed everywhere before the passagre through the liver has activated it." —
Dr. Sabouraud. La Clinique.
As a result of numerous clinical experiments. Dr. Bagrov, of Moscow, confirms this.
THE ANGLO-FRENCH DRUG CO., Limited
WILSON BLDG.. 1270 BROADWAY Phone MadUon Square 6683 NEW YORK CITY
J
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Influenza and
Pneumonia
PROPHYLAXIS: D,. e. C Roacnow. of the Mayo Clinic, read a paper
before the American Medical Association at the last annual meeting in which
he reported on the use of a prophylactic vaccine in the influenza epidemic
of 19 18-1 919 There was a total of 100,000 cases, with 300,000 controls.
He asserted that the incidence of the disease was three times as great in the
unvaccinated persons as in the vaccinated, and the mortality five times as
great
Parke, Davis & Company's Influenza-Pneumonia Vaccine is prepared in
accordance with the original formula and method of Dr. Rosenow. It is
administered in three injections, at intervals of six or seven days.
Influenza-Pneumonia Vaccine
(Prophylactic)
Bio. 632. Three bulbs in a package.
Bio. 633. Three syringes in a package.
Bio. 634. Rubber-stoppered vials containing five mils.
Bio. 635. Rubber-stoppered vials containing twenty mils.
• Ei A 1 ifl EilN 1 • Physicians who used Pneumonia Phylacogen last winter
as a routine measure in the treatment of influenza gave an initial injection of
1 6 minims. The second day the dose was increased to 32 minims, the third
day to 48 minims, and so on until convalescence was established.
When pneumonia had already developed, 1 6 minims of Pneumonia Phy«
lacogen was administered immediately. Twelve hours later 32 minims w^<s
injected, and the dose was gradually increased every twelve hours until tho
critical period had been passed.
Pneumonia Phylacogen
Bio. 605. Bulbn of ten mils, one in a package.
Bio. 607. Bulbs of one mil, five in a package.
Send for our booklet, "Prophylaxis and Treatment of Influenzal Pneumonia***
Parke, Davis & Company
DETROIT
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Valentine's Meat-Juice
In Hospital and Private Proctice during:
Efridemics, and in their own persons,
when ill, Physicians have demonstrated
the Value of Valentine's Meat- Juice in
Sustaining and Strengthening the weak-
ened Vital Forces.
Pneumonia and influenza.
Dp. £. Beltran, Valencia, Spain : "I have known
and used Valentine's Meat -Juice on many occasions
and for many years and always with the most satis-
factory results. Three years ago I was desperately ill
witli a stubborn attack of Grippal Pneumonia, and
during my convalescence from said illness I used Val-
entine's Meat- Juice. The results were extremely
satisfactory, as the excessive debility was soon ame-
liorated and the period of convalescence made rela-
tively short. "
Cavalier Or, Enrico Ballerini, Late Surgeon
to the Hospital of Rowi\ Italy : *'l have used Valen-
tine's Meat- Juice in the treatment of patients, and
also personally, after having been ill with Influenza,
and I must say it is an excellent tonic in conditions of
great organic weakness. "
For Kale by American and European Chemiats and DrugRiets.
VALENTINE'S MEAT- JUICE CO..
JT 175 RICHMOND, VIRGINIA, U. S. A.
vy«S
m
_V3
MEAT JUICE.
' n« r»«TiU of u crvRl- ' niRElTIONJt-Dtt-
Ul I'rt.cfiii of Frrj«r. j toUm una )«»»pi,.BjVil if 1
1(1 Juic« It sbioli tli« or thrw nhtttpxmflils atv
' tl«ni«tn» .1 nutrltltiti 0>'1J f>r mtna vu«r. Th» \
I kr« el.tiiovd Id • »tit«. um of UuiUqj; water '
I Ttmdj fur lJoni*dtat« %h- e^iukc* (be l.•^LU«et«r ttt 1
9«rpU«B. tb« |.r«pv«ti<ia.
In the Treatment of
RHEUMATIC and
NEURALGIC ILLS
you "H^ill obtain substantial aid from the through use of
K-Y ANALGESIC
This non-greasy, water-soluble loeal anodyne will enable you
to ease your patient^s pain and diseomfort, while your internal or
systemic medication is combating the cause of his condition.
The advantages, moreover, of relieving the pain of a facial
neuralgia, an inflamed joint, or aching lumbar muscles without re-
course to coal tar derivatives cannot fail to appeal to medical men.
K-Y ANALGESIC is a safe and efiFective adjunct that will daily
grow more useful to the practitioner as the many opportunities for
its efiFective use are realized.
(J NEW BRUNSWICK,(7 N. J., U.S.A.
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>'. !*
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