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Southern Medical Journal 

Journal of the Southern Medical Association 

Published monthly by the Southern Medical Association, Empire Building, Birmingham, Ala. Annual subscription 
$4.00. Entered as Second-Class Matter at the Post Office at Birmingham, Ala., under Act of March 3, 1879. Accept- 
ance for mailing at special rate of postage provided for in Section 1103, Act of Oct. 3, 1917, authorized Dec. 20, 1921. 

SOUTHERN MEDICAL ASSOCIATION—Twenty-first Annual Meeting, Memphis, T November 14-17, 1927 


i i Ga.: W. L. Funkhouser, Atlanta, 
Natural Immunity to Infection as nt eee’, meee’. gece 

Observed in Natives of the Tropics. Tenn.; L. T. Royster, University, 

R. W. Mendelson, New Orleans, La. 501 va-; openiamin Pashinak. Macon, 
Discussed by R. S. Leadingham, At- weet Wika! bo LAE Me Rrra Msg orc) gi ha gpa 
f Wilbur M. Salter, Anniston, Ala.; A 

tee sy G. McF. Mood, Charles- S. Root, Raleigh, N. C.; Horton Cas- 

Ua ei ds paris, Nashville, Tenn.; William Wes- 

3 ton, Columbia, S. C.; Wilburt C. 
Importance of Embolic Phenomena Davison, Baltimore, Md.; Joseph 

in the Diagnosis of Coronary Oc- Yampolsky, Atlanta, Cs. 

ne Ma an ieneecasnoemieanaat Uveitis. Wm. Thornwall Davis, 
Washington, D. C 

Myocardial Damage in Coronary Oc- ses m 
clusion. John W. Scott and John Overt, Wm. Earle Clarke, Wash 

Harvey, Lexington, Ky 510 Papers of Dr. Davis and Dr. Clarke 
Papers of Dr. Hamman and Drs. Scott discussed by J. A. Stucky, Lexing- 
and Harvey discussed by G. C. Kil- ton, Ky.: J. Brown Farrior, Tampa, 
patrick, Mobile, Ala.; I. I. Lemann, Fla.; G. C. Savage, Nashville, Tenn.; 
New Orleans, La.; Henry A. Chris- W. B. Gill, San Antonio, Tex.; W. R. 
tian, Boston, Mass. Buffington, New Orleans, La.; J. W. 
Jervey, Greenville, S. C.; James B. 

Transfusion in Infancy. James W. Stanford, Memphis, Tenn 
Bruce, Louisville, Ky That Diagnosis Indigestion. M. L. 

Effect of Blood Transfusions in Cer- and Ghent Graves, Houston, Tex... 

tain Streptococcic Infections. = cn, ww os — -<S- 
A anta, Ga.; J. . ickie, Southern 
Frank C. Neff, Kansas City, Mo Pines, N. C. 

Papers of Dr. Bruce and Dr. Neff dis- 
cussed by A. J. Waring, Savannah, (Concluded on next page) 




This work brings together 130 specialists who have collaborated to present those diseases 

which usually come to the general practitioner, the diseases which comprise the study of the 

medical student. 

Authorities, completeness, arrangement, modern methods — all these features combine to 

make a most practical guide for the doctor and student. 

Octavo of 1,500 pages, illustrated. Cloth, $9.00. 
Send orders to 



New Method for Measuring Intra- 
Nasal Distance to Sphenoid Sinus. 
Homer Dupuy, New Orleans, La... 

Aneurysms from Surgical Service of 
Emory University Unit of Grady 
Hospital. J. L. Campbell, Atlanta, 

Sporotrichosis with Report of an Un- 
usual Case. Howard King, Nash- 
ville, Tenn 

Discussed by Earl D. Crutchfield, Gal- 
veston, Tex.; Bedford Shelmire, Dal- 
las, Tex. 

Solitary Pyogenic Abscesses 
(Brodie’s) of Long Bones: Report 
of an Unusual Case. William 
Barnett Owen, Louisville, Ky 

Discussed by Wm. T. Graham, Rich- 
mond, Va.; E. G. Brackett, Boston, 
Mass.; Arthur M. Shipley, Baltimore, 
Md.; R. L. Diveley, Kansas City, Mo. 

The Diagnosisof Intracranial Lesions. 
Ralph N. Greene, Jacksonville, Fla. 

Discussed by Charles E. Dowman, At- 
lanta, Ga.; H. Mason Smith, Tampa, 
Fla.; E. Bates Block, Atlanta, Ga.; 
Ernest Sachs, St. Louis, Mo. 

Diagnosis of Gall Bladder Disease. 
Paul L. Hudson, Atlanta, Ga. 

Familial Syphilis. Charles C. Den- 
nie, Kansas City, M 

Discussed by Joseph Yampolsky, At- 
lanta, Ga.; W. W. Harper, Selma, Ala. 

The Neglected Third Stage and 
Puerperium. Willard C. Hearin, 
Greenville, S. C 

Discussed by Lewis H. Wright, Augusta, 
Ga.; Jerre Watson, Anniston, Ala. 

Diverticula of the Bladder. W. Hous- 
ton Toulson, Baltimore, Md 
Discussed by Edgar G. Ballenger, At- 
lanta, Ga.; H. W. E. Walther, New 
wn La.; J. L. Estes, Tampa, 

Preliminary Field Training for the 
Health Officer. W. G. Smillie, 
New York, N. Y 

Discussed by C. W. Garrison, Little 
Rock, Ark.; W. K. Sharp, Jr., Nash- 
ville, Tenn.; John A. Ferrell, New 
York, N. Y.; W. S. Leathers, Nash- 
ville, .; Felix J. Underwood, 
Jackson, Miss. 

The Infant’s Second Summer 
Effects of Hyperthyroidism in Various 
Paralytic Ileus 

All Year Round Golf at Memphis 



Ormsby on Diseases 

VERY disease of the skin known today is considered in this edition. Thirty new dis- 
eases are described and seventy-six illustrations and ninety-six pages have been added. 
The bibliography is extensive with many references to the literature of 1926 and 1927. Prac- 
tical both in plan and treatment. it is a work that will give you the looked for information 

and—with a 34 page index—give it quickly. 

New (3rd) 

of the Skin 

Rare conditions are covered thoroughly but the 

bulk of the book is devoted to those affections more commonly met. 

Much new material will be found on all forms of 
Allergy (clinical, serum, drug, local, food and physical 
and on desensitization). The section on Syphilis in- 
cludes the latest conclusions as to the use of Bismuth, 
Flumerin, Sodium Thiosulphate, on the Herxheimer 
reaction, etc. The occupational dermatoses, also der- 
matitis from matches, hair-dye, dyed furs and from 
rouge, face powders and creams, are fully covered. 
The growing use of Roentgen Therapy and Photo- 
therapy (both carbon are and quartz lamps) is shown. 
Other subjects on which there is much that is new 
are Drug Eruptions, including Arsphenamin; Khry- 
solgan; Rhus Toxicodendron, Rhus Toxine; the effect 
of light on Cholesterol; protein sensitivity in Eczema; 
Hyperglycemia as a factor in many dermatoses; 
Pick’s theory of Prurigo Nodularis; sodium salicylate 
injections in Psoriasis; cresol in alcoholic dilution for 
scalp lesions in Neurodermatitis; convalescent serum 
and mercurochrome in Erysipelas; Mercurochrome in 

Pemphigus and also the Davis and Davis Treatment 
of intravenous injection of cacodylate of iron with 
intramuscular injection of coagulen; the cutaneous 
test, immunization and anti-toxin treatment of Scarlet 
Fever; the endocrine factor in several skin conditions 
notably in Acanthosis Nigricans, Scleroderma, etc.; 
Paraffinoma; MHypercholesterolemia in Xanthoma; 
fatty acids of chaulmoogra oil; Fisherman’s Erysipe- 
loid; Guy's theory of Epidermolysis; Bullosa; splenec- 
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sarcoma; Granuloma Inguinale; Mycotic Paronychia 
and Dermatitis peculiar to fruit canners; Madura 
foot; Danish treatment of scabies and the cause of 
creeping eruption. 

By OLIVER S. ORMSBY, M.D., Clinical Professor and Chairman of the Department of Der- 
matology, Rush Medical College of the University of Chicago; Dermatologist to the Presby- 
terian, St. Anthony’s and West Suburban Hospitals, etc., of Chicago. Octavo, 1262 pages with 
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International Medical Annual 1927 




T HIS old friend of thousands of physicians and surgeons is still unique as the one single volume authoritative review of 
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Ear, NosE AND THROAT DiseasES—A. J. M. Wright. 

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GaLL-BLADDER DisEase-J. H. Anderson; Edmund I. Spriggs. 



Inrectious Diseases, AcUTE—John D. Rolleston. 

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Nervous SysteM, DisEAsSEs or—Sir James Purvis-Stewart. 

Nervous SysteM, SuRGERY oF—Geoffrey Jefferson. 

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PHOTOTHERAPY—R. G. Bannerman; Sir Henry J. Gauvain. 

PiruiTrary Bopy, DisEAsES or—Norman M. Dott. 

Pustic HEALTH AND ForENSIC MEDICINE—Charles Corfield, 
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Skin Diseases—A. M. H. Gray. 

SurGery, GENERAL—Sir W. Ireland De Courcy Wheeler. 

Surcery, Recrat—J. P. khart-Mummery. 

TROPICAL DisEASES—Sir Leonard Rogers. 

VENEREAL DisEASES—L. W. Harrison. 

LEES—Practical Methods in the Diagnosis and Treatment of Venereal Diseases. 

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By CHARLES W. CHAPMAN, M.D., M.R.C.P. Consulting Physician to the National Hospital for Diseases of the Heart, Lon- 
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RACHET—Practical Gastroscopy. 

By JEAN RaCHET, M.D. Assistant to the Hospital St. Antoine, Paris. Authorized translation by Fred F. Imianitoff, D.S.C., 
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By Witt1aM KNox Irwin, M.D., F.R.C.S. Surgeon to Out-Patients, St. Pauls Hospital for Genito-Urinary Diseases, London. 
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MANSON-BAHR AND ALCOCK—Life and Work of Sir Patrick Manson. 

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247 pages. 28 Illustrations. Cloth, $3.50 


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of Vitamine-B and as a cure for specific disease. 

Sample bottle of yeast or Yeast Vitamine Tablets. 

To physicians only . . $1.00 each 


Tuckahoe, New York 

July 1927 

Vol. XX No. 7 

SQUIBB Professional Service Representa- 
tives are serving thousands of physicians 
yearly, bringing, as they do, valuable infor- 
mation concerning improvements on old- 
established products, and vital facts con- 


These Representatives are proud of their 
work, proud of their House, and the Prod- 
ucts which bear its name. Physicians 
everywhere recognize their helpfulness and 
are ever pleased to welcome them. 

cerning recent discoveries. 

“* IN wars of the past, a silent, re- 
lentless battle was waged in training 
camps and behind the active fronts, 
which involved an even greater loss 
of life than on the battleline. It was 
the war against Typhoid Fever. This 
dreaded disease is virtually unknown 
among soldierstoday. Yettyphoidac- 
counted for 60% of the total German 
mortality in the Franco - Prussian 
War, and another tremendous loss of 
men in the Spanish-American War.” 

“Do you realize, Doctor, that if the 
same prevalence of Typhoid Fever 
existed in the World War, as it did 
in the Spanish-American War, our 
loss of men would have been twice the 
number that were killed in battle?” 

“Fortunately, the disease was so 
effectually controlled by the Army 
Officials through the use of Typhoid 

Vaccine, that there were only 156 
deaths. That great strideshave been 
made in eradicating this disease from 
American communities is shown by 
the fact thatitispractically unknown 
today in some communities where it 
was once prevalent every summer.” 

Squibb Typhoid Vaccines are pre- 
pared from the same strains and ac- 
cording to the method used by the 
Medical Department of the United 
States Army. They contain only a 
minimum quantity of preservative. 
Typhoid Vaccit.e so prepared is con- 
sidered by the best ‘authorities to 
yield more satisfactory results. 

A few words to our Professional 
Service Department expressing your 
interest will bring additional in- 
formation and literature on this 

Occult Blood Test Squibb 

A convenient and accurate 
test for occult blood. Market- 
ed as tablets in bottles of 100 
with a dropping bottle of gla- 
cial acetic acid. 

Ampuls Sterile Ergot 


In sterile aqueous solution for 
hypodermic or intramuscular in- 
jection. Physiologically tested. 
Stable and free from inert ex- 
tractive. Offeredin 1 cc. ampuls 
in boxes of 6. 

Rabies Vaccine Squibb 
(Semple method — 14 Doses) 
Phenol-killed Virus 

Supplied in packages of 14 
sterile syringes, ready for use 
(no mixing or diluting). All 
doses alike. reatment com- 

leted in 14 doses Can be 
Can in stock by druggists for six 
months with no loss of potency. 






Sold to the Physicians of Alabama at special prices under contract with the 
Alabama State Board of Health 


Diphtheria Antitoxin Tetanus Antitoxin 
Scarlet Fever Antitoxin 


Antimeningococcic Serum 

Antipneumococcic Serum 

Antistreptococcic Serum 
Normal Horse Serum 

Catarrhalis Vaccine Pertussis Vaccine 
Gonococcic Vaccine Pneumococcic Vaccine 
Influenza Vaccine Staphylococcic Vaccine 
Typhoid Vaccine Streptococcic Vaccine 

Typhoid-Paratyphoid Vaccine 
Rabies Vaccine (Pasteur Method) 
Vaccine Virus (Smallpox Vaccine) 


Tuberculins Culture Media 
Schick Test Silver Nitrate Solution 
Diphtheria Toxin-Antitoxin Mixture 

Your State Distributor will supply you with Gilliland State Board of 
Health products. If there is no Distributing Station accessible, send 
your orders direct to the Alabama State Board of Health, Montgomery, 


Marietta, Pa. 

U. S. Government License No. 68 


Summer Diarrhea 

The following mixture is recommended as a temporary diet in intestinal 
disturbances of infants commonly spoken of as summer diarrhea: 

Mellin’s Food 4 level tablespoonfuls 
Water (boiled, then cooled) 16 fluidounces 

Weight in grams of food elements in each ounce 
of the above mixture: 

Proteins 0.176 Grams 
Maltose 1.002 6s 
3 Dextrins 0.352 « 
Salts 0.073 « 

Individual conditions will guide the physician in regard to the amount to be 
given at each feeding and the intervals of feeding, and naturally the intake per 
day will be thus influenced. Assuming, however, that the above-stated amount 
(16 fluidounces) is administered during the full twenty-four hours, the actual 
daily intake of food elements would be as follows: 

Proteins 2.82 Grams 

Maltose 16.03 grams 
Carbohydrates } Dextrins 5.63 grams 21.66 Grams 

Salts 1.17 Grams 

This gives a total of 25.65 grams of nourishment that is readily digestible 
and available for immediate assimilation. The mixture also contributes 101 
Calories for the generation of heat and energy. 

The above accurate examination of the quantity and quality of food elements 
in the suggested mixture is set forth in order that physicians may determine 
to their own satisfaction the value of this means of replenishing elements with- 
drawn from the infant’s organism as one of the results of frequent bowel 

In submitting these details we are following our long-established 
custom of furnishing physicians accurate information in regard to 
all matters concerning Mellin’s Food and its use in infant feeding. 

Mellin’s Food Company, 177 State Street, Boston, Mass. 



is being successfully practiced 

It is now generally admitted that in 
ultra violet radiation El Paso’s sunshine 
is properly comparable with that of the 
Swiss Alps, and in an altitude which is 
but 3762 feet above sea level. 
moderate altitude, with the greater 
comfort it affords, may be the reason 
why such a large percentage of recov- 
eries from tuberculosis are effected in 
this “miracle” climate. The Gateway 
Club does not presume to discuss the 
specific properties of El] Paso’s sunshine 
but it does call attention to the large 
number of definitely recorded cures— 
otherwise, this story would never have 
been written. 

This . 

-----In EF] Paso 

Climatic facts are as follows: 

Average yearly sunshine (U. S. 
Weather Bureau), 331 days re- 
corded “sunny.” 

Humidity, 37%, or less. 

Rainfall, 5 year average, 9.1 inches. 
A winter temperature of 25° is rare. 
Summer temperature is cooled by 
July and August rains and con- 
stant mountain breezes. 

Let us send you our booklet for 
your files. It is free, impartial 
and authentic. Contains nothing 
but recorded facts. Please mail 
the coupon. 

O,, cis 


615-I Chamber of Commerce Building 

El Paso, Texas 

Please send me free booklet, “Filling the Sunshine Prescription.” 







Hill Crest Sanitarium is ideally located on the crest of Higdon Hill on the proposed Scenic Highway 
All modern conveniences. S2parate buildings for convalescent women patients. 

overlooking the city. 
Several acres of well shaded lawn. Adequate nursing service maintained. 
in Charge Consultants: 

JAS. A. BECTON, M.D., Physician 
B. L. Wyman, M.D., 
H. S. Ward, M.D. 

P. O. Box 96, Woodlawn, Birmingham, Ala. 
Phone Woodlawn 1200 C. M. Rudulph, M.D. 



FOR THE pee edad pat a OF 

KERRVILLE X-Ray and Laboratory Graduate Nurses 
Seventy-five miles northwest of San Antonio—1400 feet higher 

Ideal all year climate. 



DOCTOR:---This new Resort 
with its spacious grounds, on- 
ly 15 minutes from downtown, 
will delight your patient. Pa- 
tients’ rates average $50 per 
week. All rooms have bath. 

We take pride in our Hydro, 
Electrical, Dietetic and Colon 
Lavage departments; also our 
Clinicaland X-ray laboratories, 
Our best results are obtained 
in heart-artery-kidney, diabe- 
tic, digestive, nervous, toxic, 
anemic, underweight and ov- 

1824 Peachtree Road, Atlanta, Ga. May we send you a boox:et? 


San Antonio, Texas 

A MODERN institution in beautiful San 
Antonio. Climate unexcelled the year 
round for treatment of tuberculosis. Pri- 
vate rooms with bath and sleeping porch; 
individual cottages; high-class accomm 

tions; Radiographic and Fluoroscopic serv- 
ice; complete medical staff ; moderate rates. 

For booklet and information address 
REV. PAUL F. HEIN, D.D., Supt., 
P. O. Box 214 

South Mississippi DRS. KEITH & KEITH 

746 Francis Bldg. Louisville, Ky. 

Established 1901 Modern equipped X-Ray Laboratories 
Standardized at 

Office and Hospitals for 

GENERAL HOSPITAL Diagnosis and Therapy 

An ample supply of Radium 

for the treatment of superficial and deep 
lesions in which radium is indicated 







Provides the comforts and luxuries of a resort hotel and the complete equipment of a 
modern hospital, including major and minor operating rooms; x-ray, clinical and metabolic 
laboratories; physiotherapy department, etc. SpreciAL DEPARTMENT OF DIETETICS. 

Leased and operated by the SEALE HARRIS CLINIC For THE DIAGNOSIS AND 


Individual and group instruction is given to diabetics under treatment. Ordinarily a two weeks’ 
course is required, depending upon the severity of the case and the intelligence of the patient. 


Combined with the treatment in favorable cases of gastro-intestinal and nutritional diseases, 
cardio-vascular-renal (high blood pressure) cases, undernourished nervous patients; obesity, the 
thyropathies, the anemias, etc., special courses of group and individual instruction are given. Follow- 
ing the thorough physical examination of healthy adults instruction in the prevention of chronic dis- 
eases is offered. This course includes dietetics for the normal individual. 

Reasonable Rates. Every room in the Gorgas Hotel-Hospital has either a private or connecting 
bath, but the rates are reasonable—the same as in all first class hotels and hospitals. The ANNEX 
was recently opened. This building was formerly the Nurses Home and is connected by a closed cor- 
ridor with the Gorgas Hotel-Hospital. It provides a number of ward rooms, in some of which the 
rate for board, nursing, and usual hospital attention is $3.00 a day. No charge is ever made for pro- 
fessional services rendered physicians and the dependent members of their families, and special rates 
are given them in the Gorgas Hotel-Hospital. 

The Gorgas Hotel-Hospital is advertised only to the medical profession. 

Physicians are cordially invited to visit the Clinic and the Gorgas Hospital at any time. 

For further information address: 


Postelle-Larkey Clinic 

Long Distance Phones: Walnut 7270-Walnut 7154 
947 W. 13th St., Oklahoma City, Okla. 

This Clinic is confined strictly to internal medicine, and especially to gastro-enterology 
and nutritional diseases; diseases of the heart and circulatory system and the ductless 
glands. Specially equipped laboratories are maintained for the working out of these 
cases and in charge of specially trained technicians for this class of work. 

Dr. J. M. Postelle, Diagnosis and Gastro-Enterology; Dr. Walter A. Lackey, Diseases of the Heart; Myron 
8. Gregory, M.A., M.D., Psychiatry and Nervous Diseases; Charles D. Blachly, B.S., M.D., Gastro Intestinal 
Diseases; Mrs. Grace Smith, R.N., Superintendent; Mrs. Grace Marshall, Superintendent of Laboratories; 

Mrs. Sadie Struble, Secretary-Treasurer. 




A high-class, modern institution for the treatment of al forms of tuberculosis; all approved methods of treatment 


used. Dry mountain climate, altitude 4000 feet, rainfall 9.12 inches; 835 sunshiny days, average humidity .40. 
Rates, $20.00 to $30.00 per week. Heliotherapy and quartz light therapy, x-ray. Booklet on request. Address 

E. D. PRICE, M.D., Medical Director 

204 Roberts Banner Bldg., El Paso, Tex. 



Mild Mental Cases 

Physician in Chief 

Write for Descriptive Circular 


_El Paso, Texas 
Chas. M. Hendricks, James W. Laws, 
Medical Directors 
A modern and thoroughly equipped pri- 
vate institution for the treatment of all 
forms of tuberculosis, located at an ideal 
point, where atmospheric conditions ap- 
proach perfection in the treatment of such 
disorders. For full information, address 
T. B. Craft, Business Manager. 

Altitude 4,000 feet. Percentage of Humidity .40 
335 Sunny Days. Average Rainfall 9.12 inches. 


A strictly modern Psychopathic Hospital, fully 
equipped for the scientific treatment of all nervous 
and mental affections. Rates include private room, 
board, general nursing, tray service and medical 
supervision. Separate apartments for male and fe- 
male patients. Our treatment for Alcoholics is one 
of Gradual Reduction and Elimination which destroys 
the craving for alcohol. Our drug treatment is one 
of Gradual Reduction which builds the patient up 
physically while being reduced, restores their appetite 
and sleep and relieves their constipation. Location 
retired and accessible. Long distance phone: East 
1488. For further information apply to E. W. Stokes, 
M. D., Supt., 923 Cherokee Road, Louisville, Ky. 

July 1927 



a i's 


General Surgery: Obstetrics : Internal Medicine: Ophthalmology, Oto-Laryngology: 
Stuart N. Michaux, M.D. Greer Baughman, M.D. Alex G. Brown, Jr., M.D. Clifton M. Miller, M.D 
Charles R. Robins, M.D. Ben H. Gray, M.D. Manfred Call, M.D. R. H. Wright, M.D. 

With consulting offices for the staff, laboratories, surgical and obstetrical operating rooms, equipment for the treat- 
ment of medical cases and a training school for nurses the STUART CIRCLE HOSPITAL is a modern standard- 

ized hospital for private patients. 
CHARLOTTE PFEIFFER, R. N., Superintendent. 

M t Regis S tori 
(Incorporated) i 
SALEM Twixt the Alleghany and Blue Ridge Mountains of Virginia VIRGINIA 
A modern, thoroughly equipped, private institution for the treatment of early and moderately advanced tuberculosis. 
Complete Laboratory Equipment, X-Ray, Alpine Sun Lamp, Artificial Pneumothorax. Physicians in constant 
attendance. Training School for Nurses with affiliation with general hospital. 

EVERETT E. WATSON, M_.D., , VRS R. L. BRADLEY, Business Manager 
CHURCHILL ROBERTSON, M.D., ’ Physicians in Charge MISS ORA WIGFIELD, Supt. of Nurses. 

Descriptive booklet on request. 





A modern hospital com- =< _—— a A modern laboratory tests 

pletel;) equiped for the treatment ted | #2 the blood, blood serum, gastric 

‘ . " be juice, biliary secretion by a blad- 

of neurological and internal med- ay ae Man, © der drainage, feces, sputum, urine, 

icine cases. | spinal fluid, etc. 

Giving a complete diagnosis ) ie P atients refered for diagnosis 

: . } only, will be kept for the time 

50 as to find the underlying causes r necessary for the ‘di agnosis an d 
of the patients illness. 1 laboratory tests. 

HYDROTHERAPY THERMOTHERAPY Cooperation of the physician is always sought 

ACTRO RAPT MECHANOTHERAPY and they are cordially invited to visit and see 


ve a a eo ieaiae 

are some of the things it can do for the patients THE POPE HOSPITAL 

We do not accept Insane, Morphine, or other POPE, M. D. 

Objectionable cases. Medical Director 

POTTENGER SANATORIUM, Monrovia, California 

For Diseases of the Lungs and Throat 

F. M. Pottenger, A.M., M.D., LL.D., J. E. Pottenger, A.B., M.D., Asst. Med. 
Med. Director Director and Chief ef Laboratory 

Situated on the Southern slope of the Sierra Madre Mountains at an elevation of 1,000 feet. 
Winters delightful; summers cool and pleasant. Thoroughly equipped for the scientific 
treatment of tuberculosis. We have established, in connection with the Sanatorium, a clinic 
for the diagnosis and study of such non-tuberculous diseases as asthma, lung abscess and 

Address POTTENGER SANATORIUM, Monrovia, California, for particulars. 

Los Angeles Office: 1045-7 Title Insurance Building, 5th and Spring Streets. 


Located in the heart of the great Southwest, the Land of Sunshine. Average annual rain- 
fall 7 inches. Altitude moderate. Albuquerque is the largest city in New Mexico and is 
served by the main line of the Santa Fe. 

The open-air hygienic treatment of Tuberculosis is supplemented by artificial Pneumo- 
thorax and X-Ray Therapy under the direction of a staff of 5 physicians specially trained 
in Internal Medicine. Special facilities for Sun Baths. 

Private sleeping-porches, baths, bungalows and modern fire-proof buildings. 

On request information will be given concerning accommodations available. 
W. A. GEKLER, M. D., Medical Director 
A. L. Hart, M.D. H. P. Rankin, M.D. B. J. Weigel, M.D. 



(Established 1907) 


Moved to its new location July 1, 1922 
An entirely new plant has been erected 

Separate buildings for men and women, ideally arranged and equipped with every facility for the comfort, care and 
treatment of the class of patients received. Situated in the midst of a fifty-acre tract, and surrounded by large 
grove and attractive lawns. Two resident physicians. Training school for nurses. 

References: The medical profession of Nashville 
JOHN W. STEVENS, M.D., Physician-in-Charge 

On Murfreesboro Pike, one-half mile east of old location. 



A modern neuropsychiatric hospital with special 
laboratory facilities for the study and treatment 
of early cases. Also a department for the treat- 
ment of drug and alcoholic addictions. 

The Sanitarium is located on the Marietta Elec- 
tric Car Line ten miles from the center of At- 
lanta, near Smyrna, Ga. The grounds comprise 80 
acres. The buildings are steam heated, electrically 
lighted, and many rooms have private baths. 

Address communications to Brawner’s Sanita- 
rium, Smyrna, Ga., or to the city office, 157 
Forrest Avenue, N. E., Atlanta, Ga. 

Dr. Jas. N. Brawner, Medical, Director. 
Dr. Albert F. Brawner, Resident Physician. 



For Nervous Diseases and 
Selected Cases of Mental Dis- 

(Incorporated under laws of 


Resident Physician 


VON ORMY COTTAGE SANITORIUM ¥** the Treatment of Tuberenlosis 

W. R. GASTON, Manager F. C. COOL, Assistant Manager R. G. McCORKLE, M.D., Medical Director 

Ideally located near San Antonio, Texas. An institution that offers the proper care of tuberculous patients at 

moderate rates. For Booklet and other information please address the Manager. 


For the Treatment of Drug Addictions, Alcoholism, Mental and Nervous Diseases 
Located in the Eastern Suburbs of the City—Sixteen Acres of Beautiful Grounds 
All Equipment for Care of Patients Admitted 




Near Washington, D. C. Baltimore & Ohio Railroad and Electric Line from 
This sanitarium under experienced management offers superior advantages for the 

treatment of patients suffering from Nervous and mild Mental Diseases, and for elderly per- 
sons needing skilled care and nursing; combining the equipment of a modern Psychopathic 

ee in every detail, including the Nauheim Baths for Arteriosclerosis, Heart and Kidney 
DR. E. L. BULLARD, Physician-in-Charge 
DR. DEXTER M. BULLARD, Assistant Physician 

Hospital with the appointments of a refined home. The Hydretherapy Department is com- - 


Established in 1888 by Dr. Karl von Ruck 
Medical Staff: Dr. R. E. Flack, Dr. Edw. W. Schoenheit, Dr. Louis Dienes 

A modern and_ completely 
equipped institution for the treat- 
ment of tuberculosis. High-class ac- 
commodations, Strictly scientific 
methods. For particulars and rates 
write to 


Business Manager. 

(Please mention this Journal) 


Beautifully and conveniently located opposite Ryan Park 

Neuropsychiatry and Internal Medicine Surgery 
Dr. I E. D. Bondurant, Dr. E. S. Sledge Dr. F. M. Inge 

A private general hospital. Specially equipped for and adapted to the diagnostics and treat- 
ment of neuropsychiatric and internal medical conditions. Adequate facilities for surgical 
and obstetrical cases. Complete radiologic, clinical pathologic, _physiotherapy and dietetic 
departments. Troublesome insane or otherwise objectionable patients not received. 

- H. A iologist MISS MARTHA MARSH, Clinical Pathologist 
miss Su BROWN. ENE Supt. of Nurses MRS. A. M. NABORS, Superintendent 



Yarbrough’s Dietetic Sanatorium 
21 South Jackson St. 


Chronic Dysentery Chronic Diarrhoea Nervous Indigestion Gastric Ulcer 
“Bright’s Disease” High Blood Pressure Chronic Rheumatism 
Ideal Environment for Nervous Patients 
Pellagrins in Separate Building. No Infectious Cases Accepted. 
Adequate Night Nursing Staff Maintained. Rate Reasonable. 
Highest Elevation in the City. Above Noise of Traffic. Two Blocks East of Capitol. 




For the Treatment of Nervous Diseases 

Located in a beautiful park of twenty-five acres, in one of the famous all- 
the-year-round health resorts of the world, where climate, air, water and scenery 
are unsurpassed. Five separate buildings, thoroughly modern, afford ample 
facilities for the classification and separation of patients. 

Treatment is limited to Nervous and Mental Diseases, Selected Cases of 
Alcoholic and Drug Habituation. 

Hydro-therapy, Electro-therapy, Occupational-therapy and Massage exten- 
sively used. The two physicians in charge reside in the Institution and devote 
their entire time to the care and treatment of the patients. 

For information and booklet write Drs. Griffin and Griffin. 




Situated in the suburbs of Memphis in a natural park comprising 28 acres of beautiful woodland and 
ornamental shrubbery. Modern and approved methods in construction and equipment. Sanitary plumb- 
ing, low-pressure steam heat, electric light, fire protection and an abundance of pure water. The ele- 
gance and comforts ofa well appointed home. Rooms single or en suite with private bath. Facilities 
"for giving Hydrotherapy, Electrotherapy, Massage, Physical Culture and Rest Treatment. Experienced 
nurses and house Physician. An improved treatment for Opium-Morphin Addiction. 
S. T. RUCKER, M. D., Director Medical Department 

Memphis, Tenn. Bell Telephone Connections 


(Established 1905) 

C. & N. W. Railway, 6 miles North of Chicago } 
Built and equipped for the treatment of nervous | 
and mental diseases. Approved diagnostic and 
therapeutic methods. An adequate night nursing ff 
service maintained. Sound-proofed rooms with ff 
forced ventilation (no different in appearance from 
other rooms). Elegant appointments. Bath rooms jj 
en suite, steam heating, electric lighting, electric | 
elevator. | 
Resident Medical Staff: 
(Consultation by appointment only) ff 

All correspondence should be addressed to 
Kenilworth Sanitarium, Kenilworth, Ill. 


Madison and Franklin Streets 

This is the Private Sanatorium for the Neurological Practice of Drs. Beverley 
R. Tucker and R. Finley Gayle 

The Tucker Sanatorium is for the treatment of nervous diseases. Insane and acute 
alcoholic cases are not taken. The Sanatorium is large and bright, surrounded by a lawn 
and shady walks and large verandas. It is situated in the best part of Richmond and is 
thoroughly and modernly equipped. There are departments for massage, medicinal exercises, 
hydrotherapy, occupation and electricity. The nurses are specially trained in the care of 
nervous cases. : 




Waukesha, - - 

For the Care and Treatment of 

Building Absolutely Fireproof 

Medical Director 

St. Elizabeth’s Hospital 


J. Shelton Horsley, M.D., Surgery and Gynecology 
J. S. Horsley, Jr., M.D., Surgery and Gynecology 
Wm. H. Higgins, M.D., Internal Medicine 

O. O, Ashworth, M.D., Internal Medicine 
Austin I. Dodson, M.D., Urology 

Fred M. Hodges, M.D., Roentgenology 

Helen Lorraine, Medical Illustration 

Thos. W. Wood, D.D.S., Dental Surgery 

Business Manager 

N. E. Pate 


The Training School is affiliated with Johns 
Hopkins Hospital in Baltimore for a _ three 
months’ course, each, in Pediatrics and Ob- 
stetrics. A course in ‘Public Health Nursing is 
given as an elective in the Senior year at the 
Richmond School of Social Work and Public 
Health which is a department of William and 
Mary College. All applicants must be graduates 
of a high school or have the equivalent educa- 



Superintendent of Hospital and 
Principal of Training School. 


Dugan-Stuart Bldg. 

Chief of Staff 



Clinical Pathology 




J. C. King, M.D. 
John J. Giesen, M.D. 

A modern, ethical Institution, fully 
equipped for the diagnosis, care and 
treatment of medical, neurological, mild 
mental and addiction cases. Ideal lo- 
cation, 2000 feet above sea level. Rates 
reasonable. ailway facilities excellent. 
Write for full details. 

July 1927 





McGuire Clinic 

Richmond, Virginia. 
Medical and Surgical Staff 

General Medicine 
Garnett Nelson, M.D. 
James H. Smith, M.D. 
Hunter’ H. McGuire, M.D. 
Margaret Nolting, M.D. 
John Powell Williams, M.D. 
Douglas G. Chapman, M.D. 

Pathology and Radiology 
S. W. Budd, M.D. 

A. L. Gray, M.D; 
J. L. Tabb, M.D. 

Austin I. Dodson, M.D. 

General Surgery 
Stuart McGuire, M.D. 
W. Lowndes Peple, M.D. 
Carrington Williams, M.D. 
Beverly F. Eckles, M.D. 

Orthopedic Surgery 

William T. Graham, M.D. 
D. M. Faulkner, M.D. 

Dental Surgery 

John Bell Williams, D.D.S. 
Guy R. Harrison, D.D.S. 

Eye, Ear, Nose and Throat 
Thomas E. Hughes, M.D. 

Hospital For General Diagnosis 
and Nervous Diseases 


1820 E. 10th Street, Indianapolis, Ind. 

An institution devoted to the Research, Study and 
Diagnosis of all problems in Medicine and Surgery, 
especially of conditions involving the Nervous Sys- 
tem. All newer methods of Diagnosis, particularly 
the Chemistry of the blood, spinal fluid, secretions 
and excretions of the body are employed. The im- 
portance of the body metabolism and its relation to 
diseased conditions is emphasized. 

The co-operation of physicians is invited. It is the 
Policy of the Hospital to return patients to their 
home and family physician for treatment, at the 
earliest possible moment, after diagnosis is made. 
Only at the request of the patient’s physician will 
any case be kept in the Hospital beyond the neces- 
sary period of observation. 

. complete staff of skilled specialists in go-opera- 
For further particulars regarding rates, etc., write 


“Norway” Hospital for General Diagnosis 
and Nervous Diseases. 


With the Majestic Hotel and Bath House and the 
Bethesda Bath House. 

Three thoroughly modern institutions under the same 
roof. All recognized methods of physiotherapy, die- 
tetics, x-ray, and laboratory are utilized. A graduate 
experienced physician in charge of each department 
aided by trained nurses and assistants. Water similar 
in composition and properties to the famous Carlsbad. 
We also have a chartered Nurses’ Training School em- 
phasizing Physiotherapy. 

J. W. Torbett, B.S., M.D., Supt., 
ternal Medicine. 

Diagnosis and In- 

“O. Torbett, Ph.G., M.D., Asst. Supt., Diagnosis and In- 

ternal Medicine. 
Edgar P. Hutchings, M.D., Eye, Ear, Nose and Throat. 
J. B. White, Ph.C., M. D., Urology and Syphilology. 
F. A. York, M.D., Roentgenology and Gastro-Enterology. 
Howard Smith, M.D., Physician and Surgeon. 
8S. A. Watts, M.D., Internist. 
Cromweli Rogers, M.D., Pathology. 
S. P. Rice, M.D., M. A. Davidson, M.D., Obstetrics 
and General Practice. 
H. H. Robertson, D.D.S. 
Miss Sarah Kirvin, R.N., Supt. of Nurses & Dietetics. 
Miss Mary Valigura, R.N., Supt. Surgical Dept. and 
For further information, write for folder to 


July 1927 

Inc. 1873 
For Mental and Nervous Diseases. 
A strictly modern hospital fully 
‘equipped for the scientific treat- 
ment of nervous and mental affec- 
tions. Situation retired and acces- 
# sible. For details write for descrip- 
tive pamphlet. 

F. W. Langdon, M.D., 
Robert Ingram, M.D., 
Visiting Consultants 
D. A. Johnston, M.D., 

H. P. COLLINS, Business Manager 
Medical Director 

Box No. 4, College Hill 

The Cincinnati Sanitarium | 

eee tT eet eet 

“REST COTTAGE?” College Hill, Cincinnati, Ohio 

For purely 
nervous cases, 
nutritional er- 
rors and con- 

equipped for hy- 
massages, etc. 

Cuisine to 
meet individual 

F. Ww. Lan 
d f gdon, 
Robert Ingr. 
ig ‘am, 


DO. A. Johnston, 
M. D., Medical 

H. P. Collins, 
Bus. Mgr., Box 
No. 4, College 
Hill, Cincin- 
nati, Ohlo 

Vol. XX No. 7 




Unioweiy College of Medicine 
edical College of Virginia 
(Consolidated, 1913) 

Schools of 

Modern laboratories and equipment. Extensive dis- 
pensary service; hospital facilities, furnishing 400 
clinical beds; individual instruction; experienced 
— practical curriculum. For general catalog, 

J. R. McCAULEY, Secretary-Treasurer 
1112 East Clay Street Richmond, Virginia 

The New York Skin and Cancer Hospital 

For Graduates In Medicine 

Wil be given as follows 

1—Hospital and Dispensary instruction, _Dornente 
and treatment of diseases of the skin. 

2—Instruction in syphilis—diagnosis, laboratory 
work and treatment. 

3—Instruction in X-ray Therapy. 

4—Laboratory instruction in the pathology of 

in diseases and new growths, including 

linical methods for the demonstration of 

he commoner parasites. 

6—Hospital and dispensary instruction in the 
surgical treatment of cancer. 

Apply to Superintendent 
301 E. Nineteenth Street, NEW YORK CITY 


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Vol. XX No. 7 


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Volume XX 

JULY 1927 

Number 7 


New Orleans, La. 

As an introduction to this paper, permit me 
to quote an editorial comment on a short article 
published in the Philippine Journal of Science 
some few years ago, the subject being ‘“‘Natural 
Immunity to Infection and Resistance to Dis- 
ease as Exhibited by the Oriental with Special 
Reference to the Siamese:” 

“The problem of successfully meeting the complex 
and unusual conditions that confront the sanitarian in 
the less developed semi-tropical countries of the world 
is one that tries the patience and engages the intellect 
of even the most highly trained persons. The principal 
medical officer of health of the Siamese government has 
recently stated that parlor sanitarians are uncommonly 
successful in devising ways and means to be applied to 
combating the epidemic diseases, but practicing hy- 
gienists not infrequently discover the impracticability of 
many of the hard-and-fast rules as decreed, and in no 
place is this so pronounced as in the Orient. This 
hygienist has gained the conviction that students of the 
subject have overlooked a high degree of natural im- 
munity to infection and resistance to disease that has 
gradually been acquired by the Oriental peoples. Thus 
he believes that the specific immunity to typhoid de- 
monstrable in 15 per cent of the population of Siam is 
in the nature of racial immunity, acquired as the result 
of using for many generations an infected water and 
food supply. Mendelson believes that the nervous sys- 
tem of the Oriental is more resistant to the effects of 
germ infection than that of Occidentals, and he alleges 
that, owing to a ‘general infection immunity,’ mortality 
may often be low, even when morbidity from common 
infectious diseases is high. The instances of so-called 
natural immunity are always interesting to the student 
of hygiene. Will statistics and a broader experience 
bear out the thesis that has just been discussed? If 
they do, it will represent an important generalization 
in relation to world-wide conditions.” 

Since the publication of the above I have had 

*Read in Section on Pathology, Southern Medical 
Association, Twentieth Annual Meeting, Atlanta, 
Georgia, November 15-18, 1926. 

tFrom the Department of Tropical Medicine, Tulane 
University of Louisiana. 

the opportunity of further observing the clinical 
manifestations of what I have termed “general 
infection immunity.” The existence of such im- 
munity is so evident in everyday practice in the 
tropics that I do not hesitate to include such 
observations in support of the theory that a 
natural immunity to infection as a whole is de- 
veloped by people living in a highly infected 
environment under natural conditions. 

Kolmer defines natural immunity as 

“the resistance to infection normally possessed, usually 
as the result of inheritance, by certain individuals or 
species under natural conditions.” 

It is to be noted that he definitely states, 
“usually as the result of inheritance.” This 
would mean that it is not necessarily always the 
result of such inheritance. It may be the result 
of other conditions. I wish it clearly under- 
stood that I have in mind the broader inter- 
pretation of the definition. I am discussing 
natural immunity as I have observed it in the 
Oriental, acquired under natural conditions. I 
am not trying to prove that it is inherited, but 
merely trying to demonstrate its existence as I 
have noted it, the result of both clinical experi- 
ence and laboratory research by myself and 
others. With your kind indulgence, I shall first 
take up the clinical side of the subject. 

To the medical man who has not practiced in 
the Far East the citation of the following case 
histories may sound like fiction. I beg to assure 
you they are genuine cases, the result of daily 
experience in a clinic taking care of some 20,000 
medical and surgical cases a year. Bangkok is 
a city of more than half a million people. There 
are some 200,000 Chinese. Now the Oriental is 
prone to enter into serious argument over the 
most trivial thing and he has a marked tendency 
to impress his point of view with the aid of a 
knife. The redeeming feature of this mode of 
controversy is an unlimited supply. of the most 
serious and complicated emergency surgery one 
could possibly desire. I have been treating just 
this type of case for some ten years and the only 


difference that I have noted during that time is 4 
tendency on the part of the native to. become 
more civilized by substituting firearms for dag- 

Case 1—A Chinese woman, aged 38, eight months 
pregnant, was stabbed in the abdomen at 12 noon. She 
ran some 500 yards to the police station, where she was 
questioned before being taken to the hospital, where she 
arrived at about 1 p. m. She was operated upon at 
1:20 p. m. The abdomen was full of blood. There 
was no injury to the intestines, but an incision in the 
fundus of the uterus one inch long. This was sutured, 
the abdomen was dry mopped and drained, and the 
patient put to bed with the indicated after-treatment. 
She aborted that night, and returned home in ten days 
apparently perfectly well. 

Case 2.—A Chinese male, aged 23, was stabbed 
through the anterior and posterior wall of the stomach. 
The abdomen was full of blood, rice and curry. The 
stomach was repaired, the abdomen flushed with nor- 
mal salt solution, drained and the patient put to bed 
with the indicated after-treatment. Recovery was un- 

Case 3—A small Siamese boy, aged about 10 years, 
the servant of an European, was gored by a deer. The 
abdomen was ripped open and the intestines were 
pierced in several places. The lad gathered up the pro- 
truding intestines in his sarong and ran into the house. 
He was brought to the hospital and operated upon. 
The intestines were repaired, the abdomen dry mopped 
and drained, and he was put to bed with the indicated 
after-treatment. Recovery was uneventful. 3 

Case 4.—A Siamese male, aged 37, received a sword 
cut of the lower left anterior thorax, exposing part of 
the left lower lobe of the lung and the incised peri- 
cardium with the pulsating heart. This patient was in- 
jured while up-country and it took two days to bring 
him to Bangkok. The pericardium was sutured, the 
plural cavity closed with drainage and one suture to 
hold the anterior pericardium to the wall of the thorax 
with the idea of preventing, as far as possible, adhesions 
between the heart and pericardium. Except for tem- 
porary empyema, the patient made an uneventful re- 

Year before last we treated seventy compound 
fractures of the skull, with a mortality of 5+- 
per cent. Many of these cases came from up- 
country, having been injured from violence, and 
presenting an exposed and superficially infected 
brain. Unless otherwise indicated, expectant 
treatment was followed and no reparative work 
was done until the patient had completely over- 
come the infection. 

Case 6.—A male Siamese, aged about 40, walked into 
the clinic complaining of obstruction of the bowel for 
forty-eight hours. The diagnosis was confirmed and 
he was operated upon at once. Some eight inches of 
small intestine were resected and anastomosed, with no 

drain. Continuous salt solution was given, with the 
usual after-treatment, and recovery was uneventful. 

Case 7A male Chinese, aged about 35, was brought 
into the clinic the same morning as Case 6 with a stab 
wound into the left anterior abdominal wall. The small 

July 1927 

intestine was completely severed in two places in the 
lower ileum. The abdomen was full of feces and blood. 
The intestines were repaired, the abdomen dry mopped 
and drained. The usual after-treatment was given, and 
there was an uneventful recovery. 

Case 8.—A private patient, a Siamese girl of 18, suf- 
fered perforation of a typhoid ulcer. She was seen in 
consultation some twelve hours later and operated upon 
a few hours afterwards. The perforation was closed 
and the abdomen dry mopped and drained. Except for 
local peritonitis, the patient made an uneventful re- 

Case 9.—A private patient, a male Siamese, aged 42, 
suffered strangulation in a large ventral hernia. He 
was seen in consultation thirty-six hours later, but 
operation was refused. He had also active diabetes 
and chronic nephritis. The strangulation partly relieved 
itself, but the intestine had perforated. I was not per- 
mitted to operate until one week after the original 
strangulation and perforation, yet the patient survived 
the operative procedure another week. 

This is an exhibition of remarkable resistance 
to general infection. Certainly all cases do not 
recover, but a large percentage of those one 
would expect to die overcome their infection 
and survive. 

Numberless cases could be cited that indicate 
the remarkable peritoneal resistance to infection 
of the tropical Orientals. One more surgical 
condition tends to substantiate my theory. Ap- 
pendicitis is not a common disease in natives of 
the tropics. At least it is very uncommon in the 
Siamese. Various theories have been advanced 
to account for this, great stress being put on 
the question of diet. I cannot subscribe to the 
theory that diet has very much to do with the 
matter. It is a question of natural resistance 
to infection. In appendicitis the exciting causes 
are not always known, but infection is a neces- 
sary factor. This infection is not specific. We 
find a variety of organisms in such cases any 
one of which might be capable of producing ap- 
pendiceal lesions under proper conditions. Now 
the tropical native has a far richer bacterial 
flora in his intestinal tract than does one living 
under modern sanitary conditions. I assume, 
therefore, that this rich and varied flora has so 
increased his resistance that he is able success- 
fully to overcome a tendency to acute appendi- 
citis. We, on the other hand, living under com- 
paratively ideal sanitary conditions, have lost 
our one time immunity and the slightest ten- 
dency to a lowered appendiceal resistance per- 
mits a bacterial flora otherwise harmless to be- 
come acutely pathogenic. 

This natural immunity or resistance to infec- 
tion is ewdenced not only surgically but also in 
non-surgical cases. During the first few years 

a ce 

Vol. XX No. 7 

of my sojourn in Bangkok, typhoid fever was 
certainly an uncommon disease in the native as 
I observed him in the clinic. But during the 
last three or four years the cases have gradually 
increased, and especially during 1925 and the 
early part of 1926. I cannot at the moment give 
you the exact numbers, but the ratio would be 
about 1 to 10, comparing the first three years 
with the last three during a ten-year period. 
Similar observations were made with regard to 
the dysenteries. There is, I think, a scientific 
reason for this marked increase in bacillary in- 
fections of the intestinal tract. 

The same applies to cholera. In 1919 we 
suffered from a severe epidemic of this disease 
and the vital statistics are of considerable in- 
terest. Bangkok is a city that is unevenly 
divided by a large river. The east side had at 
the time a population of 607,126 and had been 
supplied with pure water since October, 1914. 
The west side, on the other hand, had a popula- 
tion of 72,610 and always has had a highly 
polluted and impure water. 

East Side West side 

Population 607,126 72,610 
Cases 829 684 
Case mortality, per cent ............ 58.26 52.63 
Absolute mortality, per 1000 .... 0.8 4.9 s 

Now, although the mortality per thousand 
was much higher on the west side, the chances 
of infection being much greater, the case mor- 
tality per cent was actually lower. The ex- 
planation of this, together with the gradual in- 
crease of typhoid and other bacillary infections, 
is, I think, as follows: 

First, permit me to state that there is no rea- 
son to expect that a natural immunity, however 
acquired, should be absolute and permanent any 
more than an artificially induced immunity, es- 
pecially if we gradually reduce the natural im- 
munizing factors.. As a matter of fact, if we re- 
duce the immunizing factor, we should expect 
the immunity gradually to decrease and finally 
disappear. That is actually taking place in the 
City of Bangkok on the east side of the river, 
where they have provided a pure water supply. 
These people have had their immunizing factor 
cut in half, and as the food supply comes under 
control, as it eventually will, we may expect 
them gradually to lose their natural immunity 
to pathogenic intestinal bacteria. This would, 
of course, increase their susceptibility to all in- 
testinal infections. It is gradually doing so. One 


may argue that the population is still being im- 
munized by an infected food supply. Yes, but 
not to the same extent, and furthermore, it takes 
more of the same immunizing factor to main- 
tain an immunity than it does to produce an 
active infection in one who is partially pro- 
tected. I quote the following from the China 
Medical Journal of June, 1926, abstracted in the 
Journal of the American Medical Association: 


“For the whole of Korea, Cate says, there were among 
the Japanese 5,980 cases of typhoid, with 1,191 deaths 
during four years. For the same period there were 
among the Koreans 8,093 cases, with 1,532 deaths. This 
gives the following: 

Incidence 373 per 100,000 
Per. cent mortality...:...........4.. 19 or 72 per 100,000 
Incidence 11 per 100,000 
Per cent mortality —................. 18 or 2 per 100,000 

The conditions under which the Koreans live, the 
sources of water supply, washing food in dirty pools 
and streams, would lead one to expect a higher incidence 
among the Koreans than among the Japanese, but the 
figures given show a vastly greater frequency among 
the latter.” 

Now, as a matter of fact, that is just what I 
would not expect for the reasons already given. 
I take it from the abstract that the Japanese 
live under very much better sanitary conditions 
than the Koreans, which means to me that the 
Koreans have developed a natural immunity to 
typhoid and are keeping it alive while the Jap- 
anese are not. This is a very good example, 
by another worker, of what I wish to illustrate. 
It is really a striking instance of what nature is 
doing in the way of protecting the insanitary 
Koreans. Our experience with fully developed 
cases of tetanus is not less striking, since 90 per 
cent of the cases brought to the hospital recover. 
I speak of adults only. The disease is very 
fatal in infants, which would tend to prove that 
this type of immunity at least is not inherited, 
or if so, to a limited degree only. An observer 
in China has noted that 50 per cent of the Chi- 
nese harbor the tetanus bacillus in their intestinal 
tracts, and he has been able to demonstrate im- 
mune bodies in their blood. Although the child 
is evidently not protected from its mother against 
this disease, the adult does develop sufficient im- 
munity to assist materially in overcoming viru- 
lent infection. Osler states that of 1,264 cases 
only 414 recovered, or only 3.2 per cent. 

I shall make one more observation with re- 
gard to syphilis before we take up briefly the 


laboratory side of the question. It has been 
noted by many observers, both in the Near and 
Far East, that syphilis of the nervous system is 
not a common disease. Certainly it is a very 
uncommon disease in Siam. This has also been 
my experience in the Balkans. The explanation 
is possibly this: the people usually suffer very 
severe secondary manifestations. It is not at 
all improbable that the coverings of the brain 
and spinal cord also suffer a profuse secondary 
eruption. If they do, it is possible, and even 
probable, that the fluids of the cerebrospinal 
nervous system react sufficiently to protect the 
central nervous system from the action of the 
syphilitic virus. I have never had the opportu- 
nity of performing a post-mortem examination 
upon one suffering from pronounced secondary 
syphilitic manifestations. It would be interest- 
ing to investigate the matter. 

Laboratory Findings.—It has not yet been 
definitely determined to what extent the young 
are dependent upon their immune mothers for 
the development of normal antibodies or of nat- 
ural immunity. Clinical experience in the tropics 
would lead one to believe that the infant does 
receive a high degree of protection from its im- 
mune mother, but whether this is an inherited 
immunity or obtained in the form of antibodies 
in the mother’s milk remains to be investigated. 
I am inclined to believe that the infant does 
actually inherit from its immune mother suffi- 
cient protection to overcome the effects of early 
infection, thus giving it a chance to develop its 
own immunity from oral vaccination through the 
medium of infected food and water. 

Environment has a great deal to do with the 
development of a natural immunity. Necessity 
is the mother of invention and nature, in an 
effort to protect the native against his own hy- 
gienic shortcomings, has built up a natural resist- 
ance to infection as a whole that is certainly 
easily recognized clinically and can be demon- 
strated, to a certain degree, in the laboratory. 

It is not my intention to give here a complete 
resume of all the research that has been done 
along this line. A few examples will suffice to 
illustrate the unsettled status of the question at 
the present time. 

With regard to the actual transmission of im- 
mune bodies from the mother to the young, Mor- 
ganroth, in his review of the literature, discussed 
the various possibilities under the following head- 


July 1927 

(1) Direct transmission of the newly acquired im- 
mune factor of the parents to the germ plasm (true 

(2) The active immunization of the mother and the 
fetus by the same immunizing factor. 

(3) The passive immunization of the fetus by cir- 
culating antibodies in the mother’s blood. 

(4) The transmission of antibodies through the moth- 
er’s milk. 

He came to the conclusion that there was no 
actual inheritance of immunity. That the im- 
munity in the young of immune mothers resulted 
from the transfer of antibodies in the circula- 
tion of the fetus and through the mother’s milk. 

Howell and Eby, after a series of experiments 
on rabbits, could not determine whether the 
young of the immune mothers receive a passive 
immunity from the mother or whether they re- 
ceived antibodies from the mother’s milk. 

With regard to non-specific immunity, Clark, 
Zellmer and Stone came to the following conclu- 
sions after a series of animal experiments: 

(1) By intravenous injection of gram positive cocci, 
rabbits are rendered more resistant to a totally unre- 
lated organism, B. typhosus. 

(2) This type of non-specific vaccination causes the 
rabbit to respond when subsequently inoculated with 
B. typhosus by building up a higher concentration of 
agglutinins against this unrelated antigen than do nor- 
mal animals kept under the same living conditions. 

Their research was the result of observations 
upon city and country reared students, the latter 
being more subject to the ordinary infections 
than the former. They ask the following ques- 

“Is it not possible that similar non-specific immunity 
may be built up because of the rich and varied bac- 
terial environment of our city life, and may it not be in 
part responsible for the greater resistance of city dwell- 
ers aS compared with those reared in a rural popula- 
tion?” . 

My personal experience leads me to believe 
that this is so. With regard to the question of 
typhoid infection, I undertook to determine to 
what extent the native Siamese harbored im- 
mune bodies in his blood, and to that end I ex- 
amined some six hundred patients in one of the 
Bangkok institutions under my control. It was 
determined that 15.5 per cent of these subjects 
possessed agglutinins in their blood. It must be 
explained that this number represents half the 
yearly turnover of patients in this institution. 
In other words, about 60 per cent of the inmates 
are permanent and have lived under very good 
sanitary conditions for years. They have had 
pure water, a fairly well protected food supply 
and a very good system of night-soil disposal, 

Vol. XX No. 7 

as compared with that of patients living outside 
of the institution. Practically 99 per cent of 
the positive reactions were in new patients. This 
would indicate that the older inmates had lost 
their one time natural immunity to typhoid, 
while the more recent arrivals had not yet lost 
the protection resulting from repeated vaccina- 
tions with infected food and water. Eventually 
severe secondary manifestations, and it is not at 
they will, if they remain in the institution long 

If what I have here attempted to demonstrate, 
the natural immunity acquired as the result of 
living in a highly infected environment under 
natural conditions, is based upon scientific fact, 
one might view with alarm any sanitary advance 
that tends to increase one’s susceptibility to 
germ infection. On the other hand, I believe 
these people are more prone to the non-infec- 
tious degenerative diseases than are we. They 
succumb earlier to the degenerative diseases of 
the cardiovascular system, the liver, the kidneys. 
This is in part due to the fact that their body 
tissues, constantly called upon to exert the full 
force of their protecting powers, wear out at a 
greater pace than do ours. 


(1) Natural immunity to infection is devel- 
oped by persons living in a highly infected en- 
vironment under natural conditions. 

(2) Clinical experience in the tropics leads 
one to believe that the newborn does inherit 
sufficient general infection immunity to protect 

it until more specific immunity is developed as- 

the result of a more or less continuous vaccina- 
tion with infected food and water. 

(3) When instituting sanitary reforms in a 
virgin field, both food and water should come 
under control at the same time; otherwise there 
is a real danger of increasing susceptibility to 
intestinal infection as a result of decreasing the 
natural immunizing factor by half. 

(4) Although a material degree of protection 
is acquired as the result of living in a highly in- 
fected environment under natural conditions, de- 
generative diseases are earlier developed. They 
are the result of an overtaxation of the body 
tissues in developing and maintaining general 
infection immunity. 



pares 6) Jour. of Sci., 22:No. 2, Feb., 1923. 
~ ke 80:1941, 1922. 

Tuan Inf. Dis., 27: 551, 1920. 
Jour. Inf. Dis., 31:215, a 
Amer. Jour. Obst. Gyn., 8 , July and August, 1924. 
China Med. Jour., June, 1926. 

DISCUSSION (Abstract) 

Dr. R. S. Leadingham, Atlanta, Ga—The mortality 
among infants and children in the Orient is so high 
that those who survive their early experience surely 
possess at least an acquired immunity to many infec- 

Whether or not a natural or racial immunity has been 
developed in certain instances may be difficult to prove 
until more comprehensive and reliable vital statistics 
are available. 

Dr. G. McF, Mood, Charleston, S. C-—At one time I 
was very much interested in trying to eradicate an un- 
hygienic condition in the City of Charleston. The old 
city at that time was sewered with a system of sewage 
which was drained only at low tide. The sewers were 
flushed at high tide and drained at low tide. Beside 
the sewered portion of the city, there was a rather ex- 
tensive portion, which was entirely unsewered, and in 
that part there were by actual count about 3,500 privy 

vaults. I was very anxious to have it sewered, and 
expected to get some data to back up my 
points from investigation among those who had 

for years cleaned out the privy vaults in the 
unsewered part of the city. The business of cleaning 
these vaults was passed on from father to son and had 
been done by the same families for years. I wanted to 
study the incidence of typhoid fever among these peo- 
ple. To my disappointment, going back for fifteen 
years, I could find no case of typhoid fever among 
them. I concluded that for some reason these people, 
who had for years been handling the discharges which 
we believe carry typhoid fever, had developed an im- 
munity. We had for years had from 150 to 200 cases 
of typhoid fever a year and did not look upon that as 
alarming at all. Immediately after the sewering of the 
city and removal of the privy vaults (along with which 
went improvement in the water supply and in the 
dairies), the incidence of typhoid fever dropped in a 
year or two to fifty or sixty cases. 

The thing that impressed me, as I say, was that in 
looking over the histories of these people who had been 
engaged for years in cleaning the privy vaults I could 
find, for a period of fifteen years, absolutely no case of 
typhoid fever. 

Dr. Mendelson —— .—Pneumonia, erysipelas and 
such diseases can readily be devastating in Korea or 
Siam, because the people have not had the opportunity 
of building up immunity to them as they have to 
gastro-intestinal diseases. Certainly one cannot receive 
many inoculations of pneumonia without succumbing to 
it, and I believe that is why that type of disease is so 



By Louis Hamman, M.D., 
Baltimore, Md. 

The clinical picture of coronary occlusion has 
been clearly drawn only during the past fifteen 
years. Before that time coronary obstruction 
was recognized as a common cause of sudden 
death in angina pectoris but excited no inde- 
pendent interest and the diagnosis, except under 
these dramatic circumstances, was rarely ven- 
tured. It is now rapidly becoming an almost 
commonplace diagnosis. 

In reviewing the literature of coronary occlu- 
sion one is puzzled to explain why its distinctive 
features were so long unrecognized. It required 
no new discovery nor any fresh fact to bring 
them clearly to view but only a novel way of 
assembling and looking at facts long known 
though unheeded. For the literature of the past 
hundred and fifty years is crowded with both 
clinical and anatomical observations on coronary 
occlusion and one may find there recorded all of 
the essential marks by which we now readily 
identify this important disease. To spare un- 
needed labor, we may take for convenience the 
summary prepared for us by Huchard. This 
author was a staunch coronarian, that is, a 
zealous advocate of the view that angina pec- 
toris is the clinical evidence of disease of the 
coronary arteries. To establish firmly this re- 
lation he assembled one hundred and eighty-five 
reported instances of autopsies upon the bodies 
of patients who had suffered during life from 
angina pectoris. If you will read over these re- 
ports, even in the condensed form in which 
Huchard publishes them, you will be able to 
cull out all the essential clinical and pathologi- 
cal features of coronary occlusion. You may 
find there described the status anginosus, the 
symptoms of myocardial insufficiency following 
the attack of pain, the pericarditis and the peri- 
_ cardial friction rub, the feeble cardiac impulse 
and distant heart sounds, the pulmonary edema, 
the pulmonary infarction and other embolic 
phenomena, the cardiac infarction, cardiac scars 
and aneurysm, the sudden death, delayed death 
and even recovery from the accident. Only now 
and again were efforts made to use this valuable 

*Read in Section on Medicine, 
Association, Twentieth Annual 
Georgia, November 15-18, 1926. 

Southern Medical 
Meeting, Atlanta, 


July 1927 

material, lying ready at hand, to construct the 
clinical framework of coronary occlusion. Chief 
amongst these is the admirable article of von 
Leyden. In a lengthy discussion of the mani- 
festations of sclerosis of the coronary arteries, 
he gives an excellent account of the symptoms 
that accompany occlusion of the vessels. How- 
ever, these scattered comments remained un- 
heeded and unfruitful until in 1910 an article 
by Obratzow and Strachesko attracted atten- 
tion and stimulated further interest. American 
authors, conspicuously, deserve the credit for 
having developed in great detail the experi- 
mental and clinical data that firmly establish 
the identity of this disease. The first important 
American article, published by Herrick in 1912, 
was soon followed by notable contributions from 
Libman, Levine and Tranter, Smith, Gorham, 
Pardee, Paullin, Willius, Robinson and Herr- 
man, Longcope, Thayer, Wearn, Gordinier, 
Faulkner, Marble and White, and Christian. 
The disease picture has now been clearly drawn 
and anyone familiar with the outlines may rec- 
ognize it almost at a glance. It remains only to 
fill in details and to emphasize certain features. 

I have elsewhere suggested that it is conven- 
ient for purposes of description to divide the 
symptoms of coronary occlusion into four groups, 
as follows: 

(1) The immediate symptoms associated with the oc- 
clusion, the anginal seizure: 
(a) Pain. 
(b) Shock: 
(1) Prostration. 
(2) Fall in blood pressure. 
(3) Suppression of urine. 

The symptoms associated with myocardial dam- 
age, myocardial insufficiency: 
(a) Dyspnea. 
(b) Passive congestion: 
(1) Cyanosis. 
(2) Pulmonary edema. 
(3) Enlarged liver. 
(4) Albuminuria. 
(5) Subcutaneous edema. 
(c) Cheyne-Stokes breathing. 
(d) Feeble cardiac impulse, faint heart sounds, gal- 
lop rhythm, murmurs, cardiac arrhythmias. 

The symptoms associated with the myocardial in- 

(a) Fever and leucocytesis. 

(b) Pericarditis. 

(c) Embolic phenomena. 

(d) Cardiac aneurysm and rupture. 







Additional symptoms: 

(a) Nausea, vomiting, diarrhea. 
(b) Facies. 

(c) Vasomotor symptoms. 

(d) Nervous symptoms. 

Vol. XX No. 7 

This schema embraces all of the characteristic 
manifestations. The onset of the occlusion is 
marked by pain and the symptoms of shock, chief 
among which is a fall in blood pressure, accom- 
panied occasionally by suppression of urine. 
The associated cardiac damage gives rise to the 
characteristic symptoms of myocardial insuffi- 
ciency; shortness of breath, cyanosis, chronic 
passive congestion, enfeeblement of the heart 
sounds and varied changes in rhythm. The 
myocardial infarct causes fever and leucocytosis, 
an important and often misinterpreted symp- 
tom. If the infarct reaches the pericardial sur- 
face of the heart, pericardial friction may be 
heard. If it reaches the endocardial surface, 
mural thrombi form and bits of these thrombi 
may be loosened and float free in the chambers 
of the heart. If it is in the right ventricle, they 
are carried to the lungs and cause the charac- 
teristic symptoms of pulmonary embolism; if in 
the left ventricle, they are carried into the gen- 
eral circulation and may lodge in the vessels of 
the extremities, of the central nervous system, 
of the viscera, or elsewhere, causing the symp- 
toms characteristic of infarction in these va- 
rious locations. Finally, there are certain im- 
portant symptoms that do not fall into any of 
these three groups, namely, the gastro-intestinal 
symptoms, the peculiar facies, vasomotor symp- 
toms, and others. 

However, the schema tells nothing about the 
varied way in which the symptoms combine to 
produce the colorful and dramatic clinical pic- 
ture of the disease. Nor can I stop, though it is 
tempting to do so, to illustrate some of chese 
combinations. I may only point out that, al- 
though marked instances of the disease are easily 
recognized, there are many occasions when diag- 
nosis is difficult and insecure. Under these cir- 
cumstances, we are grateful for any added symp- 
tom that may clear away our uncertainty. 

I shall limit my remarks on this occasion to 
the diagnostic value of embolic phenomena. 
How emboli come about is clear, and that they 
should frequently be discharged is a reasonable 
assumption. This assumption, in my experi- 
ence, has been borne out by observation, and 
therefore I am surprised to find that medical 
literature is almost destitute of comment upon a 
symptom that frequently confirms and occasion- 
ally suggests an important diagnosis. In the 
older literature the occurrence of emboli is fre- 
quently noted, but no diagnostic significance is 
attached to them. 



For instance, Huchard, observation 12, describes the 
occurrence of hemiplegia; at autopsy, occlusion of left 
coronary artery, cardiac infarct and rupture of the 
heart. Observation 14, following an attack of angina 
disappearance of the pulse in the right arm; at autopsy, 
extensive coronary sclerosis with obliteration. Observa- 
tion 55, at autopsy, cardiac infarct, thrombi in left 
ventricle, embolus in left internal carotid. Observation 
90, attacks of angina for a month, a few weeks later 
cerebral attack with aphasia, then sudden death; 
autopsy, sclerosis of coronary arteries with obliteration 
of lumen of left coronary. Observation 116, attacks of 
angina; dyspnea, cough, numerous rales over lungs; at 
autopsy, obstruction of lumen of anterior coronary, 
pulmonary infarcts. Observation 130, severe attack of 
angina followed by left hemiplegia; at autopsy, single 
coronary artery partly occluded. Observations 167 and 
173, pulmonary infarcts. 

One of the earliest comments upon the diag- 
nostic value of embolic symptoms in coronary 
occlusion was made by Paullin. In his Chair- 
man’s Address before this Section of the South- 
ern Medical Association in 1920, he reported 
four instances of coronary occlusion. In one 
an embolus lodged in the right femoral artery 
and gangrene of the leg followed. In another, 
there was embolism to the right brachial artery 
and to the right middle cerebral artery. Thayer, 
in an article entitled “Reflections on Angina 
Pectoris,” published in 1923, cites a number of 
interesting examples of embolic phenomena in 
coronary occlusion. In one instance there were 
pulmonary infarcts; in another, right hemiplegia 
with aphasia; in still another, embolism of kid- 
neys, spinal cord, both iliacs and the left femoral 
artery. . One of Gordinier’s thirteen patients had 
pulmonary embolism and he speaks of its diag- 
nostic value. 

In contrast to these few notices is the almost 
uniform silence of authors about the occurrence 
of embolic phenomena in coronary occlusion. 
Herrick does not mention it, nor does Libman. 
Wearn reports nineteen cases and Longcope 
seventeen without an instance. Recently Chris- 
tian has discussed the diagnosis of cardiac in- 
farction, analyzing seventy-one cases, but ap- 
parently in none did emboli occur. 

My own experience has been different from 
this, for during the past eight years I have seen 
sixteen instances of coronary occlusion, and em- 
bolic symptoms occurred in four. In one of 
these the presence of a large pulmonary infarct 
led by proper reasoning to the correct diag- 
nosis; in the other three the occurrence of em- 
boli added valuable confirmatory evidence. 

In 1918 I saw a patient the day after he had had a 
severe anginal seizure at the theater. During the night 

he had been deeply prostrated, but in the morning he 
wads better. Quite suddenly he complained of severe 


pain in the left chest, the pulse disappeared at the 
wrist, he was profoundly shocked and death seemed 
imminent. He gradually improved and twenty-four 
hours later there was complete consolidation of the left 
upper lobe. Days of critical illness followed, but finally 
he grew better and in the end made a good recovery. 
Three years before he had similarly recovered from a 
less severe attack. He remained well for four years 
when he died shortly after a third seizure. 

In August, 1922, a farmer, aged 69 years, entered the 
Johns Hopkins Hospital (Med. Hist. 48000) complain- 
ing of indigestion, shortness of breath and blood spit- 
ting. He was a sparely nourished man, with a peculiar 
grayish pallor, propped up in bed on account of mod- 
erate dyspnea. He was coughing constantly and raising 
large amounts of dark brown clotted blood. Examina- 
tion of the lungs revealed consolidation of the whole 
right lower lobe and patches of consolidation in the left 
lower. The heart was a little enlarged to the left, the 
sounds clear but remarkably feeble. The liver was en- 
larged. The peripheral vessels were tortuous and thick- 
ened. The characteristic sputa and the consolidation of 
the lung left no doubt about the diagnosis of pulmonary 
infarction. Since there was no evidence of venous 
thrombosis, it seemed altogether likely that the emboli 
came from mural clots in the heart. However, the 
heart was but little enlarged and the usual causes of 
myocardial failure, namely, valvular disease, hyperten- 
sion and chronic pulmonary disease, were absent. The 
possibility of coronary occlusion was suggested and the 
history taken with this possibility in mind supported 
the impression. The illness began four months earlier, 
suddenly, with an attack of severe pain in the epigas- 
trium, followed by shortness of breath. Later attacks 
of pain radiated down both arms and the symptoms of 
myocardial insufficiency slowly progressed. Hemoptysis 
began three days before he came to the hospital. After 
entering the hospital the patient drifted from bad to 
worse and died a week later of myocardial insufficiency. 
The autopsy disclosed coronary sclerosis, with thrombotic 
occlusion of the anterior descending branch. The cardiac 
infarct involved the right and left ventricles and mural 
thrombi were attached to the walls of both chambers. 
There was extensive pulmonary infarction. 

In December, 1918, I saw a man, then 56 years of 
age, who complained of an occasional feeling of oppres- 
sion about the heart and the skipping of beats. Two 
years before it had been noted that the blood pressure 
was a little elevated. 

He was a robust man, somewhat overweight. The 
heart was a little enlarged to the left, a systolic blow 
was heard in the aortic area, and the aortic second sound 
was accentuated. The peripheral vessels were mod- 
erately sclerotic, the blood pressure, systolic 166 mg. 
mm. of mercury, diastolic 90 mg. mm. The electro- 
cardiogram showed a normal mechanism with levogram 

I saw the patient again in March, 1923, at which 
time he complained of epigastric distress and pain. In 
view of subsequent developments, it may well be as- 
sumed that these supposed digestive troubles were 
really masked attacks of angina. However, the history 

did not suggest this, bvt led instead to a suspicion of 
cancer of the stomach. A detailed investigation lent no 
support to the suspicion. The circulatory system showed 
no important change from the conditions revealed four 
years before. 

In May, 1924, after dining indiscreetly, he had during 
the night a severe attack of pain under the lower part 


July 1927 

of the sternum radiating over the chest and down the 
inner side of the left arm. The pain was severe for 
several hours and did not disappear entirely until twelve 
hours had passed. During the following week less severe 
attacks occurred on two other occasions. 

The examination of the heart revealed no conspicuous 
change from what had been found before, except that 
the aortic systolic murmur was louder and rougher. At 
previous examinations, occasional ventricular premature 
beats had been observed. The blood pressure was: 
systolic 166 and diastolic 94 mm. mercury. The electro- 
cardiogram again showed a normal mechanism with the 
levogram predominant. On June 5, 1924, after several 
mild attacks of pain similar to those already described, 
he had a severe and prolonged attack, associated with 
sweating and mild symptoms of collapse. Large amounts 
of morphia were required to control the pain. When 
the attack passed off, it left him prostrated, with a 
rapid, feeble pulse, interrupted by numerous premature 
beats. Attacks of pain recurred at frequent intervals 
and were very severe. 

On June 12 he suddenly developed a left hemiplegia. 
Following this he was much worse with delirium and 
Cheyne-Stokes breathing. However, a period of im- 
provement followed, punctuated from time to time by 
attacks of substernal pain. Toward the end of August 
he again became more and more delirious and drifted on 
in this condition for a week or two until he finally 
sank to death. 

Last January I was hurriedly called one evening to a 
friend and colleague. For a number of years he had 
had mild attacks of angina on exertion. About 8 
o’clock, while sitting quietly in his office, he was sud- 
denly seized by a severe pain in the epigastrium, which 
in a few seconds became an excruciating torture. I 
have never seen such agonizing distress. Morphia had 
no effect and only the inhalation of ether brought some 
relief. There he sat for hours inhaling ether until his 
hand dropped from his face, arousing after a few min- 
utes with cries of pain, again taking ether almost to 
the point of insensibility, again awakening to further 
anguish. He sat almost immobile, guarding against the 
least movement for fear of increasing the pain, talking 
volubly and inceherently under the intoxication of 
ether. At midnight, after a brief respite, he had an 
extremely severe paroxysm of pain and then quite sud- 
denly his whole appearance changed; his face, which 
had been flushed, became ashen gray; his head fell 
backward and momentarily he stopped breathing. He 
roused a little, was helped to his side on the pillows 
and immediately fell into. a deep coma, with slow 
sterterous breathing. 

I was sitting at the patient’s side now and again feel- 
ing the right radial pulse, which throughout the evening 
was slow, regular and full. When the sudden change 
came on, I felt for the pulse again, but could detect no 
radial movement, and hurriedly assumed that the change 
in the patient’s condition was due to a failing heart. 
Slowly the pulse returned to the wrist but remained 
feeble, almost imperceptible. The patient was in coma 
all of the night, but in the morning aroused sufficiently 
to permit an examination which disclosed a left-sided 
hemiplegia, and a faint pulse in the right arm, but a 
strong, bounding pulsation in the left. 

What had happened the evening before was now per- 
fectly clear. A clot loosened from the wall of the left 
ventricle when shot into the aorta must have divided 
into two, one portion traveling through the right sub- 
clavian artery and lodging in the brachial; the other 

Vol. XX No.7 

traveling through the right internal carotid artery and 
lodging in the middle cerebral, causing simultaneously 
the sudden onset of coma and the disappearance of the 
pulse at the right wrist. At the same time, or subse- 
quently, emboli reached the kidneys, for the urine con- 
tained blood. The patient’s condition gradually grew 
worse and he died six days after the onset of pain. 

These few examples, as well as others that 
have been reported, illustrate that emboli. may 
be dislodged from the surface of cardiac infarcts 
an hour or two after the infarct has formed, or 
they may be loosened months later. The early 
appearance of embolic accidents will often add 
the final evidence to complete the diagnosis of 
coronary occlusion. Delayed emboli may some- 
times be misleading and their true significance be 

‘missed, unless their possible association with 
cardiac infarction be thought of and further evi- 
dence be sought by a careful inquiry into the 
early symptoms of the illness. Occasionally 
there may be difficulty in distinguishing between 
coronary occlusion and pulmonary embolism. I 
saw such an instance last June with Dr. H. M. 

A woman, 69 years of age, was operated upon by Dr. 
E. H. Richardson and a perineal repair performed. She 
had been carefully examined a few weeks before by 
Dr. Thomas, who found no important abnormality, ex- 
cept that the blood pressure was systolic 160 and dia- 
stolic 80. After the operation, convalescence progressed 
uneventfully, and on the twelfth day the patient was 
out of bed. On the evening of the fifteenth day, while 
walking about the corridor, she suddenly had a feeling 
of faintness and would have fallen had she not been 
supported by a nurse. When she had been gotten to 
bed she complained of a feeling of pressure over the 
chest and difficulty in getting her breath. The follow- 
ing morning she still complained of constriction in the 
chest and shortness of breath. 

The blood pressure was much lower than it had been 
before operation, but no estimate had been made after 
operation. The pulse rate, previously around 80, rose 
to 100 and over and remained thereabout. The heart 
was a little further out to the left. The patient had a 
grayish, slightly cyanotic color, was deeply prostrated, 
and gave one the impression of being seriously ill. The 
following afternoon a definite coarse, to-and-fro peri- 
cardial frictoin was heard over the sternum and to the 
left of it, which disappeared after six or eight hours and 
did not return. The lungs remained clear except for a 
few rales at the base, and there was no cough and no 
bloody expectoration. 

For a week or longer the patient remained prostrated, 
was delirious and displayed Cheyne-Stokes breathing. 
On the twenty-seventh day after operation, swelling of 
the left leg with pain in the groin pointed clearly to 
thrombosis of the left femoral vein. The swelling of 
the leg subsided, the delirium cleared, the pulse slowed 
and the patient gradually improved. In September she 



was out of bed and she left the hospital September 24 
in good condition. 

It was my own belief, shared by Dr. Thomas, 
that the patient had had a coronary occlusion. 
The character of the attack, the appearance of 
the patient, the rapid pulse, the fall in blood 
pressure, the pericardial friction together make 
a convincing picture. Hearing about the illness 
without an opportunity to see the patient, one 
might well argue for pulmonary embolism. The 
time after the operation, the sudden onset, the 
symptoms of shock, the left femoral thrombosis, 
all strongly suggest pulmonary embolism. It 
might even be suggested that the rub heard over 
the heart may have been a pleuro-pericardial 
friction. I am convinced it was not. It is not 
my intention to argue the point but rather to 
illustrate how difficult at times the diagnosis 
may be. 

Christian, H. A.: Cardiac Infarction (Coronary 
Taresnbenis): An Easily Diagnosable Condition. 

Amer. Heart Jour., 1:129, 1925. 

Faulkner, Marble and White: Differential Diagnosis 
of Coronary Occlusion and of Cholelithiasis. J, A. 
M. A., 83:2080, 1924. 

Gordinier, H. C.: Coronary Ameria Occlusion. 
Jour. Med. Sc., 168:181, 

Gorham, L. 8 The 2 ae ll of Transient Local- 
ized Pericardial Friction in Coronary Thrombosis 
(Pericarditis Episteno-Cardica). Albany Med. 
Ann., 41:109, 1920. 

Hamman, Louis: The Symptoms of Coronary Occlu- 
sion, Bull. Johns Hop. Hosp., 37:273-319, April, 1926. 

Herrick, J. B.: Clinical Features of Sudden Obstruc- 
tion of the Coronary Arteries. J. A. M. A., 59: 
2015, 1912. 

Huchard, H.: Traite des maladies du coeur, Vt. 3. 
Octave Doin, zum. 1905 

Levine, S. A., and Tranter, Cc. L.: Infarction of the 
Heart Simulating Acute Surgical Abdominal Con- 
ditions. Amer. Jour. Med. Sci., 155:57, 1918. 

Libman, E.: Some Observations on Thrombosis of 
the Coronary Arteries. Trans. Assn. Amer. Physi- 
cians, 34:138, 1919. 

Longeope, W. T.: The Effect of Occlusion of the’ 
Coronary Arteries on the Heart’s Action and Its 
Relationship to Angina Pectoris. Illinois Med. 
Jour., 41:186, 1922. 

Obratzow, W. P., and Straschesko, N. C.: Zur Kennt- 
nis der Thrombose der Koronararterien des Her- 


zens. Ztschr. f. klin. Med., 71:116, 1910. 

Pardee, H. E. B.: An Electrocardiographic Sign of 
Coronary Artery Obstruction. Arch. Int. Med., 
36:244, 1920 

Paullin, J. E.: 

Thrombosis of the Coronary Arteries; 
Scones ‘and Pathological Study. S. M. J. 6, 

Robinson, G. C., and Herrmann, G. R.: Paroxysmal 
Tachycardia. of Ventricular Origin and Its Rela- 
tion to Coronary Occlusion. Heart, 8:59, 1921. 

Smith, F. M.: The Ligation of Coronary Arteries, 
with Blectrocardiographic Study. Arch. Int. Med., 

Thayer, W. S.: Reflections on Angina Pectoris. In- 
ternat. Clin., 23:Series 1, 1923. 

Von Leyden: Ueber die Sclerose der Coronar-Arterien 
und die davon abhangigen Krankheitszustande, 
Zeitschrift f. klinische Medicin, 7:459, 1884. 

Wearn, J. T.: Thrombosis of the Coronary Arteries, 
with Infarction of the Heart. Amer. Jour. Med. 
Sci., 165:250, 1923. 

Discussion follows paper of Dr. Scott, page 514. 



By Joun W. Scott, M.D., 
Joun Harvey, M.D., 
Lexington, Ky. 

Although for a century or more the symptoms 
characteristic of coronary occlusion have been 
described and the pathological changes upon 
which they rest have been recognized, it was not 
until 1912 in this country that the disease as a 
clinical entity was first described by Herrick.? 
With a few important exceptions, little reference 
to it is found in the literature until Herrick’s 
second paper in 1919.2 Since then, there has 
been no lack of investigation and discussion of 
the subject. Indeed, attention has been focussed 
upon coronary occlusion as a clinical entity to 
such an extent that it seems not out of place to 
remind ourselves that coronary sclerosis is the 
primary disease during the course of which oc- 
clusion is only an event of more or less frequent 
occurrence. We cannot, however, agree with 
Nathanson,’ who insists that the clinical features 
of coronary thrombosis are essentially similar to 
coronary sclerosis. 

Herrick? divides these patients into four 
groups, according to their clinical symptoms: 

(1) Patients who suffer instantaneous, apparently 
painless death. The patient, to use Hamman’s* graphic 
phrase, “is congealed in the very attitude of the un- 
finished act.” 

» (2) Patients who die within a few minutes or a few 
hours after fatal obstruction. 

(3) Instances of severity in which death is delayed 
for several hours, or days, or months, or in which re- 
covery occurs. 

(4) A group may be assumed to exist, embracing pa- 
tients with mild symptoms, ordinarily not recognized, 
due to obstruction in the smallest branches of the 

When we consider these groups in detail we 
realize that this is far from being a rare disease. 
The great majority of instantaneous deaths, ap- 
parently without warning, are due to coronary 
occlusion followed by ventricular fibrillation. 
Most of these, on close inquiry, will be found to 
have had mild symptoms usually attributed to 
indigestion and considered of no moment. It 
is still necessary to remind some physicians that 
acute indigestion is never the cause of death, 

*Read in Section on Medicine, Southern Medical As- 
sociation, Twentieth Annual Meeting, Atlanta, Geor- 
gia, November 15-18, 1926. 


July 1927 

sudden or otherwise. In spite of Allbutt’s® opin- 

~ jon to the contrary, there is general conviction 

based on abundant pathological evidence that at 
least the usual basis of angina pectoris is coro- 
ary disease. Commonly the terminal event in 
angina is occlusion with death after a few min- 
utes or a few hours, or after an illness of days 
or weeks, or sometimes after recovery from the 
infarction but with progressive myocardial fail- 
ure ensuing. 

LeCount® found in one hundred and seventy- 
five autopsies in cases of heart disease that only 
the twenty-six that showed coronary obstruction 
were associated with symptoms of angina pec- 

Whether or not occlusion is recognized when 
death is instantaneous, or occurs after a few 
minutes, or a few hours’ illness, is chiefly of 
academic interest. It is, however, of great im- 
portance that it be recognized in the last two of 
Herrick’s groups, for upon the correct diagnosis 
of these depends the management of the patient, 
which is a large factor in the result. 

In the last few years attention has been di- 
rected abundantly to the patients with imme- 
diate extreme illness who present the picture 
which has come to be recognized as typical of 
coronary occlusion, the sudden agonizing persist- 
ing pain, the shock, the symptoms of myocardial 
failure, the embolic phenomena, the pericardial 
friction, the leucocytosis, all of which constitutes 
sudden violent illness likely to terminate in death 
within a few days. This clinical picture has 
been frequently described and should not escape 

We wish to call special attention to the pa- 
tients with milder symptoms, so mild that in 
many of them positive diagnosis is not possible. 
The initial symptoms in these patients are not of 
great intensity. Some have sudden attacks of 
moderate substernal or epigastric pain, others 
suddenly become dyspneic, still others have 
nausea and vomiting, with, perhaps, heavy 
sweating. The relation of these milder attacks 
to angina without occlusion is close, but the in- 
tensity is less and the duration longer than in 
angina, and they signalize the beginning of defi- 
nite lowering of cardiac reserve. The heart 
drops, often permanently, to a lower level of 
efficiency. This is in contrast to angina in which 
this change commonly occurs very slowly. 

It is difficult to predicate the extent of the 
damage upon the symptoms when a relatively 
large branch of a coronary artery is occluded. 

Vol. XX No. 7 

The severity of the symptoms depends on at 
least three factors, namely: the suddenness of 
the closure, the presence or absence of antecedent 
myocardial failure, and the location of the oc- 
cluded vessel. If the closure is gradual allow- 
ing the collateral circulation to develop, there 
may be no symptoms. 

Many hearts have been seen following death 
from other causes in which there was no associa- 
tion with symptoms suggesting coronary disease 
and in which infarction had not occurred, al- 
though occlusion of large branches of the coro- 
naries was present. 

When occlusion occurs in the presence of 
antecedent, myocardial failure there is likely to 
be only sudden increase in the pre-existing 
myocardial failure. 

The location of the occluded vessel may also 
be a determining factor. A large occlusion may 
permit recovery after a more or less stormy 
illness, while a very small one may result in 
ventricular fibrillation and immediate death. 
This is illustrated in two of our cases, both of 
which came to autopsy. 

One of these, Mr. W., a man of 42, afebrile for seven 
days after crisis in a severe lobar pneumonia, was sud- 
denly seized with violent substernal pain and intense 
dyspnea, and died in a few minutes. Autopsy showed a 
hemorrhagic area the size of a dime in the wall of the 
left ventricle. Section from this area showed considera- 
ble extravasation of blood and the blood vessels filled 
with dense clot. 

Minute coronary embolism had been followed 
by almost instantaneous death, presumably from 
ventricular fibrillation. 

In contrast with this was a man, Mr. H., aged 61, 
whose heart at autopsy after an illness of four days 
with coronary occlusion, in addition to the recent in- 
farct, showed a large “soldier’s patch” evidently the scar 
of an occlusion he had suffered five years before, and 
from which, after an illness of only moderate severity, 
he had apparently completely recovered. 

Sudden myocardial failure suggests occlusion 
of a coronary vessel. When pain, either sub- 
sternal or epigastric, is added, the probability is 

The relation of myocardial disease to coronary 
sclerosis is intimate. After clinical and path- 
ological study of eleven patients dying of heart 
failure and an equal number of normal hearts, 
Pardee and Master’ declare that muscle disease 
occurs rarely in the absence of coronary disease. 
Clawson,® in a series of one hundred and two 
patients dead of non-infectious myocardial fail- 
ure, found only twenty-one in whom myocardial 
fibrosis was conspicuous. There was also close 



correspondence between the situation and, extent 
of myocardial fibrosis and the situation and de- 
gree of the coronary sclerosis. He concludes 
that myocardial fibrosis is usually due to coro- 
nary disease (excepting a minor degree which 
may follow rheumatic infection) and that these, 
namely, coronary sclerosis and myocardial 
fibrosis, are the only anatomic changes found in 
these hearts. ; 

The following cases illustrate how innocuous 
at the time of occurrence the cardiac accident 
may seem: 

Mr. F., aged 47, eight months previous to examina- 
tion had been attacked suddenly with nausea, vomiting, 
tremendous sweating and prostration. He seemed to 
have recovered promptly from this attack, but soon 
afterward began to have substernal oppression and pain 
in the right arm on exertion, and a week before we saw 
him he had had such an attack and with it nausea and 
heavy sweating. His systolic blood pressure was 125, 
diastolic 85, heart rate 116 per minute. The heart was 
considerably enlarged. The electrocardiogram showed 
a T-wave iso-electric in lead one and inverted in the 
other leads, and notching of the initial ventricular com- 
plex in all leads. He returned to his home and four 
days later, following his evening meal, was suddenly 
attacked with nausea and vomiting and died in eight 
hours. No autopsy was obtained. 

It seems fairly certain that this man’s first at- 
tack was due to coronary occlusion, and that a 
second occlusion was the cause of his death a 
few days after our examination. 

Another patient, Mrs. D., a woman of 63, while in 
bed in the early morning hours, suddenly became very 
short of breath. Though confined to bed, she continued 
for ten days to have dyspnea aggravated by any move- 
ment. The electrocardiogram two weeks later showed 
right bundle branch block. On prolonged rest in bed 
her cardiac reserve improved and five months later the 
electrocardiogram was normal. Four months after this 
she was attacked suddenly again with dyspnea, which 
persisted as at first, and the electrocardiographic record 
again showed bundle branch block. Sudden myocardial 
failure, together with an electrocardiogram showing 
bundle branch block, seems to us to warrant a positive 
diagnosis of occlusion of a branch of a coronary 
artery.9 10 11 

These milder cases lack the severe shock and 
immediate extreme illness of the severer and 
more familiar type, and it is in these cases that 
myocardial failure plays the principal role from 
the outset. Since we are considering specially 
the symptoms referable to the myocardial fail- 
ure, we shall mention only in passing the pain 
and shock of the occlusion, and the signs and 
symptoms arising from the infarct per se and 
shall limit our discussion to the symptoms and 
signs associated with the damage to the mechan- 
ism and function of the heart. 

The first and most striking of these is dysp- 


nea. It is second only to pain in frequency of 
occurrence as the initial symptom. Then it may 
come on violently as in Wearn’s'* patient, who 
ran out of doors to get air, or suddenly in the 
night as in our patient just referred to, or it 
may be associated with cough. During the 
course of the disease, it is commonly the out- 
standing symptom. It is provoked by the slight- 
est exertion and is remarkable in being out of 
proportion to the physical findings. 

After partial recovery it is dyspnea on any 
exertion which is a constant reminder of the 
crippled heart. Thus dyspnea often dominates 
the scene from beginning to end. 

It may be that paroxysmal cough precedes 
dyspnea as an initial symptom. Severe noc- 
turnal paroxysms of cough were the first symp- 
toms in a patient of Elliott’s,* who went on to 
rupture of a cardiac aneurysm, which was found 
to have followed thrombosis of the anterior 
descending branch of the left coronary. 

While respiratory distress with either cough or 
dyspnea as the initial symptom is of myocardial 
origin in a sense, it is quite distinct from that of 
congestive cardiac failure, and is present before 
the latter has appeared. The same may be said 
of nausea and vomiting, which sometimes are 
the initial symptoms, as in a patient we have 
referred to. 

Soon congestive cardiac failure ensues, with 
cyanosis, effort dyspnea, cough, pulmonary 
edema, liver enlargement and tenderness and 
subcutaneous edema. 

Pulmonary edema is regularly present, but its 
severity varies. Sometimes its only sign is fine 
crackling rales throughout the lung areas or 
only at the bases. In patients having epigastric 
pain, tenderness in the right upper quarter and 
muscle rigidity, with nausea and vomiting, fever 
and leucocytosis, resembling closely an inflam- 
matory process in the upper abdomen, rales, in- 
dicating as they do pulmonary edema, may be 
a critical factor in diagnosis. This often hangs 
upon recognition of myocardial failure of which 
pulmonary edema is an outstanding sign. When 
this is present, attention is turned from the ab- 
domen to the heart as the seat of the pathologic 

In some cases pulmonary edema overshadows 
all other symptoms and obscures the other 
physical signs. 

A striking picture of this was a man first seen some 
twelve hours after his occlusion. He was sitting up in 

bed with intense dyspnea, coughing up quantities of 


July 1927 

bloody froth. He survived the edema only to die five 
days later of cerebral embolism. 

Cyanosis is usually prominent, though it is 
not always present. This is fairly described as 
cyanosis, although this term conveys the idea of 
depth and intensity of color which is foreign to 
this condition unless congestive cardiac failure 
has occurred. It may be better described as a 
“leaden tint,” or as a “pasty ashen hue.” There 
is at least an element of blueness, in which it 
differs distinctly from the pallor of an acute ab- 
dominal catastrophe. It follows close upon the 
shock of the occlusion and usually persists for 
weeks. In some cases disordered vasomotor 
function produces flushing; Wearn’? reports a 
striking bright red flushing of the entire skin 
area, with severe sensations of heat, and at the 
same time heavy sweating. 

Blood pressure is always lowered. It may 
appear either normal or elevated and yet be 
lower than it had been previous to the occlusion. 
Hamman refers to the fact that the immediate 
causes of the oliguria commonly occurring in 
these patients is lowered blood pressure. 

The physical findings in the heart itself are 
in the main those of a failing myocardium. One 
finds normal signs diminished rather than ab- 
normal ones occurring. Thus the apex beat is 
found with difficulty, the sounds are muffled and 
distant and in both quality and rhythm may 
give evidence of feeble heart action. En- 
largement may or may not be present, dependent 
chiefly upon the load which the heart has pre- 
viously borne. Murmurs whether present or ab- 
sent are not significant. There is, however, a 
sign of importance, not dependent on myocardial 
failure but upon the infarct, which should be 
mentioned here. This is the pericardial friction 
which is of great diagnostic import when pres- 
ent. Its incidence varies widely in the experi- 
ence of different observers and its absence is not 

In some instances of coronary occlusion there 
may be found no gross abnormalities of rate or 
rhythm; in others, arrhythmias and sudden 
changes in rate give unmistakable evidence of 
disordered mechanism. Cases have been re- 
ported’? in which sinus rhythm, complete block 
and a very rapid rate thought to be ventricular 
tachycardia occurred in relatively short periods 
of time. Fulton’ reports an instance in which 
on the last day of illness there were frequent 
sudden changes in rate from 40 to 120, these 
changes being associated with Adams-Stokes at- 
tacks. One of our patients, Mr. H., whose 

Vol. XX No. 7 

autopsy findings have been already referred to, 
on the day following occlusion showed a rate of 
200, which from study of his polygraphic trac- 
ing we believed to be auricular flutter; the next 
day the rate was 36, which we interpreted as 
complete block; on the fourth and final day of 
illness scores of Adams-Stokes attacks occurred 
when the rate was 36 with sudden change to 108 
upon the termination of the syndrome. 

The work of Carter, Andrus and Dieuaide’® 
showing that in the isolated dog’s heart quite 
notable and abrupt changes in rate follow rela- 
tively slight changes in the hydrogen-ion con- 
centration of the perfusing fluid, is of interest in 
this connection. They found that an increase 
in the hydrogen-ion content was followed by 
slowing and a decrease by acceleration of the 
heart rate. They were also able to demon- 
strate the occurrence of ectopic rhythms after 
such changes in the hydrogen-ion content of the 
perfusing fluid. 

A later report from their laboratory'® indi- 
cates that this is due at least in part to changes 
produced in the refractory period of the heart 
tissue by changes in hydrogen-ion concentration. 
These workers also point out that local change 
in the hydrogen-ion concentration in the heart 
tissue follows mechanical obstruction to the coro- 
nary circulation, and that clinically in such in- 
stances changes in rate and rhythm are fre- 
quently met. 

Use of the electrocardiograph in coronary oc- 
clusion is for obvious reasons impossible in many 
instances. When circumstances permit its em- 
ployment, valuable information may at times be 
obtained. In the presence of arrhythmias, its 
graphic record reveals their nature with a cer- 
tainty that no other method can equal. Such 
records have demonstrated from time to time 
almost every form of arrhythmia in this disease. 

Robinson and Herrmann!’ report four in- 
stances of ventricular tachycardia following coro- 
nary thrombosis, a form of arrhythmia rarely 
found in the absence of occlusion of a coronary 

Electrocardiograms obtained by Smith'® after 
experimental ligation of coronary arteries in dogs 
frequently showed arrhythmias of various kinds 
and not infrequently ventricular tachycardia fol- 
lowed by terminal ventricular fibrillation. Oth- 
ers'® 2° in more recent experimental work have 
reported essentially the same findings. 

In animals surviving experimental occlusion 
there have been observed certain changes in the 



form of the T wave. Frequently this has been 
first an upright wave of increased amplitude 
branching directly from the R or S wave before 
it reaches the iso-electric position. Later this 
form is replaced by a sharply inverted T wave 
which gradually returns to an iso-electric or pos- 
itive form. These changes are attributed to 
damage to the ventricular muscle resulting from 
the occlusion, and therefore, in individuals sur- 
viving the immediate effects of occlusion, one 
would expect to find in the ventricular complex 
of the electrocardiogram some evidence of the 
myocardial injury. 

Clinically there has been observed, first by 
Pardee”! and later by others!* ** *° soon after 
occlusion, a form of T wave branching directly 
from the R or S wave very similar to that ob- 
served after experimental ligation. This is trans- 
ient and soon, like its analogue in the experi- 
mental animal, is replaced by a sharply inverted 
T wave. Pardee*t * has called particular at- 
tention to what he terms the coronary T wave. 
This, he describes as consisting of “an upward 
convexity followed by a sharp downward peak 
in one lead.” If this occurs in lead three only, 
it is not considered significant unless there is 
present an inverted T wave in at least one other 
lead. He found this form of T wave present in 
36 per cent of fifty cases of coronary sclerosis. 
Where infarction had occurred the incidence was 
50 per cent, and it was found in 27 per cent of 
the hearts showing narrowing only. 

Other abnormalities of the ventricular complex 
such as low voltage, deflections indicating intra- 
ventricular block, and inversion of the T wave 
without the preceding upward convexity, all of 
which point to myocardial diseases, have been 
found in coronary sclerosis. 

In a recent publication by Willius*? reporting 
thirty-one cases of cardiac infarction with elec- 
trocardiographic study, it was shown that there 
was some abnormality of the T wave in twenty- 

Other observations*> attempting to correlate 
electrocardiographic curves with subsequent 
autopsy findings have shown that normal elec- 
trocardiagraphic study, it was shown that there 
was more than a small degree of myocardial 
damage found at autopsy. 

The available evidence seems to justify the con- 
clusion that in the great majority of patients 
with occlusion the electrocardiograph will add 
valuable confirmatory information and that in 
many ef the patients with symptoms which are 


mild but suggestive of coronary occlusion there 
will be found abnormal deflections indicating 
myocardial disease. 

The symptoms and signs referable to myo- 
cardial failure in coronary occlusion have been 
discussed. In doing this we have laid special 
emphasis upon the instances in which at least 
partial recovery has occurred, and particularly in 
which the initial symptoms have been mild, 
first, because in these patients there are com- 
monly no symptoms except those of myocardial 
failure; second, because we believe that appre- 
ciation of the significance of sudden lowering of 
cardiac reserve and of electrocardiographic find- 
ings indicative of myocardial disease will result 
in the recognition of coronary occlusion as the 
underlying process in a large number of these 

1. Herrick, J. B.: Clinical Features of ubten Ob- 
struction of the Coronary Arteries. J. A. M. A., 

59:2015, 1912. 

. Herrick, J. B.: Thrombosis of the Coronary 
Arteries. J. A. M. A., 72:387, 1919. 

- Nathanson, M. H.: Disease of the Coronary Art- 

eries. Amer. Jour. Med. Sci., 170:240, 1925. 
- Hamman, Louis: The Symptoms of Coronary Oc- 
clusion. Bull. Johns Hopkins Hosp., 38:273, 1926. 

. Alputt, T. C.: 
ing Angina Pectoris. 

Diseases of the Arteries, Includ- 
London, 1915. 

oo 7 -»- W PP 

. LeCount, E. Pathology of Angina Pectoris. 
a. dh 2X, 70: 974, 1918. 
7. Pardee, H. E. B., and Master, A. W.: 


cardiograms and Heart Muscle Disease. J. A. 
M. A., 80:98, 1923. 

8. Clawson, B. J.: The Myocardium in Non-Infectious 

a ae Failure. Amer. Jour. Med. Sci., 168: 

9. Herrick, J. B., and Smith, F. M.: Clinical Ob- 
servations on Block of the Branches of the Auri- 
culoventricular Bundle. Amer. Jour. Med. Sci., 
164:469, 1922. 

10. Oppenheimer, B. S., and Rothschild, M. A.: Elec- 
trocardiographic Changes Associated with Myo- 
cardial Involvement. J. A. M. A., 69:429, 1917. 

11. Hamburger, W. W.: Disease of the Coronary 
Vessels. Med. Clin. N. A., 9:1261, 1926. 

12. Wearn, Joseph T.: Thrombosis of the Coronary 

Arteries with Infarction of the Heart. Amer. 
Jour. Med. Sci., 165:250, 1923. 
13. ro A. R.: Cardiac Aneurysm. Med. Clin. 
A., 8:495, 1924. 
14. Fulton, F. T.: Remarks Upon the Manner of 
Death in Coronary Thrombosis. Amer. Heart 
Jour., 1:138, 1925. 

15. Carter, E. P.; Andrus, E. C., and Dieuaide, F. R.: 
A Consideration of the Cardiac Arrhythmias on 
the Basis of Local * ekaamanetd Changes. Arch. 
Int. Med., 34:669, 1924. 

16. Carter, E. P., and Dieuaide, F. R.: The Influence 
of Changes ‘in the Hydrogen-ion Concentration 
Upon the Refractory Period of the Perfused Mam- 

7 Heart. Bull. Johns Hopkins Hosp., 39:99, 
pb oe Robinson, G. C., and Herrmann, G. R.: Parox- 

ysmal Tachycardia of Ventricular Origin and Its 
Relation to Coronary Occlusion. Heart, 8:59, 1924. 
18. Smith, F. M.: The Ligation of Coronary Arteries 
by Electrocardiographic study. Arch. Int. Med., 
19. Hamburger, W. W.; Priest, W. S., and Bettman, 
mB Experimental Coronary Embolism. Amer. 
Jour. Med. Sci., 171:168, 1926. 

20. Gold, H.: Action of Digitalis in the Presence of 
Coronary Artery Obstruction. Arch. Int. Med., 
35:482, 1925. 

21. Pardee, H. E. B.: An Electrocardiographic Sign 
of. fon 1920, Artery Obstruction. Arch. Int. Med., 


July 1927 

22. Willius, F. A., and Barnes, A. R.: Myocardial In- 
farction, An Electrocardiographic Study. Jour. 
Lab. and Clin. Med., 10:427, 1925. 

23. Clarke, N. E., and Smith, F. T.: The Electro- 
cardiogram in Coronary Thrombosis. Jour. Lab. 
and Clin. Med., 11:1071, 1926. 

24. Pardee, H. E. ’B.: Heart Disease and Abnormal 
Electrocardiograms with Special References to the 
ae f T Wave. Amer. Jour. Med. Sci., 169: 

25. Master, A. W., and Pardee, H. E. B.: The Effect 
of Heart Muscle Disease on the Electrocardio- 
gram. Arch. Int. Med., 37:42, 1926. 

DISCUSSION (Abstract) 

Papers of Dr. Hamman and Drs. Scott and Harvey 

Dr. G. C. Kilpatrick, Mobile, Ala—The clinical chaos 
which has enveloped the rank and file of the medical 
profession in matters of the heart is happily beginning 
to lift, and incidents rather than accidents of pathology 
such as coronary occlusion are more readily recognized. 

It is most remarkable that a clinical entity presenting 
such well marked characteristics could have failed of 
proper recognition by physicians the world around, gen- 
erally speaking, until the past few years, especially since 
pathologists have long described the findings usually 
noted in these cases. Within the past year the literature 
has become voluminous because of the ease with which 
the disease is recognized. 

The descending branch of the left coronary artery is 
the one most often involved. It becomes sclerosed, the 
inner coat becomes roughened at some point, causing the 
development of a thrombus; this shuts off circulation to 
a portion of the heart muscle, resulting in necrosis or an 
infarct. If the infarct extends to the outer layer of the 
myocardium, pericarditis occurs. 

A majority of patients with this disease are over 40 
years of age, mostly between 50 and 70. They are 
often in perfect health apparently when stricken; the 
attack may come when they are asleep. The pain is 
exceedingly great, constant, lasting for hours, even days 
ona stretch. It usually locates in the lower chest, upper 
abdomen or precordium. Nitroglycerin and allied drugs 
are unavailing. Often morphin in tremendous doses is 
without marked effect. Air hunger is severe. Cheyne- 
Stokes breathing is present. The patient is the picture 
of shock. 

The findings in the heart at first may mislead by 
their absence. Later the heart dilates; the blood pressure 
falls; the heart sounds are distant; pericardial friction 
rubs come and go; white blood count is moderately 
high, and there is some temperature. Death may result 
suddenly or be postpened for years, though most pa- 
tients die in a year or two. The expectancy is sudden 

The healing of an infarct takes six to eight weeks. 
Tili that time, the patient should be kept in bed, espe- 
cially around the eighth to ninth day, when the injured 
area begins to soften. It is an interesting observation 
among those who recover from an attack of this dis- 
ease that they find themselves relieved of the angina, 
while the high blood pressure previously present is 
markedly lowered. 

Dr. I. I. Lemann, New Orleans, La.—I wish to con- 
fine my remarks to the prognosis of the condition. 

In the early part of November, 1925, a colleague in 
his early fifties, while making a professional call, was 
seized with a terrific pain in his chest, which radiated 
to the arm, and required a grain of morphin to relieve 
it. His blood pressure, which was in the neighborhood 
of, 200, later fell to about 120. In the course of a few 

Vol. XX No. 7 

days he developed a pericardial rub. He had a leucocy- 
tosis, a little fever and some crepitant rales at the base 
of his left lung. After this attack, he made a complete 
recovery and was quite well in about six weeks, at 
which time Dr. George Herrmann made an electro- 
cardiogram which showed a coronary T wave. 

About two months after the first attack he was about 
to go to sleep when he suffered another attack with 
terrific pain. He became unconscious and remained so 
for three or four days. It became apparent that he had 
suffered a hemiplegia. It is now a year since the first 
attack. The doctor is quite able to get about, hobbling 
in the typical classical hemiplegic fashion. His heart 
shows no signs of any abnormality whatever. A recent 
electrocardiogram shows a T wave which is almost 

In contrast to the experience of another speaker, I 
wish to emphasize the very grave prognosis that should 
be attributed to the status anginosus and to the fall of 
blood pressure. I have never seen a patient with coro- 
nary occlusion, characterized by a constant falling of 
blood pressure and by constant presence of pain through 
hours and in some cases through several days, recover. 

Dr. Henry A. Christian, Boston, Mass—Most of the 
information that we have about these conditions is the 
result of simple bedside study, which indicates to physi- 
cians, whether they practice in the home or in the hos- 
pital, that there are stili fine contributions to be made 
from that source. I should like also to venture the 
prophecy that a considerable increment to our present 
knowledge will come from_a thorough anatomical study 
of the hearts in these , and perhaps in that study 
we shall discover the cause of the discrepancy between 
the observations of Dr. Hamman in regard to the fre- 
quency of embolic phenomena and my own observa- 
tions in similar cases with regard to the paucity of em- 
bolic phenomena. I think the cause lies in the anatom- 
ical distribution of the infarcted area. We shall learn 
a great deal more from a careful, thorough pathological 
study of these hearts. 


By James W. Bruce, M.D., 
Louisville, Ky. 

The field of usefulness of blood transfusion is 
probably greater in pediatrics than in any other 
branch of medicine or surgery. Anemia is a 
common finding among children, being brought 
about by unhygienic surroundings and improper 
food, as well as by disease. The obstacle which 
has prevented more widespread use of trans- 
fusion is the mechanical difficulty of its per- 
formance. This difficulty is greater with chil- 
dren than with adults for obvious reasons. It is 
the particular object of this paper to discuss the 
simpler methods of transfusion and their indi- 

*Read in Section on Pediatrics, Southern Medical 
Association, Twentieth Annual Meeting, Atlanta, 
Georgia, November 15-18, 1926. 



Transfusions of whole blood are generally ad- 
mitted to be more effective than those to which 
some anti-coagulant is added. Reactions are 
fewer, platelets are not affected, and it is prob- 
able that the red corpuscles reach their destina- 
tion in more efficient condition.! However, does 
this somewhat greater efficiency outweigh the 
very much greater difficulty of performance? It 
will be well at this point to discuss briefly the 
methods of transfusion of whole blood and modi- 
fied blood most commonly used, laying particular 
emphasis on operative skill required and neces- 
sary outlay of material and space. 

The three most popular methods of whole 
blood transfusion probably are: 

(1) Kimpton-Brown paraffin tube method. 
(2) Syringe method of Lindeman. 
(3) Four way stop cock method of Unger. 

The Kimpton-Brown tube method probably 
requires more operative skill than any other. 
The vein is dissected out on both donor and 
recipient. Blood is collected in a paraffin lined 
tube by blood pressure from the donor and is 
forced out by air pressure into the recipient. 

The syringe method of Lindeman consists of 
withdrawing syringefuls of blood from the donor 
and passing them to an assistant who injects the 
blood into the reeipient. Syringes must be care- 
fully washed before being used a second time. 
It is not necessary to cut down on the vein. 

The method of Unger is probably the least 
difficult technically of the methods of whole 
blood transfusion. Blood is withdrawn through 
a stop cock by means of a syringe. The stop 
cock is then turned toward the recipient and 
blood is injected. Clotting within the instru- 
ment is prevented by perfusion of saline between 

These methods all require organization and 
teamwork. They are difficult to perform outside 
of an operating room. All difficulties inherent in 
these methods are greatly increased when work- 
ing with children by the difficulty of entering 
and staying in the child’s vein. 

With the citrate method on the other hand, 
ease of performance and assurance of success 
are vastly greater. There is no rush for fear the 
blood will clot. Many methods have been de- 
vised for mixing blood and citrate. A very simple 
one is to use 50 c.c. syringes and draw the nec- 
essary amount of citrate (5 c.c. of a 2.5 per 
cent solution) into each syringe before with- 
drawing blood. In this way the mixture is ac- 
curately and quickly prepared. The citrated 


blood should be filtered through gauze. The 
container should be continually and gently 
agitated. It is not necessary to apply external 
heat to the container unless the transfusion is 
delayed for some reason. No assistance is re- 
quired in a citrate transfusion that cannot be 
rendered by a trained nurse. An operating room 
is not necessary, although it is more convenient. 
This simplicity of performance makes it possible 
for anyone to do transfusions without the ex- 
pense and complexity attendant upon whole 
blood transfusions. We will admit for the sake 
of argument that citrated blood is somewhat less 
efficient than whole blood, but we will not ad- 
mit that there is any great difference. Nothing 
is more difficult in medicine than absolute proof 
of the relative merits of two therapeutic pro- 
cedures. Personal equation of observers and 
natural variation in cases are variables which 
are impossible to account for accurately. 

We have evidence that intravenous injection 
of sodium citrate affects blood platelets in some 
way. Rosenthal and Baehr* believe that the 
platelets are damaged and removed from the 
circulation by the spleen. This results in diminu- 
tion of platelet count and increase of thrombo- 
plastic substance in the circulating blood with 
shortening of coagulation time. Sodium citrate 
in the test tube does not destroy blood platelets. 

Purpura hemorrhagica or thrombocytopenic 
purpura is a disease characterized by unex- 
plained diminution of blood platelets. Clinical 
experience shows us that blood transfusion, 
whether of citrated or whole blood, is of only 
temporary benefit.. The thing that really helps 
the disease is splenectomy. Transfusion is 
chiefly valuable, therefore, in controlling hemor- 
rhage and in preparation for operation. For 
these purposes citrate transfusions are perfectly 
efficient. It is much safer not to postpone oper- 
ation more than twenty-four hours after transfu- 
sion. In the case of purpura hemorrhagica re- 
ported below, it will be seen that hemorrhage 
was controlled and bleeding time was reduced 
following transfusion of citrated blood. 

Reactions are probably a little more common 
following. citrate. transfusions. They are gen- 
erally due to one of the following causes: 

(1) Blood Not Properly Matched.—It is gen- 
erally agreed that choice of donors according to 
group will occasionally lead to reactions, and it 
is much safer to match directly the blood of 
donor and recipient.* 


July 1927 

(2) Use of Old Distilled Water—Distilled 
water used in making saline and citrate should 
be made on the day of transfusion. This is less 
important in the case of citrate because so little 
of it is used and I have never had cause to re- 
gret the use of ampoules of sodium citrate, which 
can be bought on the market. 

(3) Chilling of Citrated Blood——This may 
be hard to prevent. If the transfusion is de- 
layed beyond fifteen or twenty minutes, it is well 
to apply hot towels to the container. 

Attention to these three points will minimize 
the number and severity of reactions. 

Choice of vein is an important point, in trans- 
fusing infants and children. Very few children 
less than three years old who need transfusion 
have veins in the elbow that can be successfully 
used for this purpose without cutting down. The 
two most popular routes are the superior longi- 
tudinal sinus and the jugular. The objection 
to the sinus is that it is possible to break through 
into the subarachnoid space and produce an 
intracranial hematoma. This accident has un- 
doubtedly happened. However, if the needle in 
the sinus is disconnected évery few minutes dur- 
ing transfusion and a few drops of the infant’s 
blood is allowed to flow back through it, there is 
little or no danger of its occurrence. The su- 
perior longitudinal sinus is much the easiest vein 
to enter. The Goldbloom needle, or some needle 
with a guard on it, should be used. The jugular 
is hard to enter and hard to stay in. The in- 
sertion of a needle into the jugular seems to ex- 
cite more crying and resistance on the part of 
the baby than insertion into the longitudinal 
sinus. The reason for this is probably the 
cramped position in which the infant must lie 
during the former. Excessive crying raises in- 
trathoracic venous pressure very high so that it 
is advisable to have at least four feet of tubing 
attached to the container to overcome this. The 
femoral vein as it passes under Poupart’s liga- 
ment has been successfully used. 

Intraperitoneal injection of blood is becoming 
more and more popular because of its great sim- 
plicity.»5 The peritoneum has long been rec- 
ognized as capable of absorbing quickly large 
amounts of fluid. It has been demonstrated on 
experimental animals that foreign corpuscles in- 
jected intraperitoneally can be recovered in the 
blood stream in fifteen minutes.’ Children in- 
jected in this manner improve clinically as after 
transfusion. Blood injected intraperitoneally is 
usually completely absorbed in a few hours. Un- 

Vol. XX No. 7 

fortunately this is not always true and blood 
has been found unabsorbed many days after in- 
jection. Difference of opinion exists as to 
whether intraperitoneally injected blood should 
be citrated or not and as to whether blood 
matching is necessary. It seems reasonable to 
believe that citrated blood would be absorbed 
more quickly and completely than uncitrated, 
because it maintains its fluid state longer. 
Matching of donor and recipient can only be 
recommended because of the possibility of in- 
creased efficiency of the injected blood. Reac- 
tions apparently do not occur after intraper- 
itoneal injection of incompatible blood.’ I be- 
lieve, therefore, that blood matching before in- 
traperitoneal injection is unnecessary. 

The chief value of intraperitoneal_transfusion 
lies in its simplicity. While few observers be- 
lieve it is as efficient as intravenous transfusion, 
yet it can be used in cases where intravenous 
therapy is contra-indicated, or unusually diffi- 
cult, of performance. Also it can be used where 
laboratory facilities are not available for match- 
ing of blood. Contra-indications to this pro- 
cedure are distention of the bladder or intestines. 
If a dull needle is used, there is little or no 
danger of puncture of a viscus. 

We must get away from the idea that trans- 
fusion is an heroic measure to be used only 
when death seems imminent. Any therapeutic 
procedure used under such circumstances is 
doomed to disrepute. Transfusion should be 
done before the case becomes desperate. With 
the simple methods at our command, it is easy 
to give blood as soon as indications arise. 

The indications for transfusion may be classi- 
fied as follows: 

(1) Hemorrhage.—Indications here are ob- 
vious and results very good. 

(2) Diseases of the Blood.—The bleeding of 
hemophilia -and purpura hemorrhagica can 
usually be checked temporarily. Neither dis- 
ease is cured by transfusion. In hemorrhagic 
disease of the newborn, it is a specific and re- 
sults are brilliant. If the bleeding is from a 
visible source such as the conjunctiva, umbilicus 
or genitalia, it is safe to inject first 20-30 c.c. of 
blood subcutaneously or intraperitoneally and 
see if it will stop. If bleeding is from the gastro- 
intestinal tract, or if subcutaneous or intra- 
peritoneal injection does. not stop the bleeding 
mentioned above, transfusion should be done 
immediately. The superior longitudinal sinus is 
the vein of choice, because it is so much the 


easiest at this age. In intracranial bleeding of 
the newborn, transfusion through the fontanelle 
is contra-indicated. Blood matching is not nec- 
essary in transfusing the newborn.® 

(3) Infections—In general blood stream in- 
fections transfusion with or without the anti- 
septic dyes is the accepted method of treatment. 
Blood from a donor who has been previously 
immunized against the infecting samen is 
particularly valuable.!? 

In prolonged infections such as sinters 
pyelitis, empyema and whooping cough, it has a 
broad field of usefulness. Unfortunately it is 
often delayed too long. Transfusion in these 
cases should not be used as a last resort, but 
should be given just as soon as the patient’s 
strength begins to fail and while there is still 
good hope of recovery. Intravenous transfusion 
ia bronchopneumonia in some men’s hands has 
been successful. My own experience in this 
field is limited to two cases and my results were 
such that I would not attempt it again. In both 
cases severe reactions took place during trans- 
fusion, although every precaution had been taken 
to prevent them. After about one hour’s hard 
work, both babies began to breathe again, but 
died in twenty-four to forty-eight hours. I at- 
tributed these reactions to sudden increase in 
the load on the heart caused by the injection 
and struggling against restraint. 

It seems to me that pneumonia should be a 
good field for intraperitoneal injection of blood. 
Transfusion should be used in all severe cases 
of acute gastro-intestinal intoxication. 

Those who have used the method of exsan- 

guination and transfusion report very good re- 
sults in such severe infections and intoxications 

-as erysipelas, septicemia, toxemia following 

burns, whooping cough with convulsions, and 
severe gastro-intestinal intoxication. By this 
method the patient is first bled almost to the 
point of exsanguination and then given a very 
large transfusion of whole blood." 

(4) Nutritional Disorders—In malnutrition 
and secondary anemia transfusion should be 
done just as soon as it is found that the infant 
is not responding to careful feeding and hygiene. 
In athrepsia it is best to transfuse right away 
and repeat as often as necessary. An athreptic 
baby is bankrupt and transfusion will give it 
some capital to make a start. 

(5) Pre-Operative and Post-Operative. — 
Babies do not stand surgical operations well. 
Pre-operative transfusion reduces operative mor- 


tality greatly.12 Nearly all cases of pyloric 
stenosis should be transfused at least once be- 
fore operation. This operation should never be 
considered an emergency. Better results will be 
had if at least twenty-four hours are devoted to 
storing blood, glucose and water in the infant’s 
body before operation. 

Transfusion sometimes gives brilliant results 
in post-operative shock. 

The following case reports are of patients who 
were given intravenous or intraperitoneal injec- 
tions of citrated blood. The dose of blood gen- 
erally used is 10 to 15 c.c. per pound of body 

Case 1.—Intussusception, Post-Operative Shock.— 
Mary M., age five months, was operated upon for in- 
tussusception five hours after her first symptoms ap- 
peared. The intussusception was reduced with great 
difficulty, necessitating some traumatization of the 
bowel. Three hundred c.c. of 5 per cent glucose by hy- 
podermoclysis was given after the operation. 

Twenty-four hours later the condition was very bad. 
The temperature was 101° and pulse 160. The ab- 
domen was distended. She was vomiting coffee ground 
material. A convulsion lasted ten minutes. Transfu- 
sion was given of 90 c.c. of citrated blood through the 
anterior fontanelle. Her condition rapidly improved 
and within forty-eight hours after transfusion she was 
out of danger. 

Case 2—Hemorrhagic Disease of Newborn. Helen K., 
a first-born baby, of normal labor, seemed all right 
until the third day when she passed a tarry stool. She 
was immediately given 30 c.c. of her father’s blood sub- 
cutaneously. She continued to pass large tarry stools 
and six hours after injection was given a transfusion of 
40 c.c. of citrated blood by the fontanelle. No more 
blood was passed and her recovery was uneventful. 

Case 3—Congenital Hypertrophic Pyloric Stenosis. 
Richard M., age seven weeks, vomited at times for one 
month, and with force for one week. His birth weight 
was 7 pounds 12 ounces, and present weight the same. 
Thick paste feedings and atropin were tried for six days 
in which time he lost 10 ounces and became dehydrated. 
This line of treatment would not have been followed so 
long, but the patient was not brought back to the 
office for that length of time. 

He was immediately given 80 c.c. of citrated blood 
by the anterior fontanelle and glucose subcutaneously. 
Rammstedt operation done the next day was successful 
and convalescence was uneventful. 

Case 4.—Congenital Hypertrophic Pyloric Stenosis. 
Robert McG., age 21 days, weighed at birth 9.25 pounds. 
His present weight was 8.25 pounds. Forceful vomit- 
ing had occurred for the preceding week. He was 
bottle fed and moderately dehydrated. Fifty c.c. of 
citrated blood were given intraperitoneally. Paste feed- 
ing and atropin was tried for forty-eight hours without 
success, i.e., cereal was retained but all fluids were 

Fifty c.c. of citrated blood were again given intra- 
peritoneally and 200 c.c. of 10 per cent glucose sub- 
cutaneously. Next day the Rammstedt operation was 
done. About 2 c.c. of current jelly clot was found in 


July 1927 

the peritoneal cavity. The omentum was apparently 
engorged with red blood cells. Convalescence was un- 

Case 5—Purpura Hemorrhagica. Mary H., age 12 
years, had noticed for years that she bled easily from 
small cuts and bruised easily. Two days before admis- 
sion to the hospital she had several teeth extracted. 
Bleeding from the tooth sockets had been continuous 
since. Physical examination revealed a poorly nourished 
girl. There were innumerable large _ small ecchy- 
moses over the whole body. 

Blood examination was as follows: 

Wassermann negative. 

Red cells 3,300,000; hemoblobin 50 per cent. 

White cells 6,300; differential not done. 

Bleeding time 36 minutes; clotting time 6 minutes. 

There was no clot retraction in two days. The 
capillary resistance test was strongly positive. 

A transfusion of 250 c.c. of citrated blood was given 
intravenously. The bleeding time after transfusion was 
fifteen minutes. Oozing from the gums stopped after 
transfusion. The blood platelets were not counted be- 
fore transfusion because of some difficulty about getting 
the diluting fluid. After transfusion, platelets were 

Five days after the first transfusion, she was again 
transfused with 400 c.c. of citrated blood and imme- 
diately afterward splenectomy was done. Two days 
after splenectomy, the bleeding time was five minutes 
and clotting time four minutes. They have continued 
within normal limits ever since. All ecchymoses have 


(1) Citrate transfusions, while possibly not 
so efficient as whole blood transfusions, are much 
more practical on account of the ease of per- 
formance. For this reason they are preferable 
in children in the vast majority of cases. 

(2) Careful matching of bloods, the use of 
freshly distilled water, and maintenance of body 
temperature in the injected blood will make re- 
actions few and not severe. 

(3) Intraperitoneal injection of blood has a 
field of usefulness where intravenous transfusion 
is impossible. 

(4) Transfusion should be done sooner, while 
there is still good hope of the patient’s recovery, 
and not as a last resort. 

1. eT and Smithies: J. A. M. A., 85:1193, Oct. 

2. McLester: S. M. J., 19:1, Jan., 1926. 

3. Rosenthal and Baehr: ‘Arch. Int. Med., 33:535, 
May, 1924. 

4. Guthrie, Huck and Pessel: Bull. Johns Hop. Hosp., 
35: Jan., Feb., March, April, 1924. 

5. Siperstein: Amer. Jour. Dis. Chil., 25:107, Feb., 
1923, and 25:202, March* 1923. 

6. MacCallum: Bull. Johns Hop. Hosp., 14:105, 1922. 

7. Ruh and McClelland: Ohio State Med. Jour., 19: 
780, March, 1923. 

8. Meyer: Jahrb F. ae 105:188, 1924. 

9. Biasi: J. M. A., 1:17, Nov. 24, 1923. 

10. Unger: ‘abt's Pediatrics, 4:634. 

11. Robertson: Arch. Surg., 60:1, 1924. 

12. Ward: Amer. Jour. Surg., 39:110, Oct., 1925. 

~ Discussion follows paper of Dr. Neff, page 521. 

Vol. XX No.7 


By Frank C. Nerr, M.D., 
Kansas City, Mo. 

Streptococeus sepsis during early life has such 
an unfavorable prognosis, and the treatment thus 
far by horse serum and other methods has been 
so unsatisfactory that the writer wishes to make 
a report of a few cases in which blood trans- 
fusions were used. It is generally agreed that 
newly born infants who develop erysipelas have 
little chance for recovery. The mertality is 
estimated at 95 per cent, and for this disease in 
the whole first year of life the mortality is as 
high as 50 per cent. 

Before this society in 1921, John Mason Knox, 
in reporting fifty-three cases of erysipelas, 
thirty-eight of which were under two years of 
age, concluded that resistance is lower the 
younger the child, and that no treatment is 
curative. Such a large group as he collected is 
seldom available for therapeutic conclusions. 
Most observers report isolated cases. 

Abscesses of the middle ear and deep tissues 
are the most common complications which, with 
the resulting severe intoxication, are apt to 
overwhelm the child. The favorable influence 
of localization which is said to occur in other 
types of bacteriemia and sepsis certainly does 
not hold good in erysipelas. Furthermore, in 
two of my cases, a recurrence of the generalized 
eruption definitely followed abscess formation 
and drainage. 

The high leucocyte count indicates the im- 
portant part that the white blood cells play in 
the attempt to combat the infection. There- 
fore, it would seem that the introduction of nor- 
mal blood into the veins would be indicated in 
early life when the resistance to this type of 
organism is much lowered. 

The most favorable recent reports from any 
treatment of erysipelas are by Jordan and Dus- 
tin! at the Providence City Hospital, where, 
since 1919, convalescent human serum has been 
used. Kaiser? in 1915 reported a prompt cure 
of erysipelas in a six-year-old girl with one intra- 
muscular injection of seven ounces of citrated 
blood from a donor five days convalescent. 

*Read in Section on Pediatrics, Southern Medical 
Association, Twentieth Annual Meeting, Atlanta, 
Georgia, November 15-18, 1926. 



While it is possible for any well conducted hos- 
pital or health department to secure and keep 
on hand such serum, it has not yet become the 
custom of these institutions to provide con- 
valescent blood, nor is it ever produced on a 
commercial basis, and for the average commu- 
nity one cannot count upon procuring it when 
it is needed. 

Normal blood, however, is available in any 
emergency, and when it is used with proper pre- 
cautions as regards infection with syphilis and 
compatibility it is free from danger and worthy 
of trial. During the past year at Bell Memorial 
Hospital we had the opportunity to treat three 
young children by the blood transfusion method 
and a fourth case which showed a beginning 
favorable result was removed from the hospital 
with only one treatment. As a result of the 
experience gained in these few cases, I feel that 
it would have been more effective to give the 
transfusions at shorter intervals and that they 
should have been begun as soon as the diagnosis 
was made. The cases which I shall briefly re- 
port do not represent, therefore, in their treat- 
ment the exact technic which I shall try to fol- 
low subsequently. 

All four of these were proven by blood culture 
to be infected with a hemolytic streptococcus. 
Three were clinically erysipelas and one was 
streptococcemia with multiple abscesses. 

Case 1—Erysipelas in a breast-fed three months old 

Dorothy J., was admitted to the hospital on the 
third day of illness with erysipelas of the vulva spread- 
ing to the surrounding parts. The entire body surface 
finally became covered. The leucocyte count was 21,000 
and the temperature of a typical septic type. After 
failure of the usual general and local treatment, the 
child was given four blood transfusions into the vein 
during the remaining course of the disease from the 
seventh to the thirty-third day of the illness. There was 
no apparent effect upon the temperature following the 
first injection, but there was a definite response after 
the second, following which the temperature remained 
near the normal for a week. An abscess of the buttocks 
was then opened, and a recurrence of the erysipelas took 
place. The third and fourth transfusions were similar 
to the first and second in that marked relief appeared 
promptly after the repeated transfusion, following which 
the infant made an uneventful recovery. From 150 to 
180 c.c. of citrated blood were used for each transfusion. 
Unnecessarily long delays occurred in the sequence of the 
transfusions and the treatment should have been begun 
earlier and repeated every three or four days as long as 

Case 2——Hemolytic streptococcemia with multiple ab- 

Margery K., two years old, ten days following chicken 
pox, had a cracked and infected lower lip, then an in- 
flammatory mass in the left cheek, and an abscess of 



July 1927 

Temperature curve M. K. Streptococcus sepsis with multiple abscesses. (Case 2.) 

the dorsum of the right foot. She entered the hospital 
with sepsis therefrom. Blood cultures on brain broth 
and blood agar were postive for a hemolytic strepto- 
coccus. The hemoglobin was 58 per cent and the 
leucocyte count 17,000. On the tenth day of the hos- 
pital stay when the child was desperately ill, a trans- 
fusion of 300 c.c. of her mother’s blood was given. 

Following the transfusion for a period of three days 
she was free from fever, then an irregular rise for a few 
days to 103.6° F. occurred. A second transfusion was 
followed by a few days’ drop in fever, another rise for 
two days, after which the child made a prompt recovery. 
The presence of several superficial metastatic abscesses 
complicated the course of the case and made it difficult 
to prove the effect of the serum, but the gradual im- 
provement and especially the increase in the hemoglobin 
seemed to the attendants due entirely to the injection of 
blood. Not only were the symptoms generally better 
following the transfusions but undoubtedly the resist- 
ance was increased after these injections were begun. 
In this case the delay for ten days in beginning the 
treatment is regrettable. 

Case 3-—Erysipelas in a six-months-old Mongolian. 

Baby B., with a history of cervical gland fistula for 
two months, entered the hospital May 2, 1926, on the 
third day of cervical and thoracic erysipelas with a tem- 
perature of 106.4° F., white blood count of 23,000 and 
a positive culture of hemolytic streptococcus. The child 
showed no improvement clinically but curiously the 
temperature curve was irregularly downward in the next 
six days during which time four blood transfusions of 
from 100 to 200 c.c. of citrated blood were given in- 
travenously. Death occurred on May 10, the eleventh 
day of illness. Autopsy revealed in addition to the 

erysipelas and mongolism, a thymus gland weighing 20 
grams, atelectasis, serofibrinous pleurisy, pneumonia, 
pericarditis, hemorrhages of the pleura and adrenal 
glands. Transfusions in the amount given were without 
any effect in this case. 

Case 4.—Erysipelas in the newly born. 

Patricia S., aged three weeks, developed erysipelas of 
the vulva, buttocks and abdomen, following a persist- 
ent umbilical discharge. The child received one blood 
transfusion, was apparently benefited, but was taken 
from the hospital against advice, and was returned two 
weeks later in a dying condition. The autopsy showed 
multiple abscesses of the groin, of the psoas muscle, of 
the occipital lobe of the brain, and a meningitis, all a 
part of the hemolytic streptococcus sepsis. 

The effect of therapy cannot be accurately 
determined from a small number of cases. Two 
children recovered and seemed to be markedly 
benefited. The Mongolian infant died in spite 
of four transfusions. The newly born infant, 
apparently helped by one transfusion, got ne 
further treatment and died two weeks later from 

Certain details are worthy of study in the 
technic of transfusions for infections of this type. 
The interval between injections should probably 
be three or four days and the quantity based 
upon the needs of the individual. It is possible 
that citrated blood is of less phagocytic value 
than unmodified blood, which is advocated by 
Unger® and by Colebrook and Storer.* It is fur- 
ther possible that the potency of the injected 


Vol. XX No. 7 

blood may be increased by employing the immu- 
notransfusion method of Sir Almroth Wright,> 
in which the donor is given a subcutaneous in- 
jection of vaccine four hours before his blood is 
withdrawn, thereby enhancing its phagocytic and 
protective activity.* 


. Jordan, H. P. B., and Dustin, C. C.: Jour. Amer. 
Med. Assn., 82:874, 1924. 

. Kaiser, A. D.: Arch. Pediat., 32:519, 1915. 

br ap L. F.: Jour. Amer. Med. Assn., 77:2107, 

. Colebrook, L., and Storer, E. J.: Lancet, 2:1341 
and 1394, 1923. 

. Wright, Sir Almroth: Lancet, 1:489, 1919, and 
Wright, Sir A., Colebrook, L., and Storer, E. J.: 
Lancet 1:365, 1923. 

oo wD 

DISCUSSION (Abstract) 
Papers of Dr. Bruce and Dr. Neff 

Dr. A. J. Waring, Savannah, Ga—One of the books 
that stand out in medical literature is entitled “The 
Gold-Headed Cane.” It has the coats of arms of five 
famous old London physicians on it and is in the library 
of the Academy of Medicine of London. In it is an ac- 
count of a transfusion by Gower, of Oxford, in about 
1665, a few years before Sir Christopher Wren, who 
was a member of the Royal College, made exhibition of 
the use of intravenous agents. Dr. Gower transfused 
dogs, using the femoral artery. The Royal Academy 
approved his treatment and suggested its use in hemor- 
rhages in 1665. 

We are all familiar with the indications for trans- 
fusion, but much may be said about the methods that 
are used. The brief, so far as we have heard it pre- 
sented this morning, is in favor of the citrated methods. 
Very little has been said about the reactions from the 
use of citrated blood. I think we can weigh the re- 
actions which we get from citrated blood and which 
occur in approximately. 50 per cent of cases against the 
ease of the procedure. The medical profession has been 
striving for about ten years to develop this important 
adjunct to its armamentarium to be serviceable to the 
greater majority of physicians. Bernhardt, before going 
into the army, advocated almost exclusively the citrated 
method, which has its marked dangers. In the average 
community one man uses the. Unger method or the 
citrate method and does it perfectly, and it seems 
the easiest thing in the world. He has developed great 
perfection in its technic. In my home town we are 
turning all our transfusions over to one man, who is 
perfecting himself in his technic and does them very 
rapidly and easily. 

Dr. W. L. Funkhouser, Atlanta, Ga—Until recently 
blood transfusion was a spectacular procedure, often 
getting into the headlines in our daily press; but with 
simplified methods we are now able to use it with 
many patients, especially children. Convalescence has 
unquestionably been shortened, and in a number of in- 
stances lives, no doubt, have been saved. Various meth- 
ods of ministration are in vogue, but we should adhere 
to the one that can be done best by us individually. 
The advantages, I believe, of the citrated blood out- 
weigh the disadvantages or the difficulties of giving 

_ *Acknowledgment is hereby made of the cooperation 
in this work given by Dr. R. L. Haden at Bell Me- 
morial Hospital. 


the uncitrated. The difficulty of getting into children’s 
veins may be of advantage to them in that they will 
not be given medication or transfusions indiscriminately. 
The longitudinal sinus, of course, is the easiest entry, 
but the unpleasant experience which many have had 
prevents them from using it unless the patient is in an 
institution where the best of assistants are available. 

Dr. Bruce did not point out in his paper, but did in 
case histories, the advantages of giving transfusions 
after the patient has had several injections of normal 

We can reduce the number of reactions considerably 
if we have the blood both typed and matched, and if 
the injection is given very slowly. 

Dr. Eugene A. Rosamond, Memphis, Tenn.—I sup- 
pose most of us here, even in the simple intramuscular 
injection of whole blood, have decorated the ceiling 
and surrounding gallery, and been thereby very much 
embarrassed when the needle stopped up. We shall 
all agree for the present with Dr. Bruce that the sim- 
plicity of the citrated method makes it the method of 
choice. If we are to popularize blood transfusion and 
give it the place in the therapeutic sun that we know 
it deserves, we have to simplify the method and bring 
it out of the operating room. Therefore the citrated 
method is today the method of choice. It has not been 
definitely proven that the use of sodium salt does 
much harm. As Dr. Bruce said, the use of freshly dis- 
tilled water will do away with many reactions. The 
reason for the intraperitoneal method which we are all 
trying out today is that it is simple. Every one of us 
can use it without making it a heroic measure to be 
undertaken just before the patient’s death. 

Dr. L. T. Royster, University, Va——Those of us who 
have practiced for a generation or more have seen spe- 
cifics come and go and the pendulum of thought swing 
from one extreme to another, so that one is perhaps a 
little skeptical whenever a therapeutic measure becomes 
suddenly and violently popular. We as yet do not know 
enough about the effects of blood from one person put 
into the body of another to speak with any degree of 
certainty on the subject. Much more study must be 
put on this subject before we know exactly what we 
are doing. We have not done enough controlled work 
on parallel cases. We are trusting to our memory, 
sometimes, as to how cases progressed in the past with- 
out transfusion; and one or two brilliant results, either 
post or propter hoc, make us extremely enthusiastic on 
the subject. This procedure is not as yet a proven 
panacea. Again, one or two brilliant results make us 
less careful about our technic. 

I do not, however, wish to sound a discordant note, 
for transfusion is an extremely valuable measure, and 
one which has been too long neglected. In many in- 
stances it is a life saver. I believe, generally speaking, 
that in infectious conditions especially of the type of 
which Dr. Neff spoke, it would appear to be advisable 
to use whole blood by the direct method. I am not 
prepared to state even that with any degree of posi- 
tiveness, but I am inclined to think that is the case 
and that it will be done. In cases in which anemias 
are ameliorated by the blood at all, it is quite likely 
that citrated blood will do as well. 

Dr. Benjamin Bashinski, Macon, Ga—In Dr. Nefi’s 
first case in which transfusion was given after seven 
days, and in which he reported very good results, I 
wonder if perhaps the crisis was not due, and if the 
good results were not due to the crisis. 





Of course, transfusion is very difficult to the ma- 
jority of us, and is not simplified enough for most of 
us to use. It is to be hoped that someone will work 
out a specific method of combating erysipelas like that 
for scarlet fever. The Dochez method for treating 
scarlet fever is very effective. 

Dr. Oliver W. Hill, Knoxville, Tenn—In the early 
part of this year we published in the Archives of Pe- 
diatrics a short paper giving results from thirty-five 
cases in which intraperitoneal injection of blood was 
used. We concluded that with careful, clean technic 
there is no danger. Four cases came to post-mortem. 
In no case was there found any evidence of injury, and 
unabsorbed blood was observed in only one. We used 
the citrated method at first. We were careful to select 
our needles and boil them for half an hour before 
using. I have come to the conclusion that it is not 
necessary to match the blood for intraperitoneal trans- 
fusion or to citrate under normal conditions. We use 
the father’s blood, usually, or that of some close rela- 
tive, which is readily available. 

In cases of dehydration in infants, when you are 
using normal salt solution intraperitoneally and blood 
is indicated,.you can combine the two by this very 
simple technic. Inject the normal salt solution; with- 
draw the amount of blood that you wish to use from 
the donor; disconnect the normal salt solution at the 
needle; inject the blood, and continue the injection of 
normal salt. In that way you give the food value and 
other curative properties of blood and relieve the de- 
hydration at one operation. 

I hope that transfusion will be so simplified as to 
become readily available; not, as Dr. Royster fears, to 
be indiscriminately used for everything, but so that 
we can borrow from the healthy adult his blood, with 
its food values, antibodies and stimulating effect, and 
give it to the little dehydrated or infected infant and 
thus push him over to recovery. 

Dr. Wilbur M. Salter, Anniston, Ala.—Dr. Neff spoke 
of treating streptococcic infection with blood transfu- 
sion. I would like to report two cases of erysipelas 
treated with scarlet fever antitoxin. One was a child 
two years of age, with erysipelas extending from the 
foot to above the knee. The child’s temperature was 
105°, and he was delirious. Five hundred thousand 
skin-test units, or a curative dose, were given. In 
twelve hours there was a normal temperature, followed 
by an uneventful recovery. Another physician told me 
that his mother was desperately ill with erysipelas, her 
temperature 106°, and she was delirious. She was 
sixty-five years of age. On my advice he gave her a 
curative dose of scarlet fever antitoxin on a Friday at 
6 p.m. Saturday morning, twelve hours later, she had 
a normal temperature, and by Monday she was per- 
fectly normal and seemed to be making an uneventful 
recovery. I wonder whether anyone else has treated 
cases with scarlet fever antitoxin, or whether any other 
blood serum would have given the same results. 

I understand that there is on the market an erysipelas 
streptococcic antitoxin, but as the above cases were in 
extremis, and I was unable to get any erysipelas anti- 
toxin, I used the scarlet fever antitoxin. 

Dr. A. S. Root, Raleigh, N. C.—I wish to take issue 
with Dr. Royster, who indicated that blood transfusion 
is in the experimental stage and that we do not know 
whether or not it is effective, though, trusting to our 
memory, we rather think it is. I cannot let that state- 
ment, coming from such a high authority as Dr. Royster, 


a professor at the University of Virginia, go unchal- 
lenged before the Southern Medical Association. Many 
of us know that this procedure is life-saving. 

Dr. Horton Casparis, Nashville, Tenn —We have trans- 

fused a number of patients with septicemia, with sub- 
acute and chronic non-tuberculous pulmonary infections, 
and young infants with erysipelas. I mention these 
three conditions especially because their treatment we 
know has not been satisfactory. Transfusions have 
given us strikingly good results. 

Donors vary markedly in the value of their blood 
against specific conditions. We got this impression on 
several occasions, but specifically we transfused a three 
months old infant with extensive erysipelas and high 
fever from one donor. There was not the slightest 
change. A different donor was selected and a second 
transfusion was given two days later. There was a 
critical disappearance of fever and all symptoms, and 
the erysipelas not only stopped spreading but rapidly 
cleared up. 

As we go further we may find a more intelligent 
method of selecting donors or of fortifying the blood of 
the donors against the specific organism which we are 

Dr. William Weston, Columbia, S. C-—Undoubtedly 
the use of citrated blood has the effect of increasing the 
number of blood platelets. 

Dr. Wilburt C. Davison, Baltimore, Md.—Probably 
no one procedure is of more value than transfusion in 
the treatment of children. In the Harriet Lane Home 
we have done more than two thousand in the last three 
years. Knowing that the procedure is safe and that 
there are many types of cases in which its efficacy has 
been demonstrated, we feel we are too ignorant to say 
that in this or that type of case the condition of the 
child may not be improved. So we give the patient the 
benefit of the doubt and proceed to transfusion. The 
blood of the child and donor, of course, must be 
matched. We have done a few intraperitoneal transfu- 
sions, but these children have usually had vomiting, 
distention, and sometimes a sharp rise of temperature, 
especially those who were dehydrated from diarrhea, 
whereas with the intravenous method, except in two 
patients who had hematuria and sharp rise of tempera- 
ture, our other reactions have not exceeded twenty. We 
use citrated blood, but it is possible that direct trans- 
fusions may be more valuable. 

Dr. Bruce made a valuable suggestion that the trans- 
fusion must be given early. We have given transfusions 
in a number of cases of pneumonia, both primary and 
secondary. Usually at least one of every three patients 
is benefited, but clinically we cannot distinguish the two 
patients whose course may not be affected from the 
third child of the three whose condition will improve. 

The first man to demonstrate the value of trans- 
fusions in the treatment of erysipelas was Bruce Robert- 
son, of Toronto. He felt that it would be a rational 
procedure to exsanguinate the patient: remove the blood, 
and to replace it with normal blood. We have not ex- 
sanguinated our patients but have transfused them, and 
our present mortality in infants under two years of age 
is 21 per cent, whereas formerly our mortality was 47 
per cent. As a routine now in children suffering from 
erysipelas, we give a large dose of Amoss’s anti-strepto- 
coccal serum and then as an extra safeguard transfuse 
the patients. In adults the mortality from many in- 
fections is very low, whereas in children there is a very 
high mortality. Probably adults develop immunity and 

PTE ET Le pe eT ee otmap owe 

— = 

Vol. XX No.7 

as a result their blood gives children the power to com- 
bat infection. 

Dr. Casparis emphasized an important point, namely: 
that if a transfusion has not benefited a patient we 
should not regard the procedure as hopeless, for the 
blood of the donor may not have contained sufficient 
antibodies. We have sometimes found after a trans- 
fusion which has not been of value that a second or 
third transfusion with blood from a different donor may 
cause an improvement in the patient’s condition. 

Dr. Joseph Yampolsky, Atlanta, Ga—lIt is a natural 
thing that when a method is being popularized there is 
a mad rush to use it in every disease possible. It is 
also possible that, due to the development of the intra- 
peritoneal method, transfusion has become more popular. 
Before the intraperitoneal method was used, very few 
men dared to give transfusion directly. However, meth- 
ods which are popular are not always useful in tr~ 
hands of every member of our profession. Do not 
think that because we know transfusion is useful every- 
one is able to do it. We are not attempting to pop- 
ularize this method because we want everyone to use 
it, but because it is life-saving and can be used by 
those men who are able to use life-saving methods. 
These men will after a time teach us when transfusion 
is useful and when it is not. 

Dr. Bruce (closing).—During the past summer in 
Louisville we have for some unknown reason had more 
cases of ileocolitis or dysentery than we had had for 
many years before. Probably something has been 
wrong with the milk. With these cases of ileocolitis we 
have had the opportunity to use transfusion a great 
deal, and it was remarkable to see the babies who had 
been going gradually downhill, with loss of weight and 
strength, in a few days after transfusion improve. 

I wish to agree with Dr. Casparis that different donors 
give different effects, depending, of course, upon whether 
the particular donor has antibodies to combat what you 
are trying to combat. A number of observers have 
advocated giving a dose of vaccine to the donor to pro- 
duce antibodies before transfusing, but the difficulty is 
that it takes considerable time to develop antibodies. 

Dr. Neff (closing).—Dr. Salter spoke of using scarlet 
fever serum. Not only has convalescent human serum 
been used in infections with scarlet fever but also nor- 
mal blood and immune blood from adults; and if I 
could not get some more or less specific blood or serum 
to use, I should certainly think that immune blood 
would be of some value. 


By Wa. THorNWALL Davis, M.D., 
Washington, D. C. 

Uveitis should be considered as a symptom, a 
local inflammation of the uveal tract which re- 
sults from systemic disease. To look upon this 
most serious malady of the eye as a local dis- 
ease is a grave error. 


*Read in Section on Eye, Ear, Nose and Throat, 
Southern Medical Association, Twentieth Annuai 
Meeting, Atlanta, Georgia, November 15-18, 1926. 


The usual course of an unchecked uveitis is a 
chronic one with.acute exacerbations lasting over 
a long period of time with ultimate loss of vision 
and destruction of the globe. Briefly, the 
pathological condition consists of inflammatory 
changes in the iris, ciliary body, and chorioid, 
more particularly the ciliary body. The changes 
are those of a simple inflammation with round 
cell infiltration and plastic exudation. To the 
latter most of the destructive effects of the dis- 
ease are due. The plastic exudate glues the iris 
to the lens and may completely fill the posterior 
chamber, causing a complete posterior annular 
synechia. The crystalline lens may lie in an 
envelope of this plastic material. The vitreous 
body becomes cloudy with masses of it. This 
exudate undergoes organization and is trans- 
formed into sclerotic tissue which undergoes con- 
traction. The contraction then draws the iris 
back against the lens until the rotundity of the 
latter may be clearly outlined in the anterior 
chamber. The ciliary body is drawn from its bed 
as may be the retina and chorioid. 

Early in the disease there is a change in the 
character of the aqueous, the nutrient fluid of 
the eye, so that the nutrition of the globe begins 
to suffer. Likewise the filtration of the aqueous 
becomes interfered with, due to its altered char- 
acter and the partial occlusion of the filtration 
angle and later to the total posterior synechia. 
Iris bombe may result. 

Secondary glaucoma occurs, the attacks of high 
intra-ocular tension alternating with hypotony 
of the globe. Due to the above named changes, 
the vision slowly sinks; attacks of high tension 
and acute exacerbations of the disease cause 
great suffering and depletion of the strength of 
the patient. The globe slowly shrinks and com- 
plete detachment of the retina occurs. The lens 
may be dislocated and absorbed and the pupil 
completely occluded by the cyclitic membrane. 
A blind and often painful eye closes one of the 
most melancholy spectacles that presents itself 
to the ophthalmologist. 

We do not refer in this report to traumatic 
cases but only to those cases resulting from sys- 
temic disease or focal infection resulting in tox- 
emia. The affinity of the uveal tissue for these 
toxins results in the beginning of the disease. 
There is no more difficult problem confronting 
the ophthalmologist than the treatment of this 
affliction. It is absolutely essential to have 
within one’s reach a competent internist who 
will co-operate with interest and energy. 
Many of these cases elude our most exhaustive 


study and pursue their melancholy course in 
spite of everything we can do. - 

One should not forget that in the so-called 
cured cases, relapses are the rule, and even 
should these not occur, the nutrition of the eye 
has suffered. The ciliary body, the secreting 
gland of the eye, has been damaged and later in 
life glaucoma may occur, or more probably 
cataract. I am of the opinion that many cases 
of apparent glaucoma simplex and presenile and 
senile cataracts are due to previous attacks of 
uveitis which have perhaps been so mild as to 
be overlooked or mistaken for a conjunctivitis. 
We should be suspicious of recurring attacks of 
presumable conjunctivitis without apparent 
cause. The slit lamp should clear the diagnosis. 

The cases will be grouped as to etiology and 
only a few of the more instructive ones will be 
given in detail. I confine myself to the ocular 
symptoms. Dr. Clark, who has so efficiently and 
faithfully studied these cases, will report on the 
etiological factors. 

Thirty-five cases are grouped, according to 
etiology, as follows: 

Tonsils and intestinal 
Pulmonary tuberculosis 
Teeth and tonsils 
Chemical burn 
Uterin fibroids (?) .. 

Dental infection 6 
Tomiar infettion i220! 220s 6 
Mea ees * 2 ie le 1 
Undetermined ....................---- 6 
Cardiovascular disease 1 
Gall bladder disease 2 
Diplobacillus corneal ulcer ................-------------- 1 
Intestinal toxemia 2 
Senility 4 
Syphilis ..... 1 

Case 1—E. K., a white woman, age 47, was first seen” 

November 30, 1925, with chronic uveitis of both eyes. 
The right eye showed one posterior synechia. The 
fundus was seen through a very thick haze. The slit 
lamp showed numerous mutton fat deposits on the 
posterior corneal surface. The aqueous and lens rays 
were greatly intensified. Cyclitic deposits on the pos- 
terior corneal surface were in the retrogressive stage. 
There -was almost complete seclusio pupillae, and proba- 
bly cataractous changes in the lens. The fundus was 
scarcely visible. V. O. D. 20/40, and V. O. S. 20/70, 
not improved with glasses. Blind spots normal; visual 
fields normal. T. 15 mm. Hg. (Schiotz) each. 

She has been under treatment now for eleven months. 
The local treatment has been atropin until intolerance 
for the drug appeared some months ago, when scopol- 
amine was substituted; hot fomentations, sweats with 
and without pilocarpin, salicylate of soda, mercury by 
inunction, and leeching of the temples. 

The right eye has been subject to acute exacerbations 


July 1927 

with ciliary congestion, pain and increase in the cyclitic 
deposits, together with reduction in vision. She was in 
the hospital for many weeks at different intervals, and 
in a nursing home for some time, all without the slight- 
est effect on the eye. 

The left eye has remained in statu quo with no acute 
exacerbations. Lately x-ray has been used on this 
eye locally. There may be some improvement in the 
vision; it is too early yet to be sure. I am aware of 
no treatment that has been omitted in her case; but 
all alike have been without avail. We had great hopes 
of cure when the gall bladder was found diseased and 
removed in March, 1926. The diagnosis of this condi- 
tion was a brilliant one, as the patient had been studied 
carefully before she came into our hands and nothing 
had been found. The state of the case at this time is 
very melancholy indeed. Both eyes show steadily pro- 
gressing destruction. 

Case 2.—M. B., a white female, age 52, was first seen 
December 15, 1925. She had been suffering with her 
eyes for twenty months, during which period there had 
been acute exacerbations with steadily declining vision. 
She was treated in the Naval General Hospital and the 
Walter Reed Hospital, remaining in the latter for sev- 
eral months. This patient frankly gave a history of 
alcoholism of a severe type, which was under control. 
Examination showed V.O.D. 15/200, and V.OS. 10/200. 

Both eyes showed almost complete posterior synechiae, 
cyclitic deposits on the back of the corneae, and a very 
hazy fundus scarcely discernible. The slit lamp showed 
innumerable deposits on the posterior corneal surface, 
increased aqueous and lenticular rays, together with 
granules in the aqueous and anterior layers of the 
vitreous body. She was unable to use atropin, as it 
caused nausea. She was put on scopolamine 0.25 per 
cent and salicylates with hot applieations and referred 
for study. Several points in her history might be 
stressed here. 

The father became insane before death. The mother 
died of progressive spinal paralysis. She had had three 
miscarriages during her life. She had suffered from 
chronic constipation. She was always well until five 
years before when she had influenza and pneumonia 
and was ill a year. There was a confused history of 
domestic infelicity and of alcoholism over a period of 
ten years. She had not indulged herself for eight years. 

She was operated upon by Keller, of Walter Reed 
Hospital, about February 5, 1926, and many gall stones 
with a “strawberry” gall bladder wére found. In the 
interim between the time I first saw her and the oper- 
ation, there were acute exacerbations with rise in 
tension, ciliary congestion, pain and increased exudate. 

On March 9 she was seen at the office; there had been 
no subjective ocular symptoms. V.O.D. 20/200, and 
V.O.S. 20/200 were observed. 

There were no cyclitic spots on the corneae, or any 
evidence of acute inflammation. She was put on sub- 
conjunctival injections of normal salt solution. On 
March 23 her vision had risen to 20/30-+-2, and 20/70 
with correction. The eyes have remained quiet. On 
October 19, 1926, the vision was 20/50 and 20/200. 
This decrease in vision, I think, is due to cataractous 
changes in the lenses resulting from the nutritive changes 
in the eyes. I believe this is a case of cured malignant 

Case 3—Mrs. W. J. White, age 33, was seen January 
25, 1926. She complained of dimming vision during 
the preceding month, with no other symptoms. Ex- 





 -=— + SS OO mes 

Vol. XX No. 7 

amination showed slight ciliary congestion. The irides 
were a little dimmed, pupils slightly dilated and slug- 
gish to light reaction, and the corneae showed many 
cyclitic deposits. The left eye was worse. V.O.D. 
20/15, and V.O.S. 20/30 were found. 

The slit lamp showed numerous granules in the 
aqueous in both eyes, with fibrin deposits of ciliary 
origin on the front of the lens and iris. Tension was 
normal in each eye. She was put on atropin, hot ap- 
plications and rest with dark glasses, and referred for 
study to the attending surgeon of the Army. This study 
was negative. The sinuses were negative. On March 
11 she was put on a course of milk injections without 
benefit. In fact, both eyes were growing worse. In 
April the left fundus showed two retinal hemorrhages, 
one near the macular and one near the disc. 

In May, following study by Dr. Clark, she was put 
on tuberculin and been on this treatment alone, 
with rigid dietary and hygienic measures, which she has 
carried out in the most wonderful way. At one time 
after a dose of 8 minims of tuberculin (O. T.) she had 
a distinct focal reaction consisting of slight ciliary con- 
gestion, with very little increase in the corneal deposits. 
We considered this focal reaction to be sufficient to 
establish fully the diagnosis. 

On October 4 the right eye was completely well. The 
left showed four cyclitic deposits. There are no symp- 
toms. Local treatment has been discontinued, and she 
is getting tuberculin. We consider this case cured, and 
as it was gotten in time, without damage to the eye. 
Only future years will tell if there has, or has not, been 
sufficient injury to the ciliary body to cause some far- 
reaching effect such as cataracts or glaucoma. 

Case 4—J. S. H., a white man, age 17, was a clerk 
for the Southern Railroad. He was seen first June 30, 
1923, with hypermetropia with astigmatism; eso- 
phoria, 5° for near and 9° for distance. His eyes were 
otherwise normal. On May 18, 1925, he complained of 
blurred vision in the right eye. There was found a 
well developed uveitis with cyclitic deposits on Decemet’s 
membrane. The slit lamp showed golden yellow gran- 
ules in the aqueous, also very marked in the vitreous. 
A thorough medical survey showed only infected tonsils. 
After removal of these, the eye slowly cleared. There 
was increase of tension on several occasions, which 
promptly yielded to pilocarpin. The eye was white 
and normal and the patient discharged December 1, 
1925. On March 8, 1926, he complained that the eye 
felt scratchy and there was encanthis. On March 11 
the left pupil was slightly dilated; there was very slight 
discoloration of the iris, with a few cyclitic deposits on 
the cornea, and brown granules in the aqueous, as 
shown by the slit lamp study. The tension by Schiotz 
was 40 mm. of mercury, which promptly was reduced 
to 18 by pilocarpin 1 per cent solution every three 
hours. The tension remained down after atropin was 
begun. He was placed in a sanitorium for study. The 
uveitis developed into a very severe and ominous condi- 
tion with much exudate into the vitreous, large and 
numerous fibrinous deposits on Decemet’s membrane, 
iris and anterior capsule of the lens, and great discolora- 
tion of the iris. The globe became very soft. Hot 
packs and leeches to the temple, inunctions of mercurial 
ointment and salicylates by Gifford’s method, together 
with local treatment had little effect upon the eye. It 
was apparently a malignant form of uveitis. The vision 
was reduced to light perception. Here is the remarkable 
aspect of the case. After leaving the sanitorium he de- 


veloped suddenly a lobar pneumonia, which was thought 
to -be tuberculous. This cleared up, however, quite 
promptly, and the uveitis with it. The eye rapidly re- 
turned to normal and has remained well since. 

Case 5—Mrs. A. S. G., white, age 59 years, was seen 
first January 2, 1923. She gave a history of recurrent 
attacks of redness and pain in both eyes over a period 
of years. No cause had been found. 

Examination showed uveitis of both eyes with typical 
symptoms. She suffered severe pain and was greatly re- 
duced in strength thereby. The fundi could not be 
seen. She was placed in the hospital for study. There 
was well marked tuberculosis of both lungs. The 
uveitis slowly cleared and examination of the fundus 
then showed disseminated chorioiditis, macular changes 
and dust-like particles in the vitreous in prodigious 
numbers. Vision at first examination was 10/200 with 
correction. It finally came up to 20/200 each eye. The 
eyes never cleared but remained in a state of low grade 
uveal inflammation until the patient died of tuber- 
culosis after two years. 

The two following cases illustrate how intract- 
able is the uveitis which follows chemical burns. 
Both were caused by strong alkalis. 

D. H., age 5, had had lye thrown in the face. The 
left eye was involved. He was seen forty-eight hours 
after the accident. The cornea was slightly hazy, and 
there was mild ciliary congestion with but little pain. 
There was a beginning symblepheron of the lower lid. 
The eye became quiet. He was seen again in six weeks 
with a uveitic eye, great pain and vision reduced to 
fingers at three feet. The case relapsed into a severe 
chronic uveitis with periods of increased tension. The 
cornea became vascularized and then sclerosed. The 
uveitis lessened, but the eye remained soft with acute 
exacerbations of pain. Enucleation was necessary. 

The second case, J. Mc.C. White, age 64, got lime 
sulphur in the right eye while spraying trees a month 
before. There was a burn and ulceration of the lower 
part of the cornea and adjacent conjunctiva with uveitis 
and severe pain. This case ran the same course as the 
above with acute exacerbations, vascularization fol- 
lowed by sclerosis of the cornea, soft, painful 
and blind eye. He was under observation for eighteen 
months and enucleation was recommended. This week 
he died of pneumonia, the old man’s friend, the end no 
doubt hastened by the long suffering with his eye. 

Case 7—J. D. H., a white man of 55, complained of 
blurred vision in the left eye for about two weeks. The 
condition occurred at intervals and cleared usually after 
dinner. Examination showed only a deep haziness in 
the cornea which appeared and disappeared in a few 
minutes. The anterior chamber was deeper than its 
fellow, and there was slight ciliary congestion. The 
pupils were normal, blind spots normal, and vision 
20/30. There were intervals of increased tension. Med- 
ical survey was negative. He was a hard working man, 
who took but little exercise and ate unwisely. This 
had been going on for many years. Under a proper 
regimen of exercise and diet, he improved, but drifted 
away after three months of observation. This case was 
interesting in the unusual symptoms. Edema of the 
cornea exactly resembled that due to increased tension. 
The fields and fundus were normal. The increase of 
tension occasionally occurring bore no relation to the 
corneal edema. 


He was an unsatisfactory patient and did not co- 
operate. The condition was undoubtedly of intestinal 

Case 8—Mrs. B. B. was first seen July 16, 1917. 
There was a history of tonsillitis some time before, 
since which time she had been suffering with a severe 
case of erythema nodosum. Shortly before I saw her 
she complained of blurring of the vision. 

Examination of the eyes showed a posterior uveitis. 
There was vitreous haze with retinal edema and con- 
gestion of the retinal vessels, with exudate on the disc, 
moderate in amount. There was ciliary congestion, 
tenderness of the globe and a sluggish iris. I have no 
doubt the slit lamp would have shown cyclitic exudate 
on the cornea. 

The interesting point in conjunction with the case is 
the complicating erythema nodosum. This was, no 
doubt, due to toxic absorption from the tonsils. The 
vision was 20/100 and 20/20 in the right and left eye, 
respectively. She left with her husband, an officer of 
the Army, on December 6 for the Pacific Coast. The 
vision was 20/20 each eye, with still some retinal con- 
gestion. Treatment was eliminative with hot packs, 
and attention to diet and hygiene. 

Case 9—V. R. J., a white woman, was refracted in 
November, 1923. The eyes were normal, with moderate 
hypermetropic astigmatism. In March, 1926, she pre- 
sented herself complaining of pain and blurring in the 
right eye. The pupil was moderately dilated and oval, 
with long axis vertical. There were cyclitic spots on 
the back of the cornea, with moderate ciliary conges- 
tion; media hazy, retinal vessels and disc somewhat 
congested.. Tension in the right eye was 46 and left 
eye 25 mm. of mercury (Schiotz) which was reduced 
to 43 in the right eye by dilating with eupthalmine. 
She was hospitalized with the usual treatment; hot 
packs, leeches to the temple, salicylates and mercurial 
inunctions, pilocarpin nitrate solution gr. 2 3 1 every 
four hours, together with hot fomentations for the 
right eye. 

The tonsils were infected and were promptly re- 
moved. Now comes the interesting aspect of this case. 
The uveitis cleared completely within three weeks and 
the case then presented a typical picture of glaucoma 
simplex. There was cupping of the disc of three diop- 
ters with moderate paleness. Tension remained between 
27 and 35 and the visual fields showed contractions 
with a paracentral scotoma. At this stage, should one 
have seen this case for the first time, there was not a 
single symptom to show that it was a secondary glau- 
coma. The tension returned to normal, the fields as- 
sumed their normal contour, and the vision returned to 
normal. The cupping of the disc remained. She was 
seen a few months ago for change of glasses and the 
eye was, and had remained, normal. 

To me the valuable lesson learned in this case was 
to be very careful with apparent glaucoma simplex and 
not operate too quickly. 

927 Farragut Square 

Discussion follows paper of Dr. Clarke, page 530. 


July 1927 


By Wm. Ear.e CriarkE, M.D., 
Washington, D. C. 

Among the most interesting cases that have 
been sent to our clinic for study have been 
those just reported by Dr. Davis. When Dr. 
Davis is planning to refer us a case he asks one 
of us over to his office so that he can get per- 
sonal contact and better understanding of the 
problem than if he referred the patient by phone 
or with a note. 

The large percentage of cases seem to be due 
to focal infection. Although some had gall blad- 
der disease, one renal disease, two intestinal 
toxemia, it seems probable that most of the 
trouble originated in diseased sinuses or tonsils 
or roots of teeth. Secondary foci were later set 
up, as bacteria were carried by the blood stream 
to the gall bladder or other organs. 

There seems to be even at this time some con- 
fusion and doubt about the relationship of focal 
infection to systemic disease. Kolmer in a re- 
cent atticle states that 80 to 90 per cent of all 
deaths are due to infection and that the acute 
specific infections account for only a small pro- 
portion of this number. Every year it is more 
firmly established that toxins from areas of focal 
infection, or bacteria themselves, are carried to 
distant tissues and set up inflammatory changes. 

The streptococcus is the most important and 
frequent offender, followed in order by staphylo- 
coccus, pneumococcus, gonococcus, and finally 
the colon bacillus. Tubercle bacilli even in a 
small apparently quiescent focus will set up 
changes in body tissues, especially in the uveal 
tract of the eye. Most observers feel that the 
inflammatory eye changes are due to toxins 
rather than to bacteria themselves. Kolmer sug- 
gests that this can be determined if the ophthal- 
mologists will save the bits of iris removed dur- 
ing iridectomy and culture them in hormone 
glucose broth. 

Dr. Davis is sure that in cases of uveitis as- 
sociated with a tuberculous-focus the eye condi- 
tion is caused by the toxin rather than by the 
tubercule bacilli themselves; since when the 
organism actually settles in the eye and sets up 
disease the picture is very different from what 
one sees in uveitis. 

*Read in Section on Eye, Ear, Nose and Throat, 
Southern Medical Association, Twentieth Annual 
Meeting, Atlanta, Georgia, November 15-18, 1926. 












Vol. XX No. 7 

Pemberton, without minimizing the impor- 
tance of focal infection in arthritis, speaks of 
other factors, such as exposure, overeating, and 
menopause, that play an etiological part in the 
production and perpetuation of this disease. It 
may be that some of these operate with focal 
infection in the causation of serious inflamma- 
tory conditions of the eye. 

In the search for the underlying condition that 
is causing uveitis one cannot too strongly em- 
phasize the need of a most careful diagnostic 
study, beginning with a painstaking history. 

Physical examination should include the teeth, 
tonsils, nasopharynx and sinuses. Any suspi- 
cious change of physical signs in the chest is 

-noted. Muscular resistance over the gall blad- 

der area or appendix may give one a clue. An 
infected prostate is often overlooked. If the 
patient gives a history of Neisserian infection 
in the past, or if there is nocturia or urinary 
frequency the prostate and seminal vesicles 
should be investigated by a specialist in genito- 
urinary work. Even if the prostate feels normal 
on rectal examination this may be necessary. 
Two or three strippings are sometimes required 
before this area can be excluded. In women it 
is not only important to exclude tubal or ovarian 
disease, but to be sure there is no infection in 
the cervix. Pyelitis or other perirenal infection 
may be suggested by the finding of an enlarged 
palpable tender kidney or marked tenderness 
and muscular rigidity in the kidney region. 

Laboratory study of the blood, including a 
Wassermann examination, is made. The urine 
and feces are studied. Gastric analysis and a 
study of the bile by Lyon-Meltzer drainage are 
made if the history indicates the possibility of 
liver, gall bladder or gastro-intestinal disease. 
Blood chemistry will occasionally give one im- 
portant evidence as will the ’phthalein test for 
kidney function. 

The patient is sent to the x-ray laboratory. 
The very best technic is needed to get good 
films or plates from different angles, and inter- 
pretation of the films or plates must be made 
by a competent person. The teeth are carefully 
x-rayed, then the sinuses, especially the deeper 
ethmoid and sphenoids, are studied. If one 
Suspects the chest, it is fluoroscoped and stereo- 
scopic films are made. Infected lymph nodes 
may be demonstrated at the hilus or root of the 
lung. Tuberculous involvement often occurs as 
is well known during childhood. If the level of 
general health is brought up, the lesion may be 


quiescent for years, to light up again if the 
patient’s resistance is lowered. A tuberculous 
focus in a gland or glands has been called the 
most typical focus of infection. 

X-ray of the gastro-intestinal tract is indi- 
cated in most cases. Frequently the motility 
of the stomach with spasm of the pyloric region 
or duodenal cap suggests diseases of the gall 
bladder or appendix. X-ray also gives us val- 
uable information in regard to intestinal motility, 
stasis or rarer foci such as diverticulitis of the 

We are not sure how important a part in- 
testinal stasis and absorption play in the causa- 
tion of disease processes in the body, but there 
is frequent clinical evidence suggesting toxemia 
in patients who eat too heavily of rich foods 
and at the same time have poor bowel elimina- 
tion. In two cases of the series we could find 
no other explanation of the toxic condition of 
the eyes. Careful planning of the diet and the 
correction of the colonic stasis seemed to lessen 
the metabolic load and enable them to throw off 
the condition. 

Finally, if all other clinical investigations and 
laboratory studies have been made and ope is 
still unable to determine the cause of the uveal 
tract inflammation, the cutaneous tuberculin test 
is made. Both the test and treatment of the 
case, if the test is positive, require.judgment and 
care. When the test is positive, there is not 
only the characteristic reaction at the site of 
the injection into the skin but a focal reaction 
in the eye. 

Case 1—Mrs. E. M. K., age 48, a housewife, had a 
past history of scarlet fever, rheumatic fever and ma- 
laria. She had had one healthy child and one mis- 
carriage. She had nephritis while pregnant. x 

She considered herself healthy until three years be- 
fore. Gradually at this time she began to feel below 
par. Everything became an effort on account of a 
chronic sense of fatigue. She also became conscious 
of numbness of the arms and other vague sensory dis- 
turbances. About this time she began to have dimness 
of vision so that she could not attend to her sewing. 
An ophthalmologist diagnosed uveitis and the search for 
the cause was instituted. She had the following oper- 

Operation on ethmoids and sphenoids three years 

The left antrum was drained two and a half years 

Tonsillectomy was performed three weeks after the 
antrum drainage. 

The right antrum was drained three months pre- 

Her chief complaints when Dr. Davis referred her to us 
this past March were: recurring inflammation of both 
eyes with dimness of vision; lack of reserve strength 
and chronic fatigue; recurring ‘attacks of gaseous in- 


digestion, with epigastric pain referred into the chest 
and back. 

She stated that the eye condition had improved after 
the above operations, especially after the removal of 
the tonsils, which were buried and contained pus. For 
a time she thought her eyes were well. Then about 
four months before we saw her the eye condition 
lighted up again. The attacks of epigastric pain with 
gaseous indigestion and belching sounded like gall blad- 
der attacks, although she had never required a hypo- 
dermic for one. Raw apple and fried and greasy foods 
disagreed with her, and this fitted in with a diagnosis 
of cholecystitis. The eyes always seemed worse if she 
indulged in much sugar. 

The only points worth noting in a careful physical 
examination were a few darkened suspicious teeth; a 
small tag of tonsil tissue on the right side; some tender- 
ness when an attempt was made to palpate the right 
kidney; and a cervix that was a little red and swollen. 

Gastric analysis, blood examination, urine and stool 
examinations were all negative. 

X-ray of the gastro-intestinal tract was negative, ex- 
cept for the observation of pylorospasm and a streaky 
distribution of barium in the colon, which suggested 

X-rays of her teeth were negative. 

One of our leading nose and throat men reported 
that she was free from any definite focus of infection 
in sinuses or throat. 

The Graham test suggested a pathological condition 
in the gall bladder. 

Operation—Cholecystectomy and appendectomy were 
done. A pale thickened gall bladder with stones and a 
white fibrous cord of an appendix were removed. 

Three weeks later Dr. Davis reported that he was 
very much encouraged over her eye condition, which 
had been quiescent since the operation. She could see 
very well with the right eye, which was the last one 
to become involved. There had been some improvement 
of the left eye, but not so much. 

A month later the patient came in again, reporting a 
recurrence of the uveitis. We gave her a number of 
biliary drainages on the theory that there might have 
been some residue of liver damage. Again the eyes im- 
proved for a period of weeks, but recently, as Dr. Davis 
has stated, there has been a recurrence of this devastat- 
ing eye inflammation. 

We shall consider again: 

The cervix. 

Lues. She has had one miscarriage. 

Intestines. Her bowels moved perfectly normally. 

Tuberculosis. Our next step. 

Sinus infection or tonsil stump. Check again. 

Organisms in the tissues of the eye itself as happens 
in some arthritis cases. 

Mrs. E. L. B. was a housewife of 52 years. The 
principal points in her past history were that she had 
frequent attacks of tonsillitis and bronchitis. Frail and 
undernourished as a child, she grew stronger as she 
reached womanhood and felt she was as well as the 
average woman. She married an army officer and, like 
most people in the service, moved about from place to 
place and went out a great deal socially, and became 
very tired and run-down at times. 

In May, 1921, while in a run-down condition, she 
developed bronchopneumonia. Convalescence was long 


July 1927 

and tedious and she had never been up to her normal 
level of health since. 

The onset of the inflammatory condition of her eyes 
was sudden. At least, she remembered almost to the 
hour when she became conscious of it. In April, 1923, 
after stepping out of her car into the sunlight she was 
seized with agonizing pain in her left eye. Soon the 
condition improved, but after a month recurred. In 
June of the same year the nature of the trouble was 
discovered, and like Case 1 she had a series of oper- 
ations with the idea of eliminating all infection from 
the body. Five teeth with abscessed roots were re- 
moved. There was a tonsillectomy, hysterectomy and 

The uveitis continued to recur and vision in her 
eyes became worse and worse. She was under observa- 
tion-at the Walter Reed Hospital from November, 1924, 
to March, 1925, and nothing was found to stop the 
progress of the disease. 

Dr. Davis referred her to our clinic December 23, 
1925. Her only complaint in addition to the eye symp- 
toms was a gaseous indigestion, with epigastric weight 
and pressure. There was excessive belching, and she 
was much annoyed with flatulence. 

Physical examination was negative, except for a 
moderately distended abdomen and tenderness under 
the right costal border. 

The studies of her blood, urine and stool were nega- 
tive. Her Wassermann was negative. X-ray showed 
marked hypertonicity of the stomach with pylorospasm. 
The duodenal cap filled irregularly and with difficulty, 
giving us the impression of an abnormality in this region. 

The Graham test pointed to gall bladder disease. 

A short time later Colonel Keller operated at Walter 
Reed Hospital and removed a strawberry gall bladder 
containing several stones. There were enlarged glands 
down along the cystic and common ducts and the liver 
adjacent to the gall bladder showed a pale fibrosed area. 

The patient had an uneventful convalescence. One 
day shortly before she was to leave the hospital one of 
the Red Cross girls came through the hospital with 
magazines. The patient asked for one meaning to look 
at the pictures. To her surprise she was able to read 
much of the print, a thing that had been impossible for 
weeks or months before. 

As Dr. Davis stated in his report, this patient has 
had no further recurrences, although nearly a year has 
passed. She has apparently been cured of the uveal 
tract inflammation, though, of course, there has been 
some permanent damage to the eye that causes haziness 
of vision. 

In reviewing this case it looks as though the abscessed 
teeth, infected tonsils and frequent upper respiratory 
tract infections had been the original foci. The broncho- 
pneumonia lowered her resistance and the eye condi- 
tion resulted. The gall bladder disease must have re- 
sulted from the original foci. Finding one or two foci 
and clearing them up does not free the patient of in- 
fection. The more unusual areas must be kept in mind 
and excluded if one hopes to clear up inflammation of 
the uveal tract. 

Mrs. W. A. J. was a housewife, age 33. She was 
referred by Dr. W. T. Davis to locate a focus of infec- 
tion which might be causing her eye trouble. Dr. Davis 
stated that she had a low grade uveitis involving the 
optic nerve, ciliary body, and other structures of the 
eye. The condition, he said, was much like some of 
the other cases he had sent us, except that it was in- 




Se el el ed 

bit cet a ee i ed 

Vol. XX No. 7 

cipient and had not progressed far enough to damage 
the eye. 

The patient’s family history is unimportant. 

The one thing in her past history worthy of note was 
that following the measles she had acute rheumatic 
fever which involved mostly the knees and ankles, and 
she was unable to walk for several months. She did 
not remember having had much trouble from tonsillitis, 
abscessed ears or sinuses, but thought that she was un- 
usually subject to colds. She had an attack of acute 
nephritis when she was eleven or twelve years of age, 
and a severe attack of pneumonia. 

She was the wife of an army officer. She had one 
child living and well. She apparently lived a simple 
wholesome life. In the past she had ridden horseback 
a great deal, but for five or six months previous to her 
coming to us had had practically no exercise in the 
open. She thought she might have gone out too much 
socially to bridge parties, dances, etc. 

In describing her present illness, she stated that about 
December, 1925, she became conscious of her eyes. They 
seemed to ache so that she felt disinclined to read or use 
them for any very close work like sewing. About 
Christmas her family called it to her attention that her 
eyes were red, and she then began to realize that she 
had a little dimness of vision of the left eye. About 
this time she became conscious of feeling somewhat 
below her normal level of health in a general way. 
She seemed to lack her usual reserve energy and enthu- 
siasm. She felt tired much of the time, with backache, 
and had a marked tendency to drowsiness. She tried 
to convince herself it was laziness and by dint of will- 
power to drive herself. She seemed to have a very 
healthy horror of neurasthenia and resented being ill 
in any way. She applied to the Army Dispensary for 
treatment, and they gave her some drops to use locally 
which did not help. Two weeks later, not getting any 
better she consulted Dr. W. T. Davis, who found a 
low grade uveitis and sent her to us for study. 

As a result of study we made a working diagnosis 
of: undernutrition, chronic constipation, tonsil infection, 
and slight infection of the uterin cervix. 

We referred her to Dr. W. B. Mason to check on her 
throat. He reported that she had small buried tonsils 
containing pus. On pressure one obtained a sour smell- 
ing, milky secretion. He took a culture and the pre- 
dominating organism.was Streptococcus hemolyticus. 
The patient had her tonsils removed a few days later. 
Dr. Davis observed some improvements in her eyes 
after the tonsillectomy. Then the process lighted up 
again, though it was not so bad as at first. 

There was an absence of hydrochloric acid in her 
gastric contents, and she had recurring nausea and 
gaseous indigestion. The possibility of another mild 
low grade cholecystitis was considered, but the Graham 
test was negative. We did everything we could to bring 
up the general level of her health, and succeeded in im- 
preving it, but the uveitis did not clear up. On April 
27 Dr. Davis noted that her eyes were not improved. 
Recently they had been a little worse, showing a slight 
hemorrhage into the retina. Dr. Davis was trying to 
increase her resistance by giving her 3 c.c. of milk 
hypodermically. If she failed to respond to protein in- 
jections, I planned to have stereoscopic plates made of 
= chest and to give her an_intracutaneous tuberculin 

_ There was no improvement from the protein injec- 
tions and the x-ray report of her chest showed a num- 


ber of calcified nodules (at both hila) and there was 
evidence of the presence of caseous glands and of in- 
filtration. The condition did not seem to extend into 
the parenchyma of the lungs. It could not be stated 
certainly that the condition was tuberculous. The in- 
tracutaneous tuberculin test was positive, and Dr. Cabel 
Moore was to give her tuberculin injections. 

Within six weeks or two months her uveitis had im- 
proved remarkably and she was practically well. Two 
weeks ago the uveitis seemed practically cured. Dr. 
Davis told her that there was still a little blurring of 
the left eye and that she. would have to be careful for 
the next six months. Her appetite, digestion and bowels 
are normal. She is weighing one hundred and twenty- 
eight pounds, which is nearly ten pounds more than 
when she came to us. She walks two or three miles a 
day without fatigue. She sleeps well at night and has a 
general sense of well-being. 

The uveitis in this case was probably due in part to 
the tonsil infection and in part to an acid-fast glandular 
infection of her chest. There was quite a definite im- 
provement for a time after the tonsil operation, then 
the trouble lighted up again. Dr. Cabel Moore has 
worked with Dr. Wilmer for years and has had a num- 
ber of cases like this. Whenever a case fails to improve 
after the usual sites of focal infection have been cleared 
up, one should consider the possibility of a lategt acid- 
fast infection. 

Mr. G. E. N., a bank clerk, 19 years old, was re- 
ferred to us by Dr. Sawyer, Dr. Davis’ associate, with 
the following note: “This patient has a severe case of 
uveitis involving the left eye. He has been gone over 
by a physician and his tonsils have been removed. 
X-ray of his teeth by Drs. Groover, Christie and Mer- 
ritt is negative. Evidently we have not arrived at the 
focus of infection. I am referring him to you to see if 
you can find the cause.” 

The patient stated that the eye trouble had been 
present two months. His tonsils were removed five 
weeks previously. He had had no symptoms which 
could be related to his heart, lungs or kidneys. His 
digestion had always been good. His bowel elimination 
was normal. He gave no history and there was no in- 
dication of venereal trouble. His father was living and 
well at the age of forty-one, his mother living and well 
at the age of thirty-eight. He was an only child. 

Upon physical examination, most of the superficial 
lymph nodes were plainly palpable. The x-ray study 
was negative, except for an ileac stasis. At first we were 
inclined to think that perhaps the ileac stasis might 
through intestinal absorption be causing the eye condi- 
tion. We gave him acidophilus milk and milk of 
magnesia to keep peristalsis in the small intestines very 
active, but no improvement in the condition of the eyes 
was apparent. After he had failed to improve in rea- 
sonable time on this treatment we referred him to Dr. 
Cabell Moore for a tuberculin test. Dr. Moore found 
that the eye condition had come on during the preced- 
ing summer while the patient was up the river swim- 
mjng each day. Knowing how frequently sinus infec- 
tion occurs among those who swim in contaminated 
river water, Dr. Moore suggested investigation of the 
deep sinuses. This had been done. Nevertheless we 
sent him to Drs. Groover, Christie and Merritt for x-ray 
of the deep sinuses. We received the following report: 

“Examination of the nasal accessory sinuses shows a 
moderate degree of opacity over both antra and over 
the posterior of the ethmoid cells and the sphenoids. The 
frontal sinuses are very small. The appearance points 


quite definitely to the presence of disease of the antra 
and the posterior ethmoids and sphenoids.” The patient 
was then referred to Dr. W. H. Jenkins, who reported: 

“The patient has considerable congestion around his 
middle turbinate region. The turbinates did not shrink 
easily but remained impinged against the septum. The 
washing from the antra showed a very decided amount 
of thin pus in the antra. After three treatments the 
nose looked much better, congestion was less, and the 
patient could breathe better.” Dr. Jenkins felt that he 
could clear up the infection without opening the ethmoid 
and sphenoid sinuses. 

Undoubtedly the first rhinologist centered most of his 
attention upon the tonsils and missed the sinus infec- 

Negative reports upon teeth, tonsils and sinuses should 
be rechecked at a later date if the patient fails to im- 

DISCUSSION (Abstract) 
Papers of Dr. Davis and Dr. Clarke 

Dr. J. A. Stucky, Lexington, Ky—TI have had much 
experience with uveitis in a locality where I could get 
no help. We have been able to control trachoma in 
the mountains of Kentucky; but only a few years ago 
many pitiable cases of trachoma with keratitis and 
uveitis were followed by the loss of an eye in spite of 
all we could do. 

The slit lamp, of course, is now used as a diagnostic 
measure. Cases may be accurately diagnosed by it, al- 
though which are uncertain without it, and I think the 
slit lamp should be a part of every clinic equipment. 
First make an accurate physical examination, deciding 
upon the focal infection if possible. In the mountains 
we have more focal infection from the teeth than from 
anything else. There the average man and woman of 
forty or fifty is almost toothless. When atropin or 
scopolamin do not enable me to get dilatation of the 
pupil, I use protein therapy, either milk or lactigen. If 
lactigen fails, I prefer sterile milk, and if I do not get a 
decided reaction and relief after the use of protein 
therapy, then I am sure that the cause of the trouble is 
in the intestinal canal, from absorption of toxins therein. 
So many cases have decided evidence of deficient nutri- 
tion that I begin treating them with cod liver oil and a 
balanced diet, and I am getting better results than I 
ever have before. 

Dr. J. Brown Farrior, Tampa, Fla—I should like to 
hear the Doctor’s distinction between uveitis and irido- 
cyclitis. I regard a uveitis case as one in which there is 
a deposit or exudate of the inner layer of the cornea. 
How do these deposits get there? Why should they 
come with uveitis and not in iridocyclitis? Whether 
they go off from the ciliary body through the blood 
stream, I have been unable to determine. 

I treated one case very successfully with dionin and 
atropin locally. 

Another case recovered after drainage of the maxillary 

Dr. G. C. Savage, Nashville, Tenn—I have never 
used the expression, “malignant infection,” in this con- 
nection, because malignancy has a different meaning. I 
think it would be weil to substitute another term. 

Of course, uveitis means inflammation of some part of 
the uveal tract, the choroid, the ciliary body and iris. 

In the case of uveitis with symptoms of glaucoma, if 


July 1927 

the author of the paper had observed that case very 
closely, he might have seen what I have often seen in 
cases where there is increased tension of the eye, that 
the iris was pushed backward and not forward. The 
increase of pressure is due to over-accumulation of 
aqueous humor and not the watery part of the vitreous 
body. In glaucoma proper the pressure is from a 
filling of the vitreous chamber by a watery effusion or 
secretion, but in iridocylitis where there is increase of 
tension the increase is due to an overfilling of the 
aqueous chamber. Of course, that is not true in glau- 
coma. Pressure would indicate glaucoma, but the posi- 
tion of the iris would not indicate the presence of glau- 
coma. To mistake a case of that kind and do an 
iridectomy would be bad. 

The part of the uveal tract that is most commonly 
diseased, especially in people beyond middle life, is the 
chorioid, and when the chorioid is involved in people 
who are growing old, they usually have no symptoms 
of pain or redness, no symptom except that pertaining 
to the sight. The patient who has beginning inflam- 
mation of the central part of the chorioid, if it is in 
one eye, will probably not observe it. If it is in both 
eyes, he will see a vertical line zig-zag, he will see let- 
ters of any line, some up and some down, one higher 
than the other. Of course, the ophthalmoscope helps 
us to make a diagnosis. Of all the diseases of the uveal 
tract the most important is inflammation of the central 
chorioid. : 

In dealing with inflammation of the iris and ciliary 
body, the sine qua non is atropin: to dilate the pupil 
and get the ciliary body into a state of rest. The cases 
that formerly gave me trouble in dilating do not trou- 
ble me very much now, for the reason that I use dionin 
with atropin. The atropin should be put into the eye 
in the ordinary way; and at least ten minutes should 
intervene before dionin is used. Dionin, in some way, 
has a softening influence on the plasma that binds the 
iris to the lens and makes it more easily possible for 
the atropin to pull the adhesions loose. It has become 
much easier, in my experience, to get full dilatation of 
the pupil in iritis by the combined use of dionin and 
atropin than by the use of atropin alone. But these 
drugs should never be in the same solution, nor should 
the order of their use vary. 

Dr. W. B. Gill, San Antonio, Tex.—There are two 
important factors in the production of uveitis. The 
first is focal infection, which has been duly emphasized. 
The second is the sensitizing of the uveal pigment. We 
have tested a series of about fifteen cases with the 
intradermal. pigment test of Dr. Allan Wood, and in all 
these cases have obtained positives. The degree of 
positiveness varies apparently in direct proportion to 
the length of time that the focal infection has appeared 
to produce the uveitis. In other words, the old case is 
strongly positive, but the recent case only mildly so. 

So far as the origin of the focal infection is con- 
cerned, in our experience the teeth head the list. We 
have recently had one case, a positive syphilitic, in 
which there was an associated maxillary involvement, 
and we felt that the anterior involvement was responsi- 
ble for his uveitis. In another case of multiple divertic- 
ulitis the colon seemed to be the only focus responsi- 
ble. In that case the patient was accustomed to have 
tenderness over the abdomen, then two days ‘later a 
flare-up in the eye. It was impossible, of course, to 
eliminate that focus of infection; the patient still has 
his trouble. 

— Oe ee ee ee ee Ce 

Vol. XX No.7 

We have therefore divided these cases into three 
classes for treatment: in the first, there is the elimina- 
tion of the focus of infection; in the second, the de- 
sensitization of the patient under the method promul- 
gated by Dr. Allan Wood; and third, is the local treat- 
ment. The sensitization, we feel, is accomplished 
through the action of either the bacterium responsible 
for the disease or some protolytic enzymes liberated 
from it. The patient is sensitized by absorbing his own 
uveal pigment, and any remaining pigment in the other 
eye will be responsible for a continuation of his symp- 

Dr. W. R. Buffington, New Orleans, La.—There are 
three diseases of the uveal tract which may be classified 
as unusual. I shall name them in the order of their 
frequency: tuberculous uveitis, sympathetic ophthalmia 
and leprosy. All three are characterized by microscopical 
or macroscopical nodular formation somewhere in the 
uveal tract. A case of mine showed tuberculous uveitis 
(iridocyclitis), with multiple visible tuberculous nodules 
in the iris. The patient, a young colored woman, whose 
health had been good, developed an inflammation of 
the right eye in May, 1925. The eye was red and 
moderately painful. The condition grew progressively 
worse till the eye was completely blind. In August, 
1926, she had a painful, slightly inflamed atrophic right 
eyeball, with no vision. 

In the early part of 1926 the left eye became in- 
flamed very much as the right had previously. 

She was seen by me some three months after the left 
eye became inflamed. There was moderate ciliary in- 
jection, and fine deposits could be observed on the post- 
surface of the cornea. Several yellow white nodules 
were clearly seen in different parts of the iris, some 
larger than others. One or two were capped by a 
fibrinous exudate. Many post-synechiae were present, 
and the fundus was not visible. 

Her mother had active pulmonary tuberculosis. The 
patient gave no history of lues. Physical examination 
of chest, abdomen and other organs was negative. No 
foci of infection could be found. The blood Wasser- 
mann was negative. Two spinal fluid Wassermanns 
made at different times were negative. After the 
cutaneous (von Pirquet) test for tuberculosis there was 
a marked reaction. The x-ray examination gave defi- 
nite evidence of pulmonary tuberculosis. Some two 
months later a second x-ray examination showed a 
marked tracheo-bronchial adenopathy. Occasionally she 
ran a low temperature. 

Active anti-luetic treatment was carried out before 
she came into my hands. Under this treatment her 
general as well as her eye condition grew worse. 

When I took charge of the case, I began treatment 
along anti-tuberculous lines. The patient rapidly im- 
proved in general health and put on weight. The eye 
condition, however, had advanced so far that blindness 
will probably be the end. This case emphasizes two 
things: first, the necessity of employing every means 
which we have at hand to find the cause of obscure 
diseases of the uveal tract; and second, the importance 
of early diagnosis in tuberculous uveitis. 

Dr. J. W. Jervey, Greenville, S. C—I wish to en- 
dorse very strongly Dr. Stucky’s remarks upon the use 
of proteins, and also his observation that in these 
obscure cases there is also a question of nutrition. 

Tuberculin injections either for diagnostic or thera- 
peutic purposes, are highly dangerous because of the in- 
evitable reaction on the eye. I have seen very disas- 


trous results in the hands of others, which taught me 
the lesson that that treatment should be avoided. 

Another very important matter that I was delighted 
to hear Dr. Savage bring out was the very necessary 
differentiation between uveal cases and glaucoma. Many 
uveal cases have hypertension, and there will be an in- 
terference with intra-oculas drainage and hypersecre- 
tion on account of the excess of inflammatory reaction 
in the uveal tract, but if we try to treat the cases as 
glaucomatous we may add fuel to the fire. 

Dr. Farrior suggests the use of dionin in connection 
with atropin for the purpose of increasing the mydriatic 
effect. Subconjunctival injections of adrenalin have 
sometimes given us marvelous results, but, of course, 
cases differ. 

A lady from a neighboring city was under my care 
for two or three years with recurrent attacks of uveitis 
with hypertension. Fortunately I preserved my equili- 
brium and used atropin. In every instance she re- 
covered, but recurrences came. Her son was just out of 
medical college and he apparently became worn out 
with his mother’s attacks and suggested to me that he 
take her to an ophthalmologist in another city. I was 
delighted. I got a brief curt note from this physician 
after a time, saying: “I have seen your patient and she 
has acute glaucoma. I shall operate upon her tomor- 
row.” He operated the next day and two weeks later 
her son advised me that he had enucleated the eye. 

Dr. James B. Stanford, Memphis, Tenn—We are not 
justified in the diagnosis of ocular tuberculosis by the 
use of tuberculin, nor are we justified in treating 
ocular tuberculosis with tuberculin, except when we 
start with exceedingly small doses and increase them 
very gradually. Our function is to conserve vision, and 
we are apt to destroy it by too free use of tuberculin. 

Dr. Davis (closing).—I wish to agree with Dr. Stucky 
as to the nutritional element in these cases. We have 
tried to follow out that idea in the treatment. Of 
course, in the class of patients he speaks of, and in the 
class he sees in his clinics, this would play a much more 
important role than in private practice in a city like 

I appreciate very much Dr. Savage’s discussion, and 
particularly his reference to the increase in tension in 
the eye in uveitis, due to a secondary glaucoma caused 
by an increase in the secretion of the aqueous. 

When we see for the first time a case of glaucoma 
simplex we should study the case carefully before we 
operate. ; 

I have had no experience with uveal pigment or de- 
sensitization. We consider tuberculin of great value, 
though dangerous. It should be used by one who is 
thoroughly experienced. It should not be used in suffi- 
cient dose to produce a focal reaction in the eye. It is 
best to start with exceedingly small doses and gradually 
increase them. We may or may not secure a focal re- 
action. It is not safe for diagnostic purposes, since one 
may get a reaction that will destroy the eye. If one 
uses very small doses and gradually increases to the re- 
quired dose, it is a most valuable treatment and with- 
out danger. . 

It was not my intention to speak of uveitis with in- 
creased tension as glaucoma. It is frequently referred 
to as secondary glaucoma, but this is unfortunate, since 
it is not glaucoma. In the acute cases one frequently 
sees the deep .anterior chamber, dilated pupil and 
cloudy aqueous with cyclitic deposits on Decemet’s 
membrane. In my experience the more chronic a case 


is the less frequently do we see the above described 
condition. We usually observe the shallow anterior 
chamber with glueing of the iris root to the back of the 
cornea and with periods of increased tension alternating 
with hypotony of the globe. 

To operate upon of uveitis with increased ten- 
sion, particularly an acute case or with an acute ex- 
acerbation, is of course quite destructive to the eye. 
Many cases of so-called acute glaucoma and glaucoma 
simplex are in reality uveitis. Careful study, particu- 
larly with the slit lamp, will give us the true diagnosis 
and enable us to save these eyes. 

Answering Dr. Farrior’s question: I am accustomed 
to teaching the students that any inflammation of the 
uveal tract, iris, ciliary body or chorioid is in reality 
uveities, and that depending on which part of this tract 
is involved we designate it as iritis or iridocyclitis, etc., 
and when the whole tract is involved as uveitis. 

Since we have in later years more thoroughly under- 
stood the pathology of the uveal tract, a change in the 
designation of diseases of this tract would be advan- 
tageous.” I am in thorough agreement with Dr. Buffing- 
ton that we must diagnose uveitis due to tuberculosis 
early if the eyes are to be saved. Tuberculin for treat- 
ment, together with other proper measures, is of great 
value. I do not favor tuberclin for diagnostic purposes 
in eye disease. I am in hearty accord with Dr. Stan- 
ford in this. 


By M. L. Graves, M.D., 

GHENT Graves, M.D., 
Houston, Tex. 

Indigestion is a diagnosis frequently used and 
often abused. It is a cloak of ignorance to cover 
a group of cases sometimes also called dyspepsia, 

or gastritis. The anatomical designation gas- 
tritis is thus exchanged for the physiological 
term indigestion. Diagnostic methods and cumu- 
lative experience are separating out from this 
conglomerate group more definite clinical en- 
tities. The following pathological conditions 
have constantly associated with them indiges- 

(1) Gastric ulcer. 

(2) Duodenal ulcer. 

(3) Chronic cholecystitis and pericholecystitis with 

(4) Cholelithiasis. 

(5) Gastric carcinoma of certain types. 

(6) Chronic or recurrent appendicitis. 

(7) Carcinoma of the colon. 

(8) So-called spastic constipation or irritable colon. 

Southern Medical 
Meeting, Atlanta, 

*Read in Section on Medicine, 
Association, Twentieth Annual 
Georgia, November 15-18, 1926. 


July 1927 

(9) In women, who are biologically deficient, fibro- 
cystic ovaries may cause nervous and digestive phe- 

(10) Some displacements and lacerations and certain 
infections, such as salpingo-oophoritis, endocervicitis, 
and endometritis. 

(11) Worry psychosis with gastro-intestinal symp- 
toms in neurotics. 

The public is accustomed to accept indiges- 
tion as a definite diagnosis. The laity and the 
profession should regard it instead as a symp- 
tom, and its occurrence should at once serve to 
initiate rather than to culminate a scientific in- 
vestigation of the case. We frequently see 
specimens from cases of perforated gastric ulcer, 
coronary thrombosis, gall bladder sepsis, and 
perforated appendicitis on the pathologist’s ta- 
ble, although the only diagnosis made in the case 
was acute indigestion. No patient dies of acute 
indigestion, and any physician, who is satisfied 
with such a diagnosis is seriously neglecting his 
duty and his patient’s welfare. 


These cases usually complain of sudden onset 
of moderate to severe pain with or without 
nausea and vomiting and abdcminal cramps. 
The condition of the bowels may vary from con- 
stipation to an active diarrhea; the temperature 
may range from normal or even subnormal to 
104 or 105° F.; the white blood count may be 
normal or show leukopenia or leukocytosis. 
Physical examination may disclose general or 
local tenderness with or without. spasm. In 
other words we may have almost any combina- 
tion of symptoms. The diagnostic possibilities 
are: gastric or duodenal ulcer with or without 
perforation, gall bladder disease with or without 
stones, intestinal obstruction, mesenteric throm- 
bosis, acute pancreatitis, rupture of spleen, food 
poisoning, acute appendicitis, inflammatory pel- 
vic disease, ruptured ectopic pregnancy, renal, 
ureteral or bladder stone, Dietl’s crisis, spastic 
colitis, certain infections, such as malaria, ame- 
bic dysentery, pellagra, even pneumonia at 
times, metal poisoning, atypical angina pectoris, 
acute alcoholism with or without hepatic cirrho- 
sis, cerebrospinal lues, perforated typhoid ulcer, 
abdominal aneurysm and psychoneurosis. It is 
unnecessary to describe the differential diag- 
nosis of these diseases as they may be found in 
any text book of diagnosis. A few cases will 
remain obscure even after all available methods 
of diagnosis have been exhausted. 

Recently the writer observed such a c»°e in a man of 
67 with acute abdominal cramps, rigors, temperature 




ee ee ee ee ee” a ae 


Vol. XX No. 7 

ranging from 99 to 104° F., with a normal white blood 
count and differential He had a slow regular pulse 
(50 to 60) of good volume and tension; the urine was 
highly colored but otherwise negative; stool examina- 
tions were negative; physical examination revealed 
nothing certain except generalized arteriosclerosis; 
smears were negative for malaria, and the Widal re- 
action was negative, and there was no response to 
quinine therapy. 

A period of two weeks’ observation after its onset, 
the attack exhibited another picture. The patient de- 
veloped distinct jaundice and an enlarged and tender 
gall bladder, with muscular hypertension in the right 
quadrant. The white blood count rose from normal to 
22,000. That day the surgeon removed a large stone, 
completely occluding the common duct. 

I have seen coronary thrombosis, with acute 
onset, nausea, vomiting, pallor, weak and 
thready pulse and epigastic pain, pronounced 
acute indigestion with grave consequences. If 
we critically analyze the daily press accounts 
and note from time to time that well known 
public men are suddenly and fatally stricken 
with so-called “acute indigestion,” it is more than 
probable that a fair percentage of them at post- 
mortem would reveal obstruction of the coronary 
artery. The recognition of these cases is sim- 
plified by careful consideration of the follow- 
ing diagnostic criteria: 

(1) There is sudden and severe pain over the epi- 
gastrium or cardiac region. 

(2) Ashen, white pallor, usually with clammy skin. 

(3) The condition almost always occurs in individuals 
over 40 years of age, predominantly men. 

(4) A low blood pressure is observed, or precipitate 
drop of a previously high blood pressure. 

(5) There is rapid, irregular or imperceptible pulse of 
small volume and low tension. 

(6) Usually an enlarged heart with weak or inaudi- 
ble first sound at the apex. 

(7) Signs of fluid at the lung bases. 
Perhaps a slight rise in temperature (100° to 

(9) Slight or moderate leucocytosis (10,000 to 12,000). 
(10) Pericardial friction rub may or may not be 

(11) Electrocardiogram, if available, will show an 
upward convexity of the S-T interval, other than in 
lead three. 

The recognition of cases of coronary occlusion 
is of vital importance. The chief danger lies in 
the fact that the day. following such an accident 
the patient may feel relatively well and wish to 
get up. He may look well, but it is imperative 
to exercise caution, for often such an indiscre- 
tion is only a step in the direction of the grave. 

Another type of acute indigestion worthy of 
mention is so-called “ptomaine poisoning.” It has 


been conclusively shown that these cases are 
usually due to one of two causes: 

(1) Food infection, caused by Bacillus enteriditus or 
organisms of the same group. 

(2) Food intoxication, caused by Bacillus botulinus. 

The symptoms of the former are gastro-in- 
testinal, while those of the latter may be early 
gastro-intestinal and later referred to the cen- 
tral nervous system in the form of paralysis. 
Other intoxications of unknown character may 
produce a similar picture. 

A 10-year-old Texas boy, living in a small commu- 
nity, was first seen with sudden abdominal cramps, 
diarrhea, temperature (101° to 102°), and a leucocytosis 
of 10,000 to 16,000, with 34 per cent eosinophils. 

Physical examination was negative, except for ab- 
dominal tension, the urine was normal and the stools 
were entirely negative except for a few larval forms, 
which were looked upon at the time as fly larva con- 
tamination. There was no history of ingestion of sea- 
foods or spoiled meats or milk, and no other member 
of the family eating with the child had been ill. In 
the course of ten days to two weeks he developed pain- 
ful erythematous, nodular swellings in some of the 
muscles. A portion of the quadriceps extensor group 
over one of these swollen areas was excised and ex- 
amined by a competent pathologist, who reported nor- 
mal striated muscle. A few weeks later a small larval 
form was recovered from one of these nodular swellings, 
which was identified as Hypodermia lineatum, a species 
of fly larva which is at times pathologic to men in 
Texas and in some of the neighboring states. 

The universal history of acute appendicitis is 
replete with tragical diagnoses of acute indiges- 
tion, even to the present day. 


These cases embrace a group where the his- 
tory of onset is insidious and symptoms are less 
urgent and definite. It is, therefore, with ease 
and with a certain sense of relief that they are 
classed as chronic indigestion, stomach trouble, 
intestinal indigestion, and let go. There are a 
few common points in this large class of cases, 
facts which are elicited in whole or in part upon 
inquiry, and are worthy of careful investigation. 

(1) The condition is usually described as chronic. 

(2) There is epigastric discomfort ranging the entire 
gamut to severe paroxysmal attacks of pain. 

(3) Gas, distension or fullness usually is associated 
with belching and relief. The soda habit is quite fre- 

(4) Nervousness, slight or, extreme. 

(5) Constipation or laxative habit. 

(6) Intermittency and irregularity of symptoms over 
weeks or months or years. 

(7) Subjective soreness and tenderness. 

(8) Nausea and vomiting, with later, in some cases, 
hemorrhage from the stomach or bowel. 


(9) Insomnia. 

(10) Fatigue. 

(11) Cardiac symptoms such as palpitation, irregu- 
larity, throbbing and dyspnea. 

The physical findings may be meager and in- 
conclusive. Ordinarily, objective tenderness and 
muscular hypertension may be found; hyper- 
acidity is usual but rarely hypo-acidity is pres- 
ent. The latter is accounted for in two classes 
of cases, namely, gall stones, cholecystitis and 
the gastro-neuroses with achlorhydria. 

Happily, the newer methods of diagnosis are 
removing from such a category many definite 
clinical entities. Thus the x-ray took from it 
gastric and duodenal ulcers, and x-ray helps at 
times in the diagnosis of chronic appendicitis. 
Pyelographic studies have served to differentiate 
the diseases of the genito-urinary tract which 
sometimes simulate gastro-intestinal derange- 
ment. The proctoscope and sigmoidoscope, to- 
gether with x-ray and stool examinations, have 
done much to separate the various colitis groups. 
The rediscovery of digital examination, with the 
aid of the proctoscope and x-ray, has revealed 
some cases formerly classed as chronic indiges- 
tion to be neoplasm or malignancy. 

The excellent work of Graham has enabled us 
to demonstrate gall bladder pathology in many 
cases hitherto classed as chronic indigestion. 

A woman in mid life, over stout, came to me with 
her own diagnosis of indigestion, which she had been 
treating for several months, and upon inquiry it devel- 
oped that her only symptom was heart burn. When 
she was advised to have an x-ray examination of the 
gall bladder, she demurred because she had no pain or 
other symptoms. Upon my insistence, however, it was 
done, and the gall bladder was found to be diseased 
and to contain a number of gallstones. These were 
removed at once and the patient had no more heart 
burn or indigestion. If I had permitted her wishes to 
govern, as we too frequently do, she would still be suf- 
fering with indigestion and be dieting and taking medi- 
cine for relief. 

As we learn more of the chemistry and path- 
ology of the body, the group of chronic indiges- 
tion cases will dwindle to extinction. 

In reviewing two hundred and sixty-two office 
cases recently, we found that seventy had entered 
the Clinic with a diagnosis of indigestion, made 
either by themselves or by physicians whom 
they had consulted. It was quite interesting to 
note the final diagnosis in these cases. Among 
them we find duodenal ulcer, chronic appendi- 
citis, pelvic abnormalities, and irritable colon 
with bad dietetic regime. Several had been sub- 
jected to appendectomy without relief of symp- 
toms. There was cholelithiasis; mucous colitis; 

July 1927 

syphilis of the central nervous system; worry 
neurosis; pulmonary tuberculosis with gastro- 
intestinal symptoms; obesity; cardio-vascular 
hypertension, or Albutt’s disease; excessive 
carbohydrate diet with fermentation and stasis; 
ulcerative colitis; carcinoma of the stomach; 
arteriosclerosis; Addison’s disease; post-opera- 
tive complex with disordered colon after tubes 
were ligated, appendix removed, uterus sus- 
pended, and left ovary and hemorrhoids re- 
moved without relief. 

It is from such gastro-intestinal presentations 
that the forces of chronic invalidism are largely 
recruited. The effect of anger, anxiety and 
worry on the digestion is a matter of common 
experience, and Cannon has shown that a 
physiological effect of these emotions is intestinal 
stasis. Such patients, thinking they are con- 
stipated, begin the use, or rather the abuse, of 
cathartics and enemas; their abdomens become 
sore and they enter our offices with a complaint 
of indigestion. Another cathartic, or the com- 
mon advice to eat fruit, will not help them. 

Many patients drag about from clinic to clinic 
spending all their money and are like a certain 
woman, reported by St. Mark, “which had an 
issue of blood twelve years and had suffered 
many things of many physicians and spent all 
that she had and was nothing better, but rather 
grew worse.” 

After all possible definitions and earnest at- 
tempts at etiological and pathological classifica- 
tion have been made, there remains a large 
group of cases of intestinal invalids in whom no 
definite pathology can be demonstrated, except 
perhaps the almost invariable coincident pelvic 
disorder discovered in females, such as fibrocystic 
ovaries, or uterin displacements, in which sur- 
gery gives disappointing results. 

At present we are grouping these cases under 
the head of disordered colon. It is possible that 
further studies of the vegetative nervous system 
may illuminate that large group of nervous in- 
valids with digestive disturbances who are known 
as vagotonic individuals. They present a clin- 
ical complex indicating abnormally increased 
function of the vagus, both in its secretory and 
motor functions. They may have gastric hyper- 
acidity, excessive sweating, with cold and 
clammy hands and feet; cool, pale skin; low 
blood pressure; slow heart; contracted pupils 
and spastic constipation. Many cases of dis- 
ordered colon are seen in the intensely emotional 
type of individual, the so-called asthenic type, 

I ng gg aay 


A MO es , 


— ee ae 


ee, Ry ME cs I ee 

Vol. XX No.7 

which is not outwardly demonstrative. Barker 
at a recent meeting in Cleveland called attention 
to the fact that if this group developed mental 
disorder it was particularly prone to be of the 
dementia precox type rather than of the manic- 
depressive type. As we learn more of the emo- 
tional control and reflex stimuli, we shall better 
understand such cases. 


(1) The term indigestion, whether acute or 
chronic, is undesirable both as a diagnosis and 
as an indication of mental attitude. 

(2) The diagnosis of acute indigestion often 
obscures and delays accurate diagnosis and 
treatment in a critical condition, such as acute 
appendicitis, perforated ulcer, acute gall bladder 
and coronary occlusion. 

(3) Acute indigestion is never the cause of 

(4) The gall bladder, the stomach, the ap- 
pendix and the colon are the four chief seats of 
indigestion. Careful consideration of these and 
other abdominal viscera by the method of ex- 
clusion will enable the careful and painstaking 
Clinician to solve 90 per cent of his cases of 
chronic indigestion from abdominal cause. 

(5) The large groups of biologic deficients 
and chronic nervous exhaustions may be suc- 
cessfully differentiated in the same manner and 
many useless and injurious surgical operations 
may be avoided. With a more scientific in- 
vestigation of the so-called nervous cases of 
vagotonic and sympathetico-tonic types, fewer 
costly errors will be made and better plans of 
treatment will be devised. 

(6) Indigestion should be considered merely 
as a symptom of disturbed secretory, sensory 
and motor functions of the digestive organs, al- 
ways to be thoroughly investigated before diag- 
nosis is determined. 

(7) We should educate ourselves and the 
public that we may earlier recognize organic 
and functional pathological conditions in that 
great arcana of mystery, the abdomen, and in- 
augurate appropriate. medical and _ surgical 
regia before chronic invalidism is established. 


1. Alvarez: Oxford Medicine, 3:19. 
2. Cannon: Bodily Changes in Pain, Hunger, Fear 
or Rage. D. Appleton & Co., N. Y. and London, 

. Barger: Mayo Clinic ene My 241, 1924. 

- Emery: Med. Clin. of N. A., 1765, March, 1925. 

. Pardee: Clin. Aspects of hie "Blectrocardiogram, 
p. 81, Paul B. Hoeber, 1924. 

. Campbell: Canadian Med. Assn. Jour., 16:151, 
Feb., 1926. 

a Mee 


7. Kellogg: Colon Hygiene. Mod. Med. Pub. Co., 
Battle Creek, Mich., 1923. 

8. Barker: Med. Clinic” Before Post Graduate Med. 
Assembly, Cleveland, 1926. 

9. Graves, M. L., and Graves, Ghent: S. M. J., 19: 
260, April, 1926. 

10. St. Mark, Bible, Chapter 5, 25-26. 

DISCUSSION (Abstract) 

Dr. Stewart R. Roberts, Atlanta, Ga—The word ab- 
domen comes from a Latin verb of the third conjuga- 
tion meaning to conceal, and it is well named. I have 
a book written about 1850 called, “The Memories of a 
Stomach.” It is written in the first person and is the 
story of a stomach that went to Harley Street, London, 
and received polyglot prescriptions and then went from 
one physician to another, but receiving no relief. 

In the seventies there came from Germany a stomach 
tube, and in the eighties and nineties there sprang up 
over the world an individual known as “the stomach 
specialist.” Internal medicine gradually shrank from 
this and really considered that he was ill named and ill 
placed in the profession. Whether the conclusion was 
correct or not, the profession came in time to feel, even 
though internists continued to neglect gastro-intestinal 
diseases, that ‘much quackery has been committed in 
thy name, O stomach!” As time went on, the Mayos 
developed their theories of the frequency of cancer, 
ulcer and gall bladder disease. Moynihan in Europe 
worked on duodenal ulcers, and then the surgeons came 
forth saying that there were only three disorders of im- 
portance: ulcer, cancer and gastritis, incidentally also the 
gall bladder, the appendix and perhaps the colon, with 
certain problems relating to adhesions. So that we 
internists as a whole stopped studying the abdomen and 
have rather studied the thorax, or the nervous system, 
or the endocrines. 

Then came Fenwick’s book on “Dyspepsia” and 
Hurst’s book on “Sensitivity of the Alimentary Tract,” 
and his other book on “Constipation and Allied Disord- 
ers,” and Adams and Cassidy in England published a 
book, “The Acute Abdomen.” Those books represent 
probably the greatest repertoire of advance in ab- 
dominal study, diagnosis and therapeutics that medical 
literature has offered. 

We have shrunk from abdominal study. Fifty per 
cent of the patients who come to our office complain of 
some form of indigestion. 

While Dr. Graves classified his abdominal complaints 
on the basis of time as acute or chronic, it is perhaps 
well to use another classification involving the point of 
view of the origin of the complaint. For example, we 
have the reflex abdomen from an emotional or psychic 
disorder, the symptoms having their point of origin 
outside the abdomen; second, there is the functional ab- 
domen; and third, the organic abdomen with a struc- 
tural pathological condition in the abdomen. 

Furthermore, there are some abdominal cases that 
cannot be diagnosed by the human mind. Twenty per 
cent of the persons who go to the Mayo Clinic go to 
the operating table for an exploratory laparotomy. We 
have just seen a patient who came to us with a diag- 
nosis from two physicians of duodenal ulcer. We con- 
curred in the diagnosis, but after much observation it 
was found he was suffering from an adhesive appendix, 
buried post-cecally. We need a re-birth, a re-touch 
to drive us back to a scientific study of abdominal com- 
plaints, or of the indigestion which is the expression on 

the part of the patient that he is conscious of his ab- 

Dr. J. W. Dickie, Southern Pines; N. C.—Dr. Graves 
merely touched on the question of diet, which was not 
within the province of his paper. I should like to em- 
phasize one point in regard to diet. It is the tendency 
of many physicians to advise patients to eliminate cer- 
tain articles of food from their diet without giving 
them anything else as a substitute. A certain number 
of calories a day are essential to health. Yet a patient 
with a stomach disorder frequently goes from one 
physician to another, is advised to eliminate first one 
and then another article of food from his diet until 
eventually either the patient or some physician wakes 
pi - the fact that the patient is practically starving to 


In my experience, tuberculosis heads the list of all 
diseases responsible for stomach disorders. An appalling 
number of patients are treated for months and some- 
times for years for stomach disorders when the under- 
lying condition has been pulmonary tuberculosis. It is 
just as important to eliminate the possibility of tuber- 
culosis in such a case as it is to have a chest examina- 
tion before a tonsillectomy. 


By Homer Dupuy, A.M., M.D.,** 
New Orleans, La. 

The topography of the sphenoid sinus with its 
relations to such important 
structures as the optic, sixth, 
and third cranial nerves, the 
cavernous sinus, internal 
carotid artery, and the cere- 
brum, is now well under- 
stood. We recognize this 
region as the danger zone of 
the skull. Rightly do we 
approach the sphenoid with 
the utmost circumspection. 

Too long have we accept- 
ed the 7-8 cm. measurement 
from the anterior nasal spine 
to the anterior sphenoid wall 
as our average distance. This 
is too standardized, and is 
only a near-truth, which may 
lead the unwary into trouble. 

*From the Departments of 


July 1927 

Further research convinces me that there are 
wide variations of this distance in different in- 
dividuals. We have so often observed such 
variances on the living subject and on cadavers 
that I have long sought a reliable pre-operative 
method of measuring this distance to the sphe- 
noid wall. My method is essentially that of 
x-raying as perfect.a lateral view of the skull as 
possible. A straight line is then drawn from 
the tip of the anterior inferior nasal spine 
through the anterior sphenoid wall to the floor 
of the sella turcica, and the distance measured to 
the anterior wall, and to the sella. In the sub- 
ject (Fig. 1) the measurements are as follows: 

6, 5 cm. from the nasal spine to the sphenoid wall; 
8, 2 cm. from the nasal spine to the floor of the sella. 
By subtraction we further get the distance from the 
anterior wall to the floor of the sella as slightly over 
2 cm. 

Dr. Amadee Granger, whose advice and as- 
sistance has made possible this contribution, also 
insists on a technically good lateral view to 
insure accuracy in these measurements. In the 
Journal of the American Medical Association, 
October 20, 1923, he states that a perfect lateral 
view of the skull is one, 

“wherein the outline of the sella is perfect; and the 

curved lines (A.A. Fig. 1) formed by the greater wings 
of the sphenoid are separated from each other by not 

Oto-Laryngology and Radiology, 
Charity Hospital, New Or- 
leans, La. 

Fig. 1 

**Senior Visiting Surgeon, De- A nearly perfect lateral view, clear outline of sella, lines AA’ separated by 

partment of Oto-Laryngology, not more than 2 

Charity Hospital. 

4mm. Distance from nasal spine to anterior sphenoid 
wall 6.5 cm.; to floor of sella 8.2 cm. 


elena pean ee enreemgala tipper nai 

ae Se ae 


——— ee ee 

Vol. XX No. 7 


ness of the soft parts. These 
measurements were com- 
pared, and checked up, by 
intra-nasal soundings, using 
graduated probes. When a 
difference presented itself, 
as it did in very few in- 
stances, it never exceeded 4 
lmm. This slight difference 
is accounted for by the occa- 
‘sional difficulty of locating 
the tip of the anterior nasal 
spine by tactile manipula- 
‘tion. This difference was 
the exception, and cannot 
militate against the accuracy 
of our method as compared 
to the haphazard groping 
usually employed. We have 
further corroborated our 
X-ray measurements in a se- 

Fig. 2 

Imperfect lateral view; lines AA’ greater wings of sphenoid are over 1 cm. 


more than 2-4 mm., and not like (Fig. 2) wherein they 
are 1 cm. or more apart. The greater wings of the 
sphenoid are normally in line with the anterior wall of 
the sphenoid sinus. This lateral view of the head is 
made at a target plate distance of six feet, taking great 
care that the side of the head is held correctly against 
the casette. At this distance the magnification is less 
than it would be at the usual 
26 in. target plate distance, and 
while it is true that there is still 
some slight magnification (2-4 
mm.), which would not be pres- 
ent if a target plate distance of 
20 feet were used, the latter tech- 
nic, even if it could be em- 
ployed in the average x-ray 
room, would prove difficult, and 
the great increase in time of ex- 
posure necessary would make it 
almost impossible to obtain good 
radiographs, clear from blurring 
caused by the involuntary move- 
ment of the patient.” 

To the operator the ques- 
tion of supreme importance 
is the distance from the na- 
sal spine to the anterior 
sphenoid wall. I have found 
that the measurements made 
by Granger in my work at 
the Charity Hospital are ac- 
curate, because the slight 
magnification of 2-4 mm. is 
compensated by the thick- 

ries of experiments by again 
x-raying the patients with 
graduated instruments with- 
in the sinus itself (Fig. 3). 

As our pre-operative x-ray lateral view is to 
make safer the various steps in the intra-nasal 
surgery of the sphenoid, I wish to stress: (1) as 
the line from the tip of the nasal spine to the 
floor of the sella and to the anterior wall is at 
an angle of nearly 45 degrees, our surgical in- 

Fig. 3 
Showing Dupuy burr within left sphenoid sinus. A test and proving measure- 


struments must be directed along this line in 
first entering the sinus. Only by observing this 
technic can we be helped by the measurements; 
(2) our point of entrance in the anterior wall 
will be about midway between the spheno- 
ethmoidal recess and the nasal septum; (3) the 
x-ray picture will show whether, in its varia- 
tions, the nasal spine is long or short. Such in- 
formation will assist in locating by touch this 
landmark, which is our proximate point in the 
measurement; (4) the success of this method 
obviously depends to a large extent on the tech- 
nical ability of the radiologist to furnish the 
proper kind of a picture. 

I wish to acknowledge my indebtedness to 
Dr. Wm. Devlin, of the X-Ray Laboratory, 
Charity Hospital, and to Dr. J. R. Fernandez, 
my clinical assistant, for their invaluable co- 


By J. L. Campsett, M.D., F.A.CS., 
Atlanta, Ga. 

We have collected from the college clinic and 
the surgical service of the Emory University 
Unit of Grady Hospital twenty-seven aneurysms. 
One patient had four during the course of a few 
years; so this series represents twenty-four pa- 

My chief reason for studying this subject is 
that 25 per cent of the aneurysms in this series 
had been opened by some one, under the impres- 
sion that they were abscesses. The location of 
the aneurysms opened were as follows: femoral, 
three (two deaths); dorsalis pedis, one, and 
digital, two. The cases may be divided into: 

(1) True aneurysms, in which there was no history 
of trauma, fifteen cases, located as follows: femoral, 6; 
popliteal, 4; common carotid, 3; subclavian, 1; external 
carotid, 1. 

(2) Traumatic, or false, aneurysms in which there was 
a history of trauma, contusion or wound, twelve cases, 
located as follows: femoral, 3; sacciform, 2; arterio- 
venous, 1; brachial, 2; radial, 1; anterior temporal, 1; 
dorsalis pedis, 1; popliteal (arteriovenous), 1; common 
carotid (arteriovenous), 1. 

All of these patients were negroes. There 

*Clinic, Clinic Session, Southern Medical Associa- 
tion, Twentieth Annual Meeting, Atlanta, Georgia, 
November 15-18, 1926. 

July 1927 

were three women and twenty-one men. I have 
made no effort to analyze the incidence of syph- 
ilis, for in many of the older cases there is no 

If we accept the statement that the sac of a 
true aneurysm is made up of one or more coats 
of the artery, this classification will not hold 
good. For instance, in one of the popliteal (re- 
ferred to in group one) the bone was badly 
eroded, and in one of the femoral (in group 
two) the sac, even though it held about 400 c.c. 
of blood, appeared to be lined throughout with 
intima. All of the traumatic aneurysms of long 
standing, except one, appeared to be lined with 
intima. However, this has not been proven 

In the traumatic group there were four pul- 
sating hematomas, a name given by Aetius in 
the Sixth Century to recently formed aneurysms, 
or collections of blood contained in the tract of 
a wound which had invaded an artery. Two of 
these hematomas were in the arm: one from a 
knife stab that had wounded the artery at its 
upper end, and the other from a bullet wound 
which had shattered the lower end of the 

le ———————_ ] 

Fig. 1 
Case 1.—Photograph showing the patient just before 
operation. Note the exophthalmos of the left eye; 
the bulging beneath the sternomastoid muscle and 
the scar where the bullet entered the neck. 

ee — ce ee 


Vol. XX No. 7 

Fig. 2 

Shows how the blcod may be controlled by passing 
small Dakin tubes arcund the vessels proximal and 
distal to the point of fusion or wound; they are 
clamped with broad bladed forceps just tight enough 
to control the blcod stream but not enough pressure 
is made to injure the walls of the vessels. This 
drawing was made from an operation which ex- 
posed the femoral vessels to control the hemor- 
rhage from a wound of the profunda artery and 
vein 1 ecm. from their origin, resulting in an in- 
direct arteriovenous aneurysm through a sac which 
contained 300 c.c. of blood. Note the bulging in 
the vein when:-the clamps were removed. The 
arterial blood entered the vein and distended it al- 
most to the point of rupture. The same method 
was used in operating on the case we are pre- 

humerus and lacerated the artery just above its 
bifucation. The third was in the popliteal space 
and was also the result of a bullet wound which 
had injured both the artery and vein. This 
cavity contained 500 c.c. of soft blood clot. The 
fourth was in the neck and will be discussed 

Case 1 (presenting patient).—An arteriovenous aneu- 
rysm of the common carotid artery and internal jugular 
vein, with a pulsating hematoma beneath the sterno- 
mastoid muscle. 

This patient, a colored man 28 years of age, is the 
one just referred to as the fourth of the hematomas. 
He was wounded on December 13, 1924, by a .32 
calibre pistol ball, which entered just to the left of the 
cricoid cartilage, passed entirely through the néck, and 
lodged just beneath the skin, two inches to the left of 
the second thoracic vertebra. For two days there was 
no bleeding or pain, but on the morning of the third 
day he noticed a swelling in the side of his neck, with 
pain extending to the shoulder, arm and hand. He 
came to the hospital and was admitted to my service. 
At first, there were no symptoms of blood vessel injury, 
but the next day the interne’s notes showed that the 
pain was worse and that a thrill and bruit had developed 


during the night. He suspected an arteriovenous aneu- 
rysm. Three days later the patient complained of roar- 
ing in the left ear. 

On December 24, the tinnitus aurium, thrill, and bruit 
disappeared when pressure was made at the point of 
entrance of the bullet. It was also noted that there 
was bulging along the tract of the bullet beneath the 
sterno-mastoid muscle and a slight exophthalmos of 
the left eye. 

January 2, 1926, Branham’s syndrome was present; 
pressure on the bullet wound scar caused the thrill and 
bruit to disappear, the pulse to fall from 60 (the pre- 
pressure rate), to 52, and the blood pressure to change 
from 110 over 60 (pre-pressure) to 100 over 65. Three 
days later the pre-pressure pulse rate was 71 and the 
pressure rate 62, with the same variation in the blood 
pressure previously noted. Atropin in large doses failed 
to produce any change in the symptoms. As there were 
no changes in the eye ground, Dr. F. P. Calhoun sug- 
gested sympathetic nerve irritation as the cause of 
the exophthalmos. In the lantern slide photograph you 
can see the exophthalmos, the bullet wound scar, and 
the swelling beneath the sterno-mastoid muscle. 

Operation—Under ether anesthesia given by Dr. T. J. 
Collier, I made an incision along the anterior border of 
the sterno-mastoid muscle, beginning at the angle of the 
jaw and ending at the sterno-clavicular articulation, 
then along the clavicle to its middle. The muscle was 
separated from its attachment to the clavicle and re- 
flected upward and outward with the skin and super- 
ficial structures. The artery and vein were exposed 
above and below the point of fusion and, as there was no 
change in their size (either proximal or distal), they were 
compressed separately by rubber tubes clamped with 
broad bladed forceps, as shown in the lantern, slide cut. 
This controlled the circulation perfectly and we were 
able to separate the vessels. There was a single elliptical 
opening 1.5 cm. long and 3 mm. broad in the vein and 
two similar openings in the artery; the long axes of these 
openings were parallel. The margins of the anterior 
opening in the artery were fused to the opening in the 
vein, forming an arteriovenous fistula, while the pos- 
terior opening communicated with the bullet wound 
tract. After separating the vessels, the openings were 
closed with fine silk and a band of deep cervical fascia 
was placed around the artery to reinforce the sutured 
line. A strip of the sterno-mastoid muscle was sutured 
between the two vessels. The sterno-mastoid muscle 
was replaced and the skin wound cloeed, except for a 
small drain in the lower angle. 

The patient is now in perfect condition. There is 
some keloidal formation, so common in colored people, 
but this can be removed by the use of radium. 

Cases 2 and 3+ (presenting patients)——Both of 
these cases were true aneurysms of the common carotid 
arteries. I am presenting them, because we have had 
such splendid results by partial occlusion of the arteries 
with autogenous fascia bands. 

L. M. S., a colored man 42 years of age, was ad- 
mitted to my service in the Emory University Unit of 
Grady Hospital for a swelling in the left side of the 

He was in poor condition for an operation on such an 
important structure as the common carotid artery. His 

¢These cases were reported in detail together with 
my method of applying the detached fascial band 
(Fascial Bands in the Treatment of Aneurysms. S. M. 
J., pp. 795-798, November, 1926) 



" BLL 

Case 4—(A) Sketch showing the oblong, almost 
fusiform, thin walled aneurysmal sac located just 
beneath the sartorius muscle. (B) Sketch showing 
=, proximal diverticulum lined with calcareous 

heart was enlarged and the vessels were moderately 
hard. The blood pressure varied from 150 over 84 to 
175 over 90; the pulse rate also varied from 56 to 70; 
and his blood Wassermann was strongly positive. Hop- 
ing to increase the clot in the aneurysmal sac and possi- 
bly get an improvement, we put him on large doses 
of potassium iodide and a low caloric diet with limited 
fluids. However, he did not improve, and a few days 
before the operation his diet and fluid intake were in- 
creased to prevent a post-operative acidosis. 

Operation —Local anesthesia with 1 per cent novocain 
was used. An incision, extending from the cricoid 
cartilage to the upper border of the sternum, then at 
right angles along the clavicle to its middle, was made; 
the inner third of the clavicle was removed to expose 
the thoracic portion of the artery. It was partly oc- 
cluded by an autogenous band of fascia drawn just 
tight enough to stop the pulsation, thrill, and bruit in the 
sac, but not tight enough to stop the pulsation in the 
temporal artery. The band was sutured in place with 
No. 1 chromic catgut and reinforced by a strip of mus- 
cle. The wound was closed, except for a small drain. 

Following the operation, the patient reacted and suf- 
fered no inconvenience for twenty-four hours, then he 
developed a hemiplegia, coming on as follows: aphasia, 
then motor and sensory paralysis of right side of face, 
shoulder, arm, forearm, and hand. The loss of sensa- 
tion extended only to the waist; the paralysis was only 
partial in the leg with no loss of sensation. About ten 
days later, this began to clear up and disappeared in 
the reverse order. At present, there is no evidence of 

July 1927 

the paralysis, except a slight wrist drop. He is com- 
pletely cured of the aneurysm. 

B. B., a colored man 40 years of age, gave a history 
of lues several years before he noticed the pulsating 
mass in the right side of his neck, for which he was 
seeking relief. The mass was about the size of a large 
lemon and presented all the symptoms and physical 
signs of an aneurysm. After our experience in the case 
just related, we did not attempt a period of preparation, 
but operated five days after admission. 

Operation.—Local anesthesia with 1 per cent novocain 
was used. The artery was exposed by an incision along 
the anterior border of the sterno-mastoid muscle, and 
partly occluded with an autogenous facia band. The 
wound was closed without drainage. When the patient 
was returned to the ward there was no pulsation in the 
sac. However, forty-eight hours later a slight pulsation, 
without thrill or bruit, could be felt in the upper pole. 
It disappeared in two or three days and the patient 
made an uneventful recovery. He was allowed to leave 
the hospital at the end of two weeks. At the present 
time, three months after operation, it is only’ two-thirds 
its original size, firm and movable. 

From our observation of these two cases (one 
a year after operation and the other ninety 
days), and three other cases (two of my own 
and one operated upon by the late Dr. E. G. 
Jones), I have concluded: 

(1) Partial occlusion with an autogenous 
fascia band is the method of choice in aneurysms 
of the common carotid artery, or in any aneu- 
rysm where the collateral circulation is insuffi- 


Figs. 4 and 5 
Case 5.—Shows the patient before and after opera- 

—- — 

— = ————— 

Vol. XX No. 7 

Fig. 6 
Photograph of the cyst sac blending with the kidney. 
(It contained 5,000 c.c. of fluid and weighed 16 
pounds.) The specimen was filled with and had 
been in formaldyhide solution twenty-four hours 
when the picture was made. 

cient, or where the arterial wall is badly dis- 

(2) Owing to the fact that the paralysis in 
Case 2 began to clear soon after stimulants and 
general diet were given, I now believe it would 
have been prevented had we given him a liberal 
diet and stimulants instead of the low diet be- 
fore operating. 

(3) Autogenous fascia bands have given no 
trouble with the wound healing in my cases, or 
in the experiments conducted by Dr. C. E. 
Waits at the suggestion of Dr. E. G. Jones. 

Case 4 (presenting lantern slides)—Traumatic aneu- 
rysm of the femoral artery in Hunter’s canal. The 
lantern slide shows you a very peculiar aneurysm sac, 
the result of a pistol bullet wound several years ago. 
Local physical signs were pronounced, and there was 
marked cardiac enlargement and decompensation. 

After a long period of rest in bed and efforts on the 
part of the medical department to build up the heart 
had failed, we decided to attempt an operation with 
the idea that it might be an arteriovenous aneurysm, 
though all the features of Branham’s syndrome were 

Operation.—Local anesthesia with 1 per cent novocain 
was used. The artery was exposed above the sac. It 
was dilated and thickened, but tough and leathery in 
feel and appearance. A rubber tube was thrown around 
it and clamped in the usual way. Pulsation stopped 
and the sac collapsed. The vein was seen lying along- 
side, but not involved. 

When the sac was opened a most interesting feature 
was presented. At the proximal end there was a divertic- 
ulum about one inch deep and three-fourths of an inch in 
diameter lined by flakes of calcareous material. Beyond 
this was a fusiform sac three and a half inches long; 
near the distal end was a smaller diverticulum projeet- 


ing outward beneath the sartorius muscle. The sac 
terminated in a small opening from which the blood 
continued on through the femoral artery. 

The enlarged artery was ligated with two strands of 
No. 1 chromic catgut. The proximal opening was 
sutured within the sac and the wound closed. The pa- 
tient made a slow recovery, as there was 2 great deal of 
drainage. However, there were no changes in the 
cardiac condition that could not be accounted for by 
the rest and digitalis. 

Case 5 (presenting patient) —This is a large unilocular 
cyst of the kidney in a child 2.5 years old. I am going 
to take advantage of a few remaining moments of my 
time to show you a child from whom I removed the 
largest unilocular cyst of the kidney ever reported, so 
far as we can find. She had all the appearance of a 
woman at full term; she weighed 35 pounds previous 
to the operation and 19 pounds after her return to the 
ward. The abdomen was opened and the cyst removed 
by trans-peritoneal route, first by aspiration, then blunt 
dissection. The vessels and ureter were ligated sep- 
arately. The cyst contained 5000 c.c. of a clear fluid, 
and the combined weight of the fluid and cyst wall was 
16 pounds. 

As you see, the child looks well and has only a small 
scar to the left of the umbilicus through which the mass 
was removed. 

436 Peachtree Street. 


By Howarp Kine, M.D., 
Nashville, Tenn. 

In the past I held an erroneous conception 
of sporotrichosis and regarded it as a rather 
simple affair, more or less localized in nature, 
and showing no great amount of tissue destruc- 
tion. Since others may still hold this view, I 
desire to review the condition briefly and to re- 
port a case. 

The disease was described first by Link in 
1809. In 1844 Montague also called attention 
to it, but the first accurate description of it was 
in 1898 when Schenk reported a case in which 
the organism was recovered from the patient, 
cultured on different media, and inoculations 
were made into dogs, guinea pigs and white 
mice. This case was treated in 1896 at the 
Johns Hopkins Hospital and reported in the 
Bulletin of December, 1898. Between 1902 and 
1912, de Buerman and Gourgerot collected over 
two hundred cases from France. Since the re- 
port of Schenk’s case, the disease has been found 
in almost every country on the globe, cases hav- 

*Read in Section on Dermatology and Syphilology, 
Southern Medical Association, Twentieth Annual 
Meeting, Atlanta, Georgia, November 15-18, 1926. 


Fig. 1 

Surface growth on agar slant— 
four weeks. 

ing been reported from Germany, Switzerland, 
Spain, Italy, England, Turkey, Madagascar and 
Ceylon. The disease appears to have been espe- 
cially prevalent in Brazil and the United States. 
In the United States it has occurred in over half 
the states and has received careful study by nu- 
merous physicians and veterinarians. The 
American cases, with rare exceptions, have been 
of the simple localized type, such as those re- 
ported by Trimble, Davis, Hyde, Sutton, Blais- 
del, Foerster, Cole and others. 

This type usually begins as a trifling injury 
in the nature of an abrasion which does not heal 
promptly and is usually located on the hands or 
feet. In from three to six weeks an indurated 
nodule develops at the site of the abrasion which 
gives little or no pain, is bluish or purplish in 
color, and a few days later softens in the center, 
leaving a cup-like area of fluctuation with an 
indurated border. Incision at the point of fluc- 
tuation allows the escape of a seropurulent or 
gelatinous material, leaving an indolent crateri- 
form sore with overhanging edges and a reddish 
granular base. Sometimes crusts of variable 
thickness appear. In two or three weeks, other 


July 1927 

nodules form, similar to the first and situated 
along the lymph channels for a distance of one 
to six inches. Between the nodules there is 
often a small, hard ridge. As many as five or 
six may occur in a single chain. These nodules 
produce very little discomfort and no marked 
illness and remain indefinitely unless they are 
diagnosed and treated by saturating the patient 
for four to six weeks with potassium iodid. 

The object of this paper is to call attention 
to and emphasize a type of case which from a 
pathological standpoint infinitely transcends the 
type just described. It is very different 
in appearance and severity and resists the ordi- 
nary treatment by potassium iodid so that it is 
difficult to realize that one is dealing with the 
same malady. De Buerman, writing in the 
British Medical Journal of August 10, 1912, re- 
fers to the lesions of this more serious type as 

“We have described large subcutaneous cold abscesses 
and gummatous lymphangitis with gummata arranged 
according to size along the affected limb as involve- 
ments of the lymphatic glands. We may further ob- 
serve in the same patient cutaneous lesions of different 

forms, papules, vesicles, vesicopustules, pustules of 
greater or smaller size, ulcero-crustaceous lesions, lupoid 

Fig. 2 
Colonies on agar plate; fuzzy border is composed of 
mycelial threads; indirect illumination; low power. 

Vol. XX No.7 

Fig. 3 
Hanging drop preparation; yeast-like germination of 

infiltrations, ulcerated or non-ulcerated, which resem- 
ble tuberculous lupus, patches of fungating and weep- 
ing papillae or verrucose and squamous sporotrichotic 
lesions which resemble tuberculosis verrucosus and 
trichophytoid kerion, epidermic lesions, trichophytoid 
lesions of the epidermis surrounding an ulceration the 
pus from which has inoculated the epidermis, acneform 
folliculitis, vesicles, eczematoid or pityriasic patches, 
pemphigus, ulcerating or papillomatous lesions of the 
mucosa, lesions of the muscles, bones, synovial mem- 
branes resembling syphilitic or tuberculous gummata, 

The disease may attack the various tissues of 
the body, except the nervous system, which is 
rarely, if ever, involved. De Buerman’s cases 
all promptly responded to treatment with potas- 
sium iodid. 

A fatal case in a negro man was reported by 
Warfield in the American Journal of Medical 
Sciences in 1922. This case presented wide- 
spread lesions of the skin and subcutaneous tis- 
sues and a definite lesion in the right lung. He 
was under potassium iodid treatment at the time 
of his death. 

Pels, in the Archives of Dermatology and 
Syphilology, September, 1926, reported a case 



crustaceous nature. This case responded poorly 
to potassium iodid treatment, but showed 
marked improvement in areas when x-ray treat- 
ments were supplemented. At the time of the 
report he had not entirely recovered. 

With the exception of these two cases, all 
others that I could find reported in this country 
have shown no tendency to widespread dissem- 
ination, and most of them have responded 
promptly to treatment. 

Usually the organism is recovered easily and 
in most instances shows a disposition to grow 
freely on certain media, especially gelatin glu- 
cose agar. The growth is generally quite char- 
acteristic. The organism is rather resistant, 
being able to withstand moderate extremes of 
temperature and sunlight. It may grow on va- 
rious forms of vegetation, whether living or dead, 
such as bark, thorns, etc. Foerster has noted 
cases in workers injured by the thorn of the 
barberry shrub. It is noteworthy that in differ- 
ent parts of the United States horses have had 
this infection, usually diagnosed epizootic lym- 
phangitis. Meyer, in San Francisco in 1913, 
accidentally inoculated his hand while working 
with equine strains. Individuals may become 
carriers, the organism being lodged in the 
pharynx or in the intestinal tract. Horses and 
other animals at times become carriers. Thus 

. . | Fig. 4 
of widespread cutaneous lesions chiefly of a deep panging drop preparation; sporophore with conidium. 

Fig. 5 
Photograph of active lesions on nose and 
other parts of face. 

it can readily be seen there are numerous ave- 
nues of contact, and it is not surprising that 
the disease covers a wide territory. Under the 
circumstances, it appears strange that more hu- 
mans do not contract the disease and that the 
lesions are not oftener of a diffuse character. 


J. H., a colored laborer, age 47, was admitted to the 
Vanderbilt Hospital December 22, 1925. Most of his 
life had been spent in North Carolina and Georgia. 
For the preceding three years he had lived in Nashville, 
Tenn. For the preceding two years he was an employe 
in a snuff factory. 

His chief complaint was multiple cutaneous and sub- 
cutaneous sores on the face, forearms, feet and legs. 

Present Illness—On May 15, 1925, he sustained a 
trifling injury to the dorsal surface of his left foot, 
produced by a truck. There was no abrasion of the 
skin, but slight edema ensued. Three days later the 
right foot showed swelling on the dorsal surface and 
there was also swelling in the right ankle. Seventeen 
days after the injury the swelling on the dorsal surface 
of the left foot was incised and a small amount of pus 
evacuated. About the same time, on the top of the 
right foot, three or four small abscesses developed, rup- 
tured and coalesced. Six weeks after the onset, a small 
abscess appeared on his chin. Three weeks later, this 
was followed by a sore on the right nostril which 
rapidly involved the entire right side of his nose. One 
month later a lesion occurred on the right upper eyelid 
and at the same time one on the skin of the dorsal 
surface of the middle finger of his right hand. Similar 
lesions then appeared on both wrists and forearms. All 
of the lesions sooner or later discharged pus from va- 
rious points, leaving ulcerations or thick crusts. The 
lesions were continuously painful, tending to discharge 
and dry up from time to time. The patient was never 
very ill. Occasionally there was some aching and malaise 


July 1927 

The appetite was not greatly 
impaired at any time. On July 3 he was admitted to 
the Nashville General Hospital for ten days. No spe- 
cial treatment was instituted. On July 14 he was ad- 
mitted to the Hubbard Hospital, where he remained 
three weeks. He re-entered Hubbard Hospital Sep- 
tember 1 for a six weeks’ stay. Five hypodermic treat- 
ments at eight-day intervals were administered. The 
patient did not know the nature of the remedy used. 

The previous history was unimportant. There was 
no evidence of tuberculosis or syphilis. 

The family history was negative. 

Physical examination showed the patient to be fairly 
well nourished, considering the duration of his illness. 
The most striking features were the unusual lesions on 
his face, hands, forearms, feet and legs. There was a 
generalized, smooth swelling of the soft parts of the 
left instep reaching from the base of the toes to the 
ankle, in the center of which was an old incisional scar. 
The swelling was soft and fluctuating in spots. Brownish 
pus could be squeezed from the site of the old incision. 
Above the left ankle were two oval areas of granulation 
tissue 3 by 4.5 cm. in size. The edges were sharply 
defined, and punched out ulcers appeared with granula- 
tion tissue rising above the margins. The right foot 
had a similar appearance, showing three ulcerated areas, 
one extending up the center of the leg, the largest oc- 
cupying the lower third of the leg. A few small nodules 
may be seen over the malleoli. One large fluctuating 
area with thin walls appeared ready to rupture. The 
hands showed numerous lesions. The left thumb pre- 
sented an ulcerating crustaceous area over the terminal 
phalanx and a similar area over the proximal phalanx. 
The outer aspect of the wrist presented a large grayish 
area covered with crusts. There were numerous lesions 
on the right hand similar to those just described. The 
largest one was situated on the dorsal surface of the 
middle finger. There was a large lesion situated over 
the first metacarp-phalangeal joint. The dorsal sur- 
face of the hand presented a purplish area 1 by 2 cm., 
which was elevated and fluctuating. The lesions gave 
an impression of abscesses which had ruptured and 
crusted over. There was very little induration. The 
lesion on the chin presented a striking appearance, being 

for twe or three days. 

Fig. 6 
Photograph of lesions on hands. 

Vol. XX No. 7 

Fig. 7 
Photograph of lesions on feet and legs. 

vesicular and having a crater in the center. This area 
was 2 cm. in diameter and had definitely indurated 
edges. The nose was almost entirely covered by a 
lesion which had a papilliform, slightly nodular, bulbous 
appearance. There were points of softening here and 
there in this area. The lesion on the nose extended well 
down on the right cheek, where there was a definite 
raised ulcerated area surrounded by skin which ap- 
peared fairly normal. The right upper eyelid was red, 
swollen, ulcerated and crusted, especially on the outer 
half. The lower lid was slightly involved with a sim- 
ilar process. There was a general enlargement of the 
lymphatic glands, which was marked in certain regions. 
On the right side of the neck and on the left side 
posteriorly the glands were diffuse and nodular. The 
axillary glands were palpable. Both epitrochlears were 
greatly swollen and tender. The inguinal glands were 
enlarged and on the left side presented a visible mass. 
The left knee joint was distended with a large amount 
of fluid. The mouth, chest, abdomen and genitals 
were negative. X-ray examination of the chest showed 
rather marked peribronchial thickening, with some 
calcification about the lung roots. This suggested an 
old inactive tuberculosis. There was some absorption 
of the calcium salts in both feet and about the left knee 
joint, but there were no destructive areas. The blood 
Wassermann was negative. His hemoglobin was 65 per 
cent, white blood cells were 12,000, and his temperature 
fluctuated around 100° F. 

The diagnosis of sporotrichosis was suggested by Dr. 
G. Canby Robinson. 

Cultures were taken by Dr. Hugh Morgan, who re- 
ported as follows: 

“No difficulty was encountered in obtaining growth 
in pure culture on the usual laboratory media. Dex- 



trose agar seemed to yield the most abundant culture 
in the shortest time. The same organism was obtained 
on several different occasions from pus aspirated from 
fluctuant gummata situated on the lateral aspect of the 
left ankle, the scrotum, and the wrist. No organisms 
of any sort were found in direct smears of the pus 
stained by either the Gram method, carbol fuchsin or 
methylene blue. Cultures of pus were made in acid 
agar (Sabouraud’s), dextrose agar, blood agar and dex- 
trose broth, and growth was obtained in each instance. 
Growth was more rapid and abundant on dextrose 
agar plates at room temperature than in the other 
media employed at incubator or at room temperature. 
Growth became visible after about five to seven days 
as small pale colonies. These steadily grew in size, be- 
came confluent, and at the end of three or four weeks 
covered the entire surface ef the media. As the growth 
aged, the surface became wrinkled and cream-colored. 
Invasion of the media occurred by extension down- 
ward of the surface growth. In liquid media growth 
occurred in the bottom of the tubes in the form of 
whitish balls with somewhat fuzzy edges. 

“On microscopic examination the organism was found 
to possess septate hyphae, showing some branching. 
Spores were present in abundance in some preparations 
and scanty in others. Ascospores were not observed. 
Exact classification of the organism has not been at- 
tempted. It seems justifiable to designate it as belong- 
ing to the genus Sporotrichum.” Photomicrographs of 
the hanging drop cultures in broth will be shown. 

Treatment—Potassium iodid was administered in- 
ternally in thirty grain doses after meals three times 
daily and the lesions were dressed with a diluted Lugol’s 
solution. Within a few days the patient showed im. 
provement which was very marked at the end of six 
weeks. In February, enlargement of the testes was no- 
ticed. The entire scrotum showed thickening with in- 
durated areas on either side and fluctuation shortly ap- 
peared on the left side. Palpation showed the left 
testicle and epididymis greatly enlarged and the right 
testicle slightly enlarged, apparently surrounded by fluid. 
Aspiration of this area yielded 130 c.c. of clear fluid and 

Vig. 8 
Photograph ef lesions in scrotum. 


aspiration of the left scrotal wall yielded 2 c.c. of pus 
from which cultures were made, and the organism 
grew in two weeks. Sodium iodid was then given in 
15 to 30 grain doses intravenously every five days, but 
no improvement was noted in the lesions about the 
testes or scrotum. Several consultants suggested cas- 
tration, but we thought it advisable to try x-ray first. 

The first treatment by x-ray was instituted on March 
25, 1926, with the following factors: 7 inch spark gap, 
5 milliamperes, 5 minutes, 5 mm. aluminum filter and 
12 inch distance. The treatment was repeated every 
two or three weeks. After the second exposure, slight 
improvement was noted, and in two months there was 
marked improvement in the genital lesions. The skin 
lesions disappeared and the patient was discharged from 
the hospital on April 15, 1926. He was instructed to 
return to the out-patient department for further radia- 
tion. Ninety grains of potassium iodid daily and 15 
grains of sodium iodid intravenously at five day in- 
tervals were continued. 

The patient failed to report for treatment after July 
19, 1926, until October 4, 1926. On the latter date he 
presented himself in the clinic and examination revealed 
a definite increase in the lesion in the left testicle and 
epididymis and also a recurrence of the lesion on his 
eyelid. An x-ray treatment of these lesions was ad- 
ministered, the factors on the eyelid being 5 inch gap, 
5 milliamperes, 1 mm. aluminum filter, 3 minutes and 
12 inch distance. 

When seen two weeks later, the testicular lesion was 
much improved and the eyelid almost clear. Potassium 
iod). treatment was again administered and at the 
present time the patient’s general health is fairly good. 
He has gained weight and strength and is able to do 
light labor. 


(1) Sporotrichosis as a rule is a simple localized dis- 
ease. Such cases are not serious and respond promptly 
and satisfactorily to treatment with iodid saturation. 

(2) Diffused, infiltrating, gummatous cases are very 
rare. They resist much more stubbornly the potassium 
iodid treatment, but will show definite improvement or 
cure when radiation is combined with potassium iodid. 


De Buerman: Brit. Med. Jour., August 10, 1912. 
. Warfield: Amer. Jour. Med. Sci. 

Pels: Arch. Dermat. and Syphil., September, 1926. 
. Foerster: J. A. M. A., 1926. 

. Meyer: J. A. M. A., August 14, 1915. 

Ol wm CO bo et 

DISCUSSION (Abstract) 

Dr. Earl D. Crutchfield, Galveston, Tex—Ordinarily, 
we think of sporotrichosis as a disease with a predilec- 
tion for lymphoid tissue. In the case presented by Dr. 
King, the clinical picture which is so different from the 
usual picture is probably due to the unusual conditions 
and environment in which the fungus is growing. Sev- 
eral years ago Dr. M. L. Graves reported a case of 
sporotrichosis of the lungs, which occurred in Galveston. 

Dr. Bedford Shelmire, Dallas, Tex—Cases of wide- 
spread sporotrichosis of this type frequently respond 
very slowly, or not at all, to potassium iodid therapy. 
The generalized type of sporotrichosis is apparently rare 
in this country, yet a considerable number of cases 
have been reported in France. I have had the op- 
portunity of observing two examples of this type in 
America, the first while I was assisting Dr. Howard 


July 1927 

Fox. His patient, a young marine, presented a gen- 
eralized type of gummatous sporotrichosis of two years’ 
duration, and showed little improvement under potas- 
sium iodid therapy. In a second case, seen in private 
practice, surgical removal of the arm was necessary. A 
widespread sporotrichosis of the arm and chest was lit- 
tle influenced by the oral administration of massive doses 
of potassium iodid. 

I suggest that Dr. King try the intravenous injection 
of Lugol’s solution in this patient, giving 3-5 c.c..of the 
drug at each injection and repeating the injection every 
two days until some ten or more doses have been given. 
In my hands this has proven a specific for sporotrichosis. 

Dr. King (closing).—As I stated in the paper, sporo- 
trichosis cases that I have seen heretofore have been 
such simple affairs and so easy to treat that when I 
struck this one I was astonished at its resistance to 
treatment. I appreciate Dr. Shelmire’s suggestion as 
to the intravenous administration of Lugol’s solution in 
large doses. 

Another point I wish to emphasize is that this man 
got well in one part of the body and at the same time 
had a recurring lesion in another. We did, by safe 
radiation, bring about a resolution of these recurring 


By WiLt1AM Barnett Owen, M.D.,** 
Louisville, Ky. 

Sir Benjamin Brodie, in 1850, first described 
a chronic inflammatory lesion occurring in the 
articular extremity of the tibia, terminating in 
the formation of a localized abscess in the center 
of the bone, but contiguous to the joint. He 
pointed out with great accuracy the pathological 
changes, but not the causative organism. He 
simply trephined the bone over the abscess 
cavity in six cases with complete relief of symp- 
toms. His original description of the symp- 
tomatology, prognosis and treatment of the lesion 
stands as a classic at the present day. At that 
time most chronic inflammatory bone lesions 
were considered tuberculous in origin, although 
Brodie in his original description does not specifi- 
cally state that he considered the process to be 
tuberculous in nature. However, the literature 
on the subject, particularly some of the modern 
treatises on surgery,° still consider the tubercle 
bacillus the chief offending organism. With the 
refinement of bacteriological technic, the condi- 

*Read in Section on Bone and Joint Surgery, South- 
ern Medical Association, Twentieth Annual Meeting, 
Atlanta, Georgia, November 15-18, 1926. 

**Thanks are due Dr. R. Glen Spurling, of the 
Louisville City Hospital, for his assistance in compil- 
ing the data incorporated in this paper. 

Vol. XX No.7 

ris. + 
Shows outline of location of Brodie’s abscess. 

tion has been definitely shown to be due to low- 
grade pyogenic organisms, particularly the 
streptococci.” 7 

Pathology.—According to Alexis Thompson,® 
there first develops in the center of the bone a 
cavity which is filled with serum and lined with 
a membrane like the periosteum of young bone. 
This membrane apparently forms new bone of a 
spongy nature. Surrounding the cavity the old 
bone is sclerosed and the medullary cavity is 
obliterated. Later, as Brodie pointed out, the 
cortex of the bone may be greatly thickened 
from the associated periostitis in the region of 
the lesion. The common findings, when one 
opens one of these abscesses, are a circumscribed 
cavity filled with spongy bone and gelatinous 
material from which staphylococci can usually 
be grown. Surrounding the cavity the bone is 
unusually hard and like ivory. Periosteal reac- 
tion may or may not be present. 

Brodie’s original description was based upon 
lesions situated in the upper end of the tibia at 
about the level of the tuberosity. Since then 
similar lesions have been observed in the ex- 
tremities of most of the long bones of the body 
and all of these lesions, regardless of location, 
have become known as “Brodie’s abscesses.” 

The greatest number of cases we have been 
able to find in the literature are those published 
by Alexis Thompson.’° In his series of one hun- 
dred and sixty-one cases he found that 74 per 
cent of the lesions occurred in the tibia; 11 per 
cent in the femur (lower end); 11 per cent in 
the humerus; 3 per cent in the radius, and 1 per 
cent in the ulna. These figures probably repre- 
sent a fairly accurate estimation of the inci- 



dence of location of the lesions. Just how fre- 
quently the condition is encountered is prob- 
lematical, as the literature on the subject is 

McWilliams® states that at the Presbyterian 
Hospital in New York, of one hundred and fif- 
teen cases of chronic suppurative osteomyelitis 
of the long bones, there were three of undoubted 
Brodie’s abscesses (2.6 per cent). Perhaps this 
estimate is too low, as the author has observed 
four proven cases during the last two years in 
general surgical clinics where the number of 
chronic bone cases is distinctly limited. 

Diagnosis —Usually a history of predisposing 
trauma can be elicited. However, this is not 
always the case. Often the patient gives a his- 
tory of osteomyelitis or some long-standing in- 
fection during childhood. The usual age is young 
adult life, according to the recorded cases and 
our own observations. Localized pain and ten- 
derness over the extremity of a long bone are 
the first and most predominating symptoms. 
The pain is usually dull and aching in character, 
and is often passed with a diagnosis of “rheu- 
matism.” There frequently are periods of ex- 
acerbation and periods of entire relief. More 
often, however, the patient is partially or com- 
pletely incapacitated. Chronicity is the keynote 
of the condition. The pain is commonly thought 
to be in the joint, but when pressure is applied 
the maximum point of tenderness is always 
found to be over the involved bone. Movement 
usually increases the pain. There may or may 
not be fever, most frequently not. The pain is 
worse at night, and therefore emaciation and 
exhaustion from sleeplessness are often encoun- 

Fig. 2 
Shows same condition after operation and regenera- 
tion of ne. 

Fig. 4 

Wound healed and shows normal 
range of motion. 

Fig. 3 
After operation. 

The roentgenographic evidence is quite char- 
acteristic. ‘Phere is a less dense translucent area 
in the center of the bone, which is circumscribed 
and well outlined. Surrounding this rarefied area 
there is a more dense shadow which represents 
the ivory-like bone overlying the abscess cavity. 
There may or may not be periosteal reaction. 

Treatment.—Simple drainage of the abscess 
cavity by trephining, as advocated by Brodie, 
remains the treatment of choice even at the 
present day. In addition, it is well, perhaps, 
thoroughly to evacuate the cavity by vigorously 
curetting the spongy bone and inflammatory 
exudate. We have practiced drainage for seven 
to ten days with gentle irrigation with Carrel- 
Dakin solution twice daily. After that, the 
wound is allowed to granulate from the bottom. 

Prognosis.—Of course, the hope for a complete 
cure depends upon several factors, most impor- 
tant of which are: (1) the amount of involve- 
ment of the nearest joimt. (2) The amount of 
associated periostitis. (3) The thoroughness 
of the drainage. (4) The response of the pa- 


July 1927 

tient to general treatment for chronic sepsis. 
On the whele, the outlook for a complete cure is 
excellent, especially in an uncomplicated case. 

The following case is of especial interest be- 
cause of the location of the lesion. Brodie’s 
abscess of the greater trochanter of the femur is 
not unusual, but an abscess localized in the neck 
of the femur is distinctly rare. 


The patient, a white American man, aged 20 years, 
entered the Louisville City Hospital complaining of 
_— and tenderness on the outer aspect of his right 

He was employed as a stock boy in a local factory. 
The family history was negative. In the past history 
we found that he was admitted to the ward of the 
Louisville City Hospital in 1915 because of nasal ob- 
struction. At that time the tonsils and adenoids were 
removed. He had measles in childhood, but had none 
of the other acute infectious diseases. In fact, his gen- 
eral health had always been excellent aside from the 
present complaint. The remainder of the past history 
was entirely negative. 

The patient dated the beginning of his present illness 
from ten years previously when he fell and struck his 
right knee. The knee was quite painful and swollen 
for several days, and the symptoms then subsided only 
to recur at frequent intervals during the next three or 
four years. At that time the pain was never referred 
to any part of the leg except the knee. 

Four years previously the patient began having 
transient attacks of pain in the region of the right hip. 
The pain would persist for three or four days and then 
subside, only to recur at intervals of from one to two 
months. During these attacks he was unable to walk 
without limping, and when reclining in bed he felt more 
comfortable if the affected leg was somewhat flexed. 
The pain often kept him awake at night during these 
attacks. There was no history of night sweats, loss of 
weight, or anorexia. During the intervals when the 
patient was free from pain, he was unhampered by 
stiffness or soreness in the region of the hip. How- 
ever, during the attacks of pain he was almost totally 
incapacitated. He does not recall that he had any 
fever with the attacks. 

During the preceding year the attacks of pain had 
been more frequent and of greater severity. Three 
weeks before admission, following an attack of pain in 
the hip, the patient noticed a localized swelling of the 
soft parts at the level or just below the right greater 
trochanter. This swelling was hot, red and tender. 
Coincident with the development of this swelling the 
pain in the hip subsided, and he was able to move his 
leg without discomfort. He came to the dispensary of 
the Louisville City Hospital and was referred to the 
surgical department with the diagnosis of “osteomye- 
litis of the femur.” 

Physical examination showed the patient to be a 
somewhat undernourished boy of twenty, lying quietly 
in bed, with the right knee moderately flexed. He 
complained of pain in the region of the hip. The en. 
tire physical examination was negative, except for the 
local condition. 

In the soft tissues of the right hip, just below the 
level of the greater trochanter, there was a hot, red, 
fluctuant swelling about the size of a small orange. 

Vol. XX No.7 

There was considerable edema of the soft tissues about 
this swelling. The abscess was pointing. Movement 
of the hip caused extreme pain in the region of the 
swelling. This was particularly true of abduction and 
adduction. No pain was referred to the hip joint. 

Clinical Data —His temperature ranged between nor- 
mal and 99.6° F.; his pulse rate between 80 and 110. 
Blood examination showed 28,000 leucocytes, 5,600,000 
erythrocytes, and the blood Wassermann reaction was 
negative. The roentgenogram of the hip is shown in 
Fig. 1. 

Clinical Course—As the abscess was pointing and 
rupture obviously impending, it was incised and ap- 
proximately one-half pint of yellowish pus was evac- 
uated. Smear of the material revealed many pus cells 
but no organisms. Cultures showed Staphylococcus 

Following evacuation of the abscess, the patient was 
much more comfortable. However, his temperature and 
leucocyte count remained about the same. The dis- 
charge and inflammation about the abscess subsided 

On the twenty-third day of his stay in the hos- 
pital, the right hip was explored through an anterior 
incision at the level of the greater trochanter. The 
muscles and ligaments were divided in line with their 
fibers, and the anterior aspect of the capsule of the 
joint was exposed. A longitudinal slit was made in the 
capsule and the anterosuperior portion of the neck was 
brought into view. A drill hole was made in the bone 
at the level of the abscess cavity as shown by the 
roentgenogram. The drill passed through a very thick 
cortex of bone into a soft, mushy substance. The over- 
lying shelf of bone was removed with rongeur forceps 
and the entire abscess cavity was exposed. It was 
filled with a gray, gelatinous material and spicules of 
soft bone. These were thoroughly removed with the 
curette. The abscess was surrounded on all sides by 
dense, hard bone. A small opening in the anterior 
surface of the neck was demonstrated with the probe; 
this undoubtedly represented the site of perforation of 
the original abscess. The probe could be passed from 
the opening of the abscess on the outer aspect of the 
thigh directly through the soft tissues to the opening 
in the bone on the anterior surface of the neck. Two 
small rubber tube drains were inserted and the wound 
partially closed in layers. The patient was placed on a 
Bradford frame and no other form of immobilization 
of the hip was attempted. 

The patient made a prompt recovery from the oper- 
ation. The wound continued to discharge pus in grad- 
ually diminishing amounts. The temperature, pulse and 
respirations have been normal since the second post- 
operative day. 

Fig. 2 shows the roentgenographic picture of 

the hip joint forty-nine days after the operation. 
The abscess cavity seems to be practically obli- 
terated when the films are examined in the 
stereoscope. The wound now has practically 
ceased to discharge. There is still slight limita- 
tion of motion, especially in extension and ad- 
duction. There is no demonstrable shortening. 
Pathological examination of the curettings, 
and a piece of soft tissue from the sinus tract, 
shows “chronic inflammatory tissue with no 
microscopic evidence of tuberculosis.” 



The development of the abscess in the soft 
tissues is self-explanatory. Undoubtedly the 
abscess in the bone, which had probably been 
present for at least four years, broke through 
the cortex of the bone and the infected material 
passed downward along the muscle and fascial 
planes to a point in the region of the greater 

The prognosis in this case certainly seems to 
be favorable. There probably has been some 
arthritis of the hip joint, as it is impossible to 
conceive of the lesion’s existing within the cap- 
sule of the joint without there having been some 
involvement of the articular surfaces. The ab- 
sence of roentgenographic evidence of path- 
ological changes in the joint makes the hope of 
securing a good functional joint all the more 


Surg. Clin. of Chicago, p. 743, 1919. 
Ann. Surg., 65:483, 1917. 

. Bevan: 
. Brechner: 
oe Jour. Bone and Joint Surg., 5:492-500, 

. Bryant and Buck: 
Wm. Wood & Co., N. Y., 1907. 

\ : Modern Surgery, Ed. 8, W. B. Saun- 
ders Co., Phila., 1919. 




4 Amer. Prac. of Surg., p. 314, 

: Dowd: Ann, Surg., 64:112, 1906. 



- Martin: Ann. Surg., 66:254, 1917. 

. McWilliams: Ann. Surg., 74:568-578, 1921. 

. Miller: Ann. Surg., 67:460, 1918. 

3 es Alexis: Edin. Med. Jour., 19: April, 

Francis Building. 

DISCUSSION (Abstract) 

Dr. Wm. T. Graham, Richmond, Va.—Brodie’s abscess 
occurs so relatively infrequently that we cannot get a 
rich clinical experience in it. Dr. Brackett is the out- 
standing figure in bone and joint surgery in the States, 
and I am going to ask the Chairman if he will let Dr. 
Brackett take my place in the discussion. 

Dr. E. G. Brackett, Boston, Mass——Dr. Owen’s advice 
to treat the cases of Brodie’s abscess which have lighted 
up, and have become active and present indications 
for operation by evacuation and drainage, is sane. I 
believe it to be the safer method. On the other hand, 
there is a large number of cases of Brodie’s abscess of 
long duration, which are in general quiescent, but which 
have frequent exacerbations and periods of increased 
pain. The x-ray shows them to be more or less walled 
off with normal bone in the surrounding areas. These 
cases can ordinarily be successfully treated by opening, 
thoroughly cleaning out, wiping with crude carbolic and 
alcohol, and closing, allowing them to heal by first in- 
tention. A very large percentage of cases can be 
treated successfully by this method, which obviates the 
risk of drainage to the bone and diminishes the time of 
the otherwise long convalescence. 

The larger number of cases are found in the shaft of 
the bone, and it has been claimed that they never in- 
vade the epiphysis, but when such abscesses are found 
involving or passing through the epiphyseal line they 
are tuberculous. This probably is in general true, but 
occasionally we find non-tuberculous abscesses, which 
invelve the eniphyseal line, and sometimes invade the 


epiphysis. This has happened a few times in my ex- 
perience, and the diagnosis was proved, by the finding 
of a pure culture of Staphylococcus aureus. 

Occasionally there is difficulty in locating these local 
and isolated abscesses. I saw a young boy who com- 
plained of pain in the knee, accompanied by a definite 
limp. The knee showed no evidence of involvement of 
any kind, and the limp was not particularly suggestive 
of knee-joint origin. The x-ray of the whole femur 
disclosed a definite Brodie’s abscess in the shaft of the 
femur just below the level of the trochanter quite well 
walled off, with no symptoms in the hip except that of 
the limitation in the extremes of flexion and abduction. 
Many abscesses, we must remember, are of milder de- 
gree, and in a way are self-limited, rather definitely 
and thoroughly walled off, and may remain permanently 

Dr. Arthur M. Shipley, Baltimore, Md—lIn operat- 
ing for Brodie’s abscess and in the removal of small 
sequestra, the surgeon is in the habit of doing a great 
deal of damage to good bone. This rough handling of 
the involucrum leads to later sequestration and a pro- 
longed convalescence. 

If we could remember always to enter these cavities 
and to do whatever we have to do with a minimum of 
handling; if we bore in mind that the ordinary burr 
generates much heat, we should do less operative dam- 
age to the bone. If we directed much more of our at- 
tention to gentle handling of the bone in these chronic 
cases, the repeated operative procedures which are nec- 
essary would not be followed so often by secondary 
sequestration and prolonged sinus formation with drain- 

Dr. R. L. Diveley, Kansas City, Mo—Most of these 
cases can be opened and thoroughly cleaned out and 
closed immediately. The infection is of a low grade 
nature, yet I do not believe the cases can be success- 
fully treated or evacuated by drill holes. I have never 
felt that any percentage of infection of the bone, such 
as osteomyelitis, or Brodie’s abscess, could be success- 
fully evacuated and treated by drill holes. If these 
cavities are thoroughly curetted and cleaned out and 
followed by chemical cautery, they can be closed im- 
mediately and will heal by primary intention. 

Dr. Owen (closing).—This case interested me pri- 
marily because of the unusual location of the Brodie’s 
abscess, and secondarily, because the infection extended 
into the capsule of the hip without infecting the joint. 


By Ratpy N. GREENE, M.D., 
Jacksonville, Fla. 

The author who remarked that 

“Errors like straws upon the surface flow, 
He who pearls would find must dive below” 

might very properly have had in mind the en- 
grossing problem of intracranial diagnosis. 

*Read in Section on Neurology and Psychiatry, 
Southern Medical Association, Twentieth Annual 

Meeting, Atlanta, Georgia, November 15-18, 1926. 


July 1927 

No form of illness calls for more painstaking 
diagnostic effort. The burden of proof as to 
the presence of an intracranial lesion lies with 
the physician who denies its existence and not 
with the clinician who alleges its presence. This 
impression is entertained for the reason that 
with the development of more refined methods 
of diagnosis, mechanical and otherwise, certain 
cases which would, under other conditions, be 
classified as non-surgical, are now amenable to 
satisfactory operative procedures. 

With the rapid development of intracranial 
diagnostic methods, we have reached a point 
wherein the neurologist, because of the develop- 
ment of neuro-surgery, is no longer laboring 
under the odium of dealing with the hopeless 
problems of degenerative lesions of the central 
nervous system. The increasing frequency of 
surgically accessible central nervous system 
lesions has brought a degree of optimism into 
the field of neurology because of cures in a cer- 
tain group of patients who have heretofore been 
regarded as hopeless. 

It is probably not unwise to adopt the posi- 
tion that a patient presenting widespread symp- 
toms of intracranial disease should center upon 
the hope that he has a surgical lesion, for other- 
wise he is usually classified as beyond the possi- 
bility of therapeutic aid. 

With the advent of rapid transportation, head 
injuries are being encountered as frequently as 
the classically inflamed appendix. The injury 
cases presenting immediate symptoms are be- 
ginning to be handled in a manner indicating 
understanding of the proper approach. The de- 
layed symptoms in certain head injury cases are 
at times overlooked, particularly the cases of 
subdural hematoma usually described as chronic 
pachymeningitis hemorrhagica interna. For 
those who wish to profit by an adequate de- 
scription of this condition, an article by Dr. 

-Tracy Jackson Putnam, entitled “Chronic Sub- 

dural Hematoma; Its Pathology; Its Relation 
to Pachymeningitis Hemorhagica and Its Sur- 
gical Treatment, with Cases Contributed by 
Members of the Society of Neurological Sur- 
geons, with Prefatory Note by Harvey Cushing, 
M.D.,” which appeared in the Archives of Sur- 
gery (2:No. 3, Sept., 1925), and may be re- 
viewed with profit. It is stated in this article 

“One of the first recorded cases of subdural hemor- 

rhage in history is that of Henry II of France, who 
died in 1559 following a supraorbital wound received 

Vol. XX No. 7 

Fig. 1 
Illustrating the bilateral incision. 

in a tourney, according to Pare. This was an acute 
hemorrhage, however, and no operation was attempted. 

“In 1657 Johanas Wepfer performed a necropsy on a 
patient of seventy who died some hours after of 
apoplectic stroke, with an aphasia and hemiplegia. A 
bloody cyst the size of a hen’s egg was found beneath 
the dura.” 

Patients usually present a history of having 
received a head injury as long as six weeks be- 
fore the development of the ominous symptoms. 
In the beginning they are regarded as slightly 
injured. As weeks usually pass before serious 
symptoms arise, the connection between the in- 
jury and the end results is often overlooked. 

The following description is that of a case of 
chronic pachymeningitis hemorrhagica interna 
bilateral. Although it is stated in literature 
that the condition is frequently bilateral, so far 
as I have been able to determine, the case herein 
presented represents the only one in which a 
bilateral decompression was performed. 

The patient was struck by an automobile ten weeks 
before examination. He was unconscious for ten hours, 
was taken to a hospital and remained there for about 



forty-eight hours. He went home following this and 
remained well and symptom free for six weeks. Early 
one morning he awoke feeling nauseated and vomited. 
Following this he felt well and went to work. The 
next night he again awoke, felt nauseated and vomited. 
About an hour later he began to have a dull headache 
and felt all out of sorts. He again went to work, but 
remained only half a day, because he felt weak and 
suffered with an increasing headache. He gradually 
became dull and drowsy. Four days after his first 
vomiting spell he became unconscious and was taken 
to the hospital, where he remained unconscious almost a 
week. No definite history was obtainable of his condi- 
tion during this period. He gradually became conscious 
again, but could remember practically nothing of recent 
past events. He became better and was taken home but 
failed to improve, remaining drowsy and still complain- 
ing of dull headache. According to the history, he had 
no bleeding from his nose or ears and showed negative 
x-ray findings as to fracture of the skull. 

The physical examination was negative. The patient 
was alert and cooperated very well. He had no com- 

Neurological Examination—He did not recognize the 
odor of camphor. The pupillary responses were nor- 
smal. There was bilateral choking of the discs, more 
marked on the right side. The veins were full and 
tortuous, but no hemorrhages were seen. There was 
slight facial weakness on the left side. The hearing was 
normal. The Webber test was negative. His memory 
was good, except for events following his accident. His 
intelligence was normal. There were no aphasia, motor 
or sensory weakness or uncinate attacks. 

There was no hemi-anopsia. The patient stated that 
he had a peculiar sensation in his left leg, particularly 
when walking. There was no apparent weakness of 
either arm or leg. There was a suggestive positive 
Romberg, with the patient falling toward the right. 
There was no staggering gait, nystagmus, ataxia or 
diplopia. There was no cervical rigidity or suboccipital 
tenderness. The abdominals were equal in the two 
sides; the Babinski was negative. The corneal reflex 
was present on both sides. The knee kicks on the left 
side were slightly more active than on the right. There 
was an absence of clonus. 

An attempt was made to puncture the lateral ventricles 
anteriorly, but on both sides the blood spurted freely, 
and it was assumed that a vein had been punctured, al- 
though it seemed unsual to puncture a vein on both 
sides. The patient was in such a serious condition that 
it was deemed advisable to give him decompression on 
the right side, this procedure revealing no abnormality, 
except pressure. 

Fifteen days later the patient had remained well in 
every way, except that his decompression was tight. We 
suspected that a bilateral lesion was present and operated 
upon the right side first. The dura was blue and a 
typical process of chronic subdural hemorrhage was ex- 
posed when the dura was incised. The left side was 
then exposed and presented no unusual feature over the 
right, except that the amount of the hemorrhage was 
probably about half as great. The stereoptican slides of 
the air ventriculograms indicate the ventricular distor- 
tion before the operation and the normal appearance of 
both ventricles after operation. 

It is believed that this patient who made a 

complete and uneventful recovery represents a 
unique picture in the domain of intracranial 

Fig. 2 
Showing the wound scars resulting from right 

pathology. It has not been attempted to give 
the details of the operative technic. 

A white woman presented herself to Dr. H. Mason 
Smith, Tampa, Fla., with a history of convulsions be- 
ginning in the left face and hand. It was my privilege 
to follow this case through. The history was one of 
onset in January, 1925, at 1 o’clock in the morning 
when the patient got out of bed, went to her mother’s 
room and told her mother that her left arm was jerk- 
ing. The patient then fell unconscious. The jerking 
continued ten or fifteen minutes, followed by severe 
headache for an hour. 

The past history was definitely negative, except that 
the patient had had a fall at the age of sixteen months, 
was unconscious for twenty minutes; struck the back 
of her head, vomited ten times during the next twenty- 
four hours and was kept quiet for three days. Follow- 
ing the first Jacksonian seizure, there was an interval 
of five months before the second attack, after which she 
had four or five attacks. Since January, 1926, she had 
had two attacks. She would complain of being dizzy 
and would call for a spool so that she would not bite 
her tongue, realizing that the attack was coming on. 
She held the left hand rigid for about five minutes be- 
fore the jerking began. Twitchings lasted five minutes 
without unconsciousness, only the left side being in- 
volved. Slight headache followed the attacks. She was 
right-handed. There was no history of ear infection. 

Neurological examination was mainly negative. Vision 
was unimpaired, and the visual fields were normal, but 
changes were noted in both optic discs, more prenounced 
on the right side. There was haziness of the disc line 
and enlargement of the tortuosity of the vessels. It 
will be noted from the x-ray slides that a calcified area 


July 1927 

is in the left cerebrum in what is thought to be the 
post-Rolandic region near the arm center. 

Upon operation a hard tumor mass was encountered 
with the ventricle needle 2 cm. within the cortex. A 
second small calcified tumor nodule was encountered 
and removed. The post-operative condition remained 
satisfactory except for slow respiration, and the fact 
that twenty-four hours after operation the patient de- 
veloped some twitching of the left side of the face. 

She has made satisfactory progress since, with no 
recurrence of the Jacksonian attacks. This young 
woman has an intact speech. The arm and leg centers 
are on the left side. 

A white man, age 35, a college graduate, noted a 
slurring of speech for five or six years and had consid- 
erable headache, which was more intense in the morn- 
ing. For two years he had been aware of his inability 
to walk in a straight line. For two or three years he 
had had double vision. The family history was nega- 
tive, except that his father at the age of 63 was suspected 
of having cancer of the lower jaw. The patient’s past 
history was negative, except for the fracture of the left 
femur at eight years of age. He had never had a dis- 
charging ear or head injury. His present complaint was 
of general breakdown and neuritis. 

Neurological Examination—There was a marked 
slurring of speech, definite horizontal and verticle ny- 
stagmus bilaterally, and marked ataxia of the upper 
extremities. The patellars were exaggerated. There 
was a bilateral Babinski and an extremely positive Rom- 
berg. The patient in walking reeled to the right. There 
was definite ataxia of the lower extremities and he had 
a paranoid trend. He was irritable, suspicious and 
adopted a superior attitude. His memory was unim- 
paired, but insight and judgment were markedly im- 
paired. He was unaware of his lamentable plight. 

On November 22, 1924, he showed no impairment of 
hearing, but in February, 1925, there was bilateral 
partial deafness and mental changes which were most 
unusual with a cerebellar tumor. 

Ventricular estimation showed fluid under pressure in 
both lateral ventricles. Upon exposing the cerebellar 
dura, considerable pressure was evidenced. On open- 
ing the dura a most remarkable condition appeared. 
Tremendous tortuous herophili over both the cerebellar 
lobes downward toward the inferior surface of the 
cerebellum were noted. It was evident that the condi- 
tion was one of angioma. There was no arterial pulsa- 
tion or thrill. On exploring the undersurface of the 
left cerebellar lobe, the cause of the condition was at 
once evident. The vertebral artery ran directly forward 
from its point of entrance into the skull along the inner 
side of the brain stem as a tremendously dilated vessel 
easily as large as one’s index finger. Instead of follow- 
ing its usual course, it ran straight to the middle of the 
undersurface of the brain stem to form the basilar 
artery. It was so large that it had turned the brain 
stem over more or less on its side. On lifting up the 
undersurface of the cerebellum still further, one could 
see the passage that this big arterial channel made per- 
fectly straight without a bend or evident branch, just 
mesial to the group of nerves coming out of the brain 
stem. These nerves were curved around to conform to 
the vessel which was lifting them up. 

It was then easy to understand the cause of the lower- 
ing of the hearing in the left ear. The entire under- 

surface of this lobe of the cerebellum was a great 
In the opinion of the operator, he was 

venous bed. 

Vol. XX No. 7 

Fig. 3 
Showing wound scars from left craniotomy. 

dealing with an arteriovenous aneurysm between this 
great arterial trunk and some vein, the site of which 
could not be determined because of the danger of 
rupturing one of the thin walls. It was his opinion 
that to ligate this big artery in the cranial chamber 
would have been fraught with too much danger. It 
was decided to close the wound and at a subsequent 
operation ligate the left vertebral artery between the 
atlas and axis. 

On February 12, this was accomplished. The details 
of the operation will doubtless be presented in surgical 
literature by the surgeon. 

It was by no means assured that the ligation of one 
vertebral artery would correct the condition, and it has 
been borne in mind that a later ligation may be done 
of the right vertebral artery, either partially at first or 
after testing it and seeing that it produces no harm, 
making a complete ligation at one time. 

Following recovery from the operation, which was 
done under local anesthesia, the great bulging of the 
occiput which occurred following the removal of the 
bone at the first operation, and which had been present 
ever since, subsided to normal, remained soft and flush, 
and even sunken, so that, unless it later bulges, one 
must assume that the ligation of one vertebral artery, 
for the present at least, is sufficient. 

The patient made an uneventful surgical convalescence, 
left the hospital with his symptoms, both neurological 
and mental, materially improved. He was heard from 
after a period of about one year during which time no 
increase in symptoms had been noted. The case has 
unfortunately been lost sight of in the other time that 
has elapsed. 

These cases in neurological practice constitute 
a refreshing diversion from the usual monotonous 
work of dealing with multiple sclerosis and other 


hopeless degenerative conditions. The more 
frequent occurrence of brain tumor cases also 
gives rise to the hope that the future in neurol- 
ogy holds more encouragement than the past. 

As has been stated herein, the author is not a 
surgeon and the operative procedures described, 
other than air injections in certain cases, were 
not performed by himself. 

The neurological surgeon, Dr. Walter E. 
Dandy, of Baltimore, who operated upon these 
cases will doubtless elaborate the surgical pro- 
cedures in a future article. 

DISCUSSION (Abstract) 

Dr. Charles E. Dowman, Atlanta, Ga—The neu- 
rologic surgeons have received enormous encouragement 
in the last few years from the neurologists. It is less 
than ten years ago that I heard one of the most 
prominent neurologists in the- United States say that to 
touch the brain was sure death. 

Dr. Greene has presented three interesting cases, two 
of them very rare, which are yet liable to occur in the 
practice of any of us. I have never heard of a case 
exactly like his last one. 

There are some things the essayist did not touch on: 
the Royal operation, the relief of symptoms in Ray- 
naud’s and Buerger’s disease, the performance of chor- 
dotomy in intractable pain, quite a number of bene- 
ficial procedures that can be used in conditions that 
formerly were considered hopeless. Neurology, partic- 
ularly from a surgical standpoint, is just beginning. 
The bulk of the patients come to the neurologist, and 
unless he is keen and alert in regard to surgical possi- 
bilities a great number of remediable conditions will 
continue to be considered hopeless. 

Dr. H. Mason Smith, Tampa, Fla—In the last three 
years Dr. Greene has picked up fifty intracranial lesions 
in his neurological practice. In the last three years I 
have come across ten or eleven. There is rarely ever a 
night that comes when I return to my home that I do 
not think there is a possibility that I have let a brain 
tumor leave my office unrecognized. Dr. Greene has 
stimulated the neurologists over the country. to look out 
for intracranial lesions, and he has demonstrated the 
fact that they are far more frequent than is usually 
supposed. His beliefs have caused me to subject several 
patients whose condition was functional to air ven- 
tricular injection, but in some of them intracranial 
lesions have been picked up which were correctable. 

Dr. E. Bates Block, Atlanta, Ga—In Case 2 where 
there was a calcified mass in the brain did the patient 
have worms? It is very interesting to know just how 
and why calcified masses are produced in the brain. 
Worms many times produce them. Probably the most 
frequent causative worm in Europe is the echinococcus. 
The trichina spiralis and the tenia saginata also become 
calcified and act as pathologic foci and lime salts are 
deposited around them. Though we have no tenia 
solium in this country, they are frequent in Europe. 
One case of tenia solium, the only one reported in this 
country, occurred in Philadelphia. Brain cysts have 
been reported often in cases of tenia saginata. I 

ee ee eee 


slender see 



ee eee 


should like to know whether Dr. Greene’s case was a 
calcified parasitic larva. 

I wish the surgeons would describe the cysts which 
they find, and specify whether they are degenerative or 
are encysted parasites. The surgeons are rarely specific 
in their statements as to the cause of the cysts. 

Dr. Ernest Sachs, St. Louis, Mo—I have had one 
case of multiple cysts in the brain. None of the cysts 
contained any calcium. On the other hand, I have had 
two cases of calcified nodules which were examined very 
carefully, and which I reported in a discussion last 
spring at the American Neurological Association in con- 
nection with the question of tuberculoma. I am in- 
clined to think that they were healed tuberculomas, 
though histologically there was no great bit of evidence 
to point that way. I have always thought that the 
calcified nodules were healed tuberculomas. Dr. Block’s 
suggestion is interesting. 

Dr. Greene (closing).—By using cacodylate, sodium 
bromide and other drugs in the treatment of degenera- 
tive conditions, we may get some results. It is very 
pleasant to see the surgical work developing and to see 
patients who have been sick for years, usually under a 
diagnosis of encephalitis, recover under the care of the 
neurologic surgeon. 

In answer to Dr. Block, I reported this case as an 
encysted cysticercus. Dr. Dean Lewis, who was present 
and who examined these specimens, said they might be 
encysted cysticerci. The pathologic report did not reach 
me in time for inclusion in the paper. 


By Paut L. Hupson, M.D., 
Atlanta, Ga. 

It has been found in a large series of autopsies 
that one out of every ten adults has gall bladder 
disease, and many of these cases go through life 
undiagnosed. The importance of gall bladder in- 
fections has not been appreciated until fairly 
recent years. We now know that an infection 
here is always associated with infection and 
damage to the liver often of a permanent nature. 
The gall bladder may also be the source of an 
infection that may spread to the pancreas, stom- 
ach, duodenum, appendix, or be a focus that 
may cause cardiac, renal or other injury, and 
the resulting damage to these tissues is often 

Of course, the most common clinical symp- 
toms of the chronic gall bladder are the fam- 
iliar train of gastric disturbances, chronic dys- 
pepsia with much gas. We are accustomed to 
speak of the gall bladder type as “fair, fat, forty 
and belching,” but it is dangerous practice to 

*Clinic, Clinic Session, Southern Medical Associa- 
tion, Twentieth Annual Meeting, Atlanta, Georgia, 
November 15-18, 1926. 


July 1927 

look only for this train of symptoms. They are 
not always present, nor is the disease confined 
to adults. Likewise the presence of stones does 
not always produce classical symptoms. 

With the advent of the x-ray, much hope was 
held out for a more accurate diagnosis, but the 
x-ray alone has been disappointing in many 
cases. Even in the presence of stones, an ac- 
curate diagnosis can be made in only about 30 
per cent of cases by the x-ray alone. There are, 
of course, certain indirect signs visible to the 
x-ray, and beside these, many clinical symp- 
toms that often justify operation. Nevertheless, 
with the aid of all means formerly at our com- 
mand, there still remained a much too high per- 
centage of error in this important disease. 

One of our most prominent gastro-enterologists 
told me that he could tell his patients that they 
did not have a gastric ulcer or tumor that they 
did not have duodenal ulcer, or chronic appendi- 
citis, but whether they had gall bladder disease 
or not he was unable to say. Many of us have 
had our patient examined by the roentgenologist 
probably more than once with negative findings 
and yet the patient’s clinical symptoms were 
such that an operation was justified. At oper- 
ation the opinion was perhaps confirmed by 

Fig. 1 
Cholecystogram showing gall stones not visible in ordi- 
nary x-ray. 

Vol. XX No. 7 

Fig. 2 
cholecystogram shows gall stones. 

Clinical history of X-ray negative, 
finding a large grossly diseased gall bladder con- 
taining stones. We have even gotten out the 
old films and after again looking them over 
found absolutely nothing that would indicate a 
grossly diseased organ. 

As science advances, our ideal is to develop 
more accurate diagnostic means. The patient 
will much more readily follow our advice if she 
can be shown the source of her trouble than if 
we can only say that we think this is the trouble. 

Graham, Cole and Copher first showed that 
the gall bladder can be rendered opaque to the 
x-ray by the injection of certain substances into 
the blood stream. As soon as we read of their 
discovery, we took up their idea and have now 
for some time used it with gratifying results. 

Theoretically, any compound containing a 
chlorine, bromine or iodine radical will be ex- 
creted into the bile if it is given intravenously. 
It will then back up into the gall bladder, be 
concentrated there and render the gall bladder 
opaque to the x-ray. Obviously not every chem- 
ical compound containing one of these elements 
would be practical, because it might be toxic to 
the patient. Many compounds were tried out, 
but the most satisfactory is a cempound con- 
taining an iodin radical. Iodin having a large 



atomic weight can be used in small doses. After 
experimenting with a variety of substances, the 
one we use now is sodium tetra-iodo-phenol- 
phthalein. This substance when injected intra- 
venously will, after a few hours, render the gall 
bladder opaque to the x-ray and thus visible. 
In October of last year, Dr. Lake and I pre- 
sented to the Fulton County Medical Society a 
series of sixty-four patients whose clinical symp- 
toms suggested gall bladder ‘disease of such 
severity as to justify operation. One-half of 
this number was studied by the x-ray methods 
then available and a diagnostic error of about 
30 per cent was found at operation. The re- 
mainder were worked up in a similar way but 
with the addition that a cholecystogram was 
done. In the latter group there was only a 4 
per cent error in diagnosis, as was proven at 
operation. This was a selected group whose 
chief symptoms suggested gall bladder disease. 
This series, though not large, certainly impressed 
us with the value of the cholecystogram in de- 
termining the presence of gall bladder disease. 
It is, in addition, valuable in proving the gall 
bladder normal in doubtful cases. We have been 
able to find in the literature to date over a 
thousand proven cases in which the correct diag- 

Fig. 3 

Gall stones shown in cholecystogram, 
ordinary x-ray. 

not seen in 


Fig. 4 
Case previously x-rayed many times with negative 
results. Cholecystogram shows deformed gall blad- 
der containing many stones. 

nosis was made in 96 per cent of cases, and 
Graham has recently stated that with the proper 
technic we should expect practically 100 per 
cent correct diagnoses. 

The method is fairly simple. We now use 
sodium-tetra-iodo-phenolphthalein in a dosage of 
.04 gram per kilo of body weight. A patient 
weighing 160 pounds would require about 31% to 
4 grams. The dye is dissolved in sterile water, 
rendered alkaline by the addition of sodium 
carbonate, filtered and sterilized and injected 
slowly intravenously on the evening preceding 
the x-ray examination. The patient is sent 
home and told not to take any food. The next 
morning he is x-rayed. If the gall bladder is 
seen, he is then given a meal consisting of egg 
yolks and fat. It has been shown that the en- 
trance of fat into the digestive tract causes the 
gall bladder to empty itself more effectively than 
any other substance. After the meal of 
fat and egg yolk, there is a two-hour interval 
before the patient is again x-rayed. At this 
time, if the gall bladder be normal, it will be 
found to be almost empty. That being the 
case, no further study is necessary. If the gall 
bladder: does not empty itself, the patient is told 

to come back in twenty-four hours when he is 
x-rayed again to see the amount of retention in 
the gall bladder. 

The criteria upon which the diagnosis is made 
are based upon an understanding of its physi- 
ology. This has been worked out in the last 
year or two principally by means of the chole- 
cystogram. The gall bladder acts as a reservoir, 
and the bile is excreted and backs up into it and 
is concentrated there to about ten times that in 
the ducts. The dye substance being excreted by 
the liver backs up into the gall bladder and 
renders the gall bladder opaque to the x-ray. 
If the cystic duct be occluded by stones or swell- 
ing of any kind, the dye cannot get into the gall 
bladder and we can get nothing by the x-ray. 
If our technic has been carried out and we get 
no picture at all of the gall bladder, we simply 
diagnose occlusion of the cystic duct. Chronic 
disease of the gall bladder allows the dye to 
enter, but it is not concentrated, and you may 
get a very faint shadow of the gall bladder. If 
the presence of stone is demonstrated by this 
method there is a negative shadow, or the stones 
may become coated with the dye and rendered 
opaque, and then we can see them. 

I shall show a few cholecystograms. The 

Fig. 5 
Large stone thought to be gall stone. Cholecystogram 
shows it not to be in gall bladder. 

Vol. XX No. 7 

Fig. 6 
Stones apparently in gall bladder. Shifting patient to 
lateral view and cholecystogram showed them nct 
in gall bladder. 

first series of films illustrates the different shapes, 
sizes and positions of the normal gall bladder. 
Some gall bladders are long and pedunculated; 
others short, fat and round. It has been shown 
that the size, shape and position of the gall 
bladder corresponds to the size and shape of the 
individual; therefore, a tall individual would 
have a narrow pedunculated gall bladder and a 
short, fat individual would have a short, broad 
gall bladder. If we should give each of these 
patients a meal of fat and egg yolks and x-ray 
them in two hours, we should find the gall blad- 
der practically empty. Therefore, in these cases 
we can show the size and shape of the gall 
bladder and its position, and we can also test its 
ability to empty itself properly. In addition, 
the gall bladders are in nearly all cases visible 
to the fluoroscope. 

The next two films illustrate pathological gall 

The first one is small and contracted, with very defi- 
nite bands running through it. At operation the dis- 
eased gall bladder was found with no stones. The next 
gall bladder is much larger than the first, but there is a 
deformity on the mesial side and a band across the 
lower side. This gall bladder you can safely say is 

abnormal, and you can make a diagnosis of cholecystitis. 
That condition was found on operation. 


In the next two cases you will notice the gall 
bladders have an hour glass deformity where 
tight bands of adhesions bind them down. In 
this connection I should like to mention this 

A man who consulted me was small, thin, anemic, 
and a chronic dyspeptic. I made a cholecystogram of 
this patient and showed a very definitely deformed gall 
bladder with poor concentration of the dye. However, 
at that time we were not sure of our technic, and did 
not feel that we should advise operation. Six months 
later we x-rayed him and found the same deformity 
and, when I operated, found identically the condition 
shown in the x-ray, removed the gall bladder and re- 
lieved his symptoms. 

The next two films are of patients who had 
been x-rayed many times. They both had symp- 
toms of gall bladder disease, but the diagnosis 
could not be proven. The x-ray was negative. 
The day after injection of the dye a cholecysto- 
gram was made and the stones were plainly visi- 
ble in the gall bladder. After administration of 
a meal, we would expect the gall bladder to 
empty, but the stones were still there. 

The next case is similar and a cholecystogram 
shows a gall bladder with stones. These nega- 
tive shadows you see are gall stones. This case 
was operated upon and the stones were found. 

The next case shows a gall bladder with a deformity 
at the lower end and a band across the gall bladder. 
In the lower part you will see a large bubble-like area 
about the size of a pecan. That was produced by: a 
large stone which was not opaque to the x-ray by 
ordinary means. One large stone was found in the gall 
bladder at operation. 

The next case was an old lady of 81, who had had 
gastric symptoms for years. She had frequent vomit- 
ing, had lost weight, and recently had vomited blood. 
Her physician looked for carcinoma of the stomach. 
The gastro-intestinal series were negative. Cholecysto- 
gram showed a large gall bladder, and in the middle 
was this mass of stones like cockle burrs. This was 
also proven at operation. 

These other two films show the gall bladder plainly 
visible, small and contracted in form. This case was a 
chronic cholecystitis alone, and was relieved by oper- 

The next two films represent first, one in which the 
gall bladder is plainly visible, normal in outline, and 
there is a good density of the dye. You can see on 
one side two stones. This patient was a young woman 
about twenty and she had had attacks of colic with 
nausea and vomiting. Urinalysis was negative. On 
casual observation the stones appeared to be within the 
gall bladder, and that is another point we must watch. 
The stones were in the kidney, and by shifting the 
patient laterally one can bring up the gall bladder and 
definitely locate the stones without it. 

The next case was sent in to be operated upon for 
gall stones. She was given the usual gastro-intestinal 
x-ray series, and in making an x-ray of the stomach 
this large stone was seen. It was thought to be a gall 


stone and she was being prepared for operation upon 
the gall. bladder when’ it was suggested that a cholecysto- 
gram might bring out the stones more clearly. We 
injected this patient and the following morning found 
that the stone was not in the gall bladder. It was a 
kidney stone. 

At first we encountered many difficulties in 
making cholecystograms and experienced some 
reactions. In recent months the dye is better 
prepared and can be safely injected, and we do 
not hesitate to use it. 

Some observers have objected to the intra- 
venous use of the dye. If one gives it orally in 
capsules, some of the capsules do not dissolve, 
some do, and some people absorb more of the 
drug in the intestinal tract than do others. It 
is a leap in the dark as to whether the patient 
really has the dye or not. If we put the sub- 
stance into the vein, we know it is there, and 
when we give a certain amount we know a nor- 
mal gall bladder must show it. 

It is not necessary for a person to have a gall 
bladder full of stones or pus to have gall bladder 
disease. The Graham method enables us to 
diagnose gall bladder disease correctly in about 
96 per cent of cases. In the future we should 
not delay the diagnosis of gall bladder disease 
until in late life when there is permanent dam- 
age to the liver, pancreas and other vital organs 
and tissues. We can remove a diseased gall 
bladder, but we cannot live without a liver, al- 
though fortunately, however, a small part of 
liver will do much work. 


By Cuartes C. Denniz, M.D.,** 
Kansas City, Mo. 

The days of the Hutchinsonian triad are at 
an end. No longer do we look for pegged teeth, 
deafness and interstitial keratitis to confirm a 
diagnosis of congenital syphilis, since a very 
small per cent of syphilitic children show this 
combination of signs. In order to comprehend 
the whole subject of familial syphilis, one must 
begin with the fathers and mothers of patients. 

The most important member of the family is 

*Read in Section on Pediatrics, Southern Medical 
Association, Twentieth Annual Meeting, Atlanta, 

Georgia, November 15-18, 1926 
**Assistant Professor of Dermatology, University of 
¢From Children’s Mercy Hospital. 


July 1927 

the mother. If she be a syphilitic before her 
marriage, she will bear syphilitic children in al- 
most twice the proportion that she would if she 
contracted syphilis in the marital relation, since 
it is generally agreed that the mother, and not 
the father, infects her offspring. If the father 
is syphilitic, the mother may escape, and bear 
healthy children, but the mother who bears a 
syphilitic child is always herself a syphilitic, al- 
though her serological reaction may at the time 
be negative. 

The age of the disease in either parent is the 
most important factor. If the disease be young 
in the infected father, he will most certainly in- 
fect the mother, who will in turn bear a syph- 
ilitic child. If the mother becomes pregnant 
early in her marriage, that is, during the first 
six months, she will bear a child who has syph- 
ilis resembling the acquired type. If she bears 
it after the first year of marriage has passed, it 
will be a congenital syphilitic. 

If the disease be old in the father, the mother 
often escapes and bears healthy children. This 
is due to the fact that syphilis fluctuates with 
peaks of activity followed by periods of inac- 
tivity, when the blood stream and ectodermal 
tissues are free from Treponemum pallidum. 
Therefore, the age of the disease in father or 
mother, or both, determines the fate of the 

The age of the individual is the next most im- 
portant factor. At the age of thirty years, 
physical deterioration has set in, resistance is 
lowered, and syphilis, which has been held in 
check by the natural forces of the body, begins 
to assert itself. In proof of this, we have only 
to mention the fact that central nervous system 
involvement and cardiovascular changes begin to 
make their appearance at this time of life. 

Infectious diseases, exhaustion, malnutrition 
and diseases of metabolism complete the chapter 
in the downfall of the syphilitic who has resisted 
his disease up to middle life. 


Most young mothers who bear a syphilitic 
child show no visible signs of the disease. It 
must be that the pregnancy itself protects the 
mother against manifestations, and the first in- 
dication we have that she is suffering from syph- 
ilis is the recognition of it in the child. After 
this discovery, the problem becomes fairly easy. 

The serological reaction of the father is the 


Vol. XX No. 7 

most important fact in diagnosing the mother’s 
disease. Next is that of the mother (bearing in 
mind that we are considering the first child 
born). The father will most frequently have a 
positive Wassermann, because his blood, ecto- 
dermal and glandular tissues must carry 
spirochetes in order to infect the mother. The 
history and physical examination of the father 
will in the great majority of instances show evi- 
dences of this disease, while the mother will 
show none. 

The history of miscarriage in the mother is 
of great importance since syphilis is the greatest 
single factor in the production of miscarriage. 
The diagros’s of svphilis in the pregnant woman 
will be determined by the serological reactions 
of her and her husband, and the careful exami- 
nation of the father for evidence of the disease. 

As soon as the diagnosis is established, treat- 
ment of the mother must be instituted, unless 
grave physical defects intervene, in which case 
an abortion must be done. 

The treatment must be a combination of 
arsphenamine and mercury, for mercury and the 
iodides alone will not insure a healthy offspring. 
Treatment must be continuous up to the eighth 
month and as energetic as the prospective mother 
can tolerate. All safeguards such as urine ex- 
aminations, blood pressure and blood chemistry 
should be carefully used. The reason that treat- 
ment must be stopped at the eighth month is 
self-evident. At this time the liver is carrying a 
great load and the kidneys are excreting at their 
greatest capacity. Additional toxins thrown 
upon these important organs of excretion would 
be likely to precipitate eclampsia, nephritis, or 
both. The corollary is also true: if the syphilis 
is not discovered until the eighth month, no 
treatment should be instituted on account of (1) 
the great danger to the mother; (2) minimum 
benefit received by the child; (3) danger of 
stimulating the disease in the infant or of pro- 
ducing an arsenic-fast organism. 

After the birth of the child, both the mother 
and the infant should receive vigorous treatment. 
In successive pregnancies, the mother should re- 
ceive energetic treatment during the first four 
months of each pregnancy. The father should 
be treated in order that his body may be made 
as healthy as possible. 

There are two types of children born to syph- 
ilitic mothers. The first becomes infected in 
utero before the fourth month and before the 
skeletal system has become well formed. This 



produces the truest type of congenital syphilis, 
and if the child bears stigmata at all, he will bear 
them in spite of all treatment after birth. The 
embryo which has acquired syphilis during the 
periol of formation of his skeletal system will in- 
evitably bear the marks of the disease. Since the 
periosteum of teeth and bones are the favorite 
sites of the Treponema pallidum, these delicate 
membranes will be disarranged and may be 
finally destroyed. This is especially true of the 
nose, upper jaw and primary and secondary 
teeth, since both sets of teeth are formed in 
utero. Cole has shown the destruction of the 
membranes of the embryo tooth buds by the 
Treponema pallidum. ‘Therefore, in order to 
prevent the stigmata of congenital syphilis, treat- 
ment must be instituted in the mother before the 
fourth month of pregnancy. 

If the unborn child contracts syphilis from 
its mother after the sixth month, it is very un- 
likely to bear any of the stigmata of congenital 
syphilis, whether it be treated or not. The in- 
fection has occurred after skeletal formation 
and after the growth of healthy placenta. These 
children show the same manifestations as adults 
who acquire Syphilis: typical secondary erup- 
tion if it makes its appearance early, and typical 
tertiary skin manifestations if it makes its ap- 
pearance late. Hutchinsonian teeth, interstitial 
keratitis and deafness are practically unknown, 
unless the deafness be of the nerve type, com- 
mon in acquired syphilis. Contrast these chil- 
dren with the typical congenital types: the little 
old man with a pot belly and a cold in his head, 
who, if he lives, will have a saddle nose, Hutch- 
insonian teeth, undeveloped upper jaw, and 
square head. The children who are born with 
acquired syphilis are usually lusty, strong, well 
nourished, and have no snuffles, large spleen or 
liver. Where the secondary eruptions make 
their appearance, the liver and spleen may be- 
come enlarged and a general adenopathy may 
develop, but the marks of senility, such as 
wizened appearance, tough skin, pot belly and 
flat nose are absent. 

Congenital Syphilis Diagnosed After the Birth 
of the Child—The author is inclined to agree 
with Jeans that the Wassermann reaction on a 
child up to three months of age is very untrust- 
worthy, especially if it be negative. Nearly all 
the children who have active, unmistakable signs 
of syphilis will give a positive Wassermann, no 
matter what the age. 


From Birth to One Year of Age.—Most cases 
of congenital syphilis in children up to one year 
of age are so diagnosed because of cutaneous 
or mucous membrane manifestations. Where 
these manifestations are very florid, if the child 
has marked snuffles, fissures about the mouth, 
mucous erosions around the rectum, a large 
spleen and liver, the cerebrospinal fluid usually 
shows a positive Wassermann, an increased cell 
count, positive globulin and changes in Lange’s 
gold solution. A few cases will show manifesta- 
tions of central nervous system involvement and 
a few bone changes. We have observed mul- 
tiple bone involvement in three infants under 
3 months of age. 

If these children show none of the usual mani- 
festations of syphilis, they will often refuse to 
gain weight, develop rickets, or be subject to 
chronic infection. 

One to Five Years of Age.—If the child has 
escaped manifestations of syphilis during his 
first year, he will often have no sign of it until 
his permanent teeth make their appearance. A 
few cases will show tertiary skin manifestations, 
bone disease, central nervous system involve- 
ment, lack of development of mentality, or in- 
terstitial keratitis. 

From the fifth to the fifteenth year is the 
period in which congenital syphilis becomes most 
apparent, after the eruption of the permanent 
incisors. Interstitial keratitis and bone disease 
are most common. The probabilities are that 
the saddle nose, together with the spurring of 
the nasal process of the molar bone is the most 
consistent sign of congenital syphilis, and can be 
demonstrated in the new-born infant as well as 
the ten-year-old child. Other manifestations 
will be taken up in the order of their occurrence. 

Latent or mute syphilis characterizes 25 per 
cent of all congenital syphilitics. A diagnosis 
of latent congenital syphilis is made upon: 

(a) Finding of syphilis in the father or mother, or 

(b) Finding of a typical congenital syphilitic in the 

(c) Repeated positive Wassermanns on a child who 
has no family history of syphilis. Those children occur 
in four types of parental syphilis. 

(d) In some families the first children are congenital 
syphilitics and bear the stigmata, which become less 
marked in each child until the last are apparently free. 

(e) The first born may be apparently healthy and 
the last diseased. 

(f) The first and last of the family may be diseased 
and the middle ones apparently free. 


July 1927 

(g) Or the first may be apparently healthy and the 
next diseased. 

The serological reaction in this class of pa- 
tients is the most easily changed of all types of 
congenital syphilis. ; 

Interstitial Keratitis—This constitutes about 
15 per cent of our cases. The youngest patient 
was two years and the oldest thirty-seven. The 
most common complication was disease of the 
bones. Arsphenamine is the most effective agent 
in combating this disease, as about 75 per cent 
of the cases clear up with the first course of 
arsphenamine. Rarely do these patients develop 
keratitis in the other eye after treatment has 
been instituted. 

Syphilis of the Bones and Joints —Twelve and 
a half per cent of all our cases had this form of 
disease; 40 per cent had negative Wassermanns 
and about 60 per cent had no other sign of the 
disease except the specific manifestation. A his- 
tory of trauma was given in nearly all. Perios- 
titis of the long bones with leg ache was the 
most common manifestation. Peri-articular in- 
filtration of bilateral joints, disease of the flat 
bones, multiple osteitis of the long bones followed 
in this order. The study of x-ray films gave us 
most information. Many times the cases sim- 
ulated acute osteomyelitis. The most common 
accompanying sign was interstitial keratitis. 

Syphilis of the Central Nervous System.—Ten 
per cent of our cases were of this type. Tabes 
dorsalis and paresis were rare, but mixed lesions 
of the spinal cord and brain were more com- 
mon, manifested by epileptiform attacks, simu- 
lating both true epilepsy and the Jacksonian 
type, paralysis of single muscles, such as the 
upper eyelid, spastic paraplegia, and flaccid 
paralysis, simulating infantile paralysis. Seven 
cases in our series who were not able to walk 
or even stand, gained that ability under treat- 
ment. Mental deficiency did not improve under 

Syphilis of the Skin—Ten per cent of cases 
showed skin manifestations. Except in the new- 
born, these occurred most frequently in children 
who had none of the stigmata of syphilis. The 
manifestations are typical, and cannot as a rule 
be differentiated from the acquired type. The 
serological reaction is nearly always positive 
and the lesions recede rapidly under treatment. 

Demonstrable syphilis of the cardiovascular 
system and viscera is rare, but does occur. The 
prognosis is the same as in that in adults. 

Vol. XX No.7 

The remaining cases were children with pos- 
itive serum reactions and meager symptoms, such 
as ill defined eye lesions, palpable lymph glands, 
mental retardation, poorly developed physique. 
They responded well to treatment, which often 
brought them up to par both mentally and physi- 


In an examination of the parents of suspected 
congenital syphilitics, the age of the father and 
mother and the age of their disease should be 

It should be remembered that infection exist- 
ing in the mother alone is more likely to insure 
unhealthy offspring. 

Very few mothers show any evidence of syph- 
ilis before the first child is born. 

Diagnosis of syphilis in the embryo must de- 
pend upon serological examination of the father 
and mother, and careful history and physical ex- 
amination of the father. 

Treatment- of the mother is necessary before 
the fourth month of pregnancy and before each 
successive pregnancy. The treatment of the 
father is necessary to keep him fit to support his 
family, but not for cure of the child. 

In the congenital type of syphilis the embryo 
is infected before the sixth month and usually 
before the fourth. Later syphilis is of the ac- 
quired type. Stigmata which occur in the con- 
genital type will persist in spite of treatment 
after birth. They can be controlled by treat- 
ment only if it is begun as soon as the mother 
becomes pregnant. 

Children with acquired syphilis, treated or un- 
treated, will not, as a rule, develop stigmata. 

Congenital syphilis discovered after birth may 
manifest itself as florid syphilis of congenital 
type. Other manifestations make their appear- 
ance up to the fifth year. In the eighth year 
the eruption of permanent teeth may shew stig- 

The types of syphilis most prevalent in chil- 
dren are: 

(1) Latent syphilis. 

(2) Syphilis of the eye. 

(3) Syphilis of the bones and joints. 

(4) Syphilis of the central nervous system. 
(5) Syphilis of the skin. 

(6) Mental deficiency. 

(7) Syphilis of the viscera. 

(8) Syphilis of the cardiovascular system. 



DISCUSSION (Abstract) 

Dr. Joseph Yampolsky, Atlanta, Ga—My experience 
with syphilis has been in the outpatient department of 
Emory University, in which the patients are mostly of 
the Ethiopian race. Negroes commonly have involve- 
ment of the skin, bones, mucous membranes and eyes. 
Syphilis is manifested in every way, shape and form. 
It makes no difference how many cases of syphilis you 
have seen, you may be sure that the next day you will 
see a case with altogether different manifestations. Many 
doubtful cases are improved by anti-luetic treatment. 

Diagnosis of syphilis in children is sometimes most 
difficult, even if you go through the routine of examina- 
tion of the father and mother’s blood, go into the his- 
tory of miscarriages, and Wassermann examination of 
a liver puncture, in which live spirochetes can be found 
under the dark field. Women of twenty-five are still 
seen with that telling smile, or young men with scrotal 
tongues, which show that they were born of a syph- 
ilitic mother. Hutchinsonian teeth are disappearing. 
Yet now the second teeth show evidences of syphilis, 
which makes us doubt that our treatment of the present 
day is doing so much to eradicate syphilis as we had 

Dr. W. W. Harper, Selma, Ala—Does the essayist 
think that every syphilitic mother who has not been 
treated before the fourth month of pregnancy should 
have an abortion? 

Dr. Dennie (closing).—If a syphilitic woman is preg- 
nant and for physical reasons cannot receive treatment, 
it is just as great an indication for abortion as tuber- 
culosis. No greater calamity can happen to any child 
than to be born into the world with congenital syphilis. 

I stressed the need of making the diagnosis in the 
mother before the fourth month of pregnancy and be- 
fore the skeletal development of the fetus. We have 
a good chance to remove the stigmata of congenital 
syphilis in the child if treatment is begun before the 
fourth month. 


By Witrarp C. Hearin, M.D., 
Greenville, S. C. 

Much has been said and written in regard to 
prenatal care and the conduct of labor. At 
last, the lay public and most of the medical pro- 
fession are beginning to realize the importance 
of adequate prenatal care, and a vast majority 
of physicians are improving their technic of de- 
livery, thereby lessening many of the accidents 
and complications of the first and secondi stages. 
But many of us still think that the duties of the 
accoucheur are ended when the baby is born. 
The third stage and puerperium are neglected, 
even by those who have been diligent in their 

Southern Medical 
Meeting, Atlanta, 

*Read in Section on Obstetrics, 
Association, Twentieth Annual 
Georgia, November 15-18, ' 1926. 


prenatal care and have done their utmost for 
mother and baby until the safe arrival of the 
latter. We forget that infections, post-partum 
hemorrhage and shock are not uncommon 
sequellae of the third stage or puerperium. More 
important still is the fact that the numerous 
birth injuries of the second stage are either over- 
looked or neglected, and the physician leaves 
the patient with many good wishes but very 
superficial care of this important period. 

Of course, many injuries and complications 
would be avoided if we were more diligent 
throughout the period of prenatal care and in 
the first stages of labor, for at this time by early 
recognition of pathological conditions many lives 
are saved and many birth injuries can be 
avoided. It is equally true that a post-partum 
hemorrhage of the third stage may often be 
avoided by the intelligent handling of the second 
stage. The same is true of infections, for a 
large percentage of these are incurred before the 
third stage. But during the third stage, too, 
many infections are incurred. 

Enough about prenatal care and the first 
stages of labor, for it is my purpose to deal only 
with the third stage and puerperium. The fea- 
ture which I wish to emphasize especially in this 
paper is the too numerous birth injuries and the 
utter disregard of the need of repair, which is 
shown by the majority of physicians who are 
doing obstetrics. 

I shall present to you a series of two hundred 
consecutive cases which I examined this year. 

The age limits were 17 to 53, 80 per cent being be- 
tween the ages of 18 and 35 years. Parity was 1 to 13, 
of which 64, or 32 per cent, had borne one child. The 
chief complaints were varied as the following will 

14, or 7 per cent, complained of vaginal discharge. 
98, or 46 per cent, complained of backache. 
44, or 22 per cent, complained of pain in pelvis on 
one or both sides. 
18, or 9 per cent, of weakness. 
30, or 15 per cent, complained of nervousness. 
1, or 0.5 per cent, complained of incontinence of 


2, or 1 per cent, complained of a protruding mass 
from vulva. 

4, or 2 per cent, complained of itching about the 

14, or 7 per cent, complained of profuse menstruation. 

19, or 9.5 per cent, complained of irregular menstrua- 

15, or 7.5 per cent, complained of painful menstruation. 

36, or 18 per cent, complained of headaches. 

13, or 6.5 per cent, complained of painful urination. 

22, or 11 per cent, complained of sense of fullness or 
pressure in pelvis. 

July 1927 

4, or 2 per cent, complained of incontinence of urine. 

9, or 4.5 per cent, complained of pain in back or sides 
only when walking or exercising. 

5, or 2.5 per cent, complained of repeated abortions. 

Many in this series had multiple complaints, but the 
above were the chief complaints in each case. The 
physical findings were as follows: 

192, or 96 per cent, had lacerations of the cervix. 

20, or 10 per cent, had lacerations extending through 
the body of the cervix and into the angle of the 

111, or 55.5 per cent, had second degree lacerations ex- 
tending through the body of the cervix but not into 
the fornices. 

12, or 6 per cent, had slight lacerations with marked 

49, or 24.5 per cent, had slight lacerations with no 
erosions, eversions or leucorrhea. 

120, or 60 per cent, had bilateral lacerations. 

6, or 3 per cent, had third degree lacerations pos- 
teriorly extending into fornix. 

36, or 18 per cent, had stellate lacerations of varying 

30, or 15 per cent, had unilateral lacerations. 

62, or 31 per cent, had leucorrhea. 

70, or 35 per cent, had cervical erosions. 

43, or 21.5 per cent, had eversions of cervix. 

32, or 15 per cent, had markedly hypertrophied cer- 

22, or 11 per cent, had Nabothian cysts. 

32, or 16 per cent, had retroverted uteri, of which 11, 

or 5.5 per cent, were fixed in pelvis. 

8, or 4 per cent, had fibroids of uterus. 

2, or 21 per cent, had bilateral or unilateral salpingitis. 

7, or 3.5 per cent, had eroded and prolapsed urethrae. 

1, or 0.5 per cent, had primary chancre of cervix. 

3, or 1.5 per cent, had carcinoma of cervix. 

1, or 0.5 per cent, had carcinoma of uterus. 

1, or 0.5 per cent, had carcinoma of vulva. 

166, or 83 per cent, had relaxed pelvic floors. 

131, or 65.5 per cent, had definite evidence of lacera- 
tions of vaginal portions of birth canal. 

26, or 13 per cent, had rectocele. 
10, or 5 per cent, had cystocele. 

, or 3.5 per cent, had both cystocele and rectocele. 

2, or 1 per cent, had third degree prolapse of the 


18, or 9 per cent, had second degree prolapse of the 


or 0.5 per cent, had third degree laceration of the 

perineum of three years’ duration with no repair. 

100 per cent had had no primary or intermediate repair 
of cervix. 

3, or 1.5 per cent, had had secondary repair of cervix. 
10, or 5 per cent, had had primary repair of pelvic 





16, or 8 per cent, had had one or more instrumental 

72, or 36 per cent, had had abortions or premature 

43, or 60 per cent, of this 43 had aborted from two to 
seven times and the average time was 2.5 to 3.5 

A vast majority of this series gave a history 
of having had pituitrin before the completion of 
the second stage of labor, and quite a few before 
the completion of the first stage. 

Vol. XX No. 7 

154, or 77 per cent, were white. 
46, or 23 per cent, were colored. 

A vast majority of these deliveries were done 
in the home, and while I have no accurate 
statistics in regard to the deliveries I think it 
will be conservative to state that 85 per cent 
were delivered by practicing physicians and only 
about 15 per cent by midwives. 

I regret to say that a routine Wassermann 
was not taken, and for this reason I am unable 
to state the incidence of syphilis. Vaginal and 
cervical smears were not taken routinely, but 
among those that were taken there was a rela- 
tively low percentage of gonococcus infections. 

A very small percentage of cases go through 
labor without some visible birth injury, and the 
major portion of them have presented them- 
selves for examination, seeking relief from symp- 
toms due to unrepaired birth injuries. 

It is my custom to repair birth injuries after 
the completion of the third stage of labor, and 
to date I have found no reason for delaying this 
repair until a later period. In more than 85 per 
cent of the cases primary repair will be success- 
ful, granting that the surgical technic is not 
faulty, and strict asepsis is maintained through- 
out the puerperium. I am quite sure that a 
primary repair of birth injuries will not meet 
with the approval of many in this audience, and 
there is much to be said in favor of intermediate 
repair within the first ten days after delivery. 
The method of intermediate repair is used by 
many of the foremost obstetricians. After six 
or seven days the edema has subsided and the 
lochial discharge is less profuse, and repair is 
perhaps a little easier, but the patient must 
again be prepared and taken to the operating 
room, an additional anesthetic must be ad- 
ministered, convalescence is delayed; and the 
burden of expense is increased, which to many 
is no small item. 

Many men advocate waiting six or eight 
weeks before making the necessary repairs, and 
the results should be most excellent. But im- 
mediate repair hastens involution and lessens 
hemorrhage. And most important is the fact 
that a number of patients who need repairs will 
not submit to them after the expiration of six or 
eight weeks, if they feel well, but will procras- 
tinate and fall into the hands of the gynecologist 
months or years later. 

Many physicians tell me that their birth in- 
juries are few, but the majority of these are 
men who do not carefully and systematically 


examine the birth canal after the completion of 

Some of us seem to think it a reflection on 
our professional skill to have birth injuries, and 
often that is the case. But if we convince the 
laity that many birth injuries are unavoidable, 
as they are, and that a failure to repair injury is 
inexcusable except in rare instances, then we 
shall make real progress toward elevating the 
plane of the practice of obstetrics. 

I wish to say just a word in regard to retro- 
displacement, a common complication of birth 
injury. By early repair we hasten involution, 
prevent prolapse and promote better drainage, 
and this alone will naturally decrease our re- 
troversions. But position throughout the puer- 
perium will be of great value. If our patients 
lie prone upon the belly for fifteen minutes twice 
daily after the third day, drainage is promoted 
and tension on the uterine ligaments is relieved. 
After ten or twelve days the knee chest posture 
once or twice daily will accomplish the same 
purpose. At the expiration of six or eight weeks 
when the patient presents herself for a final ex- 
amination, if retroversion is present, we can 
often replace it manually. A large tampon in 
the posterior fornix or a well fitting pessary 
worn for a short time will correct the condition 
and give the ligaments time to regain their tone 
and the uterus its normal size if sub-involution 
is present. 

Various complications and sequelae of the 
third stage and puerperium might be dwelt upon 
at length, but I wish to discuss only the neg- 
lected birth injuries at this time. 


(1) Birth injuries are by no means uncom- 

(2) A large percentage of this series had 
pituitrin before the completion of the second 
stage of labor. The abuse rather than use of 
pituitrin is far too prevalent. 

(3) Neglected birth injuries are responsible 
for much suffering and semi-invalidism of the 
mothers of today, and the economic loss is 

(4) Unrepaired birth injuries are responsible 
for a large number of our abortions and many 
cases of sterility. 

(5) Many physicians are unfair to their pa- 
tients, failing to make systematic examinations 
for birth injuries and then minimizing to their 
patients the extent of the injury. 


(6) It is more satisfactory, though not es- 
sential, to have the patient in a hospital for the 
usual repair of the cervix and pelvic floor. But 
with the aid of an intelligent nurse, asepsis can 
be obtained and maintained in the home. 

(7) As obstetrics is surgery, we should en- 
deavor to teach the lay public the importance 
of hospitalization of obstetric cases, especially 
during the first confinement. We should point 
out the many advantages of hospital care, and 
impress upon them that, even from an economic 
standpoint, the hospital is to their advantage. 
For modern obstetrics cannot be done without 
the aid of a nurse, and, usually the services of a 
trained anesthetist. Most women refuse to en- 
dure the needles¢ suffering without an anesthetic, 
and nearly 50 per cent of the modern women no 
longer have normal deliveries. 

DISCUSSION (Abstract) 

Dr. Lewis H. Wright, Augusta, Ga-—I wish that Dr. 
Hearin had gone into the whole of the subject of his 
paper instead of just one phase of it. The improper 
method of expressing the placenta, leaving clots in a 
flabby uterus, is very important. The proper immediate 
treatment of lacerations is very important and too often 

I doubt that one is justified in examining the cervix 
routinely, particularly in the home where one cannot be 
sure of asepsis. 

Dr. Jerre Watson, Anniston, Ala—There is a pro- 
nounced tendency among physicians to overlook in- 
juries to the birth canal. From the standpoint of parts 
involved, there are three types of injury to the birth 
canal: the cervical, vaginal, and vulval. The tears may 
be posterior, extending toward the rectum, or anterior, 
extending toward the bladder. 

It is easy for any man who is ordinarily careful to 
detect an external tear. A blind man might do that 
with his finger without actual inspection. But the tear 
within the vagina will be detected only by careful ex- 
amination. It is important that every tear be found. 
I would, therefore, urge painstaking post-partum ex- 
amination of the perineum, vulva and vagina in all 
cases. I would further urge, except in the presence of 
shock or other contra-indications, that all lacerations be 
immediately repaired. 

The habit that many men have of delivering a 
woman under a sheet without determining what injury 
has resulted and without making whatever repair is 
needed is a species of carelessness that should be rel- 
egated to the past. 

Dr. Hearin (closing)—To determine the extent of 
birth injuries, it is well to have a routine procedure, 
never depending upon our sense of touch. We should 
expose the field of probable trauma well, and with two 
cervix forceps pull the cervix down and inspect it by 
going around it carefully. A surprisingly large number 
of cervical tears will be observed. 

It was not my intention to convey the impression 
that a simple mucous tear of the cervix should be re- 


July 1927 

paired. All second degree tears should be repaired, for 
their repair will eliminate quite a few erosions and 
leucorrheal discharges. 


By W. Houston Tovutson, M.D., 
Baltimore, Md. 

It is generally accepted that congenital and 
acquired factors play a part in the formation of 
bladder diverticula, as was shown by Rose; also 
they occur chiefly in those parts of the bladder 
that are deficient in musculature, namely, in the 
vicinity of the ureteral orifices or the obliterated 
urachus. While intra-cystic pressure produces 
enlargement of the diverticulation, certainly in- 
tra-abdominal pressure plays some part in its 
direction. Watson believes that while there is a 
congenital predisposition to diverticula their 
clinical recognition during adult life is hastened 
and their dimensions are greatly increased by 
any of the factors that would bring about in- 
creased vesical distension or increased activity 
of the bladder musculature. Obstruction to 
urination causes trabeculations, cellules result, 
and if there be a congenitally weakened bladder 
wall the cellule may become deepened and form 
a diverticulation. 

Cases occur that are a part of other anatomical 
defects, as for example, in mental defectives 
without any apparent obstruction to the outlet, 
but in the main the factors of congenital weak- 
ness plus acquired obstruction exist. Compul- 
sory retention of urine may play some part. A 
street car conductor, a patient of our clinic, who 
was forced to retain urine to an uncomfortable 
degree many times, developed diverticula; but, 
of course, intra-cystic pressure was there in his 
case, which amounted to obstruction. 

While it is customary to view this condition 
as occurring in men coincidental with prostatic 
obstruction, Hyman in reviewing a series of 
six hundred cases, reported twenty or thirty in 
children. Of the fifteen cases which form the 
basis for this article, one occurred in a woman, 
and all but three in association with obstructing 
prostatic conditions. 

The cavities of these diverticula are lined by 
mucous membrane, which is continuous with 

*Read in Section on Urology, Southern Medical As- 
sociation, Twentieth Annual Meeting, Atlanta, Geor- 
gia, November 15-18, 1926. 

+From the Department of Urology, University of 
Maryland, School of Medicine. 

Vol. XX No.7 

that of the bladder, but differentiated from it by 
its smooth glazed appearance. The submucous 
coat is often absent, but the thinned out and 
scattered bands of the muscle coat are usually 
noticeable. Externally, the sac is covered by 
layers of connective tissue, fixing it more or less 
firmly to the neighboring structures. Mean- 
time, while this thinning out process of the 
diverticulum is taking place, the bladder wall 
becomes thickened: 

The sac enlarges from the weight of the 
fluid, plus the intra-vesical pressure. The wall 
of the sac sooner or later becomes infected from 
the trapped urine in the diverticulum, which 
can empty itself only through the small com- 
municating opening, usually about 0.5 centimeter 
in diameter. In most of the cases, the opening 
is well above the bottom of the sac, which pre- 
vents proper drainage into the bladder. This 
gives rise to a stagnation of the urine within 
the diverticulum with a resultant infection, so 
that at operation the wall of the sac is at times 
‘densely adherent. The ureteral orifice may open 
‘in the sac, making its identification impossible 
‘by cystoscopy. Occasionally the infected sac 
amounts practically to an abscess. This condi- 
_tion occurred in one of our cases and had to be 
drained immediately by suprapubic incision. 

Diverticulation may be single or multiple. 
Stone formation is common. , There was an in- 
cidence of 12 per cent in the Mayo series of two 
hundred and twenty-two cases. Only one of our 
cases had stones in the sac. Many instances of 
dumbbell-shaped stones occur, with the stone 
half in the bladder and half in the diverticulum. 

The condition may be present for years with- 
out producing any noticeable symptoms. 

Urinary symptoms are most common, and 
these vary greatly. Frequency and difficulty 
are pronounced, a sense of incompletion is a 
common complaint, as is slowness in emptying 
the bladder. Many patients are forced to as- 
sume different positions for ease in urination. 
The urinary troubles may exactly resemble those 
occasioned by prostatic obstruction, and, of 
course, diverticulation is often seen in associa- 
tion with these obstructions. 

The urine soon becomes purulent on account 
of the stagnation in the sac and is badly in- 
fected in late cases. 

Hematuria is due to inflammation of the blad- 
der or diverticulum and is possibly increased by 
the presence of calculi and rarely by the pres- 
ence of an associated new growth (Ward’s case). 


The pain is usually constant as a vague supra- 
pubic distress. In one of our cases, there was 
constant pain in the lower left abdomen imme- 
diately over the sac. This pain, which had per- 
sisted for years, entirely disappeared upon re- 
moval of the diverticulum. 

There is a low ’phthalein output due to the 
fact that the dye remains in the false pouch. 

The plain x-ray may show an obscure mass 
in -the pelvis, and calculi, if present; but the 
x-ray is usually negative without the cystogram. 

In pronounced cases there are gastro-intestinal 
disturbances, probably caused by the absorption 
of toxins from the sac and constipation caused 
by the pressure of the sac on the rectum. Most 
of our cases had these symptoms. 

Later on, symptoms due to ascending infec- 
tions and consequent kidney damage ensue. 
Many of our patients ran a septic temperature 
and some had secondary anemia from prolonged 
absorption from the infection in the sacs. 

On the other hand, there may be no diagnostic 
symptoms, and the condition may be discovered 
only during cystoscopy. 

Occasionally the diverticulum can be palpated 
through a relaxed abdominal wall as a soft 
rounded tumor extending up from the pelvis, 
but more often can be felt through the rectum 
as a soft cystic mass. 

Cystoscopy establishes the diagnosis. The 
opening of the diverticulum into the bladder is 
seen as a sharply defined black hole in the blad- 
der wall in proximity to the ureteral openings. 
This condition may be overlooked unless the 
bladder be well distended. Calculus formation 
or rarely new growth may also mask the open- 
ing. At times the cystoscope can be introduced 
directly into the diverticulum opening. 

Probably the most important aids are the 
contrast cystograms of Hinman.® The technic 
is simple. The diverticulum is filled with the 
sodium iodide solution differing in density from 
the solution which fills the bladder, or the diver- 
ticulation is filled with the opaque fluid and the 
bladder distended with air. This is sometimes 
difficult to do in the presence of an irritable 
bladder in the long standing cases. Even cystos- 
copy is difficult in cases of large diverticula 
with an ipflamed and irritable bladder: so much 
so that in some cases we had to resort to sacral 
anesthesia. Ordinary cystograms can be satis- 
factorily made by filling the bladder under the 
fluoroscope and making an x-ray film-at -the 



moment the bladder and diverticulum show up 
best. Several attempts may be necessary before 
satisfactory cystograms are made. Cystography 
is a better diagnostic aid when made at different 

Many patients suffering from this condition 
are, like prostatics, poor risks. Two of our 
cases were over eighty years old and, like pros- 
tatics, had to be studied and prepared very care- 
fully before operative interference was under- 

Palliative treatment is unsatisfactory in well 
defined cases. The diverticula will increase in 
size and become more and more infected, so that 
excision of the sac remains the only treatment 
by which we may expect a cure. In spite of 
this, there was a patient in this series who had a 
rather large diverticulum complicating an ob- 
structing prostate. Following the operation he 
had 250 c.c. of infected residual urine. Weekly 
bladder lavages were used and a gradual reduc- 
tion in the residual urine was seen, so that five 
months after prostatectomy the diverticulum dis- 
appeared by cystoscopy, leaving a small cellule, 
and the cystogram was negative for diverticula- 

The operation is difficult and tedious. The 
space in which the operator has to work is con- 
fined. The wall of the sac being chronically in- 
fected is adherent to the neighboring structures 
and the peritoneum is frequently dissected away 
with difficulty. In one of our cases the sac was 
adherent to the posterior wall of the bladder and 
the ureter was incorporated in the wall of the 
sac. Dissection in this case was facilitated by 
the previous introduction of a ureteral catheter. 
There is also some risk of injuring the bowel 
and the pelvic vessels. 

If the diverticulum be a small one, Young’s 
method of suction may be employed to advan- 
tage. In order to invert the sac, in large cases 
Lower recommends packing the cavity with 
gauze. Judd suggests introduction of the finger 
for properly outlining the sac. The latter method 
we have found the most satisfactory. In some 
instances of small diverticula, it is possible to 
enlarge the opening into the bladder by fulgura- 
tion. This has been done to promote drainage. 
I have had no experience with this procedure. 

Preliminary cystotomy should be avoided, if 
possible, since it drains the bladder and makes 
it more difficult than ever to wash out any of 
the contents from the diverticulum, as the blad- 
der cannot then be distended. 


July 1927 

It is important to realize that it is very often 
insufficient merely to excise the diverticulation, 
for an obstruction should always be suspected 
until its non-existence can be proved. 

If a diverticulum be present and is overlooked 
during prostatectomy, a suprapubic fisula may 
persist. Hence it is a serious matter to over- 
look the presence of a diverticulum in dealing 
with an enlarged prostate, as prostatectomy will 
not be followed by relief of symptoms and re- 
storation to health. 


Hyman: Jour. Urol., 9:No. 5, 1922. 
Judd: Ann. of a p. 298, 1918. 
. Watson: J. A. M. 75, Nov. 27:, 1920. 

Ward: Brit. Jour. ~ 4 Surg., 13:No. 29, July, 1925. 
Crenshaw and Compton: Jour. of Urol., 8:185. 
Hinman: Surg. Gyn. Obst., 172:150, 1919. 

Ball: St. Bartholmew’s Hospital, Sept., 1923. 
. Young: Surg., Gyn. or Pits A a 1918. 

. Geraghty: S. M. J., 

- Rose: S. M. J., Vol. is 1926. 


DISCUSSION (Abstract) 

Dr. Edgar G. Ballenger, Atlanta, Ga.—Often we see a 
patient with a very big prostatic gland with inability to 
empty the bladder, and with all the indications for an 
operation. Yet we may not take the trouble to find 
the diverticulum upon which the subsequent results 
largely depend. Perhaps the patient’s health is not 
such that we can operate upon the diverticulum. It is 
important, however, to protect ourselves by the prog- 
nosis, and explain to the patient and to the family that 
the patient’s health is not sufficiently good to remove 
the diverticulum and. that later palliative measures may 
be required. 

We have one patient now, eighty-four years old, who 
has a very large diverticulum, and the bladder is con- 
tracted to a very small capacity. The catheter can be 
passed up into the diverticulum, and we drain off the 
urine about once every week or ten days. He is getting 
along very well. To remove it would be out of the 
question. We removed his prostate four years ago. He 
voids quite well, has no frequency, no trouble, but he 
cannot empty the diverticulum. He has a slight 
cystitis, but with a little care the infection is controlled. 

Important questions to decide are: will the patient’s 
health permit the removal of the diverticulum as well 
as the prostate? If we are going to attempt to remove 
the diverticulum, at what stage shall we do it, the first 
stage or the second stage? 

It is difficult to decide whether to remove the diver- 
ticulum or leave it. In our examinations we are likely 
to overlook it, because the more obvious facts are star- 
ing us in the face. 

Dr. H. W. E. Walther, New Orleans, La.—Dr. Toul- 
son has brought out regarding the bladder what was 
emphasized by another essayist yesterday in regard to 
the kidney. More x-ray work is needed in our study 
of cases than. we are using today. We cannot do too 
much of it. Cystoscopy is often an inadequate means 
in itself of determining the relative position, the dis- 
tribution and the size of a diverticulum. We should 
make more cystograms to bring out more clearly the 
actual status of our cases. 

Vol. XX No. 7 

I should like to ask Dr. Toulson the most satisfactory 
way of taking care of the inoperable cases. 

Dr. J. L. Estes, Tampa, Fla—I should like to ask 
about the merits of silver and sodium iodide. 

Dr. Toulson (closing)——I have had no experience 
with silver iodide. We used sodium iodide entirely 
and the strength in these cystograms is 12.5 per cent, 
merely an arbitrary per cent. We have no basis for it. 

The inoperable cases are told to return to the clinic 
at first perhaps twice a week, later on once a week, 
then perhaps once every two weeks, accordng to the 
amount of infection they have in their diverticulum. 
We find that if we can keep the urine reasonably clear 
of infection the patient’s symptoms improve. I believe 
an indwelling catheter will do more harm than good, 
though we have never tried it. 


By W. G. Smite, M.D., 
New York, N. Y. 

In October, 1922, the International Health 
Board, in conjunction with the State Health 
Department, established a Field Training Sta- 
tion for health officers at Andalusia, Alabama. 
The Station has functioned for four years and 
one hundred and eighty-one physicians and ten 
medical students have been registered. Most of 
these trainees are now actively engaged in pub- 
lic health work in all parts of the United States 
and some are scattered to the four corners of 
the world. After four years of experience, it is 
desirable to pause and analyze the results 
achieved, study critically our methods and 
rectify our mistakes and attempt to determine 
the value of this preliminary field training. 

The original purpose of the Training Station 
was to provide field experience and appraisal 
for the newly appointed regular staff members 
of the Board in preparation for the responsi- 
bilities of foreign service. It was planned to 
give each man at least six months’ training un- 
der supervision in the methods of control of 
hookworm disease, malaria, in epidemiology and 
in public health organization. 

This purpose has been well served. Eleven 
regular staff members have received this pre- 
liminary training and are now serving the Board 
satisfactorily in foreign countries. Several of 
them have made an outstanding success of their 

*Read in Section on Public Health, Southern Med- 
ical Association, Twentieth Annual Meeting, Atlanta, 
Georgia, November 15- 18, 1926. 

tThe observations on which this paper was based 
were conducted under the auspices of the Interna- 
tional Health Board of the efeller Foundation. 



work. The average cost of training each of 
these men was a little less than $1,500. 

The chief benefits of the Training Station 
have accrued to the State and local boards of 
health. In 1923, a plan was devised to interest 
promising young physicians who had made a 
good record in their medical school and hospital 
work in the field of public health as a life 
career. These men are selected with some care 
and are appointed as temporary field staff mem- 
bers of the International Health Board for a 
period of two to four months. All are sent to 
the Training Station for field experience. They 
are given a modest salary to cover their actual 
expenses, and at the end of their training are 
expected to resign from the Board’s staff. There 
is no obligation on the part of the trainee to 
engage in public health work if, after a period 
of training, he should feel that it is unattractive 
or that he is not suited for it, but it is antici- 
pated that at the end of his training, if he has 
demonstrated aptitude, there will be several op- 
portunities in health work open to him. 

Since the establishment of the Training Sta- 
tion, forty-one temporary special staff members 
have received field training at the Station. The 
distribution of these men on October 15, 1926, 
was as follows: 


Per cost of 

No. cent training 
Regular staff members of the 

International Health Board. 6 14.7 $1,409.05 
Directors of essential divisions 
of state health work in 7 

states 10 24.4 1,103.93 
Directors of county health work 

in 10 states 12 29.2 1,256.42 
Directors of non-official health 

wo: 4 9.7 1,256.42 
Unsuited for or uninterested in 
— health work as a 

care 6 14.7 869.44 

Still ~ training. 3 1.3 

The data of this table are very encouraging. 
Only three or four of these men had previously 
been engaged in health work. Most of them 
came to the Station with some prejudice in re- 
gard to public health as a career. In many in- 
stances, their only training in public health had 
been a short perfunctory course of lectures in 
their medical school course. The attitude of 
their professors and fellows toward public health 
as a career had been one of indifference, or per- 
haps of scorn. From the very onset of their 
medical training they had developed an antip- 
athy toward public health as a career. 

One of the achievements of the Training Sta- 
tion is that it has been able to interest so many 
of these men in public health. Only six of the 
forty-one have found that they were not inter- 


ested in or were unsuited for some one of the 
various phases of public health work and have 
abandoned the field to take up some other type 
of work. After three months’ association with 
the group of well-trained earnest enthusiastic 
officials of the state and county health staffs, the 
trainees have come to the realization that public 
health is not a quiet harbor for doddering super- 
annuaries, or a waste basket of incompetents as 
they had supposed, but is a real job offering a 
wonderful opportunity to apply all that they 
have learned in medical school and hospital, and 
in addition is a test of their ability to meet 
emergencies, to develop their latent but potential 
qualities of tactfulness, sympathy, adaptability, 
and a sense of responsibility to the community, 
qualities which go far in making the health offi- 
cer’s efforts a success. 

Some of these men have already made a 
striking success of their work as county health 
officers, state epidemiologists, laboratory direc- 
tors, organizers of county health work or other 
lines of endeavor. It is probable that these 
same men would have made a success of their 
work in other fields. The achievement has been 
that they have been recruited for public health, 
and in time their interest and enthusiasm will 
tend to draw other men of their type into the 
field of preventive medicine. 

After the Training Station had been in oper- 
ation about a year the various state health offi- 
cers began to request that their own new ap- 
pointees be given a short preliminary field train- 
ing at the station. This was tried and proved 
so satisfactory that the majority of the person- 
nel of the Station now belongs to this group. 

Seventeen states have been granted funds by 
the Board for the field training of forty-two 
men for the period of one to three months. The 
great proportion of these men were prospective 
county health officers. Twenty-six of these men 
had had no previous experience in public health 
work. This group has been given thirty-nine 
months of training at an average cost of $345.00 
per trainee. Eleven physicians with some pre- 
vious experience in health work have been given 
a total of twelve months’ training at a cost of 
$228.00 per man. Three men in these groups 
have. made a failure of their work and two are 
still in training. 

It is obvious that one to two menths of field 
training cannot prepare the prospective county 
health officer for all the contingencies that will 
arise when he assumes his new duties and re- 
sponsibilities in an independent post, nor does 


July 1927 

this period of training give him even a ground 
work in the fundamentals of preventive medi- 

The chief value of the field training is that it 
stimulates an enthusiasm for public health work 
and develops a public health sense. Further- 
more, it enables the trainee to learn the routine 
and to balance his program. It also gives him 
an inkling as to the varied activities of a county 
health officer and the relative values of the va- 
rious activities. 

The training period does not consist of a 
course of lectures, nor is it a school. There are 
no formal field exercises, and, though the men 
are given every opportunity to study public 
health’ procedure in the small field library, there 
is no proscribed reading. The men learn the 
various activities by actually doing them. The 
trainee is assigned to some task, under super- 
vision of one of the experienced health officials 
of the state or county. The director! of the 
Training Station is part of the official family of 
the State Board of Health, being regional di- 
rector of county health work. 

Usually a conference is held on Saturday aft- 
ernoon to discuss the work of the past week and 
the plans for the next. Some phase of public 
health procedure is usually discussed at these 
conferences by one of the state directors, but 
this is the only formal exercise of the Training 

In addition to those men who have been given 
field training for state work by means of special 
grant to state government by the Board, some. 
thirty-five men have been sent to the Training 
Station by state health officers either at their 
own expense or at the expense of the state that 
desired to employ them. A summary of this 
group of trainees is as follows: 

period of 
No. States training 
Men with some previous prac- 
tical experience in public 
health work 9 5 3 weeks 
New inexperienced men.................. 16 4 4% weeks 
Unsuited for or uninterested in 
public health work........................ 10 2 5 weeks 

It will be noted that almost a third of this 
group was found to be unsuited for or unin- 
terested in health work. This fact was usually 
determined during the training period and be- 
fore the prospective health officer had been 
given an independent assignment. Thus one im- 
portant and somewhat unexpected function of 

1. The director is Dr. Charles N. Leach and the 
headquarters of the Training. Station is now in 
Montgomery, Alabama. j : 

Vol. XX No. 7 

the Training Station was developed, namely, the 
classification of the men-as to their suitability 
for the positions which they were expected to 
fill. This service has been of considerable value 
to the state and county organizations, for the 
state health officers agree that one of the chief 
causes of failure of county health units that have 
occurred from time to time in the various parts 
of the United States has been the unsuitability 
of the director of the unit for public health 
work. If this fact can be determined while the 
prospective health officer is still in training and 
before he assumes office, it will be a great relief 
in the executive ‘responsibilities of the state 
health officer. Practically no county unit fail- 
ures have occurred where a satisfactory trainee 
has been employed. 

One fact has been clearly brought out after 
four years’ experience, namely, that one month 
is too short a period of field training to prepare 
the inexperienced man for his new duties. The 
best arrangement is to send the man to the 
Training Station for a period of two to three 
months. He should then proceed to the state 
in which he plans to work, and if practicable 
should spend one month in learning the details 
of his own state health organization and pro- 
cédure and the special problems that he will be 
called upon to solve. 

No one would claim that the field training can 
in any sense be considered as a substitute for 
the theoretical courses of our well established 
schools of hygiene and public health. Preven- 
tive medicine is one of the important specialties 
of medicine and there are no short cuts. The 
chief value of the preliminary field training is 
that it gives the young, well-trained, open- 
minded medical graduate an opportunity to de- 
termine for himself whether he is interested in 
public health as a career, and enables him to 
obtain sufficient practical experience to carry 
on creditable work under supervision of a 
trained state director. After two or three years 
in field work, the ambitious man will make every 
effort to obtain the regular courses of theoretical 
training, and when he does enroll for his degree 
in Public Health he will find that his field ex- 
perience has been of great value to him in the 
interpretation and application of his theoretical 
work. If he remains for too long a time in the 
field work, his ideas become fixed, his mind 
crystallized, and when he finally undertakes the 
theoretical courses they may be of limited value 
to him. 

Dr. E. L. Bishop, in recent correspondence, 



sums up the general sentiment of health.officials: 
in regard to this matter. He says: een S| 
“My observation, and what little experience I have 
had, both with the theory and practice of public. 
health, does lead me to believe that practical experience 
in the field is most desirable. One learns best by doing 
things. I would prefer for men under my direction 
not to have special training in theory and additional 
scientific training until after they have had a year or 
two’s practical experience, for I think they will’ learn’ 
much more rapidly, and that they will correlate ‘theory’ 
and practice in a much better way than if all intra:’ 
mural work is taken at one time.” : 
The experience of many health officials seems. 
to show that those men who have taken their. 
theoretical work for a public health degree di-: 
rectly following their medical training and with-' 
out having some field training in public health 
are seldom prepared to undertake the duties of. 
an independent responsible position in public 
health. Thus a man of real ability and. excel- 
lent theoretical training but without practical. 
experience under trained supervision may make 
a total failure of his first public health post and: 
abandon public health work for some other field. 
It is clear that the field training in public: 
health corresponds to the medical student’s hos- 
pital internship and is closely comparable to it. 
Perhaps it should not be required as part of the, 
credits toward a degree, but nevertheless the 
students in public health courses should be en- 
couraged to obtain as much field experience: as- 
possible, during summer vacations or after the 
degree is obtained, for the same reason that the 
medical student does summer work in fhe out- 
patient departments and struggles for a, good 
teaching hospital internship after graduation. 


Preliminary field training for prospective in- 
experienced health officers who have not had 
theoretical training in preventive medicine does 
not offer a short cut to a career in public health. 
Its chief value is that it awakens: an interest in 
public health work, gives an inkling of the va-' 
rious activities of the health officer, and de- 
velops a sense of the relative values of these’ 
various activities. Also it may offer. an op-. 
portunity for the superior officer to determine a 
man’s fitness for the position which he is destined 
to fill. As a supplement to thorough theoretical: 
groundwork in preventive medicine a period of: 
preliminary field training is of tremendous value, ' 
for it offers the enthusiastic novitiate the op-' 
portunity to try out his theoretical knowledge’ 
in the field under the careful sympathetic su-. 
pervision of the experienced conservative, battle- 


scarred senior health officer. Thus his theoretical 
knowledge becomes tempered with sound judg- 
ment and experience to the great benefit of his 
future work. 

DISCUSSION (Abstract) 

Dr. C. W. Garrison, Little Rock, Ark—Every speaker 
who has discussed health work in any of its phases this 
morning has stressed the importance and necessity of 
trained personnel, but the character, extent and method 
of training has caused some difference of opinion. 
Those of us who have had an opportunity to see bene- 
fits from this wonderful little field training school 
established in Alabama will attest, I am sure, to its 
success. We have sent two or three inexperienced young 
physicians from our State there for preliminary train- 
ing, and all are now making good. In my judgment 
it is impossible to estimate the value of the practical 
field training received. 

The Smillie Unit gives this inexperienced personnel a 
limited experience and an awakening vision of what it 
is all about, and also impresses them with the great 
scope of public health work and the possibilities before 
them 5 

While this field training is now serving a useful and 
necessary purpose, it seems to me that we should con- 
centrate in our efforts to get the medical schools 
throughout the Country to begin now to give the stu- 
dents a thorough and comprehensive course in pre- 
ventive medicine. Medical students graduating from 
such schools could then serve thirty or ninety days’ 
intensive training like that offered in the Smillie Unit, 
after which they will be fairly well equipped as health 
officers and sanitarians. ~ 

The field training school established by the Inter- 
national Health Board in Alabama is a distinct boon to 
the South and should be encouraged and utilized to the 
fullest extent. 

Dr. W. K. Sharp, Jr., Nashville, Tenn—We are 
obliged to agree with Dr. Smillie in his plan of training 
men, because the International Health Board pays for 
it. It does not cost us anything to have the men sent 
to and from the training base. The next most important 
thing is that it gives the men an opportunity to mix 
with each other, as he usually has men from all over 
the country, and it gives us a most excellent opportu- 
nity to study the men, for a period of three months. 
In one or two instances, we have sent men to the 
training station and found them not to be interested in 
public health work. They were misfit, and it is better 
to spend the money to have them under preliminary ob- 
servation and find out about them than to put them 
in a county and lose the county appropriation. 

We first thought that it was best to send men around 
for a preliminary investigation to some of our best coun- 
ties, and this still is a good plan if we have not the funds 
to send them to the training station. It is a good 
plan to let them spend the last month of their time 
doing just this thing. We found out, though, that this 
interfered with the local health officer’s plans, and up- 
set his program. We believe a man gets less training 


July 1927 

at a training base, but he begins to realize that public 
health is a specialty, and that he does not know any- 
thing about it. 

Dr. John A. Ferrell, New York, N. Y.—In cooperating 
with state boards of health in the development of 
county health organizations, the Public Health Service 
and the International Health Board in the 
found it necessary to give financial aid for several 
years, five years usually, and frequently for longer 
periods. Even then there was a large percentage of 
tailures among the units established. They were due, 
as a rule, to lack of ability, training and experience by 
members of the staff. The experience has led the offi- 
ciais gradually to avoid, wherever practicable, organiz- 
ing new county organizations until trained personnel 

can be obtained. Since this policy has been in force, 
- number of county organizations to fail has been 
negligible. Should anyone doubt the wisdom of em- 
pioying capable, professionally trained personnel, he 
should study the failures which have occurred in county 
organizations to ascertain where the percentage of 
tauures has been highest and whether or not the failures 
have been due to compromising on the question of 
thorough training of personnel. 

Since 1922, the organization with which I am con- 
nected has aided state boards of health in giving from 
one to three months’ field training at its Alabama Train- 
ing Station to each of one hundred and twenty-seven 
young physicians who are now occupying positions in 
state health work. All but a few of them are serving 
as county health officers. There have been practically 
no failures among the men who, at the Training Sta- 
tion, demonstrated aptitude for the work. We find 
that, in addition to fewer failures, the Board can with- 
draw its aid completely from one to three years earlier 
than was practicable when directors without any pre- 
liminary training were employed, and the risk of failure 
is minimized. As the preliminary training usually costs 
only from $200.00 to $500.00, it will be seen that this 
small investment is well worth while, if it greatly 
diminishes the number of failures and transfers entirely 
to the public health agencies quite promptly the cost 
of conducting the work. No expenditure of money in 
the field of public health yields more satisfactory re- 
turns than that invested in competent, professionally 
trained, full-time personnel. 

Dr. W. S. Leathers, Nashville, Tenn.—Medical stu- 
dents should be given more opportunity for learning 
the principles of public health while taking the under- 
graduate courses of medicine. I am impressed with 
the fact, so far as my contact with medical students is 
concerned, that young men have been graduated in the 
past without having much of an idea with reference to 
the problems involved in public health work and the 
relation which the physician should sustain to it. They 
do not know the scope of public health or its possi- 
bilities. It is therefore not unnatural for them to be 
out of sympathy with many of the health activities 
which are at present being carried on when they enter 
upon the practice of medicine. 

In order to get able medical graduates to enter the 
public health field, they must be interested while taking 

Vol. XX No. 7 

the medical course. This will require a course of in- 
struction which will afford more opportunity for them 
to come into contact with the practical operations of 
public health work, and it is also desirable that the pre- 
ventive aspects of medicine be taught throughout the 
curriculum. The basic thing is to have in medical 
schools a department of preventive medicine and public 
health which will orientate. and correlate the medical 
teaching so that proper emphasis will be given to the 
preventive idea. Until preventive medicine and public 
‘health are given more recognition and a better relative 
position in the medical school, we need not expect to 
secure a considerable number of recruits for public 
health among recent graduates of medicine. 

The medical student must be trained so that he will 
have a better appreciation of the whole field of public 
health. He should know the relation which he ought 
to sustain to official and voluntary health agencies as a 
practitioner. He should be imbued with the spirit of 
prevention. He should be interested in health activities 
in the community and participate in a more concrete 
way in the improvement of individual and community 
health. In order to effect this result, the regular course 
of instruction for -medical students must bring them 
into more intimate contact with public health organ- 
ization and administrative practice. It is only in this 




way that they can properly comprehend the relation 
which the physician should sustain to the official health 

Dr. Felix J. Underwood, Executive Officer, Missis- 
sippi State Board of Health, Jackson, Miss—The Mis- 
sissippi State Board of Health is very grateful to the 
International Health Board for the training of .a num- 
ber of men who are now directing full-time county 
health departments in the State. After some unpleasant 
and unprofitable experiences in the past, we deem it 
wise to wait for a trained man to take charge of a county 
health department. We have found by experience that 
it is extremely unwise to employ a local physician as a 
director of a department,’ regardless of how much 
training he may receive. 

We have advanced so far in Mississippi in health 
work that, where a director fails, the department is not 
abolished by local authorities but another director is 
installed and the program continues. This is as it 
should be. When a teacher fails in a school, the board 
of trustees does not abolish the school but changes the 

The South, particularly, needs more well trained 
health officers and public health nurses. 



Southern Medical Journal 


Published monthly by the Southern Medical Associa- 
tion, Empire Building, Birmingham, Ala. Annual 
subscription $4.00. Single copies 35c each. 

Entered as second-class’ matter at the Post Office at 
Birmingham, Ala., under Act of March 3, 1879. Ac- 
ceptance for mailing at special rate of postage pro- 
vided for in Section gl » of October 3, 1917, 
authorized December 20, 

DR. M. Y. DABNEY, Editor 
Cc. P. LORANZ, Secretary-Manager 

Vol. XX JULY 1927 No.7 


Twenty-First Annual Meeting 
Memphis, Tennessee, November 14-17, 1927 

As the hot weather approaches, hundreds of 
mothers are dreading their infant’s “second sum- 

mer.” It is unreasonable to assume that Provi- 
dence has decreed that the second summer of 
a baby’s life should be its most strenuous period. 
Therefore, some cause other than Divine decree 
should be sought. The real cause is easily 

During the first summer the baby is either 
breast fed or is fed boiled milk with scrupulous 
care from boiled bottles and nipples. In the 
second summer the baby is allowed strained 
cereals, mashed and strained vegetables, meat 
broth, eggs, crisp bacon, etc. With the advent 
of the more liberal diet there is a tendency to 
feel that the baby has passed. beyond the period 
of infant care, and a let-up in the minutiae of 
infant feeding technic develops. The mother is 
in a hurry; the milk is not boiled; the cereal is 
not cooked quite long enough; the vegetables 
are not mashed; the baby is permitted to come 
to the table and the father feels that no harm 
would result from sucking a chicken bone, and 
maybe the next day a ham bone; and so it goes. 
The deadly ice cream cone is encouraged in 


July 1927 

many circles, and the infant’s total daily supply 
of sweets is notably increased. 

In a recent study of six hundred and twenty- 
eight normal white infants under two years of 
age from the Baltimore Welfare Clinic, Wilkins! 
has collected statistics upon the incidence of 
summer dysentery and diarrhea. Of the chil- 
dren, who were observed from June to Novem- 
ber, 1925, more than half had no gastro-intestinal 
disturbances whatever. Twenty-seven per cent 
had diarrhea, and 7.6 per cent or more had 
dysentery. One-fourth of the infants were ex- 
clusively breast fed. Of these, only ten per cent 
had diarrhea, and none had dysentery. 

Fifty-four per cent of the infants developed 
gastro-intestinal disease in some form during the 
second summer, and only 34 per cent in the 
first summer. Dysentery appeared to be one of 
the most common infectious diseases of the non- 
breast fed. 

Wilkins? investigated the method of protec- 
tion of infants against dysentery by oral admin- 
istration of vaccines, for which results have else- 
where been claimed. The vaccinated infants 
developed dysentery as readily as the unvacci- 
nated; and so the attempt to vaccinate in this 
way was entirely unsuccessful. However, ag- 
glutinins were demonstrated in the blood of rab- 
bits which had been fed large doses of killed 
Flexner dysentery bacilli, which shows that or- 
ganisms administered orally can affect the serum 
defense reactions. 

By these statistics of children among the 
poorer classes then, the old wives’ fear of the 
second summer appears to be justified. Many 
more children suffered from  gastro-intestinal 
conditions in the second summer than in the 
first. The picture of the second summer is, 
however, by no means pre-ordained and inevit- 
able, but on the other hand, is readily remedia- 
ble. Cleanliness, correct diet, and regular care 

1. Wilkins, Lawson: Incidence of Dysentery and 
Diarrhea Among White Infants Under Two Years of 
Age. Amer. Jour. Did. Child., 33:705, May, 1927. 

2. Wilkins, Lawson: Unsuccessful Attempts to Pro- 
tect Infants Against Dvsentery by Oral Administra- 
baad of Vaccine. Am. Jour. Dis. Child., 33:711, May, 

Vol. XX No.7 

are all that are necessary to prevent its occur- 

If all utensils are properly sterilized, if the 
milk is boiled and properly iced, if the more 
liberal diet is correctly preparedeif suitable 
cool clothing is worn, the baby will thrive and 
even cut eye and stomach teeth in its second 
August without dire results. 

During the summer the question. is frequently 
asked, “Will so-and-so hurt the baby?” The 
answer should be, “Will so-and-so help the 
baby?” If this cannot be answered in the af- 
firmative, the article in question should not be 
further considered. 

If mothers were correctly informed on this 
subject, many babies would be saved and the 
second summer would lose its horror. 


In the last few years iodin has attained a 
definite and limited place in the treatment of 
hyperthyroidism, and from clinical errors in a 
number of cases it has been proven to be very 
dangerous when misused. It is valuable in pre- 
and post-operative treatment, since it produces 
a temporary remission of the high basal metab- 
olism and other symptoms of hyperthyroidism. 

In so-called exophthalmic goiter, the percent- 
age of iodin in the gland is in inverse proportion 
to the hypertrophy and hypefplasia present.” 
If iodin is given to such a case, there is a 
prompt amelioration of clinical symptoms, which 
is directly associated with a change in the his- 
tological structure of the thyroid gland.* A 
marked classical hyperplasia under iodin medi- 
cation reverts to a colloid or less active state 
which more nearly approximates an inactive col- 

1. Starr, Paul: Course of Hyperthyroidism Under 
on Medication. Arch. Int. Med., 39:520, April, 

2. Marine, D.; and Lenhart, C. H.: 
Iodin to the Structure of Human Thyroids. 
Int. Med., 4:440, 1909, quoted by 3 

3. Rienhoff, W. F., Jr.: The Histological Changes 
Brought About in Cases of Exophthalmic Goiter 
by Iodin Administration. Arch. Int. Med., 37:285, 

Relation of 



loid goiter, or even a normal gland. The clinical 
syndrome is mild when the colloid or resting 
stage is present in the gland, and severe when 
a hyperplastic stage is found: it varies directly 
with the histological structure of the thyroid. 
Administration of iodin causes a temporary re- 
turn to the colloid stage, followed by an exag- 
geration of symptoms if administration is pro- 
longed, and reversion to the more severe his- 
tological picture. 

After iodin medication the heart condition, 
among other symptoms, is temporarily im- 
proved. Rabbits which are fed thyroid extract 
have an increase in cardiac output of 241 to 
270 per cent, which decreases after thyroidec- 
tomy.! Animals which receive iodin after thy- 
roid feeding show also a marked decrease in the 
cardiac output and basal metabolic rate for six 
to ten days, after which both increase rapidly.” 
The hyperthyroid rabbit on iodin repeats the 
clinical picture of temporary improvement fol- 
lowed by reaction. 

Thyroid feeding depresses gastric secretion in 
dogs. Thyroidectomy results in a decided in- 
crease in the volume of gastric juice of the same 
dogs, and also a less marked but demonstrable 
increase in the acidity. After thyroidectomy, 
gastric secretion may be depressed by thyroid 
feeding or elevated to its previous level as thy- 
roid feeding is stopped.* 

In view of the increased basal metabolism of 
hyperthyroidism, it might be expected and has 
often been suggested that the disease should be 
accompanied by an increase in gross bodily ac- 
tivity. Yet careful measurement of the run- 
ning activity of albino rats who are fed thyroid 
extract shows that the activity is markedly de- 
creased as long as the feeding continues. The 
animal is apparently rendered more susceptible 


1.. daira: I. T.: Med., 
quoted by 5. 

2. Blalock, A.; and Harrison, T. R.: Effect of Thy- 
roidectomy and Thyroid Feeding on Cardiac Out- 
put. Surg. Gyn. Obst., 44:617, May, 1927. 

3. Hardt: Amer. Jour. Physiol., 40:315, 1916, and 
Truesdell: ibid., 76:20, 1926. Quoted by 7. 

4. Chang, H. S.; and Sloan, J. H.: Influence of Ex- 
perimental Hypothyroidism Upon Gastric Secre- 
tion. Amer. Jour. Physiol., 80:732, May, 1927 

Jour. Exper. 6:325, 1925, 


to fatigue. The heart circulates the blood more 
rapidly to supply oxygen for the increased burn- 
ing process, and waste products which accumu- 
late probably produce fatigue.’ 

Both the hypo- and hyper-thyroid conditions 
are reasonably amenable to specific therapy, and 
should thus be a bulwark of comfort to the 
practicing physician and surgeon. As time goes 
on finer and finer points will be drawn in the 
diagnosis and treatment of mild phases of thy- 
roid disease. Certain less understood conditions 
of the skin, hair, heart and alimentary tract will 
be shown to be affected by the quantity of thy- 
roid secretion. 

A specific therapy for every clinical syndrome 
is the end and aim of medical science, but like 
the star Vega toward which the solar system is 
moving, it is still far away. Also, though the 
medical world is fortunate in having a funda- 
mentally sound approach to treatment of hypo- 
and hyper-thyroidism, it should be held in mind 
first that disease of the thyroid is largely pre- 
ventable, and that the tissue damage may be 
much better prevented than repaired. 


Ileus is common when intra-abdominal sur- 
gical manipulations are extensive. There is also 
immediate cessation of bowel movements in 
patients following perforation of a gastric, duo- 
denal, or typhoid ulcer, and paralytic ileus is a 
common accompaniment of acute diffuse per- 
itonitis. Dogs with peritonitis which are treated 
for obstruction are said to improve.2 The onset 
of cessation of intestinal movement in most cases 
is sudden and probably reflex, extending later 
to paralytic ileus if conditions are not modified. 

In dogs the intestinal movements cease after 
certain operations but begin again strongly if 

1. Wang, J. H.: Effect of Thyroid Feeding on the 
Spontaneous Activity of the Alvino Rat and Its 
Relation to Accompanying Physiological ' enn 
Bull. Johns Hop. Hosp., + 504, May, 1927. 

2. Kelby, H. M.; and Ivy C.: Preliminary Re- 
port on Therapy for * peritonitis. Amer. Jour. 
Physiol., 76:227, 1926. 


July 1927 

spinal anesthesia is given.’ It is suggested that 
the chemical changes which have been described 
in the blood are the result, not the cause, of 
ileus. If the condition in man corresponds with 
that in the dog, paralytic ileus, like reflex in- 
hibition, depends upon the integrity of the re- 
flex arc. Novocain intraspinally stops afferent 
stimuli, probably blocks the splanchnics, par- 
alyzes the voluntary motor nerves, and tempo- 
rarily blocks transmission through the cord. 

Paralytic ileus after operation under spinal 
anesthesia theoretically should be less common 
than after inhalation anesthesia. 

Memphis—Where We Meet 


Sooner or later, if one stays around a golf 
course any length of time, he will hear a person 
accused of being a “fair weather golfer.” That 
in itself is considered a term of opprobium, even 
in Memphis, where everyone who uses the links 
may be considered a fair weather player. It is 
fair weather sometime or other during the course 
of nearly every day at Memphis, and conditions 
never have been so bad that some zealot did not 
gather his clubs and attempt to make a course in 

Memphis has seven golf courses, three mu- 
nicipal links and four private country clubs. 
Six of the links are open during the entire year. 
The seventh was just recently closed, not be- 
cause of the weather, but for the necessity of 
improving parts of the fairways on some of the 
holes. The weather is seldom so cold or so dis- 
agreeable as to prevent playing, and during De- 
cember the starters at all of the courses reported 
the usual steady flow from the first tee. 

As a matter of cold fact, difficulties in playing 
golf in Memphis hardly assemble in copious 
quantities until the middle of February, and 
then last for a month. During that brief period 
rains are frequent, and cold spells follow the 
rains; but cold and rain even in combination 

Relief of 

1. Markowitz, J.; and Campbell, W. R.: 

Experimental Ileus af — Anesthesia. 
Jour. Physiol., 81:161, 

*From the Publicity bi Mrs. Percy Finlay, 

Memphis Chamber of Commerce. 

Vol. XX No.7 

Memphis Country Club 

are seldom sufficient to douse the enthusiasm of 
hardened linksmen. 

The remainder of the year offers no climatic 
obstacles to golf. Of course, there are preferred 
seasons, just as there are preferred seasons for 
almost everything. But taken as a whole, golf 
is the steady year around sport of Memphians. 

The late fall of this part of the South usually 
makes itself manifest along the first of Decem- 
ber. Until that time the weather is unusually 
balmy. In December, 1926, there was hardly 
a day in Memphis that was not pleasantly at- 
tuned to golf, and on*Sunday, December 12, 
with a temperature of 70 degrees, thousands of 
players flocked to the various courses. 

Three of the Memphis courses are nine-hole 
affairs, and the other four have eighteen holes. 
One of the nine-hole courses is to be stretched 
to the full distance in a few years. ‘ Bermuda 
grass is on the gteens, and the various green- 
keepers have become so proficient in the manip- 
ulation of Bermuda that putting is greatly fa- 
cilitated. The greens are true and smooth. — 

The Memphis Country Club course is the old- 
est in-Memphis. It was built in 1905, and then 
rebuilt in 1914. The links were laid out by an 
excellent golfing engineer, and combine artificial 
hazards that are peculiarly effective with the 
natural hazards that the rolling ground in and 
about Memphis affords. The course was the 
scene of the 1926 Southern Amateur Tourna- 

The Colonial ranks next in point of age, and 
is one of the most difficult of the Memphis 
links. It is an eighteen-hole affair of many per- 
plexing possibilities for the anxious golfers. The 
Western open was played on that course in 1923. 

The Ridgeway and the Chickasaw are two of 
the newer courses, but each has been perfected to 
a point of unusual attractiveness. Ridgeway has 



but nine holes, and is considered 
one of the most difficult courses in 
the South. The Chickasaw is an 
eighteen-hole course. 

Overton Park, Riverside Park 
and Galloway Park encompass the 
three municipal courses. The 
Galloway Park course was opened 
in 1926, a. magnificent natural 
course of eighteen holes, laid out 
in an enticing way, bounding with 
traps and bunkers. 

The Overton Park course is the most popular 
in the City. It is crowded from early morning 
till late at night through all seasons. It is a 
veritable Mecca for club wielders. Extensive 
improvements have been made on the links, and 
its setting in the natural beauty of a spacious 
park makes it particularly attractive. 

The Riverside links parallel, in part, the Mis- 
sissippi River, several of the tees being located 
on the high bluff. The undulating land of the 
riverside makes it an ideal “natural,” and the 
course patronage daily runs into large numbers. 

The Riverside and Overton courses require no 
green fees. Local hotels have made arrange- 
ments for guest privileges at private courses, and 
hundreds of visitors take advantage of the golf 

Book Reviews 

Intracranial Tumors and Some Errors in Their Diag- 
nosis. By Sir James Purves-Stewart, K.C.M.G., C.B., 
M.D. (Edin.), F.R.C.P., Senior Physician to West- 
minster Hospital; Physician to the Royal National 
Orthopedic Hospital; Consulting Physician to the West 
End Hospital for Nervous Diseases; Membre Corre- 
spondant de la Societe de Neurologie de Paris; Hon- 
orary Member of the Philadelphia Neurological So- 
ciety; Associate Member of the American Neurologi- 
cal Society; Colonel, Army Medical Service (Retired). 
206 pages, illustrated. New York: Oxford University 
Press. Cloth, $3.75. 

The monograph is based upon material collected by 
Sir James for his presidential address to the Section 
on Neurology of the Royal Society in 1926. The sub- 
ject is presented in the form of carefully worked up 
case reports followed by a discussion of them. Diag- 
nostic errors are freely admitted and the author tries to 
explain their occurrence. 

Intracranial tumors in all locations are covered and 
the book is to be highly commended for its clearness 
and the satisfactory manner in which the subject is de- 


Management of the Sick Infant. By Langley Porter, 
BS., M.D., M.R.C.S. (Eng.), L.R.C.P. (Lond.), Pro- 
fessor of Clinical Pediatrics, University of California 
Medical School; Visiting Pediatrician, San Francisco 
Children’s Hospital; Consulting Pediatrician, Babies’ 
Hospital, Oakland; Consulting Pediatrician, Mary’s 
Help Hospital, San Francisco, and William E. Carter, 
M.D., Instructor in Pediatrics, University of Cali- 
fornia Medical School, San Francisco. Third Revised 
Edition. 726 pages, illustrated. St. Louis: C. V. 
Mosby Co. Cloth, $8.50. 

The general plan of this third edition is the same as 
that of the previous two editions. However, there has 
been a general revision and the latest developments in 
the management of the sick infant have been incor- 
porated. The book is well written and should be espe- 
cially useful for the busy practitioner. It contains many 
recipes and descriptions of therapeutic procedures which 
will be useful to keep within arm’s reach. 

Birth Injuries of the Central Nervous System. By Frank 
R. Ford, Johns Hopkins Hospital, and Bronson 
Carothers and Marian C. Putnam, Harvard Medical 
School. 220 pages, with 70 illustrations. Baltimore: 
Williams & Wilkins Co. Cloth, $4.00. 

This little monograph is a careful digest of the litera- 
ture, to which the authors have added their own experi- 
ence. Dr. Ford has described the cerebral birth injuries 
and their results with the cooperation of other mem- 
bers of the staff of the Johns Hopkins. Drs. Carothers 
and Putnam, with the cooperation of the staff members 
of the Peter Brent Brigham Hospital, have covered the 
obstetrical injuries to the spinal cord. 

The book is certain to hold a place on the reference 

The Medical Clinics of North America (issued serially, 
one number every other month), Volume X, Number 
X (Boston Number, March, 1927). Octavo of 311 
pages with 34 illustrations. Philadelphia and Lon- 
don: W. B. Saunders Co. Per clinic year, July, 1926, 
to May, 1927, paper, $12.00; cloth, $16.00 net. 

As is usual in the “Medical Clinics,” a great diversity 
of subjects is well presented. The contributors are all 
physicians of standing and in the list there is no one 
article that is more worthy of mention than the others. 

Examination of Children by Clinical and Laboratory 
Methods. By Abraham Levinson, B.S., M.D., Asso- 
ciate in Pediatrics, Northwestern University Medical 
School; Attending Physician, Children’s Department, 
Cook County Hospital, Chicago; Attending Pediatri- 
cian, Sarah Morris Hospital for Children of the 
Michael Reese Hospital, Chicago; Attending Pedi- 
atrician, Mount Sinai Hospital, Chicago. Second Edi- 
tion. 192 pages, with 85 illustrations. St. Louis: 
C. V. Mosby Co. Cloth, $3.50. 

The second edition has been brought up to date, and 
is in accord with the latest thought in pediatric pro- 
cedure. The technic and procedures are described briefly 
and clearly, and some acquaintance of the reader with 
them is presupposed. The illustrations and arrange- 
ment of subject matter are good. 

The book should be of greatest use to the interne in- 
terested in children. However, the sections on examina- 
tion would serve the student also. The pediatrician will 
find it elementary, yet good for frequent reference. 

July 1927 

The Normal Chest of the Adult and the Child. By J. A. 
Myers, Associate Professor of Preventive Medicine, 
Medical and Graduate Schools, University of Minne- 
sota; Medical Director, Lymanhurst School for Tu- 
berculous Children, Minneapolis, Minn., in collabora- 
tion with several others. 419 pages, illustrated. Balti- 
more: The Williams & Wilkins Company. Cloth, 

The book is the result of a course organized to bridge 
the chasm between the fundamental and clinical branches 
in the medical school at the University of Minnesota. 
The subject is clearly presented and logically developed. 
The physician as well as the medical student should 
familiarize himself with the normal, since if this is mas- 
tered the abnormal will always be recognized. 

It seems unfortunate that under x-ray examination 
of the heart, cardiac areas are given instead of the usual 
diameters. Cardiac areas are more difficult to compute. 


The Artificial Light Treatment of Children. By Kath- 
erine M. L. Gamgee, M.R.CS. (Eng.), L.R.C.P. 
(Lond), D.P.H. (R.C.P.S.), formerly Assistant Med- 
ical Officer of Health for Maternity and Child Wel- 
fare, Hull and Medical Officer in Charge, Hull Cor- 
poration Artificial Light Clinic; Late House Physi- 
cian, Brompton Hospital for Consumption, Etc 172 
pages, illustrated. New York: Paul B. Hoeber, Inc. 
Cloth, $4.00. 

The author’s claims in the “Artificial Light Treat- 
ment of Children” are always conservative, and the data 
on which they are based are always submitted. This is 
especially appreciated at a time like the present when 
most of the literature on physiotherapy is written by 
extremists. The author has a real command of the 

The Quartz Mercury Vapour Lamp. By J. Bell Fergu- 
son, M.D., B.P.H., Medical Officer of Health, Tuber- 
culosis Officer, and School Medical Officer, County 
Borough of Smethwick. 105 pages, illustrated. New 
York: Paul B. Hoeber, Inc. Cloth, $2.50. 

In this little volume clearness is in no way sacrificed 
to brevity. As a practical manual, it can be studied 
with profit by physicians using this form of physio- 

A Textbook of Medicine. By 130 American Authors. 
Edited by Russell L. Cecil, M.D., Assistant Professor 
of Clinical Medicine, Cornell University, Medical 
School, New York. Octavo of 1,500 pages, illus- 
trated. Philadelphia and London: W. B. Saunders 
Co., 1927. Cloth, $9.00 net. 

The one hundred and thirty authors have covered 
their allotted subjects satisfactorily. 

It is noted with interest that Cecil does not consider 
the routine administration of digitalis to be indicated in 
pneumonia, and that he does not use the body weight 
method of Eggleston. Deserving of special mention 
is “Rheumatic Fever” by Homer F. Swift, but there is 
no reference to the work of Small on the etiology of 
this disease. Also it is to be regretted that Swift’s re- 
cent work on the contra-indications to the use of the 
salicylates was not added in a footnote. 

McCann and Maitland Jones’ article on pernicious 
anemia is complete, except that Minot’s work on diet is 
dismissed in two and one-half lines. Christian’s con- 
tributions are, as always, well presented. The sections 

ee see enn 

eer ee TE 

Vol. XX No. 7 

on gastro-enterology covered by T. R. Brown are care- 
fully written, but there is no mention of prognosis under 
peptic ulcer. 

The sections on tuberculosis are models of clearness. 

In a book as well written as the present volume, it is 
difficult to select articles for special mention. The sec- 
tion on syphilis by J. S. McLester, a member of the 
Southern Medical Association, is one of the best papers 
contributed. The sections devoted to “Diseases of the 
Nervous System” are well written. The book is a credit 
to its editors and contributors, and to the American 
medical profession. 

Practical Nursing for Male Nurses in the R.A.M.C. and 
Other Forces. By Colonel E. M. Hassard, A.MS. 
(Retd.) and A. R. Hassard. Second edition. 407 
pages. New York: William Wood & Company. 
Cloth, $3.50. 

For the enlisted personnel of the medical department 
of the British Army and Navy this book is written, and 
it complies with their regulations. Its usefulness is nat- 
urally limited, but is real. 

Self-Care for the Diabetic. By J. J. Conybeare, M.C., 
M.D., Oxon., F.R.C.P. (Lond.), Assistant Physician 
to Guy’s Hospital. 70 pages. New York: Oxford 
University Press. Cloth, $1.15. 

This manual is clearly written and can be recom- 
mended to the patient. The section given to insulin is 
complete from the layman’s point of view. Those de- 
voted to “Daily Menus for Diabetics” are perhaps not 
extensive enough. “Hygiene for the Diabetic” is well 

Modern Views on Digestion and Gastric Disease. By 
Hugh MacLean, M.D., D.Sc., M.R.C.P., Professor of 
Medicine, University of London, and Director of the 
Medical Clinic, St. Thomas’s Hospital; Honorary 
Consulting Physician to the Ministry of Pensions; 
Consulting Chemical Pathologist to St. Thomas’s Hos- 
pital. 170 pages, with 14 Charts and 23 Figures. 
New York: Paul B. Hoeber, Inc. Cloth, $4.00 net. 
Little that is modern is included in this text. The 

author is an extremist who states that gastric carcinoma 

is easily diagnosed and that the absence of hydrochloric 
acid and the presence of lactic acid are pathognomonic 
of this condition. 
The sections devoted to anatomy and physiology are 
what one would expect to find in a nurse’s text book. 
The section on treatment is so short as to be of small 
practical value. 

The Theory and Practice of Massage. By Beatrice M. 
Goodall-Copestake, Examiner to the Chartered So- 
ciety of Massage and Medical Gymnastics, Teacher of 
Massage and Swedish Remedial Exercises to the Nurs- 
ing Staff of the London Hospital. Fourth Edition. 
267 pages, illustrated. New York: Paul B. Hoeber, 
Inc. Cloth, $4.50 net. 

The book is written for the laity, although through- 
out the author stresses the fact that the methods should 
be used only under medical supervision. The pro- 
cedures are explained in detail and well chosen illus- 
trations are freely used. The fact is stressed that mas- 
sage cannot be learned from a book but must be gained 
through study and supervised clinical work. 


A Handbook of Diseases of the Stomach. By Stanley 
Wyard, M.D., B.S., M.R.C.P., Physician to the Bol- 
ingbroke Hospital and the Victoria Hospital for Chil- 
dren; Assistant Physician to the Cancer Hospital. 
387 pages, illustrated. New York: Oxford University 
Press. Cloth, $5.00. 

The book is too dogmatic in its statements for a 
medical work, and it may also be said in just criticism 
that the chapters devoted to anatomy and physiology 
are too brief to be clear. 

The section on “Clinical Examination of the Patient” 
is better than the rest of the book, but it is difficult 
to understand why radiography is dismissed in less than 
two pages. 

The chapter given to “Pathological Investigations; 
Test Meals; and Examination of the Stomach Contents, 
Vomitus, Feces and Urine,” is too meager and the au- 
thor is too positive in his statements. 

After having read the section on “Consideration of 
Certain Therapeutic Measures,” one gains the impres- 
sion that all in use are worthless and that there has 
been none recommended by the author to take their 

The clinical. conditions are only fairly well covered, 
as the treatment mentioned would be difficult to apply 
because it is too general for those for whom it is in- 
tended, i.e., the practitioners. The section on gastric 
ulcer is not clear and is below the average of the book, 
while that devoted to carcinoma of the stomach is 
somewhat better. 

The last chapter is given to “Gastric Symptoms and 
Extra-Gastric Disease” and is too sketchy to be of 

The Heart and Its Diseases. By Charles W. Chapman, 
M.D., (Durh.), M.R.C.P. (Lond.), Consulting Physi- 
cian to the National Hospital for Diseases of the 
Heart, London; Late Physician to the Farringdon 
General Dispensary, London. New York: William 
Wood & Co. Cloth, $3.50. 

The author has attempted to present the subject of 
cardiology in an elementary form. The subject is diffi- 
cult and has been better covered by other authors. 

Southern Medical News 


Dr. W. Groce Harrison, of Birmingham, on June 21, 
on the eve of his departure for a four-month visit to 
Europe, was the host at a dinner at the Southern 
Club celebrating the forty-eighth year of practice of 
Dr. John D. S. Davis, of Birmingham. Dr. Davis, who 
was Professor of Surgery of the former Birmingham 
Medical College, with his brother, Dr. W. Elias B. 
Davis, was a founder of the Southern Surgical Asso- 

At the annual meeting of the Medical Association 
of the State of Alabama, held April 19-20 at Mont- 
gomery, Dr. John D. S. Davis, Birmingham, was 
elected President; Dr. Malcolm O. Grace, Ozark, Vice- 
President; Drs. William D. Partlow, Tuscaloosa, and 
Benjamin L. Wyman, Birmingham, censors for five 
years; Dr. Douglas L. Cannon, Montgomery, Secre- 
tary. Dr. Samuel W. Welch, Montgomery, was elected 
State Officer for five years. The next annual meet- 
ing will be held at Birmingham, April 17-20, 1928. 

Dr. Henry Beechum Burdeshaw, of Dothan, and Miss 
Pauline Byrd, of Enterprise, were married April 14. 


Dr. Henderson E. Watts, Holly Pond, aged 58, died 
April 1 in Birmingham. 



At the annual meeting of the Arkansas Medical So- 
ciety, held recently at Little Rock, Dr. nT ad Thi- 
bault, Scott, was elected President; Dr. Robert H. T. 

Mann, Texarkana, Yb egg Drs. Homer Scott, 
Little Rock; Joseph Wharton, El Dorado, and Os- 
car J. T. Johnston, Batewviie Vice-Presidents; Royal 
J. Caleote and William R. Bathurst, both of Little 
Rock, Treasurer and Secretary, respectively. The 
next annual meeting will be held at El Dorado. 

Ashley County Medical Society has elected Dr. L. C. 
Barnes, Hamburg, President; Dr. J. W. Simpson, 
Hamburg, Secretary. 

Greene County Medical Society has elected Dr. F. M. 
Scott, President; Dr. W. M. Majors, Secretary-Treas- 

Montgomery County Medical Society has_ elected 
Dr. W. D. Freeman, President; Dr. J. H. McLean, 

The City of Helena recently approved the proposed 
$150,000 bond issue for the purpose of erecting a new 
city hospital. 

Dr. E. L. Watson, of Newport, was appointed to 
succeed Dr. R. O. Norris, of Tuckerman, on the State 
Board of Health, and Dr. W. P. Parks, of Hot 
Springs, was appointed to succeed Dr. S. A. Southall, 
formerly of Lonoke. 

Dr. James F. Merrit has been appointed Health 
Officer of Hot Springs, to succeed Dr. William L. 
Holt, resigned. 

At a meeting of the Board of Trustees of the Uni- 
versity of Arkansas, Little Rock, recently, Dr. Morgan 
Smith resigned as Dean of the School of Medicine, ef- 
fective July 1,- and Dr. Frank Vinsonhaler, Little 
Rock, was appointed to that position. Dr. Vinsonhaler 
is Professor of Diseases of the Eye, Ear, Nose and 
Throat at the Medical School, and a member of the 
American Board of Ophthalmology. 

Dr. Kenneth K. Kimberlin, of Tuckerman, and Miss 
Lola Scott, of Little Rock, were married April 20. 


Dr. Idus L. Bradley, Little Rock, aged 45, died 
— 26. 
Dr. H. C. Dunavant, Osceola, aged 83, died May 2. 
Dr. William C. Moody, Bentonville, aged 89, died 

April 5 of senility. 

Dr. Jason S. McCants, Osceola, aged 85, died April 
30 of heart disease. 

Dr. C. C. Price, Dumas, died recently. 


A three-story building for Howard University School 
of Medicine, Washington, is under construction at a 

cost of $500,000. Howard University School of Medi-— 

cine and Meharry Medical College at Nashville, Ten- 
nessee, are the only negro medical colleges in the 
United States. 

The senior class of George Washington University 
Medical School presented to the school oil portraits of 
the Dean, Dr. William C. Borden, and of Dr. John 
Wesley Bovee, formerly: a professor. The President 
of the University, William M. Lewis, LL.D., ac- 
cepted the portraits on behalf of the Medical School. 


Dr. Henry Bernard Kauffman, Washington, aged 
52, died April 29 of heart disease. 


Columbia, Hamilton, Madison and Suwannee county 
medical societies recently met and organized a joint 
society to the Suwannee River Medical Society. 

Central Florida Medical Society reorganized in March 
— Dr. George C. Tillman, Gainesville, Presi- 

The Florida Railway Surgeons’ Association has 
elected Dr. J. S. Turberville, Century, President; Dr. 
C. W. Shackelford, West Palm Beach, Vice-President; 
Dr. E. W. Warren, Palatka, Secretary-Treasurer. 

Dr. B. S. Stutts, formerly of Munson, has recently 
moved to Dunnellon, where, in addition to his prac- 
tice, he will act as surgeon for the Atlantic Coast 
Line Railway Company. 

July 1927 

Dr. Clarence W. Shackelford has been appointed 
Superintendent of the Good Samaritan Hospital, West 
Palm Beach, to succeed Dr. William E. Van Land- 
ingham, resigned. 

Dr. J. N. Fogarty tendered his resignation as Mayor- 
Commissioner of St. Augustine on May 2. 


Dr. Robert L. Harris, tohncn vite, aged 68, died 
suddenly April 26 of heart disease. 

Dr. J. W. Hassler, of St. Petersburg, and Belmar, 
New Jersey, died May 29 at Reading, Pennsylvania, 
following an operation. 


The Chattahoochee Valley Medical and Surgical As- 
sociation will meet at Warm Springs July 12-13. 

At the annual meeting of the Medical Association 
of Georgia, held in Athens May 13, Dr. William A. 
Mulherin, Augusta, was elected President; Drs. Henry 
M. Fullilove, Athens, and Cleveland Thompson, Mil- 
len, Vice- Presidents; Dr. Allen H. Bunce, Atlanta, 
Secretary. The next annual meeting will be held at 

Ben Hill County Medical Society has elected Dr. 
Chas. Wilcox, Fitzgerald, President; Dr. W. D. Dor- 
miny, Fitzgerald, Vice-President; Dr. L. 8. Osborne, 
Fitzgerald, Secretary-Treasurer. 

Campbell County Medical Society has elected Dr. T. 
P. Bullard, Palmetto, President; Dr. A. J. Green, 
Union City, Secretary-Treasurer. 

Dooly County Medical Society has elected Dr. T. F. 
Bivins, Vienna, President; Dr. W. N. Bdenfield, Vi- 
enna, Vice-President; Dr. F. E. Williams, Vienna, 

Elbert County Medical Society has elected Dr. G. A. 
Ward, Elberton, President; Dr. J. E. Johnson, Elber- 
ton, Vice-President; Dr. B. B. Mattox, Elberton, 

Fifth District Medical Society has pg ee Dr. W. 
S. Ansley, Decatur, President; Dr. W. E. Barber, At- 
lanta, Vice-President; Dr. R. T. Camp, Fairburn, Sec- 

Franklin County Medical Society | elected Dr. S. 
D. Brown, Royston, President; Dr. T. Pool, La- 
vonia, Vice- President; Dr. B. T. ‘Smith, Carnesville, 

Jones County Medical Society has elected Dr. J. W. 
Anderson, Gray, President; Dr. J. O. Zachery, Gray, 

Laurens County Medical Society ae elected Dr. 
Sidney Walker, Dublin, President; Dr. A. T. Coleman, 
Dublin, Vice- President; Dr. O. H. Cheek, Dublin, 

Madison County Medical Society has elected Dr. 

G. Banister, Ila, President; Dr. W. D. Gholston, 
Danielsville, Secretary- Treasurer. 

Screven County Medical Society has elected Dr. H. 
E. Ezell, Oliver, President; Dr. L. F. Lanier, Rocky 
Ford, Vice-President; Dr. E. E. Downing, Newington, 

Seventh District Medical Society has elected Dr. W. 
E. Wofford, Cartersville, President; Dr. R. M. Harbin, 
Rome, Vice-President; Dr. M. M. McCord, Rome, 

Spalding County Medical Society has elected Dr. W. 
C. Miles, Griffin, President; Dr. L. T. Hawkins, Grif- 
fin, Secretary- Treasurer. 

Tattnall County Medical Society has elected Dr. J. 
H. Bowen, Cobbtown, President; Dr. R. D. Jones, Elza, 
Vice-President; Dr. J. C. Collins, Collins, Secretary- 

Walton County Medical Society has elected a? H. 
L. Upshaw, Social Circle, President; Dr. J. B. Day, 
Social Circle, Vice- President; Dred. KK. MeClintle, 
Monroe, Secretary-Treasurer. 

Wheeler County Medical Society has elected Dr. D. 
C. Colson, Glenwood, President; Dr. W. A. Rivers, 
Glenwood, Secretary-Treasurer. 

The School of Medicine of Emory University has 
opened at Wesley Memorial Hospital a free heart 
clinic for white patients unable to pay. The clinic 
will be under the direction of Dr. Stewart R. Roberts, 
and the time of the clinic at present is 9 o’clock on 
Thursday mornings. 

(Continued on page 34) 



A Diet For 

Reliquefied SIMILAC is a complete diet in which the fats, sugars, 
proteins and salts of cow’s milk have been modified and rear- 
ranged to meet the physical, chemical and metabolic requirements 
of infant nutrition. SIMILAC is prepared according to the for- 
mula devised and developed in the research laboratories of the 
Boston Floating Hospital, Boston, Mass. 


(1 ounce or 4 level tablespoonfuls powdered 
SIMILAC in 7% ounces of water.) 

Peek tS a cay: 4k cg PAS Giecik oH acot-e Wel oak tad eee 
eg Ge kt ere, eee See ores ek ee 
PPR SS eee ea Peer 6S Pio ae eee 
SE IN igs Asis task poytd-c a See Se Ee 5. chan 38.43 he, @ wees 
PT fe ee a Wee ka es eiee tating anf one Oe 
Meeordss..c8 Eeokeigeye> te ae 

1 ounce of Powdered SIMILAC a .... 153.2 Calories 

1 level tablespoonful Powdered SIMILAC................ 38.3 Calories 

1 ounce of Reliquefied SIMILAC. 19.0 Calories 

In offering SIMILAC to the’ Medical Profession, 
we do so with the thought in mind that breast 
milk is nature’s food for the infant, but as many 
infants are deprived of their natural food, 
either wholly or in part, some form of nourish- 
ment must be substituted, and SIMILAC is 
offered as this substitute. 

Samples and Literature will be mailed upon receipt 
of your prescription blank. 

5) MooRES & Ross, INC. udoeatores COLUMBUS, OHIO 





(Actual Price 
Size) $25.00 

The Tycos Self-verifying Sphygmo- 
manometer is built like a fine watch— 
the utmost care being taken to insure 
its dependable action under all circum- 
stances. The needle registers the actual 
pressure when the dial is in any posi- 
tion, and may be relied upon absolutely 
for the fine determination of systolic, 
diastolic and pulse pressure. The whole 
outfit, including carrying case and steri- 
lizable sleeve, can be conveniently 
carried in the pocket. See them at your 
surgical dealer. 

For Your Library 


These are free, send for them 
for Instrument Companies 
ROCHESTER, N. Y., U. 8. A. 
Manufacturing Distributors 
ling, in Great Britain, 
Toronto Short & Mason, Ltd., London 

There is a Tycos or Taylor Temperature Instru- 
ment for Every Purpose 

(Continued from page 578) 

A dozen railroads and twenty-five hospitals in Geor- 
gia are cooperating with the State Board of Health 
in supplying needed medical and surgical attention for 
rural school children of the State. Children may be 
taken to the nearest hospital, where they will receive 
care and treatment for two days at minimum rates. 
Railroads have authorized half fare for the parent 
accompanying the child, and one-half of the a fare 
rates for children under twelve years of ag 

Dr. L. B. Robinson, Atlanta, was vesehtey” plected a 
member of the Alpha Omega Honorary Society, the 
honor conferred by the chapter at Vanderbilt Uni- 

Dr. W. E. Person, Atlanta, has been elected Vice- 
President of the Alumni Council of Emory University. 

Dr. LeRoy W. Hubbard, Atlanta, formerly Ortho- 
pedic Surgeon in charge of after-care of poliomyelitis 
cases in New York State, has accepted the position 
as Director of Hydrotherapeutic Center at Warm 

Dr. Daniel L. Seckinger, Springfield, has been elect- 
ed Assistant Health Officer of the City of Savannah 
and Deputy Health Commissioner of Chatham County. 
He is on the staff of St. Mary’s Hospital, Pierre, 
South Dakota, but will assume his new duties at an 
early date. 

Dr. B. F. Minchew, Waycross, has been appointed 
Superintendent of the Red Cross first aid school under 
the direction of the local chapter. 

Mr. J. B. Franklin, of Houston, Texas, was recently 
elected Superintendent and Executive Head of the 
Georgia Baptist Hospital, Atlanta, succeeding Dr. E. 
B. Elder. 

Dr. Jos. Yampolsky, Atlanta, has been elected Pres- 
ident of the Georgia Pediatric Society, and Dr. W. N. 
Adkins, Atlanta, Secretary. 

Dr. B. McH. Cline; Atlanta, is in Europe for a 
three-months’ visit to European clinics. 

Dr. S. L. Morris, Jr., Atlanta, and Miss Marion 
Lumpkin Hull. daughter of Dr. M. McH. Hull, of At- 
lanta, were married May 14. 


Dr. J. D. Bailey, Summertown, aged 55, died April 
17 at a hospital in Savannah of nephritis. 

Dr. George Willis Malone, Sandersville, aged 58, 
died April 4 at a hospital in Atlanta. 

Dr. Oscar Henley Snider, Atlanta, aged 61, died April 
15 at a local hospital. 


Russell County Medical Society has elected Dr. L. D. 
Hammond, President (re-elected); Dr. W. G. D. Flan- 
agan, Vice-President; Dr. J: B. Sholl, Secretary and 

Lyon County Medical Society has elected Dr. C. H. 
Linn, Kuttawa, President; Dr. Y. L. Phillips, Kuttawa, 
Vice-President; Dr. W. G. Kinsolving, Eddyville, Sec- 
retary and Treasurer. 


Dr. Felix Coblens, Louisville, aged 76, died April 15 

of myocarditis. 
Dr. Joseph Walk Irwin, Louisville, aged 76, died 

in April. 
(Continued on page 36) 


Ridgetop, Tenn. 

Cottage sanitarium for the treat- 
ment of tuberculosis. 

Location ideal, elevation 1000 feet. 
Rates reasonable. 

Illustrated booklet on application. 
DR. W. S. RUDE, Medical Director 


| generally recognized. The story the x-ray 

A Scientific Method 

The medical profession has long since dis- 
carded the rule of thumb. The scientific 
method of ascertaining diagnostic facts is 

tells results from one application of the 
scientific method. It is another step toward 
the realization of the professional ideal of a 
correct diagnosis, quickly arrived at. 

Practically all patients would demand 
radiographic confirmation if they understood 
its sureness and accuracy. 

If you do not make radiographs 
refer your patients to a compe- 
tent roentgenologist. 

Eastman Kodak Company 

Medical Division Rochester, N. Y. 


(Centinued from page 34) 

Dr. George B. Spencer, Carlisle, aged 58, died March 
25 cf chronic nephritis. 


At the recent meeting of the Louisiana State Medi- 
cal Society, held in New Orleans April 29, Dr. Ar- 
thur A. Herold, Shreveport, was elected President; 
Dr. Leon J. Menville, New Orleans, President-Elect; 
Drs. David I. Hirsch, Monroe; Charles C, DeGravelles, 
Morgan City, and James Birnie Guthrie, New Orleans, 

During the summer months Vice-Presidents; Dr. P. T. Talbot, New Orleans, Sec- 
retary-Treasurer, re-elected. The next meeting will 

inci i in- be held at Baton Rouge. 
the incidence of the various in ae ee me = a Puc ie 9 ig Tulane ant 
* . . . versity, son o Ras ‘ orck, has been appointed 
testinal infections of infancy Junior Assistant House Surgeon of the Charity Hos- 
pital, New Orleans. 

may be expected to increase. Construction has been started on the Fuqua Me- 
morial Hospital, a building to be erected at the Cen- 

tral Louisiana Hospital for the Insane in memory of 


The value of lactic cultures in the late Governor, Henry L.. Fuqua. ai a 
r. Bert L. nson, Great Bend, Kansas, has taken 
such cases has been amply dem- up the duties of Director of the Tangipahoa Parish 

Health Unit, succeeding Dr. T. C. W. Ellis. 

onstrated. The Orleans Paris Medical Society is sponsoring a 
laws i hold . eg roe AF ns ted —— fall 
an as appointe . Pau . Gelpi, Jr., airman 

Our Cultures are at your serv- of the Committee to arrange plans whereby. every 

e . person in the city will be provided with a physical 

ice at our conveniently located examination. 

s ‘ Dr. big | r — ae .> appointed Presi- 
ore ent of the Boa ° ea. at nton. 

dep ository st 8. The Royal College of Surgeons of England conferred 

an honorary fellowship on Dr. Rudolph Matas, New 

Orleans, during his visit to London in April. 


Dr. Robert Moses Littell, Opelousas, aged 65, died 
recently at the menlce Sanatorium of mitral insuffi- 

ciency and diabetes. 
Yonkers, New York Dr. Frederick William Parham, New Orleans, aged 
71, died May 6. 

(Continued on page 38) 

There is just so much real worth built into any 
scientific instrument~—So much accuracy~ 
So much reliability ~So much free- 

dom from expensive upkeep ~ So 
much service ~ So much sat- 
isfaction— The most ever 
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—removed bya simple pres- SF 
sure of the thumb. STANDARD FOR BLOODPRESSURE ease in twenty seconds! 




i - —) ee ee ' 




a complaints caused by 

imperfect milk digestion may 
often be prevented through the 
protective colloidal ability of 
Knox Sparkling Gelatine... 

RESCRIBING a successful milk formula 

for the baby is every physician’s prob- 

lem—sometimes a baffling one—especially 
in the heat of the summer. 

We know, therefore, that you will be interested in 
our reports on the protective colloidal ability of Knox 
Sparkling Gelatine—reports of research work and 
actual practice proving that, when Knox Gelatine is 

dissolved and — to Fn baby’s Pome amg and digestion and 

fuller digestion takes place, normal weight is more ends appetizing 

easily attained, colic, regurgitation and similar ail- le > = 

ments are largely prevented! variety to all kinds —— 

May we send you this authoritative data? ; of diets * 
The approved method of adding Mis ese cd cals Nn 
gelatine to milk is as follows: a 

Soak, for about ten minutes, one level tablespoonful = 
of Knox Sparkling Gelatine in one-half cup of cold 
milk taken from the baby’s formula; cover while 

soaking ; then place the cup in boiling water, stirring ; . aes NOx | 
until gelatine is fully dissolved; add this dissolved =} 
gelatine to the quart of cold milk or regular formula. : 
NOTE: Knox Gelatine blends with all milk for- 
t The oe d owt: ert = aaa From raw material te 
action promo’ igestion and absorption e 
milk nutrients SPARKLING _ Soutlin, "Seiecine 
The complete reports are at your command. Please is constantly under chem- 
te GELATINE 22° = 
con) - 
KNOX GELATINE LABORATORIES touched by hand while 

408 Knox Ave., Johnstown, N. Y. - “The Highest Quality for Health” tire ™°°°* manufac: 


In Sickness—or in Health 
Horlick’s the Original 

Malted Milk 

| te ll 


Easily Digested 

For more than a 
third of a century, 
Horlick’s Malted Milk 
has been the standard 
of purity and food 

value among 

nurses and 

Write for free samples and 

Avoid Imitations Prescribe the Original 

Horlick’s Malted Milk Corporation 

July 1927 

(Continued from page 36) 


Dr. William H. Welch, Professor of the History of 
Medicine, Johns Hopkins Medical School, and formerly 
Director of the School of Hygiene and Public Health, 
was awarded the 1927 medal for scientific research 
in medicine by the Association of American Physi- 
cians, the medal being given in recognition of the 
many contributions made by him to medical science. 

A dinner was given at the Maryland Club in April 
honoring Dr. Edward N. Brush’s seventy-fifth birth- 
day. Dr. Brush is Superintendent Emeritus of the 
Sheppard and Enoch Pratt Hospital, Baltimore. For 
thirty years he has been on the editorial board of the 
American Journal of Psychiatry, and since 1904 Editor- 

Dr. David L. Gifford, North East, was tendered a 
testimonial dinner by the Cecil County Medical So- 
ciety, Elkton, April 23 in honor of his fiftieth year in 
the practice of medicine. 

Dr. Hugh H. Young, Baltimore, has been elected 
an honorary member of the German Society of Urol- 

Dr. Henry M. Hurd, from 1889 to 1911 Superintend- 

h birthday recently. 
ent of the Johns Hopkins Hospital, celebrated his 

Dr. Caper L. Woodbridge has returned to Baltimore 
from China, where he was engaged in missionary 
work in a medical college near Nanking. 

Dr. Francis M. Root, Associate in Medical Ento- 
mology, School of Hygiene, Johns Hopkins Univer- 
sity, Baltimore, sailed for Venezuela April 27 to study 
mosquitoes under the auspices of the International 
Health Board. 


Dr. Philip Briscoe, Mutual, aged 72, died May 4 at 
the Mercy Hospital, Baltimore, of pneumonia. 
pr." _ H. Roberts, Churchville, aged 86, died 

pr s 

Dr. Gilman Pit Evans, Baltimore, aged 69, died 
April 18 of chronic nephritis and myocarditis. 

(Continued on page 40) 

Mulford Intensive 

with Pollen Extracts 

More doses, of higher protein 
content, at shorter intervals. 

Fifteen doses are now regarded 
as the minimum, while some 
authorities recommend 20 doses or 
more, and a continuation of treat- 
ment through the hay fever season. 

Mulford Pollen Extracts are 
specific pollen proteins in refined 
form, accurately standardized in 
terms of protein units. 

Supplied in measured, individual 
doses, in ready-to-use containers, 
as follows: 

15-dose Treatment Package (Doses 1 to 15) 
First Series Package..... (Doses 1to 5) 
Second Series Package ..... (Doses 6 to 10) 
Third Series Package..... (Doses 11 to 15) 
Fourth Series Package ..... (Doses 16 to 20) 

Also in 5 cc vials. 

Supplied either in Aqueous solution or 
in Glycero-Saline form with diluent 

Convenient—safe—sterile. Easy to use, for general practitioner or specialist 

H. K. MULFORD COMPANY, Philadelphia, U.S. A. 




All Secon NORTH EAST—BOUTH—WEST—all Seasons 


imide available for the first time 
a proper assortment of individ- 

| ualized diagnosticand treatment | 
‘possible also for the first time dif- 
ferential diagnoses, specifictreat- 
-ment and the development of an 
authentic literature. 

The number and ares of 
pollens have been constantly in- 
creased until they now cover the 
mote essential requirements ‘of | 
the entire country. 


" were originated to assure the 
scientific study of hayfever—pre- 
_ viously impossible—owing to 
the lack of individualized diag- - 
nostic material or specific treat- 
" ment extracts. And the accom- 
panying pictures illustrate the - 
first steps necessary to be taken, 
~ both far and wide, to assure that 
our yariety of pollens shall cover 
= all sections and all seasons, ade- 

- quately and accurately. 

Arlco-Pollen Shedding Station in the Rocky Mountains 

. Lrrerature with List oF PoLLens ror Any SecTion AND Any SEASON ON Request 

5 SOON New York . 




Suprapubic, Perineal, Urethral 
Ureteral, Bile 


Probang - Spiral - Balloon 


Pezzer, Straight and Angle; Malecot, 
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(Trade Mark Registered) 
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79 Madison Avenue New York City 

July 1927 

(Continued from page 38) 
Dr. James Luther Truax, Baltimore, aged 55, died 
April 22 of heart disease. 

Dr. Edward Emory Tull, Salisbury, aged 60, died 
suddenly April 29 of heart disease. 


At the annual meeting of the Mississippi State Med- 
ical Association held at Jackson recently, Dr. John 

Darrington, Yazoo City, was elected President; Drs. 
Edward Benoist, Natchez; E. S. Bramlett, Oxford, 
and L. Posey, Jackson, Vice-Presidents. The 

meeting place for 1928 will be in Meridian. 

Dr. May F. Jones has resigned her post at the Mis- 
sissippi State Sanatorium because of ill health and re- 
turned to her home in West Point, Virginia. Dr. 
Jesse L. Roark, Water Valley, will take over the du- 
ties formerly in charge of Dr. Jones. 


Dr. Fortunato Bottista Sirianni, Greenville, aged 52, 
died March 1. 

Dr. W. H. A. Bemis, Pope, aged 75, died March 4 
of paralysis. 

Dr. Harry Greenwell Fridge, Hattiesburg, aged 47, 
was killed March 31 in an automobile accident. 
pe... ica M. Haley, Utica, aged 74, died suddenly 

Dr. William H. Broomfield, Mound Bayou, aged 43, 
died in April of injuries received when the automobile 
in which he was driving was struck by a train. 


At the annual meeting of the Missouri State Medi- 
eal Association Dr. Frank G. Nifong, Columbia, was 
elected President; ne Frank I. Ridge, Kansas City, 
President-Elect; Dr. J. Goodwin, St. Louis, Secre- 
tary; Dr. G. W. A Salisbury, Treasurer. 

Ray County Medical Society has elected Dr. Grover 

(Continued on page 42) 


IDEA in headlights. 
It embodies an unusual 
combination of spectacle 
frame and lamp to pro- 
vide a very practical and 
efficient means of local 

Standard Model, packed complete with 
Battery in Pasteboard Box, $6.00. 

Mail orders shipped promptly 



Catalogue sent on request 




illumination. The dis- 
tinctive feature of the 
SPECLIGHT is that the 
light emanates from a 
source directly between 
the eyes, throwing the 
beam of light in the plane 
of vision. SPECLIGHT 
just naturally throws the 
light where you are look- 





i= ' ta- 


HEN the physician prescribes cod liver oil, the administration of the oil 
is not always easy. 

This is not a problem, however, when PATCH’S FLAVORED COD LIVER 
OIL is prescribed. Children (and older folks, too) really like it. 

We had the patient in mind when we conceived the idea of adding a stight 
amount of flavoring to our vitamin-tested cod liver oil. This won immediate 
favor because it solved a real problem. 

Owing to its high vitamin potency, the dose is small—one-half teaspoon- 
ful for children or one teaspoonful for adults. To guarantee the high vitamin 
potency, every lot of oil produced in our plants is biologically assayed in our 

The pleasant taste and the small dose make PATCH’S FLAVORED COD 
LIVER OIL a most desirable product. 

If you wish to become better acquainted with this “different kind” of cod 
liver oil, mail the coupon below for a sample and interesting literature. 


(Indicate with a cross the information desired.) 
The E. L. Patch Company, Stoneham 80, Boston, Mass. 

Send a sample of Patch’s Flavored Cod Liver Oil............ 
Send booklet, “How Potent Cod Liver Oil is Produced”............ 
Send booklet, “How We Test for Vitamin A”’............ 


Street and No 
City and State 



(Continued from page 40) 
W. Gaines, Rayville, President; Pe Cc. B. Shotwell, 

p H y S i C | A N S ’ 0 F F | C E Richmond, Vice-President; Dr. R. Remley, Rich- 
mond, Secretary; Dr. T. F. Cook, Richmond, Treas- 

F U R N | T U R E A survey of health conditions in St. Louis is being 
conducted by Dr. Clarence St. Clair Drake, of the 
Mahogany American Public Health Association, under the direc- 
tion of the Citizens’ Committee for the promotion of 
Walnut Bt. jae penith par tea Among various questions 
o be considered wi e the necessity for more hos- 

Quartered Oak pital beds in St. Louis. 

One hundred senior students in St. Louis School of 
Medicine volunteered their services to the American 
Red Cross to assist in caring for the sick and injured 
persons in the flooded areas of the Mississippi Valley. 

A new St. Louis Maternity Hospital has been erected 
adjoining Barnes Hospital and the Washington School 
of Medicine. It is an eight-story fireproof building, 
with one floor reserved for colored patients, and will 
accommodate 104 mothers and an equal number of 

The Interstate Postgraduate Medical Assembly of 
North America and the Kansas City Southwest Clin- 
ical Society will hold a clinical meeting in the Ararat 
Shrine Temple, Kansas City, October 17 to 22, 1927. 
Pre-assembly clinics of Greater Kansas City Hospitals 
will be held on October 14 and 15. 

Dr. Jacob J. Singer, Assistant Professor of Clinical 
Medicine, Washington University School of Medicine, 
St. Louis, sailed for Europe June 17 to inspect chest 
clinics in various medical schools. 

Dr. Harry M. Gilkey, Kansas City, sailed May 1 for 
Europe, where he will spend several months in the 
clinics and hospitals of important medical centers. 

Dr. W. G. Patton, St. Louis, was elected Vice- 
President of the Kansas City Eye, Ear, Nose and 
Throat Society at their meeting held April 22. This 

Style G-123 

Tables, Chairs 

Stands, Cabinets 
Stools, Accessories 
Catalog sent on request 

Sold by Declers Style 1000 —. pr, sage | — living in Missouri, 
ansas, ahoma an rkansas. 
W. D. ALLISON COo., Mfrs. Dr. Joseph T: Brennan, Grandview, has been ap- 
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931 No. Ala. St. ndianapolis . Crandall, who resigned to go to California. 
— Dr. Dominick M. Nigro has been appointed Commis- 

(Continued on page 44) 

_ For Clean Hands ~ 

“Antiseptic. but not irritating” 


We we 
—— — = ~ Ns 

Showing the treatment of Alopecia Areata 
with ALPINE SUN LAMP. Note the close- 
ness of the lamp to the subject. 

Suggested Technique for Treating 
LAMP, administer a third to fourth degree 
erythema, at 10 inches distance. For Alopecia 
Areata the Kromayer Lamp should be used on 
small areas. 

MAY physicians favor the quartz lamp to all other means of treat- 
ing Alopecia. Its germicidal property, and its stimulation of the 
blood supply have made quartz light a valuable aid in this condition. 
Every physician interested in the subject can, without obligation secure 
helpful literature, by using the coupon below. 


Main Office and Works: Chestnut Street & N.J.R.R. Avenue, Newark, N. J. 
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Routine Analgesic 

N every 

field of medicine the 

utmost reliance can be placed 

upon the pa 

in relieving properties . 

of Pyramidon. Its action is prompt, 


and prolonged, as 

demonstrated by over thirty years 
of clinical application. 

Supplied for your prescription in 


tablets of 5 grains, 

tubes of 10 and bottles of 100, and 
114 grains bottles of 25 and 100. 

H. A. Merz Lasoratories, INc. 

122 Hudson 

St., New York, N. Y. 


July 1927 

(Continued from page 42) 

sioner of Child Hygiene and Communicable Diseases 
in the Kansas City Department of Health, succeeding 
Dr. John L. Lavan. 

The fellowship established by a gift from Theron 
E. Catlin for the study of communicable diseases at 
the St. Louis Children’s Hospital has been awarded to 
Dr. Edith I. M. Irvin-Jones, of the University of Cali- 
fornia. The research will be on influenza. 

Dr. Victor J. Weiss and Miss Mabel M. White, both 
of Kansas City, were married at Dallas, Texas, 

April 21. 

Dr. David Hough Dolley, St. Louis, aged 48, died 
April 11 at El Paso, Texas, of pulmonary tuberculosis. 
May 18 A. Milbourne, Kansas City, aged 52, died 

a a 

Dr. George M. Nichols, Higbee, aged 66, died March 
24 at a hospital in Moberly. 

Clara Sauter, St. Louis, aged 84, died March 
17 of chronic cholecystitis. 

Dr. Mon Fong Young, Kansas City, died February 

26 of cerebral hemorrhage. 


At the annual meeting of the North Carolina State 
Medical Association held at Durham April 18-21, Dr. 
John T. Burrus, High Point, was elected President; 
Drs. Gideon H. Macon, Warrenton; Robert F. Lein- 
bach, Charlotte, and William R. Griffin, Asheville, 
Vice-Presidents; Dr. L. B. McBrayer, Southern Pines, 
Secretary- Treasurer, re-elected. 

At a meeting of the State Board of Health, April 
28, Dr. W. S. Rankin, Raleigh, resigned as a member 
of the Board, and Dr. Laurence E. McDaniel, Jack- 
son, was elected to fill the vacancy. Dr. Rankin re- 
signed, it is reported, to permit an appointment to the 
Board from the eastern part of the State. Dr. Charles 
O’H. Laughinghouse, Raleigh, was elected Secretary 

(Continued on page 46) 



Precision Stereograph 

Rigid in construction and beau- 
tiful in finish, this horizontal 
cassette changer has a motor 
driven action that is fast and 
Positive. Tested to 5000 con- 

secutive operations without 
single failure. 


oq N?: EXPERIENCE of the past pro- 
vides a criterion for the very de- 
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in roentgen rectifiers for fast radio- 
graphy, horizontal motor driven cas- 
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intestinal work and high frequency 
generators for medical and surgical 


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Precision Model IV Prvcieion a ee and 
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Cable Address: INTERACME 






(GN LY FRESH MEIER from tuberculin tested 

cows and from dairy farms that have fulfilled the sanitary 
requirements of the City of Cleveland Board of Health, is used as 
a basis for the production of S. M. A. In addition, the milk must 

meet our own rigid standards of quality. >» > >» >» 

1—Ie resembles breast milk both physically and chemically. 

2—Simple for the mother to prepare. 

3—No modification is necessary for full term normal infants. 

4—It gives excellent nutritional results in most cases and in addi- 
tion these results are obtained more simply and more quickly. 

5—Prevents Rickets and Spasmophilia. 

Manufactured by permissic n of the 
Babies and Childrens Hospital of Cleveland 


Fine Products for the Infants Dret 7 




Contrast Medium 

2 Cc. ampuls 
Bottles of 25 Gm. 

Literature on request 

64 Park Place New York 

‘see on 


In Pregnancy 
and Lactation 

There is a constant drain of mineral salts, 
tending to mineral starvation and “acidosis”. 
(Fischer, Losee, Van Slyke, etc.). 

Combat acidosis in pregnancy with Kalak 
Water. Prescribe in sufficient amounts to 
keep the urine always neutral. 

KALAK WATER CO., 6 Church St., New York City 


(Continued from page 44) 

of the Board and State Health Officer for a period 
of six years. 

Dr. A. T. Pritchard, Asheville, was elected Presi- 
dent of the Southern Railway Surgeons, which met in 
Mobile, Alabama, May 65. 

A Pediatric Clinic will open in Charlotte, with Drs. 
John R. Ashe, Yates Faison and Robert Moore in 

Dr. S. P. Sebastian, Physician to the State Agri- 
cultural and Technical College of North Carolina, is 
Secretary of the newly opened Richardson Memorial 
Hospital, Greensboro, N. C. 

Dr. John P. Munroe, Charlotte, has been elected 
President of the New Charlotte Sanatorium in that 
city for the current year, and Dr. Silas R. Thompson, 
Chairman of the staff. 

Dr. William E. Warren, Williamston, was elected 
President of the Second District Medical Society. 

Dr. Ryland Atwood Blakey, Fayetteville, and Miss 
Catherine Hagood, of Easley, South Carolina, were 
married April 14. 


Dr. Samuel Westray Battle, Asheville, aged 72, died 
April 29 of cerebral hemorrhage. 

Dr. John C. Testerman, aged 68, died April 23 of 
heart disease. 

Dr. J. P. Whitehead, Rocky Mount, aged 54, died 
April 11 at a hospital in New York of acute colitis. 

Dr. Charles Sterling White, Winston-Salem, aged 
25, died April 18 at a local hospital of injuries re- 
ceived in an automobile accident. 

At the annual meeting of the Oklahoma State Med- 
ical Association held recently, Dr. Ellis Lamb, Clin- 
ton, was elected President; Drs. W. T. Tilly, Mus- 
kogee; C. H. Hendershot, Tulsa, and E. O. Barker, 
Guthrie, Vice-Presidents. The next meeting . place 

will be Tulsa. 
ong, Duncan, has been appointed City 

ir. D,. 15 
Health Officer. 
(Continued on page 48) 

Es ss 

pee ee ee ee 

Vol. XX No. 7 


M ervrell-Soule, 
(In Use Since April 1921) 

An Accepted Standard Corrective Diet 

In Summer Diarrhea 

No accident or trick of fate ever established a food or drug as 
Standard. Merit alone can do this. 

Merrell-Soule Powdered Protein Milk owes its enviable reputation 
and position as Standard to, 

Its Dependability— Made to a standard which has 

never varied in six years. 

Keeping Qualities —Characteristic of all Merrell- 
Soule Products, the container and manner of 
packing insure its keeping qualities. 
Results—One experience usually betokens con- 
tinued and increased use. 

A pioneer organization of experts with 25 years experience in the 
dehydration of milk is back of Merrell-Soule Powdered Protein Milk. 
Not an ambitious flash in the pan, therefore, but a tried product made 
by men who have learned by doing under the supervision of an in- 
comparable scientific staff. 

Rapidly Replacing Other Methods 

Difficulties of preparation retarded the use of Protein Milk until. 

1921 when Merrell-Soule Powdered Protein Milk became available, 
Rapidly it is replacing other methods used in the treatment of summer 
diarrhea with a consequent decrease in mortality. 

Literature, as well as liberal samples, 
with which to start cases, will be sent on 
request. Physicians are requested to use 
their letterhead for identification as no 

information is sent to the laity. ie Reena A co. SS 



(Continued from page 46) 

Dr. J. D. Leonard, Muskogee, has resigned as Health 
Officer of the County and entered the practice of 

e . 
medicine at Wagoner. 
Quality Merchandise Dr. and Mrs, Hubert W. Callahan, Tulsa, sailed 
June 15 to visit various European countries. Dri Cal- 
lahan will spend two months in the clinics of Buda- 

:. pest and Vienna in the study of urology. 
at Reasonable Prices m 
ant reed Bezanson, Oklahoma City, aged 79, died 
pri 5 
Dr. G. H. Dye, Mill Creek, aged 79, died April 4 of 

atin heart disease. 
: Dr. M. J. Pirtle, Caddo, aged 61, died recently of 
injuries received when the automobile in which he 
was driving overturned. 

Dr. Henry Collins Rogers, Muskogee, aged 60, died 

Surgical Instruments and Aprii 18 of uremia. 

Hospital Supplies SOUTH CAROLINA 
Dr. Isaiah H. Macon, Rock Hill, aged 57, died 
Laboratory Apparatus March 30. 
Montgomery County Medical Society has elected 
= Dr. M. L. Hughes, President; Dr. M. L. Shelby, Vice- 

President; Dr. H. A. Nesbitt, Secretary-Treasurer, all 
of Clarksville. 

Robertson County Medical Society has elected Dr. 
G. R. Jones, Orlando, President; Dr. J. R. Connell, 

| a LYONS & CO Ltd Adams, Vice-President; Dr. W. F. Fyke, Springfield, 
* * °9 ° Secretary-Treasurer. 

West Tennessee Medical Association at its recent 

Established 1866 meeting in Jackson elected Dr. R. M. Little, Martin, 
eo ee’ eee a te har thar ae a a 

roctologica inics w e he this at St. 

NEW ORLEANS Joseph’s Hospital, Mémphis, every Tuesday at 2 

o’clock by Dr. John L. Jelks. These clinics will be 
(Continued on page 50) 

2 7 
When All Other 
Diuretics Fail -- 


“The excellent results 

obtained by us_ with Trademark Reg. U. S. Pat. Off. 
Novasurol in true myo- 
carditis led us to try it Brand of Merbaphen 
in valvular disease with - ‘ 
severe dropsy, and here Frequently relieves obstinate dropsy 
also we could often con- in Cardiorenal Disease, Nephroses, 
ene See ee Oe Cirrhosis of the Liver, Banti’s Dis- 
spite of undeniable car- 
dint tusiiliebndy, Genesis ease, etc. Return of dropsy may be 
occurred promptly after prevented by occasional administra- 
the injection.”— Professor tion 
H. Eppinger, Vienna. s ‘ 

This has been demonstrated by num- 

erous observations in European hos- 

anes yy Neo pitals and in the Mayo Clinic end 
Pamphlet on request Rockefeller Institute. 

WINTHROP CHEMICAL CO., Inc., 117 Hudson Street, New York, N. Y. 

._ SA 



When the Diagnosis 

Shows Constipation 

Either of the Atonic or Spastic Type 
There is a need for PETROLAGAR 

Itsvalue in these conditionsisdue tothe man- 
ner in which it mixes with and softens the fecal 
content. When you realize that PETROLAGAR 
is readily miscible with water, you know why 
this emulsion is more effective in the treat- 
ment of constipation than is plain oil. 
PETROLAGAR does not coat the intestines 
or the food with a film of oil, which might 
retard the digestive processes. 

It mixes intimately with the fecal content, 
producing asoit, easily moved mass—a val- 
uable aid tothe instigation of “Habit Time.” 

536 Lake Shore Drive - Chicago 





The “MESCO” Laboratories 

manufacture the largest line 
of Ointments in the world. 

Sixty different kinds. We are 
originators of the Professional 
Package. Specify “MESCO” 
when prescribing Ointments. 
Send for lists. 

Manhattan Eye Salve 

Louisville, Kentucky. 

(Continued from page 48) 

open to the profession and to senior students at the 
University of Tennessee School of Medicine. 

Dr. J. B. Hibbetts, Jr., of Nashville, Captain and 
Flight Surgeon of the 105th Observation Squadron, 
Tennessee National Guard, has been appointed Medi- 
cal Examiner of the Aeronautics Branch of the De- 
partment of Commerce. 

Dr. J. S. Lyons, Rogersville, has accepted the posi- 
tion as Medical Director of the Tuberculosis Sanita- 
rium at Pressmen Home. 

Dr. J. A. Johnson, of Kansas City, Missouri, has 
accepted the position of Assistant Medical Director of 
the Tuberculosis Sanitarium at Pressmen Home and 
resides in the building. 

Dr. W. C. Lyons, Surgoinsville, was elected City 
Physician of Kingsport the first of the year. 

Dr. E. A. Patton, formerly Medical Director of the 
Tuberculosis Sanitarium at Pressmen Home, has re- 
signed and accepted the position of Medical Director 
at Beverly Hills, Knoxville. 

Dr. Roger H. Burrus, Vanderbilt, 1926, has been 
appointed Resident Physician at the Nashville Gen- 
eral Hospital, succeeding Dr. Theodore Davis, who 
has been Resident Surgeon of the General Hospital 
since last July. 

Dr. O. F. Agee has been appointed to. succeed Dr. 
Collins as Physician with the Dyer County Health 
Unit. Dr. Agee went to Dyersburg from Weakley 
County, while Dr. Collins goes to serve with the 
Roane County Health Unit. . 

Dr. A. J. Kimmons, Bristol, opened Grace Hospital 

on April 19. 

Dr. John F. Arnold, Limestone, aged 67, died 
March 30 at a sanatorium in Greeneville. 

Dr. John R. Charlton, Antioch, aged 74, died April 2. 

Dr. Chalmers Deaderick, Knoxville, aged 79, died 

April 14. 
Dr. James Lafayette Fisher, Lancaster, aged 73, 

died recently at Nashville of cerebral hemorrhage. 
Dr. James E. George, Rockwood, aged 70, died 

April 11. 
(Continued on page 52) 


Central 2268-2269 

William L. Baum, M.D. 
Frederick Menge, M.D. 



Incorporated under the laws of Illinois, not for profit, but for the pur- 
pose of making radium available to Physicians to be used in the treat- 
ment of their patients. Radium loaned to Physicians at moderate 
rental fees, or patients may be referred to us for treatment if pre- 

Careful consideration will be given inquiries concerning cases in which the use of Radium 
is indicated 


1100 Tower Bldg., 6 N. Michigan Ave. 


Louis E. Schmidt, M.D. 

Managing Director: 
Wm. L. Brown, M.D. 

Wm. L. Brown, M.D. 
Walter S. Barnes, M.D. 

Vol. XX No. 7 


Stainless Steel Needles 


Note the permanent sharp edge—a needle made from 
Firth Stainless Steel 

Will Not 

STEEL NEEDLES in quantities specified 
below. I shall expect them to be sharp— 

strong—rustproof—and all that you claim 
VIM-FIRTH needles to be. 

27 % in $2.50 Doz. 
26 od 2.50 “ 
25. 5% 2.50 “ 
|24. = 2.50 “ 
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22 i‘ 3.00 “ 
22 2 6 3.50 “ 
21 1% * 3.00 “* 
21 3 4.50 “ 
20 1 3.00 “ 
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20. 4 pee 5.50 “ 
19 2o 3.50 ‘ 
18 2 ’ 3.50 “ 
16 1 . 3.00 “* 
Assorted 3.00 “ 



2106-2110 First Ave. 

VIM-FIRTH Needles 

cost but a trifle ever so much longer. 


Trial lens 

oreater range, 
thrice the speed 

J UST what is our NEW “Phoroptor?” 

A complete, self-contained instrument for 
the refraction of the eye, with a battery of lenses 
for each eye, giving accurate, quick, and ex- 
haustive data on both refraction and muscle work 
for the oculist. 

Unlike all instruments of similar purpose, our 
new Wellsworth-DeZeng Phoroptor is equipped 
with additive lenses—lenses so adjusted in posi- 
tion and power that actual effective power is in- 
dicated by adding together their marked values. 
A new method, fully as accurate as the trial 
frame, accomplishing correct refraction at thrice 
the speed. 

And our Phoroptor retains the muscle testing 
advantages of all older models, facilitated, how- 
ever, by longer handles on its rotary prisms. 

The instrument is suspended from above, easy 
of manipulation, systematically designed, with a 
greater range of effective power lenses than the 
average trial case: The spherical range is 23.88 
to —24 and cyl. —0.12 to 3.00 increased by 




American Optical Company 

Rx shops in all principal 
cities of the South 




Get Our Price List and Discounts 
Before You Purchase 

Among the Many Articles Sold Are 
X-RAY FILM, Eastman, Buck X-Ograph or Agfa Duplitized 
and Dental Film. Heavy discount on s ard package 

lots. Eastman, Buck X-Ograph and Just-Rite Dental Film, 

fast or slow emulsions. 

DIAPHRAGM insures finest 
radiographs on heavy parts, such as kidney, spine, gall- 
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Curved Top Style—up to 17x17 size cassettes.............. 
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DEVELOPING TANKS, 4, 5 or 6 compartment stone, will 
end your darkroom troubles. Ship from Chicago, Brooklyn, 
Boston or Virginia. Many sizes of enameled steel tanks. 
INTENSIFYING SCREENS—Buck X-Ograph or Patterson 
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om our mailing list. CHICAGO 

July 1927 

(Continued from page 50) 

Dr. Nathaniel Hawthorn Keyes, Covington, aged 47, 
died April 24. 

Dr. R. H. Milam, Lexington, aged 56, died March 13. 
Dr. Henry Austin Mann, Memphis, aged 38, died 
March 23. 

Dr. W. T. Medling, Dyer, aged 78, died March 28. 
Pe. ba R. McKenzie, Center Point, aged 72, died 
pri " 

Dr. William J. McCurdy, Memphis, aged 67, died 
suddenly in April. 

Dr. William Hardin Ragland, Cookeville, aged 84, 
died April 2 at the home of his son in Murfreesboro. 
Dr. William Thompson Redmond, Crockett Mills, 
aged 59, died April 21 at the Methodist Hospital, Mem- 
phis, of heart disease. 

Dr. Simon Reynolds Spight, Bolivar, died March 29 
from a fractured hip. 

Dr. Bert G. Simmons, Maryville, aged 69, died April 
4 at Jefferson Hospital, Philadelphia, Pennsylvania. 
Dr. Joseph H. Smith, Knoxville, aged 68, died 
April 2. 


At the annual meeting of the State Medical Associa-. 
ticn of Texas held at El Paso April 28, Dr. a 
Gilbert, Austin, was elected President; Dr. Felix P. 

(Continued on page 54) 


BECAUSE OF ILLNESS I am compelled to sell my home 
and give up my practice. Will introduce my patients to pur- 
ehaser. G. F. W., care Journal. 

successfully treated in Glenwood Park Sanitarium, Greens- 
boro, N. C.; reprints of articles mailed upon request. Ad- 
dress W. C. Ashworth, M.D., Owner, Greensboro, N. C. 


apartments and boarding houses. 

For further information write— 


Hot Springs National Park, Arkansas 

“America’s National Health Resort” 

(Under the control of the Interior Department) 
The attention of the American Medical Profession is invited to the great benefits to be 
derived from the use of the radio-active waters of Hot Springs in the treatment of dis- 

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The resort is provided with a number of modern and luxurious bath houses, hotels, 

Pleasures and amusements in the way of golf, tennis, mountain climbing, horseback rid- 
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Medical Intelligence Bureau 
Box 886 
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| Announcing 

A New 


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The Instrument is correctly designed to get This speculum is 
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ORDER through your DEALER 

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Acetylamino-oxyphenylarsonic Acid 

Indicated in Amebic. Dysentery 

Accepted by Council of Pharmacy and Chemistry A. M. A. 

Distributed in bottles of 25 tablets, each tablet 0.25 grams 
May be obtained through your druggist 

Literature furnished on request 



New York PHILADELPHIA St. Louis 


(Continued from page 52) 

Miller, El Paso, President-Elect; Drs. Henry R. Link, 
= are Palestine; Arthur H. Flickwir, Houston, and William 
N. Wardlaw, Palestine, Vice-Presidents; Dr. Holman 


This _ instrument 
lends itself equally 

Price Taylor, Fort Worth, Secretary and Editor-in-Chief; 
$39.00 Dr. Witten B. Russ, San Antonio, a member of the 
Board of Trustees. 

Fannin County Medical ¥ » * — cone Dr. J. E. 

to the Pathologist in 
the Hospital and to Nevill, Bonham, President; Dr. Daniel, Bon- 
the practicing ham, Vice- -President; Dr. M. i Grab, Secretary- 

Knox-Haskell County Medical Society has elected 
Dr. William P. Farrington, Munday, President; Dr. 
Joe Davis, Munday, Vice-President; Dr. T. P. Friz- 
zell, Knox City, Secretary-Treasurer. 

Panhandle District Medical Society has elected Dr. 
H. H. Latson, President; Dr. W. L. Baugh, Lubbock, 


The application and 
the technic of ex- 
amination are de- 

No. 1011 Type 

scribed in all works For sale by 
of Hematology and all Supply President- — Dr. C. J. Nichols, Plainview, Vice- 
Clinic Diagnosis Houses. President; Dr. J. Crume, Amarillo, Secretary 
- Smith County J Medical Society has elected i “Albert 
Ask for descriptive circular \ ge og ly oy ce Ml er 
RIEKER INSTRUMENT CO. The Bieghsavilie Chamber of Commerce has re- 
Sole Mfrs. cently donated a plot of ground to local physicians 

on which is to be erected a new and up-to-date hos- 
pital. It has been figured that the building, equip- 
ment and lot will approximate an investment of about 
$25,000, and should be ready for occupancy not later 
than August 1, 1927. 

1919-1921 Fairmount Ave. 
Philadelphia, Pa. 

Dr. Thomas Joshua Bennett, Austin, aged 73, died 
HIGH POWER March 16 of angina pectoris. 

Dr. Charles Walter Goddard, Austin, aged 58, died 

e e 
Electric Centrifuges “— A. Koontz, Lacoste, San Antonio, aged 50, 

died March 18, from pneumonia which followed an 

operation for appendicitis. 
Send for PR: Cat Cn Dr. J. H. Murphy, Valley View, aged 63, died Feb- 
, ruary 1 of chronic interstitial nephritis. 
Dr. James Edwin Thompson, Galveston, aged 63, 

died April 8 of endocarditis and influenza. 
neem EQUIPMENT Co. Dr. Emelious A. Cox, Teague, aged 53, died in Feb- 
estern Ave., Boston, Mass. ruary following an operation for appendicitis. 

(Continued on page 56) 

Laboratories of 

Drs. Bunce, Landham and Klugh 


George F. Klugh, M.D., Director, Laboratory of Clinical Pathology 
Jackson W. Landham, M.D., Director, Laboratory of Radiology (X-Ray and Radium) 

These laboratories are equipped for making every test of clinical value 
in the diagnostic study of medical and surgical cases. Only standardized 
methods and technique are used. 

In addition to the diagnostic study of cases there are adequate facilities 
for the x-ray and radium treatment of conditions in which these forms of 
treatment are indicated. 

Containers for pathological specimens and information in reference to x-ray and 
radium work furnished upon request. 


139 Forrest Avenue, N. E., Atlanta, Ga. 




WHERE the food tolerance is lessened and where 
there is no regular gain in weight, the use of 

is of great advantage. By virtue of the 
fact that the quantity of water may be 
diminished ad libitum, the physician may readily 
obtain a concentrated diet of high caloric value. The fine- 
ness of the DRYCO eurd assures its maximum assimilation and 
absorption with a minimum of digestive effort. In view of its palatabil- 
ity, dyspeptic infants readily adapt themselves to DRYCO, showing at the same 
time, a marked improvement in appetite and weight. 

Weight Chart and Clinical Data will gladly 
be mailed to the physician upon request. 

THE DRY MILK COMPANY, 18 Park Row, New York 


REOSOTE has long been used as an intestinal antiseptic as well as 
for its effect on pulmonary inflammations such as influenza, bron- 
chitis, and tuberculosis. 

Calcreose eliminates the usual objections to creosote. It is a chemical 
combination of creosote and hydrated calcium oxide from which the 
creosote is slowly liberated, thus aiding absorption and toleration. 

Calcreose can be given in large doses for 
long periods without apparent difficulty. 

Powder: Tablets: Solution Samples of Tablets on Request 



Urinary Test Equipment 
Cin Steel Cabinet) 

Ready to use, easy to put out of way. Design 
approved and contents arranged by R. A. Kil- 10 50 
duffe, M.D., Director of Laboratories, Atlantic . 
City Hospital. 
Equipment included as follows: 12 chemical test tubes; one 
indican tube; Esbach’s albuminometer; special tube for 
qualitative albumin tests; one serological pipette, 1 cc. in 
1/10; 1 graduated dropper, 1 ce. in 1/10; 1 glass stirring 
test tube brush; 1 package of filter paper; 1 alcohol 
lamp; 1 porcelain evaporating dish; 1 test tube holder; 1 
book each red and blue litmus paper; 1 urinometer with 
cylinder; 1 glass marking pencil; 1 beaker; 3 microscope 
slides; 1 box cover glasses; 1 bottle each of the following 
reagents : Nitrate of silver, 5% (chlorides); Nitric acid, 
concentrated (albumin, bile) ; Obermeyer’s reagent (indican) ; 
Sodium carbonate, powder (quantitative sugar); Benedict’s 
qualitative reagent (qual. sugar); Benedict’s quantitative 
(quant, sugar); Tschuya’s reagent (quant. albumin) ; 
Rothera’s reagent (acetone); Ferric Chloride 5% {diacetic 
acid) ; Ammonia, cone. (acetone). 1 Text Book, “A Con- 
densed Manual of Urinalysis,” by Robert A. Kilduffe, M.D. 

2SM320. Kilduffe’s Urinary Test Cabinet, $10.50 
Use Coupon in Ordering 

Send me on approval the 2SM820 Kilduffe’s Urinary Test 
Cabinet. My check for $10.50 is attached. 

FRANK S. BETZ CO., Hammond, Ind. 



City State. 

July 1927 

(Continued from page 54) 

Dr. Joel Mathis Gooch, Temple, aged 68, died April 
11 of angina pectoris. 

Dr. Joseph Hugh French, Greenville, aged 82, died 
April 16 of aphasia. 


Bedford County Medical Society has giosted Dr. 
Thomas P. West, Bedford, President; Dr. Ww. 
Gibbs, Goodes, Vice- President; Dr. A, Hennes 
Bedford, Secretary-Treasurer. 

Amelia County Medical Society has elected Dr. 
George A. Arhart, Amelia, President; Dr. H. Cowles 
Rucker, Mattoax, Vice-President; Dr. James L. Ham- 
ner, Mannboro, Secretary-Treasurer. 

Nottoway-Dinwiddie-Prince George County Medical 
Society was organized recently by the doctors of these 
respective counties. Dr. E. . Yount, Petersburg, 
was elected President; Dr. W. W. Bennett, Black- 
stone, and Dr. S. E. Gunn, Hopewell, Vice-Presidents; 
Dr. W. C. Powell, Petersburg, Secretary-Treasurer. 

The Warren-Rappahannock-Page Medical Society 
has elected Dr L. Grubbs, Front Royal, President; 
Dr. D. M. Kipps, Front Royal, Secretary-Treasurer. 

Plans are being made to enlarge the Petersburg 
Hospital, Petersburg, to meet the needs of the sur- 
rounees country as well as the City. The committee 
of physicians having plans in charge are Dr. Wright 
Clarkson, Chairman; Drs. W C. Powell, William B. 
McIlwaine and George H. Reese. 

Dr. Charles R. Robins, Richmond, has been elected 
Vice-President of the Richmond Rotary Club. 

At the April meeting of the Board of Visitors of 
the University of Virginia, the following changes in 
the Medical Department were announced: Dr. Stephen 
H. Watts resigned as Professor of Surgery and Gyne- 
cology, as he is retiring from active service; Dr. I. 
Bigger resigned as Assistant Professor of Surgery to 
be on the staff of Vanderbilt University, Nashville, 
Tennessee; Dr. Cuthbert Tunstall was named Instruc- 
tor in diseases of the ear, nose and throat; Dr. James 
C. Flippin was promoted from Acting Dean to Dean 
of fhe Medical Department. 

By the will of the late Mrs. Bertha yachbur Gug- 
genheimer, the Memorial Hospital of L burg was 
left about $500,000 for the establishment’ @ and mainte- 
nance of a children’s and maternity hospital. 

A drive for funds for the proposed Page Memorial 
Hospital at Luray opened April 18. 

The rural hospital at Farmville, made possible by 
an appropriation by the Commonwealth Fund, is ex- 
pected to be open about September 1. 

More than 400 physicians of Virginia and other 
states attended a banquet at the Commonwealth 
Club, Richmond, April 19, to celebrate the seventy- 
ninth birthday of Dr. Joseph A. hite, for many 
years Professor of Ophthalmology, Otology, Rhinology 
and Laryngology at the Medical College of Virginia, 

Dr. R. H. Fuller, until recently in charge of Little 
Retreat Hospital at Clover, has closed that place and 
opened a hospital in South Boston known as the 
South Boston Hospital, which is able to care for 
about twenty-four patients. 

(Continued on page 58) 

The Better Acid Medium Urinary Antiseptic 


Sulphosalicylic Hexamethylenamine 
Allays severe burning and has a soothing effect in kidney 
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when taken for a long period of time. To 
clear shreds and pus in chronic 
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can be effective only through the use of dependable endocrine products. The reputation and in- 
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Minimum post-operative reactions. 

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was first brought to the attention of the medical profession of Great Britain 
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H. E. F. Notton, B. Se., A. R. C. S., University of Cambridge, England. 


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under License from the British Drug Houses, Ltd., London 

New York Chicago NewOrleans St.Louis Philadelphia Atlanta KansasCity SanFrancisco Boston 


(Continued from page 56) 
Dr. Margaret Nolting, Richmond, has been ap- 

ee ar pointed Professor of Physiology and Hygiene at the 
Westhampton College, University of Richmond, to 
MREG. succeed Dr. Margaret P. F. Kuyk, who has retired. 

Dr. Donald St. C, Campbell has been appointed 

minal Su Health Officer of Newport News. 

er 0 weed Sidney S. Negus, Ph.D., Professor of Organic 
Chemistry at the University of Richmond, has been 

(Patented) appointed to a similar position in the Medical College 

of Virginia, Richmond. 

Dr. George S. Silliman, fcrmerly with the U. S. 
Veterans’ Hospital at Aspinwall, Pennsylvania, is now 
with the Johnston Willis Memorial Clinic at Abingdon 
as Roentgenologist and Urologist. 

Dr. J. A. Tyree, Danville, has been elected Vice- 
President of the Rotary Club of that City. 

Dr. Frank McCutchan, for some time House Surgeon 
at the Manhattan Eye, Ear and Throat Hospital of 
New York City, has located in Roanoke, where he is 
a member of the staff of the Gill Memorial Eye, Ear 
and Throat Hospital. 

Dr. Howard Urbach was elected President of the 
Richmond Pediatric Society March 31 

Dr. Charles Perry Howze, Danville, and Miss Han- 
nah Morris Keith, of Fairfax, were married March 19. 


Dr. Estelle H. Henderson, Marion, aged 55, died re- 
cently of heart disease. 
. Dr. McMinn M. Pearson, Bristol, a 1 63, died Apri 
For Men, Women and Children ye ey teen ioe Ae 
; ; : Dr. John E. Mapp, Keller, aged 80, died April 30. 
For Ptosis, Hernia, Pregnancy, Obesity, Dr. J. K. Simmons, Nace, aged 86, died April 9 of 
Relaxed Sacro-Iliac Articulations, High and heart disease. 
Low Operations ete Dr. Harry M. Tayloe, Hague, aged 50, died April 
‘ " 21 of pneumonia. 

Ask for 36 page Illustrated Folder ae 
Mail orders filled at Philadelphia only— WEST VIRGINIA 

within 24 hours. Central West Virginia Medical Scciety has elected 
Dr. C. Fred Fisher, Richwood, President; Dr. M. T. 

KATHERINE L. STORM, M.D., Morrison, Sutton, bas ain Dr. s. S. Hall, 
iginato ntee Ww nd Maker Buckhannon, Secretary- reasurer. 
Originat 3 Patentee, Owner a d < Dr. A. N. Frame’s family has donated his entire 
1701 Diamond St. Philadelphia medical library to the Academy of Medicine, Parkers- 
burg. It consists of 250 to 300 volumes. 




20 ce. contain 2 Grams (31 grains) Sodium Iodide U. S. P. 
10 cc. contain 1 Gram (15 grains) Sodium Iodide U. S. P. 
Chemically and biologically standardized. Ready to inject. 
For the treatment of Asthma, Hay Fever, Bronchitis, Pneumonia, Arterio- 
sclerosis, Hypertension, Nephritis, the Sequelae of Gonorrhea and Chronic Infec- 

Send for literature and the May number 
of the Journal of Intravenous Therapy. 

New Location: 22 WEST 26th STREET, NEW YORK, N. Y. 


: ME. 6. Co. Si 


Samples and literature on request 


HEORY and practice both agree upon the many advantages of 
human milk in infant feeding whenever it is possible to keep the 
baby on the breast. 

Theory and practice meet again, on common ground, in the accept- 
ance of cow’s milk modifications, principally dilutions and additions, 
with water the diluent and carbohydrate the chief reconstituent. 

Theory has long maintained that the next step in the evolution of 
modern infant feeding would result in something more than a mere cow’s 
milk modification. It has affirmed that an approximation of breast 
milk could not be secured without a process of complete cow’s milk 

This theory has become a fact. Recolac is cow’s milk—disinte- 
grated—then reconstructed. The practical results of its use in the 
clinic and under the observation of the physician in the home has 
now fully established the theory that such a formula could be prepared 
and used with success. 

Again theory and practice are in accord. 



Infant Diet Materials Exclusively 

sesedewenens Qt REORAEDOED 

MMMM . T ‘e 7] e 0 SS Eee ee ES 
poo See i = i a a at a ate aa (Ss 



For Prevention and Treatment of Hay Fever— 


Parke, Davis & COMPANY’S 


Convenient—Accurately Standardixed—Potent 

the nh tho’ LD 


) ee timely administration of Pollen Extracts, P. D. & Co., will save many 
hours of needless suffering and loss of time, or the necessity of seeking a pollen- 

free climate for the hay fever period. 

The first prerequisite for the successful use of Pollen Extracts, P. D. & Co., is to 
determine the nature of the pollen or pollen group to which the hay fever patient 
is susceptible. Pollen Extracts, Diagnostic, P. D. & Co., are ramet adapted to 
this purpose, being put up in paste form in individual collapsible tubes, each con- 
taining a single pollen or a group of related pollens. The diagnosis is rapidly made 
—the technic is very simple. 

If the patient reacts promptly to the pollen of the common ragweed, for example, 
the most frequent offender at this season of the year, or to the pollens of related 
genera, such as other ragweeds, marsh elders, or cocklebur, it is good practice to 
cover the entire ground by using the indicated group of pollens for immunization. 
This insures best results and affords satisfaction to both physician and patient. 

For prophylactic or curative treatment, four groups are supplied in specially con- 
venient packages, each containing 14 cc. of a glycerin extract of the various pollens belonging 
to that particular group, in all, 10,000 units per cc.; and three vials of physiologic salt solution 
for making dilutions, each vial containing 4 14 cc. 

BIO. 360: GRAMINE& (Timothy and related grasses)—timothy, Johnson grass, orchard grass, 

Bermuda grass, and red top. 

BIO. 362: cHENoPoDIAcEe (Russian thistle group) Russian thistle, white goosefoot, yellow 
dock, western water-hemp, and halberd-leaved orache. 

BIO. 364: AMBROSIACEZ (Ragweed and related genera)—common and giant ragweeds, rough 
marsh elder, burweed marsh elder, western ragweed, and cocklebur. 

BIO. 366: aRTEMIsSI2 (Wormwood and related species)—mugwort, prairie sage, sagebrush, 
wormwood sage, and Indian hair tonic. 

For diagnosis, each of these groups is supplied in paste form as follows: 

Pollen Group No. 28: Graminex (Timothy and related grasses). 

Pollen Group No. 29: Chenopodiacea (Russian thistle group). 

Pollen Group No. 30: Ambrosiacez (Ragweed and related genera). 

Pollen Group No. 31: Artemisia (Wormwood and related species). 

If preferred, tubes containing single pollens or other proteins are supplied. 

Literature will be gladly sent to any physician on request 


[United States License No. 1 for the Manufacture of Biological Products} 

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